ChanBeDu/relevant_section_length · Datasets at Hugging Face

45,979

154,474

36200

Discharge summary

report

Admission Date: [**2173-2-11**] Discharge Date: [**2173-2-18**] Date of Birth: [**2096-7-16**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: transfer for eval of possible TBM Major Surgical or Invasive Procedure: mechanical ventilation Pigtail catheter placed in left pleural space History of Present Illness: 76M h/o Afib, dCHF, obesity, COPD on home O2, DM2, recurrent left pleural effusion with reported TBM at OSH, failure to wean from vent transferred from IP service for multifactorial respiratory failure. . Initially presented to [**Hospital6 **] with increased cough and dyspnea on [**2173-2-1**]. Reported sleeping upright for 2-3 days in a recliner. Also occasional subjective chills and minimally productive cough. Increase in chronic LE edema. Reported that he previously received all medical care in [**State 108**], and not established care in MA yet, but had long ICU stay in [**Month (only) **] or [**Month (only) **] [**2172**] for respiratory failure requiring chest tube for pleural effusion, possible heart failure, treated with steroids and antibiotics. . At OSH, he was admitted to ICU. CXR with complete opacification of left hemithorax and left chest tube placed with drainage of 600cc serous fluid. Started on BiPAP. Wife had reversed DNR/DNI decision and therefore intubated. Labs with WBC 6.4, HCO3 36, Cre 1.1, negative cardiac enzymes, and pro-BNP 1173. CTA chest negative for PE on [**2173-2-2**] but revealed bilateral pleural effusions with complete left lung field volume loss. Developed rapid Afib intermittently that responded to Diltiazem, started on IV heparin gtt. Ruled-out for MI. Echo was poor study due to obesity and could not be interpreted. Antibiotics were discontinued when cultures returned negative. Flexible bronchoscopy revealed left mainstem collapse, mucous plugging. Unable to wean off vent. Accepted by IP service for evaluation and management of TBM. . Bronch here without significant TBM, but moderate bilateral BM. L pigtail chest tube placement on [**2173-2-11**] drained 2.4L since that time. Extubated on [**2173-2-12**] to BiPAP 24/10 with occasional desats to 86%. CHF thought to be major component and diuresing with IV lasix. Intermittently poorly rate controlled. With his wife, the patient requested to be made DNR/DNI. IP suggesting consideration of trach for obesity-hypoventilation, although this has not yet been discussed in detail. Transfer from IP service to MICU for further care. Past Medical History: A-fib diastolic CHF morbid obesity COPD on home O2 DMII left pleural effusion Social History: Recently moved to MA from FL, has not established medical care. Married, daughter. Former [**Name2 (NI) 1818**], quit [**2155**]. Denied heavy EtOH use. Family History: NC Physical Exam: General Appearance: Well nourished, Overweight / Obese Lymphatic: Cervical WNL Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic, No(t) Diastolic), limited exam due to obesity Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles : bilateral, Diminished: ) Abdominal: Soft, Non-tender, Obese Extremities: Right: 2+, Left: 2+, No(t) Cyanosis Skin: Warm, Rash: venous stasis shins Neurologic: Attentive, Follows simple commands, Responds to: Verbal stimuli, Movement: Not assessed, Tone: Not assessed Pertinent Results: CXR [**2173-2-11**]: FINDINGS: Technically limited study shows a left subclavian PICC line extending into the inferior vena cava. There is opacification of much of the left hemithorax without displacement of the midline structures. This suggests large pleural effusion with some underlying atelectasis. Prominence of pulmonary vessels could reflect elevated pulmonary venous pressure or shunting of blood flow to the right lung. The tip of the endotracheal tube is somewhat difficult to see, though appears to be about 5 cm above the carina. . CXR [**2173-2-12**]: Since yesterday, a left pigtail was installed, with significant improvement in left pleural effusion and left lung aeration. This study is technically very limited. No pneumothorax is seen given those technical limitations. ETT and nasogastric tube are still in unchanged position. Right basilar opacities persist, likely atelectasis . CXR [**2173-2-13**]: 1. Stable leftward shift of the mediastinum. This appears slightly more pronounced than on the initial film from [**2173-2-11**] at 21:53 p.m., but unchanged compared with [**2173-2-12**] at 14:37 p.m. 2. Continued opacity throughout the left lung, particularly at left base -- pt is difficult to distinguish how much of this is due to consolidation, pleural fluid, or possible elevated left hemidiaphragm. However, compared with [**2173-2-11**], there is some increase in degree of aerated lung. No pneumothorax is detected. . CXR [**2173-2-14**]: 1. Worsening opacification of the left lung and, I suspect, increased leftward shift of the mediastinum, suggesting an element of atelectasis. There is also probably associated pleural fluid and underlying collapse and/or consolidation. 2. Pulmonary vascular plethora on the right, likely reflecting CHF. 3. More confluent alveolar opacity at the right base - - ? alveolar edema. The differential diagnosis includes a pneumonic infiltrate. In the appropriate clinical setting, this could also reflect the presence of ARDS. . CXR [**2173-2-15**]: FINDINGS: In comparison with the study of [**2-14**], there is persistent opacification of virtually the entire hemithorax on the left. Some displacement of the trachea to that side is again seen. The evidence of increased pulmonary venous pressure persists and the pigtail catheter is again seen at the left base. IMPRESSION: Little overall change . Echo [**2173-2-15**]: The left atrium is elongated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with preserved biventricular systolic function. Moderate pulmonary artery systolic hypertension. No definite valvular pathology identified. These findings are suggestive of a primary pulmonary process (e.g., pulmonary embolism, pneumonia, COPD, sleep apnea, etc.). . Labs On admission: [**2173-2-11**] 09:19PM PT-13.3 PTT-66.6* INR(PT)-1.1 [**2173-2-11**] 09:19PM PLT COUNT-295 [**2173-2-11**] 09:19PM WBC-9.9 RBC-3.12* HGB-9.0* HCT-27.6* MCV-89 MCH-29.0 MCHC-32.7 RDW-16.1* [**2173-2-11**] 09:19PM CALCIUM-8.6 PHOSPHATE-4.1 MAGNESIUM-2.5 [**2173-2-11**] 09:19PM estGFR-Using this [**2173-2-11**] 09:19PM GLUCOSE-158* UREA N-18 CREAT-0.9 SODIUM-138 POTASSIUM-5.2* CHLORIDE-100 TOTAL CO2-33* ANION GAP-10 [**2173-2-11**] 09:28PM O2 SAT-94 [**2173-2-11**] 09:28PM TYPE-ART PO2-72* PCO2-56* PH-7.37 TOTAL CO2-34* BASE XS-4 INTUBATED-INTUBATED Brief Hospital Course: 76M h/o Afib, dCHF, COPD, Obesity, DM2, and TBM by report from OSH with multifactorial respiratory failure. Discussions with patient??????s wife indicate that he is DNR/DNI and moving towards comfort care only. . # Respiratory failure: Multifactorial in etiology. No evidence of tracheobronchial malacia on bronchoscopy today. Secondary to COPD, obesity-hypoventilation, diastolic CHF, and pleural effusion from volume overload. The patient was intubated on transfer, and was successfully extubated on [**2173-2-12**], requiring BiPAP at pressures of [**1-11**] as needed for episodes of hypoxia, especially while sleeping. Thoracentesis with chest tube placement by interventional pulmonary. Results showed transudative fluid secondary to CHF. The patient was diuresed with IV lasix with a goal of 2L per day. He should continue on Lasix 40mg IV Q6H with a goal of 2L per day, should check daily lytes and replete as needed. Continued albuterol and ipratropium as needed. Plan for the drain to be pulled by IP prior to discharge. However if decided to keep in place, please pull when output is < 150ml/day. . # Afib: The patient was not well rate controlled, therefore beta blockers were increased. He was increased up to metoprolol 100mg Q6H with good result. He should continue on this regimen while at rehab. He was continued on heparin bridge to coumadin. Should continue coumadin at 5mg QD with daily INR checks with goal of [**3-9**]. . # DM2: The patient was maintained with good blood glucose control with sliding scale insulin. Checked FS BG QID. . #Tinea cruris: The patient complained of scrotal pruritis. Started on Miconazole topically. . # FEN: regular diet as tolerated, repleted electrolytes as needed . # PPX: heparin IV until patient was therapeutic on coumadin, PPI, bowel regimen . # Access: Left PICC . # Code: DNR/DNI, Do not escalate care . # Communication: [**Name (NI) **] [**Name (NI) **] (wife) [**Telephone/Fax (1) 82075**] Medications on Admission: Advair Spiriva Albuterol Glucotrol 10 QD Lasix 60 QD K-Dur 20mEQ QD Imdur 30 mg QD Avandia 8 mg QD Discharge Disposition: Extended Care Facility: [**Hospital 671**] Healthcare @ [**Hospital6 10353**] Discharge Diagnosis: Primary Diagnoses: Obesity Hypoventilation syndrome OSA Diastolic CHF, acute on chronic COPD . Secondary Diagnoses: A fib DM type 2 Hypertension Obesity Discharge Condition: The patient is currently hemodynamically stable. His respiratory status is stable with use of BiPap as needed for hypoxia. Discharge Instructions: You were admitted to [**Hospital1 18**] for evaluation of your bronchial tree as you were thought to have a disorder called, tracheobronchial malacia, however this was not seen on bronchoscopy completed by the interventional pulmonologists here. You were able to be extubated without difficulty. Your respiratory status was maintained with noninvasive ventilation of nasal cannula and BiPap as tolerated. The decision was made not have you reintubated. You were treated with a catheter to drain the fluid around your left lung. You were also treated with diuretics to remove excess fluid. You were transferred to a rehab facility. Followup Instructions: Please follow up with your primary care physician in the next week to discuss your hospital course. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2173-2-19**]

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icd9cm

[ [ [] ] ]

[ "38.93", "34.91", "96.71", "33.24", "88.72", "96.05" ]

icd9pcs

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7695, 9671

356, 426

10099, 10225

3667, 7087

10910, 11177

2891, 2895

9923, 10018

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283, 318

454, 2603

7101, 7672

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12,920

111,750

47526

Discharge summary

report

Admission Date: [**2201-7-18**] Discharge Date: [**2201-8-5**] Date of Birth: [**2127-12-13**] Sex: F Service: CCU NOTE: This is a Death Summary. HISTORY OF PRESENT ILLNESS: This is a 73-year-old Asian female with a complicated past medical history significant for diabetes, hyperlipidemia, hypertension, and coronary artery disease (status post 4-vessel coronary artery bypass graft on [**2201-5-4**] which was complicated by postoperative atrial fibrillation). She was started on amiodarone and converted back to sinus rhythm in one day. She was continued on amiodarone and beta blocker and was sent to cardiac rehabilitation. She returned on [**2201-5-23**] with chest pain thought to be associated with pericardiotomy syndrome. She was found to have a moderate-sized left pleural effusion which was tapped for about 500 cc, but this was not sent for any laboratory studies. She returned on [**2201-7-18**] with rapid worsening of dyspnea over the last two days. She was brought by Emergency Medical Service who had intubated her in the field. PAST MEDICAL HISTORY: 1. Coronary artery disease; status post 4-vessel coronary artery bypass graft on [**2201-5-4**] (left anterior descending artery to left internal mammary artery, saphenous vein graft to first diagonal, saphenous vein graft to posterior descending artery). 2. Diabetes (hemoglobin A1c of 8.2 in [**2201-4-27**]). 3. Hyperlipidemia. 4. Hypertension. SOCIAL HISTORY: No tobacco and no alcohol use. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: Outpatient medications included amiodarone 200 mg p.o. q.d., Zestril 20 mg p.o. q.d., oxycodone 5 mg p.o. q.4-6h. as needed, Lopressor 25 mg p.o. b.i.d., Lasix 20 mg p.o. b.i.d., Colace 100 mg p.o. b.i.d., enteric-coated aspirin 325 mg p.o. q.d., Protonix 40 mg p.o. q.d., Lipitor 20 mg p.o. q.d., Plavix 75 mg p.o. q.d., insulin 70/30 30 units q.a.m. and 16 units q.p.m. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission to the Coronary Care Unit revealed a temperature of 105, blood pressure was 117/61, heart rate was 91, respiratory rate was 20, oxygen saturation was 97% on FIO2 of 100%. In general, physical examination revealed the patient was intubated and sedated. Head, eyes, ears, nose, and throat examination showed normocephalic and atraumatic, Asian female. Pupils were equal, round, and reactive to light. They were not icteric. Cardiovascular examination revealed she had a regular rate. She had a normal first heart sound and second heart sound. No murmurs, rubs or gallops were heard. Pulmonary examination revealed she was clear to auscultation bilaterally anteriorly. Abdominal examination showed a soft, nontender, and nondistended abdomen with normal active bowel sounds. Her extremities were cool to touch. She had no noticeable edema, but her dorsalis pedis pulses could not be appreciated. On neurologic examination, she was sedated. She had an indeterminate Babinski, but she was moving all four extremities. Her ventilator settings on admission were synchronized intermittent mandatory ventilation 500, respiratory rate was 20, positive end-expiratory pressure was 8, FIO2 of 200%. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory values revealed a white blood cell count of 11.7, hematocrit was 46.4, platelets were 231. PT was 16.5, PTT was 30, INR was 1.2. Sodium was 143, potassium was 3.6, chloride was 107, bicarbonate was 20, blood urea nitrogen was 27, creatinine was 1.4, blood glucose was 88. Cardiac enzymes showed a peak creatine kinase of 1787 on [**8-18**], with a CK/MB of 11, and an index of 0.6. Troponin was 1.5. RADIOLOGY/IMAGING: Initial electrocardiogram showed sinus rhythm with a rate of 77, a normal axis, and a left bundle-branch morphology. A follow-up electrocardiogram on the same day showed a new arteriovenous junctional rhythm with antegrade P wave conduction. Initial chest x-ray showed bilateral patchy basilar opacities which could be consistent with aspiration pneumonia, as well as a fine interstitial pattern, and engorgement of the pulmonary vasculature; consistent with pulmonary edema. HOSPITAL COURSE: 1. CORONARY ARTERY DISEASE: Upon admission, the patient had signs of cardiogenic shock and status post coronary artery bypass graft two months earlier. Therefore, she was taken straight to the catheterization laboratory. Her hemodynamics indicated elevated filling pressures with a cardiac index of 1.09. On coronary angiography, coronary angiography showed an 80% left main stenosis, an occluded left anterior descending artery, a left circumflex with a 70% proximal stenosis and 80% distal disease, and an occluded right coronary artery. The saphenous vein graft to posterior descending artery had 50% middle and 80% stenosis at the touchdown site. The saphenous vein graft to first diagonal had a 90% middle stenosis which was stented with 0% residual stenosis with normal flow afterwards. The saphenous vein graft to second diagonal showed a 90% stenosis which was also stented and had 0% residual stenosis. The left internal mammary artery to left anterior descending artery had an 80% distal stenosis. Her hemodynamics initially improved with angioplasty, and she was started on aspirin, Plavix, and Integrilin which was continued for 24 hours. Cardiac enzymes were cycled, and although creatine kinases were elevated, the CK/MB fraction never bumped, and the troponin remained flat at 1.5. Therefore, given the evidence of restenosis on catheterization, it was unknown whether an ischemic event precipitated the patient's presentation. 2. CONGESTIVE HEART FAILURE: The patient was started on dopamine and dobutamine while in the catheterization laboratory due to a cardiac index of 1.1. An echocardiogram done after her initial coronary artery bypass graft on [**2201-5-21**] showed an ejection fraction of 55%. A repeat echocardiogram which was done on [**5-22**] (on hospital day two) showed an ejection fraction of 35% with inferior wall akinesis and biventricular hypokinesis. The patient's initial presentation was consistent with pulmonary edema secondary to congestive heart failure, and likewise she was continued on pressors for the majority of her hospital course. Pressors were weaned on a number of occasions, at which time captopril and metoprolol were used for blood pressure control. The patient was initially diuresed approximately 9 liters of fluid; at which time she was judged to be at her dry weight and the Swan-Ganz catheter was removed. Due to a fluctuating systemic vascular resistances and cardiac output/cardiac index, it was unsure whether an entirely cardiogenic versus septic (or both) etiology was responsible for the patient's hypotension. Therefore, a Swan-Ganz catheter was refloated on [**2201-7-29**] for better hemodynamic monitoring. The patient was diuresed an additional 2 liters to 3 liters at that time. Although pressors had been weaned radically throughout the hospital course; staring on [**8-2**], the patient's blood pressure became dopamine dependent, and dopamine was unable to be weaned until the patient expired on [**2201-8-5**]. 3. ARRHYTHMIA: Upon admission to the hospital, the patient had a junctional rhythm with arteriovenous dissociation and significant sinus bradycardia. While in the catheterization laboratory, a temporary pacemaker was placed. It was assumed that the junctional rhythm was associated with the beta blocker and amiodarone used, which were both stopped. The patient had an occasional episode of ectopy which was thought to be associated with reperfusion, and the temporary pacemaker was pulled on hospital day four without any additional arrhythmias noted. 4. PULMONARY: The patient was admitted with a 2-day history of increasing dyspnea on exertion which eventually led to dyspnea while at rest. The patient was intubated in the field by Emergency Medical Service and was initially diuresed 9 liters for an episode of acute pulmonary edema. An initial chest x-ray showed signs of left lower lobe consolidation, and given the field intubation the patient was started on empiric therapy for presumed aspiration pneumonia. Her pulmonary mechanics improved throughout the first three hospital days, and she was weaned from the ventilator and extubated on [**2201-7-21**]. The following day, the patient developed a hypertensive episode with systolic blood pressures in the 240s, and she dropped her oxygen saturation. Her PO2 pressure was in the low 50s. It was assumed that an episode of acute pulmonary edema had occurred and the patient was temporarily managed on intravenous nitroglycerin as well as a nonrebreather face mask. Her pulmonary status continued to deteriorate, and she was electively reintubated on [**2201-7-23**]. By chest x-ray, the known pleural effusion from the previous admission appeared to have increased in size, and the effusion was tapped on [**7-24**]; which indicated a purely transudative fluid. By [**7-27**], chest x-rays indicated a collapse of the left lower lung lobe. By [**2201-7-28**], the patient's bilateral pulmonary infiltrates had increased in size, and a diagnosis of acute respiratory distress syndrome was made. The Pulmonary team was consulted, and a bronchoscopy with bronchoalveolar lavage was performed. The bronchoscopy showed very collapsible airways with thick mucous plugging in the left lower lobe and thick secretions diffusely. There were no endobronchial lesions. After the bronchoscopy, the patient was maintained on an increased positive end-expiratory pressure to prevent airways from collapsing. However, the positive end-expiratory pressure was unable to be weaned much lower than 12.5, and the patient had a pressure support requirement of at least 10 without the PO2 falling below 60. Staring on [**2201-8-2**], the patient's pulmonary mechanics began to deteriorate, and her peak inspiratory pressures began to rise into the 50s and plateau pressures rose into the 60s. It was determined that the acute respiratory distress syndrome was not improving, and the patient was started on high-dose steroids. By [**2201-8-4**], it appeared that pulmonary function was not improving, and she was switched to pressure control ventilation; however, she was unable to pull consistent large tidal volumes. Her oxygen requirement increased, and she was unable to be weaned from an FIO2 of 70%. 5. INFECTIOUS DISEASE: On presentation to the Coronary Care Unit, the patient had a temperature of 105. Given recent surgery, there was a concern for mediastinitis, and Cardiothoracic Surgery was consulted who recommended a CT scan of the chest once the patient was stable. Given the high likelihood of aspiration pneumonia, the patient was empirically started on ceftazidime, vancomycin, and Levaquin. Her antibiotic regimen was changed after a sputum culture on [**7-22**] and [**7-23**] grew out Pseudomonas plus Enterobacter. She was continued on a 21-day course which included ciprofloxacin, ceftazidime/imipenem. The bronchoalveolar lavage showed stenotrophomonas maltophilia which was started on Bactrim for a 21-day course. Given her diminished systemic vascular resistance and high cardiac output and index, there was concern for sepsis, and the blood cultures were taken from the patient on approximately 10 separate occasions which all were negative for growth. Despite the antibiotic regimen for aspiration pneumonia, the patient continued to have fevers ranging from 101 to 103 consistently from the date of admission until [**2201-8-1**]. Infectious Disease was consulted, and appropriate changes were made to her antibiotic regimen. The fevers defervesced after initiation of Bactrim for stenotrophomonas as well as vancomycin for a stage II decubitus ulcer on the patient's back. 6. NEUROLOGY: During the patient's period of extubation (between [**7-21**] and [**7-23**]), sedation was completely weaned, and the patient was very agitated and fairly nonresponsive. She would follow only occlusion commands but was never completely coherent in speech or purposeful movements. She was resedated during the time of reintubation on [**7-23**]. Sedation was weaned again on [**2201-7-29**], and for the following 48 hours the patient was completely nonresponsive; would not respond to sternal rub, was unable to follow commands, had a positive Babinski bilaterally, and a weak gag reflex. Therefore, Neurology was consulted. During Neurology's assessment (on [**2201-7-31**]), the patient became hemodynamically unstable. Due to agitation leading to hypertension, it was determined that sedation would have to be restarted. The patient was continued on sedation for the remainder of her hospital stay and for comfort measures. 7. HEMATOLOGY: The patient's hematocrit fell from 46 on admission to a low of 26. She received 3 units of packed red blood cells throughout her hospital course. Her platelets fell to a low of 100, and she was found to be heparin-induced thrombocytopenia antibody positive. On [**2201-7-24**], all heparin was stopped and platelets rebounded. A DIC panel was negative. 8. FLUIDS/ELECTROLYTES/NUTRITION/GASTROINTESTINAL: The patient with mild transaminitis. A right upper quadrant ultrasound was performed which was unchanged from [**2201-6-27**]. Hyponatremia developed in the last week which was thought to be related to congestive heart failure. Hyponatremia was treated with a concentration of intravenous fluids. The patient was intermittently on tube feeds throughout her hospital course; however, high residuals were noted near the end of her hospital course. Red wine was used to improve gastroparesis; however, tube feeds were unable to be continued at goal at the end of her hospital course. 9. SOCIAL WORK: An initial family discussion occurred on [**2201-8-2**]; at which time the patient's four children agreed on pursuing aggressive diagnostic and therapeutic interventions. As the patient's condition did not improve, a second discussion was held on [**2201-8-1**]; at which time the family changed the patient's code status from full code to do not resuscitate. On [**2201-8-5**], after the patient's pulmonary mechanics continued to deteriorate and there was little sign that pulmonary or neurologic condition would improve, the patient's family decided to withdraw support, as this was consistent with her wishes. At 1820 on [**2201-8-5**], the patient was extubated and all medication drips were stopped except for morphine sulfate. The patient's four children were present after extubation. At 1845 the patient oxygen saturation had fallen into the low 70s, and she became bradycardic to the 30s with continuation of no electrical activity noted on the monitor. The patient was examined by medical doctor and found to have no pulses, respirations, with fixed dilated pupils. The patient was pronounced dead at 1845. DIAGNOSES AT THE TIME OF DEATH: 1. Acute respiratory distress syndrome. 2. Aspiration pneumonia. 3. Coronary artery disease; status post 4-vessel coronary artery bypass graft and two bypass vessel stenting. 4. Cardiac arrest. 5. Respiratory arrest. 6. Cardiogenic shock. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**] Dictated By:[**Last Name (NamePattern1) 6240**] MEDQUIST36 D: [**2201-8-13**] 19:20 T: [**2201-8-18**] 11:30 JOB#: [**Job Number 100478**]

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icd9cm

[ [ [] ] ]

[ "96.04", "33.24", "96.71", "37.23", "88.56", "36.06", "99.20", "36.01", "96.6" ]

icd9pcs

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32707

Discharge summary

report

Admission Date: [**2139-10-6**] Discharge Date: [**2139-10-10**] Date of Birth: [**2072-7-30**] Sex: F Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 3326**] Chief Complaint: progressive SOB Major Surgical or Invasive Procedure: Intubation History of Present Illness: This is a 67yoF with a history of breast cancer(dx '[**18**]) s/p left mastectomy and metastatic non small cell lung cancer of LUL lesion s/p XRT to brain and chemo who was brought by EMS to OSH w/severe progressive SOB. Per report, she had had 2 days of progressive SOB. Not much other hx was able to be taken due to respiratory distress. . At the OSH, initial vitals were T 99.9 HR elevated 120s BP 140/70 RR 40s. She got etomidate/succinylcholine and had RSI w/7.5cm ETT and then received norcuron versed for further sedation. She also received Vanc 1gm IV, Flagyl IV, and Levo IV, and hydrocortisone 100mg IV x 1 for possible COPD. He lactate 3.2 WBC 33.6 and bandemia 24. Per report, she did have diarrhea x 1. . ROS: pt is unable to give hx as she is intubated and sedated. Per oncologist's report she has had diarrhea for 3 weeks on and off. Recent CT scan revealed smaller mass and resolving empyema. Currently, s/p taxol, carboplatin, avastin therapy. Past Medical History: -1 cycle of chemo, pleurex at [**Hospital3 **] for malignant effusion. c/b empyema. -Metastatic non small cell left lung cancer LUL: PET-CT on [**2138-9-6**] at [**Hospital6 41256**] in [**Hospital1 1559**] showed a 3.2 x 1.7 cm lesion in the left upper lobe at the fissure, which may extend into the left lower lobe, FDG avid with an SUV of 6; +prevascular, paratracheal, pretracheal, and subcarinal lymph nodes meeting size criteria for being pathologic, mild increased FDG avidity suspicious for metastases; on my review, a subcarinal lymph node had an SUV of 2.4; no adrenal or bone metastases -2 doses of brain XRT-[**2138**]8 -Status post pleurex catheter insertion for malignant pleural effusion and partial lung collapse c/b empyema -left breast CA s/p left mastectomy in [**2121**] followed by chemotherapy and radiation therapy at the [**Hospital 17405**] Medical Center; treated with tamoxifen for 5 years, no evidence of recurrence of the breast cancer -history of CAD with prior ??????silent?????? MI -Chronic obstructive pulmonary -history of 'valvular heart disease' -h/o c.diff -Hypertension -Hyperlipidemia -osteoporosis -s/p appendectomy -s/p cholecystectomy -s/p back surgery in [**2103**] . Social History: The patient is married and lives with her husband 3 children, ages 47, 43, and 41. She has a 60-pack-year history of cigarette smoking but quit in [**2136-1-17**]. No ETOH. Family History: Father died at age 48 from a myocardial infarction, mother died at age 81 from complications of Crohn's disease; brother had a myocardial infarction; the patient??????s paternal grandmother had gastric cancer, and a maternal aunt also had gastric cancer; a paternal aunt also had cancer- site of origin is unknown. . Physical Exam: Vitals: T: 98.4 BP: 116/72 HR: 129 RR: 12 O2Sat:100% on AC 50% 500x12 PEEP 5 GEN: intubated, sedated, no acute distress HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea NECK: Flat JVP, no cervical lymphadenopathy, trachea midline COR: tachy RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: crackles in LUL o/w CTAB, no W/R/R ABD: scars noted, soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: sedated, paralyzed. SKIN: + peripheral skin mottling, no jaundice, rash, gross dermatitis. No ecchymoses. Pertinent Results: Admission labs: [**2139-10-6**] 03:34PM BLOOD WBC-24.4* RBC-3.10* Hgb-9.3* Hct-30.5* MCV-98 MCH-29.8 MCHC-30.3* RDW-19.3* Plt Ct-462* [**2139-10-6**] 03:34PM BLOOD Neuts-97* Bands-1 Lymphs-0 Monos-1* Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [**2139-10-6**] 03:34PM BLOOD PT-16.9* PTT-29.9 INR(PT)-1.5* [**2139-10-6**] 03:34PM BLOOD Plt Smr-HIGH Plt Ct-462* [**2139-10-6**] 03:34PM BLOOD Glucose-126* UreaN-24* Creat-1.1 Na-135 K-3.9 Cl-110* HCO3-14* AnGap-15 [**2139-10-6**] 03:34PM BLOOD ALT-6 AST-15 LD(LDH)-285* CK(CPK)-65 AlkPhos-196* TotBili-0.2 [**2139-10-6**] 03:34PM BLOOD CK-MB-3 cTropnT-<0.01 [**2139-10-7**] 03:31AM BLOOD CK-MB-3 cTropnT-<0.01 [**2139-10-6**] 03:34PM BLOOD Albumin-1.5* Calcium-6.3* Phos-5.2* Mg-1.5* [**2139-10-6**] 02:38PM BLOOD Type-ART pO2-405* pCO2-55* pH-7.14* calTCO2-20* Base XS--10 [**2139-10-6**] 03:55PM BLOOD Lactate-3.0* [**2139-10-6**] CXR IMPRESSION: Single chest view indicating appropriate position of ETT and left-sided lung mass in periaortic position as well as extensive pleural thickening and left-sided volume loss. [**2139-10-6**] CT HEAD: IMPRESSION: 1. Multiple extra-axial, supratentorial punctate densities along the sulci may be vascular in origin or could represent prior cisternogram, however given the clinical history secondary hemorrhagic metastasic deposits are also included in the differential. 2. No evidence of acute intracranial hemorrhage, new region of edema, or new mass effect. 3. Previously described ring-enhancing lesion is not well demonstrated today, but could be due to differences in technique. For more sensitive evaluation for metastasic disease and infarction direct comparison with prior MR, repeat MRI may be performed as clinically indicated. [**2139-10-6**] CT chest/abd/pelvis: IMPRESSION: 1. Allowing for respiratory motion, no large or central pulmonary embolism seen. 2. Moderate-sized left loculated and septated hydropneumothorax. The patient is status post recent procedure (reportedly VATS at OSH) in the left posterior thorax with skin staples in place and small locules of subcutaneous gas. 3. Subcutaneous collection in left posterior chest wall deep to surgical incision could represent postoperative hematoma although communication with pleural fluid cannot be excluded. 4. Left upper lobe atelectasis/mass with attenuation of pulmonary artery and bronchi. Correlation with prior imaging is recommended. 5. Diffuse abnormality of the colon and rectum with mucosal enhancement, submucosal thickening and pericolonic stranding. Findings are nonspecific and could represent, for example, an infectious colitis. Ischemic colitis less likely. Trace fluid tracking along the left paracolic gutter with small fluid in pelvis. No free air. 6. Multiple sclerotic lesions in the axial skeleton concerning for metastatic disease in this patient with history of malignancy. Correlation with prior bone scan or other imaging recommended. Anterior wedge compression deformity of T12 of indeterminate chronicity without comparison. 7. Presacral hyperattenuating lesions likely representing enhancing soft tissue, the more superior one abutting the sacrum with possible bony involvement, concerning for metastases. 8. Diffuse atherosclerotic disease, with focal ectasia of infrarenal abdominal aorta. Brief Hospital Course: This is a 67yoF with a history of breast cancer and metastatic non small cell lung cancer who was intubated at an OSH for respiratory distress and transferred for further management of respirator failure. # Respiratory failure: in the setting of known NSCLC. She had leukocytosis at OSH prior to transfer w/bandemia. Otherwise, CXR revealed mass and left sided effusion, but no other acute changes. Exam is w/o evidence of COPD flare and CXR does not reveal evidence of PNA. Respiratory distress may have been secondary to primary metabolic acidosis. Unlikely [**12-20**] high tumor burden causing respiratory failure. CT chest ruled out PE. Repeated attempts to wean the pt or extubate her were complicated by tachypnea and high auto PEEP to the 40s only relieved with sedation of versed and fentanyl gtts in large amounts. When sedated to this degree, the pt did have significant drops in her BP requiring pressor support. In the early afternoon of [**10-10**], given her lack of improvement and inability to wean from the vent, a family meeting was held and the pt was made CMO. She was continued on A/C vent settings, fentanyl and versed gtts titrated to comfort. Pressors were discontinued. Her family was present in the ICU during this time. Dr. [**Last Name (STitle) **] was notified of these decisions. She was pronounced at 5:50 pm [**2139-10-10**], the family refused autopsy. . # Metabolic acidosis - nongap at time of presentation to OSH ED; pt did have diarrhea with later positive C diff.; No h/o fevers and pt had been afebrile prior to admisison but w/leukocytosis to 33.7 and impressive bandemia and lactate of 3.2. Vent settings were continually changed based on ABG's. Pt was best maintained on A/C with large amts of fentanyl and versed gtts. Her C diff was treated with PO flagyl and vanco. . # NSCLC - had XRT to brain and per report had scheduled chemo prior to admission. Dr. [**Last Name (STitle) **] (her outpatient oncologist) was consulted and continuously involved in her care during her ICU stay. Medications on Admission: Lorazepam 1 mg at bedtime p.r.n. Prozac 10 mg p.o. daily Xanax 0.25 mg p.o. t.i.d. Detrol LA 4 mg p.o. daily Zocor 10 mg p.o. at bedtime Prilosec 20 mg p.o. daily MOM 30 cc p.o. p.r.n. Advair Diskus 500/50 one puff b.i.d. enoxaparin 40 mg subq until ambulatory aspirin 325 mg p.o. daily DuoNeb one vial q.6h. inhaled oxycodone one to two tablets q.3h. p.o. p.r.n. for pain. Discharge Medications: Pt expired Discharge Disposition: Expired Discharge Diagnosis: Pt expired. Discharge Condition: Pt Expired. Discharge Instructions: . Followup Instructions: . Completed by:[**2139-10-22**]

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icd9cm

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43975

Discharge summary

report

Admission Date: [**2143-2-20**] Discharge Date: [**2143-2-26**] Date of Birth: [**2078-6-29**] Sex: M Service: MEDICINE Allergies: sodium carbonate / aspirin Attending:[**First Name3 (LF) 2186**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: NONE History of Present Illness: 64M with complicated medical history including ESRD baseline Cr 4(from DM/HTN), monoclonal gammopathy and recent left craniectomy and cranioplasty for osseus hemangioma, CAD s/p [**2135**] PTCA and stenting, PAF on coumadin, legally blind pw AMS. Patient had a recent craniotomy on [**2143-1-24**]. He was discharged from rehab last Friday and feeling well until 2 days ago when he began complaining of neck pain (per note also low back pain, though patient denies) and was noted to be confused for example needed help with dressing and waking up in middle of night. No headache or fevers at this time. +chills. Sister also noted the patient has not been eating and has been in bed. He also had some nausea and emesis x4 over the last 2 days, and has been unable to take his medications for the last day or two because of this. He has had 1 episode of diarrhea. Denies fevers at home but has had chills. as well as neck pain that started Monday night. He is legally blind but has not had photophobia. He denies phonophobia. Oldest brother with recent pneumonia. . From HD center at [**Name (NI) 882**] (pt on M/W/F HD) 1 day prior to presentation was called and told had positive blood cultures (G+ cocci). Received Vancomycin yesterday. Sent to AV care for HD catheter removal morning of presentation. After catheter removal, the patient came to ED with sister. In the ED, initial VS were: 100.5F 88 126/70 18 98% RA. He was A+Ox3. No meningismus. He had a right chest bandage from pulled line with wound clean, dry and intact. He also had no obvious infection at his craniectomy site. He was noted to have tenderness to palpation over his thoracic spine. Neurosurgery was consulted and recommended a head CT. The head CT showed "no ICH stable L praietal craniotomy, small vessel [**Last Name (un) **] disease, cerebellar encephalomalacia. Note no obvious signs of infection on noncontrast CT, but MRI w gad is more sensitive if of clinical concern. Trace L vetex scalp thickening could be a small hematoma". Patient given Zosyn and Ceftriaxone (received vancomycin after dialysis yesterday). An MRI of his entire spine was ordered but given a Cr of 7.7 immediate dialysis would be needed after gadolinium administration. As such the patient was first admitted to the MICU. . On transfer to the MICU his vital signs were 98.4 80 126/64 20 96%RA. He only endorsed some neck pain, no back pain. No CP/SOB. No nausea or vomiting currently. No abdominal pain. No other pains. . Review of systems: (+) Per HPI (-) Denies fever, 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. Denies, constipation, abdominal pain. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: recent craniectomy showing osseous hemangioma ([**2143-1-24**]) Monoclonal gammopathy ESRD [**12-27**] HTN/DM with Baseline Cr of 3.3 with left brachiocephalic fistula which is functional CAD with [**2134**] PTCA/stenting of PDA Diastolic dysfunction Hypertension, severe Diabetes mellitus, type II c/b retinopathy, nephropathy, and neuropathy Chronic infected diabetic ulcer PAF on coumadin OSA Stasis dermatitis Peripheral edema Hyperlipidemia BPH Obesity GERD Social History: Currently lives with sister and son in [**Name (NI) 2268**]. Retired [**Company 2318**] bus driver and tollbooth worker. Reports drinking half a pint of gin on an occasional basis. ~10 pack-year smoking history, quit 10 years ago. No illicit drugs Family History: Father with diabetes. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.4 80 126/64 20 96%RA General: Alert, oriented x4, no acute distress,Eyes closed when talking HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, right pupil at 5 not reactive, left at 2 minimally reactive Neck: JVP not elevated, no LAD. pain with turning to the right. tenderness to palpation in the midline. pain with flexion. none with extension CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rhonchi, minimal rales at the bases. Abdomen: soft, obese, non-tender, non-distended, bowel sounds present, no organomegaly Back: ttp at T3-4 GU: foley in place Ext: warm, well perfused, 2+ pulses, Chronic venous stasis changes with scaling skin bilaterally Neuro: CNII-XII intact, Right pupil not reactive, dilated at 5. Left pupil minimally reactive at 2. 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. . DISCHARGE EXAM: Vitals: 98.6 98.6 110/70 80 23 93 CPAP I/O: 1000/anuric, HD . Exam: General: Alert, oriented x4, no acute distress, HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, right pupil at 5 not reactive, left at 2 minimally reactive Neck: JVP not elevated, no LAD. pain with turning to the right. tenderness to palpation in the midline. pain with flexion. none with extension CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rhonchi, minimal rales at the bases. Abdomen: soft, obese, non-tender, non-distended, bowel sounds present, no organomegaly Back: ttp at T3-4 Ext: warm, well perfused, 2+ pulses, Chronic venous stasis changes with scaling skin bilaterally Neuro: CNII-XII intact, Right pupil not reactive, dilated at 5. Left pupil minimally reactive at 2. 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Pertinent Results: [**2143-2-25**] 12:30PM BLOOD WBC-8.7 RBC-3.57* Hgb-10.2* Hct-33.3* MCV-93 MCH-28.6 MCHC-30.7* RDW-15.4 Plt Ct-158 [**2143-2-20**] 12:25PM BLOOD WBC-15.7*# RBC-4.06* Hgb-11.7* Hct-38.2*# MCV-94# MCH-28.7 MCHC-30.6*# RDW-15.2 Plt Ct-120* [**2143-2-20**] 12:25PM BLOOD Neuts-59 Bands-18* Lymphs-13* Monos-9 Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 [**2143-2-21**] 07:19AM BLOOD Neuts-78.8* Lymphs-12.1* Monos-6.4 Eos-2.3 Baso-0.4 [**2143-2-25**] 12:30PM BLOOD PT-35.9* PTT-45.8* INR(PT)-3.5* [**2143-2-20**] 12:25PM BLOOD PT-21.5* PTT-38.9* INR(PT)-2.0* [**2143-2-24**] 07:00AM BLOOD ESR-122* [**2143-2-25**] 12:30PM BLOOD ESR-125* [**2143-2-25**] 12:30PM BLOOD Glucose-142* UreaN-52* Creat-7.0*# Na-131* K-3.7 Cl-93* HCO3-25 AnGap-17 [**2143-2-20**] 12:25PM BLOOD Glucose-296* UreaN-49* Creat-7.7* Na-130* K-8.3* Cl-85* HCO3-29 AnGap-24* [**2143-2-25**] 12:30PM BLOOD Calcium-8.3* Phos-4.5 Mg-2.2 [**2143-2-20**] 12:25PM BLOOD Albumin-3.4* Calcium-8.7 Phos-5.1* Mg-2.2 MR [**Name13 (STitle) **] W& W/O CONTRAST Study Date of [**2143-2-20**] 8:16 PM Abnormal signal and enhancement involving C6, C7, and T1 vertebral bodies and disc spaces, likely representing discitis and osteomyelitis. There is associated epidural enhancement projecting posteriorly and lateral at these levels likely representing epidural spread of the infection. There is no evidence of large epidural collection to represent an abscess, but the epidural enhancement might represent an epidural phlegmon. Dedicated MR of the cervical spine with a smaller FOV may be beneficial if clinically warranted. Portable TTE (Complete) Done [**2143-2-21**] at 9:57:13 AM FINAL IMPRESSION: Very small, thin, mobile echodensity on the left ventricular side of the anterior mitral leaflet consistent with redundant mitral valve leaflet vs a remnant chordal structure vs a possible vegetation. Biatrial enlargement. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Dilated, normally functioning right ventricle. Abnormal septal motion. Mildly dilated ascending aorta. Indeterminate pulmonary artery systolic pressure. Compared with the prior study (images reviewed) of [**2142-3-31**], the mobile mitral leaflet structure was also present, although not commented upon. The right ventricular systolic function has improved. Moderate tricuspid regurgitation is no longer seen. The pulmonary artery systolic pressure is indeterminate on the current study, but was previously moderate in severity. If clinically indicated, a transesophageal echocardiogram may be considered to further evaluate the possible presence of endocarditis, but given that this mitral valve structure was noted previously it is unlikely that it represents a vegetation. CT HEAD W/ & W/O CONTRAST Study Date of [**2143-2-20**] 1:52 PM IMPRESSION: 1. No acute intracranial process. 2. Stable changes of left parietal craniotomy, cerebellar encephalomalacia, and right subinsular and left frontal lobe remote ischemic injury and/or small vessel ischemic disease. 3. Stable appearance of right globe. 4. Right maxillary sinus disease MR HEAD W & W/O CONTRAST Study Date of [**2143-2-20**] 8:19 PM IMPRESSION: 1. No evidence of infarction or hemorrhage. No evidence of suspicious enhancement or collection to represent an infection. 2. Post-surgical changes status post left parietal craniotomy with expected postoperative changes. 3. Fluid in the right mastoid air cells and mucosal thickening in the right maxillary sinus, bilateral ethmoid air cells and bilateral sphenoid sinuses likely related to recent intubation. Brief Hospital Course: 64M with ESRD baseline Cr 4(from DM/HTN), monoclonal gammopathy, recent left craniectomy and cranioplasty for osseus hemangioma, CAD s/p [**2135**] PTCA and stenting, PAF on coumadin, legally blind admitted for cervical osteomyelitis with high-grade MSSA bacteremia and ?valve vegetation. . ACTIVE DIAGNOSES: . # MSSA Sepsis/Osteomyelitis: Patient was admitted with fevers, white count, and neck pain with high grade MSSA bacteremia from OSH as well as here. He underwent urgent MRI with gadolinium contrast which showed discitis and osteomyelitis of the C6, C7, and T1 vertebral bodies and disc spaces as well as an epidural phlegmon. He was admitted to the MICU for urgent dialysis due to the contrast from the MRI and neurosurgery was consulted and recommended conservative management. He was started on vanc/cefepime and ID was consulted. Ultimately, his MSSA bacteremia was thought to be from his temporary dialysis catheter which was removed. He underwent ultrasound of the temporary dialysis catheter site which did not show any infectious collection. Additionally, a question of small vegetation was seen on TTE on his mitral valve which was seen on prior echos. He was narrowed to cefazolin per HD protocol and he was called-out to the floor for further management. On the floor he continued with cefazolin therapy and tolerated this well without fevers and improved neck pain although he still had neck pain on day of discharge with some muscle spasm of right trapezius. . #Afib with RVR: Following call-out from the MICU the patient underwent dialysis and had 2.5L taken off and went into afib with RVR (although his strips looked like VT given his abherency) up to a rate of 180 which did not respond to 3 pushes of 5mg of IV metoprolol. His blood pressure dropped to the 90's systolically and he was given a 500cc bolus and transferred back to the ICU for management. He recieved a single 5mg IV push of verapamil and a 1L NS and his HR and BP returned to wnl's. He was started on standing PO verapamil in place of metoprolol, continued on warfarin and called-out to the floor for further management. . # ?Endocarditis - TTE with questionable vegetation on mitral valve that was seen on previous ECHO in [**Month (only) 116**]. Regardless, pt will be on antibiotics for 6 weeks which would cover both osteomyelitis and endocarditis. . # Neck pain ?????? Likely from osteomyelitis: given oxycodone 5-10mg q4h prn pain with acetaminophen and lidocaine patch prn pain with the antibiotics. . CHRONIC DIAGNOSES: # ESRD- Removed HD line during this admission. Access fistula, currently working well. HD on M/W/F with antibiotics given with diaylsis. . # CAD/HTN ?????? history of cardiac stent. Held his home BBlocker in setting of sepsis, but then became tachy with A fib with RVR. On Verapamil now in place of BBlocker. . # Hyperlipidemia - held simvastatin in setting of verapamil. Ok to start pravastatin. . # Diabetes - maintained on home insulin and ISS . TRANSITIONAL ISSUES: - keep infectious disease doctor appointments - continue dialysis M W Friday and given Abx with this as directed - surveillance blood cultures still pending from past several days prior to discharge. Medications on Admission: 1. insulin lispro 100 unit/mL ISS 2. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL NEB PRN wheezing 3. metoprolol ER 25mg T/Th/Sun 4. senna 8.6 mg Tablet daily 5. Colace [**Hospital1 **] 6. simvastatin 80mh qday 7. ferrous sulfate 325 mg qday 8. folic acid 1 mg Tablet qday 9. omeprazole 20 mg Capsule qday 10. Humulin 10U [**Hospital1 **] 11. warfarin 5 mg Tablet qday 12. calcium carbonate 650mg TID with meals 13. oxycodone 5mg q4-6hours prn pain. Discharge Medications: 1. insulin lispro 100 unit/mL Solution Sig: sliding scale as directed Subcutaneous qAC qHS. 2. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) Inhalation three times a day as needed for shortness of breath or wheezing. 3. verapamil 40 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours): hold for SBP<100, HR<60. 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. pravastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime. 7. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. Humulin N 100 unit/mL Suspension Sig: Ten (10) units Subcutaneous twice a day. 11. warfarin 2 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 12. calcium carbonate 260 mg (650 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID w/ meals. 13. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for Pain: hold for RR>12, sat<93. 14. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). 15. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation. 16. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): only to be in place for 12 hrs per da. 17. ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain. Tablet(s) 18. CefazoLIN 2 g IV 2X/WEEK (MO,WE) Please administer after HD on Mondays and Wednesdays. 19. CefazoLIN 3 g IV QFRI Please adminster after HD on Fridays. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 1268**] Discharge Diagnosis: Primary: cervical osteomyelitis Staph aureus bacteremia Secondary: End stage renal disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure participating in your care at [**Hospital1 18**]. You were admitted to the hospital for an infection of the bone in your neck. You have been treated and will continue to get antibiotics for this infection. REGARDING YOUR MEDICATIONS... START: verapamil, pravastatin, tylenol, polyethylene glycol, lidocaine patch, ibuprofen STOP: metoprolol, simvastatin CHANGE: warfarin decreased to 2mg from 5 mg Otherwise, it is very important that you take all of your usual home medications as directed in your discharge paperwork. Please followup with your primary care physician [**Name Initial (PRE) 176**] [**6-4**] days regarding the course of this hospitalization. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Department: INFECTIOUS DISEASE When: TUESDAY [**2143-3-19**] at 10:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4593**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: ADVANCED VASC. CARE CNT When: WEDNESDAY [**2143-3-20**] at 11:00 AM With: [**Name6 (MD) 5536**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 5537**] Building: [**Street Address(2) 7298**] ([**Location (un) 583**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: INFECTIOUS DISEASE When: TUESDAY [**2143-4-9**] at 10:00 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4091**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2143-2-26**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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10

Discharge summary

report

Admission Date: [**2196-8-20**] Discharge Date: [**2196-8-23**] Date of Birth: [**2121-4-19**] Sex: M Service: OMED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 99**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Central line placement at Right internal jugular History of Present Illness: 75 yo male with advanced gastric ca recently started on chemotherapy presenting and hypotensiona nd episode of unresponsivenes after diarrhea and narcotics + megace. Pt was seen on [**8-17**] by his oncologist where he was determine to be hypovolemic and received a total of 3 L IVF between We and Fri but still c/o poor po intake secondary to abdominal pain and fullness, nausea, and decreased appetite. This morning upon awakening pt was lethargic. He took MSO4, Dilaudid and an unspecified dose of Megace. He then became flushed and pale, had copious diarrhea (non-bloody), then became unresponsive. EMS called and he was found with SBP 80. Narcan given with improvement in mental status but in [**Name (NI) **] pt was persistently hypotensive requiring 6 L IVF and Levophed. Labs notable for ANC 500 and lactate 17. Sepsis protocol was initiated. Pt given Flagyl, Levofloxacin, and cefepime and sent to [**Hospital Unit Name 153**]. Past Medical History: 1. Metastatic gastric adenocarcinoma 2. Portal vein obstruction 3. Portal hypertention 4. Biliary obstruction -s/p ERCP 5. Esophagitis 6. Gout Social History: lives with his wife at home. He has 1-2 drinks a night and denies any illicit drug use. He quit smoking in [**2168**], but has a 30 pack year history. Family History: Non contributory Physical Exam: VS: T96.7 BP 84/49 HR 112 RR20 T95% 15L mask Gen: Fatigued appearing, in NAD, feeling slightly confused but A+O HEENT: anicteric, OP dry Neck: supple, flat JVP CV: tachy RR, nl S1 S2, soft diastolic murmur at LSB Lungs: diminished BS @ bases Abd: soft, distended, tympanic on R epigastic, dull to percussion on LUQ and LLQ with mild TTP LLQ. No masses, well healed midline scar Ext: 1+ pitting edema BLE Neuro: A+Ox2, moving all extremities symmetrically Pertinent Results: [**2196-8-20**] 10:50PM LD(LDH)-300* [**2196-8-20**] 09:47PM LACTATE-10.1* [**2196-8-20**] 07:30PM TYPE-ART TEMP-37.3 RATES-/20 O2 FLOW-4 PO2-95 PCO2-31* PH-7.22* TOTAL CO2-13* BASE XS--13 INTUBATED-NOT INTUBA COMMENTS-NASAL [**Last Name (un) 154**] [**2196-8-20**] 07:30PM LACTATE-11.1* [**2196-8-20**] 06:10PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020 [**2196-8-20**] 06:10PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2196-8-20**] 06:10PM URINE RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0-2 [**2196-8-20**] 04:48PM LACTATE-16.5* [**2196-8-20**] 03:46PM LACTATE-17.2* [**2196-8-20**] 03:28PM GLUCOSE-539* UREA N-40* CREAT-2.2*# SODIUM-127* POTASSIUM-4.5 CHLORIDE-86* TOTAL CO2-9* ANION GAP-37* [**2196-8-20**] 03:28PM ALT(SGPT)-16 AST(SGOT)-37 CK(CPK)-85 ALK PHOS-320* AMYLASE-47 TOT BILI-0.8 [**2196-8-20**] 03:28PM LIPASE-32 [**2196-8-20**] 03:28PM CK-MB-9 cTropnT-<0.01 [**2196-8-20**] 03:28PM ALBUMIN-3.0* CALCIUM-9.0 PHOSPHATE-6.5*# MAGNESIUM-2.3 [**2196-8-20**] 03:28PM CORTISOL-57.9* [**2196-8-20**] 03:28PM CRP-6.18* [**2196-8-20**] 03:28PM PT-15.8* PTT-32.4 INR(PT)-1.7 [**2196-8-20**] 03:28PM GRAN CT-540* CXR ([**2196-8-21**]) IMPRESSION: The tip of the IJ line had advanced since the previous study and is in the right atrium. Worsening partial atelectasis of the lower lobes bilaterally as well as the right upper lobe. [**2196-8-20**] 4:25 pm BLOOD CULTURE #2. AEROBIC BOTTLE (Preliminary): REPORTED BY PHONE TO [**Doctor First Name 156**] [**Doctor Last Name 157**] AT 11:45 ON [**8-21**]. STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN-------------<=0.25 S PENICILLIN------------ 0.25 R ANAEROBIC BOTTLE (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. SENSITIVITIES PERFORMED FROM AEROBIC BOTTLE. [**2196-8-21**] 11:12 am STOOL CONSISTENCY: WATERY Source: Stool. FECAL CULTURE (Final [**2196-8-23**]): NO ENTERIC GRAM NEGATIVE RODS FOUND. NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2196-8-23**]): NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [**2196-8-22**]): NO OVA AND PARASITES SEEN. . FEW MACROPHAGES. . 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. CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2196-8-22**]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. Reference Range: Negative. VIRAL CULTURE (Preliminary): No Virus isolated so far. Brief Hospital Course: Pt admitted to the ICU after being hypotensive and being found with altered mental status. Pt received 6 L IV fluids in the ED and more aggressive volume rescuscitation was done at the floor. Pt's mental status improved but still oriented x2. Pt was requiring Levophed to keep the MAP>60. IV Zosyn was started to cover for gram negative enterococcus coverage due to history of . Patient was breathing in the 90's with Face mask. Immediately after pt was admitted, discussion was held with the family and patient management was changed to CMO. Pt was awake and alert during this discussion, and he was requesting for comfort measure only and did not want any more aggressive treatment. All of the medications were held except for the morphine drip. Blood cx result was positive for coag negative Staph aureus, but not treatment was initiated. Pt remained on morphine drip over 2 days without any oxygen support. Pt was transferred to the regular floor on the monrning of [**8-23**], and pt immediately passed away upon arrival. Discharge Disposition: Home Discharge Diagnosis: Sepsis Coag negative Staph bacteremia Gastric adenocarcinoma Discharge Condition: Pt deceased Completed by:[**2196-8-23**]

[ "789.5", "785.52", "584.9", "276.2", "151.9", "286.7", "197.7", "537.0", "038.19" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

6383, 6389

5323, 6360

321, 371

6494, 6536

2198, 5300

1689, 1707

6410, 6473

1722, 2179

270, 283

399, 1337

1359, 1503

1519, 1673

63,402

117,508

41882

Discharge summary

report

Admission Date: [**2115-10-12**] Discharge Date: [**2115-10-25**] Date of Birth: [**2061-4-2**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 695**] Chief Complaint: Right inguinal hernia, undescended testis on the right. Major Surgical or Invasive Procedure: [**2115-10-11**]: Right inguinal hernia repair with mesh, appendectomy, right orchiectomy. [**2115-10-17**]: Reclosure of abdomen with surgimend History of Present Illness: PeDr [**Month/Day/Year 4727**] note, this is a 54-year-old male with a history of morbid obesity and bilateral inguinal hernia repairs as child. He reports over the past 3 years, he has noticed a lump in his right groin that has been increasing in size. Initially this lump was reducible; but over the past year, it has become irreducible. He was seen in Dr [**Last Name (STitle) 4727**] office and noted to have a giant right inguinal-scrotal hernia that was chronically incarcerated and filled with small bowel and sigmoid colon. He also has a history of an undescended testis on the right side. Preoperative scrotal ultrasound demonstrated the testis in the inguinal canal. Past Medical History: adult-onset diabetes type 2, obesity, history of left and right inguinal hernias, arthritis, GERD, bronchitis, and varicose veins. PSH: bilateral inguinal hernia repair as a baby. Social History: He denies any history of alcohol. He has smoked less than one pack a day for the past 42 years. He plans to quit smoking prior to this operation. He works for the animal rescue of [**Location (un) 86**] Family History: Father [**Name (NI) 90934**] CA and heart failure, mother, alive and well Physical Exam: VS: 98.8, 77, 121/71, 20, 95% 3L (Post Op) Gen: AXO x 3, pain controlled with intermittent Morphine Card: RRR Lungs: No crackles or whezes, distant [**Last Name (un) **] sounds Abd: OR dressing clean and intact, JPfrom R scrotum serosanguinous Extr: :Large amount edema bilateral lower extremities (present prior to surgery) At dischage: Wound vac ~ 10cm ~7 cm black sponge in place, 125 mmHg. 3 JP drains with serosang/serous fluid. Staples to groin incision. Staples to upper midline incision. Abd: No tender, non-distended Ext: B/L lower ext edema improved from admission. B/L LE venous statis changes Pertinent Results: Post OP Labs: [**2115-10-11**] WBC-13.0*# RBC-4.95 Hgb-14.3 Hct-44.6 MCV-90 MCH-28.9 MCHC-32.1 RDW-14.3 Plt Ct-202 Glucose-154* UreaN-21* Creat-1.5* Na-138 K-4.8 Cl-104 HCO3-26 AnGap-13 Calcium-8.7 Phos-6.8* Mg-1.7 Brief Hospital Course: 54 y/o male admitted following Right inguinal hernia repair with mesh, appendectomy, right orchiectomy with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. At the time of exploration, the patient is noted to have a massive indirect inguinal hernia, and a large, chronic, thick hernia sac with small bowel, right colon and appendix in the scrotum. Please see the operative note for surgical detail. The patient was kept NPO and had an NG tube in place, and was d/c'd on POD 2. Diet was slowly advanced and tolerated. On POD 3 the patient had a regular diet and tolerated without nausea or vomiting. He was then started on oral pain meds with good relief and tolerance. Some erythema was noticed on the lower portion of his midline incision and ancef was continued. On POD 5 an abdominal/pelvis CT scan was conducted for continued drainage from the lower portion of the midline abdominal wound. This showed a large fascial dehicence. The patient was taken to the OR where abdominal closure with sergimed was performed. There were no complications. 2 addition JP drains were placed. Please see the separate operative note for further details on the procedure. The patient was transferred to the ICU for monitoring post operatively (patient remained intubated overnight). The patient did well post operatively and was extubated and transferred on POD7/1. Patient was started on sips and bariatric pneumo boots. On POD [**7-30**] the patient was advance to clears which he tolerated well. POD [**8-31**] the patient was advanced to regular diet and changed to PO pain medication. On POD [**11-2**] the patients abdominal JP drains lost suction as a 1cm area in his lower midline incision had opened. The wound was then opened and explored. A vac dressing was placed over an ~10cm by ~7cm area of the lower midline incision. The JP drains returned to holding suction after vac placement. The patient tolerated vac placement well. On POD 13/7 the vac dressing was changed. The wound was healing well. On POD 14/8 the patient was discharge home in good condition with wound vac to lower midline incisional wound, 2 abdominal JP drains in place, 1 scrotal JP drain in place. Patient was tolerating regular diet, pain controlled with minimal PO pain medication, amublating without assistance. While hospitalized the patients blood sugars were controlled with sliding scale insulin. His metformin was restarted POD13/7. Medications on Admission: metformin 500'' Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain: Maximum 8 tablets daily. 3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 5. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 6. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Right inguinal hernia, undescended testis on the right, wound dehisence Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -AllCare Visiting Nurse services have been arranged for Vac dressing change -Please call Dr[**Name (NI) 1369**] office at [**Telephone/Fax (1) 673**] for fever, chills, nausea, vomiting, increased abdominal pain, swelling of the abdomen, increased scrotal swelling, incisional redness, drainage or bleeding. -Please call the office if you are unable to tolerate food, fluids or medications or if you are having diarrhea or constipation. -Do not strain when having a bowel movement. Take stool softener and drink plently of fluids. -Drain and record the JP drain output twice daily and as needed. Keep a record of the output and bring a copy with you to your clinic visit. -No driving if taking narcotic pain medication -No lifting of any objects greater than 10 pounds until notified you may do so. You may shower, no tub baths or swimming until notified you may do so. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2115-10-30**] 10:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2115-10-25**]

[ "998.31", "564.89", "550.11", "250.00", "E878.1", "553.8", "V85.42", "752.51", "998.59", "553.21", "278.01", "305.1" ]

icd9cm

[ [ [] ] ]

[ "53.04", "47.19", "53.51", "53.9", "54.61", "62.3" ]

icd9pcs

[ [ [] ] ]

5614, 5689

2612, 5046

360, 507

5805, 5805

2373, 2589

6851, 7183

1657, 1732

5113, 5591

5710, 5784

5072, 5090

5956, 6828

1747, 2354

264, 322

535, 1215

5820, 5932

1237, 1419

1435, 1641

21,091

119,631

22761

Discharge summary

report

Admission Date: [**2164-1-29**] Discharge Date: [**2164-2-8**] Date of Birth: [**2091-5-2**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2641**] Chief Complaint: coffee-ground emesis, alcohol binge for past month Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a 72 yo man with pmh sig for heavy alcohol use, EGD in [**5-/2162**] without varices, who presented to OSH by EMS [**2164-1-28**] after family called because he was semi-conscious, lying in feces and urine, after a 2 week vodka binge, and had been having of multiple episodes of coffee ground emesis over course of 2 weeks. On arrival to OSH pt was hypotensive with SBP 70s, hct 21, guaiac +, afebrile. He was started of neo transfused 2uPRBC's and given broad abx out of concern for sepsis v. meningitis as he had depressed mental status. Surgery was consulted as there was a large wound on his back resembling an infected pressure ulcer. There was no fluid able to be aspirated, though the lesion on the back appeared infected. His tox screen was positive for benzo's despite none being given at OSH, and ETOH 10 mg/dl. Back wound group B strep, CT head without acute bleed. . On transfer to [**Hospital1 18**] MICU pt was hypotensive and the clinical judgement of the team was that he was hypotensive secondary to volume depletion, but the team questioned the possibility of sepsis since the pt had increased white count. He was resuscitated with fluids and blood transfusions and is currently off pressors, with stable blood pressure. Although a source of sepsis was never identified, antibiotic coverage with Levofloxacin and Flagyl was started. An EGD was done which showed esphagitis with denuded epithelium, c/w Barrett's, and esophageal nodules which were not biopsied due to the fact that the bleeding risk. Past Medical History: Lipoma removed from breast on [**11/2163**] alcohol abuse anemia (baseline hct 30) gout colonoscopy within past 10 years with "benign polyp" Social History: Long term alcohol abuse, nonsmoker, lives with daughter, has a degree in mathematics. Planning on moving to [**Country 3594**] (owns property there). Family History: Father with alcoholism. Physical Exam: 98.6 73 (60s-70s) 102/83 (102-120/40-70) RR 15 (14-24) 94%RA . Lying in bed, NAD PERRLA, anicteric, mmm JVD flat, no TM Card RRR nl s1s2, no mrg Lungs clear Abd soft nt nd nabs Ext with pneumoboots, no edema Pertinent Results: [**2164-1-29**] 01:50AM WBC-18.5* RBC-3.06* HGB-7.7* HCT-24.4* MCV-80* MCH-25.3* MCHC-31.7 RDW-16.4* [**2164-1-29**] 01:50AM NEUTS-82.8* BANDS-0 LYMPHS-11.8* MONOS-5.0 EOS-0.2 BASOS-0.1 [**2164-1-29**] 01:50AM ALT(SGPT)-21 AST(SGOT)-18 LD(LDH)-132 ALK PHOS-64 TOT BILI-0.8 [**2164-1-29**] 01:50AM GLUCOSE-108* UREA N-15 CREAT-0.9 SODIUM-131* POTASSIUM-3.9 CHLORIDE-94* TOTAL CO2-29 ANION GAP-12 [**2164-1-29**] 11:33AM CORTISOL-18.1 [**2164-1-29**] 12:08PM CORTISOL-35.2* [**2164-1-29**] 01:23PM CORTISOL-46.5*. . EGD- esophagitis without evidence of acute bleed . MRI- mod to severe brain atrophy . EEG- within normal . TSH - normal RPR- nonreactive . Blood cx's: negative Urine cx's: negative Wound cx's: (from OSH) group A streptococcus Brief Hospital Course: A/P: 72M w/ history of alcohol binge/abuse, transferred for sepsis and GI bleed. . 1)GI BLEED: EGD was performed and found esophagitis and denuded esophagus c/w Barrett's Esophagus, as well as nodule at GE jxn. He was treated with high dose Protonix with plan to continue this until re-evaluation EGD at [**Hospital 18**] [**Hospital **] clinic in [**2164-3-23**]. At this time the nodule will be biopsied to determine whether it is cancerous. It was decided not to biopsy this at the initial EGD out of concern for bleeding. Pt required blood transfusion, and continued to have occult heme in stool, but no gross blood, and stable hematocrit thereafter. On Iron replacement for iron deficiency. Will need follow up colonoscopy as determined by Dr. [**Last Name (STitle) **] (performed previous colonoscopy ~ 1 year ago ([**Telephone/Fax (1) 58891**].) . 2)MENTAL STATUS - Pt was markedly delerious during most of the hospitalization but improved overall to a baseline mild dementia with some waxing/[**Doctor Last Name 688**] agitation. TSH normal, RPR nonreactive, EEG normal, MRI with mod to severe atrophy. Pt responded very well to Zyprexa and was followed by psychiatry throughout his hospitalization. It was felt that these changes were due to alcohol use, the hyponatremia he had upon the early hospital days. . 4)ALCOHOL ABUSE: Pt did not demonstrate any signs of alcohol withdrawal. Continued treatment with MVI/Folate/Thiamine. . 5)ID: Wound on back with group A strep - antibiotic treatment completed, local care continued at rehab. . 6)Social: Social work, psychiatry, an primary medical team met with family and pt. Pt is agreeable to rehab. However, due to his medical problems including alcoholic dementia, it is unlikely that this pt will be able to care for himself independently, likely proressing further if alcohol use continues. This was all explained to the family. Medications on Admission: valium ambien colchichine cialis Discharge Medications: 1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day). 2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 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 Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day): until ambulating TID. 7. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 9. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for agitation. 10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 672**] Hospital Discharge Diagnosis: Esophagitis Wound infection Sepsis Delerium Discharge Condition: stable Discharge Instructions: Please call your PCP or return to the ED if you develop chest pain, difficulty breathing, or other concerning symptoms. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 24305**] - call ([**Telephone/Fax (1) 58892**] for an appointment. . You will also need to have a biopsy of the esophageal nodule. You are scheduled for this to be done at [**Hospital1 **] Hospital on [**2164-4-9**] at 7am at [**Hospital Ward Name 121**] Building [**Location (un) **]. Please call [**Telephone/Fax (1) 2756**] and ask for the [**Hospital **] Clinic if you need to cancel. Do not eat from midnight on the night before. Completed by:[**2164-2-8**]

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icd9cm

[ [ [] ] ]

[ "38.93", "00.17", "45.13" ]

icd9pcs

[ [ [] ] ]

6197, 6252

3328, 5232

364, 370

6340, 6348

2550, 3305

6516, 7030

2280, 2305

5315, 6174

6273, 6319

5258, 5292

6372, 6493

2320, 2531

274, 326

398, 1932

1954, 2096

2112, 2264

23,123

184,104

29652

Discharge summary

report

Admission Date: [**2180-12-23**] Discharge Date: [**2181-1-8**] Date of Birth: [**2101-7-23**] Sex: M Service: MEDICINE Allergies: Percocet Attending:[**First Name3 (LF) 2181**] Chief Complaint: s/p mechanical fall Major Surgical or Invasive Procedure: None History of Present Illness: 79 M c hx normal pressure hydrocephalus and VP shunt in place, nephrotic syndrome hx, who had an unwitnessed fall down 6 stairs. Hx as per EMS and [**Hospital1 1474**] ED notes suggest that pt. found face first with neck bent back; unknown LOC - found in seconds with spontaneous eye movement, somewhat confused, not answering questions appropriately; also c obvious vomitus on patient. Also complaining of R arm pain. Presented to [**Hospital 1474**] Hospital complaining of nausea, R arm pain, not following commands; CT head done with concern for intraparenchymal hemorrhage in the occipital [**Doctor Last Name 534**] of the R lateral ventricle and pt. intubated for airway protection. Post intubation, R shoulder reduced which was dislocated. Underwent CT abdomen - Received 10 mg vecuronium prior to transport and 1 gm dilantin enroute. . At [**Hospital1 18**] ED, trauma w/u negative. CT head with no hemorrhage, CT C/T/L spine with no fracture or malalignment. HD stable, afebrile. Transferred to [**Hospital Unit Name 153**] because pt. intubated. He was successfully extubated and transferred to the floor, only to be transferred back after having onset of stridor. In the ICU, he was treated for aspiration pneumonia. His sedation was weaned and, although slower than expected, his mental status cleared and he was successfully extubated. Several hours after extubation, he developed stridulous upper airway sounds. His stridor was unresponsive to steroids and racemic epinephrine and he was reintubated (without e/o soft tissue edema per anesthesia) for airway protection. While intubated it was found that there was no air leak even w/ the cuff down, of note, however, a larger ETT was placed (8.0) for second intubation and it was thought that perhaps the large tube size was preventing air leak rather than true airway edema. After 48 hours of solumedrol, he was extubated with success. He was transferred out of the ICU to a medical floor. . 2 days after transfer, ICU team was called to eval. patient for ? stridor. By report, he had just been cleared by speech and swallow bedside evaluation to eat. His son-in-law was feeding him when he began to cough and then became stridulous. At the time of developing stridor, he was apparently breathing more rapidly. He received racemic epi and solumedrol x1 and his respiratory rate decreased; in this setting his stridor improved. He was transferred back to the ICU for closer monitoring and bronch vs. CT neck to eval. for fixed lesion obstruction. Pt was transferred on [**2181-1-4**] from [**Hospital Unit Name 153**] to [**Hospital Ward Name **] for OR-Rigid bronch, Flex bronch, dilatation (13.2cm), Tumor debridement (granulation tissue) and rigid forceps. Past Medical History: - NPH c VP shunt - Nephrotic Syndrome - Chronic renal insufficiency- Baseline creatinine 1.5-1.7 - Arrow in L pupil injury; now fixed and dilated - R elbow ulnar neck release - Anemia Social History: Lives with daughter who is power of attorney Family History: NC Physical Exam: VS- 97.3, 79 (74-79), 91-116/64-85, 17, 98%, CPAP c PS 5/0, RSBI 50s, MV 6 HEENT- alopecia, large head, R pupil reactive to light, L pupil fixed LUNGS- clear to auscultation, no wheeze, crackles HEART- RRR, distant heart sounds ABD- umbilical hernia, distended, no grimace to deep palpation, BS+ EXT- wwp, no edema NEURO- not arousable Pertinent Results: labs - see below, notable for elevated alk phos (127), LDH (420) but hemolyzed samples, Cr 1.7 (baseline unknown). at [**Hospital1 1474**]: HCT 37.4, Cr 1.9 . micro - U/A c mod blood and trace protein . ekg - NSR at 70, axis -30, nl intervals, no ST change . imaging - -Head CT: No intracranial hemorrhage. Hydrocephalus with ventriculoperitoneal shunt in place. -C Spine CT: No fracture or malalignment within the cervical spine. Multilevel degenerative change as described above. -L Spine CT: No fracture or malalignment within the lumbar spine. Multilevel degenerative changes as described above. -T Spine CT: No fracture or malalignment within the thoracic spine. Cystic lesion at the upper pole of the right kidney, which is incompletely characterized. Ultrasound or MRI is recommended if clinically indicated. Gallstones. . CT Right shoulder: 1. [**Doctor Last Name **]-[**Doctor Last Name 3450**] fracture of the humerus consistent with prior anterior dislocation. 2. No osseous Bankart is identified. 3. Deformity of the posterior wall of the glenoid may represent prior posterior dislocation. 4. Degenerative changes of the acromioclavicular joint with a small loose body. CT Chest: IMPRESSION: 1. Severe circumferential narrowing of the upper trachea, most likely post intubation edema or granulomatous tissue. 2. Cardiomegaly, coronary calcifications. 3. Possible left liver lobe lesion. Evaluation with ultrasound is recommended. 4. Cholelithiasis with no evidence of cholecystitis. 5. Right upper pole kidney cyst. 6. Possible splenic infarct. 7. VP shunt in standard location. Brief Hospital Course: A/P: 79 M c NPH and VP shunt s/p fall with no associated trauma presenting because pt. was intubated at OSH for airway protection. . # Intubation: Pt. had no clear evidence of respiratory failure and no clear reason for needed airway protection upon intubation at OSH. By report, he was apparently agitated and was intubated in this setting in order to reduce his dislocated right shoulder. Per OSH report, intubation was not traumatic. Depspite good mechanics, 1st extubation c/b stridor resistent to racemic epinephrine. He was intubated w/ a slightly larger tube (8.0) and was without air leak w/ balloon down suggesting airway edema. He was started on dexamethasone without clear improvement of edema (still no air leak). Dexamethasone was continued x 48 hours. It was thought that perhaps he would not develop an air leak if ET tube was large enough in his airway compared to original tube even if edema was not present. Thus, anesthesia was called to be present for extubation in case of failed extubation, but 2nd extubation attempt was successful without the development of stridor. Post extubation ABGs were normal. . # Stridor: As above, patient developed stridor hours after first extubation. 2 days after his second extubation, he developed stridor on the floor. He developed stridor after coughing and increasing his respiratory rate and the stridulous sounds resolved with normalization of his respiratory rate. ICU team evaluated him on the floor and he was transferred to the unit for further studies. ENT was consulted and visualized his upper airway which revealed mild arytenoid edema thought not to be the cause of stridor. CT neck was obtained which showed severe tracheal stenosis and interventional pulmonology was then consulted. A rigid bronchoscopy was performed that revealed mild tracheomalacia and granulation tissue in the upper trachea was cleaned out. He will need follow up with IP if stridor persists as a stent may need to be placed. He will also need to follow up with IP 4 weeks from discharge for repeat evaluation and CT scan and flexible bronch. . # Fall: By history, appears to be mechanical given known ataxia in setting of NPH. Right shoulder dislocation reduced at OSH, recurred while at [**Hospital1 18**] and again reduced by orthopedics. Subsequent imaging reveals shoulder in place. When mental status cleared, he was able to repsond subjectively regarding pain and denied cervical soft tissue pain, so his c-spine was cleared and collar removed. He has had no further issues and remains in a sling. He will need follow up with orthopedics following discharge from the hospital. . # Altered mental status: Patient remained somnolent and largely unresponsive for nearly 24 hours following wean of fentanyl and propofol and appears to be very sensitive to these medications. He does have baseline dementia per his daughter's report in the setting of his NPH, but peri sedation, he was much less responsive than his baseline. He was evaluated by neurosurgery here and V-P shunt appears to be functioning properly w/o e/o of worsening hydrocephalus on CT head (CT also negative for bleed). Narcotics and other sedating medications were avoided and his mental status began to clear following extubation and wean from sedation. He improved on the floor and, per family report, was at his baseline mental status, alert and oriented generally x 2. . # ? Aspiration pneumonia: Was febrile with elevated WBC count on admission. By hx, he had emesis x1 at OSH prior to intubation so there was concern for possible aspiration pneumonia. He was started on Levo/flagyl and fever and white count resolved. He finished a 10 day course of antibiotics. . # Anemia: Baseline hct appears to be high 30s from recent labs at PCP's office. He had initial drop on admission without clear source. No bleed on head on CT, no RPB on CT. Stools were negative for blood. Iron studies revealed normal iron, elevated ferritin and low TIBC c/w ACD, but does not account for the acute drop during his stay at [**Hospital1 18**]. His hct has stabilized in the high 20s since. This will need to be followed. . # Nephrotic syndrome: Urine protein:creatinine ratio revealed 0.2. Trace protein on admission UA, but negative for protein on subsequent UA. . # CRI: Basline creatinine from PCP records reveals creatinine of 1.5-1.7. Thus, he has been at his baseline during his stay. . # Hyperglycemia: Throughout his stay, he had borderline blood sugars which became markedly elevated while on steroids (for stridor) into the 180s. This improved to BS generally 120s-160s. He was placed on HISS and HgbA1C was found to be 6.5. He has no diagnosis of DM, but likely has baseline element of impaired glucose tolerance. This should be followed up as an outpatient. . # Hypernatremia: Sodium began to climb as his tube feeds had been held for extubation (he had not been getting free water flushes via his OG tube while previously intubated). Additionally he had not been receiving free water via IVFs. On the day of elevated sodium, patient's mental status was much improved and he reported feeling thirsty and diet was advanced. He was encouraged to drink free fluid to evaluate whether his sodium would correct with PO free water alone. . # FEN: During his hospital stay, there was some concern for aspiration with eating as he occasionally had coughing with PO intake. He was evaluated at the bedside by speech and swallow and then had a video swallowing studying performed; both of which cleared him for PO intake. He has tolerated regular diet since then. . # Hyperlipidemia: He was continued on his home dose statin. Medications on Admission: levothyroxine 137mcg' furosemide 40' pepsid 20' senna QOD lipitor 40" flomax 0.4" Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Tracheomalacia with granulation tissue causing airway obstruction. Dementia Anemia Hypothyroidism Discharge Condition: Stable Discharge Instructions: Please continue all medications as prescribed, continue non-weightbearing precautions for right shoulder injury, continue out of bed with assistance, and keep all follow-up appointments as listed below. Followup Instructions: Please return to [**Hospital1 18**] for CT scan scheduled for [**2181-2-5**] at 1PM in [**Hospital Ward Name 23**] [**Location (un) **]. Please follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] in interventional pulmonology following your CT scan on [**2181-2-5**] at 2 PM located in [**Hospital1 **] 2; call ([**Telephone/Fax (1) 17398**] to confirm your appointment. Completed by:[**2181-1-8**]

[ "584.9", "285.29", "293.0", "E880.9", "276.0", "781.2", "518.81", "831.01", "251.8", "585.9", "519.19", "331.3", "581.9", "369.60", "294.8", "E932.0", "507.0", "244.9", "V45.2" ]

icd9cm

[ [ [] ] ]

[ "33.22", "38.93", "96.72", "31.5", "79.71", "96.6" ]

icd9pcs

[ [ [] ] ]

11161, 11233

5353, 8008

289, 295

11375, 11384

3721, 3991

11635, 12052

3345, 3349

11254, 11354

11055, 11138

11408, 11612

3364, 3702

230, 251

323, 3060

4000, 5330

8024, 11029

3082, 3267

3283, 3329

27,088

170,858

51054

Discharge summary

report

Admission Date: [**2198-5-7**] Discharge Date: [**2198-5-19**] Date of Birth: [**2142-5-13**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: Left arm tingling/numbness Major Surgical or Invasive Procedure: [**5-9**] Cardiac Catheterization [**5-15**] Coronary Artery Bypass Graft x 6 (LIMA to LAD, SVG to Diag, SVG to PDA, SVG to Ramus w/ y-graft of SVG to OM1 to OM2) History of Present Illness: The patient is a 55 yo M p/w L arm discomfort that started about 1 week ago. Peak sx yesterday with dizziness upon exertion, worsened arm pain, "numbness" in teeth,nausea, slight dyspnea, and diaphoresis. Did routine 2 mile walk with friends and sx worsened with the walk. Has attributed to stress in his job; yesterday went to bed early about 8:30am with sx felt better today in AM. Seen in [**Company 191**] only because daughter who is training to be a nurse insisted. Took ASA 81 mg yesterday and today. Only chest pain "indigestion" substernal area felt need to burp; that occurred yesterday and today. He does have some odd discomfort on deep inspiration. In the ED, initial vitals were HR 57, BP 210/96. EKG showed q in III and TWI in avF. Initial troponin was 0.18. He was given an aspirin in the ED. Heparin drip was started for UA/NSTEMI. He also received SL nitro and morphine. BB was held secondary to bradycardia. At one point he became hypertensive to the 200's and was placed on a nitro gtt. Past Medical History: Benign Prostatic Hypertrophy, Lumbar Disk Disease, Obstructive Sleep Apnea, h/o ETOH abuse Social History: Social history is significant for the absence of current tobacco use. There is history suggestive of alcohol abuse. Admits to drinking several drinks a night. Working as senior buyer for medical company; lives with wife; daughter in college and another at home. EtOH "too much" drinking most days up to several margaritas a night Family History: There is possible family history of premature coronary artery disease with mother who died in 60s. No h/o sudden death. Physical Exam: VS AF, BP 153/81 HR 66 RR 16 Sat 98% on 2L NC Gen: WDWN middle aged male 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 [**6-16**] cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+ Pertinent Results: [**5-8**] ETT WITH MIBI: 1) At the level of exercise achieved, moderate, fixed mid and basal inferior wall perfusion defect. 2) Global hypokinesis with calculated EF of 46%. [**5-9**] Cardiac Cath: 1. Coronary angiography of this right dominant system revealed three vessel CAD. The LMCA had a 70% distal lesion. The LAD had 80% proximal, 50% mid, and 50% diagonal lesion. The LCx had an 80% proximal and 100% OM1 lesion. The RCA had a 95% mid and 50% distal lesion. 2. Resting hemodynamics revealed normal left sided filling presures and normal aortic systolic pressure. 3. Left ventriculography revealed no mitral regurgitation and ejection fraction of 65% with mild inferobasal hypokinesis. [**5-10**] CNIS: Bilateral less than 40% ICA stenosis. [**5-14**] RFA U/S: No right femoral artery pseudoaneurysm or arteriovenous fistula. [**5-15**] Intra-op Echo: PRE-BYPASS: 1. The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 5. The mitral valve appears structurally normal with trivial mitral regurgitation. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine and is in sinus rhythm 1. Biventricular function is preserved. 2. Aorta is intact post decannulation. 3. Other findings are unchanged. [**2198-5-7**] 03:42PM BLOOD WBC-6.0 RBC-4.33* Hgb-13.3* Hct-37.4* MCV-86 MCH-30.8 MCHC-35.6* RDW-13.7 Plt Ct-231 [**2198-5-18**] 05:30AM BLOOD WBC-7.9 RBC-2.68* Hgb-8.3* Hct-24.0* MCV-89 MCH-30.8 MCHC-34.5 RDW-13.6 Plt Ct-157 [**2198-5-7**] 03:42PM BLOOD PT-12.7 PTT-23.5 INR(PT)-1.1 [**2198-5-15**] 05:49PM BLOOD PT-14.5* PTT-33.5 INR(PT)-1.3* [**2198-5-7**] 03:42PM BLOOD Glucose-90 UreaN-18 Creat-1.0 Na-140 K-3.6 Cl-104 HCO3-27 AnGap-13 [**2198-5-18**] 05:30AM BLOOD Glucose-98 UreaN-16 Creat-0.8 Na-137 K-4.1 Cl-102 HCO3-27 AnGap-12 [**2198-5-9**] 02:00PM BLOOD ALT-15 AST-20 AlkPhos-47 Amylase-59 TotBili-0.7 [**2198-5-15**] 06:35AM BLOOD Calcium-9.4 Phos-3.1 Mg-2.1 Brief Hospital Course: As mentioned in the HPI, he was admitted following EKG showing non-ST elevation. He was appropriately medically managed for myocardial infarction under the cardiology service. He had a positive stress MIBI on [**5-8**] and then underwent cardiac cath on [**5-9**]. Cath revealed severe left main and three vessel coronary artery disease. Because of his coronary disease he remained hospitalized for surgery, but first required Plavix to washout. During this time he was medically managed with no further complaints of pain. Vascular surgery was consulted for suspected RFA pseudoaneurysm. Repeat U/S revealed no right femoral artery pseudoaneurysm or arteriovenous fistula. He was brought to the operating room on [**5-15**] and underwent a coronary artery bypass graft x 6. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact, and extubated. On post-op day one beta blockers and diuretics were started. He was gently diuresed towards his pre-op weight. Later on this day he was transferred to the telemetry floor for further care. Chest tubes were removed on post-op day two. Epicardial pacing wires were removed on post-op day three. He worked with physical therapy during his post-op course for strength and mobility. He did quite well post-operatively without complications and was discharged home on post-op day four with the appropriate medications and follow-up appointments. To note pt was not started on ace inhibitor or [**Last Name (un) **]. His blood pressue could not tolerate. On DC BP is 100/54. He should follow-up with his PCP Medications on Admission: Sildenafil 50mg PRN, Prilosec OTC Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 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:*1* 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed. Disp:*40 Tablet(s)* Refills:*0* 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2* 8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 9. Potassium Chloride 20 mEq Packet Sig: Two (2) Packet PO Q12H (every 12 hours) for 5 days. Disp:*20 Packet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Coronary Artery Disease w/Non ST-Segment Elevation Myocardial Infarction. s/p Coronary Artery Bypass Graft x 6 Hypertension Urinary Tract Infection PMH: Benign Prostatic Hypertrophy, Lumbar Disk Disease, Obstructive Sleep Apnea, h/o ETOH abuse Discharge Condition: Good Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon. Followup Instructions: [**Hospital Ward Name 121**] 6 in 2 weeks for Wound Check Dr. [**Last Name (STitle) **] in 2 weeks Dr. [**Last Name (STitle) 73**] in [**2-11**] weeks (#[**Telephone/Fax (1) 902**]) Dr. [**First Name (STitle) **] in 4 weeks [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2198-5-19**]

[ "414.01", "410.71", "787.02", "458.29", "599.0", "530.81", "442.3", "600.00", "401.9", "722.52", "427.89", "305.00", "327.23" ]

icd9cm

[ [ [] ] ]

[ "37.22", "36.15", "36.14", "39.64", "39.61", "88.56", "88.53" ]

icd9pcs

[ [ [] ] ]

8326, 8375

5339, 7051

346, 510

8662, 8668

3025, 5316

8981, 9326

2035, 2156

7135, 8303

8396, 8641

7077, 7112

8692, 8958

2171, 3006

280, 308

538, 1555

1577, 1669

1685, 2019

27,729

126,565

19386

Discharge summary

report

Admission Date: [**2178-10-4**] Discharge Date: [**2178-10-21**] Date of Birth: [**2108-4-4**] Sex: M Service: MEDICINE Allergies: Codeine / Zofran Attending:[**First Name3 (LF) 358**] Chief Complaint: transfer from OSH for acute renal failure, nephrolithiasis Major Surgical or Invasive Procedure: intubation placement of left nephrostomy tube cystoscopy History of Present Illness: 70 y/o M with a PMHx of nephrolithiasis, COPD, UC, HTN who was admitted to [**Hospital 4199**] Hosp on [**10-2**] for 3d of worsening L flank pain. No f/chills. Able to take POs. An U/S showed 11mm calculus in mid-portion of L kidney and 8mm in lower pole. Nml R kidney. Evid of mild-mod hydronephrosis; creat elevated to 2.0. Made NPO, placed on PCA which was weaned to Percocet PO prn. Foley placed with initial hematuria now clearing. . Today, c/o dull discomfort in abd, not severe. +constipation without BMs x4d c/b bloating. Tol POs. No CP, SOB, cough. Shortly after admission, transferred to the ICU with the following admit note: 70M PMH nephrolithiasis, COPD (FEV1 of 1.17 on continuous 2-2.5L O2 at home, UC, CRF (baseline creatinine 1.5) who was admitted to [**Hospital 4199**] Hosp on [**2178-10-2**] for three-day history of worsening L flank pain and hematuria. He was found to have an 11mm calculus in mid-portion of L kidney and 8mm in lower pole with mild-mod hydronephrosis. Creatinine as 2.4. The patient was transferred to [**Hospital1 18**] and has been followed by Urology during admission. The patient was not believed to be a candidate for a surgical procedure given the requirement of general anesthesia and intubation. US-guided percutaneous nephrostomy placement was attempted [**2178-10-7**] but was unsuccessful. Per report, during the procedure the patient's blood pressure dropped to the 80s after initiation of propofol and was slow to improve despite 700cc NS bolus (not well documented). Radiology has suggested a CT-guided procedure as the next step. . Since admission, the patient has triggered three times. The first was for AF with RVR responding to lopressor and diltiazem with conversion to NSR. The second and third were for anxiety, hypoxia, and SVT, again responding to lopressor and diltiazem. . On transfer, the patient complains of left-sided flank pain. He states his breathing is at baseline. He complains of constipation. He denies fever, chills, chest pain, abdominal pain, nausea, vomiting. Past Medical History: 1) COPD on 2L home O2 (FEV1 1.17L (35% pred) in [**2175**]), steroid-dependent 2) HTN 3) UC 4) BPH 5) Nephrolithiasis 6) Stage III CKD Cr 1.5 thought due to recurrent nephrolithiasis Social History: Tob: 100pk yr hx; quit 8 yrs ago. Etoh: none. No IVDU. Currently retired. Family History: B kidney stones Physical Exam: T: 96.2, BP 124/74, HR 87, RR 20 Sat 96% on 3L Gen: Elderly male in NAD, comfortable at rest HEENT: Anicteric, PERRL/EOMI, OP clear without lesions, MM dry. Neck: supple, no LAD CV: RRR, nml s1,s2, no m/r/g Resp: Distant breath sounds. Decreased air movement throughout. Prolonged expiration, sparse wheezes Abd: soft, nontender Back: left nephrostomy tube with clear yellow urine drainage Ext: 2+ edema bilateral LE to knee Neuro: AAOx2. Moves all extremities spontaneously. Pertinent Results: [**2178-10-5**] 01:15AM BLOOD WBC-10.2 RBC-3.91* Hgb-12.2* Hct-37.4* MCV-96 MCH-31.1 MCHC-32.6 RDW-13.4 Plt Ct-223 [**2178-10-10**] 04:58PM BLOOD WBC-38.6* RBC-3.66* Hgb-11.4* Hct-35.6* MCV-97 MCH-31.3 MCHC-32.2 RDW-14.4 Plt Ct-184 [**2178-10-18**] 04:08AM BLOOD WBC-11.5* RBC-3.20* Hgb-9.8* Hct-30.6* MCV-96 MCH-30.5 MCHC-31.9 RDW-14.0 Plt Ct-534* [**2178-10-5**] 01:15AM BLOOD Glucose-120* UreaN-17 Creat-2.3* Na-138 K-4.0 Cl-106 HCO3-20* AnGap-16 [**2178-10-18**] 04:08AM BLOOD Glucose-131* UreaN-49* Creat-1.1 Na-143 K-4.3 Cl-100 HCO3-37* AnGap-10 [**2178-10-8**] 05:05AM BLOOD CK(CPK)-1366* [**2178-10-7**] 03:30PM BLOOD CK-MB-8 cTropnT-0.05* [**2178-10-7**] 10:10PM BLOOD CK-MB-12* MB Indx-1.3 cTropnT-0.08* [**2178-10-8**] 05:05AM BLOOD CK-MB-15* MB Indx-1.1 cTropnT-0.09* [**2178-10-16**] 04:59AM BLOOD Digoxin-0.9 [**2178-10-9**] 05:07PM BLOOD Type-ART Temp-36.7 Rates-25/0 Tidal V-450 PEEP-5 FiO2-40 pO2-95 pCO2-50* pH-7.24* calTCO2-22 Base XS--6 -ASSIST/CON Intubat-INTUBATED [**2178-10-15**] 02:53PM BLOOD Type-ART pO2-84* pCO2-50* pH-7.46* calTCO2-37* Base XS-9 [**2178-10-7**] 08:05PM URINE Blood-LGE Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [**2178-10-7**] 09:51PM URINE RBC-457* WBC-99* Bacteri-RARE Yeast-NONE Epi-0 . [**2178-10-7**] 8:05 pm URINE Source: Catheter. URINE CULTURE (Final [**2178-10-10**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- 32 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R . Blood Culture AEROBIC BOTTLE (Final [**2178-10-10**]): ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S . Cdiff negative x 3. . Imaging: RENAL U.S. [**2178-10-5**] 12:56 PM IMPRESSION: Moderate-sized left inter-to-lower pole collecting system calculi with mild left-sided hydronephrosis. No distal ureteral/bladder calculi could be identified, however, exam is limited due to bladder decompression from decompressed Foley. If outside imaging is available, comparison would be helpful. . CT ABDOMEN/PELVIS W/O CONTRAST [**2178-10-6**] 8:46 AM IMPRESSION: 1. Left proximal ureter obstructing stone with moderate hydronephrosis and proximal ureter dilation. 2. Severe emphysema. 3. Bladder stone . CT ABDOMEN/PELVIS W/O CONTRAST [**2178-10-8**] 4:55 PM IMPRESSION: 1. 1-cm left renal stone with 5-mm obstructing left ureteral stone with mild hydronephrosis; perinephric fat stranding likely due to recent intervention. No perinephric fluid collection or bowel perforation. 2. Persistent mildly dilated large bowel proximally with gas and liquid stool. Air bubbles along the dependent cecal and ascending colon wall are most likely luminal but the possibility of a component of pneumatosis cannot be completely excluded in this patient with mechanical ventilation and sepsis. 3. Large urinary bladder stone. 4. Bilateral pleural effusion with atelectasis and severe bullous and centrilobular emphysema. Increased opacity in the left lower lobe could be superimposed pneumonia. . CT ABDOMEN/PELVIS W/O CONTRAST [**2178-10-12**] 2:10 PM IMPRESSION: 1. No evidence of pneumatosis. 2. Limited study due to lack of intravenous contrast [**Doctor Last Name 360**]. Interval placement of percutaneous nephrostomy catheter, with a left renal stone and two left ureteral stones. Large bladder stone. Diffuse anasarca. Diverticulosis. 3. Bilateral effusion and atelectasis with consolidation in the right lung base, unchanged. ECHO Conclusions The left atrium is normal in size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is an anterior space which most likely represents a fat pad. IMPRESSION: Hyperdynamic left ventricle with mild resting outflow gradient. Due to poor echo windows, a wall motion abnormality cannot be ruled out. Brief Hospital Course: A/P: 70M PMH nephrolithiasis, COPD (FEV1 of 1.17 on continuous 2-2.5L O2 at home, UC, HTN presenting with obstructing ureteral stone, acute on [**Hospital **] transferred to ICU for peri-procedure hypotension. . # Urosepsis: Admitted with urosepsis in the setting of obstructing nephrolithiasis. Ecoli subsequently grew out of urine and blood cutlures. Nephrostomy tube was placed on [**10-10**] after failure to place on [**10-7**]. He was originally on pressors, then weaned successfully from the pressors and remained hemodynamically stable. Total 14 day course of ceftriaxone will be completed [**10-23**] (counting starting date [**10-10**] when nephrostomy placed, although he received cipro/cefipime for four days prior). . # Respiratory failure/COPD exacerbation (acute on chronic bronchitis): He has significant underlying lung disease with COPD on 2L home O2 (FEV1 1.17L (35% pred). He was intubated [**12-26**] respiratory failure and remained ventilated for roughly 6 days. Respiratory distress likely represented a COPD exacerbation in the setting of UTI and urosepsis. There was no evidence at that time of URI as he was without CXR infiltrate and sputum production. Several days of vent weening was complicated by sedation, hypoxia, hypercarbia, and acidosis. One episode of hypoxia on [**10-13**] thought to be from autopeeping, improved with increased PEEP. Extubated on [**10-14**] and was initially agitated with good oxygen saturation. His lungs had wheezing for the next couple days, but this responded to bronchodilators and steroids. He was maintained on IV methylprednisolone and bronchodilators. He remained mildly short of breath though with good O2 sats throughout the rest of his MICU stay, and subsequently returned to baseline on the floor. He was discharged on spiriva, advair, albuterol nebs, and a prednisone taper (over 3 weeks). . # delerium: Likely component of multiple meds, acute illness and ICU stay resulting in delirium. Haldol, zyprexa, and mophine was given as above and his agitation and AMS improved by the 3rd or 4th day after extubation. His family reports he is close to baseline, although he still has daily variability in mental status (worse in early AM, near baseline in PM). . # Pneumatosis intestinalis: abd CT on [**10-8**] showed pneumatosis intestinalis. He was deemed to be a poor surgical candidate. He was maintained on supportive treatment with bowel rest. On repeat CT, the pneumatosis had resolved. His bowel status improved through the rest of his IC stay and he was taking small amounts of PO before being transferred to the floor. . # Leukocytosis: He had persistently high WBC and low grade fever. It was likely multifactorial from steroids and urosepsis. He was maintained on oral vancomycin and IV flagyl while not taking PO given concern for possible c. diff, however he was toxing negative x3. WBC normal on discharge . # Hypertension: He became more consistently hypertensive and tachycardic toward the end of his stay. He was started on PO dilt which was titrated for more ideal BP and HR. . # Hypernatremia: Mild, likely secondary to relatively free water output from kidney - post-obstructive diuresis. Free water deficit 4L on [**10-13**]. . # Hydronephrosis/nephrolithiasis: Left proximal ureter obstructing stone with moderate hydronephrosis and proximal ureter dilation noted on CT as above. Bladder stone also noted. Treatment for urosepsis as above. Cystoscopy showed large papillary bladder tumor obstructing trigone. Left nephrostomy tube placed by IR on [**10-10**]. He has follow up scheduled with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**] to discuss long term options for both stones and tumor . # PAF: He was transiently in atrial fibrillation, likely caused by his sepsis and hypotension. He converted soon upon entrance to the ICU. He was begun on heparin briefly for anticoagulation, but he developed a urological bleed, so the heparin was stopped. He maintained sinus rhythm on the floor with digoxin. No anticoagulation recommended in this setting because of the propensity of bleeding from bladder tumor. # Hematuria: likely [**12-26**] heparin and large bladder stone/tumor. His heparin was d/c'd and he received continuous bladder irrigation, which began to clear on [**2178-10-18**]. Foley was discontinued without difficulty on [**2178-10-19**]. . # Acute on CRF: Improved to 1.1 then jump to 1.4 o/n in setting of lasix and ketorolac. Also has a component of CKD. Still has good UOP. . # acute on chronic diastolic heart failure -- mildly hypervolemic on discharge, probably contributing to hypoxia during exertion. Plan for three days of gentle diuresis for goal of 1 liter negative over those days. . # BPH: finasteride, tamsulosin. # UC: No active issues. - sulfasalazine d/c'd as there is tentative evidence that it may exacerbate lung disease and already on steroids for COPD - can consider restarting sulfasalazine when respiratorily stable . Medications on Admission: Meds from OSH: Lipitor 40 Sulfasalazine 1g qid Advair [**Hospital1 **] DuoNeb q4 Flomax 0.4 qhs Spiriva qD Diovan 160 qD Pred 10 qOD Beclomethasone IH [**Hospital1 **] Guanifensin 1g qD Protonix 40 qD . Meds on transfer to [**Hospital Unit Name 153**]: Metoprolol 25 mg PO Q6H Miralax *NF* 17 gram (100 %) Oral daily Acetaminophen 1000 mg PO Q6H Morphine Sulfate 2-4 mg IV Q8H:PRN pain Atorvastatin 40 mg PO DAILY OxycoDONE (Immediate Release) 5-10 mg PO Q6H:PRN pain Bisacodyl 10 mg PO DAILY BusPIRone 10 mg PO TID Pantoprazole 40 mg PO Q24H Chlorthalidone 25 mg PO BID Prochlorperazine 10 mg PO/IV Q6H:PRN Diltiazem Extended-release 240 mg PO BID PredniSONE 10 mg PO DAILY Docusate Sodium 200 mg PO BID Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H Finasteride 5 mg PO DAILY Senna 1 TAB PO BID:PRN Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] Guaifenesin 15 ml PO Q6H SulfaSALAzine 1000 mg PO QID Ipratropium Bromide Neb 2 NEB IH Q6H Tamsulosin 0.4 mg PO HS Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY Tiotropium Bromide 1 CAP IH DAILY Urocit-K 10 *NF* 10 mEq Oral [**Hospital1 **] Lorazepam 0.5-1 mg PO/IV Q4H:PRN anxiety Albuterol Inhalation Q2H:PRN SOB, wheeze Discharge Medications: 1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 4. Valsartan 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed for wheezing. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 8. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): please taper over 3 weeks (60 mg po qday x 5 days, 40 mg po qday x 7 days, 20 mg po qday x 7 days then d/c). 9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 10. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 11. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 2 days. 12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 2 days: for goal diuresis of approx 1 liter over two days. 13. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day. 14. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO at bedtime. 15. Finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: 1. E. coli bacteremia with septic shock and respiratory failure 2. urinary obstruction from nephrolithiasis s/p stent placement 3. bladder mass, awaiting biopsy for pathology 4. COPD exacerbation on home oxygen 5. paroxysmal atrial fibrillation, now resolved 6. delerium 7. acute on chronic diastolic heart failure Discharge Condition: Stable, continues to have mild delerium especially in early AM hours, but improving. Additionally, he has desaturation during ambulation and requires higher amount of oxygen for exertion. Discharge Instructions: You were hospitalized for kidney stones, but had a long hospitalization secondary to severe infection from the stones, renal failure, respiratory failure. You are being discharged to hospital level rehabilitation to continue your antibiotics and have physical therapy to regain your strenth. Please follow up with your doctors as recommended below. Call your primary doctor with questions or return to the emergency department with fever, chest pain, decreased urination, worsening mental status or other concerns. Followup Instructions: Please see Dr. [**Last Name (STitle) 770**] [**Telephone/Fax (1) 2906**] on Wednesday [**11-4**], 3:30PM. [**Hospital1 **], [**Location (un) 442**], across from [**Hospital1 11900**]. Please call your primary physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 52724**] to schedule follow up in [**11-25**] weeks. Please call Dr. [**Last Name (STitle) 52725**], the pulmonologist, to follow up regarding your COPD in [**11-25**] months at [**Location (un) 830**], E/KS-B23 [**Location (un) 86**], [**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 612**] Fax: [**Telephone/Fax (1) 9730**]

[ "518.81", "428.33", "403.90", "584.9", "995.92", "585.3", "427.31", "594.1", "491.22", "591", "592.0", "785.52", "038.42", "428.0", "592.1" ]

icd9cm

[ [ [] ] ]

[ "99.15", "38.93", "96.04", "96.72", "55.03", "57.32" ]

icd9pcs

[ [ [] ] ]

16185, 16257

8348, 13359

335, 393

16616, 16807

3321, 8325

17373, 18040

2791, 2808

14606, 16162

16278, 16595

13385, 14583

16831, 17350

2823, 3302

237, 297

421, 2477

2499, 2684

2700, 2775

47,789

176,920

37812

Discharge summary

report

Admission Date: [**2136-11-22**] Discharge Date: [**2136-11-23**] Date of Birth: [**2097-12-31**] Sex: F Service: MEDICINE Allergies: Aspirin / Codeine / Vicodin / Penicillins / Sulfa (Sulfonamide Antibiotics) / Nsaids Attending:[**First Name3 (LF) 398**] Chief Complaint: Malaise, vomiting Major Surgical or Invasive Procedure: Intubation and mechanical ventilation Central venous line placement CVVH History of Present Illness: 39F s/p gastric bypass surgery with alcoholism, fatty liver disease, and epilepsy transferred from OSH for further evaluation and management of fulminant hepatic failure. According to her fiancee and mother, she has been feeling fatigue, malaise, and, anorexia for more than a week. She attributed these symptoms to a virus and was taking tylenol for symptomatic relief. Her fiancee reports finding a half-empty bottle of tylenol pills (40 pills missing over a period of 4 days but of unknown strength). She felt as if she had a seizure 2 days prior to admission because she awoke feeling confused with soreness in her ribs, the way she has felt after prior seizures (most recently months ago.) She was noted to be hallucinating on the day prior to admission and asked her fiancee if he saw black dots. She complained of severe fatigue, nausea, vomiting and poor appetite. Family denies a history of psychiatric disease or suicide attempt, and does not feel that this episode represents a suicidal gesture. No reported fever, chills, sweats, headache, stiff neck, photophobia, chest pain, palpitations, shortness of breath, abdominal pain, diarrhea, hematochezia, melena, jaundice, edema, sick contacts, or recent travel. Called her upstairs neighbor to request that she call 911. Taken to [**Hospital6 28728**] Center in [**Location (un) **]. On arrival to the ED, was obtunded and intubated for airway protection. CT head did not show any evidence of intracranial hemorrhage. CxR showed LLL infiltrate vs. atelectasis. Labs were notable for WBC 11, Hct 31.4, Plt 23, INR 8.1, Cr 4.3, K 6.3, HCO3 7, AST [**Numeric Identifier **], ALT 2203, Tbili 6.3, Ca 7.3, CK 5076 ammonia 617, lipase 709, amylase 459, tylenol level 112ug/ml, ETOH 53mg/dl, and lactate 22.3. Remaining tox screen was negative. Her ABG after intubation was 6.68/52/352. Was hypotensive and started on levophed & vasopression. Central line, A-line, and dialysis catheter were placed. Was started on NAc & bicarb drips, vanc/cefepime/azithro/flagyl, and lactulose. Given vitamin K 5 mg SC and 2U FFP. Received emergent hemodialysis prior to transfer. Past Medical History: Fatty liver disease diagnosed by biopsy [**4-7**] ([**Hospital **] hospital) s/p gastric bypass surgery PUD s/p perforated ulcer repair calcium nephrolithiasis s/p parathyroidectomy Epilepsy Alcoholism Social History: Unemployed. Smokes [**2-3**] ppd. Drinks 2 beverages per day but has a history of alcoholism per family. Family History: Father died of complications of alcoholic cirrhosis. Physical Exam: Vitals - T 98 BP 129/43 (on levo 0.4 mcg/kg/min & vaso 2.4U/hr) HR 111 RR 22 02sat 91% on Vt 500 RR 20 PEEP 5 FiO2 0.5 GENERAL: Intubated, sedated HEENT: icteric sclera, dry MM NECK: R IJ site c/d/i JVD difficult to assess due to habitus CARDIAC: reg rate nl S1S2 no m/r/g LUNGS: diffuse rhonchi anteriorly no wheeze/rales ABDOMEN: soft obese nontender nondistended EXT: warm, dry trace pedal edema NEURO: withdraws to painful stimuli DERM: scaly dry psoriatic rash over rash and anterior chest Pertinent Results: Admission labs: [**2136-11-22**] 11:38PM WBC-4.0 RBC-2.46* HGB-8.0* HCT-25.2* MCV-102* MCH-32.5* MCHC-31.7 RDW-21.4* [**2136-11-22**] 11:38PM NEUTS-75* BANDS-1 LYMPHS-22 MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-3* [**2136-11-22**] 11:38PM PLT SMR-VERY LOW PLT COUNT-24* [**2136-11-22**] 11:38PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL SCHISTOCY-OCCASIONAL [**2136-11-22**] 11:38PM GLUCOSE-102 UREA N-19 CREAT-3.6* SODIUM-133 POTASSIUM-4.3 CHLORIDE-88* TOTAL CO2-11* ANION GAP-38* [**2136-11-22**] 11:38PM ALBUMIN-2.5* CALCIUM-5.6* PHOSPHATE-10.2* MAGNESIUM-2.0 IRON-142 [**2136-11-22**] 11:38PM ALT(SGPT)-2187* AST(SGOT)-[**Numeric Identifier **]* LD(LDH)-8040* ALK PHOS-181* TOT BILI-5.3* [**2136-11-22**] 11:38PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HAV Ab-POSITIVE IgM HAV-NEGATIVE [**2136-11-22**] 11:38PM AMA-NEGATIVE Smooth-NEGATIVE [**2136-11-22**] 11:38PM [**Doctor First Name **]-POSITIVE TITER-1:40 [**2136-11-22**] 11:38PM ACETMNPHN-47.6* [**2136-11-22**] 11:38PM HCV Ab-NEGATIVE . Imaging: CXR: The ET tube is low and at risk of intubating the right main stem bronchus. The NG tube passes into the proximal stomach and should be advanced to more optimal position. The right internal jugular catheter tip is at the cavoatrial junction. New hazy opacification of the left lung due to a combination of left lung collapse and superimposed pulmonary edema is noted. Dense consolidation in the periphery of the right lower lobe is probably due to infection and unchanged. The heart size is normal. No pneumothorax. This chest radiograph was reported in conjunction with the follow-up study in which the ET tube has been withdrawn. . ECHO: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 60%). There is no ventricular septal defect. The right ventricular cavity is dilated with borderline normal free wall function. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. 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, but cannot be fully excluded due to suboptimal image quality. No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. The estimated pulmonary artery systolic pressure is normal. No masses or vegetations are seen on the pulmonic valve, but cannot be fully excluded due to suboptimal image quality. There is no pericardial effusion. IMPRESSION: Suboptimal image quality; no obvious vegetations; normal left ventricular ejection fraction . CT head: NON-CONTRAST HEAD CT: There is diffuse obliteration of [**Doctor Last Name 352**]-white differentiation consistent with mild diffuse cerebral edema. Hypodense appearance of deep [**Doctor Last Name 352**] matter structures in the area of the basal ganglia and thalamus likely also represents sequela of diffuse cerebral edema. The basal cistern and suprasellar cisterns are patent. No lytic or sclerotic bone lesion is seen. The mastoid air cells and visualized paranasal sinuses are clear. Visualized orbits are clear. There is crowding of the foramen magnum, which may represent low lying cerebral tonsils. IMPRESSION: Diffuse cerebral edema as described above. . RUQ US: 1. Technically limited study due to the very echogenic liver which is consistent with fatty infiltration. Other forms of liver disease and more advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on this study. The degree of fatty infiltration limits the ultrasound ability to assess the hepatic architecture, but no focal lesion is identified. No biliary dilatation is seen. 2. Patent hepatic vasculature. 3. Minimal ascites. Brief Hospital Course: Patient is a 39 yo F who was admitted with fulminant hepatic failure wtih multisystem organ failure, most attributable to acetaminophen toxicity. She was continued on NAC gtt and Hepatology followed. Pt arrived intubated and was ventilated per ARDSnet protocol. She required 4 pressors to maintian a MAP >65. She initially was on a bicarb gtt until CVVH was started. When the CT head returned with cerebral edema, her family changed her goals of care to comfort. She died on [**2136-11-23**]. No autopsy was requested by the family; however, her case was referred to the ME. Medications on Admission: calcium vitamin D Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Fulminant hepatic failure Acetaminophen overdose Shock Acute renal failure Acute respiratory distress syndrome Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A

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icd9cm

[ [ [] ] ]

[ "39.95", "96.71", "87.03", "99.06", "99.29", "96.07", "38.93", "99.04", "99.21" ]

icd9pcs

[ [ [] ] ]

8308, 8317

7628, 8211

365, 439

8471, 8480

3536, 3536

8532, 8538

2951, 3005

8280, 8285

8338, 8450

8237, 8257

8504, 8509

3020, 3517

308, 327

467, 2587

6463, 6476

6485, 7605

3552, 6454

2609, 2813

2829, 2935

27,865

166,785

20219

Discharge summary

report

Admission Date: [**2105-2-9**] Discharge Date: [**2105-2-19**] Date of Birth: [**2032-10-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Heart failure exacerbation Major Surgical or Invasive Procedure: Swan ganz catheter placement and removal Coronary catheterization Right popliteal stent placement History of Present Illness: 72 yo Aremian speaking male w/ post-infarction cardiomyopathy (EF 20%) s/p BiV ICD, CAD, DM, PVD, AF who was admitted to CCU after elective RHC showed depressed cardiac index of 1.4. History is obtained with the help of his niece who acts as an interpreter. He was seen by Dr. [**First Name (STitle) **] in [**Hospital 3782**] clinic on [**2105-2-3**] w/ complaints of LE claudication. It was felt that he had critical limb ischemia but there was also concern for volume overload and decompensated CHF. At that visit, his Bumex dose was increased and he was brought to cath lab for RHC this am. In the cath lab, he was found to have elevated filling pressures and a CI of 1.4. A PA catheter was placed and he was admitted to the CCU for further management. . Of note, patient notes worsening in his baseline SOB over the last 2 months. Prior to 2 months ago, he was able to do very little w/o SOB, but over the last 2 months has been SOB with minimal exertion including going to bathroom and getting up from a seated position. His niece notes he complains of SOB w/ walking 20 ft and cannot do stairs. Also notes orthopnea but no PND. Over the last 2 months, patient also notes lightheadedness and vision changes with change in position from sitting/laying to standing. He has fallen due to these symptoms recently but denies any LOC. ROS is also notable for > 1 year of LE pain and sensation of cold LEs. He notes burning as well as pain at rest and with exertion w/o significant difference. He also developed a small ulcer on his R medial malleolus ~ 1 month ago for which he recently completed a course of antibiotics given by his PCP. Past Medical History: # CAD s/p MI [**2094**] - h/o PCIs in [**State 4565**] (anatomy unknown) # post-infarction cardiomyopathy (EF 20%) s/p BiV ICD - [**Company 1543**] [**First Name9 (NamePattern2) **] [**Last Name (un) 19961**] model 7277 BiVentricular ICD # MR, TR # DM # PVD w/ nonhealing ulcers - s/p balloon angioplasty of right lower extremity in [**State 4565**] many years ago # Afib/Aflutter # h/o CVA in [**2094**], no residual symptoms # pulmonary hypertension # CRI, BL Cr 1.7-1.9 # DVT LLE 1.5 yrs ago? Social History: Pt lives with his daughter in [**Name (NI) **]. He is separated from his wife. Denies EtOH use. Tobacco now ~ 5 cigs/day w/ 35 pack-yr hx. Family History: No hx of sudden cardiac death in family. Physical Exam: VS: T 97.1, BP 122/63 , HR 60, RR 16, O2 99% on 2LNC Gen: chronically ill appearing elderly male, laying at 30 degrees in bed in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP to angle of manible and bilat. JVD. CV: ICD pocket over L chest nontender without erythema. PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. [**2-19**] holosys murmurs at LLSB and apex. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Diffuse course rales in bilateral lung fields 3/4 up. Abd: Obese, soft, NTND. + hepatomegaly w/ pulsatile liver. No abdominial bruits. Ext: 1+ LE edema bilaterally. Ulcer over R medial malleolus Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP, 1+ PT [**Name (NI) 2325**]: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP, 1+ PT Pertinent Results: [**2-9**] PAC placement The tip of a new right transjugular pulmonary artery catheter projects over the right portion of the central mediastinum probably in a large intrapericardial right pulmonary artery. Transvenous right atrial and left ventricular transvenous pacer leads and the right ventricular pacer defibrillator lead are in standard placements. Some of the central hazy opacification on both sides of the chest at the level of the hila could be due to overlying soft tissue, but I suspect there is mild pulmonary edema. Large heart is stable and there is no pleural effusion or pneumothorax. Widening of the superior mediastinum is longstanding feature probably a combination of mediastinal fat and large head and neck vessels. No pneumothorax. If there is any concern about malpositionning of the pulmonary artery catheter standard views, including a lateral should be obtained ------------- [**2-9**] cardiac cath COMMENTS: 1. Hemodynamic assessment revealed elevated right-sided filling pressures with RVEDP 27 mmHg. There was significant pulmonary arterial systolic hypertension with PASP 80 mmHg. The PCWP was elevated with mean PCWP 21 mmHg. Cardiac output was significantly depressed, with CI 1.4 L/min/m2. FINAL DIAGNOSIS: 1. Depressed cardiac output with elevated PCWP and elevated RVEDP. 2. Pulmonary arterial hypertension. --------------- [**2-11**] cxr FINDINGS: In comparison with study of [**2-9**], the patient has taken a much better inspiration. The cardiac silhouette is essentially within normal limits, and there is no evidence of vascular congestion, pleural effusion, or acute pneumonia. Pacemaker device remains in place. CT HEAD WITHOUT CONTRAST ([**2105-2-15**], done for headache s/p eye surgery): There is no evidence hemorrhage, shift of normally midline structures, or infarction. Encephalomalacia extending from the left temporal subcortical white matter to the centrum semiovale is likely a consequence of old infaction. Atherosclerotic calcification of the cavernous carotids and vertebral arteries are noted bilaterally. Surrounding osseous structures are unremarkable. A large mucus retention cyst is identified within the right maxillary sinus. The mastoid air cells are well aerated. The orbits appear unremarkable bilaterally. IMPRESSION: No intracranial hemorrhage or edema. Renal U/S ([**2105-2-15**]): 1. Normal renal size, without evidence of hydronephrosis. 2. Slightly irregular renal contours, particularly on the left, although much less apparent than on prior CT. This could relate to scarring from prior infection or infarction. 3. New trace ascites around the liver, and in the Morison's pouch. Brief Hospital Course: 72 y/o Armenian male with post infarction ischemic CM, EF 20% s/p biventricular ICD, h/o atrial fibrillation, DM, PVD non healing LE ulcers admitted with volume overload secondary to florid heart failure on right heart cath, cardiac index 1.4 admitted for optimization of heart failure therapy prior to vascular intervention . # Heart failure exacerbation Post-infarction cardiomyopathy with EF 20%n s/p BiV ICD. Elevated filling pressures CI in cath lab 1.4. PA catheter left in place. No obvious events in recent past leading to current decompensation. No significant change in wall motion on recent ECHO. ? chronic progression of severe CMPY. Started lasix gtt after 80mg IV bolus. Lasix gtt at 7mg/hr. On second hospital day increased Coreg to 12.5 mg [**Hospital1 **] and increased to 10mg lisinopril [**Hospital1 **]. By HD#3 patient had diuresed 5 liters with creatinine holding steady, cardiac index rose to 2.08 and CVP decreased, CO 4. Patient developed renal failure likely secondary to contrast, diuresis, and increase in lisinopril. Renal function improved, did not require HD. Gradually patient became volume overloaded and was placed back on lasix gtt with transition to oral budesonide 4mg [**Hospital1 **]. At discharge he was at his baseline weight and was given strict instructions on taking medications, low sodium diet, daily weights. Patient to follow up with Dr. [**First Name (STitle) 437**] in [**Hospital 1902**] clinic on [**3-2**]. . # Acute kidney injury on Chronic kidney disease Baseline creatinine around 1.7-1.9, creatinine initially improved with diuresis. Patient was diuresed about 5 liters, initially it was thought patient would undergo revascularization after discharge, therefore he was not given NAC. Patient underwent revascularization after undergoing substantial diuresis and having lisinopril dose increased. Subsequently developed [**Last Name (un) **] secondary to combination of above. Creatinine peaked at 5.1, nephrology was consulted, placed on Renagel while kidney function improved. Creatinine improved and was in mid 3's at discharge. Lisinopril was held, he was scheduled nephrology follow up. . # CAD h/o MIs in the past w/ severely depressed EF. Unknown anatomy but may have had PCIs in past in [**State 4565**]. Increased Coreg to 12.5mg [**Hospital1 **], held ACE given [**Last Name (un) **], continued statin and ASA. . # Rhythm h/o AF s/p BiV ICD for cardiomyopathy. AV paced currently. Continued amiodarone. Held coumadin given potential repeat intervention during hospitalization. INR subtherapeutic at discharge, patient was continued at dose of 2.5mg QOD, no bridging therapy was deemed necessary given only indication of atrial fibrillation. Patient to have INR checked on [**2-23**] at Dr. [**Name (NI) 54312**] office in [**Company 191**]. . # PVD Severe PVD w/ prior interventions in past. Current nonhealing ulcer on RLE w/ claudication symptoms at rest. Recently evaluated by Dr. [**First Name (STitle) **] who felt pt had critical limb ischemia requiring LE cath and intervention. However, need to optimize CHF prior to intervention. Patient underwent PVD intervention on [**2-11**] given improved cardiac status with placement of right popliteal stent. He is to continue Plavix for at least 1 month's duration. Would discuss with cardiology stopping Plavix at that time. Patient had significantly improved pain in lower extremity after the procedure. . # DM Recent HbA1C 13.0. On insulin, discharged on home dose of 70/30 insulin. . # Recent cataract surgery Patient was off eye drops upon initial admission and developed severe headache and eye pain. Given he was on heparin a CT Head was obtained which showed no evidence of bleed. Opthalmology was consulted and recommended continuing only prednisolone eye drops. Headache and eye pain were completely resolved prior to discharge. Medications on Admission: amiodarone 200 mg p.o. daily warfarin 2.5 mg p.o. QOD aspirin 325 mg daily lisinopril 5 mg p.o. daily carvedilol 3.125 mg qam, 6.25 qhs Bumex 3 mg [**Hospital1 **] Lipitor 40 mg p.o. daily insulin 70/30 30 units qam, 20 units qhs Ketorolac Tromethamine 0.5 % 1 drop TID * pt states only using 1 eye drop. Unclear which still using Gatifloxacin 0.3 % One drop Ophthalmic TID * Prednisolone Acetate 1 % Drops,One drop TID * Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 5. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge Sig: as directed units Subcutaneous AS DIR: 30 units qam, 20 units qhs . 6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 7. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 8. Bumetanide 2 mg Tablet Sig: Two (2) Tablet PO twice a day. Disp:*120 Tablet(s)* Refills:*0* 9. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic QID (4 times a day). Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary diagnosis: # Acute systolic heart failure (post-infarction cardiomyopathy) with EF 20%, s/p BiV ICD # Acute kidney injury # Chronic kidney disease . Secondary diagnosis: # CAD s/p MI [**2094**] - h/o PCIs in [**State 4565**] (anatomy unknown) # post-infarction cardiomyopathy (EF 20%) s/p BiV ICD - [**Company 1543**] [**First Name9 (NamePattern2) **] [**Last Name (un) 19961**] model 7277 BiVentricular ICD # MR, TR # DM # PVD w/ nonhealing ulcers - s/p balloon angioplasty of right lower extremity in [**State 4565**] many years ago # Afib/Aflutter # h/o CVA in [**2094**], no residual symptoms # pulmonary hypertension # CRI, BL Cr 1.7-1.9 # DVT LLE 1.5 yrs ago? Discharge Condition: Stable Discharge Instructions: You were admitted and treated for acute systolic heart failure. You underwent a right popliteal stent to treat your peripheral vascular disease. You developed acute kidney injury secondary to diuretics and contrast, your kidneys are slowly recovering. It is important for you to take your medications as prescribed and weigh yourself daily. If you develop an increase in weight of 2lbs it is imperative you call Dr.[**Name (NI) 3536**] office for further instructions. Your lisinopril (ACEi) was held due to your resolving kidney function. You will have your kidney function, INR level as well as glucose checked on Monday at Dr.[**Name (NI) 21558**] office. . If you develop fever greater than 101F, chest pain, shortness of breath, severe back pain or lightheadedness, or if you at any time become concerned about your health please contact your PCP, [**Name10 (NameIs) 18**] at [**Telephone/Fax (3) **] or present to the nearest ED. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. . The following changes to your medications were done: - bumex was increased to 4mg [**Hospital1 **] - lisinopril is being held secondary to resolving acute kidney injury - Plavix 75mg daily . Please go to your scheduled appointments listed below. Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2105-3-2**] 10:30 Provider: [**First Name11 (Name Pattern1) 1980**] [**Last Name (NamePattern4) 1981**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2105-2-23**] 10:30 Provider: [**Last Name (NamePattern5) 7224**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2105-3-3**] 9:00 Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2105-5-20**] 10:00 Renal appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4427**] [**2105-3-26**] 3pm [**Telephone/Fax (1) 60**] in [**Hospital Ward Name 23**] 7

[ "918.1", "403.90", "362.01", "305.1", "416.8", "E947.8", "707.10", "427.31", "584.9", "V12.54", "V12.51", "397.0", "428.21", "585.3", "250.50", "440.23", "428.0", "E849.7", "427.32", "424.0", "414.01", "V45.02" ]

icd9cm

[ [ [] ] ]

[ "37.21", "39.50", "88.56", "89.68", "89.64", "00.40", "88.45", "88.42" ]

icd9pcs

[ [ [] ] ]

11820, 11869

6600, 10469

350, 450

12588, 12597

3902, 5135

13930, 14674

2812, 2854

10942, 11797

11890, 11890

10495, 10919

5152, 6577

12621, 13907

2869, 3883

284, 312

478, 2120

12069, 12567

11909, 12048

2142, 2640

2656, 2796

14,517

163,144

23267

Discharge summary

report

Admission Date: [**2146-12-24**] Discharge Date: [**2146-12-30**] Date of Birth: [**2068-1-31**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 7539**] Chief Complaint: Shortness of breath for one day Major Surgical or Invasive Procedure: s/p Inferior vena cava filter placement History of Present Illness: 78 y.o. female with h/o CAD s/p CABG x 2 [**2146-12-8**], who presented to OSH with SOB x 1 day and was found to have pulmonary embolus along with RV failure and was started on heparin. She originally presented to an OSH on [**12-4**] with a left swollen leg secondary to trauma and was found to have a leaking popliteal aneurysm. In the midst of [**Month (only) 1106**] w/u she was noted to have TWI inversions and elevated troponins and thus underwent L popliteal stent placement and cath on [**12-6**]. See results below. She then underwent 2 V CABG on [**2146-12-8**]. She was then discharged to rehab on [**12-14**] and was at rehab when she developed 1 day of shortness of breath for which she was admitted to [**Hospital3 **] and found to have a PE and hypotension along with RV dilatation on echo. She was then transferred to [**Hospital1 18**] for further management. Past Medical History: PMH: CAD s/p cardiac cath on [**2146-12-6**] which revealed: 70% distal LMCA lesion, 90% proximal LAD lesion, 80% LCX stenosis, and 50% RCA stenosis. s/p L popliteal aneursym stent placed. s/p CABG on [**2146-12-8**]- LIMA to descending LAD, reverse SVG from from LIMA to OMCA s/p cataract surgery H/o L leaking popliteal artery aneurysm s/p stent placement [**2147-12-6**] . Cataracts, s/p surgery Social History: Lives alone.Cigs: 3ppd x 50 years, quit 14 years ago.ETOH: [**12-18**] glass wine/day. Family History: + CAD Physical Exam: T = 98.0, BP = 79-101/44-54, HR = 103-111, RR = 25, SaO2= 15L NRB. Gen: Thin elderly female laying in bed, mildly tachypneic, appears slightly uncomfortable CV: nml S1, S2, no m/r/g Lungs: Bibasilar crackles 1/3 up from the bases Abdomen: nabs, soft, nt. Extremities: 2+ DPP appreciated with dopplers. Pertinent Results: [**2146-12-24**] 10:24PM TYPE-ART TEMP-36.1 RATES-/36 O2-100 PO2-80* PCO2-40 PH-7.41 TOTAL CO2-26 BASE XS-0 AADO2-619 REQ O2-97 INTUBATED-NOT INTUBA COMMENTS-SHOVEL MAS [**2146-12-24**] 10:24PM O2 SAT-96 [**2146-12-24**] 08:27PM TYPE-ART TEMP-36.1 PO2-136* PCO2-46* PH-7.40 TOTAL CO2-30 BASE XS-3 [**2146-12-24**] 08:27PM GLUCOSE-112* LACTATE-0.7 [**2146-12-24**] 08:27PM O2 SAT-98 [**2146-12-24**] 08:27PM freeCa-1.05* [**2146-12-24**] 08:00PM GLUCOSE-116* UREA N-13 CREAT-0.4 SODIUM-139 POTASSIUM-4.5 CHLORIDE-107 TOTAL CO2-27 ANION GAP-10 [**2146-12-24**] 08:00PM CALCIUM-7.1* PHOSPHATE-2.8 MAGNESIUM-1.7 [**2146-12-24**] 08:00PM WBC-8.7 RBC-3.00* HGB-8.9* HCT-27.6* MCV-92 MCH-29.6 MCHC-32.1 RDW-15.5 [**2146-12-24**] 08:00PM PLT COUNT-290 [**2146-12-24**] 08:00PM PT-13.0 PTT-25.7 INR(PT)-1.1 [**2146-12-24**] 12:40PM PT-13.7* INR(PT)-1.2 [**2146-12-24**] 12:40PM PROT C-** [**2146-12-24**] 12:31PM TYPE-ART PO2-86 PCO2-50* PH-7.42 TOTAL CO2-34* BASE XS-6 [**2146-12-24**] 11:16AM TYPE-ART PO2-214* PCO2-54* PH-7.42 TOTAL CO2-36* BASE XS-9 [**2146-12-24**] 08:29AM GLUCOSE-110* UREA N-19 CREAT-0.5 SODIUM-139 POTASSIUM-5.6* CHLORIDE-105 TOTAL CO2-29 ANION GAP-11 [**2146-12-24**] 08:29AM CK-MB-2 cTropnT-<0.01 [**2146-12-24**] 08:29AM CALCIUM-8.1* PHOSPHATE-2.7 MAGNESIUM-2.5 [**2146-12-24**] 08:29AM WBC-10.4 RBC-3.33* HGB-10.0* HCT-30.6* MCV-92 MCH-30.1 MCHC-32.8 RDW-15.4 [**2146-12-24**] 08:29AM NEUTS-86.9* LYMPHS-7.5* MONOS-2.7 EOS-2.5 BASOS-0.4 [**2146-12-24**] 08:29AM MACROCYT-1+ [**2146-12-24**] 08:29AM PLT COUNT-284 [**2146-12-24**] 08:29AM PT-13.9* PTT-71.5* INR(PT)-1.2 [**2146-12-24**] 03:20AM TYPE-ART TEMP-36.7 O2-100 PO2-121* PCO2-54* PH-7.34* TOTAL CO2-30 BASE XS-2 AADO2-564 REQ O2-90 INTUBATED-NOT INTUBA [**2146-12-24**] 03:20AM K+-3.5 [**2146-12-24**] 03:20AM K+-3.5 [**2146-12-24**] 03:20AM K+-3.5 [**2146-12-24**] 03:20AM O2 SAT-97 [**2146-12-24**] 12:59AM TYPE-MIX TEMP-36.7 RATES-/24 PO2-36* PCO2-57* PH-7.38 TOTAL CO2-35* BASE XS-6 INTUBATED-NOT INTUBA COMMENTS-NON-REBREA [**2146-12-24**] 12:59AM LACTATE-1.0 [**2146-12-24**] 12:59AM LACTATE-1.0 [**2146-12-24**] 12:59AM O2 SAT-69 [**2146-12-24**] 12:59AM freeCa-1.15 [**2146-12-24**] 12:46AM GLUCOSE-106* UREA N-28* CREAT-0.6 SODIUM-143 POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-31* ANION GAP-9 [**2146-12-24**] 12:46AM CK(CPK)-33 [**2146-12-24**] 12:46AM CK-MB-NotDone cTropnT-<0.01 [**2146-12-24**] 12:46AM CALCIUM-8.0* PHOSPHATE-2.8 MAGNESIUM-1.6 [**2146-12-24**] 12:46AM CK-MB-NotDone cTropnT-<0.01 [**2146-12-24**] 12:46AM CALCIUM-8.0* PHOSPHATE-2.8 MAGNESIUM-1.6 [**2146-12-24**] 12:46AM WBC-11.3* RBC-3.38* HGB-10.1* HCT-31.3* MCV-93 MCH-29.9 MCHC-32.4 RDW-15.3 [**2146-12-24**] 12:46AM PLT COUNT-292 [**2146-12-24**] 12:46AM PT-14.0* PTT-65.2* INR(PT)-1.2 OSH Imaging: LLE US: L popliteal stent with no flow . Chest x ray at OSH: COPD changes, Focal L basilar opacity c/w atelectasis or infiltrate, Small bilateral pleural effusions . Spiral CT:Extensive pulmonary embolus of the right main pulmonary artery extending into the right upper, right middle and right lower lobe arteries and left uppoer lobe artery. Right brachiocephalic. Small bilateral pleural effusions, atelectasis and emphysema. . Echo report from OSH: R ventricular dilatation with nml LV size and function ART DUP EXT LO UNI;F/U PORT Duplex evaluations are performed on the left lower extremity arterial system. The proximal above knee popliteal artery is patent. At the level of the knee, there is increased velocity of 541 cm per second, no flow was seen in the popliteal artery below that. Distal to the stent, there is a significant turbulent flow with diminished velocity in the popliteal artery. Chest AP: IMPRESSION: Improving CHF, decreasing bilateral pleural effusions. Bibasilar consolidation, probably representing atelectasis, however, pneumonia cannot be totally excluded. Brief Hospital Course: A/P 78 year old female with h/o CAD s/p 2V CABG who now presents with massive pulmonary embolus accompanied by hypotension requring dopamine. . 1. Massive PE: Hypotension: The patient was started on levophed in order to maintain an MAP of 60. Upon review of her old records from her previous discharge we learned that her normal BP is 90/60 and upon floating a Swan Ganz catheter her PCWP was 6. We thus realized that her hypotension was most likely secondary to dehydration and she was gently re-hydrating with IV fluids and weaned off dopamine. She was not given lytics because of her recent surgery. She was taken to the cath lab for embolectomy and found to have adequate clot dissolution and no RV compromise. A temporary optese IVC filter was then placed and she was started on heparin. (The removal of this filter should be discussed at her appointment with Dr. [**Last Name (STitle) 22423**].) Her hypoxemia continued to improve on heparin until the day of discharge when she was sating well on 2.5L of O2 and able to ambulate independently without difficulty. . 2. CAD: s/p recent CABG [**11-19**] (Lima to LAD, reverse SVG from Lima to OMCa). Upon admission her enyzymes were flat and thus we had no evidence of acute ischemia. She was thus continued on aspirin and plavix. . 3. CHF: EF 30%, near-global akinesis, 1+MR, mild pulm HTN We thought that she was grossly fluid overloaded but she was intra-vascularly dry. She also became tachycardic which we thought was secondary to her being dry and thus her lasix was held and she was gently hydrated by encouraging po intake. In light of her low EF we suggest that she start on low dose lasix 20 mg qd upon discharge from [**Hospital1 **]. We also suggest a chemistry 7 be drawn within 1 week of her resumption of lasix. . 4. Heme-occult positive stools: During her hospitalization she was found to have heme-positive stool with a stable HCT and thus we recommend an outpatient GI work up. 5. LLE aneurysym: Arterial duplexes demonstrated that her L popliteal artery stent was occluded and thus her plavix was discontinued. Since she did have good collateral flow surgery decided it best to wait until she had completed her treatment for her pulmonary embolus prior to [**Hospital1 1106**] surgery. 6. Pneumonia/COPD exacerbation: The patient developed a productive cough and had bilateral infiltrates. She was thus started on levoquin to complete a 7 day course on [**2146-1-1**]. 7. FEN: cardiac 2g Na diet, fluid restrict . Code: FULL Medications on Admission: Lasix 20 mg [**Hospital1 **] Plavix 75 mg qd ASA 81 mg qd Levo/flagyl x 7 dats Lipitor 10 mg qd Lopressor 50 mg [**Hospital1 **] From [**Hospital3 **]- Levaquin 250 mg IV q 24 hours, Tobramycin 50 mg IV q 12. Discharge Disposition: Extended Care Facility: [**Location (un) **] House Nursing Home - [**Location 9583**] Discharge Diagnosis: Primary: Massive Pulmonary Embolus Occluded L popliteal artery Hemoccult positive stools Secondary Coronary artery disease-s/p CABG Discharge Condition: Good, stable. She has required 2.5 L of oxygen via NC during her stay here. Discharge Instructions: Please return to the emergency room if you experience shortness of breath, light headedness, chest pain, black stools, or bright red rectum. Followup Instructions: Provider: [**Name10 (NameIs) 1111**],[**First Name7 (NamePattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY Where: [**Last Name (NamePattern4) **] SURGERY Date/Time:[**2147-1-5**] 1:30 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] CARDIAC SURGERY LMOB 2A Where: CARDIAC SURGERY LMOB 2A Date/Time:[**2147-1-18**] 3:15 Dr. [**Last Name (STitle) 59769**] medical director of [**Location (un) **] House ([**Telephone/Fax (1) 59770**]) has agreed to take responsibility for your care at [**Location (un) **] House.

[ "453.8", "428.0", "V45.81", "276.5", "486", "792.1", "491.21", "996.74", "427.31", "415.19", "782.1" ]

icd9cm

[ [ [] ] ]

[ "88.43", "99.04", "38.93", "38.91", "38.7" ]

icd9pcs

[ [ [] ] ]

8912, 9000

6149, 8653

357, 398

9176, 9254

2193, 6126

9443, 10005

1849, 1856

9021, 9155

8679, 8889

9278, 9420

1871, 2174

286, 319

426, 1307

1329, 1729

1745, 1833

54,883

104,390

1415

Discharge summary

report

Admission Date: [**2154-5-30**] Discharge Date: [**2154-6-3**] Date of Birth: [**2089-4-30**] Sex: F Service: MEDICINE Allergies: Penicillins / Levofloxacin / ceftriaxone / Keflex / Flagyl / vancomycin Attending:[**First Name3 (LF) 2279**] Chief Complaint: fevers Major Surgical or Invasive Procedure: None History of Present Illness: 65 yo female with no significant PMHx recently s/p excisional biopsy of salivary gland tumor on [**2154-5-16**] (did not have a parotid dissection). Two days later she presented to the ED with dysphagia and found to have cellulitis of surgical wound. She was hospitalized for 5 days, treated with antibiotics and discharged on Keflex. She had been doing well until Tuesday/Wed when she began experiencing fevers with associated generalized malaise, fatigue and weakness. These symptoms persisted, did improve with Tylenol or Advil, until she saw her OTL surgeon this morning for follow up. She was found to be febrile to 103 and with hypotension to mid-80s systolic. She was sent to the ED with evaluation. On review of systems the patient is completely asymptomatic aside from weakness and malaise. No sore throat, no runny nose, eye pain or discharge, sinus pain, no neck pain or stiffness, no redness, swelling or pain at site of incision. No cough, SOB, chest pain, no abdominal pain, nausea, vomiting or diarrhea. Patient does endorse increased urinary frequency but no dysuria. No rashes or joint pain, no leg swelling. In the ED, initial vitals were 99 101 93/49 16 96%. CBC showed white blood cell count of 5.1K. Sodium was 128 on Chem7. Lactate was 1.0. Urinalysis was negative and blood cultures were sent. Patient was administered 1 liter NS. Chest X-ray showed no focal consolidation or effusion, no acute process. ENT was consulted and initially did not think there was anything going on with the surgical site. CT neck was performed which showed fat stranding at site of right posterior submandibular node resection, with no drainable fluid collection. Overall there was an improved post-op appearance compared to recent imaging in [**4-/2154**], with less mass effect upon the parapharyngeal space and stable edema of the right sternocleidomastoid. CTA chest was also performed with no pulmonary emboli noted, but scattered mediastinal lymph nodes measuring up to 9 mm. Initially, cephalexin and trimethoprim/sulfamethoxazole were administered PO. Patient was admitted to observation with plan for likely discharge in the morning. Around 0230, patient dropped systolic blood pressures to 70s, was tachycardic to the 130s, with a temperature of 104.8F, RR 40s, with O2 sat 77% on RA, but improved to mid-90s with nasal cannula O2 administration. She was reported to have skin mottling of the extremities. A left external jugular peripheral line was inserted and administration of 2 liters NS IVF was bolused. Patient was administed vancomycin, ceftriaxone and metronidazole IV. ENT was contact[**Name (NI) **] and recommended MICU admission, and thought there was no surgical intervention needed. Past Medical History: s/p excisional biopsy of salivary gland tumor on [**2154-5-16**] hx of pneumonia Social History: She has smoked for eight to ten years, a half pack per day. She smokes generally in intervals of years and is not currently smoking. From the standpoint of alcohol, she rarely drinks it. Family History: Her mother had [**Name2 (NI) 499**] cancer, and her daughter had a brain tumor. There is also a history of hearing loss, and migraines. Physical Exam: Admission Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding 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. Discharge Exam: VITALS: 98.4 79 125/84 20 97RA GENERAL: awake, alert, NAD NECK: Surgical scar on right submandibular region is C/D/I without erythema. LUNGS: CTAB HEART: RRR, normal S1 S2, no MRG ABDOMEN: Soft, NT/ND, NABS EXTREMITIES: WWP no c/c/e. SKIN: scattered pink papules worst on back and upper arms, thighs, non-pruritic. no vesicles, no ulceration Pertinent Results: [**2154-5-30**] 06:12PM URINE HOURS-RANDOM [**2154-5-30**] 06:12PM URINE GR HOLD-HOLD [**2154-5-30**] 06:12PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.016 [**2154-5-30**] 06:12PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2154-5-30**] 06:12PM URINE RBC-1 WBC-4 BACTERIA-FEW YEAST-NONE EPI-1 RENAL EPI-<1 [**2154-5-30**] 06:12PM URINE HYALINE-5* [**2154-5-30**] 06:12PM URINE MUCOUS-FEW [**2154-5-30**] 05:14PM PT-11.9 PTT-29.3 INR(PT)-1.1 [**2154-5-30**] 04:57PM LACTATE-1.0 [**2154-5-30**] 04:50PM GLUCOSE-109* UREA N-12 CREAT-0.8 SODIUM-128* POTASSIUM-5.1 CHLORIDE-98 TOTAL CO2-23 ANION GAP-12 [**2154-5-30**] 04:50PM estGFR-Using this [**2154-5-30**] 04:50PM WBC-5.1 RBC-4.82 HGB-13.3 HCT-39.3 MCV-81* MCH-27.5 MCHC-33.8 RDW-13.6 [**2154-5-30**] 04:50PM NEUTS-87.4* LYMPHS-8.0* MONOS-1.6* EOS-2.8 BASOS-0.1 [**2154-5-30**] 04:50PM PLT COUNT-217 Brief Hospital Course: 65 yo female with no significant PMHx recently s/p excisional biopsy of salivary gland tumor on [**2154-5-16**] with a postop course complicated by cellulitis, now presenting with fevers and hypotension. Treatment with fluids and Abx in ICU resolved hypotension and fever, but she developed a rash which is most likely drug-induced. Abx discontinued and she was transfered to the floor where she has remained stable. Discharged on hospital stay day 4. Active issues: # Cellulitis: Pt admitted with hypotension occurring during treatment for cellulitis on Keflex. Pt received approximately 13days of Keflex prior to admission to ICU. While in the ICU pt received Vanc/CTX/Flagyl IV and ICU stay was complicated by drug eruption (see below). IV abx were discontinued and pt remained afebrile and stable for >36 hrs prior to discharge. Pt was transferred to the floor where she continued to do well with no evidence of recurrence of cellulitis. We discussed with ENT and they agreed that she does not need to be sent home on antibiotics. # Drug Eruption: Pt. was febrile, tachycardic and hypotensive with pruritic pink papules over her back and arms that developed after taking a cephalosporin for post-op cellulitis. There was no infectious etiology determined as CXR, UA, Ucx were negative and CT of neck did not reveal a fluid collection around surgical site. Pt was fluid resuscitated and received benadryl and famotidine for drug rxn and topical steroid for pruritis. Eruption slowly faded and became non-pruritic. #Hyponatremia: Most likely hypovolemic hyponatremia that resolved with fluid resuscitation. # Anemia: unknown etiology with HH 11.4&35. H&H remained stable over admission and eventually recovered to 12.4 on day of discharge. Chronic issues: None Transitional issues: f/u excisional salivary tumor bx Infectious workup: f/u viral Cx [**2154-5-1**] Medications on Admission: OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - 1 Tablet(s) by mouth Every 4 hours as needed for pain Discharge Medications: none Discharge Disposition: Home Discharge Diagnosis: Cellulitis Drug Eruption Discharge Condition: Stable. Incision c/d/i. No erythema. Drug eruption fading and non-pruritic. Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname **], Thank you for choosing us for your care. You were admitted with cellulitis (a skin infection) and hypotension (low blood pressure). In the ICU you received IV fluids and antibiotics. You developed a rash that was likely a response to the antibiotics you recieved. In this context, we stopped the antibiotics. You have been off antibiotics for 3 days and your skin infection has resolved. We are not sure which of the antibiotics contributed to your rash, but in the future, please just be on alert when using any of the following: Vancomycin, Ceftriaxone, Flagyl, Keflex, Bactrim. There are no changes to your medications. Please continue to take the medicines you had been on at home. Followup Instructions: Department: OTOLARYNGOLOGY-AUDIOLOGY When: TUESDAY [**2154-6-11**] at 8:45 AM With: [**First Name4 (NamePattern1) 177**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 41**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 895**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: [**Hospital **] MEDICAL GROUP When: THURSDAY [**2154-6-13**] at 10:45 AM With: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2400**] [**Telephone/Fax (1) 133**] Building: [**Street Address(2) 3375**] ([**Location (un) **], MA) [**Location (un) 858**] Campus: OFF CAMPUS Best Parking: On Street Parking [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**] Completed by:[**2154-6-3**]

[ "E930.5", "909.3", "E930.8", "458.9", "276.1", "682.1", "285.9", "780.60", "693.0" ]

icd9cm

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icd9pcs

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Discharge summary

report

Admission Date: [**2181-11-20**] Discharge Date: [**2181-11-23**] Date of Birth: [**2142-9-14**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3984**] Chief Complaint: altered mental status, hemiplegia Major Surgical or Invasive Procedure: endotracheal intubation History of Present Illness: Ms. [**Known lastname **] is a 39-year-old woman with a history of endometrial cancer with recently discovered poorly differentiated lesion to the right femur, s/p open reduction internal fixation on [**2181-11-1**] on prophylactic lovenox therapy presented with altered mental status and hemiplegia. [**Last Name (un) **] was found at her facility tonight unreponsive and hemiparetic on the left with severe weakness, was at her baseline two hours prior. . Of note patient was recently hospitalized from [**Date range (2) 100063**] with episode of chest pain. No clear source was identified, however patient was noted to new metastatic lesions of the lung, femur, and adrenals on imaging. She was noted to have hypercalcemia which was managed with pamidronate. She completed her outpt workup for RLE mass which underwent open reduction and internal fixation. She was subsquently started on carboplatin, received one dose, with plans to follow up as outpt for [**Doctor Last Name **]/taxol tx. She subsquently underwent 5 rounds of radiation tx to her right femur for pain control. Palliative care was also consulted for assistance with pain management. . In the [**Hospital1 18**] ED, vital signs were stable. Pt was noted to be drowsy with left sided hemiplegia, tachycardia, and RLE edema. Exam with L sided weakness, with some resistance to gravity. She was able to follow simple commands, alert and oriented to self and month. Code stroke was called at 2:53A. Due to initial concern for septic emboli from her surgical site she was treated with 1gm Vancomycin. CT head demonstrated multiple hyperdense lesions with surrounding edema thought to be hemorrhagic conversion of mets. Neurology will follow. Ortho also consulted for evaluation of RLE edema, thought to be related to recent surgery. RLE Xray with no acute pathology. LENI showed no DVT, CTA also ruled out PE. Compartment syndrome was thought to be highly unlikely. Vital signs on transfer HR 116 BP163/97 O2 sat 100% RA. . . On the floor, pt is very somnulant and not able to respond to questions. Past Medical History: Onc: - TAH/BSO/Lymphadenectomy on [**2181-2-19**] that revealed FIGO stage I, grade [**2-8**] endometrioid carcinoma. - Imaging from [**2181-10-6**]: bilateral hilar adenopathy up to 2cm, right adrenal nodule, multiple bilateral lesions in the kidneys, a 1.4 cm subcutaneous soft tissue nodule in the right inguinal region, andmultiple 1-cm right inguinal lymph nodes. 5X5X22 cm right distal femoral mass with soft tissue extension. - Femoral mass pathology poorly differentiated carcinoma "compatible with" endometrial carcinoma. -Hypertension -Hypercholesterolemia -DM -Back surgery on L5/S1 in [**2173**] Social History: She was born in the USA. She is not currently working. She has never smoked and does not drink alcohol or use illicit drugs. She has a mother, sister, and brother, no children Family History: The patient's father died from cancer (type unknown). She has no family history of clotting disorders or heart disease. Physical Exam: ADMISSION EXAM: Vitals: T:100.1 BP:109 P:121/86 R:21 O2:100% RA General: obtunded, unresponsive to sternal rub, nailbed pressure HEENT: Sclera anicteric, pupils small but reactive bilaterally, resists passive eye opening on the right, but not on the left. mouth open. oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation anteriorly, 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: foley in place Ext: warm, well perfused, 2+ pulses. RLE warm, nonerythemetous, twice the size of LLE, but edema nonpitting. small well healing incisions, at the right trochanter and right lateral femoral head. Neuro: pupils reactive, unable to assess other cranial nerves as pt not responsive, left facial droop. minimal to absent gag reflex. has tone in the RUE, protects arm when dropped, makes some spontaneous movements of the hand and arm. LUE flaccid. no posturing. reflexes minimal bilaterally. babinski equivocal bilaterally. . DISCHARGE EXAM General: More responsive this AM, able to follow commands HEENT: Sclera anicteric, pupils small but reactive bilaterally, oropharynx clear Lungs: Clear to auscultation anteriorly, 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: foley in place Ext: warm, well perfused, 2+ pulses. RLE warm, nonerythemetous, twice the size of LLE, but edema nonpitting. small well healing incisions, at the right trochanter and right lateral femoral head. Neuro: pupils reactive, strength is [**5-10**] on the right UE. Is not moving RLE due to pain. Cannot move left side. Facial droop on left. Pertinent Results: ADMISSION LABS: [**2181-11-20**] 01:20AM BLOOD WBC-23.8* RBC-4.44 Hgb-11.5* Hct-33.2* MCV-75* MCH-25.9* MCHC-34.6 RDW-16.4* Plt Ct-520* [**2181-11-20**] 01:20AM BLOOD Neuts-86.6* Lymphs-9.4* Monos-3.4 Eos-0.3 Baso-0.3 [**2181-11-20**] 01:20AM BLOOD PT-14.7* PTT-35.0 INR(PT)-1.3* [**2181-11-20**] 07:31AM BLOOD Glucose-153* UreaN-26* Creat-1.1 Na-135 K-4.5 Cl-100 HCO3-22 AnGap-18 [**2181-11-20**] 07:31AM BLOOD ALT-3 AST-20 AlkPhos-166* TotBili-0.2 [**2181-11-20**] 07:31AM BLOOD Albumin-3.4* Calcium-8.8 Phos-2.8 Mg-2.3 [**2181-11-20**] 07:31AM BLOOD TSH-0.56 [**2181-11-20**] 01:40AM BLOOD Glucose-148* Na-136 K-4.4 Cl-97 calHCO3-24 [**2181-11-20**] 04:17AM BLOOD Lactate-1.7 . No Labs obtained on discharge. . EEG: This is an abnormal continuous ICU video EEG study because of diffusely suppressed and slow background indicative of a moderate to severe encephalopathy. The frontally predominant delta frequency activity can be seen in toxic/metolic disturbances, but may also be seen in midline or subcortical dysfunction, including hydrocephalus. Thus, clinical correlation is recommended. No epileptiform discharges or electrographic seizures were present in the record. A note was made of sinus tachycardia and occasional premature wide complex beats. . CT head: IMPRESSION: Multiple hyperdense masses involving both the superficial and deep white matter and deep [**Doctor Last Name 352**] matter, with an area of vasogenic edema in the left occipital lobe. Differential diagnosis is broad, though findings are most likely secondary to hemorrhagic metastases given the clinical history. Other possibilities, though less likely include hemorrhagic infarcts secondary to dural venous or cortical venous thrombosis, spontaneous hemorrhage from complication of anticoagulation (given the recent history of orthopedic surgery), lymphoma or infection. Further characterization with MRI of the brain is recommended Brief Hospital Course: Mrs [**Known lastname **] is a 39 y/o f with metastatic poorly differentiated carcinoma who was admitted for AMS and new left hemiplegia found to be likely d/t newly diagnosed malignant metastases to brain (multiple lesions) with hemorrhage into right thalamic lesion. After consultation with the oncology team and patient's family decision was made to focus care on comfort and patient was discharged home with hospice. ALTERED MENTAL STATUS (AMS) ?????? patient was transientently intubatied for airway protection to allow for disgnostic testing. Attributed to multiple brain mets, some with complication of bleeding, and surrounding vasogenic edema. No clinical or EEG evidence for active seizures. Treated with oral steroids and prophylactic anti-convulsant. BRAIN LESIONS ?????? Not previously recognized. Likely metastatic disease from her known poorly differentiated CA of uncertain primary. Evidence for hemorrhage into lesions per CT. Per our oncology team no further theraputic or palliative chemo/radiation can be offered that would be of benefit to the patient. HEMIPLEGIA, LEFT ?????? likely [**2-7**] to acute bleed into brain mets(consistent with right thalamic lesion and hemmorage seen on CT). Repeat Head CT without significant change. CARCINOMA ?????? metastatic poorly differentiated, unclear etiology. Per oncology team no plans for further chemotherapy. RIGHT LEG SWELLING ?????? recent orthopedic surgery ORIF. No further interventions with Orthopedic service. No evidence for DVT by LE NIVS. Goals of care: meeting was held with patient's family, ICU and Oncology team, per patient's dire condition and family's wishes decision to transition to comfort focused care. Patient was followed by palliative care and is now dicharged to out patient hospice. DISPOSITION -- returned home with hospice services. Discharge Medications: 1. methadone in 0.9 % sod. chlor 1 mg/mL (1 mL) Syringe Sig: 0.6 mg per hour Intravenous continuous via CADD pump: + Bolus 0.2mg every 20 minutes PRN breakthrough pain . Disp:*10 100ml vials* Refills:*0* 2. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Fourteen (14) units Subcutaneous at bedtime. Disp:*30 ml * Refills:*0* 3. One Touch Ultra System Kit Kit Sig: One (1) kit Miscellaneous four times a day. Disp:*1 kit* Refills:*0* 4. Dilaudid concentrate (20mg/ml) Sig: 0.5-1 mL Sublingual q2hr as needed for pain/respiratory distress: Please use 0.5-1mL (10-20mg) q2 hours sublinguially PRN for pain or respiratory distress. Disp:*60 mL* Refills:*0* 5. Ativan liquid (2mg/ml) Sig: 0.5 ml Sublingual every six (6) hours: Please use 1mg (0.5ml) sublingually q6hrs. [**Month (only) 116**] hold for sedation. Disp:*30 mL* Refills:*0* 6. bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal once a day: [**Month (only) 116**] hold for loose stools. Disp:*30 suppositories* Refills:*0* 7. acetaminophen 650 mg Suppository Sig: One (1) suppository Rectal every six (6) hours as needed for fever or pain. Disp:*30 suppositories* Refills:*2* 8. sodium chloride 0.9 % 0.9 % Parenteral Solution Sig: One (1) liter Intravenous q nightly: Please run 1 Liter nightly at 100ml/hr over 10 hours. Disp:*7 liters* Refills:*2* 9. dexamethasone oral solution (10mg/ml) Sig: One (1) ml Sublingual every eight (8) hours: Please place 1ml sublingual q8 hours. Disp:*60 ml* Refills:*0* 10. supplies Please supply with One Touch Ultra testing strips. Dispense 100 strips, no refills 11. One Touch UltraSoft Lancets Misc Sig: One (1) lancet Miscellaneous every six (6) hours. Disp:*100 lancets* Refills:*0* 12. Normal Saline Flush 0.9 % Syringe Sig: Ten (10) cc Injection five times a day as needed for IV flush: 10cc flush to IV site PRN. Disp:*30 syringes* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 3005**] Hospice Discharge Diagnosis: Primary: metastatic brain cancer Secondary: endometrial cancer Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. [**Known lastname **], It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted because you were found unresponsive and with trouble moving the left side of your body. You had a head CT scan here that showed multiple areas of cancer in the brain. You were initially intubated to support your breathing but the breathing tube was quickly removed and you have been breathing well on your own. With the help of your family, we have arranged for you to be able to go home and be comfortable. Please take the following medications: 1. Please use a methadone pump at 0.6 mg per hour Intravenous continuous infusion via CADD pump: + Bolus 0.2mg every 20 minutes as needed for breakthrough pain 2. Please check blood sugars daily and give glargine 14 units for blood sugars >200. Please do not give if sugars are <200. 3. Please use Dilaudid for breakthrough pain control. Use 0.5-1 ml under the tongue as needed for pain every 2 hours. 4. Please use ativan to prevent seizures. Place 0.5ml under the tongue every 6 hours. This may be held if Ms. [**Known lastname **] is too sedated and sleepy. 5. Please use bisacodyl 10 mg Suppository daily. This should be held for loose stools. 6. Use acetaminophen 650 mg Suppository every 6 hours as needed for fever or pain. 7. Take dexamethasone 1mL under the tongue every 8 hours. 8. Please take 1 liter of fluid (normal saline) nightly, to be run at 100cc/hr for 10 hours. Followup Instructions: Please follow up with the hospice facility who will be following you at home. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**] Completed by:[**2181-11-23**]

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icd9cm

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Discharge summary

report

Admission Date: [**2196-5-10**] Discharge Date: [**2196-5-13**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: aspiration Major Surgical or Invasive Procedure: None History of Present Illness: This is a [**Age over 90 **] yo female with history of severe COPD on home oxygen(4L), diastolic heart failure, and kyphoscoliosis who was recently discharged to [**Hospital1 **] after admission for aspiration pna/pneumonitis who now presents with increasing shortness of breath after aspirating. She was being treated at her [**Hospital 4382**] for Pneumonia with Vanc/Zosyn through PICC, however she had an aspiration event during dinner, unable to take meds and possibly in need of NG tube prompting transfer to the ED. There she was placed on a NRB and unable to wean down, so admitted to ICU. In the ED, initial vs were: T 100.3 HR 89 afib BP 118/72 RR 28 POx 100% on NRB. CXR showed worsening Right effusion and [**Name6 (MD) **] [**Name8 (MD) **] MD, family would be okay with feeding tube in setting of chronic aspiration. On floor she appears comfortable on 100% face mask. She denies SOB and does not recall why she is here. She is confused when we attempt to explain what has happened and cannot re-iterate the consequences of chronic aspiration or a PEG tube when explained to her. Review of systems: (+) She does state she has some belly pain and has not stooled in several days. (-) Denies chest pain, nausea, vomiting, diarrhea. Past Medical History: Diastolic Heart Failure Atrial Fibrillation on coumadin Remote h/o TIAs COPD on home O2 (3-4L at baseline) Scoliosis Osteoarthritis L hip/R pelvis fx managed nonoperatively Recent LLE cellulitis Anxiety Chronic Anemia (baseline hct 32) Social History: From chart, limited [**12-28**] BIPAP Lives at nursing home. Ambulates with a walker at baseline. Alert and oriented x 3 at baseline. On home oxygen 3-4L. Past smoker but quit 30 years ago. No ethanol or illict drugs. Son and daughter live nearby and are involved. Family History: Positive for hypertension and type II diabets. Given age non-contributory to current illness. Physical Exam: Vitals: T: 96.7 BP: 113/61 P: 89 R: 14 O2: 100% on NRB General: Easily arousible, follows commands, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple Lungs: Diminished breath sounds on Right side, but otherwise clear. CV: Irregularly irreg, 2/6 SEM at LUSB Abdomen: soft, non-tender, mildly distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: 2+ pulses, no clubbing, cyanosis. No edema at ankles. Neuro: Asking questions, AOx2. Pertinent Results: [**2196-5-10**] 10:17PM PT-16.0* PTT-31.3 INR(PT)-1.4* [**2196-5-10**] 12:32PM PO2-54* PCO2-68* PH-7.46* TOTAL CO2-50* BASE XS-20 COMMENTS-GREEN TOP [**2196-5-10**] 12:32PM LACTATE-1.7 [**2196-5-10**] 12:25PM GLUCOSE-77 UREA N-26* CREAT-1.0 SODIUM-140 POTASSIUM-3.6 CHLORIDE-91* TOTAL CO2-47* ANION GAP-6* [**2196-5-10**] 12:25PM DIGOXIN-0.9 [**2196-5-10**] 12:25PM WBC-9.3 RBC-3.26* HGB-9.6* HCT-30.1* MCV-92 MCH-29.4 MCHC-31.9 RDW-17.6* [**2196-5-10**] 12:25PM NEUTS-91.0* LYMPHS-6.3* MONOS-2.2 EOS-0.4 BASOS-0.1 [**2196-5-10**] 12:25PM PLT COUNT-173 . [**2196-5-10**] CXR - poor baseline with kyphoscoliosis, interval increase in right sided effusion, increased pulmonary vascular congestion as compared w/ prior, final read pending . EKG: A-fib rate 96, nl axis, LVH, old TWI in lateral leads, unchaged from prior. . BEDSIDE SWALLOW EVAL: 1. Suggest determining goals of care with planned family meeting. 2. If the family wishes to continue to allow the pt to eat, understanding the risks of intermittent aspiration, I would suggest the following: a) PO diet of thin liquids and moist ground solids b) strict supervision for meals- pt needs to be fed to reduce risk of aspiration c) slow rate of increase - take breaks during intake to allow RR to return to baseline d) take down high flow mask and then return after each bite and sip e) pills crushed with puree f) alternate between bites and sips g) sit upright for 30 minutes after meals 3. If the family wishes to get a more objective view of her swallowing, we can certainly take her for a video swallow, but I do not feel it will be representative of a full meal and may not reveal the occasional aspiration episodes that are occurring. Brief Hospital Course: # Aspiration: Patient with known chronic aspiration risk, unable to take PO meds at [**Hospital1 **]. She gets confused during attempts to explain what has happened during her aspiration events likely due to her baseline dementia. Had S&S study in [**3-3**] with recommendation for soft dysphagia diet. HCP and grandson met with palliative care, social work, and with ICU team regarding peg tube placement. Decided NO PEG tube but are not ready to make decision re: no further hospitalizations/hospice. # Hypoxia/Hypercarbia - Baseline PO2 in 60s with PCO2 in 70s. Etiology is most likely worsening right pleural effusion vs. aspiration pneumonitis/pneumonia. Underlying COPD, kyphoscoliosis contributing. ABG with improved hypercarbia from baseline - PCO2 68. Had lactate of 1.7. Was receiving coverage for health-care associated with vanc/zosyn (Day 1=[**2196-5-4**] on previous admission). We continued these abx here and she remained afebrile. Was kept on Non-invasive ventilation when sleeping to keep sats 89-92%. - Vanc and Zosyn to end on [**2196-5-15**] # COPD and restrictive lung disease from severe scoliosis/kyphosis on home O2 (3-4L at baseline): On admission bicarb was at her baseline suggesting no CO2 retention. She was continued on atrovent/albuterol nebs. # A fib on coumadin: Last INR was [**2196-5-6**] 2.3 and she was initially rate-controlled although off home beta blocker she had HRs in 100s. She was restarted on Diltiazem with good rate control. Long-term anticoagulation with coumadin would not be beneficial, so she was kept on a full dose aspirin. # Acute on chronic Diastolic heart failure: ECHO from [**10/2195**] showed EF of 70-80% with Mild PAH and significant pulmonic regurg. IV lasix was given PRN while NPO. # Prophylaxis: Subcutaneous heparin # Goals of Care: The family will discuss further what things would constitute most important "quality of life" for Ms. [**Known lastname 54770**], and clinical plans will be guided by that. For now she will continue IV antibiotics, other meds as needed for her chronic illnesses, and efforts will be made to wean her from the mask that she does not like. # Code: DNR/DNI per nursing home records and confirmed with HCP # Communication: [**Name (NI) **] (son/power of attorney) [**Telephone/Fax (5) 81861**]. [**Doctor First Name **] (daughter) [**Telephone/Fax (3) 81862**], [**Doctor First Name 1494**] (daughter): [**Telephone/Fax (1) 81863**]. Medications on Admission: Heparin 5,000 U TID Famotidine 20 mg daily Ipratropium Nebs Q6H. Digoxin 125 mcg EVERY OTHER DAY Buspirone 10 mg TID Citalopram 20 mg DAILY Ferrous Gluconate 325 mg DAILY Senna 8.6 mg HS Bisacodyl 10 mg daily Metoprolol Tartrate 12.5 mg [**Hospital1 **] Ascorbic Acid 500 mg Daily Albuterol Neb Q4H PRN SOB, wheezing. Prednisone 20 mg daily Aspirin 325 mg DAILY Furosemide 40 mg DAILY Furosemide 60 mg Q4PM. Vancomycin 1000 mg IV Q48H First dose [**2196-5-4**] Piperacillin-Tazobactam 2.25 g IV Q6H First dose [**2196-5-4**] Ondansetron 4 mg IV Q8H:PRN nausea Cardizem CD 180 mg Daily. Insulin Lispro QACHS: sliding scale, w/ meals start at BS 160 - 2units, go up by 2 units for every increase in 40 of BS. At HS, start at BS 200 same scale. Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 2. Famotidine 20 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO twice a day. 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO every other day. 5. Buspirone 10 mg Tablet Sig: One (1) Tablet PO three times a day. 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. 7. Ferrous Gluconate 325 mg Tablet Sig: One (1) Tablet PO once a day. 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 10. Diltiazem HCl 30 mg Tablet Sig: 1.5 Tablets PO QID (4 times a day). 11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a day. 12. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization Sig: [**11-27**] neb Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 13. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO once a day. 14. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 15. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day. 16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 17. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO QPM. 18. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gm Intravenous Q 24H (Every 24 Hours) for 2 days: to end on [**2196-5-15**]. 19. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: 2.25 grams Intravenous Q6H (every 6 hours) for 2 days: To end on [**2196-5-15**]. 20. Ondansetron 4 mg IV Q8H:PRN nausea 21. Insulin Lispro 100 unit/mL Solution Sig: as directed units Subcutaneous QACHS: Insulin Lispro QACHS: sliding scale, w/ meals start at BS 160 - 2units, go up by 2 units for every increase in 40 of BS. At HS, start at BS 200 same scale. 22. Lorazepam 2 mg/mL Syringe Sig: 0.5 mg Injection Q6H (every 6 hours) as needed for agitation. 23. Polyethylene Glycol 3350 100 % Powder Sig: Seventeen (17) gm PO DAILY (Daily) as needed for constipation. 24. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital **] Health Care Center Discharge Diagnosis: Primary: - Chronic aspiration - Aspiration pneumonia - COPD/resrictive lung disease Discharge Condition: Hemodynamically stable, on stable O2 requirement of [**1-27**] L with CPAP at night. Discharge Instructions: You came to the hospital after an aspiration event and possible need for a PEG tube. It was decided that a PEG tube would not prevent aspiration and would be an unnecessary risk. YOU ARE AT HIGH RISK FOR CONTINUED INTERMITENT ASPIRATION. You had a swallow evaluation and we recommend the following: a) PO diet of thin liquids and moist ground solids b) strict supervision for meals- pt needs to be fed to reduce risk of aspiration c) slow rate of increase - take breaks during intake to allow RR to return to baseline d) take down high flow mask and then return after each bite and sip e) pills crushed with puree f) alternate between bites and sips g) sit upright for 30 minutes after meals . Medication changes: - Your cardizem was changed to short acting diltiazem - Your prednisone was weaned to 10 mg daily. - You should continue the Vanc/Zosyn until [**2196-5-15**]. . Please call your doctor or return to the ED if you have shortness of breath, fevers, chills, chest pain, abdominal pain, nausea, vomiting or other concerns. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Followup Instructions: Please see your [**First Name8 (NamePattern2) **] [**Last Name (Titles) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 608**] in the next 1-2 weeks. Completed by:[**2196-5-13**]

[ "V58.61", "294.8", "438.9", "737.30", "518.0", "507.0", "300.00", "V15.82", "428.33", "493.22", "285.9", "427.31", "V64.1", "428.0" ]

icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

10022, 10083

4485, 6931

273, 279

10211, 10298

2747, 4462

11502, 11687

2121, 2217

7724, 9999

10104, 10190

6957, 7701

10322, 11019

2232, 2728

1425, 1558

11039, 11479

223, 235

307, 1406

1580, 1817

1833, 2105

16,025

182,011

24574

Discharge summary

report

Admission Date: [**2152-7-19**] Discharge Date: [**2152-7-22**] Date of Birth: [**2092-3-16**] Sex: F Service: CARDIOTHORACIC Allergies: Codeine / Talwin / Nafcillin / Ace Inhibitors Attending:[**First Name3 (LF) 492**] Chief Complaint: Respiratory distress and stridor. Major Surgical or Invasive Procedure: [**2152-7-19**] Flexible bronchoscopy with therapeutic aspiration and excision of endotracheal tumor. [**2152-7-20**] 1. Rigid bronchoscopy 2. Flexible bronchoscopy. 3. Tracheal silicone stent replacement. 4. External fixation with the silicone tracheal stent. History of Present Illness: Ms. [**Known lastname 62065**] is a 60 y/o, F, who has a very complicated past medical history including tracheostomy followed by decannulation, status post stent placement for tracheobronchomalacia followed by removal, St. [**Known lastname 923**] valve placement for mitral valve prolapse, hypertension, and aortic stent with dissection. She S/P tracheal silicone stent with external fixation 2 days ago on [**2152-7-17**] for her cervical tracheal stenosis and did well post-op and was discharged home that same day. Earlier this morning, she started experiencing progressive dyspnea in addition to stridor with minimal productive cough. She was seen at [**Hospital 1562**] hospital ED then sent here for further eval. She denies any chest pain, fevers, chills, or hemoptysis. Past Medical History: Severe Bronchomalacia with extreinic compression of distal right main stem bronchus s/p Y stent removal [**2151-1-5**] Tracheostomy & G-tube HTN HLD CHF GERD Pulmonary AVM emboli [**1-28**] Cushings Disease s/p left adrenalectomy & incidental splenetomy\ [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 923**] [**Last Name (NamePattern1) **] Placment [**2143**] on coumadin AAA repair [**2143**] Cardiac Arrest x 2 Social History: unknown. Family History: NC Pertinent Results: [**2152-7-19**] 02:39PM BLOOD WBC-10.5 RBC-4.00* Hgb-12.3 Hct-40.0 MCV-100* MCH-30.7 MCHC-30.7* RDW-15.2 Plt Ct-117*# [**2152-7-19**] 02:39PM BLOOD Glucose-174* UreaN-13 Creat-0.9 Na-143 K-4.4 Cl-109* HCO3-23 AnGap-15 Brief Hospital Course: Mrs. [**Known lastname 62065**] was admitted on [**2152-7-19**] Respiratory distress and stridor with tracheal stenosis status post recent silicone tracheal stent placement with external fixation and [**2152-7-17**]. Overnight she was transferred to the SICU for respiratory distress. She was placed on heliox. She underwent Flexible bronchoscopy with therapeutic aspiration and excision of endotracheal tumor. Her respiratory status improved. She weaned off heliox. On [**2144-7-20**] she went to the operating room for Rigid and Flexible bronchoscopy. Tracheal silicone stent replacement. External fixation with the silicone tracheal stent. She did well was monitored in the PACU prior to transfer to the floor. She continued on Lovenox and her coumadin was restarted. Her respiratory status was monitored closely for the next 24-48 hours. Aggressive pulmonary toilet and nebs were continued. She tolerated a regular diet and was discharged on [**2152-7-22**]. She will follow-up as an outpatient. Medications on Admission: Hypertension, coronary artery disease, gastroesophageal reflux disease, she has a history of [**Location (un) **] disease status post left adrenoidectomy and splenectomy, she has a St. [**Male First Name (un) 1525**] aortic valve, and is anticoagulated, TBM, cervical tracheal stenosis. Discharge Medications: 1. Prednisone 5 mg Tablet [**Male First Name (un) **]: One (1) Tablet PO DAILY (Daily). 2. Enoxaparin 80 mg/0.8 mL Syringe [**Male First Name (un) **]: One (1) dose Subcutaneous [**Hospital1 **] (2 times a day): stop when INR > 2.0. Disp:*15 * Refills:*2* 3. Nexium 40 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. Lexapro 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 5. Ativan 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO every six (6) hours as needed. 6. Wellbutrin SR 100 mg Tablet Sustained Release [**Hospital1 **]: One (1) Tablet Sustained Release PO once a day. 7. Aspirin 325 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1) Tablet, Delayed Release (E.C.) PO once a day. 8. Multivitamin Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 9. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 10. Warfarin 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Once Daily at 4 PM: take as directed to maintain INR 2.0-3.0. 11. Mucinex 1,200 mg Tab, Multiphasic Release 12 hr [**Hospital1 **]: One (1) Tab, Multiphasic Release 12 hr PO twice a day. 12. Calcium 600 600 mg (1,500 mg) Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 13. Ergocalciferol (Vitamin D2) 400 unit Capsule [**Hospital1 **]: One (1) Capsule PO once a day. 14. Provigil 100 mg Tablet [**Hospital1 **]: 0.5 Tablet PO once a day. 15. Simvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 16. Clindamycin HCl 150 mg Capsule [**Hospital1 **]: Three (3) Capsule PO Q8H (every 8 hours) for 7 days. Disp:*21 Capsule(s)* Refills:*0* 17. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Two (2) PO BID (2 times a day) for 10 days. Disp:*20 * Refills:*1* Discharge Disposition: Home With Service Facility: VNA Assoc. of [**Hospital3 **] Discharge Diagnosis: Respiratory distress and stridor tracheal stenosis status post recent silicone tracheal stent placement with external fixation Discharge Condition: stable Discharge Instructions: Call Dr.[**Name (NI) 5070**] office [**Telephone/Fax (1) 7769**] if experience: -Fevers > 101 or chills, increased shortness of breath, cough or sputum production. -Difficulty with T-tube Lovenox: 80 mg twice daily until INR > 2.0 Coumadin 5 mg daily. Blood Draw Monday Follow-up with Dr. [**Last Name (STitle) **] for coumadin managment Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] as directed Follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 62067**] for further coumadin dosing [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**] Completed by:[**2152-7-25**]

[ "V43.3", "V58.65", "V09.80", "E915", "519.19", "V58.61", "518.81", "V02.59", "934.0", "428.0", "401.9", "493.20", "V45.79", "530.81" ]

icd9cm

[ [ [] ] ]

[ "31.93", "31.42", "33.23", "98.15" ]

icd9pcs

[ [ [] ] ]

5346, 5407

2183, 3195

346, 609

5578, 5587

1941, 2160

5974, 6277

1918, 1922

3533, 5323

5428, 5557

3221, 3510

5611, 5951

272, 308

637, 1420

1442, 1875

1891, 1902

48,292

197,329

6905

Discharge summary

report

Admission Date: [**2113-12-8**] Discharge Date: [**2113-12-11**] Date of Birth: [**2056-11-26**] Sex: M Service: UROLOGY Allergies: Magnevist Attending:[**First Name8 (NamePattern2) 19908**] Chief Complaint: Gross Hematuria, bladder tumors Major Surgical or Invasive Procedure: PROCEDURE [**2113-12-8**]: Cystoscopy; resection of extensive bladder tumor. History of Present Illness: 57yM w/ heart failure, gross hematuria, found to have multiple bladder tumors s/p TURBT with post-op hypotension requiring neo-synephrine gtt, transfer to the ICU. Past Medical History: PMH: DM2 CHF EF 20-25% HL Prostate cancer s/p brachytherapy PSH: repair ruptured quadriceps tendon CHF (thought to be secondary to viral cardiomyopathy). HTN. Prostate cancer. Hematuria. Diabetes mellitus. Irregular pulse. . Cardiac Risk Factors: +Diabetes, +Dyslipidemia, +Hypertension Unknown coronary anatomy (cath 12 yrs ago); no ICD/PPM. Social History: currently smoking a few cigarettes daily; is in a smoking cessation program. No etoh or illicit drugs. Lives at home alone and working. He is having increased stress secondary to problems with his neighbors. [**Name (NI) 1403**] for [**Company 25186**]. Family History: parents both died of cancer; hx of DM in family Physical Exam: AVSS WdWn obese Black male, NAD Ambulating about room, no antalgic gait voiding on own without difficulty No respiratory distress Abdomen obese, NT/ND, soft Lower extremities warm, dry, well perfused. no calf pain or pedal edema. Pertinent Results: [**2113-12-10**] 02:39PM BLOOD WBC-12.5* RBC-3.88* Hgb-10.4* Hct-31.5* MCV-81* MCH-26.7* MCHC-32.9 RDW-16.0* Plt Ct-330 [**2113-12-10**] 03:23AM BLOOD WBC-14.1* RBC-3.81* Hgb-10.2* Hct-30.2* MCV-79* MCH-26.9* MCHC-33.9 RDW-15.7* Plt Ct-298 [**2113-12-10**] 02:39PM BLOOD Glucose-144* UreaN-14 Creat-1.0 Na-135 K-4.1 Cl-106 HCO3-22 AnGap-11 [**2113-12-10**] 03:23AM BLOOD Glucose-99 UreaN-14 Creat-1.1 Na-137 K-4.0 Cl-106 HCO3-22 AnGap-13 [**2113-12-10**] 02:39PM BLOOD Calcium-8.4 Phos-3.0 Mg-2.0 [**2113-12-10**] 03:23AM BLOOD Calcium-8.4 Phos-2.6* Mg-1.9 Brief Hospital Course: 57yM w/ heart failure, gross hematuria, found to have multiple bladder tumors admitted to Dr.[**Name (NI) 19910**] urology service after Extensive bladder tumors (appear high-grade and invasive) with involvement of the bladder neck and proximal prostate. Intra-operatively Mr.[**Known lastname 26015**] was hypotensive requiring pressor agents and although he was he was taken to the recovery room in stable condition, he still had a tendency for hypotension and he was therefore transferred to the ICU. 57 M s/p TURBT w/ partial resection of tumor admitted to SICU for hypotension requiring neo. The patient had been found to have multiple bladder tumors and was taken to the OR with the Urology service. He tolerated the procedure without difficulty, but required continuing neosynephrine to maintain adequate BP. Of note, the patient has CHF with a known EF of ~20%. [**12-8**] - To OR for TURBT, admitted to SICU w/ hypotension on pressors. [**12-9**] - CT read prelim, fluid in pelvis likely post-op swelling, cysts in kidneys, no hydro, no renal massess, stable adrenal lesions. Cardiac recs- restart home meds as tolerated. Uro to take out foley. Was stable, about to transfer out, when spiked fever to 101, tachycardic. WBC slightly higher than yesterday. Pancultured, CXR. 5mg metoprolol IV. Weaned off pressors in AM, CT Abd/Pelvis, Febrile in evening- pancultured. [**12-10**] - Patient went into SVT vs. afib with HR in 110s. Home meds metoprolol, digoxin were restarted. Received 500ml NS for SBP 90's with HR~100s. Transferred to floor late in the day. [**Date range (1) 26016**]: Mr. [**Known lastname 26015**] remained stable on the general floor without further episodes of severe hypotension and at time of discharge was on his metoprolol and digoxin with explicit plans to f/u with his cardiologist, Dr. [**First Name (STitle) 437**] in the next day or so. All of his questions were answered. Medications on Admission: Meds: ASA 81mg (stopped) Digoxin 250mcg QD Furosemid 80mg QD Insulin Atrovent Lisinopril 5mg Toprol XL 200mg Zocor 20mg QD Aldactone 25mg QD Allergies: Magnevist injection Discharge Medications: 1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. insulin regular human 100 unit/mL Solution Sig: [**2-4**] Units Injection ASDIR (AS DIRECTED): Home Sliding Scale. 3. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain: Do not drive or consume alcohol while taking pain medication. Disp:*20 Tablet(s)* Refills:*0* 6. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. metoprolol succinate 100 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 5 days. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: PREOPERATIVE DIAGNOSIS: Bladder tumors. POSTOPERATIVE DIAGNOSIS: Extensive bladder tumors (appear high-grade and invasive) with involvement of the bladder neck and proximal prostate. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. -No vigorous physical activity for 2 weeks. -Expect to see occasional blood in your urine and to experience urgency and frequecy over the next month. -You may shower and bathe normally. -Tylenol should be your first line pain medication, a narcotic pain medication has been prescribed for breakthough pain >4. Replace Tylenol with narcotic pain medication. Max daily Tylenol dose is 4gm, note that narcotic pain medication also contains Tylenol (acetaminophen) -Do not drive or drink alcohol while taking narcotics -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication, discontinue if loose stool or diarrhea develops. -Continue with your digoxin and your Metoprolol as instructed but DO NOT RESUME LASIX, SPIRONOLACTONE, LISINOPRIL until cleared by Dr. [**First Name (STitle) 437**] later this week. Hold NSAIDs (aspirin, and ibuprofen containing products such as advil & motrin,) until you see your urologist in follow-up or until advised to resume by Dr. [**First Name (STitle) 437**]. -If you have fevers > 101.5 F, vomiting, severe abdominal pain, or inability to urinate, call your doctor or go to the nearest emergency room. Followup Instructions: 1) Please call Dr. [**Last Name (STitle) 9125**], your urologist, for follow-up and if you have any questions. [**Name8 (MD) 9125**], M.D., [**Doctor Last Name **] Office Phone: ([**Telephone/Fax (1) 26017**] Office Location: [**Street Address(2) 26018**]; [**Location (un) 620**], [**Numeric Identifier 18724**] [**First Name9 (NamePattern2) **] [**Location (un) 620**] 2) YOU MUST CALL AND ARRANGE F/U WITH YOUR CARDIOLOGIST. YOUR APPOINTMENT SHOULD BE THIS WEEK. PLEASE CALL WHEN YOU GET HOME OR FIRST THING IN THE MORNING ON [**2113-12-12**]. Name: Dr. [**First Name (STitle) 437**], [**First Name3 (LF) 449**] D Division:Cardiology Organization:[**Hospital1 18**] Office Location:W/[**Hospital1 **] 319 Patient Phone:([**Telephone/Fax (1) 2037**] Completed by:[**2113-12-12**]

[ "458.29", "188.8", "285.1", "599.71", "185", "428.0", "428.20", "V10.46", "250.00" ]

icd9cm

[ [ [] ] ]

[ "57.49" ]

icd9pcs

[ [ [] ] ]

5128, 5134

2136, 4053

314, 393

5363, 5363

1555, 2113

6832, 7618

1241, 1290

4276, 5105

5155, 5342

4079, 4253

5514, 6809

1305, 1536

243, 276

421, 586

5378, 5490

608, 953

969, 1225

15,120

113,480

7416

Discharge summary

report

Admission Date: [**2171-4-15**] Discharge Date: [**2171-4-23**] Service: CCU CHIEF COMPLAINT: The patient was transferred to the Coronary Care Unit from Catheterization Laboratory status post myocardial infarction, status post intra-aortic balloon pump placement. HISTORY OF PRESENT ILLNESS: The patient is an 82 year old female with no known prior history of coronary artery disease, with a history of lung, breast and colon carcinoma, who presented to [**Hospital 26200**] Hospital with a CK of 3,243. The patient was in her usual state of health prior to her presentation to that hospital until three days prior when she developed dyspnea on exertion. Her symptoms developed into dyspnea at rest, and she was noted to have an O2 saturation of 83%. The patient denied any chest pain at that time. At the outside hospital, her EKG showed ST elevations in V2 through V6, with Q waves present. She was transferred to [**Hospital1 69**] at which time she had a heart rate of 87, a blood pressure of 128/80 and an O2 saturation of 97 on five liters. She got aspirin, nitro paste, Lopressor intravenously, intravenous Lasix, and a heparin drip. She was then taken to the Catheterization Laboratory on arrival at [**Hospital1 69**] which showed a total occlusion of her proximal left anterior descending, total occlusion of her left circumflex, 60% proximal right coronary artery and a 30% obtuse marginal coronary artery. She had minimal right to left collaterals and left to left collaterals. Her right heart catheterization showed a wedge pressure of 27 and a PA-saturation of 49%. Her ejection fraction was 15% with anterior and inferior septal akinesis with an apical thrombus present. An intra-aortic balloon pump was placed secondary to cardiogenic shock. She was going to be evaluated by Cardiothoracic Surgery for whether she is an operable candidate. PAST MEDICAL HISTORY: 1. Hypertension. 2. Osteoporosis. 3. Colon carcinoma status post partial colectomy in 11/98. 4. Lung carcinoma. 5. Status post left upper lobe lobectomy in [**2167**]. 6. Breast carcinoma. 7. Peripheral vascular disease. 8. Irritable bowel syndrome. 9. Chronic obstructive pulmonary disease. 10. Spinal stenosis. 11. History of transient ischemic attack. 12. Depression. MEDICATIONS: 1. Imipramine 25 q. day. 2. Oxybutynin 5 q. day. 3. Aricept 10 q. day. 4. Zestril 20 q. day. 5. Tylenol 650 three times a day. 6. Lomotil 2 tablets q. day. 7. Aspirin 325 q. day. ALLERGIES: Aricept causes nausea and the patient is allergic to penicillin. SOCIAL HISTORY: The patient lives with her husband in a senior living complex. She has a remote smoking history. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: On admission, vital signs are temperature 98.9 F.; heart rate 85; blood pressure 127/68; O2 saturation 97%; respiratory rate 24. In general, the patient is mildly agitated, answering questions appropriately, in no acute distress. HEENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements intact. Tongue midline; moist mucous membranes. Neck: No bruits. Jugular venous distention above clavicle with minimal head elevation. Heart is regular rate and rhythm with normal S1 and S2, positive S3. No murmurs, rubs or gallops. Lungs are clear to auscultation anteriorly. Abdomen with positive bowel sounds, soft, nontender, nondistended. Guaiac negative on presentation at outside hospital. Extremities with palpable dorsalis pedis pulses bilaterally, trace lower extremity edema. Left groin sheath without hematoma. Neurological: Cranial nerves II through XII intact. Moving all extremities. LABORATORY: On arrival, white blood cell count 17.9; hematocrit 41.9, platelets 226; 85% neutrophils, 11 lymphs, 3 monocytes. PT 14.8, PTT 150 and INR 1.5. Sodium 149, potassium 4.5, chloride 113, bicarbonate 20, BUN 23, creatinine 1.1 and glucose 146. CK 3294, up from 3243 at the outside hospital. Arterial blood gas was 7.48, 29 and 94. EKG after catheterization showed ST elevation as well as Q waves in V2 through V6, with Q's in II and AVL. Chest x-ray showed congestive heart failure with a left sided effusion. HOSPITAL COURSE: 1. Cardiovascular: 1) Ischemia - the patient who presented with acute ST elevation myocardial infarction. She had cardiac catheterization with a total occluded proximal left anterior descending, totally occlusion in the left circumflex and 60% proximal right coronary artery. The patient had three-vessel disease. Also noted on catheterization was severe systolic dysfunction and elevated filling pressures with cardiogenic shock. She had an intra-aortic balloon pump placed. She was continued on heparin and aspirin. The patient was found not to be a surgical candidate. She was eventually started on an ACE inhibitor and beta blocker after her blood pressure had stabilized when she was out of the Intensive Care Unit and continued on aspirin. The patient was also sent home on Coumadin given her low ejection fraction. 2) Pump - the patient was found to be in cardiogenic shock and had an intra-aortic balloon pump placed during cardiac catheterization. She developed some hypotension on the following day and the patient was started on Dobutamine. The patient also was put on Nipride. She had an echocardiogram that was done on [**2171-4-17**], which showed [**Doctor First Name **] ejection fraction of 20 to 25% and severe left global hypokinesis and severe pulmonary artery hypertension. The patient was then weaned off the intra-aortic balloon pump on the 2nd and pressors were eventually weaned off. She was started on ACE inhibitor and beta blocker. Given her poor ejection fraction, she was continued on heparin and started on Coumadin. She was discharged home on Coumadin. The patient was also started on low-dose Lasix and eventually sent home on 20 q. day. DISCHARGE DIAGNOSES: 1. Acute myocardial infarction. 2. Cardiogenic shock. 3. Hypertension. 4. Osteoporosis. 5. Colon carcinoma. 6 Lung carcinoma. 7. Breast carcinoma. 8. Peripheral vascular disease. 9. Irritable bowel syndrome. 10. Chronic obstructive pulmonary disease. 11. Spinal stenosis. 12. History of transient ischemic attack. 13. Depression. 14. Severe systolic dysfunction with an ejection fraction of 20%. DISCHARGE MEDICATIONS: 1. Imipramine 25 q. day. 2. Oxybutynin 5 q. day. 3. Aricept 10 q. day. 4. Zestril 10 q. day. 5. Tylenol 650 three times a day. 6. Lomotil 2 tablets q. day. 7. Aspirin 325 q. day. 8. Lopressor 12.5 twice a day. 9. Lasix 20 q. day. DISCHARGE INSTRUCTIONS: 1. The patient is going to follow-up with Dr. [**First Name (STitle) **] [**Name (STitle) 121**] of Cardiology at [**Hospital3 4527**], whose phone number is [**Telephone/Fax (1) 4105**]. 2. The patient will follow-up with her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 27226**]. DISPOSITION: The patient will be discharged home to [**Hospital3 **] with 24-hour care, Visiting Nurses Association and Physical Therapy. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**] Dictated By:[**Name8 (MD) 2069**] MEDQUIST36 D: [**2171-6-27**] 11:15 T: [**2171-6-29**] 16:14 JOB#: [**Job Number 27227**]

[ "428.0", "414.01", "785.51", "V10.3", "V10.05", "410.01", "733.00", "V10.11", "496" ]

icd9cm

[ [ [] ] ]

[ "88.53", "37.61", "37.23", "88.57" ]

icd9pcs

[ [ [] ] ]

2700, 2718

5939, 6346

6369, 6609

4228, 5918

6633, 7356

2742, 4211

106, 277

307, 1883

1905, 2565

2583, 2682

15,541

115,662

44571

Discharge summary

report

Admission Date: [**2139-9-13**] Discharge Date: [**2139-9-15**] Date of Birth: [**2063-11-18**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3984**] Chief Complaint: sepsis, hypoxia Major Surgical or Invasive Procedure: 1. intubation 2. chest tube for pneumothorax 3. central line 4. arterial line History of Present Illness: HPI: 75yo woman with history of HTN, diverticulosis, squamous cell CA of skin, h/o expl. lap for appendicitis, "psychosis", presented from the [**Hospital3 **] facility with respiratory distress. Per outside records, she had acute onset of respiratory distress today at 1pm. She has also had 2 days of non-productive cough and low grade fever. Chest film done there demonstrated bilateral pleural effusions and bibasilar infiltrates. She also had a WBC of 18.9 with 85% pmn's. She was started on Levaquin 500mg qD. Vitals at ALF were 99.3, 64, 100/60, 18, and 93% on RA -> 79% on RA with acute episode of respiratory distress. . On admission to the ED, she was in respiratory distress. Admission vitals were 104 (rectal), 117/80, 105, 32, 83% on NRB. After intubation, a chest film demonstrated a large right pneumothorax. She had a needle decompression, then placement of a right chest tube. . She also had evidence of sepsis with fever to 104.8, pulse in 120's, initial lactate of 6.5, and hypotension to 60's systolic despite NS boluses; she was started on peripheral dopamine. A sepsis-line TLC was placed in the ED. She was given 3L NS boluses. . She also had coffee grounds per NG tube, and was guaiac negative by rectal exam. Baseline Hct per outside records of 38.9. In ED, she had gastric lavage revealing coffee grounds that cleared with continued lavage. No known history of cirrhosis or varices. . Past Medical History: Past Medical History: Hypertension polyps on colonoscopy diverticulosis sqaumous cell CA on the face s/p [**1-30**] stage removal hx of exlporatory laparotomy for appendicitis cyst on her uterus "psychosis", SI Social History: The patient was born and raised in the [**Location (un) 86**] Area. She has 2 sisters ages 85, and 65. She is currently living with her 85 year old sister who is in a wheelchair and her brother-in-law who has multiple medical problems. The patient moved to New Jersey after finishing high school where she lived with a friend for 5 years. They then moved to [**Last Name (un) 33963**], FL and she recieved associates degree and began a BA in elementary education in [**Location (un) 95454**], but did not complete this degree. She worked as a medical secretary, transcriber for 20 years in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) 1688**] in Ft. [**Last Name (un) **]. She retired in [**2120**] and moved back to [**Location (un) 86**]. She moved back into the family home with her sister before obtaining an apartment on her own. She moved back into the family home in [**2133**] to help care for her sister and her husband. The patient was never married, never had children. Reports that her only relationship was with her friend whom she lived with in FLA. She reports that this was not a lesbian relationship and that she was merely a "companion". Denies hx of sexual or physical abuse Family History: Denies. Physical Exam: Physical exam: T 104(rectal), 120's sinus tachy, 16, 117/80, 100% on AC (500 x 18, 100%, 8 peep). . gen: intubated, sedated heent: perrla neck: right IJ - sepsis line placed chest: right chest with subcutaneous air/crepitus cv: regular tachycardia with no m/r/g resp: coarse breath sounds bilaterally with basilar crackles; reduced breath sounds in right lung field abd: obese, midline surgical scar. Hypoactive bowel sounds. No appreciable tenderness. No peritoneal signs extr: 1+ pitting edema bilaterally. extremities cool, mottled . Admission data: ekg: sinus tachycardia at 121bpm, nl axis, intervals; 2mm ST depression in V3-V6. . cxr: right pneumothorax with some shift of midline structures to left; otherwise, lungs are clear. Pertinent Results: [**2139-9-13**] 01:50PM LACTATE-6.5* [**2139-9-13**] 02:01PM FIBRINOGE-796* [**2139-9-13**] 02:01PM PT-18.5* PTT-36.6* INR(PT)-2.4 [**2139-9-13**] 02:01PM PLT COUNT-556* [**2139-9-13**] 02:01PM WBC-24.6*# RBC-3.90* HGB-11.9* HCT-35.7* MCV-91# MCH-30.5# MCHC-33.4 RDW-13.0 [**2139-9-13**] 02:01PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2139-9-13**] 02:01PM ALBUMIN-2.3* CALCIUM-8.2* PHOSPHATE-3.7 MAGNESIUM-1.5* [**2139-9-13**] 02:01PM LIPASE-16 [**2139-9-13**] 02:01PM CK-MB-7 cTropnT-0.45* [**2139-9-13**] 02:01PM ALT(SGPT)-17 AST(SGOT)-39 CK(CPK)-49 ALK PHOS-55 AMYLASE-13 TOT BILI-0.8 [**2139-9-13**] 02:01PM GLUCOSE-193* UREA N-21* CREAT-1.0 SODIUM-147* POTASSIUM-3.9 CHLORIDE-108 TOTAL CO2-20* ANION GAP-23* [**2139-9-13**] 02:12PM URINE MUCOUS-MANY [**2139-9-13**] 02:12PM URINE HYALINE-0-2 [**2139-9-13**] 02:12PM URINE RBC-0 WBC-[**1-31**] BACTERIA-FEW YEAST-NONE EPI-[**1-31**] RENAL EPI-0-2 [**2139-9-13**] 02:12PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-1 PH-5.5 LEUK-NEG [**2139-9-13**] 02:12PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.025 [**2139-9-13**] 02:12PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2139-9-13**] 02:12PM URINE HOURS-RANDOM ct scan: . Large right hydropneumothorax with right lower lobe atelectasis. A traumatic cystic lesion is seen within the right lower lobe. There is a suggestion of possible bronchopulmonary fistula. 2. Nasogastric tube with tip at the gastroesophageal junction, and should be advanced. 3. Extensive subcutaneous emphysema within the chest wall. 4. Moderate sized left pleural effusion and compressive atelectasis. 5. Diffuse fatty infiltration of the liver without evidence of focal hepatic masses. 6. Wedge compression deformity of the T12 vertebral body, age indeterminate. echo: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is mild aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior report (tape unavailable for review) of [**2138-11-10**], the degree of tricuspid regurgitation and pulmonary hypertension detected have increased. [**2139-9-13**] 02:12PM URINE HOURS-RANDOM [**2139-9-13**] 05:54PM TYPE-[**Last Name (un) **] PO2-42* PCO2-40 PH-7.36 TOTAL CO2-24 BASE XS--2 COMMENTS-GREEN TOP [**2139-9-13**] 07:29PM CORTISOL-67.5* [**2139-9-13**] 07:29PM CALCIUM-7.5* PHOSPHATE-2.9 MAGNESIUM-1.3* [**2139-9-13**] 07:29PM LD(LDH)-276* [**2139-9-13**] 07:29PM GLUCOSE-221* SODIUM-145 POTASSIUM-3.1* CHLORIDE-109* TOTAL CO2-22 ANION GAP-17 [**2139-9-13**] 09:00PM CORTISOL-58.0* [**2139-9-13**] 09:30PM CORTISOL-58.5* Brief Hospital Course: 75yo woman presented with sepsis, pneumonia complicated by DIC. She was treated with pressors, IVFs and antibiotics. She developed a pneumothorax and required chest tube placement. She had persistent subcutaneous emphysema. She had rapid atrial fibrillation and developed eveidence of a myocardial infarct. Her deteriorated clincally and the team was unable to maintain her BP despite pressors. In a discussion with her nephew [**Name (NI) **] [**Name (NI) **], it wa decided to make her comfort measure. She was extubated and placed on morhine for comfort. She expired on [**2139-9-15**] at 7:45pm. Medications on Admission: ASA 81mg celexxa 30mg diltiazem 180mg metoprolol 25mg [**Hospital1 **] abilify 15mg HS Ativan 0.5mg HS Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: pneumothorax atrial fibrillation septic shock DIC pneumonia ischemia Discharge Condition: expired Discharge Instructions: none Followup Instructions: none [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**] Completed by:[**2139-12-18**]

[ "511.9", "410.81", "410.91", "038.9", "298.9", "285.9", "995.92", "785.52", "486", "512.8", "401.9", "427.31", "998.81", "276.50", "518.81" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.04", "34.04", "00.17", "96.71" ]

icd9pcs

[ [ [] ] ]

8145, 8154

7355, 7963

332, 412

8266, 8275

4167, 7332

8328, 8490

3367, 3376

8116, 8122

8175, 8245

7989, 8093

8299, 8305

3407, 4148

277, 294

440, 1858

1903, 2094

2110, 3351

638

149,359

5117+55648

Discharge summary

report+addendum

Admission Date: [**2154-1-14**] Discharge Date: [**2154-2-1**] Service: Medicine HISTORY OF PRESENT ILLNESS: This is an 84-year-old female with CAD, hypertension, CHF, atrial fibrillation, mitral regurgitation, pulmonary hypertension, status post AVR here from [**Hospital 100**] Rehab complaining of nausea and vomiting and found to have new acute renal failure and transaminitis. Patient was thought to be more confused and weaker with decreased appetite, nausea with retching. She was found to have a potassium of 6.0 in the ED and treated with Kayexalate. Recently her amiodarone dose had been increased. PAST MEDICAL HISTORY: 1. Atrial fibrillation status post cardioversion in [**12-10**]. 2. Coronary artery disease status post MI and CABG. 3. Status post AVR. 4. Status post pacer in [**8-7**] for atrial fibrillation. 5. Status post bilateral breast cancer. 6. Status post right lumpectomy with XRT and left mastectomy. 7. CHF with known EF of 55% in [**10-10**] with 3+ MR, 4+ TR, RV dysfunction and PA hypertension. 8. Status post TIA. 9. Hypertension. 10. Status post TAH/BSO. 11. Anemia. MEDICATIONS ON ADMISSION: 1. Amiodarone 400 mg a day. 2. EC-ASA 325 mg a day. 3. Calcium carbonate. 4. Captopril 6.25 mg t.i.d. 5. Digoxin 0.125 mg q.d. 6. Colace 100 mg p.o. b.i.d. 7. Lansoprazole 30 mg a day. 8. Metoprolol 50 mg b.i.d. 9. Vitamin D. 10. Coumadin 0.5 mg a day. 11. Boost. 12. Tylenol prn. ALLERGIES: 1. Sulfa. 2. Verapamil. 3. Procainamide. SOCIAL HISTORY: Patient comes from [**Hospital 100**] Rehab. Nephew, [**Name (NI) **] [**Name (NI) 21020**] is healthcare proxy. [**Name (NI) **] is widowed. Denies tobacco, alcohol use, or IVDU. PHYSICAL EXAM ON ADMISSION: Temperature 97.6, pulse 70, blood pressure 107/44, respirations 18, and oxygen saturation is 93% on room air. In general, elderly, thin, flat affect, poor historian, alert, NAD. HEENT: Pale conjunctivae. PERRLA. No scleral icterus. Dry mucous membranes. Neck: Jugular venous pressure 10 cm. Chest: Status post left mastectomy. Lungs: Decreased breath sounds at right base with few rales, otherwise clear to auscultation bilaterally. Cardiovascular: Normal S1, S2, regular rate and rhythm, [**3-15**] holosystolic murmur and 2/6 systolic ejection murmur. Abdomen: Normoactive bowel sounds, soft, nontender, and nondistended, no hepatosplenomegaly. Extremities: [**3-12**]+ pitting edema bilaterally, warm, and nonpalpable pedal pulses. Neurologic: Alert and oriented. Able to answer questions. LABORATORY DATA ON ADMISSION: White count 8.2 with 78% neutrophils, 15% lymphocytes, 5% monocytes, hematocrit 33.8, platelets 160, MCV 112. Chemistries remarkable for a K of 4.9, chloride 95, bicarbonate of 28, BUN 49, creatinine 3.4, baseline 1.3 increasing to 2.1 recently, glucose of 86. ALT 202, AST 263, amylase 182, lipase 29. Digoxin level was 3.8. STUDIES: ECG: V-paced at 70 beats per minute. No changes in left bundle branch pattern. Right upper quadrant ultrasound: Noted for ascites and gallstones. HOSPITAL COURSE: 1. Respiratory status: Patient developed progressive respiratory distress on the floor and of unclear reasons developed respiratory arrest necessitating intubation and transfer to the MICU. The etiology of this was unclear, but thought to be due to aspiration pneumonia. She had a negative head CT and no seizure activity was noted at the time. She also was ruled out with cardiac enzymes. She had a chest x-ray suggestive of worsening left upper lobe opacities and was started on levo and Flagyl with sputum cultures, which only grew out oral flora. Part of her respiratory decline while intubated was thought also to be due to progressive CHF, though diuresis did not improve her respirations. Patient had difficulty weaning from the vent, and after much discussion with the patient and healthcare proxy, it was decided finally after several weeks to extubate her with comfort measures. The patient eventually expired. This was thought to be more humane way of treating the patient given her comorbidities and likely decline if she were to have a trach and PEG. This was not in keeping with her former values to be independent and not have invasive measures performed. 2. Cardiovascular: Patient had known CHF with known very advanced valvular regurgitation. After transfer to the MICU and intubation, she was found to be in [**Month/Day (3) **] with low blood pressures requiring pressors. As all her cultures were negative, etiology was not sepsis and thought to be cardiogenic versus hypovolemic. She was aggressively volume resuscitated resulting in higher blood pressures, but total body volume overload with her being nearly 15 liters positive by the end of her admission. Although we attempted to diurese her, she appeared to be quite preload dependent and did not respond well to diuretics. She was pressor dependent until the very end when discussions were made to have her be [**Month/Day (3) 3225**]. She was also noted to be continually in atrial fibrillation, which also decreased her cardiac output. Her cardiologist and the Cardiology team were consulted/curbsided and given her grave medical condition, there was no benefit to cardioverting her. 3. Elevated LFTs: Patient had negative hepatitis serologies and acetaminophen level was normal. Leading thought was toxicity secondary to digoxin or amiodarone as transaminitis decreased since these medications were stopped. However, patient's cardiologist believed that this may have been due to poor cardiac output alone. 4. Acute renal failure: Creatinine decreased after aggressive volume resuscitation and maintaining pressors to maintain blood pressure. This was thought to be a prerenal, though patient has progressively poor urine output. 5. FEN: The patient was continued on tube feeds until extubation. 6. Glycemic control: Patient continued on sliding scale insulin. 7. Code status: Patient was initially full code, but after extensive family discussions involving the entire staff, PCP, [**Name10 (NameIs) **] social work as well as Dr. [**First Name (STitle) 9305**] [**Name (STitle) 4261**], patient, and nephew agreed that [**Name (NI) 3225**] status would be most keeping with her values. Patient was thus extubated, and pressors were weaned off and patient was transferred to the floor. She was maintained on oxygen and Morphine drip, and eventually expired on [**2-1**]. DISCHARGE CONDITION: Expired. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1019**] Dictated By:[**Last Name (NamePattern1) 1606**] MEDQUIST36 D: [**2154-4-28**] 13:53 T: [**2154-4-29**] 11:10 JOB#: [**Job Number 21021**] Name: [**Known lastname 3487**], [**Known firstname 3441**] Unit No: [**Numeric Identifier 3488**] Admission Date: [**2154-1-14**] Discharge Date: [**2154-2-1**] Date of Birth: [**2069-9-20**] Sex: F Service: [**Doctor Last Name **] MEDICINE ADDENDUM: This is the Discharge Summary addendum covering the dates of [**1-30**] through [**2-1**]. HOSPITAL COURSE: Briefly, this is an 84 year old lady with multiple medical problems with recent complicated hospital admission with sepsis requiring a prolonged Medical Intensive Care Unit stay with intubation, severe vascular disease with congestive heart failure and acute renal failure. She was finally declared comfort measures only given her poor prognosis. She was extubated and was started on morphine, ativan and Tylenol for comfort measures. She was transferred to the Floor on [**1-30**], and she passed away in peace on [**2154-2-1**]. The patient's nephew, Mr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3489**], was contact[**Name (NI) **] and her primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 84**] [**Last Name (NamePattern1) 85**] was also notified. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 88**] Dictated By:[**Last Name (NamePattern1) 3530**] MEDQUIST36 D: [**2154-2-1**] 16:09 T: [**2154-2-1**] 16:38 JOB#: [**Job Number 3531**]

[ "507.0", "427.31", "785.51", "785.52", "584.9", "518.84", "428.0", "038.9", "789.5" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.04", "99.07", "96.72", "96.04", "96.6", "38.91", "00.13" ]

icd9pcs

[ [ [] ] ]

6466, 7166

1142, 1477

7184, 8297

120, 623

2548, 3039

645, 1116

1494, 1691

68,937

109,505

98+55184

Discharge summary

report+addendum

Admission Date: [**2114-5-11**] Discharge Date: [**2114-5-23**] Date of Birth: [**2054-1-30**] Sex: F Service: SURGERY Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 158**] Chief Complaint: Abd pain and N/V Major Surgical or Invasive Procedure: s/p right and left hemicolectomy History of Present Illness: 60F with ESRD s/p deceased donor renal transplant, HTN, and diverticulitis who was initially admitted for worsening abdominal pain and N/V and now presents to the [**Hospital Unit Name 153**] with hypotension after having a n ex-lap and bowel resection for a perforated cecum. She has had approximately 3 episodes of diverticulitis in the past year which resolved with antibiotics. She was planning to have an elective outpatient laparoscopic colectomy given her frequent flares. Prior to this admission, she reportedly had intermittent [**10-3**] abdominal pain in the RLQ and LLQ and significant nausea and vomiting, she was unable to keep down any POs for 48 hours prior to admission. This felt worse than her prior diverticulitis flares and she was admitted for observation, hydration, and antibiotics. CT abd/pelvis at admission showed pericolonic stranding but no e/o diverticulitis. Since admission to the surgery service, she was staretd on Cipro and Flagyl for the colitis seen on CT. Her abdominal pain acutely worsened on [**5-12**] and she described feeling a "[**Doctor Last Name **]" in her abdomen. A repeat CT abd/pelvis showed perforation at the cecum with free air present and extravasation of PO contrast into the peritoneum. She was taken to the OR for a ex-lab where she was found to have a stricture in the signoid colon and a perforation in her cecum with spillage of stool in to the peritoneum. She underwent a right and left colectomy, the transverse colon was left in place but is discontinusous. Her abdomen was left open after the procedure. Past Medical History: Hypertension End-stage renal disease, etiology unclear Dyslipidemia Left knee patellar fracture Septic arthritis of the knee [**10/2109**] Bone spur left foot Neck/shoulder pain Diverticula UTI: cipro resistant E.coli Anemia: started Aranesp [**2112-7-4**] Past Surgical History: S/p deceased donor renal transplantation on [**2096-2-27**] S/p Bilateral reduction mammoplasties [**7-/2112**] Social History: Married. Has three children. She is a fourth grade teacher in inner city [**Location (un) 86**]. Does not smoke, drinks rarely. Family History: Father, brother, and oldest son with diverticulitis. No history of colon cancer. Mother died of MI. Denies family history of renal disease or cancer. History of hypertension and diverticulitis in brother. Father had heart failure and a pacemaker. Physical Exam: Admission Physical Exam: Vitals: T 94.3, BP 148/106, HR 91, RR 14, SpO2 100% General: Intubated, sedated HEENT: ET and OG tubes in place Neck: Right IJ in place, site is c/d/i CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation anteriorly, no wheezes, rales, ronchi Abdomen: distended, firm and surgically open GU: Foley in place Ext: Warm, well perfused, no edema Neuro: intubated and sedated, not arousable and not following commands. Discharge Physical Exam: General: Patient appears well, alert and oriented, ambulating with contact [**Name (NI) 1118**], requires assistance for ADLs, pain controlled with oral pain medicaiton regimen. + liquid brown stool and gas in ileostomy apppliance. VS: 98.1, 97.9, 70, 142/84, 16, 99% RA Neuro: A&OX3 Lungs: CTAB Cardiac: RRR Abd: flat, non-distended, midline incision intact with staples and retention sutures, ileostomy pink with stool and gas Lower Extremities: Appear very deconditioned, weak bilaterally, gait intact Pertinent Results: ADMISSION LABS: [**2114-5-11**] 10:35AM BLOOD WBC-14.8* RBC-4.14* Hgb-11.4* Hct-36.2 MCV-87 MCH-27.6 MCHC-31.5 RDW-13.7 Plt Ct-513* [**2114-5-11**] 10:35AM BLOOD Neuts-90.3* Lymphs-6.9* Monos-2.4 Eos-0.2 Baso-0.2 [**2114-5-12**] 09:23PM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL [**2114-5-13**] 04:34AM BLOOD PT-13.2* PTT-30.0 INR(PT)-1.2* [**2114-5-11**] 10:35AM BLOOD Glucose-114* UreaN-49* Creat-1.9* Na-141 K-3.6 Cl-105 HCO3-21* AnGap-19 [**2114-5-11**] 10:35AM BLOOD ALT-9 AST-16 AlkPhos-53 TotBili-0.2 [**2114-5-11**] 10:35AM BLOOD Lipase-24 [**2114-5-12**] 05:53AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.0 [**2114-5-13**] 04:49AM BLOOD Type-ART pO2-178* pCO2-33* pH-7.41 calTCO2-22 Base XS--2 [**2114-5-14**] bcx ngtd [**2114-5-13**] ucx negative [**2114-5-13**] bcx negative [**2114-5-11**] bcx x2 negative PORTABLE ABDOMEN Study Date of [**2114-5-12**] 8:07 PM Supine and decubitus view of the abdomen shows pneumoperitoneum, not present on the abdomen CT [**5-11**], but detected on the chest radiograph performed concurrently and reported prior to review of this study. Retained contrast [**Doctor Last Name 360**] in the cecum shows its diameter is 8 cm. Proximal to it, the small bowel is moderately distended to a diameter of 28 mm. A subsequent abdominal CT scan also available at the time of this review shows the effects of likely cecal perforation. IMAGING: -[**5-12**] CT Abd: IMPRESSION: 1. There is evidence of new bowel perforation at the level of the cecum, with evidence of new free air, free fluid, as well as extraluminal oral contrast surrounding the cecum. Surgical consultation is recommended. 2. Pericolonic stranding is again noted diffusely throughout the colon and greatest throughout the descending and sigmoid colon. These findings are most consistent with diffuse colitis which has likely led to perforation. 3. New small bilateral pleural effusions Cardiovascular Report ECG Study Date of [**2114-5-14**] 11:12:58 AM Sinus rhythm with low amplitude P waves. Low QRS voltage throughout. Delayed R wave transition. Diffuse non-specific T wave flattening. Compared to the previous tracing of [**2112-7-15**] the voltage is lower. P wave amplitude has decreased. Diffuse T wave flattening is present. Clinical correlation is suggested. CHEST (PORTABLE AP) Study Date of [**2114-5-15**] 3:19 AM No acute cardiopulmonary process. Low endotracheal tube position. [**2114-5-19**] 05:56AM BLOOD WBC-12.4* RBC-3.25* Hgb-9.0* Hct-28.1* MCV-86 MCH-27.6 MCHC-32.0 RDW-14.2 Plt Ct-264 [**2114-5-18**] 03:58AM BLOOD WBC-19.2* RBC-3.50* Hgb-9.7* Hct-29.7* MCV-85 MCH-27.8 MCHC-32.7 RDW-14.4 Plt Ct-259 [**2114-5-17**] 02:00AM BLOOD WBC-21.4* RBC-3.30* Hgb-9.3* Hct-27.9* MCV-85 MCH-28.3 MCHC-33.4 RDW-14.7 Plt Ct-284 [**2114-5-16**] 04:22PM BLOOD WBC-22.0* RBC-3.25* Hgb-9.1* Hct-28.2* MCV-87 MCH-28.1 MCHC-32.5 RDW-15.7* Plt Ct-269 [**2114-5-16**] 02:25AM BLOOD WBC-21.2* RBC-2.96* Hgb-8.9* Hct-25.2* MCV-85 MCH-29.9 MCHC-35.1* RDW-14.7 Plt Ct-226 [**2114-5-15**] 01:59PM BLOOD WBC-22.3* RBC-3.09* Hgb-8.8* Hct-26.8* MCV-87 MCH-28.4 MCHC-32.7 RDW-15.0 Plt Ct-241 [**2114-5-15**] 08:46AM BLOOD WBC-21.9* RBC-2.73* Hgb-7.6* Hct-23.6* MCV-87 MCH-28.0 MCHC-32.3 RDW-14.1 Plt Ct-257 [**2114-5-15**] 02:41AM BLOOD WBC-21.3* RBC-2.45* Hgb-6.8* Hct-21.4* MCV-87 MCH-27.6 MCHC-31.7 RDW-14.0 Plt Ct-328 [**2114-5-14**] 08:28PM BLOOD WBC-20.8* RBC-2.50* Hgb-7.1* Hct-22.0* MCV-88 MCH-28.4 MCHC-32.2 RDW-15.0 Plt Ct-318 [**2114-5-14**] 08:28PM BLOOD WBC-20.8* RBC-2.50* Hgb-7.1* Hct-22.0* MCV-88 MCH-28.4 MCHC-32.2 RDW-15.0 Plt Ct-318 [**2114-5-14**] 04:00AM BLOOD WBC-23.2* RBC-3.15* Hgb-8.7* Hct-27.4* MCV-87 MCH-27.6 MCHC-31.7 RDW-13.9 Plt Ct-355 [**2114-5-13**] 05:20PM BLOOD WBC-21.8*# RBC-3.35* Hgb-9.3* Hct-29.0* MCV-87 MCH-27.9 MCHC-32.2 RDW-14.7 Plt Ct-420 [**2114-5-13**] 04:34AM BLOOD WBC-3.7*# RBC-3.82* Hgb-10.7* Hct-32.8* MCV-86 MCH-28.0 MCHC-32.5 RDW-13.5 Plt Ct-512* [**2114-5-12**] 05:53AM BLOOD WBC-12.4* RBC-3.43* Hgb-9.6* Hct-29.4* MCV-86 MCH-27.9 MCHC-32.6 RDW-13.5 Plt Ct-453* [**2114-5-11**] 10:35AM BLOOD WBC-14.8* RBC-4.14* Hgb-11.4* Hct-36.2 MCV-87 MCH-27.6 MCHC-31.5 RDW-13.7 Plt Ct-513* [**2114-5-18**] 03:58AM BLOOD Neuts-89.1* Lymphs-6.2* Monos-4.2 Eos-0.4 Baso-0.1 [**2114-5-17**] 02:00AM BLOOD Neuts-94.0* Lymphs-3.3* Monos-2.4 Eos-0.3 Baso-0 [**2114-5-16**] 02:25AM BLOOD Neuts-95.7* Lymphs-2.1* Monos-2.2 Eos-0.1 Baso-0 [**2114-5-14**] 04:00AM BLOOD Neuts-84* Bands-7* Lymphs-5* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2114-5-13**] 05:20PM BLOOD Neuts-67 Bands-28* Lymphs-3* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2114-5-14**] 04:00AM BLOOD Hypochr-2+ Anisocy-NORMAL Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Burr-1+ [**2114-5-13**] 05:20PM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Burr-OCCASIONAL [**2114-5-13**] 04:34AM BLOOD Hypochr-OCCASIONAL Anisocy-NORMAL Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL Burr-OCCASIONAL [**2114-5-12**] 09:23PM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL [**2114-5-19**] 05:56AM BLOOD Plt Ct-264 [**2114-5-18**] 03:58AM BLOOD Plt Ct-259 [**2114-5-18**] 03:58AM BLOOD PT-10.2 PTT-25.3 INR(PT)-0.9 [**2114-5-17**] 02:00AM BLOOD Plt Ct-284 [**2114-5-17**] 02:00AM BLOOD PT-9.9 PTT-26.0 INR(PT)-0.9 [**2114-5-16**] 04:22PM BLOOD Plt Ct-269 [**2114-5-16**] 02:25AM BLOOD Plt Ct-226 [**2114-5-16**] 02:25AM BLOOD PT-10.6 PTT-30.2 INR(PT)-1.0 [**2114-5-22**] 06:00AM BLOOD Creat-1.1 [**2114-5-21**] 06:00AM BLOOD Creat-1.2* [**2114-5-20**] 06:05AM BLOOD Glucose-80 UreaN-25* Creat-1.0 Na-138 K-3.9 Cl-101 HCO3-27 AnGap-14 [**2114-5-19**] 05:56AM BLOOD Glucose-59* UreaN-28* Creat-1.1 Na-138 K-4.0 Cl-103 HCO3-27 AnGap-12 [**2114-5-18**] 03:58AM BLOOD Glucose-77 UreaN-34* Creat-1.1 Na-140 K-3.8 Cl-105 HCO3-25 AnGap-14 [**2114-5-17**] 02:00AM BLOOD Glucose-88 UreaN-36* Creat-1.5* Na-142 K-4.1 Cl-113* HCO3-18* AnGap-15 [**2114-5-16**] 02:25AM BLOOD Glucose-74 UreaN-38* Creat-2.0* Na-140 K-4.1 Cl-114* HCO3-20* AnGap-10 [**2114-5-15**] 01:59PM BLOOD Glucose-80 UreaN-35* Creat-2.1* Na-138 K-4.7 Cl-112* HCO3-19* AnGap-12 [**2114-5-20**] 06:05AM BLOOD Calcium-7.9* Phos-2.9 Mg-1.5* [**2114-5-19**] 05:56AM BLOOD Calcium-8.2* Phos-2.9 Mg-1.8 [**2114-5-18**] 03:58AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.8 [**2114-5-17**] 08:15PM BLOOD Calcium-8.2* Phos-2.9 Mg-2.2 [**2114-5-17**] 02:00AM BLOOD Calcium-8.2* Phos-3.6 Mg-2.0 [**2114-5-16**] 02:25AM BLOOD Calcium-7.5* Phos-4.5 Mg-2.3 [**2114-5-15**] 01:59PM BLOOD Calcium-7.4* Phos-5.1* Mg-2.3 [**2114-5-15**] 02:41AM BLOOD Albumin-1.7* Calcium-7.2* Phos-4.5 Mg-2.2 [**2114-5-14**] 08:28PM BLOOD Calcium-7.0* Phos-4.3 Mg-2.1 [**2114-5-14**] 12:51PM BLOOD Calcium-7.1* Phos-4.3 Mg-2.3 [**2114-5-14**] 04:00AM BLOOD Calcium-7.3* Phos-3.7 Mg-2.3 [**2114-5-13**] 04:34AM BLOOD Calcium-7.0* Phos-2.4* Mg-2.0 [**2114-5-12**] 05:53AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.0 [**2114-5-22**] 06:00AM BLOOD Vanco-12.9 [**2114-5-21**] 06:00AM BLOOD Vanco-13.8 [**2114-5-20**] 06:05AM BLOOD Vanco-11.5 [**2114-5-19**] 03:36PM BLOOD Vanco-13.6 [**2114-5-19**] 05:56AM BLOOD Vanco-19.9 [**2114-5-18**] 06:12AM BLOOD Vanco-15.8 [**2114-5-19**] 03:36PM BLOOD Cyclspr-112 [**2114-5-18**] 03:58AM BLOOD Cyclspr-259 [**2114-5-17**] 02:00AM BLOOD Cyclspr-45* [**2114-5-14**] 04:00AM BLOOD Cyclspr-111 [**2114-5-13**] 04:34AM BLOOD Cyclspr-200 [**2114-5-12**] 05:53AM BLOOD Cyclspr-93* [**2114-5-17**] 04:33AM BLOOD Type-ART pO2-125* pCO2-38 pH-7.39 calTCO2-24 Base XS--1 [**2114-5-16**] 08:58AM BLOOD Type-ART Temp-36.8 Rates-0/8 Tidal V-800 FiO2-40 pO2-153* pCO2-36 pH-7.28* calTCO2-18* Base XS--8 Intubat-INTUBATED [**2114-5-15**] 08:45PM BLOOD Type-ART Temp-36.8 Rates-10/ PEEP-5 pO2-149* pCO2-41 pH-7.27* calTCO2-20* Base XS--7 -ASSIST/CON Intubat-INTUBATED [**2114-5-15**] 02:13PM BLOOD Type-ART pO2-176* pCO2-33* pH-7.33* calTCO2-18* Base XS--7 [**2114-5-15**] 11:36AM BLOOD Type-MIX Comment-GREEN TOP [**2114-5-15**] 11:33AM BLOOD Type-ART pO2-140* pCO2-46* pH-7.21* calTCO2-19* Base XS--9 [**2114-5-15**] 03:09AM BLOOD Type-ART pO2-172* pCO2-30* pH-7.39 calTCO2-19* Base XS--5 [**2114-5-14**] 08:48PM BLOOD Type-ART pO2-123* pCO2-30* pH-7.35 calTCO2-17* Base XS--7 [**2114-5-14**] 01:22PM BLOOD Type-ART pO2-171* pCO2-36 pH-7.30* calTCO2-18* Base XS--7 Brief Hospital Course: Mrs. [**Known lastname 1119**], a patient known to the colorectal surgery service, presented to the emergency department on [**2114-5-11**] with nausea, vomiting, and abdominal pain. She was diagnosed with diverticulitis and she was evaluated by the acute care service in the emergency department and a plan was formulated with Dr. [**Last Name (STitle) 1120**] to admit the patient for abdominal exams, antibiotics and rehydration with plan to monitor and expedite surgical plans based on her medical history and sudden relapse of symptoms while on outpatient antibiotic therapy. Nephrology was consulted for advice related to immunosuppression medications and past renal transplant and followed the patient for the duration of her inpatient admission. On [**2114-5-12**] the patient was monitored closely. She was started on a clear liquid diet and was given a Dulcolax Supp x1 and had 2 bowel movements. She remained distended and was given a dose of milk of magnesia. The patient was improving when she had a sudden onset of abdominal pain. CT revealed extravasation of contrast and she was taken to the operating room with Dr. [**Last Name (STitle) **] for exploratory laparotomy and two segmental colectomies, was left with open abdomen and disconnected and because of the difficult case and condition of bowel as described in the operative note, the patient was transferred to the intensive care unit appropriate drains. On [**2114-5-14**] the patient returned to the operating room with Dr. [**Last Name (STitle) **] after stabilization in the ICU for washout, completion proctectomy and colectomy, ileostomy and closure of the abdomen with retention sutures and staples. The patient was transferred to the [**Hospital Unit Name 153**] and the course of ICU care is described below. [**Hospital Unit Name 153**] Course per [**Hospital Unit Name 153**] resident: 60F with ESRD s/p deceased renal transplant in [**2095**] on immunosuppression, HTN and h/o diverticulitis who presented to the [**Hospital Unit Name 153**] with hypotension after ex-lap with right/left hemicolectomy performed for cecal perforation and sigmoid stricture. . #Cecal perforation s/p colectomy: The cause of her perforation was thought to be a sigmoid stricture which was found intraoperatively, likely related to her multiple episodes of diverticulitis. She had a primary anastomosis and loop ileostomy. She was commenced on vanc/Zosyn for an 8 day course per surgery, and was maintained on a morphine PCA prn. She was intubated for the procedure, but was quickly and successfully weaned off of the vent prior to callout to the surgical floor. . # Hypertension ?????? Her initial hypotension resolved, and her home anti-hypertensives were recommenced due to her hx of HTN. . #ESRD s/p renal transplant: renal transplant recs were followed, and after her procedure, she was restarted on azathioprine, and transitioned to a 5mg daily dose of prednisone. She was restarted on cyclosporine per renal transplant on [**5-17**]. . #Non-anion gap metabolic acidosis: Resolved. Likely related to volume resuscitation with NS. Chloride is also elevated which supports this. . #Anemia: Hct trending down almost 10 points compared to her pre-op CBC. Likely from blood loss during her colectomy as well as dilutional effect from multiple fluid boluses. She was also hemoconcentrated at admission from poor PO intake and has baseline anemia with Hct in the 24-32 range from her ESRD s/p transplant. She was transfused with packed red blood cells. She was monitored closely. The patient was extubated and started on a clear liquid diet on [**2114-5-17**]. Surgical Floor Course: The patient was transferred to the inpatient floor on [**2114-5-18**] and began a regular diet. She was continued on her antibiotic course. [**2114-5-19**] the Foley was removed at midnight. The patient had temporary central venous access which was not ideal for the floor and because of intravenous antibiotics and the patient's access status unable to place PICC line after multiple attempts. IR was unable to schedule the patient for IR placement of the PICC line. The nursing staff continued to use the CVL for access. On [**2114-5-20**] the patient was voiding. She was given vancomycin 500x1, troughs were monitored closely at the patient was a renal transplant patient and she was strated on pain medications by mouth. [**2114-5-21**] Renal transplant fellow: recommend continuing home dose of immunosuppression medications. JP drains were removed. The patient was meeting discharge criteria. She was followed closely throughout her admission by the wound/ostomy nursing team as well as physical therapy. After consultation with the nephrology team the patient was started on a 14 day course of Augmentin started and fluconazole and Zosyn were discontinued. The PICC line was pulled back to midline position and the central venous line was removed without issue. Her cyclosporine trough was monitored closely throughout her hospitalization as there was a risk of interaction with fluconazole. Her last trough was 112 on [**2114-5-19**]. She continued her Cyclosporine and was discharged on appropriate dosing. The patient was ordered to have the Cyclosporine trough measured prior to the morning dose on [**2114-5-24**] and dose adjustment with assistance of the renal transplant center. Arrangements were arranged for the patient to be transferred to a rehabilitation facility appropriately as she had become deconditioned. The midline catheter was removed at time of discharge. Medications on Admission: Medications at home: AZATHIOPRINE - (Prescribed by Other Provider) - 50 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) CIPROFLOXACIN [CIPRO] - 500 mg Tablet - 1 Tablet(s) by mouth twice a day CYCLOSPORINE MODIFIED [NEORAL] - (Prescribed by Other Provider) - 100 mg Capsule - one Capsule(s) by mouth twice daily METOPROLOL SUCCINATE - 50 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth daily METRONIDAZOLE - 500 mg Tablet - 1 Tablet(s) by mouth three times a day PREDNISONE - (Prescribed by Other Provider) - 10 mg Tablet - one Tablet(s) by mouth evert other day VALSARTAN-HYDROCHLOROTHIAZIDE [DIOVAN HCT] - 160 mg-12.5 mg Tablet - 1 Tablet(s) by mouth twice a day Medications - OTC CALCIUM CARBONATE-VIT D3-MIN [CALTRATE 600+D PLUS MINERALS] - (Prescribed by Other Provider) - 600 mg-400 unit Tablet - one Tablet(s) by mouth twice daily Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 2. azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. cyclosporine modified 25 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours): Please check cyclosporin true 12 hour trough prior to morning dose on [**2114-5-24**]. Goal is between 50-100. 5. valsartan 80 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 8. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 5 days: Do not drink alcohol or drive a car while taking this medication. . Tablet(s) 9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 13 days: To complete 14 day course. Startd therapy [**2114-5-22**], lsat day of therapy [**2114-5-4**]. 11. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for anxiety. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**] ([**Hospital3 1122**] Center) Discharge Diagnosis: Sigmoid diverticulitis with abscess and stricture, perforated cecum 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 laparoscopic Colectomy for surgical management of your diverticulitis. Unfortunately after this procedure you were found to have a stricture and leaking into your abdomen which required you to be taken back to the operating room for a completion colectomy and end ileostomy. Closure of the surgical incision required placement of retention sutures which remain in place and will stay in place along with the staples until you return for your 2 weeks post-operative visit. You have recovered from this procedure 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 regarding these results they will contact you before this time. You have tolerated a regular diet, passing gas and your pain is controlled with pain medications by mouth. You may return home to finish your recovery. It is important that you continue to have your immunosupression medications monitored for your kidney transplant. Please have your level checked at rehab the morning of [**2114-5-24**] and the goal of the cyclosporin level is 50-100. The rehab should fax this level to the renal transplant office after it is back for recommendations at [**Telephone/Fax (1) 697**]. This will be ordered in your paperwork however, it is the facilities responsibility to order the test. 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, elevated ileostomy output. 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 Gatorade. 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 regular diet with your new ileostomy. However it is a good idea to avoid fatty or spicy foods and follow diet suggestions made to you by the ostomy nurses. 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 bulging 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. The bridge will be removed from the ileostomy at your follow-up appointment with the wound/ostomy nurses. You have a long vertical incision on your abdomen that is closed with staples and retention sutures. This incision can be left open to air or covered with a dry sterile gauze dressing if the staples become irritated from clothing. The staples 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. 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 exercise with Dr. [**Last Name (STitle) **]. You must continue to wear the abdomoinal binder with a whole cut for the ileostomy to fit under at least until your second post-operative visit with Dr. [**Last Name (STitle) **]. He will give you further instructions at this time. You will be prescribed a small amount of the pain medication 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 call the colorectal surgery clinic at [**Telephone/Fax (1) 160**] to make an appointment for follow-up with [**First Name8 (NamePattern2) 1123**] [**Last Name (NamePattern1) 1124**], NP for 2 weeks after discharge. At this appointment your second post-operative visit with Dr. [**Last Name (STitle) **] will be arranged. Please call the would ostomy nurses to arrange an appointment 1 week after discharge. At this appointment, the brdige will be removed from the ileostomy. Department: RADIOLOGY When: TUESDAY [**2114-9-11**] at 3:30 PM With: RADIOLOGY [**Telephone/Fax (1) 1125**] Building: [**Street Address(2) 1126**] ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: On Street Parking You have the following appointments previously arranged for you in the [**Hospital1 18**] System: Department: RADIOLOGY When: TUESDAY [**2114-9-11**] at 3:00 PM With: RADIOLOGY [**Telephone/Fax (1) 1125**] Building: [**Street Address(2) 1126**] ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: On Street Parking Department: RADIOLOGY When: TUESDAY [**2114-9-11**] at 2:30 PM With: RADIOLOGY [**Telephone/Fax (1) 1125**] Building: [**Street Address(2) 1126**] ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: On Street Parking Completed by:[**2114-5-23**] Name: [**Known lastname 91**],[**Known firstname 92**] C Unit No: [**Numeric Identifier 93**] Admission Date: [**2114-5-11**] Discharge Date: [**2114-5-23**] Date of Birth: [**2054-1-30**] Sex: F Service: SURGERY Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 94**] Addendum: After reconsidering renal function, the nephrology team recommended changing the Augmentin dosing to 500mg q 12 because of possible decreased creatinine clearance. The patient should complete a 14 day course. Major Surgical or Invasive Procedure: [**2114-5-12**] Exploratory laparotomy with right & sigmoid colectomy and small bowel resection [**2114-2-13**] Abdominal washout, Completion colectomy, diverting ileostomy Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 2. azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. cyclosporine modified 25 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours): Please check cyclosporin true 12 hour trough prior to morning dose on [**2114-5-24**]. Goal is between 50-100. 5. valsartan 80 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 8. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 5 days: Do not drink alcohol or drive a car while taking this medication. . Tablet(s) 9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for anxiety. 11. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 13 days: To complete 14 day course. Started therapy [**2114-5-22**], lsat day of therapy [**2114-5-4**]. . Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 95**] ([**Hospital3 96**] Center) [**Name6 (MD) **] [**Last Name (NamePattern4) 97**] MD [**MD Number(2) 98**] Completed by:[**2114-5-23**]

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icd9pcs

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28151, 28327

20198, 20198

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353, 1936

3821, 12233

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3280, 3786

53,098

164,981

40623+40624+58388+58389

Discharge summary

report+report+addendum+addendum

Admission Date: [**2115-5-2**] Discharge Date: [**2115-5-9**] Date of Birth: [**2046-5-14**] Sex: M Service: CARDIOTHORACIC Allergies: Plavix / Valium / Ultram Attending:[**First Name3 (LF) 1406**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Coronary artery bypass grafts x 3(LIMSA-LAD,SVG-OM,SVG-DG) [**2115-5-3**] History of Present Illness: Mr. [**Known lastname 71838**] is a 68 year old male with a history of coronary artery disease that was being treated medically. Over the past several months he has developed increase shortness of breath and chest pain that extended down his left arm. He was taking Plavix intermittently and recently [**Known lastname 1834**] a stress test that was positive. His pain then started at rest and he had medications adjusted and was referred for cardiac catheterization. He had cardiac catheterization that revealed significant coronary artery disease. He is now transferred for surgical evaluation. Past Medical History: Hypertension Hyperlipidemia Stroke - loss of vision in left eye Asthma Anxiety Depression Gastro esophageal reflux disease Bilaterl rotator cuff repairs sinus surgeries Social History: Mr. [**Known lastname 88892**] is self employed, tranporting patients to medical appointments. He denies tobacco use. He imbibes [**11-18**] glasses of wine every month. Family History: His brother died of a stroke at age 55. Physical Exam: Pulse:72 Resp:16 O2 sat: 99% room air B/P Right: Left: 147/79 Height: 5'7" Weight:230lbs General: Skin: Dry [x] intact [x] HEENT: Rt 2mm Lt 4mm - round and reactive to light Neck: Supple [x] decreased ROM due to shoulder discomfort Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: non-distended [x] non-tender [x] bowel sounds + [x]round obese firm abdomen Extremities: Warm [x], well-perfused [x] Edema none Varicosities: None [x] Neuro: Grossly intact except for unequal pupils Pulses: Femoral Right: +1 Left:+1 DP Right: +2 Left:+2 PT [**Name (NI) 167**]: +2 Left:+2 Radial Right: +2 Left:+2 Carotid Bruit Right no bruit Left: no bruit Pertinent Results: [**2115-5-7**] 06:18AM BLOOD WBC-12.6* RBC-3.20* Hgb-10.5* Hct-30.2* MCV-95 MCH-32.7* MCHC-34.6 RDW-13.8 Plt Ct-133* [**2115-5-7**] 06:18AM BLOOD Glucose-121* UreaN-23* Creat-1.3* Na-138 K-4.0 Cl-99 HCO3-34* AnGap-9 [**2115-5-7**] 06:18AM BLOOD ALT-43* AST-42* LD(LDH)-275* AlkPhos-54 Amylase-188* TotBili-1.3 [**2115-5-8**] 06:20AM BLOOD WBC-9.7 RBC-3.47* Hgb-10.8* Hct-32.3* MCV-93 MCH-31.1 MCHC-33.5 RDW-14.2 Plt Ct-182 [**2115-5-8**] 06:20AM BLOOD Glucose-134* UreaN-22* Creat-1.6* Na-140 K-3.8 Cl-94* HCO3-39* AnGap-11 TEE [**2115-5-3**] PRE-CPB: No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a small pericardial effusion. POST-CPB: The LV systolic function remains normal, estimated EF is 55-65%. The RV systolic function remains normal. There is no evidence of aortic dissection. [**2115-5-8**] 06:20AM BLOOD WBC-9.7 RBC-3.47* Hgb-10.8* Hct-32.3* MCV-93 MCH-31.1 MCHC-33.5 RDW-14.2 Plt Ct-182 [**2115-5-8**] 06:20AM BLOOD Glucose-134* UreaN-22* Creat-1.6* Na-140 K-3.8 Cl-94* HCO3-39* AnGap-11 Brief Hospital Course: On [**5-3**] Mr. [**Known lastname 71838**] [**Last Name (Titles) 1834**] a coronary artery bypass grafting x 3. Please see the operative note for details. He tolerated the procedure well and was transferred in critical but stable condition to the surgical intensive care unit. Postoperatively he had a metabolic acidosis with an elevated Lactate. He was kept intubated overnight and continued on Neosynephrine for hypotension. He was extremely anxious and given Ativan for anxiety. POD # 2 the patient was extubated with anesthesia present due to the patient being a difficult intubation. Narcotics were discontinued due to confusion after extubation. He was febrile on POD#1 with a leukocytosis to 21, was pan cultured and continued on perioperative antibiotics. He was weaned off Neosynephrine by post operative day 2 and PA catheter was discontinued at this time with good cardiac index of 2.6. He was transferred to the step down unit in stable condition. Chest tubes and pacing wires were removed per cardiac surgery protocol. Beta blocker was initiated and titrated up for better systolic blood pressure and heart rate control. He was gently diuresed toward preoperative weight. He did have an rising creatinine to 1.6 at the time of discharge(baseline 1.0) and Crestor was decreased to 5 mg daily and Lasix was stopped. He was at preoperative weight at discharge and is to have his creatinine checked tomorrow [**5-10**] at rehab. Lasix is to be resumed every other day based on creatinine levels and if clinically indicated. He did have some erythema at the mid-lower sternal pole without drainage or pain. The patient was afebrile and white blood cell count was decreasing (18->9.7), therefore, no antibiotics were started. He is to have his midsternal pole painted with Betadine daily. Patient did report a history of a rash with Ultram (although no rash was noted) so Percocet 1 tab q 6 hours was restarted for pain control. By post operative day 6 he was ambulating with assistance, his incisions were healing well and he was tolerating a full oral diet. It was felt that he was safe to [**Hospital 83362**] Nursing and Rehab in [**Location (un) 5871**], MA at this time. Medications on Admission: Diovan/Hctz 160/12.5mg daily Toprol XL 25mg Daily ASA 81mg daily Plavix 75 mg daily Crestor 20mg daily Xanax 0.5 mg prn HS Beclomethasone 1-2 puffs prn Shortness of breath Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 4. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) ML Inhalation q6h () as needed for wheezing. 5. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 6. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for sleep. 7. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 8. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 9. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation . 10. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 11. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 13. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea. Discharge Disposition: Extended Care Facility: [**Location (un) 14468**] Nursing & Rehabilitation Center - [**Location (un) 1456**] Discharge Diagnosis: coronary artery disease 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 with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [**Last Name (STitle) **] on [**6-5**] at 1:00pm Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 31888**] ([**Hospital1 **]) [**6-10**] at 11:00am ***PLEASE CHECK BUN/CREA on [**5-10**]**** Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) **] [**2-19**] 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:[**2115-5-9**] Admission Date: [**2115-5-10**] Discharge Date: [**2115-5-10**] Date of Birth: [**2046-5-14**] Sex: M Service: CARDIOTHORACIC Allergies: Plavix / Valium / Ultram Attending:[**First Name3 (LF) 1406**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: None this admission Coronary artery bypass grafts x 3(LIMA-LAD,SVG-OM,SVG-DG) [**2115-5-3**] History of Present Illness: This is a 68-year-old male who [**Month/Day/Year 1834**] a coronary artery bypass grafting x3 with the left internal mammary artery to the left anterior descending artery, and reverse saphenous vein graft to the diagonal artery and the obtuse marginal artery on [**5-3**]. Post operative course complicated by pain issues, anxiety issues and elevated creatinine. He was discharged to [**Hospital 83362**] Nursing and Rehab in [**Location (un) 5871**], MA today and upon arrival had chest pain and anxiety due to a delay in receiving pain medications. Patient describes pain as sternal and non radiating. He demanded to be sent to an ED to get pain meds. He was sent to the ED where he received Xanax and Percocet with a troponin of 0.1 with resolution of symptoms. His rehab felt that he would be better cared for at a different facility and he is readmitted to [**Hospital Ward Name 121**] 6 for further discharge planning. Past Medical History: Hypertension Hyperlipidemia Stroke - loss of vision in left eye Asthma Anxiety Depression Gastro esophageal reflux disease Bilaterl rotator cuff repairs sinus surgeries Social History: Mr. [**Known lastname 88892**] is self employed, tranporting patients to medical appointments. He denies tobacco use. He imbibes [**11-18**] glasses of wine every month. Family History: His brother died of a stroke at age 55. Physical Exam: Physical Exam Pulse:103 Resp:18 O2 sat:95 on 2L NC B/P Right:115/63 Left: Height: Weight: General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] obese, non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [x] _1+____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: DP Right: 2+ Left:2+ PT [**Name (NI) 167**]: 2+ Left:2+ Radial Right: 2+ Left:2+ Pertinent Results: [**2115-5-10**] 01:58AM GLUCOSE-194* UREA N-17 CREAT-1.3* SODIUM-136 POTASSIUM-3.5 CHLORIDE-94* TOTAL CO2-31 ANION GAP-15 [**2115-5-10**] 01:58AM ALT(SGPT)-29 AST(SGOT)-31 CK(CPK)-110 ALK PHOS-56 AMYLASE-108* TOT BILI-0.8 [**2115-5-10**] 01:58AM WBC-9.5 RBC-3.35* HGB-11.1* HCT-30.6* MCV-91 MCH-33.1* MCHC-36.3* RDW-13.3 Brief Hospital Course: Mr. [**Known lastname 71838**] was admitted for control if incisional pain and anxiety. He was treated with xanax and perocoet and his symptoms improved. He was screened, accepted and discharged to [**Location (un) 5871**] care and rehab center rehab today. Medications on Admission: Diovan/Hctz 160/12.5mg daily, Toprol XL 25mg Daily, ASA 81mg daily, Plavix 75 mg daily, Crestor 20mg daily, Xanax 0.5 mg prn HS, Beclomethasone 1-2 puffs prn Shortness of breath Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 4. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 5. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Disp:*30 Tablet(s)* Refills:*0* 6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 8. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 9. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*65 Tablet(s)* Refills:*0* 10. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 12. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 13. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea. 14. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: Three (3) ML Inhalation q6hours () as needed for as needed for wheezing. Discharge Disposition: Extended Care Facility: [**Location (un) **] care and rehab center Discharge Diagnosis: coronary artery disease s/p CABG Hyperlipidemia hypertension asthma s/p cerebral vascular accident gastroesophageal reflux anxiety/depression Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with Percocet Incisions: Sternal - healing well, mid sternal pole erythema, no drainage Leg Right- healing well, no erythema or drainage. 1+ Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [**Last Name (STitle) **] on [**6-5**] at 1:00pm in the [**Hospital **] medical office building [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 170**] Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 31888**] ([**Hospital1 **]) [**6-10**] at 11:00am Please call to schedule appointments with your Primary Care Doctor at the VA in [**2-19**] 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:[**2115-5-10**] Name: [**Known lastname 14105**],[**Known firstname **] Unit No: [**Numeric Identifier 14106**] Admission Date: [**2115-5-2**] Discharge Date: [**2115-5-9**] Date of Birth: [**2046-5-14**] Sex: M Service: CARDIOTHORACIC Allergies: Plavix / Valium / Ultram Attending:[**First Name3 (LF) 135**] Addendum: Additional medication called to rehab: ASA 81 mg po daily Discharge Disposition: Extended Care Facility: [**Hospital 14107**] Healthcare [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**] Completed by:[**2115-5-9**] Name: [**Known lastname 14105**],[**Known firstname **] Unit No: [**Numeric Identifier 14106**] Admission Date: [**2115-5-10**] Discharge Date: [**2115-5-10**] Date of Birth: [**2046-5-14**] Sex: M Service: CARDIOTHORACIC Allergies: Plavix / Valium / Ultram Attending:[**First Name3 (LF) 135**] Addendum: Expected length of stay at rehab less than 30 days. Discharge Disposition: Extended Care Facility: [**Location (un) **] care and rehab center [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**] Completed by:[**2115-5-10**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

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11723, 12051

15344, 16405

11060, 11101

12562, 13985

14098, 14243

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14521, 15321

11116, 11704

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9730, 10662

10684, 10855

10871, 11044

12,140

188,829

5088

Discharge summary

report

Admission Date: [**2151-3-26**] Discharge Date: [**2151-4-9**] Date of Birth: [**2074-1-31**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2297**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: intubation, tracheostomy History of Present Illness: 77 yo M with history of COPD, small cell lung cancer (14 years ago) and adenocarcinoma of the lung resected in [**5-/2144**] with no evidence of recurrence who presents with 2-3 days of cough and SOB. He developed worsening cough productive of yellow and white sputum 2-3 days prior to admission with shortness of breath. He reports chest pain only when coughing and his cough has been chronic for "years". No fevers or chills at home, no increased leg edema, orthopnea, wheezing or palpitations. He does report poor appetite and weight loss over the past few days. No recent travel or immobilization, no sick contacts. His lung cancer has shown no signs of symptoms of recurrence as of [**1-1**]. He called EMS and found to be 85% on RA this morning. . Vitals at presentation to the ED were: T 98.4, HR 124, BP 134/68, RR 19, O2Sat 91% 4L NC. Patient had CXR showing diffuse opacities and mild pulmonary edema. He received ceftriaxone and levofloxacin for presumed CAP. He additionally received albuterol and ipratropium and 2L NS. Labs were significant for a bicarb of 19, WBC of 11.7, and a lactate of 2.3. Vitals prior to transfer to the floor were: T afebrile, HR 119, BP 125/80, RR 24, 94% on NRB. . Upon arrival to the floor, patient was on a non-rebreather, alert and oriented, speaking in full sentences and not in respiratory distress. He denied chest pain or pressure. Past Medical History: COPD (mild obstructive defect on last PFTs) small cell lung cancer (14 years ago) adenocarcinoma of the lung resected in [**5-/2144**] HL GERD Social History: Lives at home with his wife, former [**Name2 (NI) 1818**] (40 pack-years, quit after lung ca diagnosis 14 years ago). Occasional EtOH use, no drug use. Family History: Non-contributory Physical Exam: VS: T 98.4, BP 111/61, HR 120, RR 18 97% on NRB GEN: well-appearing elderly male in NAD, sitting up in bed, alert and oriented, speaking in full sentences and in no respiratory distress on non-rebreather HEENT: EOMI, PERRLA, no scleral icterus, dry oral mucosa NECK: no elevated JVP, no cervical LAD, supple PULM: diminished breath sounds b/l, clear to auscultation with no rales or wheezes CARD: tachycardic, nl S1/S2, no m/r/g ABD: soft, NT/ND, BS+ EXT: no edema, 1+ DP on LLE, 2+ PD on RLE, 1+ PTs b/l SKIN: 1cm flesh colored nodule on L cheek NEURO: awake, alert, oriented x3, 5/5 strength in UE, 4+/5 in LE b/l Pertinent Results: ADMISSION: [**2151-3-26**] 07:25PM PLT COUNT-245 [**2151-3-26**] 07:25PM NEUTS-93.0* LYMPHS-3.5* MONOS-2.6 EOS-0.4 BASOS-0.5 [**2151-3-26**] 07:25PM WBC-11.7* RBC-4.38* HGB-13.4* HCT-40.3 MCV-92 MCH-30.5 MCHC-33.1 RDW-13.2 [**2151-3-26**] 07:25PM ALBUMIN-3.8 [**2151-3-26**] 07:25PM CK-MB-3 cTropnT-0.01 proBNP-551 [**2151-3-26**] 07:25PM LIPASE-30 [**2151-3-26**] 07:25PM ALT(SGPT)-16 AST(SGOT)-26 CK(CPK)-55 ALK PHOS-84 TOT BILI-0.5 [**2151-3-26**] 07:25PM estGFR-Using this [**2151-3-26**] 07:25PM GLUCOSE-164* UREA N-28* CREAT-1.1 SODIUM-137 POTASSIUM-3.5 CHLORIDE-102 TOTAL CO2-19* ANION GAP-20 [**2151-3-26**] 07:57PM GLUCOSE-156* LACTATE-2.3* NA+-138 K+-3.6 CL--102 TCO2-20* [**2151-3-26**] 09:10PM PT-10.7 PTT-20.3* INR(PT)-0.9 . DISCHARGE: [**2151-4-9**] 04:15 9.1 > 8.7* / 25.8* < 386 INR 1.2* 139 | 104 | 26 < 132 3.6 | 29 | 0.8 Ca 8.4 Mag 2.5* Phos 2.1 . MICRO: [**2151-3-26**] 7:25 pm BLOOD CULTURE #1. Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. OF TWO COLONIAL MORPHOLOGIES. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Aerobic Bottle Gram Stain (Final [**2151-3-27**]): Reported to and read back by [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**2151-3-27**] 12:30PM. GRAM POSITIVE COCCI IN CLUSTERS. Anaerobic Bottle Gram Stain (Final [**2151-3-28**]): GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. . DIRECT INFLUENZA A ANTIGEN TEST (Final [**2151-3-29**]): Negative for Influenza A. DIRECT INFLUENZA B ANTIGEN TEST (Final [**2151-3-29**]): Negative for Influenza B. . Legionella Urinary Antigen (Final [**2151-3-27**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. . MRSA SCREEN (Final [**2151-3-29**]): No MRSA isolated. . IMAGING: [**2151-3-26**] CXR Portable AP upright chest radiograph obtained. There is marked emphysema with stable areas of scarring along the medial aspect of the right lung with suture material projecting over the right upper lobe. Subtle nodular opacities in the lower lungs bilaterally are concerning for early pneumonia. No pleural effusion or pneumothorax is seen. Cardiomediastinal silhouette appears grossly stable. The imaged osseous structures appear intact. IMPRESSION: Marked emphysema, stable scarring in the right lung, subtle nodular opacities in the lower lungs concerning for early pneumonia. . [**2151-3-27**] CXR Comparison is made to previous study from [**2151-3-26**]. There is increased density at the right base, which is new since the previous study and suggestive of right lower lobe collapse. Volume loss in the right side is also seen. There are streaky densities within the apices projecting from the mediastinum suggestive of scarring. Cardiac silhouette and mediastinum are within normal limits. There are again seen some streaky densities at the left base, which may represent atelectasis or early infiltrate. IMPRESSION: 1. Likely right lower lobe collapse with increased density and volume loss at the right base. 2. Scarring within the upper lobes bilaterally. . [**2151-3-29**] CXR As compared to the previous radiograph, there is a slight increase in extent of the pre-existing right and left pleural effusions. The effusion on the left is confined to the lung bases, on the right, the effusion occupies approximately one-quarter to one-third of the right hemithorax. Subsequent areas of bilateral atelectasis. Known right and left paramediastinal fibrosis. No newly appeared lung parenchymal changes. No evidence of pneumothorax. . [**2151-3-29**] CXR As compared to the previous radiograph, a pre-existing opacity at the left lung base is visually minimally more apparent. Although this could be due to technical factors, aspiration cannot be excluded. The pre-existing pleural effusions are unchanged in extent. . [**2151-3-30**] CXR As compared to the previous radiograph, the patient has been intubated. The tip of the endotracheal tube projects 5 cm above the carina. The patient has also received a nasogastric tube, and the course of the tube is unremarkable, the tip of the tube is not visualized on the image. The pre-existing right pleural effusion has substantially decreased in extent. The small effusion on the left and the opacity at the left lung bases are unchanged. No evidence of complications, notably no pneumothorax. . [**2151-3-30**] ECHO (TTE) The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. There is moderate to severe regional left ventricular systolic dysfunction with akinesis of the mid- and distal anterior wall, septum and apex. The remaining segments contract normally (LVEF = 30%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Moderate to severe regional left ventricular systolic dysfunction, c/w LAD-territory infarction or Takotsubo cardiomyopathy. Mild aortic and mitral regurgitation. Moderate pulmonary hypertension. Compared with the report of the prior study (images unavailable for review) of [**2144-5-29**], regional LV systolic dysfunction appears new. Brief Hospital Course: 77 yo with h/o COPD, small cell lung cancer (14 years ago) and adenocarcinoma of the lung admitted with pneumonia. #) RESPIRATORY DISTRESS: He completed an 8-day course of vanc and zosyn for HCAP and concern for aspiration given evaluation by speech therapy. He was transferred to the MICU on [**3-29**] and intubated on arrival. A large mucous plug was removed by bronchoscpy. He was extubated and then reintubated on [**4-2**]. Trach and PEG completed on [**4-7**]. He has been tolerating trach mask for intervals spanning several hours at a time and resting on pressure support. When dyspneic, he improves with suction. #) BACTEREMIA: ED blood cx with CoNS in [**12-23**] bottles which was felt to be contiaminant. Did complete a course of vanc/zosyn for HCAP. #) TROPONIN ELEVATION Patient monitored with serial cardiac enzymes upon admission. Troponins were trending up. ECG with initial ST depressions, then new TWI in V1-V4. He remained asymptomatic throughout. Possibly demand ischemia from infection and prolonged tachycardia but concerning given focal ECG changes. He was started on a heparin drip, high-dose atorvastatin, aspirin, and metoprolol. Cardiac enzymes were followed and initially appeared to have peaked but trended up on hospital day #4. A cardiology consult was called and did not feel was ACS. We continued high dose atorvastatin, but outpatient providers should consider lowering to home dose after one month from troponin rise ([**4-25**]). He was also continued on a full dose aspirin and a low dose-beta blocker. #) TACHYCARDIA: HR in the 120s on admission with ST depressions in V3-V6, which may be rate related and resolved on f/u ECG. Patient does report a history of sinus tachycardia (PCP visits with HR 100s-120s over past 5 years) for which he does not take rate controlling agents. Tachycardia improved with fluids and a low dose beta blocker was initiated as above. #) Hypotension Patient mentates and has good urine output even with systolic blood pressure in the 80s. #) COPD: FEV1 72% in [**2147**] with mild obstructive defect. Not on home oxygen and uses combivent prn. CT chest in [**1-1**] with significant structural evidence of emphysema and chronic bronchitis. The patient was given standing nebulizer treatments of his COPD. #) LUNG CANCER Follows with Dr. [**Last Name (STitle) 3274**] for small cell lung cancer in [**2136**] s/p R paratracheal mass resection tx with XRT and chemo, and adenocarcinoma of the lung RUL wedge resected in [**5-/2144**] with no evidence of recurrence on most recent CT chest in [**1-1**]. #) TRANSITION OF CARE - Needs TSH as outpatient when acute illness has resolved - Needs outpatient stress test - decrease atorvastatin [**4-25**] Medications on Admission: Combivent 18mcg-103 mcg (90 mcg) 2 puffs prn Lovastatin 20mg daily ASA 81mg daily MVI with iron Discharge Medications: 1. docusate sodium 50 mg/5 mL Liquid [**Month/Day (1) **]: One (1) PO BID (2 times a day). 2. senna 8.6 mg Tablet [**Month/Day (1) **]: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. heparin (porcine) 5,000 unit/mL Solution [**Month/Day (1) **]: 5000 (5000) units Injection TID (3 times a day). 4. acetaminophen 650 mg/20.3 mL Solution [**Month/Day (1) **]: Six [**Age over 90 1230**]y (650) mg PO Q6H (every 6 hours) as needed for fever. 5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Age over 90 **]: 2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. 6. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler [**Age over 90 **]: 4-6 Puffs Inhalation Q4H (every 4 hours) as needed for SOB. 7. atorvastatin 80 mg Tablet [**Age over 90 **]: One (1) Tablet PO at bedtime. 8. aspirin 325 mg Tablet [**Age over 90 **]: One (1) Tablet PO DAILY (Daily). 9. insulin lispro 100 unit/mL Solution [**Age over 90 **]: sliding scale Subcutaneous ASDIR (AS DIRECTED). 10. metoprolol tartrate 25 mg Tablet [**Age over 90 **]: 0.5 Tablet PO BID (2 times a day). 11. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 12. heparin, porcine (PF) 10 unit/mL Syringe [**Last Name (STitle) **]: Five (5) ML Intravenous PRN (as needed) as needed for line flush. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**] Discharge Diagnosis: Principal: pneumonia, chronic obstructive pulmonary disease Secondary: coronarty artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: You were admitted with pneumonia and due to your COPD, you required a breathing tube and then a tracheostomy. Followup Instructions: please schedule with PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] when discharged. Department: DERMATOLOGY When: MONDAY [**2151-5-17**] at 1:15 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2762**], MD [**Telephone/Fax (1) 1971**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "272.4", "792.1", "V10.11", "E912", "285.9", "934.8", "491.21", "518.81", "511.9", "411.89", "428.0", "486", "427.89", "428.21" ]

icd9cm

[ [ [] ] ]

[ "33.22", "31.1", "96.72", "96.6", "34.91", "33.24", "98.15", "43.11" ]

icd9pcs

[ [ [] ] ]

12497, 12597

8224, 10950

324, 351

12737, 12737

2784, 3739

13006, 13437

2114, 2132

11097, 12474

12618, 12716

10976, 11074

12872, 12983

2147, 2765

3783, 8201

264, 286

379, 1761

12752, 12848

1783, 1928

1944, 2098

78,007

148,701

35376+57995

Discharge summary

report+addendum

Admission Date: [**2119-2-19**] Discharge Date: [**2119-2-23**] Date of Birth: [**2042-1-20**] Sex: F Service: NEUROLOGY Allergies: Macrobid Attending:[**First Name3 (LF) 2569**] Chief Complaint: Parasthesias, visual difficulty Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 45224**] is a 76 year old right handed woman with history of at least two prior lobar hemorrhages with evidence of amyloid, one prior left occipital parenchymal hemorrhage, and another left occipital bleed in [**2117-2-7**], HTN who now presents with the sudden onset of sustained left foot paresthesias since 9am this morning and was transferred from an OSH with evidence of a small right parietal hemorrhage. The patient was making breakfast this morning when she noticed at 9am the sudden onset of paraesthesia in her left foot. She described it as a constant tingling, with no weakness or sensory loss. The tingling was primarily on the bottom of the foot, but involved the entire foot from the toes to the heel. It did not involve the ankle. At first she ignored the sensation, rubbing the foot and moving around in hopes that it would go away. After about 30min-1 hour she decided to call her VNA who was scheduled for a visit. After describing the symptoms to the VNA she was advised to call EMS and be evaluated at the nearest hospital. During this time the patient had no other paraesthesia. She had no weakness, no problems with coordination or walking, and was able to go about her usual routine. She had no difficulty picking up and dialing the phone, no new visual difficulties, no headache, no problems with language. She denies any recent trauma. The patient was transported to [**Hospital3 417**] where a head CT revealed a new small hemorrhage (~1cm2) in the right parietal lobe. She was then transferred to [**Hospital1 18**] for further evaluation. The patient did note about 3 weeks ago she was evaluated for what she termed a TIA. It was a brief 15-30 minute sensation of paresthesias that radiated up her left arm while she was playing bingo. She was taken to [**Hospital3 **] at the time for a stroke TIA workup and had imaging which was review by Dr. [**First Name (STitle) **] in clinic and did not show any evidence of new infarct or bleeding. The paresthesias of the arm have not returned. Past Medical History: Left occipital hemorrhage- ([**2116-9-7**])- presented with "fireworks" in her visual field, no headache, she was admitted to [**Hospital1 2025**], seen by Dr. [**First Name (STitle) **] there, but no longer follows. She had visual filed testing subsequently and told she had R inferior quadrantanopsia and hence no longer drives. Hypertension Vertigo- takes meclizine PRN Bilateral TKR no history of MI Social History: Recently widowed in [**Month (only) 547**] of this year, she is a retired administrative assistant at the [**Company 3596**], now volunteers, never smoker, no EtOH for a number of years, no illicit or IV drug use. Family History: Father- colon cancer, d. 85 Mother- Dementia, d. 85 Brother- d. age 40 secondary to ETOH. Physical Exam: General: NAD Pulm: CTA B/L Abd: Soft NT/ND CV: Systolic murmur, RRR Neurologic: -Mental Status: Alert, oriented to month, date, hospital, not year. Speech is fluent, repetition and command following intact. Naming difficult to assess as she is not looking at the correct objects I am suggesting and confused by the task. Difficulty with relating history (see above). Attentive but slow, able to name DOW backwards (declines [**Doctor Last Name 1841**]). Calculation only intact for simple math (2x2) but cannot perform more challenging task (quarters in $2.25). Registers 3 objects and recall 0/3 at 5 minutes. Decreased attention to left side of room, apraxic with cutting loaf of bread. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. At first appears to have subtle inferior right quadrantanopsia seen on prior exams but subsequently has dramatic difficulty with the task often just saying "oh, I see the light, right there" and pointing to random spots on the right where there is no light. Her visual acuity is inaccurate for finger counting, it seems though that she is neglecting fingers on her left side rather than a true acuity problem. She can describe the examiner and does not report part missing from the face. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop VIII: Hearing grossly slightly diminished. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Slightly increased lower extremity tone. Normal bulk throughout. No adventitious movements noted. No asterixis noted. + left pronator drift Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB L 5 5 5 5 5- 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5- 5 5 5 5 5 5 5 5 5 -Sensory: Very inconsistent with repeated exam but no consistent deficits to light touch, pinprick, cold sensation, vibratory sense throughout. No extinction to DSS. -Coordination: No intention tremor, dysdiadochokinesia noted. HKS is intact but she cannot perform FNF as she is point to entirely random spots it seems rather than examiner's finger. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 3 2 3 2 1 R 3 2 3 2 1 Plantar response was extensor bilaterally -Gait: deferred Pertinent Results: cxr: [**2119-2-21**] Subtle retrocardiac opacification with blunting of the left costophrenic angle, possibly representing atelectasis and a small effusion. However, superimposed or developing pneumonia cannot be excluded in the appropriate clinical setting. NCHCT: [**2119-2-19**] IMPRESSION: 1. Essentially unchanged examination compared to four hours prior, with large right parietal intraparenchymal hemorrhage and small multifocal right frontal hemorrhages. Trace amount of subarachnoid hemorrhage but without intraventricular hemorrhagic extension. 2. No new foci of intraparenchymal hemorrhage. No midline shift. 3. Marked white matter ischemic disease. Brief Hospital Course: Mrs. [**Known lastname 45224**] is a 77-year old right handed woman with history of hypertension and two prior lobar hemorrhages secondary to amyloid angiopathy with pre-existing deficit of right inferior quadrantanopsia who presents with acute change in vision characterized by not being able to see the toilet which was in her right inferior visual field found to have a right parietal lobar bleed at outside hospital for which she was transferred here. Initial exam was notable for impaired orientation, memory, calculation, apraxia, decreased attention to left, left pronator drift and inconsistent visual field exam at times seeming entirely unable to see in various quadrants but at other times with only slight right inferior quadrantanopsia. Her head CT showed a larger bleed in the right parieto-occipital region with smaller area of bleed in the right frontal region in addition to punctate hemorrhages. She has remained stable. No interventions were done. Her family was updated on her condition. She was sent to Rehab for further care. Medications on Admission: Atenolol 25 mg daily Blood pressure medicine (replacement for prior hydrochlorothiazide but she is not sure of name/dose) Not sure if still on simvastatin Calcium 500mg x 2 daily Not sure if still on Minocycline 100mg at 2pm Meclizine 25mg daily PRN Discharge Medications: 1. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO QD (). 2. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. docusate sodium 50 mg/5 mL Liquid Sig: [**1-8**] PO BID (2 times a day). 5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. miconazole nitrate 2 % Cream Sig: One (1) Appl Vaginal HS (at bedtime) for 7 days. 7. Famotidine 20 mg IV Q12H 8. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 9. HydrALAzine 5 mg IV Q6H: PRN SBP > 160 10. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Heparin Flush (10 units/ml) 2 mL IV PRN line flush Mid-line, heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above, daily and PRN per lumen. 12. atenolol 25 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: New - Right parietal Hemorrhage Discharge Condition: Activity Status: Out of Bed with assistance to chair or wheelchair. Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Discharge Instructions: You were admitted as a transfer from another hospital for a brain hemorrhage. You had a right sided parietal hemorrhage that is likely secondary to amyloid angiopathy. No surgical interventions were completed. You did have deficits form this including vision problems and thus were sent to a rehabilitaiton center for further care. Followup Instructions: Dr [**First Name (STitle) **], [**First Name3 (LF) 2530**]. Date/Time: [**2120-4-21**]:00 pm Please call ([**Telephone/Fax (1) 7394**] two weeks prior to appointment to ensure date and time. [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**] Completed by:[**2119-2-23**] Name: [**Known lastname 12946**],[**Known firstname 779**] Unit No: [**Numeric Identifier 12947**] Admission Date: [**2119-2-19**] Discharge Date: [**2119-2-23**] Date of Birth: [**2042-1-20**] Sex: F Service: NEUROLOGY Allergies: Macrobid Attending:[**First Name3 (LF) 3326**] Addendum: Please note addendum to Med list on discharge. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO QD (). insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). docusate sodium 50 mg/5 mL Liquid Sig: [**1-8**] PO BID (2 times a day). bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Famotidine 20 mg IV Q12H Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol HydrALAzine 5 mg IV Q6H: PRN SBP > 160 atenolol 25 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 1174**] [**Hospital **] Hospital - [**Location (un) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 3327**] Completed by:[**2119-2-23**]

[ "368.46", "437.9", "277.39", "V43.65", "780.4", "342.92", "438.89", "401.9", "431" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10750, 10982

6356, 7410

302, 308

8853, 8921

5667, 6333

9386, 10727

3071, 3163

7711, 8657

8798, 8832

7436, 7688

9030, 9363

3892, 5648

3178, 3260

231, 264

336, 2393

8936, 9006

2415, 2821

2837, 3055

45,492

179,251

22921

Discharge summary

report

Admission Date: [**2161-6-23**] Discharge Date: [**2161-7-2**] Date of Birth: [**2111-6-30**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 78**] Chief Complaint: Headache Major Surgical or Invasive Procedure: [**2161-6-24**]: Cerebral Angiogram with coiling of left PComm Artery Aneurysm History of Present Illness: 49F was at home, had had a couple beers when developed severe sudden onset headache. Went to OSH where CT showed CT with SAH. Neuro intact. Transferred [**Hospital1 18**] ED for further management. Past Medical History: depression, inc cholesterol Social History: Etoh Family History: n/a Physical Exam: PHYSICAL EXAM: O: T:98.4 BP: 138/76 HR:86 O2Sats 97 2l Gen: WD/WN, NAD but eyes closed with cold cloth on head. HEENT: Pupils: [**4-7**] EOMs full Neck: Supple.minimal pain with flex/ex Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 5 to 4 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**4-8**] throughout. No pronator drift Sensation: Intact to light touch bilaterally. Toes downgoing bilaterally Coordination: normal PHYSICAL EXAM UPON DISCHARGE ******* Pertinent Results: ADMISSION LABS: [**2161-6-22**] 11:00PM WBC-16.6*# RBC-4.46 HGB-13.5 HCT-40.2 MCV-90 MCH-30.4 MCHC-33.7 RDW-14.1 [**2161-6-22**] 11:00PM PT-12.3 PTT-27.5 INR(PT)-1.0 [**2161-6-22**] 11:00PM GLUCOSE-167* UREA N-22* CREAT-0.7 SODIUM-139 POTASSIUM-3.9 CHLORIDE-110* TOTAL CO2-18* ANION GAP-15 [**2161-6-23**] 03:42AM PHENYTOIN-14.8 IMAGING: CTA Neck [**6-23**]: extensive SAH centered at the left aspect of the suprasellar cistern. 7mm x 7 mm lobulated aneurysm at the junction of the left MCA and carotid artery. [**2161-6-26**] Head CT: IMPRESSION: 1. New area of hypoattenuation in the left parietal lobe s/p aneurysm coiling, suspicious for acute infarction. 2. Small amount of residual subarachnoid hemorrhage. [**2161-6-30**] Head CTA: IMPRESSION: 1. No significant change in the hypodense area in the left parietal lobe at the vertex compared to the recent study of [**6-26**], though it is new compared to [**6-24**] and may represent a focus of infarction. 2. Short segment areas of stenosis, in the left posterior cerebral artery -P2 segment, may be real/related to adjacent artifacts from the coils. Short segment narrowing of the distal Basilar artery is likely related o artifacts. Atherosclerotic calcified and non-calcified plaques in the cavernous segments on both sides with some degree of stenosis. Otherwise, no flow-limiting stenosis or occlusion of the major arteries noted. [**Date range (1) 59214**] EEG: IMPRESSION: This is a normal video EEG telemetry in the awake and drowsy states. There was no organized epileptiform activity or electrographic seizures. Brief Hospital Course: The patient was admitted to the Surgical ICU for Q1 neuro checks and tight blood pressure control. She was placed on nimodipine for vasospasm prophylaxis, and dilantin for seizures. A repeat CTA was performed, which demonstrated a 7x7mm lobular aneurysm at the junction of the L carotid/MCA. She was taken to the angio suite on [**6-23**] and underwent coiling of the P Comm Artery aneurysm. Procedure was without complication but due to a small coil protrusion in the parent artery, she was left on a heparin drip overnight. Patient returned to the ICU for close neurological monitoring. The following morning the heparin was discontinued and EEG monitoring was initiated per protocol. She was also started on a prednisone taper for additional pain control. On [**6-25**] dilantin level was reloaded. On [**6-26**] a CT was performed at the discretion of the ICU team for continued headaches. This revealed a small left parietal infarction. The patient remained neurologically stable and asymptomatic, but hypertension and hypervolemia were initiated. From [**6-27**] through [**6-30**] the patient remained neurologically intact in the ICU. Pain medications were changed frequently in attempt to reach an acceptable comfort level. On [**6-30**] the patient was cleared for discharge to the floor. Her IVF was halfed to 100ml/hr. EEG monitoring was discontinued and she was encouraged to be out of bed. On [**7-1**] A CTA was obtained to assess for vasospasm and was negative. IVF was discontinued. On [**7-2**] the patient was ambulating independently and tolerating a PO diet. H/A was stable and current pain regimen is tolerable. Pt was cleared for discharge home at this time. Medications on Admission: toprimate 100hs, sertraline 150 qday, ranitidine 150 qday, valium 10 prn, gabapentin 100 [**Hospital1 **], cipro 500 [**Hospital1 **], seroquel 200 qhs Discharge Medications: 1. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4 hours) for 13 days. Disp:*156 Capsule(s)* Refills:*0* 2. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Tablet(s) 3. Quetiapine 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**12-6**] Tablets PO Q4H (every 4 hours) as needed for pain: Alternate with Florinal to decrease tylenol intake. Disp:*60 Tablet(s)* Refills:*0* 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Butalbital-Aspirin-Caffeine 50-325-40 mg Capsule Sig: [**12-6**] Caps PO Q4H (every 4 hours) as needed for h/a: Alternate with Florinal to decrease tylenol intake. Disp:*60 Cap(s)* Refills:*0* 10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Aneurysmal Subarachnoid Hemorrhage Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Angiogram with Embolization Medications: ?????? Take Aspirin 325mg (enteric coated) once daily. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs. ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). ?????? After 1 week, you may resume sexual activity. ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate. ?????? No driving until you are no longer taking pain medications Followup Instructions: You need to follow up with Dr. [**First Name (STitle) **] in 1 month. You will need an MRI/MRA of your head before this appointment. Please call Takesia at [**Telephone/Fax (1) 1669**] to schedule this. Completed by:[**2161-7-2**]

[ "430", "311", "401.9", "291.81", "272.4", "300.00", "530.81", "434.91", "303.90" ]

icd9cm

[ [ [] ] ]

[ "38.91", "88.41", "39.72" ]

icd9pcs

[ [ [] ] ]

6629, 6635

3607, 5291

325, 406

6714, 6714

1987, 1987

7886, 8119

724, 729

5494, 6606

6656, 6693

5317, 5471

6865, 7863

759, 992

277, 287

434, 635

1244, 1968

2534, 3584

2004, 2525

6729, 6841

657, 686

702, 708

9,590

132,347

190

Discharge summary

report

Admission Date: [**2102-2-19**] Discharge Date: [**2102-3-9**] Service: Neurosurgery HISTORY OF PRESENT ILLNESS: This is a 79-year-old female with a history of atrial fibrillation on Coumadin, hypertension, and cerebellar cerebrovascular accident, who presented to the Emergency Department complaining of nausea, no vomiting, and headache since one night prior to admission. When the patient woke up this morning the patient had progressive dysarthria. The patient denied any visual or auditory changes. The patient also denied any fevers, chills, changes in bowel habits, chest pain, shortness of breath, melena, bright red blood per rectum, and hematemesis. PAST MEDICAL HISTORY: 1. Hypertension. 2. Atrial fibrillation. 3. Cerebrovascular accident. MEDICATIONS AT HOME: 1. Atenolol. 2. Coumadin. 3. Plendil. 4. Lipitor. 5. Avapro. 6. Neurontin. 7. Hydralazine. ALLERGIES: 1. Codeine. 2. Macrodantin. PHYSICAL EXAMINATION: The patient's temperature was 96.8, pulse 71, blood pressure 206/110, respiratory rate 16, oxygen saturation was 94% on room air. The patient was alert and oriented x 3 in no acute distress. The patient's speech was dysarthric. The patient's pupils were equal, round and reactive to light. The patient's extraocular movements were intact. The patient had symmetric eyebrow lift, and symmetric smile. The patient had no tongue deviation, no pronator drift. The patient had 5+ strength in the shoulders and hands. The patient's heart rate was irregularly irregular. Lungs were clear to auscultation bilaterally. The patient was moving all extremities and had 5+ strength. The patient's cranial nerves two through 12 were intact. LABORATORY STUDIES: White blood cell count was 13.3, hematocrit 46.6, platelet count 305. The patient's PT was 23.4, PTT 44.5 and INR was 3.6. The patient's chemistries were normal. CT scan done on [**2-19**] showed left cerebellar intraparenchymal hemorrhage. HOSPITAL COURSE: The patient was admitted to the neurosurgery service for management. The patient was started on fresh frozen plasma to reverse her INR down to less than 1.3. The patient was started on a Nipride drip to decrease blood pressure. The patient was put on q. 1 hour neurological checks and was admitted to the intensive care unit. The patient was taken to the operating room on [**2102-2-20**] for posterior fossa craniotomy for evacuation of cerebellar hemorrhage. The patient also underwent placement of right frontal ventriculostomy drain. Postoperatively the patient had tolerated the procedure well and an ENT consultation was obtained for evaluation of dysarthria and dysphasia. The patient was gradually weaned off the ventilator. The ventriculostomy drain pressures gradually increased to 20 cm of water. The patient's intracranial pressure did not increase with the increasing drain pressure. The ventriculostomy drain was taken out on [**2102-3-8**]. The patient was reevaluated by [**Hospital1 **] for rehabilitation screening. The patient was accepted by [**Hospital1 **] and was ready for transfer to [**Hospital1 **] for rehabilitation on [**2102-3-9**]. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To rehabilitation. DISCHARGE MEDICATIONS: 1. Metoprolol 100 mg p.o. t.i.d. 2. Glutamine 5 mg p.o. b.i.d. 3. Coumadin 0.1 mg p.o. t.i.d. 4. Multivitamins 1 capsule p.o. q.d. 5. Amlodipine 10 mg p.o. q.d. 6. Hydralazine 50 mg p.o. q. 6. 7. Colace 100 mg p.o. b.i.d. 8. Albuterol nebulizer 1 neb q. 6 hours. 9. Atrovent nebulizer 1 neb q. 6 hours. 10. Losartan 50 mg p.o. b.i.d. 11. Lansoprazole 50 mg p.o. q.d. 12. Insulin sliding scale. FOLLOW UP: The patient should follow up with Dr. [**Last Name (STitle) 1906**] from neurosurgery. Please call Dr.[**Name (NI) 1907**] office for an appointment. [**First Name8 (NamePattern2) 900**] [**Last Name (NamePattern1) **], MD [**MD Number(1) 1908**] Dictated By:[**Last Name (NamePattern1) 1909**] MEDQUIST36 D: [**2102-3-9**] 06:05 T: [**2102-3-9**] 07:43 JOB#: [**Job Number 1910**]

[ "996.2", "253.6", "518.84", "995.0", "431", "E942.0", "331.4", "458.2", "427.31" ]

icd9cm

[ [ [] ] ]

[ "96.72", "96.04", "01.24", "38.93", "96.6", "31.1", "43.11", "02.2" ]

icd9pcs

[ [ [] ] ]

3250, 3645

1977, 3154

794, 933

3657, 4080

956, 1959

126, 676

699, 772

3179, 3227

13,579

148,859

10192

Discharge summary

report

Admission Date: [**2146-5-23**] Discharge Date: [**2146-6-10**] Date of Birth: [**2067-11-17**] Sex: M Service: SURGERY Allergies: Amiodarone Hcl / Zestril Attending:[**First Name3 (LF) 1**] Chief Complaint: Pt admitted s/p LAR for rectal CA Major Surgical or Invasive Procedure: LAR, anastamosis revision History of Present Illness: Pt. admitted s/p low anterior resection for rectal CA (T2 lesion) Past Medical History: afib, cabg, htn, motion sickness, rectal ca Social History: professor [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] Physical Exam: NAD, AAOx3 CV: RRR, no m/r/g Pulm: CTAB Abd: soft, NT, ND, NABS Incision: C/D/I, with minimal serosangenous drainage Ext: 1+ LE edema Pertinent Results: [**2146-6-7**] 06:50AM BLOOD Glucose-112* UreaN-19 Creat-1.3* Na-142 K-3.5 Cl-101 HCO3-34* AnGap-11 [**2146-6-7**] 06:50AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.9 [**2146-6-4**] 08:57AM BLOOD WBC-11.7* RBC-3.42* Hgb-10.4* Hct-30.3* MCV-89 MCH-30.5 MCHC-34.4 RDW-14.4 Plt Ct-502* [**2146-6-3**] 04:34AM BLOOD WBC-12.9* RBC-3.28* Hgb-10.0* Hct-29.0* MCV-89 MCH-30.5 MCHC-34.4 RDW-14.4 Plt Ct-414 [**2146-6-2**] 02:36AM BLOOD WBC-16.7* RBC-3.33* Hgb-10.2* Hct-29.6* MCV-89 MCH-30.6 MCHC-34.5 RDW-14.2 Plt Ct-391 [**2146-6-7**] 06:50AM BLOOD PT-18.2* INR(PT)-1.7* [**2146-6-6**] 01:18PM BLOOD PT-17.2* INR(PT)-1.6* Brief Hospital Course: 78 y/o male who presented for resection of a T2 rectal Ca 4 cm from the verge. He underwent a LAR on [**2146-5-23**] with a double stapled anastamosis and no ileostomy. He had a normal postoperative course until POD #5 when he had an episode of vomiting. he had no fever or vital sign abnormalities and continued to tolerate PO. On POD #6 the patient complained of vague lower abdominal pain after moving his bowels, which was new. He remained afebrile and tolerating PO so the decision was made to watch him for another 24 hours. Later that day he was found to be diaphoretic and hypotensive with a SBP in the 80's. He was resuscitated with crystalloid and physical exam revealed a disruption of his anastamosis posteriorly. Broad spectrum antibiotics were given and the patient was taken back to the OR for an ex-lap, anastamosis revision, and loop ileostomy. Post-operatively the patient was retained in the ICU for further resuscitation and maintained on the ventillator for the first day. He was then transferred back to the floor where he has had an uneventful postoperative course with the exception of excessive edema s/p his stay in the ICU. He was diuresed, restarted on his home meds, including coumadin, and has tolerated a regular diet. He is discharged to home in good condition to be followed by a VNA. Medications on Admission: Tikosin, Chlorthalidone, Lipitor, Toprol XL, Quinapril, Coumadin, Cholestyramine, Klor-Con Discharge Medications: 1. Dofetilide 250 mcg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 3. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 4. Quinapril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Chlorthalidone 25 mg Tablet Sig: 0.5 Tablet PO QAM (once a day (in the morning)). 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 days. Disp:*6 Tablet(s)* Refills:*0* 8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. Disp:*2 Tablet(s)* Refills:*0* 9. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day). Disp:*120 Capsule(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: s/p LAR for rectal CA the anastamosis revision Discharge Condition: Good Discharge Instructions: Call or return to ER for fever >101.5, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or other concerns. OK to shower but do not soak incision in tub/pools/etc. for at least two weeks. No strenuous exercise or heavy lifting until cleared at follow up appointment. Do not drive or drink alcohol while taking narcotic pain medications. Resume all home medications. Follow-up with your primary care physician within one month for reassessment of home medications post surgery Followup Instructions: Call Dr.[**Name (NI) 10946**] office to schedule a followup appointment in [**1-7**] weeks. Call [**Telephone/Fax (1) 3760**] for a followup appointment with Dr. [**First Name (STitle) **] in Oncology. Completed by:[**2146-6-14**]

[ "997.4", "427.31", "196.2", "458.9", "401.9", "V45.81", "782.3", "154.0" ]

icd9cm

[ [ [] ] ]

[ "48.63", "99.04", "46.94", "99.77", "45.94", "46.21", "54.25" ]

icd9pcs

[ [ [] ] ]

3773, 3831

1390, 2709

316, 343

3922, 3929

761, 1367

4493, 4727

2850, 3750

3852, 3901

2735, 2827

3953, 4470

607, 742

243, 278

371, 438

460, 505

521, 592

3,222

128,402

46232

Discharge summary

report

Admission Date: [**2192-8-1**] Discharge Date: [**2192-8-7**] Date of Birth: Sex: M Service: INTENSIVE CARE MEDICINE HISTORY OF PRESENT ILLNESS: This is a [**Hospital 98292**] nursing home patient with past medical history significant for hypothyroidism, chronic renal insufficiency with a baseline creatinine of 1.6, and hypertension, who was noted to have a three day history of progressively worsening mental status. At baseline, the patient is apparently independent in all her activities of daily livings, ambulates with a walker, and is appropriately articulate. In addition, the patient is status post three falls over the past three days associated with slurred speech, and increasing confusion. Patient's falls were all unwitnessed at the nursing home, but there was no reported loss of consciousness. According to nursing home notes, the patient's po intake was also poor for the past three or four days. Of note, her outpatient Lasix dose had been doubled to 40 mg q day on [**7-27**]. On the night prior to admission, patient was noticed to be increasingly agitated. As a result, she was given a total of 1 mg of Ativan. She was then found unresponsive with systolic blood pressure in the 70s, heart rate in the 50s, and was thus transferred to [**Hospital1 188**] Emergency Department. REVIEW OF SYSTEMS: Review of systems obtained from the patient's daughter was remarkable only for a chronic persistent pruritic dermatitis on the patient's legs and trunk for the past 2-3 years for which she has been followed closely by Dermatology. Of note, the patient is highly sensitive to various medications with a history of increased confusion when given drugs like Celexa, [**Doctor First Name **], and Remeron. In our Emergency Department, the patient was aggressively fluid resuscitated with 2.5 liters of normal saline without any response. As a result, she was started on a dopamine drip. She was started on empiric antibiotics consisting of Vancomycin, ceftriaxone, and Flagyl. She was also given stress dosed IV steroids. She was found to be hypothermic with a rectal temperature of 88.0 F. Chest x-ray showed a right lower lobe infiltrate, but electrocardiogram was without any acute changes. The patient was also given a dose of Glucagon for possible beta blocker overdose without any response. She was stabilized in the Emergency Department, and then transferred to the Fenard Intensive Care Unit for further management. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypothyroidism. 3. Depression. 4. Anxiety. 5. Legally blind secondary to macular degeneration. 6. Chronic dermatitis for the past two years accompanied by intractable pruritus, resistant to steroids (the patient was treated empirically for scabies in [**2192-6-17**]). 7. Left eye cataract. 8. Sensitivity to various medications. ALLERGIES: 1. Celexa (confusion). 2. [**Doctor First Name **] (confusion). 3. Ambien. 4. Remeron (confusion). MEDICATIONS ON ADMISSION: 1. Benadryl 37.5 mg q hs. 2. Lasix 40 mg po q day. 3. Atenolol 50 mg po q day. 4. Aspirin 325 mg q day. 5. Levothyroxine 88 mcg q day. 6. Tylenol prn. 7. Bacitracin ointment [**Hospital1 **]. 8. Doxepin 5% cream qid to pruritic areas. SOCIAL HISTORY: The patient is a [**Hospital 100**] Rehab resident. She was a former private secretary. She had two daughters, one of whom died of cancer. Her other daughter is [**Name (NI) **] [**Name (NI) **] and is quite involved in her care. Her home phone number is ([**Telephone/Fax (1) 98293**] and cell is ([**Telephone/Fax (1) 98294**]. She has no documented tobacco, alcohol, or IV drug use. Of note, she is DNR/DNI in terms of code status. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: Rectal temperature 88.0 F, blood pressure 105/56 on a Levophed drip at 0.5 mcg, heart rate 40 and sating 100% on 70% face mask. In general, the patient was quite confused and disoriented. She responded only minimally to voice. Pupils are equal, round, and reactive to light. Sclerae are anicteric. Mucous membranes are moist. Oropharynx is clear, but poor dentition. Cardiac examination revealed distant S1, S2, bradycardia, no audible murmurs, rubs, or gallops. Lungs were clear bilaterally with decreased breath sounds at the right base. Abdomen was soft and benign with good bowel sounds. Extremities showed 1+ pitting pedal edema bilaterally, as well as positive dopplerable pulses bilaterally. Skin showed a bilateral erythematous macular rash with confluent excoriations. There were multiple weeping open wounds and ulcerations. LABORATORIES ON ADMISSION: Notable for a white count of 5.7 with 60% neutrophils, and 24% lymphocytes, hematocrit 28. Platelets 307. INR 1.1. Urinalysis was negative. BUN 62, creatinine 2.6, potassium 5, sodium 142. LFTs were all normal. Amylase and lipase normal. TSH 4.6, T3 88, T4 1.2. Random cortisol 15.9. Arterial blood gas: 7.33, pCO2 41, pAO2 215 on a nonrebreather. Lactate level normal at 1. Head CT scan was negative for any acute processes. Chest x-ray showed a questionable right lower lobe infiltrate. Electrocardiogram showing normal sinus rhythm at a rate of 50, old right bundle branch block, old T-wave inversions in leads I, III, V1, and V3. QTc interval slightly prolonged at 500. HOSPITAL COURSE BY PROBLEMS: Hypotension: The patient's hypotension on initial presentation remains of unclear etiology. It is thought that it was most likely due to beta blocker toxicity in the setting of acute on chronic renal failure. She was initially aggressively fluid resuscitated with normal saline, but soon developed evidence of congestive heart failure, so it was decided to be more gentle in terms of hydration. She was thus kept on Levophed as a pressor [**Doctor Last Name 360**] for about 48 hours and then was successfully weaned off. She was given stress-dosed steroids initially, but as her random cortisol were normal, these were soon tapered off. She was pancultured and started on empiric antibiotics (Vancomycin, ceftriaxone, and Flagyl) with the thought that she may be displaying vasodilatory shock. But as her cultures remain negative and she remained afebrile, her antibiotics were soon stopped. Her cardiac enzymes were cycled and were all found to be negative. After a few days, the patient's blood pressure returns back to baseline and she was found to be hypertensive with systolics between 130 and 175. As a result, she was started on low dosed metoprolol at 12.5 [**Hospital1 **] and low dosed captopril 6.25 tid. Hypothermia: This too remains of unclear etiology. The patient's core body temperature returned back to normal with 24 hours of a Bair hugger. Her electrocardiogram displayed no signs of hypothermia both on admission and 24 hours later. She was able to maintain normal body temperature throughout hospital stay. Acute on chronic renal failure: The patient's acute renal failure was thought to be due to a combination of prerenal azotemia in the setting of poor po intake along with increased Lasix, as well as acute tubular necrosis in the setting of hypotension. The patient's medications were all renally dosed and all nephrotoxic medications were avoided. Over the course of her admission, the patient's creatinine returned back to baseline at the time of this dictation. Her urine output remained excellent during her hospital stay, and at no point did she display any acute indication for hemodialysis. Congestive heart failure: With a fluid load on admission, the patient became hypoxic, and displayed clinical signs of congestive heart failure. An echocardiogram is to be obtained immediately prior to discharge to better assess the patient's ejection fraction and to evaluate for any valvular disease. Daily weights were checked. Strict in's and out's were monitored and a 2 gram sodium diet adhered to during her stay. Immediately prior to discharge, the patient's chest x-ray showed increasing signs of pulmonary edema, so she was given 20 mg of po Lasix as well as 20 mg of IV Lasix with good results. At the time of this dictation summary, the patient is still slightly volume overloaded. As a result, she will be given a touch of Lasix IV to keep her in's and out's negative 1 liter. Her outpatient Lasix dose is yet to be determined depending on the results of her echocardiogram. Right lower lobe pneumonia: The patient developed low grade temperatures along with a leukocytosis during this admission. As a result, she was placed on a 10 day course of Levaquin with good results. Hypothyroidism: As the patient's T3 and T4 were found to be within normal limits, she was continued on her outpatient levothyroxine dose. Anemia: The patient was found to have iron deficiency anemia and was thus started on daily iron supplements. Her hematocrit dropped to 25.9 at one point with guaiac negative stools. As a result, she was transfused 1 unit of packed red blood cells. Mental status changes: The patient's acute confusional state was thought to be likely due to a toxic metabolic encephalopathy due to a combination of medications as well as infection from her pneumonia. A head CT scan was obtained and found to be negative for any acute changes. The patient was given low dosed Haldol during her hospitalization which was then discontinued to allow the patient to return to her baseline mental status. At the time of this dictation, the patient's mental status continues to wax and wane, and is still not quite at her baseline. All mind altering medications are to be avoided. Dermatitis: A Dermatology consult was obtained and the patient's chronic pruritic rash was thought to be consistent with asteatotic dermatitis. As a result, she was placed on Aquaphor tid, bacitracin [**Hospital1 **], Sarna lotion [**Hospital1 **], and Protopic q day with dramatic improvement. Nutrition: The patient was initially kept NPO given her unresponsive state. As her mental status began to improve, her diet was slowly advanced as tolerated to a 2 gram sodium diet. Nutrition was consulted, and it was decided to start the patient on Boost pudding supplements to improve her nutritional intake. In addition, she was placed on aspiration precautions. Hyperglycemia: The patient had a transient increase in her blood sugars while on IV steroids. During that time, she was placed on a regular insulin-sliding scale and her fingersticks were checked q6h. Once the steroids were tapered off, the patient's sugars normalized. Lines: The patient initially had a central line that was discontinued once she was weaned off her pressors. She also had a Foley placed that was discontinued before discharge. Prophylaxis: The patient was placed on Protonix daily, Heparin subQ, and an adequate bowel regimen for appropriate GI and DVT prophylaxis. DISCHARGE DIAGNOSES: 1. Hypotension secondary to beta blocker toxicity. 2. Acute on chronic renal failure secondary to prerenal azotemia and acute tubular necrosis. 3. Congestive heart failure. 4. Hypothyroidism. 5. Mental status changes likely due to toxic metabolic encephalopathy. 6. Anemia. 7. Right lower lobe pneumonia. DISCHARGE MEDICATIONS: 1. Colace 100 [**Hospital1 **]. 2. Captopril 6.25 mg tid (to be titrated up as blood pressure allows). 3. Protonix 40 q day. 4. Levothyroxine 88 mcg q day. 5. Metoprolol 12.5 mg [**Hospital1 **]. 6. Levaquin 250 mg q48h x6 more days. 7. Sarna lotion applied to skin tid prn. 8. Protopic one application transdermally q day. 9. Aquaphor ointment tid. 10. Iron sulfate 325 mg q day. 11. Heparin 5,000 units subQ q8 until the patient is ambulatory. 12. Bacitracin ointment [**Hospital1 **] to open wound on lower extremities bilaterally. 13. Tylenol prn not to exceed 4 grams a day. DISCHARGE STATUS: The patient was discharged in good condition to her [**Hospital6 459**]. She is to continue with Physical Therapy for strengthening. All sedative medications should be avoided until the patient's mental status returns back to baseline. She is to complete a 10 day course of her po Levaquin for her pneumonia. Her captopril should be titrated up as her blood pressure allows. Her echocardiogram results will need to be followed up upon. She is to remain on metoprolol instead of atenolol, as atenolol is renally excreted. She should be encouraged to take good po intake. She will be followed closely by her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at the [**Hospital3 1761**]. [**Name6 (MD) 98295**] [**Name8 (MD) **], M.D. Dictated By:[**First Name (STitle) 35062**] MEDQUIST36 D: [**2192-8-6**] 14:27 T: [**2192-8-6**] 15:01 JOB#: [**Job Number 98296**]

[ "584.9", "276.5", "458.2", "486", "428.0", "E942.9", "707.12", "244.9", "403.91" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

3711, 3729

10878, 11184

11207, 12751

2999, 3235

3752, 4612

1360, 2489

178, 1340

4627, 10857

2511, 2973

3252, 3694

681

192,229

8292

Discharge summary

report

Admission Date: [**2145-2-9**] Discharge Date: [**2145-2-11**] Date of Birth: [**2104-3-29**] Sex: F Service: MEDICAL INTENSIVE CARE UNIT CHIEF COMPLAINT: Question overdose/unresponsiveness. HISTORY OF PRESENT ILLNESS: The patient is a 40-year-old female with a history of depression, hypertension, asthma, and question of prior suicide attempts who presented after being witnessed taking an intentional overdose. Emergency Medical Service found her with four bottles, including Norvasc, Doxepin, clonidine, and Prozac; only the clonidine bottle was empty (by report). The patient was a apparently awake and alert on arrival to the Emergency Department. However, she was found in respiratory distress (by report), tachypneic, also tachycardic with blood pressures as high as 229/141, and a heart rate in the 108 range to 132 range. By report, the patient became unresponsive and was intubated for airway protection. Due to significant agitation, the patient was given multiple doses of Versed and four separate doses of pancuronium. A head CT was negative for intracranial bleed. She was given hydralazine 20 mg intravenously with a decrease in her blood pressure to the 170s. For her ingestion, she received 70 g of charcoal in the Emergency Department. On arrival to the Intensive Care Unit, the patient was intubated and paralyzed status post dose of paralytic just prior to leaving the Emergency Room. PAST MEDICAL HISTORY: 1. Depression, with recent discharge from [**Hospital6 **] for cocaine overdose and depression. 2. Asthma. 3. Hypertension. 4. Ovarian venous thrombosis, for which the patient was started on Coumadin; however, never followed up for further workup and was noncompliant with the medication. ALLERGIES: NONSTEROIDAL ANTIINFLAMMATORY DRUGS causing rash. MEDICATIONS ON ADMISSION: Per primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] (telephone number [**Telephone/Fax (1) 1792**]) the patient is supposed to be taking Doxepin 50 mg p.o. q.h.s., Norvasc 2.5 mg p.o. q.d., Prozac 20 mg p.o. q.h.s., Prilosec 20 mg p.o., Ventolin 2 puffs q.i.d., Azmacort 2 puffs t.i.d., hydrochlorothiazide 25 mg p.o. q.d., Neurontin, Accolate. SOCIAL HISTORY: Unable to obtain social history on arrival; per old record and primary care physician, [**Name10 (NameIs) **] patient is married and lives with her husband and two children. She is under a significant number of stressors at home. She actively uses cocaine. One of her family members is a drug dealer, given the patient free access to the cocaine. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed temperature of 98.4, blood pressure of 172/90, pulse of 116, respiratory rate of 12, oxygen saturation of 100%, paralyzed, on the ventilator, setting at AC 700 X 12, FIO2 of 100%, and a positive end-expiratory pressure of 5. Head, eyes, ears, nose, and throat revealed mucous membranes were moist. Pupils were 5 mm and reactive to light. Perforated nasal septum. Lungs were clear to auscultation. Heart was tachycardic but regular. No murmurs, rubs or gallops. Abdomen was soft, obese, nontender and nondistended, good bowel sounds. Extremities revealed no cyanosis, clubbing or edema. Scattered round papular scar-type lesions on the legs and arms. Multiple ecchymoses, especially on the right hand, and question right temple of the face. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory findings on admission revealed a white blood cell count of 13.8 (with a differential of 81 neutrophils, 13 lymphocytes, 4 monocytes, 0.5 eosinophils, 0.7 basophils), hematocrit of 38.5, platelet count of 483. Chem-7 revealed sodium of 135, potassium of 3.5, chloride of 98, bicarbonate of 22, blood urea nitrogen of 17, creatinine of 0.9, blood sugar of 158. Creatine kinase was 120, with a MB of 3. Urinalysis showed yellow/clear urine, with a specific gravity of 1.02, 30 protein, 15 ketones, pH of 9, 325 white blood cells, occasional bacteria, 3 to 5 epithelial cells. Urine culture was pending. Serum drug screen was positive for benzodiazepines. Urine drug screen was positive for benzodiazepines and cocaine. RADIOLOGY/IMAGING: Electrocardiogram showed tachycardic, sinus rhythm, normal axis, normal intervals. There was right atrial enlargement and poor R wave progression. There were no changes when compared with prior. Chest x-ray showed no pneumonia, ETT tube at 2.9 cm above groin with nasogastric tube well positioned in stomach. Head CT showed no intracranial hemorrhage. There was slight thickening of the sinuses. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit for further management after intubation in the Emergency Department. 1. AIRWAYS: The patient's sedation as well as paralysis was allowed to wear off with plan for extubation. However, the patient was extubated within one hour of arriving to the Medical Intensive Care Unit. She was able to maintain her airway, oxygenate, and ventilate well; and the decision was made not to reintubate. 2. OVERDOSE: It was unclear which medications the patient ingested. Once extubated, with the help of a Spanish interpreter, the patient was interviewed and insisted that she wanted to take some medication just to sleep. Her electrocardiogram was followed for QT prolongation in case one of the medications she ingested was a tricyclic antidepressant. She was placed on a CIWA scale in case part of her agitation was due to alcohol withdrawal. The Ativan was stopped once further information became available, and the patient was confirmed not to have significant alcohol history. 3. CARDIOVASCULAR: Upon presentation the patient was tachycardic and hypertensive with a blood pressure of up to 230/140. She initially received hydralazine with improvement in her blood pressure to 170/90. Intravenous hydralazine was continued during her Medical Intensive Care Unit stay. Due to positive cocaine screen, Lopressor and labetalol were avoided. The patient was ruled out for myocardial infarction with serial troponins, since she received intramuscular injections. Due to nonsteroidal antiinflammatory drugs allergy, aspirin was held. 4. AGITATION: Following self-extubation, the patient became increasingly more agitated and combative. Per Spanish interpreter, the patient was aware of herself, her location, and time, and date. She was noted to induce emesis by placing her fingers in her mouth. Due to the progressive increase in agitation and [**Last Name (LF) 29399**], [**First Name3 (LF) **] emergent Psychiatry evaluation was obtained. The patient was judged to be a danger to self as well as others, and restraints were indicated. Neither soft nor leather restraints were able to restrain the patient, and chemical restraint was recommended by Psychiatry. The patient received a cocktail of Haldol, Ativan and Cogentin leading to a decrease in her agitation. The next day, the patient woke up much more cooperative and not agitated. 5. PROPHYLAXIS: For prophylaxis, the patient was maintained on subcutaneous heparin and Prevacid through the nasogastric tube. DISCHARGE STATUS: The patient was to be discharged to [**Hospital6 18075**] for psychiatric hospitalization. MEDICATIONS ON DISCHARGE: (Her medications on discharge included) 1. Norvasc 2.5 mg p.o. q.d. 2. Azmacort inhaler 2 puffs b.i.d. 3. Hydrochlorothiazide 25 mg p.o. q.d. 4. Singulair 10 mg p.o. q.d. 5. Albuterol meter-dosed inhaler 2 puffs q.4h. p.r.n. 6. Thiamine 100 mg p.o. q.d. 7. Multivitamin one tablet p.o. q.d. 8. Folate 1 mg p.o. q.d. 9. Compazine 5 mg p.o./p.r. p.r.n. for nausea. CONDITION AT DISCHARGE: Medically stable. [**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**] Dictated By:[**Last Name (NamePattern1) 1762**] MEDQUIST36 D: [**2145-2-11**] 13:19 T: [**2145-2-13**] 06:13 JOB#: [**Job Number 29400**]

[ "787.03", "E950.3", "493.90", "518.82", "977.8", "305.60", "296.34" ]

icd9cm

[ [ [] ] ]

[ "96.70", "96.04" ]

icd9pcs

[ [ [] ] ]

7325, 7708

1842, 2223

4643, 7299

7723, 8001

173, 210

239, 1436

1458, 1815

2241, 4625

43,143

158,925

53549

Discharge summary

report

Admission Date: [**2194-4-3**] Discharge Date: [**2194-4-18**] Date of Birth: [**2146-3-8**] Sex: F Service: MEDICINE Allergies: Penicillins / Ceftin / Bactrim / vancomycin Attending:[**First Name3 (LF) 2195**] Chief Complaint: R hip infection Major Surgical or Invasive Procedure: [**2194-4-3**]: s/p right hip removal femoral component, exchange antibiotic spacer, irrigation & debridement, VAC placement [**2194-4-5**]: s/p right hip I&D and VAC exchange [**2194-4-7**]: s/p right hip I&D and VAC exchange [**2194-4-9**]: s/p right hip I&D, Abx spacer History of Present Illness: 48/F with Ehlers-Danlos Syndrome, Congential Adrenal Hyperplasia on prednisone, hx/o SVT, [**Hospital **] transferred to OSH for R hip irrigation and debridment. She a complicated history since fracturing her hip which is as follows. . On [**2193-12-27**] she pulled her right groin and was having difficulty ambulating as a result. She tripped and fell on [**2193-12-31**] and sustain and displaced R femoral neck fracture. She subsequently underwent an R ORIF at [**Hospital **] Hospital on the same day. Her postoperative course was complicated by hardware failure and SSI requiring re-expoloration on [**2194-1-14**]. An arthrotomy, I & D, and removal of prosthesis was performed with placement of an antibiotic impregnated spacer. She was also started on IV vancomycin. Per report, the infected was caused by MRSA. She had difficult tolerating vanco [**1-16**] nausea, lightheadedness and was subsequently switched to daptomycin. The patient reportedly received 4 weeks antibiotics therapy. . On [**2194-2-11**], she went back to OR for a repeat exploration and there was no sign of infection. A R hip hemiarthroplasty was performed. There were reportedly no immediate postoperative complications. She was discharged to rehab. . On [**2194-2-23**] she had a temperature of 101 and complained of RLQ pain. She was felt to have a palpable mass which was tender and patient was referred to the ED for further evaluation. . A CT abdomen at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 110066**] a large fluid collection in the subcutaneous tissue of her R hip which contained a small gas bubble. No abnormality of the RLQ was visualized. She went to the OR on [**2194-2-25**] for aspiration of the fluid collection as well as the hip aspiration. She was also found to have UTI at that time and was started on levofloxacin. . Unfortunately, documentation of her hospital course from this point forward is unavailable. The patient has been on daptomycin and levofloxacin for her R hip infection & UTI, respectively. These are reported to discontinue at some point next week. . Patient presents for right hip serial washouts and IV antibiotic management. Past Medical History: - Congenital Adrenal Hyperplasia - Ehlers Danlos - Osteoporosis - Pickwickian - HTN - Hypothyroidism s/p hemithyroidectomy - Lactose intolerant - Constipation - Anemia Social History: - Uses cane to ambulate - Tobacco: None - Alcohol: None - Lives alone - Unemployed Family History: - Father: Died from pancreatic cancer - Mother: Arthritis Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * Incision healing well with staples/sutures * Continued serosanguinous drainage, incisional vac in place * Thigh full but soft * No calf tenderness * 5/5 strength * Toes warm Pertinent Results: [**2194-4-3**] 9:57 pm URINE Source: Catheter. **FINAL REPORT [**2194-4-5**]** URINE CULTURE (Final [**2194-4-5**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [**2194-4-3**] 5:00 pm TISSUE Site: HIP SKIN AND FAT RIGHT HIP SPECIFICALLY REQUESTED NO GRAM STAIN. **FINAL REPORT [**2194-4-7**]** TISSUE (Final [**2194-4-7**]): Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 9:42 AM ON [**2194-4-5**]. ESCHERICHIA COLI. RARE GROWTH. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R ANAEROBIC CULTURE (Final [**2194-4-7**]): NO ANAEROBES ISOLATED CT PELVIS 1. No DVT in the left lower extremity. 2. Moderate subcutaneous edema in the left lower extremity. Discharge Labs: [**2194-4-18**] 04:49AM WBC-9.8 RBC-2.85* Hgb-9.0* Hct-28.6* MCV-100* Plt Ct-719* [**2194-4-18**] 04:49AM Glc-102* UreaN-7 Creat-0.3* Na-138 K-4.1 Cl-104 HCO3-30 [**2194-4-15**] 06:30AM ALT-10 AST-14 AlkPhos-90 TotBili-0.5 [**2194-4-14**] 04:57AM CRP-9.9* [**2194-4-14**] 04:57AM ESR-2 [**2194-4-14**] 04:57AM CK(CPK)-21* Brief Hospital Course: 48 yo woman with PMH of Ehlers Danlos, congenital adrenal hyperplasia on prednisone with known osteoporosis who had a left femur fracture after a fall in [**12/2193**] s/p dynamic hip screw and THR, complicated by osteomyelitis and prosthetic joint infection #. Right Hip Osteomyelitis: Patient has had osteomyelitis and prosthetic joint infection frmo MRSA, Staph epidermidis and Enterobacter cloacae treated w/ I&D, and several courses of antibiotics who was admitted for multiple I+Ds with spacer exchange as a last attempt at cure of osteomyelitis. Pt underwent 4 I&Ds with cultures while here on [**3-16**], [**4-7**], and [**4-9**]. E.coli was isolated from 1 culture on [**4-3**]. She was started on daptomycin on [**4-3**] with addition of meropenem on [**4-5**]. She was admitted to the ICU on [**4-10**] for hypotension, tachycardia, and low urine output postoperatively. In the ICU she received 10L fluid and 4u pRBC. Transferred to floor on [**4-12**] for further management. She initially had several hemo-vacs and a right incisional vac in place draining serosanguinous fluid. All drains and vacs were removed on [**2194-4-16**], and an incisional drain was re-placed on [**2194-4-17**] given ongoing serosanguinous drainage. This should remain in place until the drainage ceases. Her antibiotics should be continued for a total of six weeks, last dose to be given [**2194-5-17**]. Given her multiple surgeries and current immobility she should remain on Lovenox 40mg for at least four weeks following the date of her last surgery ([**2194-4-9**]). At that time, need for additional anticoagulation is left to the discretion of her primary care physician and orthopedic surgeon based on her degree of mobility at that time. # Left thigh hematoma: Patient developed pain in the left thigh while in the ICU. She is not sure exactly when it started. CT of the pelvis and extremities showed a 7cm hematoma. The patient's hematocrit remained stabile while on prophylactic Lovenox and the patient's leg was monitored. # Adrenal Insufficiency: Pt on florinef & Hydrocortisone 20mg IV BID while hospitalized in ICU. Endocrine service recommended changin back to her home dose of prednisone and florinef on [**4-14**]. Blood pressures have remained stable. # Depression: Continued home celexa. Medications on Admission: daptomycin 500mg IV 4mg/kg qd; levaquin 750mg qd, arixtra 2.5sc qd, florinef 0.1mg qd, prednisone 4mg qam, actonel 15mg qam, Amitriptyline 25mg qhs, coreg 6.25mg [**Hospital1 **], norvasc 2.5mg qd, synthroid 112mcg qd, dulcolax 100mg [**Hospital1 **], omeprazole 20mg qd, loestrin [**1-3**] qam; iron 325mg qd, trazadone 25mg qhs prn, vit b12 500mcg qd, potassium 40meq qd, nystatin powder prn, ativan 0.5mg q4-6h prn, celexa 40mg qd 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. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO BID (2 times a day) as needed for Constipation. 5. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 6. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 9. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg Subcutaneous DAILY (Daily) for 4 weeks: Continue for at least 4 weeks post-operatively. At that time, your PCP and Orthopedic surgeon will determine the need for further anticoagulation based on your level of mobility at that time. 12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain or fever. 13. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for spasms. 14. zolpidem 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 15. [**Doctor Last Name **] Milk of Magnesia 311 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 16. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 17. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 19. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. hydromorphone 2 mg Tablet Sig: 2-4 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*1 week's supply* Refills:*0* 21. fludrocortisone 0.1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 22. daptomycin 500 mg Recon Soln Sig: Three [**Age over 90 12887**]y (370) mg Intravenous Q24H (every 24 hours) for 1 months: Last dose [**2194-5-17**]. 23. meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg Intravenous Q6H (every 6 hours) for 1 months: Last dose [**2194-5-17**]. 24. Outpatient Lab Work Please check a CBC with differential, Chem 7, ESR, CRP, AST, ALT, AlkP, total bilirubin, and CPK weekly and send the results to the Infectious Disease R.N.s at ([**Telephone/Fax (1) 4591**]. 25. clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) for 10 days. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 8957**] Discharge Diagnosis: Right hip infection Urinary tract infection Post-op anemia due to blood loss Hyponatremia Adrenal insufficiency Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as colace) as needed to prevent this side effect. You may not drive a car until cleared to do so by your surgeon. You may shower starting five (5) days after surgery, but no tub baths or swimming for at least four (4) weeks. Any stitches or staples that need to be removed will be taken out at your follow-up visit. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, motrin, etc). ANTICOAGULATION: Please continue your lovenox for at least 4 weeks to help prevent deep vein thrombosis (blood clots). After completing the lovenox, please take Aspirin 325mg TWICE daily for three weeks. [**Male First Name (un) **] STOCKINGS x 6 WEEKS. VNA (once at home): Home PT/OT, dressing changes as instructed, wound checks, IV antibiotic administration. ACTIVITY: NON-WEIGHT BEARING on the operative extremity. No strenuous exercise or heavy lifting until follow up appointment. Followup Instructions: Department: INFECTIOUS DISEASE When: WEDNESDAY [**2194-4-23**] at 11:00 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Provider: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**] Date/Time:[**2194-5-2**] 12:00 Please follow-up with your primary care physician after you are discharged from Rehab. Department: INFECTIOUS DISEASE When: WEDNESDAY [**2194-5-14**] at 10:30 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

[ "244.0", "238.71", "255.41", "756.83", "E929.3", "733.82", "730.15", "733.90", "599.0", "401.9", "276.69", "278.01", "275.41", "693.0", "998.11", "998.59", "998.12", "733.00", "041.49", "458.29", "564.00", "255.2", "V58.65", "276.1", "285.1", "905.3", "E947.8" ]

icd9cm

[ [ [] ] ]

[ "38.97", "84.56", "80.95" ]

icd9pcs

[ [ [] ] ]

12006, 12080

6485, 8792

318, 593

12235, 12235

3712, 6123

13718, 14701

3147, 3207

9276, 11983

12101, 12214

8818, 9253

12411, 13695

6139, 6462

3222, 3693

263, 280

621, 2839

12250, 12387

2861, 3031

3047, 3131

11,242

194,209

54187

Discharge summary

report

Admission Date: [**2150-7-14**] Discharge Date: [**2150-7-18**] Date of Birth: [**2108-7-29**] Sex: F Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5644**] Chief Complaint: 1)DKA 2)Pericarditis Major Surgical or Invasive Procedure: None History of Present Illness: DKA; ?Pericarditis *** HPI: 41 yo AA female with h/o DMI, HTN, hyperchol who presented on [**2150-7-13**] c/o sharp, diffuse chest pain x 3 days, as well as intermittent N/V, abdominal pain, and diaphoresis. She also states that she noticed increased frequency of urination prior to admission as well. She reports that her pain increased significantly on the day of admission and decided to have her husband bring her to the hospital that evening. * Past Medical History: Type I DM: dx [**2144**]; Ab positive; on insulin DKA x 5 Pancreatitis Hyperchol HTN GERD Anemia Tubal ligation Social History: Lives with husband and three children. Denies tobacco, EtOH, drug use. Family History: DM (mother) Physical Exam: VS: T=98.8 (99.1); BP=103/56; HR=111 (101-111); RR=20-33; 02=98% RA FS = 50 (given juice), last one was 224. GEN: middle age female, sitting in chair, NAD HEENT: PERRL OU; EOMI bilat; MMM; OP Clear, no exudate; anicteric NECK: supple, no JVP visible LYMPH: No LAD CV: non-displaced PMI, tachy, reg, Normal S1S2, no M/R/G appreciated RESP: symmetric excursions, poor effort, CTA bilaterally, no w/r/r. ABD: Normo active BS, non-tender, no rebound, non-distended, no masses EXT: no cyanosis, clubbing, or edema SKIN: no rashes or lesions NEURO: CN II-XII intact bilat; motor and sensory exams grossly intact bilaterally Pertinent Results: [**2150-7-13**] 11:50PM BLOOD WBC-34.9*# RBC-5.22 Hgb-15.6 Hct-45.2 MCV-87 MCH-29.9 MCHC-34.5 RDW-12.9 Plt Ct-278 [**2150-7-13**] 11:50PM BLOOD Neuts-84* Bands-3 Lymphs-6* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-0 [**2150-7-14**] 01:00AM BLOOD Neuts-82* Bands-5 Lymphs-7* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-0 [**2150-7-13**] 11:50PM BLOOD Plt Ct-278 [**2150-7-14**] 01:00AM BLOOD Plt Ct-284 [**2150-7-14**] 01:00AM BLOOD PT-13.8* PTT-19.8* INR(PT)-1.2 [**2150-7-14**] 01:00AM BLOOD Glucose-145* UreaN-18 Creat-1.7* Na-137 K-3.3 Cl-108 HCO3-11* AnGap-21* [**2150-7-14**] 04:21AM BLOOD Glucose-105 UreaN-20 Creat-1.4* Na-136 K-3.7 Cl-113* HCO3-11* AnGap-16 [**2150-7-17**] 07:00AM BLOOD WBC-6.9 RBC-3.60* Hgb-10.3* Hct-30.5* MCV-85 MCH-28.5 MCHC-33.6 RDW-12.7 Plt Ct-165 [**2150-7-16**] 06:55AM BLOOD Glucose-380* UreaN-10 Creat-0.6 Na-139 K-3.6 Cl-109* HCO3-19* AnGap-15 [**2150-7-17**] 07:00AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.9 [**2150-7-14**] 01:00AM BLOOD CK-MB-4 cTropnT-<0.01 [**2150-7-14**] 05:16PM BLOOD CK-MB-73* MB Indx-12.1* cTropnT-1.21* [**2150-7-14**] 01:00AM BLOOD ALT-18 AST-13 CK(CPK)-201* AlkPhos-160* [**2150-7-14**] 05:16PM BLOOD CK(CPK)-601* [**2150-7-15**] 04:03AM BLOOD CK(CPK)-331* [**2150-7-16**] 06:55AM BLOOD CK(CPK)-91 [**2150-7-14**] 06:24AM BLOOD TSH-0.11* [**2150-7-16**] 06:55AM BLOOD T3-104 Free T4-1.4 [**2150-7-14**] 06:24AM BLOOD [**Doctor First Name **]-NEGATIVE * CATHETERIZATION [**2150-7-14**]: 1. Coronary arteries are normal. 2. Moderate systolic and diastolic ventricular dysfunction. COMMENTS: 1. Selective coronary angiography revealed a right-dominant system with mild diffuse, slightly sluggish flow but no angiographically apparent coronary disease in the LMCA, LAD, LCx, or RCA. 2. Limited resting hemodynamics revealed a mildly elevated left-sided filling pressure (LVEDP 17 mmHg). There was no gradient across the aortic valve on pullback of the catheter from the left ventricle. 3. Left ventriculography was deferred due to elevated creatinine and recent echo. * ECHO ([**2150-7-14**]): The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is moderate-to-severe global left ventricular hypokinesis (ejection fraction 30 percent). The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is no pericardial effusion. * ECHO ([**2150-7-16**]): 1. The left ventricular cavity size is normal. There is moderate global left ventricular hypokinesis. Overall left ventricular systolic function is moderately depressed. 2. Compared to the findings of the prior study of [**2150-7-14**], left ventricular systolic function has improved. Brief Hospital Course: The patient came to the ED with lethargy, CP, Abd pain, and N/V. In the ED, she was tachycardic with otherwise stable vital signs. EKG showed diffuse ST elevations and there was concern for ST elevation MI. ECHO done in ED showed depressed LVEF (30%). The patient was brought for cardiac cath and found to have patent coronaries. The patient was the transferred to the floor. Night float admitted the patient later that evening, and saw that she was in DKA with AG of 18 and HCO3 of 11. At that point, Ms. [**Known lastname 111059**] was transferred to the MICU for further management. The patient's glucose in the ED was 145. Per patient's husband, she received 80 units of "cloudy" insulin prior to coming to the ED. * In the MICU, she was aggressively rehydrated with D5NS and maintained on an insulin gtt. Her lytes were monitored q2h initially. [**Last Name (un) **] was consulted, as well as cardiology for her apparent pericarditis. Her potassium and phosphate were aggressively repleated. [**Last Name (un) **] made recommendations for NPH doses as well as ISS. They also recommended not restarting metformin (b/c acidosis) or Actos (b/c low EF). Throughout her MICU course, the patient's mental status improved dramatically. She was weaned from her insulin gtt and maintained on NPH with ISS recommended by the [**Last Name (un) **] team. She began taking PO's well without N/V. * On transfer to the floor, she was taking good PO's without N/V, and was not having chest pain. Listed below are a summary of her issues as dealt with by the floor team: * 1) DKA: The patient likely had DKA for several days given her presenting symptoms. Her gap remained resolved for her course on the floor, and continued to appear euvolemic. She continued taking good PO's. Her electrolytes (specifically potassium and phosphate) were continually repleated. While on the floor, [**Last Name (un) **] followed the patient, and periodically made adjustments to her insulin sliding scale and basal NPH doses. At the time of discharge, she was taking NPH 32u QAM and 24u QPM. Her finger sticks were controlled within the range of 100-200 on the day of discharge. A follow up appointment was made for Mrs. [**Known lastname 111059**] to be seen by Dr. [**First Name (STitle) 3636**] at the [**Hospital **] Clinic on [**7-29**] at 3 pm. * 2) PERICARDITIS: The patient had diffuse ST elevations on admission which was consistent with pericarditis. She also had elevated troponin on admission (1.21). She was taken for immediate cardiac catheterization which showed patent coronaries. Her elevated troponin on admission (1.21), was likely due to perimyocarditis. Her CK's were followed and trended down to normal. A cardiac echo was done initially in the ED which showed LVEF of 30%, however, no pericardial effusion. Cardiology was consulted and recommended follow-up in one with one of the cardiologists at [**Hospital1 18**] (see d/c planning). She will also have a follow up echo prior to this appointment. Cardiology also recommended not giving NSAIDs at this time given that the patient was CP-free. * 3) CHF: The first ECHO done on Ms. [**Known lastname 111059**] showed an EF of 30%. Follow up echo before discharge showed that there was improved systolic function. Her initial decrease in LVEF was likely related to her pericarditis. She was started on Lisinopril and Metoprolol in the ICU and changed to Toprol XL. * 4) ARF: On presentation, the patient was in ARF. This resolved quickly with with IVF rehydration. * 5) HIGH WBC: The patient's WBC count on admission was very high at 34.9. This was likely a stress response. Her WBC count trended down to 6 by the time of discharge. * 6) LOW TSH: The patient also had a low TSH on this admission; likely secondary to euthyroid sick syndrome. Her free T4 and total T3 were both normal. Anti-TPO still pending and will be followed up at her [**Last Name (un) **] appointment. * 7) FEN: At the time of discharge, the patient was taking good PO's without nausea or vomiting. Her potassium and phosphate was aggressively repleated, and normal at the time of discharge. Medications on Admission: Insulin: 85 units 70/30 Q 7AM; ~20 units Humalog Q 5PM; 20u NPH @ 10pm Others unknown Discharge Medications: 1. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO QD (once a day). 3. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO QD (once a day). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*0* 4. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: As prescribed below units Subcutaneous As prescribed below: 36 units SC QAM; 28 units SC QHS. Disp:*2 vials* Refills:*0* 5. Humalog Insulin Please follow insulin sliding scale as outlined in discharge planning paperwork. 6. One Touch Ultra Test Strip Sig: As prescribed below strip Miscell. As prescribed below: Use for finger stick blood glucose checks prior to meals and at bedtime daily. Disp:*120 strips* Refills:*0* 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 8. Lancets Misc Sig: as prescribed below as prescribed Miscell. as prescribed below: Please use for checking blood glucose prior to meals and at bedtime daily. Disp:*120 lancets* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1) Diabetic Ketoacidosis 2) Pericarditis Discharge Condition: Stable Discharge Instructions: -Please call your doctor or return to the Emergency Room if you experience more chest pain, difficulty breathing, dizziness, or confusion. -Please take your medications as prescribed. Please STOP taking your Insulin 70/30, Glucophage and Actos. In their place, you should now begin taking 36 units of NPH insulin every morning and 28 units of NPH insulin every evening. You should check your finger sticks before all meals and at bedtime and follow the insulin sliding scale as outlined in the attached sheet. Followup Instructions: Please attend appt. at [**Last Name (un) **] Diabetes Center on Wednesday, [**7-29**] with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3636**]. Please arrive at 3pm for registration, appt at 3:30. If insurance needs referral, please obtain from Dr. [**First Name (STitle) 4223**]. 1) Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3636**] at the [**Hospital **] Clinic for your diabetes management at 3:00 PM on Wednesday [**7-29**]. 2) Please follow up for a cardiac echocardiogram. Where: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) CARDIOLOGY Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2150-8-13**] 1:00 3) Please follow up with DR. [**First Name11 (Name Pattern1) 2053**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 2052**] (Cardiology) Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2150-8-17**] 1:20 -If you go to [**Hospital 12968**] clinic, please tell them that you need your TSH levels followed up and keep the above appointments.

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icd9cm

[ [ [] ] ]

[ "88.52", "37.22", "88.55", "38.93" ]

icd9pcs

[ [ [] ] ]

9962, 9968

4602, 8732

331, 338

10053, 10061

1729, 4579

10624, 11737

1061, 1075

8868, 9939

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8758, 8845

10085, 10601

1090, 1710

271, 293

366, 820

842, 956

972, 1045

32,622

178,075

44700

Discharge summary

report

Admission Date: [**2154-5-15**] Discharge Date: [**2154-6-18**] Date of Birth: [**2076-1-26**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5018**] Chief Complaint: Unable to elicit from patient due to unresponsiveness. Major Surgical or Invasive Procedure: Left occipitoparietal craniotomy and evacuation of hematoma ([**2154-5-20**]). PEG placement ([**2154-5-31**]). History of Present Illness: Code stroke called at 4pm for R side weakness . History is per EMS, chart and friend/witness/caretaker([**Name (NI) 95638**] [**Name (NI) **], [**Telephone/Fax (1) 95639**]) . HPI: 78-yo female with no known seizure disorder who presents here after a seizure. She has had a gradual decline over the past month, needing a caretaker to help her get to medical appointments, pay her taxes and take care of finances. She has remained able to feed and dress herself and walk independently, but slowly. She has had visual hallucinations over this time period, speaking to people she had seen on TV. Her speech has been normal but rambling and repetitive. . Per her friend/caretaker, Ms. [**Last Name (Titles) **], the patient had a doctor's appointment the day of admission at 3pm and she contact[**Name (NI) **] Ms. [**Known lastname **] to remind her to get ready at 11am. Her friend came around 2:30pm to take the patient to the appointment (PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1726**], [**Hospital1 **]). The patient had difficulty opening the door but finally was able to do so. Her friend found her standing in the [**Doctor Last Name **], saying that she could not see and wanting to find her glasses. But she did not walk to do so. Per the friend, she "looked like she was blind". . She told her to sit down but again the patient did not move. She brought a chair behind her and sat her down in it. She then went to call the doctor's office. While she was speaking to the RN, the patient straightened her right arm, as if she was "reaching for something" and she was leaning to her left. Her eyes then rolled back and she had bilateral convulsions and lost consciousness. 911 was called. On EMS arrival, they found her unresponsive to voice with right hemiparesis and she was brought here. En route, her right arm/leg weakness resolved, leaving only right facial asymmetry. . On our arrival, the patient was awake and alert. She would occasionally vocalize, for example, saying "wait a minute! wait a minute! what are you doing?" when moved to the CT table. She would not follow commands. At times, she uttered non-sensical speech. ROS: On review of systems, the pt's caregiver denied recent fever or chills. No night sweats or recent weight loss or gain. 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. Denied rash. Past Medical History: PMH: Dementia HTN Hyperlipidemia Hypothyroid, following thyroidectomy for nodule (benign path) Arthritis Breast cancer ([**2123**]) PSH: Left Mastectomy Social History: Lives by herself in [**Location (un) 2268**] on [**Location (un) **]. Widow for ~40years and no children of her own. Did raise a daughter. She does not eat properly or cooks. She has meals on wheels and her friends help her. At baseline, she can eat and dress herself, walks slowly. Over the last month, she's had a deterioration in caring for herself. Also visual hallucinations and short-term memory loss. Patient does not use EtOH or smoke. [**Last Name (LF) **], [**Name (NI) **] [**Name (NI) 95640**] of [**Last Name (LF) 9012**], [**First Name3 (LF) 3908**], has applied for guardianship. Family History: N/A Physical Exam: PE VS 100.0 (rectal) 180/81 72 12 100% Gen Awake, NAD HEENT NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck Supple, no carotid bruits appreciated. No nuchal rigidity Lungs CTA bilaterally CV RRR, nl S1S2, systolic ejection murmur Abd soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted Ext No C/C/E b/l Skin no rashes or lesions noted NEURO MS Awake, alert. Does not respond to questions consistently. Preference towards left side of space. Speech fluent, but often non-sensical with neologisms. Normal prosody. Unable to follow commands. No apraxia. Neglects the right side of space. No dysarthria. CN CN I: not tested CN II: Visual fields were full to confrontation, no extinction. Pupils 3->2 b/l. Fundi clear CN III, IV, VI: EOMI no nystagmus CN V: intact to LT throughout CN VII: right NLF flattening CN VIII: hearing intact to FR b/l CN IX, X: palate rises symmetrically CN [**Doctor First Name 81**]: shrug [**5-27**] and symmetric CN XII: tongue midline and agile Motor Normal bulk and tone. Moves all limbs purposefully antigravity Sensory intact to noxious stimuli Reflexes Br [**Hospital1 **] Tri Pat Ach Toes L 2 2 2 1 1 up R 2 2 2 1 1 up Coordination unable to assess Gait deferred CODE STROKE SCALE: Neurologic (NIHSS): 19 1a. LOC: alert, responsive (0) 1b. LOC questions: 2 1c. LOC commands: 2 2. Best gaze: No gaze palsy (0) 3. Visual: 2 4. Facial Palsy: 1 5a. Left arm: 2 5b. Right arm: 2 6a. Left leg: 2 6b. Right leg: 2 7. Limb ataxia: x 8. Sensory: no sensory loss bilaterally (0) 9. Language: 2 10. Dysarthria: None (0) 11. Extinction/inattention: 2 Pertinent Results: CT [**2154-5-15**] Left occipital intraparenchymal hemorrhage is little changed in appearance, currently measuring 4.8 x 2.5 cm in greatest axial dimension. As before, hemorrhage is in contiguity with the left subdural space, and acute left subdural hematoma is again seen, unchanged. Local edema and mass effect on the occipital [**Doctor Last Name 534**] of the left lateral ventricle is similar, and there is mild, 4 mm rightward subfalcine herniation, similar to previous exam. There is no intraventricular blood. Basal cisterns are not effaced. Periventricular white matter hypodensity, most prominent in the left frontal lobe most likely represents chronic small vessel ischemic disease. [**Doctor First Name **] ganglia calcifications are unchanged. IMPRESSION: Unchanged appearance of left occipital intraparenchymal hemorrhage, with left subdural hematoma, and local mass effect on the occipital [**Doctor Last Name 534**] of the left lateral ventricle. Unchanged mild rightward subfalcine herniation. EEG [**5-16**] This is an abnormal portable EEG due to the slow and disorganized background admixed with bursts of generalized mixed frequency slowing consistent with a mild encephalopathy suggesting dysfunction of bilateral subcortical or deep midline structures. Medications, metabolic disturbances, and infection are among the common causes of encephalopathy but there are others. There were no areas of prominent focal slowing although encephalopathic patterns can sometimes obscure focal findings. There were no clearly epileptiform features. PATH clot [**5-20**]: Clinical: Intraparenchymal bleed, left. Gross: The specimen is received fresh labeled with the patient's name "[**Known lastname **], [**Known firstname 55617**]" with the medical record number and "blood clot". It consists of multiple fragments of blood clot measuring 1.8 x 1.5 x 0.7 cm in aggregate. The specimen is entirely submitted in A-B. CT [**5-22**] No significant interval change compared to one day prior. The patient is status post left parietal craniotomy. Again seen is a moderate sized left parietooccipital hemorrhage with extensive surrounding edema and additional foci of blood anteriorly. There is a stable amount of pneumocephalus related to the craniotomy. Intraventricular extension of blood and blood clots within the lateral ventricles are stable. Ventricular size is stable. When accounting for head position and slice selection, there is no appreciable change in mass effect, rightward midline shift of the midline structures and unchanged asymmetry of the perimesencephalic cisterns suggesting early uncal herniation. Extra-axial blood in the left frontoparietal subdural location is unchanged and likely related to craniotomy. Subgaleal hematoma and soft tissue swelling overlying craniotomy defect are stable. IMPRESSION: No interval change in the left parietooccipital hematoma with extensive surrounding edema, interventricular extension, and mass effect. CT [**5-25**] Overall, exam is unchanged compared to the CT head of four days prior. The patient is status post left parietal craniotomy. A moderate-sized left parietal occipital hemorrhage with extensive surrounding vasogenic edema is unchanged. Small amount of extra-axial hematoma along the left convexity along with a small amount of pneumocephalus related to recent craniotomy is unchanged. There has been interval evolution of blood clots within the lateral ventricles, which is now layering within the posterior horns. There is mass effect upon the left lateral ventricle and 7-mm shift of normally midline structures towards the right, which is unchanged. Asymmetry of the perimesencephalic cisterns is unchanged, suggesting early uncal herniation. No new focus of hemorrhage is seen. Subgaleal hematoma and soft tissue swelling overlying craniotomy site are stable. The visualized paranasal sinuses and the mastoid air cells remain well aerated. IMPRESSION: Unchanged exam compared to four days prior with left parietooccipital intraparenchymal hematoma with extensive surrounding vasogenic edema, intraventricular hemorrhage, and rightward shift of normally midline structures. LIVER/GALLBLADDER ULTRASOUND [**5-31**]: The liver is normal in echotexture with no focal lesions identified. There is appropriate forward portal venous flow. The gallbladder wall is thickened to 5 mm, however, nondistended. There is no pericholecystic fluid or evidence of gallstones. The common duct measures 6 mm, within normal limits given patient's age. The limited views of the pancreatic head are unremarkable. The body and tail are obscured by bowel gas. CT neck [**6-6**] Study is very limited due to patient motion and patient rotation. No definite prevertebral soft tissue abnormality is identified. There is no obvious evidence of fracture or malalignment. Multilevel degenerative changes are seen, with most severe at C3-4, C4-5, C5-6, with anterior and posterior osteophytes and Schmorl's nodes. However, no significant canal narrowing or neural foraminal stenosis is identified. There is straightening of the normal cervical lordosis. Visualized lung apices reveal left apical scarring or atelectasis. IMPRESSION: Limited study as noted above. 1. No evidence of acute injury. 2. Multilevel degenerative changes, most severe at C3-4. However, there is no significant central canal stenosis or neural foraminal stenosis. Of note, CT is not as sensitive as MR for evaluation of the thecal contents. CXR [**6-10**]: In the interim, the left lower lobe opacity has resolved. The lungs are clear. A right PICC is again visualized but tip is obscured by cardiomediastinal structures. There is no pleural effusion. The heart size is normal. IMPRESSION: Complete resolution of lower lobe atelectasis. Clear lungs. Brief Hospital Course: 78 F h/o mild dementia, HTN, admitted with two GTC seizures, R sided visual fieldcut and R sided hemiparesis on [**5-16**]. CT brain showed a large left parietal occipital hemorrhage with a subdural hematoma. She was admitted to the floor but neurologically deteriorated slowly (hemiparesis, level of arousal, communication) - and she had an urgent craniotomy with partial evacuation of the hematoma (by then 6 x 3 x 4.5 cm, increased edema, midline shift, breakhrough in ventricles) on [**5-20**]/8. She was transferred to the ICU for further care. PMH Dementia (lives at home with help, ...) HTN Hyperlipidemia Hypothyroid Arthritis Breast cancer [**2123**] s/p L mastectomy MEDS ON ADMISSION HCTZ, zocor MEDS ON ICU TRANSFER Metoprolol Tartrate 75 mg PO/NG [**Hospital1 **] Metoprolol Tartrate 10 mg IV Q4H:PRN Amlodipine 5 mg PO DAILY Captopril 25 mg PO TID Hydrochlorothiazide 25 mg PO DAILY HydrALAzine 10 mg IV Q6H:PRN SBP>160 Insulin SC Sliding Scale & Fixed Dose Heparin 5000 UNIT SC BID Famotidine 20 mg PO Q12H Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN LeVETiracetam 500 mg PO BID Levothyroxine Sodium 88 mcg NG DAILY Bisacodyl 10 mg PR [**Hospital1 **]:PRN Docusate Sodium (Liquid) 100 mg NG [**Hospital1 **] Senna 1 TAB NG [**Hospital1 **]:PRN Acetaminophen 325-650 mg PO/NG Q6H:PRN Lorazepam 0.5-2 mg IV PRN SEIZURE>5MIN OR >2/HR ICU COURSE: Neuro - Gradual and limited recovery of consicousness, remained only minimally interactive with grimacing to noxious stimulation, verbalizing only "auw" or "no" (non-appropriate). * Developed significant L sided weakness with residual tone, serial CTs did not reveal a solid explanation, although a new subcortical [**Male First Name (un) 4746**] stroke was found on [**5-25**]/8. Critical illness neuro-/myopathy was considered but rejected. * Dilantin was tapered off and replaced by Keppra. Cardiovasc - No ECHO done. EKG on admission SR, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6192**] NOS, LVH. Was on Nicardipine drip on and off, started on multiple oral antihypertensives. CVPs 6-11. Resp - Extubated on [**5-22**] in PM, slow wean of oxygen - frequent suctioning, had prolonged stridor. Level of arousal and hypotonic orofacial musculature raised possibility for tracheostomy, but rejected after 3 more days of observation. Last bloodgas prior to extubation(!) 152* 40 7.52* 34* 9. last CXR on [**5-26**]/8: Streaky density in the right upper lobe consistent with subsegmental atelectasis, but consolidation cannot be excluded. FEN - Went through SIADH, lowest NA 126 on [**5-20**], on fluid restriction and salt tabs, d/c'd by 5/3/8. Tubefed throughout, now replete w/fiber 3/4 strength at 70 cc/hr. ID - Received Cefazolin 2 grams IV q8 up to 2 days post-surgery. White-count persistently high up to 26.4 on [**5-23**], at that time also getting low dose of dexamethasone (for edema). Multiple cultures blood, urine all negative other than [**5-20**] UCx GPR ~4000/mL (Corynebacterium). One day on Cipro for this, then off. White count came down, now back up (see below). C Diff negative on [**5-24**]. SpCx [**5-26**] 3+ GNR 2+GPC, sparse oropharyngeal flora but mixed culture (>3 species) with amongst others Citrobacter. Recommended repeat. [**5-27**] SpCx poor sample. VRE and MRSA pending. ENDO - Has been on RISS with fixed dose of 10 NPH qAM and qPM. Levothyroxine suppletion 75 ug/d, last TSH level [**5-21**] was 12 (ULN 4). FSBG in range of 140's to max 240's, mean <180. HEME - Hct trending down slowly ([**5-20**] 40.9), now hovering around 25 - 26. 1 unit transfused on [**5-27**]/8. DDx anemia of chronic illness, multiple blooddraws, GI leakage (guiac(+)). Elevate white count, infectious? See below. PPx/CODE/DISPO - DNR on [**5-25**]/8. Boots, Heparin 5000 SC TID, HOB > 30 degree, PT/OT for passive movement. Dispo acute rehab eventually. EXAM on Tx to FLOOR Vitals 100.2 (ax), HR 87, RR 21, BP 146/42 Torticollis to L. Cardiac S1S2 Pulm CTA all fields anteriorly. Wet respirations with non-cleared secretions Abdomen supple, NT/ND, BS+ Skin warm and well perfused, onychomycosis. Left arm edemateus. NEUROLOGICAL EXAM on Tx to FLOOR Alert and says name, dysarthric, wet speech. Palalalia and echolalia, but able to greet examiner with long-whined and melodious voice. Does not follow commands. Gaze deviation to L, does not attend to R. Head to L as well (torticollis). Limited atttention span, does not fix or follow. PERRL, gaze pref as above, facial droop R. Flaccid R hemiparesis, does not withdraw to noxious, L hyptonic hemiparesis, no withdraw to pain but per report brings arm out to fence off while sunctioned. Legs very weak withdraw bilaterally. Brief FLOOR COURSE: Neuro - her exam continued to improve. She would continuously alert to voice, but did not blink to threat bilaterally. She answers questions semi-appropirately, with perseveration and at times not at all. Her L arm would at times be moving purposefully but she never withdrew to noxious stimulation. When held up, it would fall back to the bed. Her R hemibody remained plegic. A movement disorder consult was done to assess for botox for the torticollis, but given the hypertrophy of the SCM muscle it was thought to be chronic, and no intervention was made. A neck CT was done to rule out luxation and cricital cervical canal stenosis but it was negative (see results). Note that she is still on a small dose of Keppra 500 mg [**Hospital1 **] and this can probably be discontinued. GI - She had a refractory diarrhea on the floor, and C diff was repeatedly negative. Her whitecount was elevated as well, persistently. When she started complaining about R upper quadrant pain (by exam) an U/S was done, revealing a thickened wall of the gallbladder, suggesting acalculous cholecystitis. She was started on a two-week course of ceftriaxone and metronidazole, with good effect. The diarrhea also resolved when the bulk of her G-tube flushes was given per G-tube, not through the J-lumen. Cardiovasc - Her bloodpressure medications were reduced and some eventually slowly tapered off (metoprolol, amlodipine). On the day of discharge, her lisinopril was held but she had no signs of illness, sepsis, pain. Endocrine - Small adjustment was made in her levothyroxine (upward by 12.5 mcg). Access - She has a PICC line for easier access but this remains a potential source of infection. Please D/C it ASAP, i.e. when she no longer needs any blooddraws. At the nurses advice, for now it has been left in place. Medications on Admission: Hydrochlorothiazide Zocor Discharge Medications: 1. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2 times a day). 4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [**Hospital1 **] (2 times a day) as needed. 5. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000 unit Injection [**Hospital1 **] (2 times a day). 8. Levothyroxine 100 mcg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Heparin Flush 10 unit/mL Kit Sig: Two (2) mL Intravenous once a day: 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: [**Location (un) 582**] of [**Location (un) 583**] Discharge Diagnosis: 1 Left parietal-occpital intracranial hemorrhage, likely due to amyloid angiopathy. 2 Dementia, Alzheimer type Discharge Condition: Stable - exam as outlined elsewhere in detail under [**Hospital **] hospital course' Discharge Instructions: You have had a left parieto-occipital stroke, and this bloodclot was surgically removed - you have a residual left hemiparesis though. Please take all your medications excactly as directed and please attend all your follow-up appointments. Please report to the nearest ER or call 911 or your PCP immediately when you experience recurrence of weakness, numbness, tingling, problems with speech, vision, language, walking, thinking, headache, or difficulties arousing, or any other signs or symptoms of concern Followup Instructions: The Stroke Service of the [**Hospital1 18**] can be contact[**Name (NI) **] at time of discharge to rehab for a follow up appointment [**Telephone/Fax (1) 7667**]. [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**] Completed by:[**2154-6-18**]

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icd9cm

[ [ [] ] ]

[ "44.32", "01.39", "96.6" ]

icd9pcs

[ [ [] ] ]

18985, 19062

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Discharge summary

report

Admission Date: [**2137-12-8**] Discharge Date: [**2137-12-13**] Date of Birth: [**2055-3-1**] Sex: M Service: MEDICINE Allergies: Phenylephrine Attending:[**First Name3 (LF) 905**] Chief Complaint: Cough Major Surgical or Invasive Procedure: None History of Present Illness: This is a 82 year old male with Hx CAD, CHF (systolic and diastolic with EF 45%), bronchiectasis who presents with SOB and cough. He reports feeling well yesterday. Then he awoke this morning with severe coughing, rhinorrhea and SOB. He reports coughing up a small amount of blood tinged sputum x4 today. He states the he has a chronic cough productive of light yellow sputum and that this has been unchanged except for the blood tinge this am. His wife states that he was also cold and chilled - shaking, ? rigors- but denies fevers. He vomited x 1 enroute to the hospital in the ambulance. In the ED: On arrival the patient had a temp of 101.6. He vomited x1. He was found to have a new left upper and [**Last Name (un) 8490**] lobe infiltrates on CXR and was given CTX, Vanc and Azithromycin. UA neg. BNP 529. Lactate 3.0. Trop <0.01 and EKG w/o any new ischemic changes. Initially, the patient's vitals were BP 155/70 RR 20 92% RA. he then dropped his BP to 80/40; inc SBP to 90's with one liter but did not respond further to the second liter. Rt IJ placed. On transfer to the floor the patient's vitals were, HR 60 BP 95/42 RR 20 100% 4L, mid 94% on 2L. Past Medical History: CAD MR AS, mild CHF, systolic and diastolic dysfunction, EF 45% and elevated E/e' Recurrent MI with cardiogenic shock [**2133-8-7**]. Multiple PCI procedures PAD with IC. Right foot plantar ulcer. CRI. Bronchiectasis/emphysema/recurrent bronchitis. Diabetic neuropathy, possible early diabetic nephropathy. Chronic recurrent left ear infection. Social History: Lives with wife. [**Name (NI) **] tobacco. Rare social alcohol. Family History: Noncontributory Physical Exam: General: Awake, alert, NAD. [**Name (NI) 4459**]: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted, MMM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Pulmonary: Lungs CTA bilaterally Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Lymphatics: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted. Skin: no rashes or lesions noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. -cranial nerves: II-XII intact -motor: normal bulk, strength and tone throughout. No abnormal movements noted. -sensory: No deficits to light touch throughout. -cerebellar: No nystagmus, dysarthria, intention or action tremor -DTRs: 2+ biceps, triceps, brachioradialis, patellar and 1+ ankle jerks bilaterally. Plantar response was flexor bilaterally. Pertinent Results: [**2137-12-9**] ECHOCARDIOGRAPHY REPORT: CONCLUSIONS: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional systolic dysfunction with severe hypokinesis of the inferior and inferolateral walls and mild global hypokinesis of the remaining segments (LVEF = 30-35%). Right ventricular chamber size is normal with borderline normal free wall function. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). No 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. A 4cm hyperechoic "mass" is seen in the liver parenchyma. Compared with the prior study (images reviewed) of [**2137-10-29**], the severity of aortic stenosis has progressed and regional LV dysfunction is now suggested. The liver echogenic "mass" was also present on the prior study (and [**2137-4-11**] and [**2135-10-18**]). If clinically [**Month/Day/Year 9304**], an abdominal CT or ultrasound may be useful to characterize the liver abnormality. [**2137-12-8**] PORTABLE SEMI-UPRIGHT CHEST RADIOGRAPH: There are new multifocal patchy opacities in the left lung, with blunting of the left lateral sulcus likely representing small pleural effusion. The right lung remains grossly clear. Allowing for lordotic positioning and decreased lung volumes, the cardiomediastinal contours are likely unchanged, with mural calcifications noted along the aortic arch, and with coronary artery stents in place. Elevation of the left hemidiaphragm is not more than before. Degenerative changes are again noted along the thoracic spine. IMPRESSION: New multifocal patchy opacities in the left lung could represent multifocal pneumonia. Small left pleural effusion. Allowing for decreased lung volumes, cardiomediastinal contours likely unchanged. [**2137-12-12**] CHEST AP PORTABLE, SINGLE VIEW: INDICATION: A right-sided PICC line is now identified, seen to terminate in the lower SVC close to the expected entrance into the right atrium. To assure safe position, withdrawal by 4 cm is recommended. A previously existing ([**12-8**]) right internal jugular central venous line has been removed. No pneumothorax is identified. The previously described, mostly left mid and lower lung field densities remain. No new abnormalities are identified. IMPRESSION: Successful placement of PICC line, recommend withdrawal by 4 cm. MICROBIOLOGY RESULTS: [**2137-12-8**] 10:25 pm URINE Source: Catheter. **FINAL REPORT [**2137-12-9**]** Legionella Urinary Antigen (Final [**2137-12-9**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. [**2137-12-8**] 1:10 pm URINE Site: CLEAN CATCH **FINAL REPORT [**2137-12-9**]** URINE CULTURE (Final [**2137-12-9**]): NO GROWTH. [**2137-12-9**] 7:04 pm SPUTUM Source: Expectorated. **FINAL REPORT [**2137-12-11**]** GRAM STAIN (Final [**2137-12-9**]): [**11-30**] PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. RESPIRATORY CULTURE (Final [**2137-12-11**]): SPARSE GROWTH OROPHARYNGEAL FLORA. [**2137-12-8**] BLOOD CULTURE Blood Culture, Routine-PENDING (No growth to date) [**2137-12-8**] BLOOD CULTURE Blood Culture, Routine-PENDING (No growth to date) [**2137-12-11**] BLOOD CULTURE Blood Culture, Routine-PENDING (No growth to date) [**2137-12-11**] BLOOD CULTURE Blood Culture, Routine-PENDING (No growth to date) [**2137-12-9**] 5:09 am ASPIRATE Source: Nasopharyngeal aspirate. VIRAL CULTURE (Preliminary): No Virus isolated so far ([**2137-12-13**]). HEMATOLOGY RESULTS (ADMIT AND D/C): [**2137-12-8**] 01:20PM BLOOD WBC-5.6 RBC-4.39* Hgb-14.1 Hct-40.0 MCV-91 MCH-32.1* MCHC-35.3* RDW-15.7* Plt Ct-158 [**2137-12-13**] 04:31AM BLOOD WBC-4.8 RBC-3.59* Hgb-11.1* Hct-32.7* MCV-91 MCH-31.0 MCHC-34.0 RDW-14.8 Plt Ct-201 CHEMISTRY RESULTS (ADMIT AND D/C): [**2137-12-8**] 01:20PM BLOOD Glucose-211* UreaN-42* Creat-1.6* Na-143 K-4.5 Cl-101 HCO3-31 AnGap-16 [**2137-12-8**] 01:20PM BLOOD ALT-22 AST-22 CK(CPK)-148 AlkPhos-96 TotBili-0.7 [**2137-12-13**] 04:31AM BLOOD Glucose-214* UreaN-50* Creat-1.7* Na-137 K-4.4 Cl-99 HCO3-31 AnGap-11 CARDIAC ENZYMES: [**2137-12-10**] 08:06PM BLOOD CK-MB-4 cTropnT-0.02* [**2137-12-10**] 07:35AM BLOOD CK-MB-3 cTropnT-0.02* [**2137-12-9**] 12:00PM BLOOD CK-MB-4 cTropnT-0.02* [**2137-12-9**] 03:30AM BLOOD CK-MB-4 cTropnT-0.02* proBNP-1371* [**2137-12-8**] 01:20PM BLOOD cTropnT-<0.01 [**2137-12-8**] 01:20PM BLOOD CK-MB-4 cTropnT-<0.01 proBNP-529 URINALYSIS RESULTS: [**2137-12-8**] 01:10PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2137-12-8**] 01:10PM URINE RBC-0-2 WBC-0 Bacteri-0 Yeast-NONE Epi-0 Brief Hospital Course: # PNA and chronic bronchiectasis: Patient with pneumonia by clinical history and portable chest xray showing LLL infiltrate upon admission. Originally triaged to medical intensive care unit due to concerns for hypotension and evolving sepsis; however, patient's blood pressures stabilized with fluids and he never required vasoactive agents. His antibiotic therapy starting on [**2137-12-9**] was Vancomycin, Ceftrizxone, and Azithromycin. On night of [**2137-12-10**], the patient spiked a fever to 101.8. His antibiotics were then modified to be Vancomycin, Zosyn, and Azithromycin. After the night of [**2137-12-10**], the patient remained afebrile through the remainder of his hospital course. Had a urine legionella antigen that was negative. Viral culture pending, but negative thus far upon discharge on [**2137-12-13**]. Respiratory bacterial culture from [**2137-12-9**] was negative. A PICC line was placed on [**2137-12-12**] due to anticipation of IV antibiotic therapy for a total of two weeks. Chest XRAY was reviewed by radiology after placement of PICC and was withdrawn 4 cm per their recommendation and then approved for use. Patient's last Vancomycin dose anticipated to be on [**2137-12-20**]. Last azithromycin dose received in hospital on [**2137-12-13**]. Patient's last Zosyn dose will be on [**2137-12-23**]. Of note, the patient did not have any respiratory, urine, or blood cultures that were positive for MRSA or VRE. Patient received treatment with fluticasone/salmeterol per home dose and received standing albuterol-ipratropium Q6H. He also was place on supplemental oxygen of 4L. At time of discharge his repiratory exam was improving with bilateral basilar crackles, left greater than right, and mildly reduced breath sounds on the left. He had some dyspnea with ambulation, which was improving. # Chest pain with history of CAD: Brief and self-limited episodes of chest pain while hospitalized. Patient loaclaized chest pain to being over the left chest without radiation. They were unassociated with exertion. Were exacerbated by deep breathing. Of note is that chest pain localized to area of identified pneumonia. Two most severe episodes of chest pain were on [**2137-12-9**] and [**2137-12-10**]. There were no substantial EKG changes from baseline and were followed by troponin measurements which all remained under 0.02, thus ruling out myocardial infarction. An ECHO obtained on [**2137-12-9**] identified worsening systolic function, worsening aortic stenosis, and new lateral and inferiorlateral wall hypokinesis since most recent prior ECHO on [**2137-10-29**]. Patient's cardiologist, Dr. [**Last Name (STitle) 1016**] was contact[**Name (NI) **] about cardiac events in the hospital and responded via email that he would like to see patient in [**3-10**] weeks for follow-up with new ECHO at that time. Otherwise, we continued Lipitor, Plavix, ASA. Pantoprazole was initiated and GI cocktail was given to patient during episodes of chest pain for concern that some of chest pain could be attributed to reflux. # Congestive heart failure: Systolic and diastolic dysfunction at baseline with ECHO [**2137-12-9**] showing worsening of systolic function. Patient's home heart failure medications were originally discontinued due to hypotension; however, they were all added back. These medications include metoprolol, lisinopril, furosemide, and spironolactone. # Liver hyperechoic mass: Discovered incidentally during ECHOCARDIOGRAPHY and not a new finding; however, patient should have this followed as an outpatient for potential work-up. # Diabetes mellitus: Patient was switched from home regimen of NPH to 35 units glargine at bedtime and sliding scale humalog. Continued gabapentin for diabetic neuropathy. # Chronic renal insufficiency: No acute changes in baseline renal function with creatinine of 1.7. Medications on Admission: Lipitor 40 Plavix 75 ASA 375 furosemide 40mg [**Hospital1 **] lisinopril 20mg daily metoprolol succinate 100XL, SLTNG 0.4 p.r.n. spironolactone 12.5. Insulin 24 units of NPH h.s RISS, Neurontin 300 two capsules b.i.d. Advair Diskus 250/50 one puff b.i.d. Allopurinol 400mg daily Gabapentin 600mg [**Hospital1 **] COLCHICINE - 0.6 mg Tablet - QOD Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) inhalation Inhalation [**Hospital1 **] (2 times a day). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**2-6**] Puffs Inhalation Q6H (every 6 hours). 10. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 15. Insulin Glargine 100 unit/mL Solution Sig: Thirty Five (35) U Subcutaneous at bedtime. 16. Humalog 100 unit/mL Solution Sig: Per sliding scale units Subcutaneous four times a day: Administer per attached sliding scale. 17. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours) for 7 days. 18. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours) for 10 days. 19. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain or fever. 20. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual Every 5 minutes as needed for chest pain: Only if SBP > 120 and only 3 doses to be given for any single episode of chest pain. Discharge Disposition: Extended Care Facility: [**Location (un) 583**] House Discharge Diagnosis: Primary Diagnosis Pneumonia Secondary Diagnoses Diabetes Coronary Artery Disease Chronic Bronchiectasis Diabetes Mellitus Chronic Renal Insufficiency Discharge Condition: Stable, improved from admission, on supplmental oxygen, on IV antibiotics Discharge Instructions: You were admitted to the hospital with a cough and difficulty breathing. Because your blood pressure was low, you were admitted to the intensive care unit. Your blood pressure normalized and you were transferred to the medical floor. On the floor we continued your IV antibiotics. We feel that you should get a total of two weeks of IV antibiotics. Concerning your heart, you had some chest pain in the hospital that caused us to check several lab tests, which [**Location (un) 9304**] that your heart muscle had not been damaged. We also got echocardiography to image your heart and this showed concern that you may have damaged your heart muscle in the last few months. For this reason we are having you follow-up with Dr. [**Last Name (STitle) 1016**] to get repeat echocardiography. Please keep all previously scheduled physician [**Name Initial (PRE) 4314**]. In addition, we have made several follow-up appointments for you: 1) We have arranged for you to see your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] ([**Telephone/Fax (1) 2205**]) on [**2137-12-25**] at 10:00 AM. 2) You will be contact[**Name (NI) **] by Dr.[**Name (NI) 49410**] office ([**Telephone/Fax (1) 62**]) so that he can see you in 2 to 3 weeks following discharge from the hospital. 3) You have an appointment to meet with your pulmonologist, Dr. [**Last Name (STitle) 575**] ([**Telephone/Fax (1) 612**]), on Friday [**2137-12-27**] at 9:30 AM. If you experience any fever, chills, night sweats, chest pain, shortness of breath, or other symptoms concerning to you, please contact your physician or come to the emergency room immediately. Followup Instructions: We have arranged for you to see your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] ([**Telephone/Fax (1) 2205**]) on [**2137-12-25**] at 10:00 AM. You will be contact[**Name (NI) **] by Dr.[**Name (NI) 49410**] office ([**Telephone/Fax (1) 62**]) so that he can see you in 2 to 3 weeks following discharge from the hospital. You have an appointment to meet with your pulmonologist, Dr. [**Last Name (STitle) 575**] ([**Telephone/Fax (1) 612**]), on Friday [**2137-12-27**] at 9:30 AM. Provider: [**Name10 (NameIs) 3712**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2137-12-19**] 10:00 [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**] Completed by:[**2137-12-13**]

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Discharge summary

report

Admission Date: [**2186-12-17**] Discharge Date: [**2186-12-21**] Date of Birth: [**2128-11-9**] Sex: M Service: MEDICINE Allergies: Glucophage Attending:[**First Name3 (LF) 5295**] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: History of Present Illness: 58 M with hx CHF, CAD s/p CABG, VT, s/p AICD/PM placement, DM who presents to ED w/ confusion and progressive SOB since d/c [**2186-12-13**] from [**Hospital3 3583**]. Pt hosp there for back pain. Taking percocet at home. At OSH, decreased Lasix from 120->80 [**Hospital1 **] and zaroxyln from qd to qod. Patient had hallucinations since Wed [**12-14**]. also of note - URI sx for approximately 2 weeks. . On arrival had several 20-30 beat runs of VTach here paced out by PM per EP interogation. Given amio bolus x2, started on amio gtt at 0.5 mg/hr, in paced rhythm. Also increased hypercapnia from baseline, increased 3 pillow orthopnea from 2. Started on CPAP in ED and transferred to the intensive care unit. Past Medical History: 1. Coronary artery disease, status post myocardial infarction in [**2180**]. Status post coronary artery bypass graft; left internal mammary artery to left anterior descending; saphenous vein graft to posterior descending artery; saphenous vein graft to obtuse marginal two. 2. Recurrent myocardial infarction in 4/00. The patient underwent cardiac catheterization which shows total occlusion of his left inferior mammary artery to left anterior descending and saphenous vein graft. The patient underwent redo coronary artery bypass graft with radial graft times two to the left anterior descending and right coronary artery. 3. Non-sustained ventricular tachycardia, status post ICD placement in [**6-2**], complicated by pocket infection in [**7-4**], requiring ICD removal. His ICD was replaced on [**9-3**]. 2. Diabetes mellitus type 2. 3. Hypertension. 4. Hypercholesterolemia. 5. CHF, EF 18%. 6. Chronic renal insufficiency, baseline 1.4. 7. Peripheral vascular disease. 8. Bilateral bypass. 9. V-tach. 10. AFib. 11. GERD. 12. Depression. 13. Psoriasis. Social History: 45 pack yr h/o smoking, quit [**2180**].No EtOH/drugs Family History: Mother MI, CVA Physical Exam: temp 99.8, BP 110/60, HR 78, R 20, O2 91% on 4L Gen: NAD, lying in bed flat, AO x 3, speaking in full sentences without use of accessory muscles HEENT: PERRL, EOMI, MM dry Neck: no JVP noted CV: RRR, distant heart sounds, no murmurs Pulm: diffuse insp and exp wheezes, increased E:I Abd: obese, soft, nontender Ext: no edema, 1+ DP bilaterally Pertinent Results: [**2186-12-17**] 08:20PM GLUCOSE-113* UREA N-62* CREAT-1.8* SODIUM-145 POTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-37* ANION GAP-17 . [**2186-12-17**] 10:30AM WBC-11.1* RBC-4.06* HGB-12.3* HCT-38.6* MCV-95 MCH-30.3 MCHC-31.9 RDW-16.1* [**2186-12-17**] 10:30AM NEUTS-87.2* LYMPHS-7.9* MONOS-3.6 EOS-0.5 BASOS-0.8 [**2186-12-17**] 10:30AM PLT COUNT-349# [**2186-12-17**] 10:30AM PT-15.6* PTT-27.7 INR(PT)-1.5 . [**2186-12-17**] 08:20PM CK(CPK)-75 [**2186-12-17**] 08:20PM CK-MB-NotDone [**2186-12-17**] 08:20PM cTropnT-<0.01 . TOX SCREEN: [**2186-12-17**] 06:03PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2186-12-17**] 10:30AM VIT B12-353 FOLATE-8.3 [**2186-12-17**] 10:30AM TSH-0.68 [**2186-12-17**] 10:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG . ABGs: [**2186-12-17**] 03:12PM TYPE-ART PO2-92 PCO2-73* PH-7.34* TOTAL CO2-41* [**2186-12-18**] 12:25AM BLOOD Type-ART pO2-79* pCO2-76* pH-7.35 calHCO3-44* [**2186-12-18**] 08:20AM BLOOD Type-ART pO2-76* pCO2-65* pH-7.38 calHCO3-40* [**2186-12-20**] 09:49AM BLOOD Type-ART pO2-70* pCO2-81* pH-7.42 calHCO3-54* [**2186-12-21**] 07:53AM BLOOD Type-ART pO2-87 pCO2-70* pH-7.41 calHCO3-46* . CXR: There is persistent elevation of the right hemidiaphragm, with associated compression atelectasis of the right middle lobe. Cardiomegaly is unchanged. No pneumothorax or pleural effusion is seen. There is mild vascular fullness, but no definite evidence of CHF. Midline sternotomy wires and staples indicate prior CABG. A new left-sided IJ catheter is in place, without pneumothorax. Right-sided AICD remains in place. . Head CT: This examination is slightly limited by patient motion. There is no evidence of acute intracranial hemorrhage, mass effect, or shift of normally midline structures. The ventricles and sulci are mildly prominent, consistent with mild atrophy. The differentiation of the [**Doctor Last Name 352**] and white matter is preserved. There is no evidence of acute major vascular territorial infarction. Bone windows show clear paranasal sinuses with no evidence of fracture. No significant soft tissue swelling is seen. . Echo: The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated with severe regional systolic dysfunction. The inferolateral wall and inferior walls are akinetic. The distal half of the lateral and anterior walls are hypokinetic. The basal half of the septum contracts best. The right ventricular cavity is dilated with prominent free wall hypokinesis. The aortic valve leaflets appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-3**]+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. EJECTION FRACTION: 20% Brief Hospital Course: A/P: 58 M with long cardiac hx here w/ ms changes, hypercarbia and increased VT 1. MS changes: Given pt's waxing and [**Doctor Last Name 688**] mental status, a head CT was done and ruled out bleed and urine and blood tox labs were sent and all returned negative. TSH, B12 and Folate were also all within normal limits. Differential diagnosis also included infection, though there was no clear source, hypercarbia and overmedication with percocet. Etiology was likely hypercarbia and by hospital day #[**1-4**], his mental status had improved. On day of discharge, pt was back to his baseline. . 2. Hypercarbic respiratory failure: Pt was initially admitted to the ICU for BiPAP to lower pCO2 and he was transferred to the floor after his mental status improved. Respiratory failure was likely multifactorial, due to combination of COPD with recent URI, overuse of narcotics and not using CPAP while at home. He was initally given IV solumedrol for his COPD exacerbation and then transitioned to po steroids. His bronchitis was trated with a 5-day course of azithromycin. Pt with chronic respiratory acidosis with baseline pCO2 likely in the 60s-70s. Once transferred out of the ICU, pt remained stable on home dose of oxygen, 3-4L. Serial ABGs showed a persistently high pCO2 in the 70s while the pt remained asx. He was continued on CPAP at night for his OSA. . 3. VT s/p AICD placement: Pt had frequent episodes of NSVT and longer runs requiring ATP. He was seen by EP and started on an amiodarone drip given concerns regarding frequency of episodes. After marked decrease in NSVT, he was returned to his outpt amiodarone dose of 200mg qd. Patient may need VT ablation as an outpatient given the fact that he is young and should not be on amiodarone for long term management. . 4. CHF: On admission, pt appeared dry and his lasxi and ACE-I were held. An echocardiogram during admission showed severely depressed systolic function with an EF of 20%. His medications were restarted later during his hospital stay when he became euvolemic and he was continued on Lasix (decreased from his regular home dose), ACE-I and toprol. His zaroxylyn was held due to his hypovolemic status on admission. . 5. CAD: Given his NSVT, cardiac enzymes were checked to rule out coronary causes. These were negative. He was continued on asa, statin, BB, plavix. . 6. ARF: On admission, creatinine elevated to 1.9 likely secondary to hypovolemia. A FeUrea was consistent with a pre-renal picture so pt was given gentle IVF. As his volume status improved, his creatinine returned to his baseline of 1.0 . 7. DM: Pt's glucose was elevated while on steroids so his glipizide was increased and his sliding scale tightened. . 8. Back Pain: Pt's narcotics were discontinued on admission [**1-3**] his altered mental status and were not restarted during his hospital stay. He should slowly restart his neurontin following discharge. Medications on Admission: zaroxylyn 2.5mg q M,W,F Plavix 75mg qd Protonix 40 Sertraline 200mg qd Glucotrol XL 5mg qd Neurontin 800mg qam, 1600mg qpm Lisinopril 20mg qd Zocor 80mg qd Toprol XL 50mg qd Lasix 80mg [**Hospital1 **] ASA 325 Amio 200mg qd Percocet prn Discharge Medications: 1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q2H (every 2 hours) as needed. 6. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q2H (every 2 hours) as needed. 7. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 8. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Take two pills for the next 2 days, then one pill each day until you see Dr. [**Last Name (STitle) **]. Disp:*14 Tablet(s)* Refills:*0* 9. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Sertraline HCl 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: [**12-3**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day). 12. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 13. Gabapentin 800 mg Tablet Sig: One (1) Tablet PO QPM: Increase to regular dose over the next week. 14. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO once a day: Increase to regular dose over the next week. 15. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. 16. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: COPD Exacerbation Ventricular Tachycardia Metabolic Alkalosis Hypercarbia Congestive Heart Failure Discharge Condition: Good Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction:1.5 L Take all medications as prescribed. - Your only new medication is prednisone which you should take 2 pills for the next two days and then one pill each day until you see [**First Name8 (NamePattern2) 5627**] [**Last Name (NamePattern1) **]. - Note: Your lasix dose has been decreased to 40mg by mouth twice a day. You should NOT take zaroxlyn at this time. Follow you weights. If you notice weight gain, then discuss these doses with Dr. [**Last Name (STitle) **]. - You should slowly restart your gabapentin, start at half dose and increase to your regular dose by the end of the week. - Continue to use your inhalers and BIPAP machine. If you have shortness of breath, chest pain, or dont feel right call Dr. [**Last Name (STitle) **] or 911 immediately. Followup Instructions: [**First Name8 (NamePattern2) 5627**] [**Last Name (NamePattern1) **] (Dr.[**Name8 (MD) 33490**] NP) at 10:00am on Monday [**12-25**]. Dr. [**Last Name (STitle) **] in [**Location (un) 1475**] at 1:45pm on Monday [**1-8**]. Dr. [**Last Name (STitle) **] in congestive heart failure clinic per routine.

[ "491.22", "403.91", "427.1", "428.0", "518.81", "584.9", "427.31", "424.0", "250.00", "V45.81", "428.22", "276.4" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10453, 10459

5589, 8519

296, 296

10602, 10608

2606, 4270

11553, 11860

2210, 2226

8806, 10430

10480, 10581

8545, 8783

10632, 11530

2241, 2587

234, 257

324, 1039

4279, 5566

1061, 2123

2139, 2194

7,393

181,880

11266

Discharge summary

report

Admission Date: [**2127-1-18**] Discharge Date: [**2127-1-20**] Date of Birth: [**2071-1-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2195**] Chief Complaint: "can't move arms and legs" Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname **] is a 55-year-old man with a history of depression, CAD s/p CABG, HTN, and [**Hospital **] transferred from [**Hospital 1562**] Hospital to the [**Hospital1 18**] ICU for further evaluation and management of acute quadriparesis. His outside hospital course was notable for empiric treatment of myalgias and vertigo with oseltamavir, which was discontinued when flu A/B testing was negative. He then had abrupt-onset arm and leg paralysis upon awaking from a deep sleep. He was able to move his neck, fingertips, and toes, and did not have any sensory symptoms. CT and MRI of the head and C-spine were negative for stroke or cord compression. Several days prior to his admission to [**Hospital1 1562**] (Thurs [**1-16**]), he felt weak and lethargic with subjective fevers. He reports decreased appetite. He presented to the outside hospital ED c/o of weakness, fatigue and began experiencing vertigo, nausea, and emesis (x3), unsteady gait, and ear pain. No hearing loss or tinnitus. He also complained of a posterior headache and right neck pain. On review of the ED records it appears he was admitted to the hospital for management of his myalgias and vertigo. In spite of his negative CXR, clear lung sounds, adequate saturation he was started on Oseltamavir for possible influenza and given Meclizine. His labs were remarkable only for a Na of 128. He was admitted to the hospital with improvement with his weakness and myalgias; his oseltamavir was d/c'd after his influenza A+B were negative. Pt states upon waking from a deep sleep, he realized he could not move his arms or legs. He denies any problems with breathing, could move his neck his fingertips on the right hand and toes on b/l feet. He denies any change in his sensory perception. He underwent a stat CT spine/head and MRI C-spine/head which was negative for any signs of stroke or cord compression. He was then transferred to [**Hospital1 18**] ICU for further neurological evaluation. Upon evaluation patient stated he felt very tired, could not raise his arms, only press down with his fingers, and move his toes. On neurological exam, he had full strength in both his upper and lower extremities. He was then transferred to the floor. On the floor, he endorsed feeling depressed and guilty recently regarding his son's home situation. He feels as though this situation is "breaking his heart." He denies and suicidal or homicidal ideation. In [**2126-11-7**], he was seen for complaints of a less severe vertigo. No nausea or vomiting. ROS: no chills, cough, sore throat, sob, rash, diarrhea, wheeze, arthralgia; no recent travel, insect bites; no known sick contacts Past Medical History: PMH: CAD s/p CABGx4 [**2118**] (LIMA-LAD, SVG-diag, SVG-OM, rad-RPDA) & multiple stenting procedures Last ACS in [**2126-2-7**] DM HTN Hyperlipidemia Laryngeal SCC s/p XRT c/b esophageal stricture ( tx w/routine balloon stricturoplasty) Hypothyroidism Depression Iron-deficiency anemia BPH SCC of skin on head GERD Gout Allergic rhinitis Bat bite 10 yrs ago, received tx PSH: Appendectomy Resection SCC neck Resection BCC left supraorbital region Right elbow surgery Right Hip surgery Social History: Lives alone and rents a room from a friend. Divorced. Son is health care proxy. [**Name (NI) **] 3 children with ex-wife: [**Location (un) 36171**], [**Doctor Last Name **]- 22, [**Doctor First Name 16376**]- 14. Former heavy ETOH, quit 5-6 years ago (? longer; used to drink 4-5 drinks/day). No tobacco or drug use. Family History: Both parents with CAD. Mother with heart failure. Father with migraines. Brother with epilepsy. Son missed 1-2 years of school for 'seizures and jaundice.' Physical Exam: Physical Exam by neuro on transfer from outside hospital to [**Hospital1 18**] MICU: Vitals: T:97.9 P:72 R: 16 BP:135/85 SaO2:98% General: Awake, cooperative, very blunted affect [**Hospital1 4459**]: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity. Limited horizontal rotation of neck bilaterally with cervical muscle tenderness and spasm pronounced on Right. Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Laparoscopy scars Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt. was able to register 3 objects and recall [**4-9**] at 5 minutes. The pt. had good knowledge of current events. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Keeps closing eyes on exam, has full movements but feels his eyes hurt with upgaze V: Facial sensation intact to light touch. To pinprick only has a normal sensation in band of v1 on forehead. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Patient has a very confusing motor exam. On the begriming of the examination patient reported that he could only intermittently move his fingers on his hands bilaterally. Initially only the index finger on left, and pink on right. However when hand was held above head, he was able to stop it from dropping and with encouragement, was able to articulate fingers and had nearly full strength at every muscle group tested. Although this was intermittent. Would have weakness initially at all muscle groups, then would improve. Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc L 5- 5 5 5 5 5* * 5 5- 5 5 R 5- 5 5 5 5 5* * 5 5- 5 5 Patient unable to life legs fully up, however could hold legs ~[**6-16**] inches above bed and able to give full strength resistance Had giveway weakness at neck flexors and extensors, and SCMs intemittently Normal rectal tone -Sensory: Patient reports decreased sensation to light touch on forearms, but not hands, normal sensation to hands and above elbow. Has decreased sensation to cold at feet and hands and improves as goes up extremities. Pinprick is dulled throughout body with exception of patients groin and saddle area, genitalia where it is normal and a band on his forehead, in a subset of V1 distribution. Patient has mild decrease in vibratory sense at feet b/l. Patient gives inconsistent answers to proprioception, from getting the answers correctly for 5 tries then stating he can't feel the toe move at all. No extinction to DSS. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 2 2 R 2 2 2 2 2 Plantar response was mute bilaterally. -Coordination: Could not test, as he felt unable to lift arms or legs -Gait: Did not feel like he would be able to walk. Physical exam on transfer to the floor: T: 97 BP: 122/71 HR: 58 RR: 18 O2 saturation: 98% on RA General: Well-appearing, in NAD. Tearful when discussing youngest son. [**Name (NI) 4459**]: NC/AT. Sclera anicteric. MMM. Oropharynx clear. Neck: Indurated (from radiation) Lungs: CTAB Heart: RRR, nl S1, S2 no m/r/g Abdomen: symmetric, nondistended. G tube scar. + bowel sounds. Nontender to palpation. No masses. No HSM. Extremities: dp pulses intact. warm, well-perfused. no edema/cyanosis/clubbing. Neuro: AOx3, [**Doctor Last Name 1841**] backwards intact. Cranial nerves: grossly intact. Motor: some giveway in proximal upper extremity (chicken arms. Otherwise, normal muscle strength ([**6-11**] in upper and lower extremities) Sensation: grossly intact to light touch. Decreased vibratory and temperature sensation in feet, no consistent pattern. Proprioception intact. Cerebellar: fine motor intact. Heel-to-shin intact. No pronator drift. DTR: Normal reflexes in upper extremities. Decreased ankle reflex in right lower extremity. Normal reflexes in left lower extremity. Gait: not evaluated, but patient reports walking to bathroom without assistance without problem Psych: [**Name2 (NI) **]- depressed [**Name (NI) 36172**] labile-- becomes tearful when discussing [**Name (NI) **] and current family problems Pertinent Results: [**2127-1-19**] 12:05AM BLOOD Glucose-115* UreaN-14 Creat-0.7 Na-137 K-3.5 Cl-103 HCO3-22 AnGap-16 [**2127-1-19**] 12:05AM BLOOD Calcium-9.3 Phos-2.9 Mg-1.8 [**2127-1-19**] 09:56AM BLOOD CK(CPK)-78 [**2127-1-19**] 12:05AM BLOOD CK(CPK)-58 [**2127-1-19**] 09:56AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2127-1-19**] 12:05AM BLOOD TSH-3.8 [**2127-1-19**] 12:05AM BLOOD WBC-5.0 RBC-4.10*# Hgb-11.7*# Hct-33.9*# MCV-83 MCH-28.6 MCHC-34.6 RDW-15.0 Plt Ct-166 [**2127-1-19**] 12:05AM BLOOD Neuts-77.2* Lymphs-16.0* Monos-4.3 Eos-2.0 Baso-0.4 [**2127-1-19**] 12:05AM BLOOD Plt Ct-166 [**2127-1-19**] 12:05AM BLOOD PT-12.0 PTT-22.0 INR(PT)-1.0 CT head, CT spine, MR head, MR spine from OSH: showed no acute process Brief Hospital Course: Mr. [**Known lastname **] is 55 year old man with a history of depression, anxiety, hypertension, CAD s/p CABG, and diabetes who presents as transfer from an outside hospital with quadriparesis. ##. Weakness/Quadriparesis: Pt presented with atypical presentation of sudden onset of upper and lower extremity weakness/paralysis. Presentation was atypical due to its sudden global onset with preservation of fine motor skills essentially. Most likely the paresis is related to his depression, such as a conversion disorder, as other possibilities were explored and ruled out. Given initial presentation of possible viral syndrome initial concern was for possible [**Last Name (un) 4584**]-[**Location (un) **]; however presentation is not consistent with [**Last Name (un) 4584**] [**Location (un) **]. Other differentials of sudden onset global quadraparesis with preservation of fine motor skills are otherwise rare that include possible infarction/impingement of spinal cord which is ruled out with MRI. Given his reported history of myalgias (although here, patient reports previous weakness, not muscle pain), it was thought that paresis may represent severe myopathy which may be related to meds or hypothyroidism; however, CK and TSH were normal. Although the time course is incosistent, the description of the onset of the weakness after waking from a deep sleep could be also consistent with sleep paralysis. - We maintained his regimen of cardiovascular risk reduction therapies (Lipitor, Plavix, Aspirin, Metoprolol Succinate XL, Tricor) - If this were to happen again, please consider work-up for CVA, TIA. ##. Depression: Pt reports feeling depressed currently, especially in past few weeks. No suicidal or homicidal ideations. Psych consult was obtained. He was maintained on his home doses of Cymbalta and Buspar. Patient did not know dose of [**Last Name (LF) 36173**], [**First Name3 (LF) **] was not given [**First Name3 (LF) 36173**] in anticipation of impending discharge to home. Patient will need outpatient follow-up with his psychologist Dr. [**First Name8 (NamePattern2) 1894**] [**Last Name (NamePattern1) 36174**], as well as a referral to a psychiatrist for assistance in psychopharmocological management. Social work consult was obtained to assist in identifying resources to help pay for visits with Dr. [**Last Name (STitle) 36174**]. - Please refer to psychiatrist in more convenient location. ##. Vertigo: Resolved here. ##. Hypothyroidism: TSH was normal. Continued on home regimen of levothyroxine. ##. DM II: Maintained on insulin sliding scale. Oral hypoglycemic medications were held. - Restart home meds (Januvia, Glyberide, Actos) on discharge. ##. CAD s/p CABG: Held Plavix and ASA initially given possibility of LP, but was re-started in the morning after patient had been stable and when an LP was no longer required due to clinical improvement and no major diagnostic benefit of LP. Patient was also initially placed on Metoprolol and switched to home Toprol XL the morning after admission. ##. Hyperlipidemia: Maintained on Tricor, Lipitor. OUTSTANDING ISSUES TO FOLLOW-UP AT NEXT VISIT: - Please evaluate psych meds/doses. - Please arrange referral to psychiatry. Medications on Admission: - Plavix 75mg qday - Cymbalta 120mg qday - Ventolin HFA 2 puff QID PRN - ASA 325mg qday - Synthriod 125mcg daily - Buspar 5mg [**Hospital1 **] - Toprol XL 100mg qd - Flonase 2 puffs intranasal once daily - TriCor 145mg qd - Glyburide 10mg [**Hospital1 **] - Omeprazole 20mg [**Hospital1 **] - Lipitor 40mg qhs - Actos 45mg qday - [**Doctor First Name **] 180mg qday allergies prn - FeSO4 325mg qdaily - Lisinopril 5mg qday - Januvia 100mg qday - Renax vitamin daily Discharge Medications: 1. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Four (4) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 5. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). 6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily): as needed. 10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily): take with [**Location (un) 2452**] juice, multivitamin or vitamin c. 11. Buspirone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Ventolin HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**2-8**] puffs Inhalation four times a day as needed for shortness of breath or wheezing. 14. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO twice a day. 15. Actos 45 mg Tablet Sig: One (1) Tablet PO once a day. 16. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day. 17. RENAX 35-2.5-70-20 unit-mg-mcg-mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: Acute remitting quadriparesis, Secondary: Depression with possible conversion, Diabetes, CAD s/p CABG and PCI's Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You were transferred to the [**Hospital3 **] Hospital for management of your paralysis. It resolved and you were discharged to follow up with your PCP and therapist. An MRI and CT scan was taken of your head and neck. You must continue to take your plavix, aspirin and other heart medications to prevent stroke and heart attack. Follow ups [**Last Name (LF) **],[**First Name8 (NamePattern2) 275**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 36175**] [**Last Name (LF) 36174**], [**First Name3 (LF) 7279**] ([**Telephone/Fax (1) 36176**] Followup Instructions: [**Last Name (LF) **],[**First Name8 (NamePattern2) 275**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 36175**] [**Last Name (LF) 36174**], [**First Name3 (LF) 7279**] ([**Telephone/Fax (1) 36176**] Completed by:[**2127-1-21**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

15352, 15358

10093, 13312

342, 349

15522, 15522

9363, 10070

16240, 16479

3911, 4068

13828, 15329

15379, 15501

13338, 13805

15667, 16217

5453, 8582

4083, 4822

276, 304

377, 3051

8598, 9344

15536, 15643

3073, 3561

3577, 3895

41,130

115,838

54738

Discharge summary

report

Admission Date: [**2182-9-10**] Discharge Date: [**2182-9-21**] Date of Birth: [**2110-8-18**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 87302**] Chief Complaint: febrile neutropenia Major Surgical or Invasive Procedure: Mediastinoscopy [**2182-9-13**] Bone marrow biopsy [**2182-9-13**] PICC placement times 2 PICC line removal time 2 Port placement [**2182-9-20**] History of Present Illness: 72-year-old male with likely lymphoma admitted to ICU with febrile neutropenia. He had been to his doctor's office today for lower extremity edema and a decubitus ulcer on his coccyx. He was found to be hypotensive and was transferred to the Emergency Department. He was given a 500cc bolus of crystalloid by EMS. In the ER vitals were initially 100.6, 112, 112/62, 22, 99% 2 L. In the ER the patient was given Vancomycin and Cefepime. A CT was done which showed no PE, extensive mediastinal LAD, and 4 mm left upper lobe pulmonary nodule. Labs were notable for WBC of 0.9 with 72% PMNs, HCT of 23.8 and PLT of 58. Calcium 7.7, troponin <0.01, lactate 2.3. On arrival to the MICU, patient's VS 98.8, 100, 109/62, 27, 98% RA. On review of systems the patient endorses a non-productive cough,60 lb weight loss over past year, night sweats, rhinorrhea with blood, constipation (ongoing) without blood. Past Medical History: Rotator cuff repair 12 years ago Lymphadenopathy since [**Month (only) 958**] sciatica B12 deficiency Social History: Lives with partner [**Name (NI) **]. Worked for self as a collectibles dealer. Drinks 1 glass wine/month, no smoking, no IVDU. Family History: Denies any family history of cancer Physical Exam: Admission: Vitals: 98.8, 100, 109/62, 27, 98% 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 irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, splenomegaly, no tenderness to palpation, no rebound or guarding GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis, 1+ edema Skin: stage I decubitus ulcer on coccyx Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, resting tremor. Discharge: Vitals: T 97.7 BP 100-140/58-73 HR 71 RR 18 O2 Sat 98% on RA BM times 1 UOP 4.[**0-0-**] General: Patient sitting at edge of bed in NAD HEENT: Pupils equal and round. MMM. Neck: Base of the neck with bandage at the site of mediastinoscopy C/D/I Cardiac: RRR. No M/R/G. Chest: Right chest with accessed port with bandage superiorly that is c/d/i. No erythema. no TTP. Lungs: Equal breath sounds bilaterally though deminished at the bases bilaterally. Nml work of breathing. No crackles or wheezes. Abd: Soft. NT/ND. BS+. Ext: 1+ pitting edema of the LE bilaterally extending midway of the shins bilaterally. Non-pitting swelling of RUE compared to left that is improved at the level of the wrist. Pertinent Results: Admission [**2182-9-10**] 02:10PM WBC-0.9* RBC-2.58* HGB-7.9* HCT-23.8* MCV-92 MCH-30.7 MCHC-33.2 RDW-19.8* [**2182-9-10**] 02:10PM NEUTS-72* BANDS-2 LYMPHS-19 MONOS-2 EOS-1 BASOS-0 ATYPS-2* METAS-0 MYELOS-0 PROMYELO-2* [**2182-9-10**] 02:10PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL TARGET-OCCASIONAL [**2182-9-10**] 02:10PM PLT SMR-VERY LOW PLT COUNT-58* [**2182-9-10**] 02:02PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017 [**2182-9-10**] 02:02PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2182-9-10**] 02:02PM URINE RBC-1 WBC-4 BACTERIA-FEW YEAST-NONE EPI-<1 [**2182-9-10**] 02:02PM URINE MUCOUS-MOD [**2182-9-10**] 12:37PM LACTATE-2.3* [**2182-9-10**] 12:30PM GLUCOSE-121* UREA N-23* CREAT-1.0 SODIUM-130* POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-21* ANION GAP-13 [**2182-9-10**] 12:30PM estGFR-Using this [**2182-9-10**] 12:30PM ALT(SGPT)-13 AST(SGOT)-59* LD(LDH)-468* ALK PHOS-91 TOT BILI-0.7 [**2182-9-10**] 12:30PM cTropnT-<0.01 [**2182-9-10**] 12:30PM proBNP-415* [**2182-9-10**] 12:30PM ALBUMIN-2.8* CALCIUM-7.7* PHOSPHATE-3.4 MAGNESIUM-1.8 URIC ACID-6.1 Imaging: CHEST (PA & LAT) Study Date of [**2182-9-10**] IMPRESSION: No definite acute cardiopulmonary process. Blunting of the left posterior costophrenic angle, potentially due to atelectasis or Bochdalek hernia, noting at underlying consolidation cannot be completely excluded. CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2182-9-10**] 1. No evidence of pulmonary embolism or acute aortic syndrome. 2. Extensive mediastinal lymphadenopathy and splenomegaly concerning for lymphoma. 3. 4-mm left upper lobe pulmonary nodule. This does not need to be followed in a low-risk patient. In a high-risk patient, one-year followup may be obtained. Lower Extremity Doppler [**2182-9-11**] No evidence of deep venous thrombosis within the bilateral lower extremities. Echo [**2182-9-12**] The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. There is no aortic valve stenosis. The mitral valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal image quality due to body habitus. Left ventricular systolic function is probably normal, a focal wall motion abnormality cannot be excluded. The right ventricle is not well seen. No significant valvular abnormality. Normal estimated pulmonary artery systolic pressure. Mediastinal lymph node biopsy [**2182-9-13**] Lymph node, mediastinal (A-B): Classical Hodgkin lymphoma, see note. Note: The nodal tissue is effaced with a dense infiltrate comprised predominantly of small lymphocytes with condensed nuclear chromatin. Frequent large atypical cells containing one to two nuclei with vesicular chromatin, large eosinophilic nucleolus, and moderate amount of cytoplasm consistent with Hodgkin cells and [**Doctor Last Name **]-Sternberg cells, are present. Scattered apoptotic "mummified" cells are noted. By immunohistochemistry, the large neoplastic cells are positive for CD30, subset dimly positive for CD15, dim positive for PAX-5, and co-express CD20, consistent with Hodgkin cells and its variants. The background reactive lymphoid infiltrate consists predominantly of small T-cells which are CD3 positive and TdT negative, along with scattered CD20 and PAX-5 positive B-cells. CD23 highlights residual disrupted follicular dendritic framework but does not stain the large neoplastic cells. BCL-2 highlights the majority of the background small reactive lymphocytes. Reticulin stain highlights fibrous tissue, separating the lymphoid tissue into vague nodules. Pericellular fibrosis is not seen. Overall, the features are consistent with classical Hodgkin lymphoma. Immunophenotyping [**2182-9-13**] INTERPRETATION Immunophenotypic findings show a B cell population. However, preliminary tissue biopsy reveals features suggestive of Hodgkin lymphoma (see separate report). Correlation with clinical and morphological findings is recommended. Bone marrow biopsy [**2182-9-14**] SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY: DIAGNOSIS: Fibrotic bone marrow with involvement by Hodgkin lymphoma, see note. Note: By immunohistochemistry, the large atypical cells stain positively with CD30, CD15 (dim), and CD20, and are negative for CD43. The staining pattern supports the above diagnosis. RUE Doppler [**2182-9-15**] IMPRESSION: Partially occlusive thrombus along the right PICC throughout the entirety of the right basilic vein, extending into the right axillary and likely right subclavian veins. CXR [**2182-9-16**] The left PICC line lies in the mid SVC. The right PICC line has been removed. No other changes are seen. Discharge labs: [**2182-9-21**] 04:48AM BLOOD WBC-1.2* RBC-2.61* Hgb-8.0* Hct-23.6* MCV-91 MCH-30.7 MCHC-33.9 RDW-19.3* Plt Ct-38* [**2182-9-21**] 04:48AM BLOOD Neuts-65.8 Lymphs-29.3 Monos-0.9* Eos-3.8 Baso-0.1 [**2182-9-21**] 04:48AM BLOOD Glucose-101* UreaN-11 Creat-0.6 Na-139 K-3.8 Cl-106 HCO3-29 AnGap-8 [**2182-9-21**] 04:48AM BLOOD Calcium-7.8* Phos-3.8 Mg-1.9 Brief Hospital Course: 72-year-old male with likely lymphoma admitted to ICU with febrile neutropenia # Hypotension: Patient was hypotensive in ED and at PCP office with SBP in 80's. Blood pressure improved with 500 cc IVF given by EMS. He did not require pressors. Differential diagnosis includes sepsis vs hypovolemia. Patient appeared volume depleted on exam and endorsed decreased PO intake. Baseline BP 115-125. Patient was fluid resuscitated and blood pressure improved. # Febrile Neutropenia: Patient presented with fever in setting of neutropenia (ANC 648). Etiology unclear, but possibly due decubitus ulcer on coccyx. Patient endorsed no respiratory symptoms and chest x-[**Month/Day/Year **] showed no acute processes. He also had no urinary symptoms and normal U/A. Patient was treated with vancomycin and cefepime. Blood cultures were negative. Fever curve improved and antibiotics were discontinued [**9-14**] after a 5 day course. # Lymphadenopathy- Patient has lymphadenopathy concerning for underlying lymphoma. He had an inguinal biopsy the week prior to which showed benign lymph node with fatty replacement. CT showing extensive mediastinal lymphadenopathy and splenomegaly. The patient was seen by Atrius hematology/oncology. Thoracic surgery was consulted for mediastinal biopsy, which was performed [**2182-9-13**]. Biopsy consistent with Hodgkin lymphoma, as was bone marrow biopsy done [**9-14**]. Patient started cycle 1 of ABVD on [**2182-9-16**]. # DVT: Right PICC placed [**2182-9-13**]. Patient subsequently developed right upper extremity swelling. An ultrasound showed a partially occlusive thrombus along the right PICC throughout the entirety of the right basilic vein, extending into the right axillary and likely right subclavian veins. Right PICC was removed and patient was started on Lovenox. Due to concern for future issues with PICC, port placement was done [**2182-9-20**] and left PICC was also removed. Previously in hospitalization, there was concern about lower extremity DVT due asymmetric edema, but LENIs were negative. # Pancytopenia: WBC 0.9, HCT 23.8 and PLT 58 on presentation secondary to underlying hematological malignancy. Patient received a total of 5 units of PRBCs over the course of his hospitalization ([**9-10**], [**9-11**] in anticipation of planned biopsy, [**9-16**], [**9-19**] in anticipation of port placement, [**9-21**]). He also received 3 bags of platelets (1 prior to biopsy [**9-12**], 2 with port placement). #. Tremor: Per patient, has been present for the past 1 year. Seems to have some Parkinsonian features, workup not done during this hospitalization. Medications on Admission: Cyanocobalamin, Vitamin B-12, (VITAMIN B-12) 1,000 mcg/mL Injection Solution Inject 1000mcg IM Codeine-Guaifenesin (CHERATUSSIN AC) 10-100 mg/5 mL Oral Liquid TAKE 10ML BY MOUTH EVERY SIX HOURS AS NEEDED FOR COUGH Discharge Medications: 1. Enoxaparin Sodium 150 mg SC DAILY RX *enoxaparin 150 mg/mL 1 injection via synringe daily Disp #*30 Syringe Refills:*0 2. Docusate Sodium (Liquid) 100 mg PO BID 3. Ex-Lax Maximum Strength *NF* (sennosides) 25 mg Oral [**Hospital1 **]:PRN constipation * Patient Taking Own Meds * 4. Ondansetron 8 mg PO Q8H:PRN nausea RX *ondansetron 4 mg [**1-28**] tablet(s) by mouth every 8 hours Disp #*100 Tablet Refills:*0 5. Allopurinol 200 mg PO DAILY RX *allopurinol 100 mg 2 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 6. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q6H:PRN pain, fever page house officer for fever not >4 g/day 7. OxycoDONE (Immediate Release) 2.5-5 mg PO Q8H:PRN pain do NOT take this medication with alcohol. do NOT operate a car or heavy machinary. RX *oxycodone 5 mg 0.5-1 tablet(s) by mouth every 8 hours Disp #*40 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: All Care VNA Discharge Diagnosis: Hodgkin lymphoma Right upper extremity deep venous thrombosis Tremor Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure taking care of you during your hospitalization at [**Hospital1 69**]. You were hospitalized with fever and found to have a low number of infection fighting cells. The cause of your fever was never found. You underwent a lymph node biopsy by the thoracic surgeons, and the biopsy results showed a new diagnosis of Hodgkin's Lymphoma. You were started on chemotherapy for treatment of Hodgkin's Lymphoma, which you will continue as an outpatient. You developed a blood clot in your right upper extremity secondary to a PICC line. The PICC line was discontinued, and you were started on a medication called Lovenox to thin your blood. You will need to have 1 injection administered daily for the next 3 months. Go pick up your prescription from the pharmacy at [**Location (un) 1456**] [**University/College **] [**University/College 38299**] on the day of your discharge so that the visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 5050**] your daily injection starting [**2182-9-22**]. Take all other medications as prescribed. A list of your medications is provided for you in your discharge paperwork. We wish you the best going forward. Followup Instructions: Oncology follow-up: [**Last Name (LF) 766**], [**2182-9-23**] at 2 PM with Dr. [**First Name4 (NamePattern1) 12967**] [**Last Name (NamePattern1) **] at the [**University/College **] [**First Name9 (NamePattern2) 38299**] [**Location (un) **] Office. It is very important that you keep this appointment. Thoracic surgery follow-up: You will need to call the Thoracic surgery office of Dr. [**Last Name (STitle) 1007**] to set up appointment in 1 week from discharge. The telephone number to his office is ([**Telephone/Fax (1) 111924**]. Primary care follow-up: You will need to establish primary care at the [**University/College **] [**University/College 38299**] Office in [**Location (un) 1456**], MA to continue to be followed by a regular doctor in light of your new diagnosis. Completed by:[**2182-9-24**]

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icd9cm

[ [ [] ] ]

[ "86.07", "41.31", "99.25", "40.11", "38.97" ]

icd9pcs

[ [ [] ] ]

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12747, 12747

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26739

Discharge summary

report

Admission Date: [**2179-10-22**] Discharge Date: [**2179-10-27**] Date of Birth: [**2109-12-15**] Sex: M Service: MEDICINE Allergies: Trileptal Attending:[**First Name3 (LF) 348**] Chief Complaint: Hyponatremia Major Surgical or Invasive Procedure: L Radial Arterial line placement - [**10-22**] Multi-lumen CVL Right IJ - [**10-22**] History of Present Illness: HISTORY OF PRESENT ILLNESS: Per MICU admit note: 69-year-old male gentleman with a past medical history of diet-controlled diabetes, hypertension, and trigeminal neuralgia recently started on oxcarbazepine, who was found by his son today unresponsive sitting on a chair in the bathroom. He did not note any convulsive activity or B/B incontinence. EMS was called, and found pt to be unresponsive to sternal rub, with FSBS 133, with other VS reportedly within normal limits. Per son, he has had intermittent dizziness, headache, and general lethargy since starting oxcarbazepine last week, but no significant altered mental status, seizures, or episodes of unresponsiveness. In the field, he had a gradual return to consciousness over ~ 15 minutes and was brought to the ED for evaluation. . In the ED, VS: 97.5 68 134/46 16 100%RA. On exam he was lethargic, with generalized weakness, vague abdominal pain, L inguinal hernia, (non-incarcerated), and a non-focal neuro exam. EKG was negative for acute ischemic change. CT scan confirmed inguinal hernia, non incercerated, but no other acute abdominal process. A CT head was also negative. CXR and U/A was negative. 11PM Labs revealed hyponatremia to 103. By that point, he had already received 700ml NS. A repeat Na at 3AM was stable at 103. Renal was consulted and then recommended hypertonic saline (70cc x 1 hr), with a sodium recheck afterwards. Repeat sodium was 106 while the pt was en route to the ICU. . Currently he denies pain or complaints and appears comfortable. Past Medical History: Per MICU admit note: # dental implants removed from his left anterior lower jaw 1 year ago, with chronic disabiling paroxysmal facial pain ever since, ? trigeminal neuralgia - seen in neuro [**2179-10-15**] by Dr. [**Last Name (STitle) 4253**] # DM2 - diet controlled # CRI - b/l Cr 1.5-1.7 # HTN # HL # Anemia - Iron deficiency and anemia of chronic disease # Glaucoma Social History: He is retired. He is married, lives with his spouse.[**Name (NI) **] tobacco/EtOH/drugs. Family History: Mother was killed in [**Name (NI) 651**] in her 20's. His father died at 69 following a bypass surgery. He has no siblings. His children are healthy. Physical Exam: VSS GEN: NAD, pleasant, talkative HEENT: PERRL, EOMI, NC/AT, mmm NECK: No LAD, supple CARDIOVASCULAR: regular rate, no mrg. RESPIRATORY: CTAB ABD: +bs, soft, NTND EXT: no edema, warm, 2+ DP pulses NEUROLOGIC: alert and oriented to person, place, time and purpose. CN 2-12 intact. Strength is [**5-24**] bilaterally, normal tone. Sensation intact to light touch. Toes downgoing. Pertinent Results: [**2179-10-21**] 11:15PM BLOOD Glucose-116* UreaN-26* Creat-1.3* Na-103* K-3.7 Cl-67* HCO3-23 AnGap-17 . [**2179-10-25**] 04:04AM BLOOD Glucose-80 UreaN-17 Creat-1.1 Na-130* K-4.2 Cl-103 HCO3-21* AnGap-10 . [**2179-10-22**] 08:34AM BLOOD TRILEPTAL-Test (Pending) . [**2179-10-26**] 04:59AM BLOOD WBC-7.1 RBC-3.23* Hgb-9.5* Hct-26.8* MCV-83 MCH-29.3 MCHC-35.3* RDW-13.2 Plt Ct-297 . [**2179-10-26**] 04:59AM BLOOD Glucose-76 UreaN-13 Creat-1.2 Na-131* K-4.8 Cl-101 HCO3-22 AnGap-13 . [**2179-10-26**] 04:59AM BLOOD Calcium-8.8 Phos-2.7 Mg-2.0 . [**2179-10-25**] 08:25AM BLOOD calTIBC-233* VitB12-1412* Ferritn-578* TRF-179* . . IMAGING: Head CT [**2179-10-22**]: . FINDINGS: There is no evidence of infarction, hemorrhage, edema, shift of normally midline structures or hydrocephalus. The density values of the brain parenchyma are within normal limits. The [**Doctor Last Name 352**]-white matter differentiation is preserved. Calcifications of the cavernous carotid arteries are noted. Imaged paranasal sinuses and mastoid air cells are pneumatized and well aerated, with the exception of minimal mucosal thickening in the maxillary sinuses bilaterally. . Imaged osseous structures and extracalvarial soft tissues are unremarkable. . IMPRESSION: No acute intracranial process, including no hemorrhage, edema, or mass. . . CT ABD [**2179-10-22**]: Non-con CT ABDOMEN AND PELVIS WITHOUT INTRAVENOUS CONTRAST . INDICATION: 69-year-old man with syncope and abdominal pain. Evaluate for abdominal aortic aneurysm and other abdominal pathology. . CT ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Lung bases are clear. There is no pericardial or pleural effusion. . The aorta is normal in caliber. . Non-contrast evaluation of the liver, spleen, adrenal glands, and pancreas is unremarkable. The collecting systems are prominent bilaterally, but no urolithiasis is noted. Several cysts arise from the right kidney, previously evaluated by the MRI. The abdominal loops of small bowel are normal. Normal appendix is seen. There is diverticulosis of the right colon, but no evidence of acute diverticulitis or evidence of colitis. The right colon is underdistended. . CT PELVIS WITHOUT INTRAVENOUS CONTRAST: Urinary bladder is distended. The prostate is enlarged, measuring 5.5 x 4 cm. There is a large inguinal hernia, containing sigmoid colon. There is small amount of fluid and inflammatory stranding in the hernia sac, but no evidence of obstruction. . BONE WINDOWS: Demonstrate no concerning lytic or sclerotic lesions. Partial sacralization of L5 with associated degenerative changes. . IMPRESSION: 1. Abdominal aorta normal in caliber. No evidence of retroperitoneal hematoma. . 2. Large left inguinal hernia containing sigmoid colon with fluid and inflammatory changes without evidence of obstruction. Surgical consultation is recommended. . 3. Renal cysts. . Brief Hospital Course: 69-year-old male with a PMH HTN and trigeminal neuralgia recently started on oxcarbazapine (trileptal), p/w unresponsiveness in the setting of marked hyponatremia. Patient was initially treated with hypertonic saline and his sodium rose to the high 120's and on day of discharge was 133. Patient also had episodes of bradycardia in the setting of his severe # Hyponatremia: The etiology of the hyponatremia was thought to be multi-factorial. Oxcarbazepine is well-known to cause hyponatremia in therapeutic use, perhaps even more so in elderly patients. Other factors in Mr. [**Known lastname 65798**] case included poor PO intake, a low sodium diet, and significant amount of diarrheal stools. Renal was consulted in the ED and recommended hypertonic saline. Sodium 103 on admission, corrected to 121 over the first 24 hours (~0.75mEq/hr. Hypertonic saline drip was discontinued [**10-24**] at ~11pm, and he was started on NS at 100ml/hr. His serum sodium was 130 on the morning of transfer to the regular floor and on discharge it was 133. He was followed closely for any signs of central pontine myelinolysis. He was discharge with a follow up appointment on [**2179-10-30**]/ # Bradycardia: On the morning after admission, patient was noted to have significant bradycardia (HRs 20s with occasional 5 second pauses) associated with relative hypotension for this normally hypertensive patient. EP was consulted and postulated that the bradycardia was likely secondary to oxcarbazepine effect vs. hyponatremia. However, there are not many cases of bradycardia assocated with either in the literature. Of note, pt's baseline HRs (on beta-blockers) prior to admission were in the 50s-60s. Given persistent bradycardia and hypotension, pt was started on dopamine (5mcg/kg/min) on [**2179-10-22**] with significant improvement. Dopamine was weaned off on [**2179-10-24**] and HRs were been stable in the 50-60s and pt has returned to his usual hypertensive baseline. On transfer to the floor, patient had one episode of bradycardia of 32 with no drop in bp and patient was completely asymptomatic. In light of this bradycardia, on discharge, patient was instructed to take only his lisinopril and medications for HTN would be titrated as an out patient. # Diarrhea: Pt continued to have loose, green, malodorous, stool without frank blood or melena. Has been C.diff negative x 2. Diarrhea significantly improved in the 24hrs prior to transfer. On the floor patient's diarrhea improved. # Anemia: As an outpatient, pt had been diagnosed with both iron deficiency anemia (on iron at the time of admission) and anemia of chronic disease. His Hct has decreased since admission, to 23 at the time of transfer. Stool guiac pending and U/A +blood (>50 rbc/hpf). Iron studies were re-sent on the day of transfer. Of note, last colonoscopy in [**5-25**] showed diverticulosis, last EGD [**5-25**] showed esophagitis, duodenitis, and gastritis. Iron studies indicated anemia of chronic disease. # UCx positive for Group B strep: uncommon cause of UTI, afebrile patient. This was thought to most likely be a contaminant, and thus was not treated. # DM - Diet controlled. Per ICU protocol, FSBS were followed q4h with insulin sliding scale as needed. FSBS well-controlled during this admission. # HTN - We initially held his anti-hypertensive medications in the setting of his bradycardia and hypotension. Given his improved hemodynamic status on the day of transfer, we re-initiated his Lisinopril at 20mg PO qday. Plan to titrate his mediation as an out patient. # Dyslipidemia - Continued statin. # Glaucoma - Home Timolol eye drops. # Code - Full. Medications on Admission: # atenolol/chlorthalidone 50-25mg qAM # lisinopril 40mg daily # nifedipine SR 90mg daily # omeprazole 20mg daily # Oxcarbazepine [Trileptal], started [**10-15**], currently being uptitrated, with most recent dose still 300 [**Hospital1 **] # simvastatin 20mg daily # ASA 81mg # FeSO4 # MVI Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hyponatremia . . Secondary Diagnoses: Diabetes Chronic Renal Insufficeny Hypertension Hyperlipidemia Trigeminal neuralgia Discharge Condition: Stable Stable Discharge Instructions: You were admitted with severe hyponatremia (low salt in the blood) and altered mental status. This was determined to be from the Trileptal that you started a week before you were admitted. This medication was stopped and your salt was replaced through an iv. Your mental status improved as your salt level increased. Your salt level is now back to normal. During your hospitalization, you also had a very slow heart rate. While in the ICU, you had episodes of low blood pressure with this low heart rate and required medication to keep your blood pressure at a high enough level. When you came to the general medical floor, you also had episodes of slow heart rate, but you had no symptoms which was reassuring. MEDICATION CHANGES: **We have stopped 2 of your blood pressure medications so you should not take them at home. -Atenolol/Chlorthaladone -Nifedipine **DO NOT TAKE: Trileptal. Please tell your health care provider that you had a SEVERE reaction to Trileptal and you should not take this medication. You can restart all your other home medications as directed which are: -Aspirin 81 mg once a day -Simvastatin 10 mg 2 tablets once a day -Multivitamin one tablet once a day -Ferrous Sulfate 325 mg tablet once a day -Timolol Maleate 0.5 % Drops once drop in each eye twice a day -Lisinopril 20 mg once a day If you have dizziness, fainting, confusion, chest pain, shortness of breath, fever higher than 100.5 or ANY other concerning symptoms, please come to the emergency room immediately. It was a pleasure meeting you and participating in your care. Followup Instructions: You have an appointment at [**Company 191**] on Friday, [**2179-10-29**] with Dr. [**Last Name (STitle) **] at [**Location (un) **], [**Location (un) 86**] [**Telephone/Fax (1) 250**] for follow up. You have an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], your new PCP on Wednesday, [**2179-12-29**] at 9am.

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icd9cm

[ [ [] ] ]

[ "38.91", "00.17", "38.93" ]

icd9pcs

[ [ [] ] ]

10483, 10489

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285, 372

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10567, 10653

11455, 12297

233, 247

428, 1928

10529, 10546

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2337, 2427

73,970

130,239

36468

Discharge summary

report

Admission Date: [**2132-8-18**] Discharge Date: [**2132-8-26**] Date of Birth: [**2092-6-10**] Sex: F Service: SURGERY Allergies: Iodine; Iodine Containing / Shellfish Derived / Diphedryl Allergy Attending:[**First Name3 (LF) 3376**] Chief Complaint: sigmoidocele/problems defecating Major Surgical or Invasive Procedure: Lap sigmoidectomy/rectopexy Exploratory laparotomy and revision of possible bleeding Placement of uterine manipulator, abdominal culdoplasty. History of Present Illness: 40 yo female with a long history of chronic opiate use for joint pain/bilateral hip pain x 10 years associated with endocrine issues (?pseudohypoparathyroidism with H/O pelvic outlet obstruction and disordered defecation. Patient was seen pre-operatively for evaluation and post-operative pain management plan. Her meds at home included OxyContin 120mg/120mg/160mg, Keppra (unsure of dose). Her baseline pain is [**2133-6-4**]. She has undergone total detox from opiates at the [**Hospital1 47193**] in [**2129**], she remained off all opiates for approximately 3 weeks. She reports being unable to function/work during the time she was off all pain medications. She has tried various opiates in the past without success. Patient reports OxyContin has managed her pain the best. Past Medical History: osteoporosis from pseudohyperparathyroidism, hypothyroid, GERD Social History: The patient lives with her husband. [**Name (NI) 6419**] her and her husband work as lawyers. The patient's husband is currently on sabbatical from his job in [**Location **]working as a visiting professor [**First Name8 (NamePattern2) **] [**Last Name (Titles) **]. The patient herself works from home doing legal research, they went through IVF using a surrogate who is due with their first child at the end of [**Month (only) 216**]. The patient denies any tobacco or alcohol use. Family History: Mother alive and well with hypertension. Father alive and well with hypercholesterolemia. No family history of pseudohypoparathyroidism or thyroid disease in the family. Physical Exam: Patient pale ,cachetic female, ambulating with cane, right arm tremors VS: HR 86, BP 102/73, RR 18, O2 Sat 96%, Temp 97.6, Pain Score [**7-9**] Height 5'0" Weight 84 lbs Pt stable, afebrile, NAD RRR nl S1, S2 CTAB Abd soft, NT/ND surgical scars well healed from prior laparoscopies. Rectal exam: good resting tone and paradoxical Valsalva with contraction. No palpable sphincter defects, and she has clinically minor rectocele. Ext no c/c/e Pertinent Results: [**2132-8-18**] 11:12AM BLOOD Hct-26.6* [**2132-8-18**] 11:12AM BLOOD Na-138 K-3.5 Cl-104 [**2132-8-18**] 11:12AM BLOOD Mg-1.8 Brief Hospital Course: Patient was taken to the OR by Dr. [**Last Name (STitle) 13543**] for a sigmoidectomy and rectopexy on [**2132-8-18**]. Her post-op course was complicated by a trigger for tachycardia to 150s and increasing JP drain and hct drop to 19 (from 26). She was also noted to have PTT 61 and INR 1.4. She was given 1 unit FFP, 2 units pRBC. She was noted to have persistent serosanguinous drainage from JP and oozing around drain site and thus was taken again to the OR for an ex lap and wash out. During the revision there was no clear evidence of an intraabdominal bleeding source. JP site injected with lidocaine to help control bleeding. The old drain site, LLQ, was restitched and the bleeding was controlled (see op note-pending). Post operatively, she was noted to have continued mild oozing from around the JP drain and thus is being transferred to the [**Hospital Unit Name 153**] for monitoring. Her foley was removed. The patient was transferred to the floor POD [**3-31**]. She was unable to void and a foley was placed. The patient was started on TPN and her electrolytes were repleated as needed. Her potassium was 2.8, repleated, placed on telemetry and trended. The patient's foley was removed and she was able to void. On [**8-25**] she was started on po pain meds, tolerating them extremely well. Drain was successfully removed as well as her staples. Medications on Admission: levothyroxine 75', oxycontin 120/120/160 TID, CaCO3 600"', Sonata 10', clonazepam 1q6h prn:anxiety, lansoprazole 30', rocaltrol 0.5' Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Hold if loose stools***. Disp:*60 Capsule(s)* Refills:*2* 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain for 2 weeks. 6. Levothyroxine 300 mcg Tablet Sig: 2.5 Tablets PO DAILY (Daily). 7. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: Three (3) Tablet Sustained Release 12 hr PO BID (2 times a day): 0800 and 1400 . 8. Oxycodone 60 mg Tablet Sustained Release 12 hr Sig: Three (3) Tablet Sustained Release 12 hr PO DAILY (Daily): [**2123**] . 9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain for 2 weeks. Disp:*50 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Sigmoidocele with rectal ostruction Post-op bleeding Discharge Condition: stable tolerating regular diet 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: -Your staples will be removed at your follow up appointment. -Steri-strips will be applied and will fall off on their own. Please remove any remaining strips 7-10 days after application. -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) 3377**] office, [**Telephone/Fax (1) 160**], to make a follow up appointment in [**2-1**] weeks. NEITHER DICTATED NOR READ BY ME Completed by:[**2132-8-26**]

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icd9cm

[ [ [] ] ]

[ "17.36", "99.04", "48.76", "38.93", "69.98", "70.92", "99.07", "99.15", "54.11" ]

icd9pcs

[ [ [] ] ]

5253, 5259

2720, 4084

358, 502

5355, 5431

2569, 2697

7038, 7228

1918, 2091

4267, 5230

5280, 5334

4110, 4244

5455, 6597

6612, 7015

2106, 2550

286, 320

530, 1311

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1413, 1902

12,567

196,308

3868

Discharge summary

report

Admission Date: [**2203-7-28**] Discharge Date: [**2203-8-17**] Date of Birth: [**2143-6-19**] Sex: F Service: SURGERY Allergies: Sulfonamides / Tetracyclines Attending:[**First Name3 (LF) 6346**] Chief Complaint: Chest pain Abdominal pain Nausea Major Surgical or Invasive Procedure: Exploratory laparotomy, washout, duodenal ulcer [**Location (un) **]-patching and gastrojejunostomy tube History of Present Illness: Ms. [**Known lastname 17327**] is a 60-year-old woman, with severe COPD on high-dose steroids for exacerbation, who came in with increasing abdominal pain over a 24-hour period. She had an upright chest film that showed free air. She was tachycardiac and had peritonitis on physical exam. Risks and benefits of surgery were offered after surgical consult was obtained. The patient was taken emergently to the operating room for an exploratory laparotomy after consent was obtained. Past Medical History: 1. COPD, last PFTs [**2202-7-22**] with FVC 2.03 and FEV1 0.94 (62 and 39% predicted respectively); never intubated 2. IgA deficiency, on IV gamma globulin with Dr. [**Last Name (STitle) 2148**]. 3. CAD s/p MIs in [**2186**] (flu symptoms), [**2192**] (jaw pain), NSTEMI in [**2197**] (chest pain with left arm discomfort). Cath in [**2197**] with single vessel CAD s/p PTCA/stent to LCx. Cath in [**4-/2202**] with stent placement to RCA and LCx. 4. Hypertension 5. Hyperlipidemia 6. Gastritis, on PPI 7. Osteoporosis, with history of multiple compression and rib fractures from coughing 8. History of thrush/[**Female First Name (un) **] esophagitis [**12-30**] steroid therapy, on Diflucan prn 9. Depression 10. Tremor Social History: She lives with her daughter, son-in-law and 3 grand-children. She is a widow. She is an ex-smoker, with about a 30-pack-year smoking history, quit in [**2201-10-28**] (had previously stopped, then restarted, then stopped again). No EtOH. Family History: Mother with DM, father with pancreatic cancer. Physical Exam: Initial Physical Exam - Surgery- [**2203-7-28**] 96.4 97 115/92 25 98% on 2L NAD, moon facies RRR CTAB, decreased BS, poor air movement Skin fragile +ecchymosis diffusely +osteoporetic Pertinent Results: Admission Labs: [**2203-7-28**] 05:20AM BLOOD WBC-29.1*# RBC-5.05 Hgb-13.2 Hct-41.5 MCV-82 MCH-26.2* MCHC-31.9 RDW-15.6* Plt Ct-590* [**2203-7-28**] 05:20AM BLOOD Neuts-92.4* Lymphs-5.2* Monos-1.7* Eos-0.3 Baso-0.3 [**2203-7-28**] 05:20AM BLOOD Hypochr-1+ Microcy-1+ [**2203-7-28**] 05:20AM BLOOD Plt Ct-590* [**2203-7-28**] 05:20AM BLOOD Glucose-98 UreaN-16 Creat-0.9 Na-132* K-4.4 Cl-92* HCO3-28 AnGap-16 [**2203-7-28**] 05:20AM BLOOD CK(CPK)-27 [**2203-7-28**] 05:20AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2203-7-28**] 10:37AM BLOOD Calcium-7.9* Phos-2.9 Mg-1.6 [**2203-7-28**] 05:20AM BLOOD GreenHd-HOLD [**2203-7-28**] 10:58AM BLOOD Type-ART pO2-200* pCO2-57* pH-7.28* calTCO2-28 Base XS-0 [**2203-7-28**] 07:11AM BLOOD Lactate-3.2* [**2203-7-28**] 10:05PM BLOOD freeCa-1.22 Discharge Labs: [**2203-8-11**] 04:10AM BLOOD WBC-17.1* RBC-3.24* Hgb-8.3* Hct-26.1* MCV-80* MCH-25.7* MCHC-32.0 RDW-15.7* Plt Ct-597* [**2203-8-11**] 04:10AM BLOOD Plt Ct-597* [**2203-8-11**] 04:10AM BLOOD Glucose-104 UreaN-22* Creat-0.5 Na-135 K-4.3 Cl-98 HCO3-30 AnGap-11 [**2203-8-4**] 02:21AM BLOOD CK(CPK)-44 [**2203-8-11**] 04:10AM BLOOD Calcium-8.9 Phos-3.7 Mg-1.9 [**2203-8-5**] 05:08AM BLOOD freeCa-1.13 Operative Report: PROCEDURE: Exploratory laparotomy, washout, duodenal ulcer [**Location (un) **]-patching and gastrojejunostomy tube. ANESTHESIA: General endotracheal anesthesia. IV FLUID: 500 cc. ESTIMATED BLOOD LOSS: 100 cc. URINE OUTPUT: 300 cc. INDICATIONS: Ms. [**Known lastname 17327**] is a 60-year-old woman, with severe COPD on high-dose steroids for exacerbation, who came in with increasing abdominal pain over a 24-hour period. She had an upright chest film that showed free air. She is on high-dose steroids. She was tachycardiac and had peritonitis on physical exam. Risks and benefits of surgery were offered after surgical consult was obtained. The patient was taken emergently into the operating room for an exploratory laparotomy after consent was obtained. PREPARATION: The patient was taken to operating room after intravenous antibiotics were administered. She was placed in the supine position. Venodyne boots were placed and activated. The patient was then endotracheally intubated in the normal fashion. A timeout was performed. The patient was sterilely prepped. PROCEDURE IN DETAIL: An upper midline incision was made with a #10 blade scalpel. Dissection of the anterior abdominal fascia performed with electrocautery. The fascia was opened with electrocautery. The abdomen was entered sharply around the umbilicus. There were no adhesions from a previous cesarean section. The fascial incision was extended with electrocautery. There was purulent material in the upper quadrants as well as the lower quadrants. The abdomen was explored. There was a hole in the anterior wall of the duodenum. This was oversewn with 3-0 silk sutures. The abdomen was then copiously washed out with sterile saline, and the effluent was carefully removed. Omentum was then oversewn over the defect with interrupted 3-0 silk sutures. The proximal stomach was then aligned with a pursestring suture of 3-0 chromic. A gastrotomy was made, and a gastrojejunostomy tube was passed through this opening with the tip in the proximal jejunum. The balloon of the gastric portion was inflated, the pursestring suture was closed, and the stomach was sutured to the anterior abdominal wall at the entry site of the gastrojejunostomy tube with 3-0 silk sutures. This was placed to gravity. The abdomen was then further explored, and there was no further bleeding, or fluid to remove. The fascia was then closed with a running 0-PDS suture, one begun superiorly, one inferiorly and tied in the middle. The skin was irrigated. Bleeding was controlled with electrocautery. The skin was reapproximated with skin staples. The tube was then secured to the skin with 2-0 nylon suture. The the patient was then transferred to the ICU, intubated, given her poor pulmonary status preoperatively. Specimens to pathology were anterior abdominal free-floating fatty mass. Sponge, sharp and instrument counts correct x2 prior to closure. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2819**] was present for the entire procedure per HCFA regulations. Swallow Study: BEDSIDE SWALLOWING EVALUATION: HISTORY: Thank you for consulting on this 60 y/o female with CAD (s/p MI x2 and stent '[**93**] and '[**01**]) and COPD on home O2 who woke up with severe abdominal pain causing SOB and left shoulder pain resolved who was found with perforated duodenal ulcer and peritonitis. She went to the OR on [**2203-7-28**] for prmimary repair with G-J tube placement. She was admitted to the SICU intubated, extubated [**7-29**]. She was transferred to the floor and advanced to clear liquids which she appeared to be tolerating well, but went into respiratory distress and a code was called on [**8-3**]. Pt was reintubated and transferred back to the unit. CXR showed "new bilateral effusions present. There are increased interstitial markings in the left lung and at the right base with sparing of the right upper lung field, suggesting asymmetrical CHF." Repeat on [**8-6**] showed "Slight interval increase in atelectasis and overlying effusion at the left lung base." while pt was NPO. The pt was extubated [**8-6**] and has been tolerating extubation well. She has been taking ice chips without difficulty, but we were asked to perform a bedside swallow evaluation prior to advancing the pt to a diet. The pt today reported she can have difficulty swallowing when she tries to take several sips in a row, likely due to her COPD/SOB. She reports she is sensate to aspiration, and sometimes has to take breaks during meals [**12-30**] SOB, but denies any history of PNA. She denied any difficulty swallowing while on the floor. EVALUATION: The examination was performed while the patient was seated upright in the bed. Cognition, language, speech, voice: Pt was A&O x3 with fluent language. Speech and voice were wfl and was able to follow all basic commands. Teeth: few bottom teeth remaining in fair condition, upper dentures in place Secretions: baseline cough productive for secretions- pt is on shovel mask humidified O2. ORAL MOTOR EXAM: Symmetrical facial appearance with adequate lip seal and buccal tone. Tongue was at midline with good strength and ROM. Palatal elevation was symmetrical, no gag. SWALLOWING ASSESSMENT: Pt was seen with ice chips, thin liquids (tsp, straw, consecutive), purees and bites of cracker at the bedside. Oral transit was timely and without oral residue. The pt did not have any overt coughing, throat clearing or changes in vocal quality and she denied the sensation of aspiration or food stuck in her throat. O2 SATS remained stable at 92-93% throughout the exam. Laryngeal elevation was timely and wfl to palpation, however pt reported consecutive sips were "harder." SUMMARY / IMPRESSION: The pt did not present with any overt signs of aspiration today at the bedside and would recommend advancing her to a PO diet of thin liquids and soft consistency solids. CXRs following her respiratory arrest do not appear to indicate aspiration from oral and pharyngeal dysphagia, but cannot rule out aspiration from reflux / tube feedings from this evaluation. It is recommended that the pt have repeat CXRs as her diet is advanced to monitor for changes. If there are any further concerns for oral and pharyngeal dysphagia / aspiration, we would be happy to take the pt for a video swallow. RECOMMENDATIONS: 1. Suggest advancing the pt to a PO diet of thin liquids and soft consistency solids. 2. Single sips of thin liquid only. 3. Attempt giving pills with thin liquids. If there are any signs of aspiration, please give with purees. 4. If there are any further concerns for oral and pharyngeal dysphagia / aspiration, we would be happy to take the pt for a video swallow. Brief Hospital Course: [**Known firstname **] [**Known lastname 17327**] was examined in the emergency department at [**Hospital1 18**] on [**2203-7-28**]. Her chest xray showed free air under the diaphragm. She was admitted to the surgery service under the care of Dr. [**First Name (STitle) 2819**]. A central line was placed, IV fluids and antibiotics were initiated, and she was taken to the operating room for an exploratory laparotomy. In the operating room she was found to have a perforated duodenal ulcer. Her ulcer was repaired and [**Location (un) **]-patched; a gastrojejunostomy tube was placed. She tolerated the procedure well. Because of her compromised pulmonary status prior to surgery she remained intubated post-procedure and was taken to the ICU for further care. Postoperatively, her vent settings were weaned to extubate, and she was extubated on POD 1 without event. Tube feedings were started per jejunostomy tube. Hydrocortisone was provided for adrenal support as she was on high-dose steroids prior to admission for COPD exacerbation. On admission a small are of stage 2 skin breakdown was noted at her coccyx and upper back: duoderm was placed. On POD 2 her NGT was removed and she was transferred to the floor. At POD 4 she was doing well. However, her WBC count was still elevated at 17.6 and we continued to await bowel function. Pulmonary toilet and ambulation were encouraged. Physical therapy was consulted. Low dose prednisone was started at 10mg. On POD 5 she passed flatus and was started on clear liquids. Primary care medicine saw her and wrote a brief note in agreement with current low dose steroid treatment and recommended increased bronchodilator treatment, which was followed. Her blood cultures came back negative from the ER. H. pylori antibody test was negative. On POD 6 she was reported to have a short episode of ventricular tachycardia while walking. During this episode she was without symptoms. Cardiac enzymes and EKG were evaluated and were negative for ischemic event. Later that day she was found with respiratory distress; respiratory rate in the 40s and oxygen saturation in the low 80s on NRB mask. Lasix was given without adequate response and she was intubated and transferred to the ICU. A post intubation chest xray showed small bilateral effusions, pulmonary edema, and no evidence of pneumothorax. Repeat EKG and ECHO were performed. The ECHO showed no acute changes from previous ECHO of [**2202-5-17**]. Her EKG showed mild demand ischemia and cardiac enzymes were mildly elevated from 0.03 to 0.09. Cardiology evaluated her and felt that despite her elevated troponin, her benign ECHO results did not support a deterioration related to acute coronary syndrome. On POD 8 a right upper extremity ultrasound was performed to rule out DVT as her arm was swollen. This was negative for clot. On POD 9 her respiratory culture was positive for pseudomonas and her antibiotic therapy was changed to Zosyn. Her fluconazole was continued. She was extubated without event. At this point her tube feeds were started back, metoprolol was added for cardiac protection, and Lasix was provided as needed to prevent pulmonary edema. A swallow study was completed, and per recommendation she was advanced to thin liquids and soft solids. The primary team left a note that mentioned a chronic elevated WBC count that would not likely normalize. On POD 11 her MRSA screen was negative. On POD 12 she was afebrile and doing better. She was transferred to the floor with aspiration precautions. At POD 15 her bowel function had fully returned and her foley catheter was removed. A chest xray was performed to assess for interval change which showed bilateral moderate pleural effusions and bibasilar atelectasis, unchanged from the prior radiograph. On POD 16 a PICC line was placed in planning for IV antibiotics at discharge and her central line removed. She was screened for discharge to a rehabilitation center. At POD 17 she was ambulating with assist. She was maintaining good oxygenation at 1L NC. She was tolerating POs, but remained with limited intake. She reported that this was because she did not like the food. She was able to swallow her medications without problems. Tube feeds remained for main nutritional support. She had several episodes of loose stool and this was sent for c. difficile which was negative. At POD 18 her staples were removed. At HD 20 we continued to await a bed at the rehabilitation center. Fiber was added to her tube feeds to improve her loose stools. Medications on Admission: Plavix Prednisone 10' Fentanyl 75mcg patch Oxycodone prn Serevent Azmacort Atenolol Singulair Nortryptiline Feldene Albuterol Simvistatin Efexor Combivent Nebulizer Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Perforated Duodenal Ulcer Acute Respiratory Distress Discharge Condition: Good Discharge Instructions: * Increasing pain or persistent pain that is not relieved by pain medications * Inability to urinate * Fever (>101 F) * Chest pain * Increased shortness of breath * Persistent nausea or vomiting * Inability to pass gas or stool * Removal or misplacement of feeding tube * Redness or drainage at incision site * Other symptoms concerning to you Please take all your medications as ordered. You may shower and wash your incision with soap and water. Pat dry. Do not remove the steri-strips(thin paper strips that are on your incision). They will fall off on their own. No immersion, soaking in the tub, or swimming for 2 weeks. No lifting more than 20 lbs or abdominal stretching exercises for 4 weeks. Followup Instructions: Please follow up with Dr. [**First Name (STitle) 2819**] in 2 weeks. Please call for an appointment. The number is ([**Telephone/Fax (1) 6347**]. Please follow up with the following scheduled appointments: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2203-8-23**] 11:40 Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2203-10-13**] 10:10 Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2203-10-13**] 10:30

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icd9cm

[ [ [] ] ]

[ "38.93", "44.39", "96.71", "96.6", "38.91", "96.04", "54.25", "44.42", "99.21" ]

icd9pcs

[ [ [] ] ]

14948, 15018

10195, 14733

322, 428

15115, 15122

2235, 2235

15876, 16571

1961, 2009

15039, 15094

14759, 14925

15146, 15853

3034, 10172

2024, 2216

249, 284

456, 940

2252, 3017

962, 1688

1704, 1945

32,673

151,884

13053

Discharge summary

report

Admission Date: [**2141-4-7**] Discharge Date: [**2141-4-10**] Date of Birth: [**2072-7-17**] Sex: M Service: MEDICINE Allergies: Cocaine Attending:[**First Name3 (LF) 358**] Chief Complaint: melena Major Surgical or Invasive Procedure: endoscopy History of Present Illness: 68 yom with PAF, CAD, Ampullary Adenomas and GAVE w/ recurrent upper GIB, s/p recent EGD on [**2141-3-27**] w/ resection of ampullary lesions p/w 1 episode of melena and blood tinged stool in last 24 hours. Patient was travelling in DC when had episode of melena. Became concerned when the following morning - day of admission he had a second blood tinged stool. Patient felt light headed yesterday as well. No syncope. Then got on a flight home and presented to [**Hospital3 17031**] for evaluation. . In the ED, T97, HR 77, BP 107/55, RR 18, 100% RA. Blood tinged stool - guaiac positive. NG lavage negative. 2 large bore IV's placed. Given 1L NS. Hgb 8 on presentation from 11.6 previously. Transfused 2 units PRBC's and started on PPI gtt w/ bolus. Transferred to [**Hospital1 18**] for further management. Has been NPO since this AM. . Denies any BM's since this AM. No other bloody stools since procedure before yesterday. No associated belly pain, nausea, emesis, diarrhea, constipation, fever, chest pain, SOB or other complaints. Denies recent Aspirin use, and recent coumadin use. . ROS: Negative. Past Medical History: - asymptomatic ampullary adenoma - h/o duodenal ulcers, with UGIB on coumadin three prior occasions - Paroxysmal Atrial Fibrillation/Atrial Flutter s/p ablations - previously on warfarin and ASA but not on anticoagulation at this time, rate controlled in sinus. - CAD, no prior MI - Lung Ca - partial lobectomy, no recurrence. Social History: NC Family History: NC Physical Exam: AF, VSS General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: regular, no murmur Respiratory / Chest: (clear Extremities: no edema, Skin: no lesion Neurologic: normal gait, grossly intact Pertinent Results: Admission: [**2141-4-7**] 10:21PM BLOOD WBC-4.3 RBC-3.04* Hgb-9.4* Hct-27.7* MCV-91 MCH-30.9 MCHC-34.0 RDW-15.3 Plt Ct-131* [**2141-4-8**] 05:17AM BLOOD WBC-3.2* RBC-2.79* Hgb-8.8* Hct-27.0* MCV-97 MCH-31.4 MCHC-32.4 RDW-15.5 Plt Ct-110* [**2141-4-8**] 08:06AM BLOOD Hct-29.7* [**2141-4-8**] 02:58PM BLOOD Hct-32.7* [**2141-4-8**] 10:31PM BLOOD Hct-29.6* [**2141-4-9**] 05:29AM BLOOD Hct-29.9* [**2141-4-9**] 05:29AM BLOOD Glucose-156* UreaN-28* Creat-1.3* Na-138 K-4.6 Cl-110* HCO3-22 AnGap-11 [**2141-4-9**] 05:29AM BLOOD Calcium-8.7 Phos-2.6* Mg-2.1 [**2141-4-7**] 10:21PM BLOOD ALT-18 AST-16 LD(LDH)-111 AlkPhos-50 TotBili-1.0 ======================= [**2141-4-10**] 06:15AM BLOOD WBC-3.8* RBC-3.47* Hgb-10.6* Hct-30.6* MCV-88# MCH-30.7 MCHC-34.7 RDW-14.7 Plt Ct-153 [**2141-4-10**] 06:15AM BLOOD Glucose-125* UreaN-31* Creat-1.5* Na-141 K-4.0 Cl-110* HCO3-22 AnGap-13 [**2141-4-10**] 06:15AM BLOOD Mg-2.1 [**2141-4-7**] 10:21PM BLOOD ALT-18 AST-16 LD(LDH)-111 AlkPhos-50 TotBili-1.0 ======================= SPECIMEN SUBMITTED: DUODENUM LESION...1 JAR. Procedure date Tissue received Report Date Diagnosed by [**2141-3-27**] [**2141-3-27**] [**2141-4-4**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **],DR. [**Last Name (STitle) **]. [**Doctor Last Name 7001**]/mb???????????? DIAGNOSIS: Duodenal lesion (A-D): Fragments of adenoma, with focal high grade dysplasia. Brief Hospital Course: 68 y/o M w/ h/o GAVE, recent resection of adenomas a/w melena and BRBPR. . #GIB: EGD showed erythema and congestion in the antrum compatible with gastric antral vascular ectasia. Area of previous polypectomy site distal to the papilla without stigmata of bleeding. Area of previous polypectomy site proximal to papilla with flat red spot. Hematocrit remained stable throughout the remainder of stay. . #duodenal adenoma s/p polypectomy -- see "results" section for pathology. Patient was informed his tissue had dysplasia, and he would need close follow up with his primary gastroenterologist as well as Drs. [**Last Name (STitle) 39930**] and [**Name5 (PTitle) **] for repeat EGD and possible future resection of the site. #chronic kidney disease -- near baseline. . #PAF: In Sinus. Off ASA and warfarin. Added back atenolol once stable. . #CAD: not taking aspirin currently. held beta-blocker, pt resumed at discharge. . #HTN: resumed medications at discharge. . Medications on Admission: Aldactone 25 daily HCTZ 25 Atenolol 50mg [**Hospital1 **] Simvastatin 20 Latanoprost 0.05% Solution Discharge Medications: 1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 5. 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:*0* 6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 7. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: 1. upper GI bleeding 2. duodenal adenoma with focal high grade dysplasia, s/p resection Discharge Condition: stable, hct stable Discharge Instructions: You were hospitalized with GI bleeding. The bleeding was probably from your polypectomy site. Please return to the emergency department if you have bloody or dark, tarry stool, fever, chills, lightheadedness, chest pain. Stop smoking, as it contributes to many chronic illnesses and death. Do not take aspirin, NSAIDs (ibuprofen, aleve, naprosen) for at least 10 days, as they increase your risk of bleeding. Because of the abnormal cells seen in your polyp resected [**2141-3-27**], you should be seen by Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 39930**] to discuss further interventions. Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 16827**] Date/Time:[**2141-4-28**] 8:40 Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2141-9-22**] 11:00 Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2141-9-22**] 11:00 Please call Dr. [**First Name (STitle) **] [**Name (STitle) 39930**] to make a follow up appointment within the next two weeks.

[ "403.90", "593.9", "585.9", "427.31", "V10.11", "305.1", "427.32", "537.82", "578.1", "285.1", "305.00", "414.01" ]

icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

5284, 5290

3548, 4523

273, 285

5422, 5443

2121, 3525

6105, 6615

1811, 1815

4674, 5261

5311, 5401

4549, 4651

5467, 6082

1830, 2102

227, 235

313, 1424

1446, 1775

1791, 1795

68,475

195,900

53953

Discharge summary

report

Admission Date: [**2179-3-28**] Discharge Date: [**2179-4-14**] Date of Birth: [**2120-8-10**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4691**] Chief Complaint: abdominal pain necrotizing pancreatitis, septic shock Major Surgical or Invasive Procedure: Bedside decompressive laparotomy for abd compartment syndrome [**2179-3-30**] Abdominal washout [**2179-4-1**] Washout, partial wound closure, NJ placement [**2179-4-5**] Washout, pancreatic necrosectomy, [**2179-4-13**] History of Present Illness: Patient is a 58 yo male with PMH of severe dyslipidemia and alchohol abuse who presented to an OSH with acute, severe abdominal pain. Pt reported having usual [**5-2**] drinks of brandy that day plus some beer which was followed by severe unbearable quickly worsening abdominal pain and nonbloody emesis. Pt denies any history of pancreatitis in the past. He is prescribed fenofibrate, simvastatin, HCTZ, and tenormin among others but does not take his medications as prescribed because he knows he should avoid alcohol while taking those medications. . On arrival to the [**Hospital3 **] ED [**3-27**] v/s were: T97.6 BP 111/86 --> 101/78, HR 113, RR 16-22 satting 100% on unclear [**Name2 (NI) **] or oxygen. Labs showed: albumin 2.6, alk phos 204, AST/AST 540/86, bilirubin 2.0. Mg 1.1. Triglycerides in the 5,000 range. Some lab tests were unable to be performed due to highly lipemic serum. Chemistries showed Na 135, K 3.4, Cl 103, HCO3 13, BUN 22, creat 0.8. WBC was 7.8, Hct 12.6, platelet 112. CXR showed no evidence of perforation or free air in abdomen. CT scan showed severe diffuse pancreatitis with nonenhancing areas suggesting necrosis in the tail of the pancreas. He received 6 L IVF, developed respiratory failure and he was subsequently intubated. Right femoral central line ws placed. Pt started on meropenem and an insulin drip. Levophed and dopamine were also initiated. Vasopressin was also initiated prior to transfer. Reported to have had fever up to 104. His vent settings on transfer were FiO2 50%, PEEP 5, TV 500, RR 20 . He was transferred to [**Hospital1 18**] for further management of his acute pancreatitis. . On arrival to the ICU, patient was intubated and sedated. . Review of systems: (+) Per HPI, patient intubated and unable to obtain full ROS Past Medical History: Alcohol abuse Dyslipidemia with very elevated triglycerides Hypertension Social History: married, lives with his wife - [**Name (NI) 1139**]: quit 5 years ago - Alcohol: per OSH records continues with alcohol abuse, [**5-2**] drinks of hard alcohol per day with beer in addition. - Illicits: none Family History: unknown Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 100 BP: 97/73 P: 132 R: 19 O2: 100% on 500/Peep 5, Fi02 50% General: intubated, sedated HEENT: Sclera mildly icteric, dry MM, NG tube in place Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally over anterior chest CV: tachycardic, Regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: firm, distended, absent bowel sounds, no pain illicited on palpation, unable to palpate liver or sleen, bladder pressure 26 GU: foley in place Ext: cool, clammy, peripheral pulses not palpable Pertinent Results: ADMISSION LABS: . [**2179-3-28**] 09:50PM BLOOD WBC-7.0 RBC-3.29* Hgb-10.5* Hct-33.1* MCV-101* MCH-31.6 MCHC-31.6 RDW-14.0 Plt Ct-60* [**2179-3-28**] 09:50PM BLOOD Neuts-77* Bands-7* Lymphs-11* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 [**2179-3-28**] 09:50PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ [**2179-3-28**] 09:50PM BLOOD PT-12.6* PTT-85.9* INR(PT)-1.2* [**2179-3-28**] 09:50PM BLOOD Glucose-186* UreaN-29* Creat-2.2* Na-128* K-4.3 Cl-106 HCO3-17* AnGap-9 [**2179-3-28**] 09:50PM BLOOD ALT-37 AST-279* LD(LDH)-1163* CK(CPK)-624* AlkPhos-40 TotBili-2.2* [**2179-3-28**] 09:50PM BLOOD CK-MB-10 MB Indx-1.6 cTropnT-0.05* [**2179-3-28**] 09:50PM BLOOD Albumin-1.5* Calcium-3.7* Phos-2.1* Mg-1.7 Cholest-294* [**2179-3-28**] 09:50PM BLOOD Triglyc-2229* HDL-14 CHOL/HD-21.0 LDLmeas-<50 [**2179-3-28**] 10:40PM BLOOD Lactate-2.8* [**2179-3-28**] 11:00PM URINE Color-[**Location (un) **] Appear-Cloudy Sp [**Last Name (un) **]-1.032 [**2179-3-28**] 11:00PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-SM Urobiln-2* pH-5.0 Leuks-TR [**2179-3-28**] 11:00PM URINE Hours-RANDOM UreaN-142 Creat-163 Na-10 K-36 Cl-16 [**2179-3-28**] 11:00PM URINE Osmolal-304 . PERTINENT LABS: . [**2179-3-28**] 09:50PM BLOOD WBC-7.0 RBC-3.29* Hgb-10.5* Hct-33.1* MCV-101* MCH-31.6 MCHC-31.6 RDW-14.0 Plt Ct-60* [**2179-3-30**] 02:25AM BLOOD WBC-5.3 RBC-2.68* Hgb-9.0* Hct-26.5* MCV-99* MCH-33.6* MCHC-34.0 RDW-14.3 Plt Ct-42* [**2179-3-28**] 09:50PM BLOOD Neuts-77* Bands-7* Lymphs-11* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 [**2179-3-29**] 04:00AM BLOOD PT-11.9 PTT-56.4* INR(PT)-1.1 [**2179-3-28**] 09:50PM BLOOD Glucose-186* UreaN-29* Creat-2.2* Na-128* K-4.3 Cl-106 HCO3-17* AnGap-9 [**2179-3-29**] 05:55PM BLOOD Glucose-330* UreaN-31* Creat-2.9* Na-126* K-3.4 Cl-92* HCO3-26 AnGap-11 [**2179-3-28**] 09:50PM BLOOD ALT-37 AST-279* LD(LDH)-1163* CK(CPK)-624* AlkPhos-40 TotBili-2.2* [**2179-3-29**] 05:55PM BLOOD ALT-33 AST-218* LD(LDH)-920* AlkPhos-45 TotBili-3.1* DirBili-2.8* IndBili-0.3 [**2179-3-28**] 09:50PM BLOOD CK-MB-10 MB Indx-1.6 cTropnT-0.05* [**2179-3-29**] 04:00AM BLOOD CK-MB-14* MB Indx-1.7 cTropnT-0.04* [**2179-3-28**] 09:50PM BLOOD Albumin-1.5* Calcium-3.7* Phos-2.1* Mg-1.7 Cholest-294* [**2179-3-29**] 05:55PM BLOOD Calcium-5.8* Phos-2.6* Mg-2.0 [**2179-3-28**] 09:50PM BLOOD Triglyc-2229* HDL-14 CHOL/HD-21.0 LDLmeas-<50 [**2179-3-29**] 04:00AM BLOOD Triglyc-1829* [**2179-3-29**] 11:02AM BLOOD Triglyc-1653* [**2179-3-29**] 02:43PM BLOOD Triglyc-1313* [**2179-3-28**] 10:40PM BLOOD Lactate-2.8* [**2179-3-29**] 01:24AM BLOOD Lactate-2.4* [**2179-3-29**] 02:51PM BLOOD Lactate-3.5* [**2179-3-29**] 03:19PM BLOOD Lactate-3.4* [**2179-3-29**] 06:11PM BLOOD Lactate-3.7* [**2179-3-30**] 12:27AM BLOOD Lactate-2.3* [**2179-3-30**] 02:51AM BLOOD Lactate-3.2* [**2179-3-28**] 10:40PM BLOOD freeCa-0.73* [**2179-3-30**] 12:27AM BLOOD freeCa-0.82* . DISCHARGE LABS: . . MICRO/PATH: . BLOOD: [**2179-4-3**] BLOOD CULTURE: Pending [**2179-4-3**] BLOOD CULTURE: Pending [**2179-3-30**] BLOOD CULTURE: Pending [**2179-3-30**] BLOOD CULTURE: Pending [**2179-3-29**] BLOOD CULTURE: No growth. [**2179-3-28**] BLOOD CULTURE: No growth. . URINE: [**2179-4-3**] URINE URINE CULTURE: No growth [**2179-3-29**] URINE URINE CULTURE: No growth [**2179-3-28**] URINE URINE CULTURE: No growth . SPUTUM: [**2179-4-3**] SPUTUM RESPIRATORY CULTURE: Pending [**2179-3-29**] SPUTUM RESPIRATORY CULTURE: No growth . PERITONEAL SWAB: Cx [**2179-4-1**]: No growth . MRSA SCREEN: [**2179-3-28**]: Negative [**2179-4-1**]: Negative . IMAGING/STUDIES: . CHEST (PORTABLE AP):[**2179-3-29**] IMPRESSION: 1. Increased retrocardiac density is likely from left lower lung atelectasis; however, in appropriate clinical setting, concurrent lung infection cannot be ruled out. Aspiration is also possible differential. 2. Minimal right lower medial lung atelectasis. . RUQ U/S: [**2179-3-29**] IMPRESSION: Heterogenous increased echotexture in the liver as can be seen with hepatic steatosis. Advanced conditions of the liver such as fibrosis/cirrhosis are not excluded. Wall thickening of the gallbladder with some fluid around it is likely secondary to the patient's known pancreatitis, given absence of gallbladder distention and gallstones. Small amount of perihepatic fluid. No intra- or extra-hepatic biliary dilatation. . CHEST PORT. LINE PLACEMENT Study Date of [**2179-3-29**] 4:23 PM IMPRESSION: Patient has received a new left internal jugular line which ends at mid SVC. Endotracheal tube ends approximately 4 cm from the carina and is appropriate. Right central line through the right internal jugular approach ends into the right atrium. Orogastric tube is seen terminating into the stomach. Since prior radiograph acquired 12 hours apart, there is no significant interval changes in the lungs. Left lower lung atelectasis reflected by increased retrocardiac density and a small right basal atelectasis and presumed small left pleural effusions are unchanged. Heart size, mediastinal and hilar contours are normal. . TTE [**2179-4-2**]: Conclusions 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. There is no aortic valve stenosis. No aortic regurgitation is seen. Physiologic mitral regurgitation is seen (within normal limits). There is no pericardial effusion. IMPRESSION: Grossly preserved biventricular systolic function. . RUQ U/S [**2179-4-3**]: IMPRESSION: 1. Severely limited study due to overlying bandages demonstrates an echogenic liver consistent with hepatic steatosis. However, more advanced liver disease such as significant hepatic fibrosis/cirrhosis cannot be excluded on the basis of this study. Although the common bile duct is not well visualized, there is no evidence of gross intra- or extra-hepatic ductal dilatation. 2. Pericholecystic fluid and gallbladder wall thickening, probably associated with third spacing, hepatic dysfunction, or regional inflammation, somewhat increased. 3. Small pleural effusions. . CT TORSO with IV Conrast [**2179-4-3**]: IMPRESSION: 1. Large bilateral pleural effusions and collapse of the lower lobes, new compared to [**2179-3-27**]. Debris in the left mainstem bronchus may be from secretions or aspiration. 2. Necrotic pancreatitis with extensive peripancreatic retroperitoneal fat stranding and retroperitoneal fluid tracking into the pelvis involving the anterior and posterior pararenal spaces and surrounding the duodenum and attenuating the splenic vein, celiac axis, splenic artery and hepatic arteries, without evidence of thrombosis or occlusion. Inflammation involves the colon and duodenum. 3. Severely fatty liver. Gynecomastia. 4. Moderate coronary calcifications. . Brief Hospital Course: 58 year old male history of alcohol abuse and hypertriglyceridemia presents with pancreatitis, septic shock and respiratory failure. In brief, he was admitted to [**Hospital1 18**] for 18 days and remained critically ill the entire time. On HD 4, he had a bedside laparotomy for abdominal compartment syndrome. His abdomen was left open for the remainder of his stay, and his necrotic pancreas was debrided HD 16. On HD 18, following an extensive family meeting discussing his prognosis and care plan, he was made CMO and expired soon after. . DIAGNOSES: . # Acute Necrotic Alcoholic/Multifactorial Pancreatitis C/B Septic/Distributive Shock: Patient presented to OSH with severe abdominal pain, hypotension refractory to IVF (9L NS), tachycardia, fevers to 104, and bandemia. He had a CT performed with evidence of necrotic tail of pancreas. Prior to transport he was intubated and started on 3 pressors (dobutamine, levophed, vasopressin). On arrival dobutamine was weaned off and he remained on levophed and vasopressin. Source appeared to be necrotizing pancreatitis per imaging and a possible pneumonia considering his sputum gram stain was positive for gram negative rods even after the administration of antibotics at the OSH. He was initially placed on Vancomycin and Zosyn and then weaned down to just Zosyn. Etiology of his pancreatitis likely multifactoral from hypertriglyceridemia >5000 and history of severe and ongoing alcohol abuse. His apache II score is 18 and his Ransom score is 4, suggesting severe pancreatitis as is also suggested by his septic shock, acute renal failure, respiratory failure, and significant lactatemia. His hypocalcemia is also likely [**1-28**] severe pancreatitis. He was continued on supportive therapy including pressor, respiratory, and CRRT support (see below) and ultimately transferred from the MICU to the SICU for further management. While in the SICU, we continued CVVH and he had a continued pressor requirement, never weaning off less than two pressors. His pancreas was debrided in the operating [**2179-4-13**]. . # Respiratory Failure: Patient had received >9 L IVF in total and developed respiratory distress at the OSH. He was intubated there and was transfered to us intubated as well. He is at high risk for ARDS given his necrotizing pancreatitis. He was continued on ARDS net protocol. Following decompression laparotomy for abdominal compartment syndrome (see below) we continued sedation with fentanyl and midazolam gtts. . # Abdominal Compartment Syndrome: On arrival, the pt's bladder pressures were elevated to 26-28 with low UOP and a rising lactate. During the following days his abdominal distention increased and UOP decreased further to less than 5cc/hr. His peak inspiratory pressures and plateau pressures began to rise as well. Surgery was consulted to evaluate the pt and determined that an emergent decompression lapartomy needed to be performed. This procedure was undertaken and immediately the pt's bladder pressure and respiratory pressures fell. His lactate also trended down as well. He remained with open abdomen until [**2179-4-5**] when his abdomen was partially closed. He tolerated the partial closure well, but when taken back to the operating room on [**2179-4-13**] his fascia was found to not be holding the stitches and his abdomen was very tight, so he was left with again an open abdomen. . # Acute Renal Failure: Patient's creatinine was 0.8 on arrival to [**Hospital3 **] and continued to increase intially during this hospital stay. This is likely in the setting of septic shock, poor perfusion, contrast dye all leading to ATN. He became progressively anasartic without a significant increase in UOP. Nephrology was consulted the decision was made to initiate CVVH for volume removal/management of acidosis. He was continued on CVVH throughout his stay. . # Acidosis: Patient with acidemia on ABG, improved from 7.16 at OSH to 7.21 on arrival. No longer with anion gap. Acidosis likely partially respiratory given pCO2>40 as well as non-gap acidosis from fluid resuscitation. We initially volume resuscitated with D5W and then switched to LR. After decompression laparatomy his lactic acid trended down and his pH normalized with manipulation of his vent settings. . # Hypertriglyceridemia: Found with initial triglycerides >5000. Likely has underlying genetic predisposition to hypertriglyceridemia which has been exacerbated in the setting of severe, prolonged alcohol abuse. At home does not take fibrate/statin/tenormin as he knows he will not be able to drink concurrently with these medications. Triglycerides ~2200 on arrival. He was placed on insulin gtt and IV fluids and his triglycerides continued to trend down. Renal did not feel comfortable performing plasmapheresis while still requiring pressors. . # Transaminitis: Pt had elevated liver function tests on admission. Differential for liver injury included alcoholic hepatitis vs hypoperfusion injury. His transaminases slowly trended down but his bili slowly rose peaking to 15 on fractionation was shown to be a direct bilirubinemia. A RUQ u/s did not show evidence of acute cholecystitis. Concern for ascending cholangitis remained so patient had repeat RUQ U/S without any evidence of biliary dilatation. . # Hyperglycemia: Blood glucose reported to be in the 300s. Pt was started on an insulin gtt. He has no known hx of diabetes but hyperglycemia may be also contributing to hypertriglyceridemia. He was maintained on the insulin drip for 2 weeks then weaned off as his lipids and sugars normalized. . # Hypocalcemia: Likely [**1-28**] severe pancreatitis, we closely monitored ionized calcium levels and and repleted aggressively via CVVH. . # Hyponatremia: on arrival his Na was 128. This was most likely related to hypertriglyceridemia and dilution from volume resuscitation. It slowly trended up to 130. On [**2179-4-14**], following family discussions regarding the patient's persistent critical state and poor prognosis, the patient was made CMO. At approximately 19:00, the patient was terminally extubated, pressors discontinued, and IV morphine administered to ensure comfort. The patient had cardiovascular collapse and passed. The time of death was 19:36. Medications on Admission: Hydrochlorothiazide fenofibrate aspirin nitroglycerin simvastatin Atenolol ranitidine MVI Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Necrotizing alcoholic pancreatitis Sepsis Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A

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icd9cm

[ [ [] ] ]

[ "54.25", "38.97", "96.6", "54.11", "52.22", "38.95", "38.91", "45.13", "54.12", "54.62", "96.72", "39.95" ]

icd9pcs

[ [ [] ] ]

16644, 16653

10235, 16476

357, 579

16739, 16748

3325, 3325

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2329, 2392

264, 319

607, 2310

3341, 4564

4580, 6263

2414, 2489

2505, 2715

14,909

112,518

3024

Discharge summary

report

Admission Date: [**2134-5-17**] Discharge Date: [**2134-5-30**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Shortness of breath with known Aneurysm Major Surgical or Invasive Procedure: [**2134-5-17**] Coronary Artery Bypass Graft x 2 (LIMA to LAD, SVG to PDA), Asc. Aorta Replacement (26mm gelweave graft), Mitral Valve Replacement (31mm CE mosaic tissue valve) [**2134-5-21**] Flexible bronchoscopy [**2134-5-28**] PICC line placement History of Present Illness: 86 y/o male with known asc. aortic aneurysm x 3yrs. He has developed increased shortness of breath and fatigue. Aneurysm has slightly increased in size. Recent cardiac cath revealed coronary artery disease along with moderate mitral regurgitation. He is being admitted for elective surgery. Past Medical History: Coronary Artery Disease, Ascending Aortic Aneurysm, Mitral Regurgitation, Diabetes Mellitus, Hypertension, Benign Prostatic Hypertrophy, Obesity, Hiatal hernia, s/p pacemaker in [**2129**], s/p left knee surgery Social History: Denies tobacco use. Admits to rare ETOH use. Family History: Non-contributory Physical Exam: On admission: VS: 60 14 112/60 5'8" 210# Gen: WD/WN male in NAD Skin: W/D -lesions HEENT: NC/AT EOMI, PERRL, OP benign Neck: Supple, FROM, -JVD, -carotid bruits Chest: CTAB -w/r/r Heart: CTAB -w/r/r Abd: Soft, NT/ND, +BS Ext: Warm, well-perfused, -edema, -varicosities, 2+ pulses throughout Neuro: A&O x 3, MAE, non-focal Pertinent Results: Echo [**2134-5-17**]: PRE-BYPASS: The probe could not be advanced beyond the mid-esophagus. Even at that level, windows and views were very limited. Therefore it was not possible to assess ventricular fxn or the tricuspid valve. No atrial septal defect is seen by 2D or color Doppler. The aortic root is mildly dilated at the sinus level. The ascending aorta is markedly dilated The aortic arch is mildly dilated. The descending thoracic aorta is mildly dilated. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is mild mitral valve prolapse. There is severe mitral annular calcification. There is mild mitral stenosis (area 1.5-2.0cm2). The mitral regurgitation jet is eccentric. There is no pericardial effusion. POST-BYPASS: Limited views of the prosthetic mitral valve were seen. From what was visible, the valve seemed well-seated without perivalvular leak or MR. Could not assess LV or RV fxn. Aortic valve appeared unchanged. Dr. [**First Name (STitle) 6507**] assisted on exam. We recommended esophagoscopy and transthoracic echo on this patient. Echo [**5-24**]: 1. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is mildly depressed. 3. Right ventricular chamber size is normal. Right ventricular systolic function is borderline normal. 4. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. 5. A bioprosthetic mitral valve prosthesis is present. The motion of the mitral valve prosthetic leaflets appears normal. The transmitral gradient is normal for this prosthesis. A small perivalvular mitral prosthesis leak is seen in the anteromedial aspect of the valve. 6. There is no pericardial effusion. UE U/S [**5-26**]:Ultrasound evaluation of the left upper extremity deep venous system using grayscale, color, pulse wave Doppler reveals the left internal jugular, subclavian, axillary, brachial, basilic veins to be fully compressible with normal Doppler waveforms, augmentation, and respiratory variation in flow. The left cephalic vein is not compressible with hyperechogenic within the lumen consistent with thrombosis. CXR [**5-27**]: The right internal jugular catheter was withdrawn in meantime interval. The pacemaker leads terminate in right atrium and right ventricle, unchanged. The heart size is markedly enlarged but stable. There is worsening of the left lower lobe and right lower lobe atelectasis. Right pleural effusion is small to moderate. Left pleural effusion cannot be assessed due to the fact that the left costophrenic angle was not included in the field of view. There is slight worsening of the perihilar haziness and upper zone pulmonary vasculature redistribution suggesting mild pulmonary edema. The distended azygos vein contributes to the diagnosis suggesting for overload. [**2134-5-17**] 02:40PM BLOOD WBC-12.0*# RBC-3.26*# Hgb-10.4*# Hct-29.2*# MCV-90 MCH-31.8 MCHC-35.5* RDW-15.0 Plt Ct-69*# [**2134-5-21**] 03:01PM BLOOD WBC-8.6 RBC-3.17* Hgb-9.9* Hct-29.4* MCV-93 MCH-31.2 MCHC-33.7 RDW-15.5 Plt Ct-103* [**2134-5-28**] 06:35AM BLOOD WBC-8.1 RBC-3.97* Hgb-12.1* Hct-36.8* MCV-93 MCH-30.4 MCHC-32.8 RDW-15.1 Plt Ct-310 [**2134-5-17**] 02:40PM BLOOD PT-19.2* PTT-65.9* INR(PT)-1.8* [**2134-5-25**] 03:34AM BLOOD PT-14.3* PTT-30.6 INR(PT)-1.3* [**2134-5-17**] 04:33PM BLOOD UreaN-14 Creat-0.8 Cl-120* HCO3-22 [**2134-5-28**] 06:35AM BLOOD Glucose-147* UreaN-25* Creat-1.4* Na-137 K-4.1 Cl-99 HCO3-32 AnGap-10 [**2134-5-27**] 06:00AM BLOOD Calcium-8.5 Mg-2.5 [**2134-5-28**] 06:35AM BLOOD Mg-2.6 Brief Hospital Course: Mr. [**Known lastname 14410**] was a same day admit after undergoing all pre-operative work-up as an outpatient. On day of admission he was brought to the operating room where he underwent Coronary Artery Bypass Graft x 2, Asc. Aorta Replacement, and Mitral Valve Replacement. Please see operative report for details. Following surgery he was transferred to the CSRU for invasive monitoring in stable condition. Over the next two days he remained intubated secondary to hemodynamic instability requiring multiple Inotropes. on post-op day two he was weaned from sedation, awoke neurologically intact and extubated. He required aggressive pulmonary toilet via multiple inhalers and diuresis. He was gently diuresed towards his pre-op weight. On post-op day four he underwent a bronchoscopy for left lung atelectasis and a mucous plug was removed. Gram stain from bronchoscopy revealed gram negative rods and antibiotics were started. On post-op day five he was transfused one unit pRBC. Chest tubes and epicardial pacing wires were removed per protocol. Despite aggressive pulmonary toilet, diuresis for CHF and antibiotics for pneumonia, patient was having worsening shortness of breath on post-op day six and eventually had respiratory decompensation that required re-intubation. He was eventually weaned from sedation on post-op day eight and extubated without incident. On post-op day nine he underwent an upper ext. U/S which revealed a thrombosis of the left cephalic vein. He began ambulating well with PT and on post-op day ten he was transferred to the telemetry floor for further care. Over the next two days there were no further complications. On post-op day eleven he required a PICC line placement d/t poor venous access. He continued to work with physical therapy for strength and mobility. He appeared stable on post-op day twelve, but still required additional physical therapy. He was therefore discharged to rehab facility with the appropriate follow-up appointments and medications.Prior to d/c a UA was sent after UOP cloudy. Results were negative for UTI. Medications on Admission: Zocor 40mg qd, Felodipine 10mg qd, Terazosin 5mg qd, Atenolol 50mg qd, Aspirin 325mg qd, Proscar 5mg qd, Novolog 70/30 5qAM, 8qPM Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 weeks. 9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 2 weeks. 10. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 11. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). 12. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. 14. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension Sig: Five (5) units Subcutaneous qAM: Please also have Insulin Sliding Scale (see attached). 15. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension Sig: 8 (eight) units Subcutaneous qPM: Please also have Insulin Sliding Scale (see attached). Discharge Disposition: Extended Care Facility: [**Doctor Last Name **] Nursing & Rehabilitation Center - [**Location (un) **] Discharge Diagnosis: Coronary Artery Disease/Ascending Aortic Aneurysm/Mitral Regurgitation s/p Coronary Artery Bypass Graft x 2, Asc. Aorta Replacement, Mitral Valve Replacement Pneumonia Congestive Heart Failure Deep Vein Thrombosis PMH: Diabetes Mellitus, Hypertension, Benign Prostatic Hypertrophy, Obesity, Hiatal hernia, s/p pacemaker in [**2129**], s/p left knee surgery Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. 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. [**Last Name (NamePattern4) 2138**]p Instructions: Dr. [**Last Name (Prefixes) **] in 4 weeks Dr. [**Last Name (STitle) **] in [**2-6**] weeks Dr. [**Last Name (STitle) 2204**] in [**1-5**] weeks Completed by:[**2134-5-30**]

[ "486", "V58.67", "424.0", "428.0", "V45.01", "285.8", "553.3", "250.00", "600.00", "518.0", "997.2", "997.3", "441.2", "518.82", "414.01", "401.9", "278.00", "453.8" ]

icd9cm

[ [ [] ] ]

[ "35.23", "38.45", "33.24", "88.72", "96.56", "36.15", "36.11", "00.13", "99.04", "39.61", "96.71", "38.93", "96.04" ]

icd9pcs

[ [ [] ] ]

9322, 9427

5515, 7593

308, 560

9827, 9833

1568, 5492

1193, 1211

7773, 9299

9448, 9806

7619, 7750

9857, 10525

10576, 10751

1226, 1226

229, 270

588, 880

1240, 1549

902, 1115

1131, 1177

52,857

178,456

27968

Discharge summary

report

Admission Date: [**2145-11-9**] Discharge Date: [**2145-11-14**] Date of Birth: [**2067-10-31**] Sex: M Service: CARDIOTHORACIC Allergies: Zestril / Clindamycin Attending:[**First Name3 (LF) 1505**] Chief Complaint: Asymptomatic Coronary Artery Disease with abnormal stress test Major Surgical or Invasive Procedure: [**2145-11-9**] Two Vessel Coronary Artery Bypass Grafting utilizing left internal mammary artery to left anterior descending, with vein graft to right coronary artery History of Present Illness: This is a 77 year old gentleman with hypertension, hyperlipidemia and diabetes is followed with annual surveillance stress tests by his PCP due to his cardiac risk factors. He denies any cardiac symptoms of chest pain, or dyspnea but does report sporadic hot flashes/diaphoresis, unrelated to activity over the last 8 months. His most recent stress test was abnormal so he has been referred for outpatient cardiac catheterization which revealed severe three vessel coronary artery disease. He was therefore referred for surgical revascularization. Past Medical History: Hypertension Hypercholesterolemia Diabetes Type II Cataracts Chronic anemia Anxiety Osteoporosis s/p Hernia repair s/p Excision Basal cell Social History: Occupation: Owns a hotel in [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1139**]: quit [**2102**], currently smokes cigar 1x/week ETOH: 21 oz per week. [**Doctor Last Name **] and wine with dinner when out Recreational drug use: NO - remote marijuana Family History: Father died of an MI at age 68. Physical Exam: Pulse: 60 SR Resp: 20 O2 sat: 100%-@LNP B/P Right: 157/87 Height: 5 feet 10 inches Weight: 170 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] MMM, normal oropharynx Neck: Supple [x] Full ROM [x] no [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] JVD Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur: no Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] EdemaNone Varicosities: None [x] Neuro: A&Ox3, MAE, Grossly intact, nonfocal exam Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: 1+ Left: 1+ Radial Right: cath Left: 2+ Carotid Bruit: no Pertinent Results: [**2145-11-9**] Intraop TEE: PRE-BYPASS: The left atrium is normal in size. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. POST BYPASS: Normal biventricular systolic function. LVEF 55%. Intact thoracic aorta. Brief Hospital Course: Mr. [**Known lastname **] was admitted and underwent coronary artery bypass grafting by Dr. [**Last Name (STitle) **]. Operative findings were notable for poor coronary distal targets. The circumflex/obtuse marginals were not suitable for bypass grafting. For additional surgical details, please see operative note. Following the operation, he was brought to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. Due to poor coronary distal targets, he was maintained on Plavix. His ICU course was otherwise uneventful, and he transferred to the step down unit on postoperative day one. Chest tubes and pacing wires were removed without complication. Respiratory: He was sucessfully extubated on [**2145-11-9**]. Aggressive pulmonary toilet, nebs, incentive spirometer he titrated off oxygen with saturations of 95% on room air. Cardiac: Beta-blockers were titrated as tolerated. He remained in sinus rhythm 70-90's. Blood pressure 100-130's, stable. He was not started on ACE due to unknown allergy. He was started on Plavix for incomplete revascularization and PCI/stenting of LCX, with Dr. [**Last Name (STitle) **]. GI: H2 blockers and bowel regime. Nutrition: diabetic diet Renal: aggressive diuesis for volume overload. Good urine output. Renal function stable with normal limits basline Cre 1.0. Endocrine: insulin drip while in ICU with BS < 130. Once oral diet restarted he was transition to SC insulin and oral hyperglycemics with BS < 150. He was sent home with a perscription for a glucometer and diabetic teaching by VNA. Heme: he was transfused 1 Unit PRBC on [**2145-11-10**] for HCT 23 and 2 UPRBC for HCT 21 on [**2145-11-13**] with HCTincrease to 25. Pain: well controlled on PO pain medications Mobility; He was seen by physical therapy for strength and conditioning and cleared for discharge to home by Dr. [**Last Name (STitle) 914**] on POD# 5. Disposition:Home with VNA services Medications on Admission: ATENOLOL 100mg daily ATORVASTATIN 40 mg daily GLYBURIDE 5 mg daily ISOSORBIDE MONONITRATE 30 mg daily TRIAMTERENE-HYDROCHLOROTHIAZID 37.5 mg-25 mg daily ASPIRIN 81 mg daliy ERGOCALCIFEROL CENTRUM OMEGA-3 FATTY ACIDS Discharge Medications: 1. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for *poor targets*. Disp:*30 Tablet(s)* Refills:*0* 3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 10 days: for 10 days then follow-up with your doctor regarding dyazide. Disp:*10 Tablet(s)* Refills:*0* 7. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10 days: take with lasix. Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 8. Omega 3-6-9 Fatty Acids 400-400-200 mg Capsule Sig: One (1) Capsule PO once a day. 9. Centrum 0.4-162-18 mg Tablet Sig: One (1) Tablet PO once a day. 10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. ferrous sulfate 325 mg (65 mg Iron) Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. Disp:*30 Capsule, Sustained Release(s)* Refills:*2* 14. glucometer glucometer and test strips One month supply 11 refills 15. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Coronary artery disease, s/p CABG Diabetes Mellitus Type II Hypertension Dyslipidemia Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. 2+LE edema bilaterally Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** -Take lasix 40 mg daily for 10 days with potassium then call your PCP regarding restarting your Dyazide. Followup Instructions: You are scheduled for the following appointments Surgeon: [**Doctor First Name **] [**Doctor Last Name **] [**2145-12-2**] 2:45PM [**Telephone/Fax (1) 170**] Cardiologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2145-12-9**] 3PM Please call to schedule appointments with your Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**4-5**] weeks [**Telephone/Fax (1) 10813**] **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:[**2145-11-14**]

[ "276.69", "280.0", "272.4", "414.01", "600.00", "413.9", "401.9", "733.00", "V10.83", "458.29", "366.9", "250.00" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6841, 6916

2868, 4849

353, 523

7046, 7268

2369, 2845

8215, 8849

1568, 1601

5115, 6818

6937, 7025

4875, 5092

7292, 8192

1616, 2350

251, 315

551, 1102

1124, 1264

1280, 1552

2,467

105,852

19523

Discharge summary

report

Admission Date: [**2169-11-8**] Discharge Date: [**2169-11-9**] Date of Birth: [**2087-4-27**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7055**] Chief Complaint: Chest discomfort Major Surgical or Invasive Procedure: cardiac catheterization with BMS to circumflex artery History of Present Illness: Mr. [**Known lastname 26442**] is a 82M with history of CAD s/p CABG (LIMA to LAD, SVG to diagonal), HTN, HL presents transferred from [**Location (un) **] with an NSTEMI. He had a recent hospital stay at [**Hospital3 **] for hip pain that had a negative workup for fracture 1 week prior and discharged to rehab. The patient states that he has been having "indigestion" over the last week that was relieved with Alka-Seltzer. The patient reports that on the day of admission to the OSH he had epigastric/substernal, non-radiation pressure/burning sensation. He rated the pain [**2170-7-2**] and notice some diaphoresis, but no other associated symptoms of N/V/SOB/palpitations. Vitals at OSH were 98 163/64 73 95% on 55% venti mask. CXR showed left lower lobe infiltrate. The patient denied F/C and reported a chronic productive cough that was unchanged. WBC of 12.1 HCT of 35.3. BUN 67 CR: 2.2 CK 277, CK-MB 33.2 Trop 2.3. He was given plavix 300mg, aspirin 325mg, solumedrol 125mg IV, lopressor 50mg, norvasc 10mg. He was transferred on heparin drip and nitro drip. No antibiotics were given. The patient underwent cardiac cath that showed: native LMCA and 3 vessel CAD with known chronic total occlusion of the RCA with progression with another subtotal occlusion in the distal AV groove CX with successfull BMS. The patient had a patent LIMA-LAD with a 75% stenosis in the mid-distal LAD downstream of the anastomosis that was not intervened on. He had occluded SVG-diagonal. The patient had an end LV pressure of 44mmHg and given 40mg IV lasix. He received a total of 270ml of dye and was started on a bicarb gtt. The patient had worsening hypoxia during the case and required non-rebreather and ABG during the case was 7.34/30/71/17. The patient was transferred to the CCU for further management. On arrive he was 99% on a non-rebreather. He diuresed 700cc to the lasix. Denied chest pain or SOB. He stated he was tired and wanted to sleep. On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. he denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of c paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS:: - Hyperlipideima - Hypertension 2. CARDIAC HISTORY: -CABG ([**2164-1-18**]) LIMA to LAD, SVG to diagonal - Dx Cath([**2164-1-17**]): LMCA 60% stenosis, LAD 60% stenosis proximally and diffusely diseased distally, D1 90% stenosis proximally, LCX had 90% stenosis in proximal vessel, RCA occluded - filled collaterals -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: - Benign prostatic hypertrophy. - s/p prostatectomy - Bell's palsy. - Peripheral vascular disease. - Blindness in the right eye due to cataracts. - Meniere's disease. Social History: Patient came from [**Location (un) **] House Rehab Center -Tobacco history: Quit 15yrs prior (1.5ppd since 18yrs old) -ETOH: denied -Illicit drugs: denied Family History: Father MI at 78 No other family history of early MI, otherwise non-contributory. Physical Exam: VS: T=97.7...BP=150/56...HR=73...RR=20...O2 sat=95% NRB GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. right eye blind and with cataract. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. dry MM No xanthalesma. NECK: Supple with JVP of 10 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. diminished breathe sounds and crackles at the bases, other clear anteriorly. no wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/ trace edema. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ DP 1+ PT 1+ Pertinent Results: ADMISSION LABS [**2169-11-8**]: [**2169-11-8**] 07:48PM WBC-14.1* Hgb-11.6* Hct-34.8* Plt Ct-317 [**2169-11-8**] 07:48PM Neuts-91.6* Lymphs-6.6* Monos-1.6* Eos-0.1 Baso-0.1 [**2169-11-8**] 07:48PM PT-16.0* PTT-150* INR(PT)-1.4* [**2169-11-8**] 07:48PM Glucose-189* UreaN-70* Creat-2.1* Na-144 K-4.1 Cl-105 HCO3-26 AnGap-17 [**2169-11-8**] 07:48PM ALT-17 AST-44* LD(LDH)-224 AlkPhos-57 TotBili-0.2 [**2169-11-8**] 07:48PM Albumin-3.8 Calcium-9.4 Phos-4.9* Mg-2.6 [**2169-11-8**] 04:55PM Type-ART pO2-71* pCO2-30* pH-7.34* calTCO2-17* Base XS--8 Intubat-NOT INTUBA [**2169-11-8**] 04:55PM Hgb-12.4* calcHCT-37 O2 Sat-94 Urinalysis: [**2169-11-9**] 12:33AM Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.022 [**2169-11-9**] 12:33AM Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2169-11-9**] 12:33AM RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0 [**2169-11-9**] 12:33AM Hours-RANDOM UreaN-403 Creat-35 Na-73 CE TREND: [**2169-11-9**] 01:41AM CK-365 CK-MB-21 MBI-5.8 [**2169-11-9**] 07:56AM CK-340 CK-MB-14 MBI-4.1 TropT-0.62 MICRO: [**Last Name (un) **] Legionella - negative [**11-8**] BCx - pending STUDIES: [**11-8**] Cardiac cath: COMMENTS: 1. Selective coronary angiography in this co-dominant system demonstrated 3 vessel disease. The LMCA was a moderately calcified vessel with a distal 50% stenosis. The LAD was a heavily calcified vessel. There was an ostial 60% stenosis immediately before D1, after D1 there was a 70% proximal LAD stenosis. The mid LAD has difuse 70% stenosis and showed competitive flow. The 1st septal branch had a proximal 50% stenosis. The D1 had a proximal 70% stenosis before a bifurcation in the vessel and a 40% stenosis in the small branch of vessel immediately after the bifurcation. The Cx had diffuse disease throughout. There was 60% stenosis in the proximal LAD prior to the OM1. There was 50% stenosis between OM1 and OM2 and 60% stenosis between OM2 and OM3. There is a series of heavily calcified 90% stenosies in the distal AV groove Cx. The distal AV groove Cx supplies a long LPL1 branch and a small LPDA. The LPL has only TIMI2 flow. The RCA had a proximal 70% stenosis prior to the atrial branch as well as a mid total occlusion after the acute marginal. The distal RCA and distal acute marginal filled via right to right collaterals. 2. Arterial conduit angiography revealed the origin of the LIMA to have a 35% stenosis which improved to 20% after intra-atrerial nitroglycerine. The LIMA was patent therafter to the mid LAD. There wasa 75% stenosis in the mid-distal LAD downstream of the LIMA touchdown and diffuse 60% stenosis of the apical LAD. The LAD provided septal collaterals to the RPDA. The SVG to D1 was occluded at the origin. 3. The left subclavian artery had a proximal 30% stenosis with midl plaquing throughout. 4. Limited resting hemodynamics revelaed severely elevated left sided filling pressures with an LVEDP of 44 mmHg. The central aortic pressure was 165/56 mmHg. There was no transaortic valve gradient on pullback of the catheter from the LV to the aorta. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Severe left ventricular diastolic dysfunction. ECHO: The left atrium is moderately dilated. The right 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 valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. CXR: Retrocardiac density seen on 2view CXR, final read pending. DISCHARGE LABS [**2169-11-9**]: [**2169-11-9**] 01:41AM WBC-16.9* Hgb-11.4* Hct-34.5* Plt Ct-263 [**2169-11-9**] 01:41AM BUN-74 Cr-2.3 K-4.2 Brief Hospital Course: Mr. [**Known lastname 26442**] is a 82M with history of CAD s/p CABG (LIMA to LAD, SVG to diagonal), HTN, [**Hospital **] transferred from [**Location (un) **] with an NSTEMI s/p BMS to the LCx. #NSTEMI: Pt underwent cath s/p BMS to the distal AV groove Cx. Pt with 75% stenosis to the mid-distal LAD downstream to the LIMA-LAD anastomosis that was not intervened on. Pt with CK 277, CK-MB 33.2, Trop-I 2.30 at OSH. CK peaked at 365. The patient is currently on ASA, Plavix, Lipitor, Labetalol. He has been weaned off nitro gtt prior to transfer to [**Location (un) **]. He was started on Imdur 30mg. He has had no further chest discomfort. # PUMP: Pt with elevated end LV pressure (44mmHg) and pulm edema on CXR. Pt also hypoxic during procedure and received 40mg IV lasix to which he responded well. TTE was performed prior to transfer (see attached report). # RHYTHM: NSR. The patient had no events on telemetry overnight. #. Hypoxia: Pt with hypoxia requiring NRB initially. CXR at OSH showed ?LLL pna vs pulm edema. CXR here was inconclusive. Pt no fevers, chills, but with chronic productive cough. Leukocytosis of 14.1 on admission here, but received IV steroids at OSH. No bands. Likely pulm edema from CHF, but started on antibiotics (Vanc/Cefepime for HAP as patient was previously at rehab) overnight given hypoxia. 2 view CXR showed retrocardiac opacity, and antibiotics were initiated to complete an 8 day course. #. Leukocytosis: Pt with elevated WBC of 14.1 up to 16.9. At OSH WBC count was 8.8 on transfer. Pt did receive IV solumedrol prior to transfer and likely cause of leukocytosis as well as reactive secondary to NSTEMI. CXR was also consistent with LLL PNA. He was started on Vanc/Cefepime as above. # Acute on Chonic RF: Pt with Cr of 2.1 on admission, up to 2.3 on discharge with diuresis. Prior records from [**2163**] indicate Cr 1.2-1.5. Unclear baseline, but likely secondary to chronic HTN and poor forward flow from ishemia. # HTN: Pt with SBP 150's on admission. Pt also with elevated BP at the OSH. Pt is on Labetalol 300mg [**Hospital1 **], Norvasc 10mg daily, and started on Imdur 30mg daily. Medications on Admission: HOME MEDICATIONS: (Per OSH records) Labetolol 200mg qam/ 150mg qpm Norvasc 10mg daily Tylenol prn Dulcolax Caltrate 600 + VitD Immodium prn MOM Percocet q6prn [**Name2 (NI) 10687**] Fleet Enema Visine eye drops prn OSH Medications given: [**2169-11-8**] am plavix 300mg --12pm norvasc 10mg, 50mg lopressor, caltrate 600mg, colace 100mg, aspirin 325mg, solumedoral 125mg. --heparin at 1100units/hr up at 12pm ntg at 6.6 mg/kg/min. --NS at 75cc/hr Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Labetalol 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units units Injection TID (3 times a day). 8. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-25**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 13. [**Month/Day (2) 10687**] 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 14. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q48H (every 48 hours) for 6 days. 15. Cefepime 1 gram Recon Soln Sig: One (1) gram Intravenous once a day for 6 days. Discharge Disposition: Extended Care Discharge Diagnosis: Primary Diagnosis: NSTEMI s/p BMS to left circumflex healthcare associated pneumonia acute on chronic congestive heart failure Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Out of Bed with assistance to chair or wheelchair Discharge Instructions: Mr. [**Known lastname 26442**], You were admitted with chest discomfort due to a heart attack. You had a cardiac catheterization which showed a blockage in one of the arteries in your heart. A bare metal stent was placed in this blockage to allow blood flow and limit ongoing injury to your heart muscle. You need to take plavix, a blood thinner, for at least 1 month and if you suffer no bleeding complications you should ideally continue this medication for one year. We also started you on treatment for a suspected healthcare- associated pneumonia with the antibiotics, vancomycin and cefepime which were started on [**11-8**], and should be continued for total of 8 day course. You are being discharged to [**Hospital3 **] for continuation of your care. Followup Instructions: Please follow up with your primary cardiologist about further testing and/or intervention that may be necessary in the future Completed by:[**2169-11-9**]

[ "366.9", "585.9", "486", "786.09", "403.90", "410.71", "600.00", "369.60", "414.02", "584.9", "428.0", "428.31", "288.60", "V15.82", "272.4", "443.9", "386.00", "414.01" ]

icd9cm

[ [ [] ] ]

[ "88.56", "00.44", "00.66", "37.22", "00.40", "00.45", "36.06" ]

icd9pcs

[ [ [] ] ]

12827, 12842

8744, 10886

332, 388

13013, 13013

4687, 7780

13971, 14128

3642, 3725

11383, 12804

12863, 12863

10912, 10912

7797, 8721

13183, 13948

3740, 4668

2972, 3254

10930, 11360

276, 294

416, 2872

12882, 12992

13027, 13159

3285, 3453

2894, 2952

3469, 3626

75,557

110,035

41233

Discharge summary

report

Admission Date: [**2157-2-28**] Discharge Date: [**2157-3-10**] Date of Birth: [**2109-5-26**] Sex: M Service: MEDICINE Allergies: Iron / lisinopril Attending:[**First Name3 (LF) 30**] Chief Complaint: Peritonitis Major Surgical or Invasive Procedure: right femoral tunnelled 12 French 20-cm hemodialysis catheter placement Removal of peritoneal dialysis catheter History of Present Illness: History of Present Illness: 47 YOM with history of ESRD on PD, H/O endocarditis s/p St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 1291**] and MVR here at [**Hospital1 18**] in [**8-/2156**] transferred from OSH for peritonitis refractory to systemic antibiotics. . Patient was initially admitted to [**Location (un) 16843**] Hoispital with Upper GI bleed secondary to esophageal ulcer that required no intervention. His [**Location (un) **] was held and following observation and stability of his HCT his heparin gtt was restarted. Unclear when he was exactly diagnosed with peritonitis bc be have no formal documentation of infected fluid but likely around 1.24. He was started on systemic Per his transfer summary cultures grew out klebsiella that is sensitive to amikacin, ampicillin and sulbactam, cefoxiti, ciprofloxacin, uimipenam and bactrim but resistent to tobramycin, gentimycin, ceftriaxone, cefepime and cephazolin and ampicillin. His antibiotic course to date is unclear as there are references to vancomycin, gentamycin, tygacil and levofloxacin. Most recently he was on levofloxacin and tygacil and recently switched to ertapenam. . . On arrival to the MICU, he is drowsy but arousable with heparin gtt running and one PIV. Poor peripheral stick. ABG attempted for labs. Right femoral line placed under ultrasound guidance. . Past Medical History: ESRD on PD HTN h/o multiple line infections restless leg syndrome asthma h/o VRE h/o endocarditis s/p [**Location (un) 1291**] and MVR h/o MRSA Social History: Social hx: pt currently in jail, has been there since [**2152**]; was previously imprisoned [**2137**]-[**2138**]. He denies any history of etoh, ex smoker quit 20 y/a, [**1-31**] PPD x 10 years, cocaine use, marijuana use, denies history IVDU Family History: family hx: mother with HTN Physical Exam: On Admission to MICU: Vitals: 88 125/89 O2 SAt 100% on RA General: Drowsy but arousable. Mild distress. HEENT: Dry mucous membranes Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, mechanical S1 + S2 Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, TTP diffusely, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: Bilateral grafts with evidence of multiple vascular procedures. On Discharge: Vitals: 98.6 100-111/68-78 95 18 95% on RA General: NAD, AxOx3 HEENT: Dry mucous membranes Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, mechanical S1 + S2 Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, mildly TTP diffusely, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: Bilateral grafts with evidence of multiple vascular procedures. ACCESS: HD tunnel catheter placed on R femoral. double lumen L femoral catheter. Pertinent Results: On Admission: [**2157-2-28**] 10:35PM BLOOD WBC-8.0# RBC-3.28* Hgb-9.4* Hct-29.5* MCV-90 MCH-28.6 MCHC-31.7 RDW-17.5* Plt Ct-239 [**2157-2-28**] 10:35PM BLOOD Neuts-80* Bands-0 Lymphs-8* Monos-9 Eos-0 Baso-1 Atyps-0 Metas-1* Myelos-1* [**2157-2-28**] 10:35PM BLOOD PT-14.3* PTT-35.1 INR(PT)-1.3* [**2157-3-1**] 10:28AM BLOOD ESR-85* [**2157-2-28**] 10:35PM BLOOD Glucose-98 UreaN-130* Creat-14.4*# Na-132* K-4.9 Cl-89* HCO3-27 AnGap-21* [**2157-2-28**] 10:35PM BLOOD Calcium-8.7 Phos-13.5*# Mg-2.5 [**2157-2-28**] 10:35PM BLOOD CRP-249.7* [**2157-3-6**] CT Abdomen FINDINGS: LUNG BASES: There are bilateral pleural effusions left larger than right. Adjacent linear opacities are seen in the lung bases representing atelectasis. Patient is status post sternotomy and mitral valve repair. ABDOMEN AND PELVIS: Within segment V/VI of the liver there is a small focal hypoattenuation which is too small to characterize but probably represents a simple hepatic cyst. There are no other focal hepatic lesions. There is no intra- or extra-hepatic biliary ductal dilatation. Gallbladder is collapsed. The spleen, pancreas, adrenal glands appear within normal limits. The patient is status post bilateral renal resections. Evaluation of bowel demonstrates regions of diffuse thickening of the small bowel (2, 53) and colon (2,46) . There is enhancement of the peritoneal layers consistent with the provided history of peritonitis. There are regions of free intraperitoneal gas (2, 30). There is an additional region of extraluminal gas seen in the right upper quadrant of the abdomen (2, 34). The etiology is not entirely elucidated and could be related to residual gas which was also seen on the previous study. There is no evidence of extravasated oral contrast [**Doctor Last Name 360**] to suggest an enteric perforation. The peritoneal dialysis catheter has been removed. There is no mesenteric or retroperitoneal lymphadenopathy. Atherosclerotic vascular calcification of the abdominal aorta is noted. The abdominal aorta is normal in caliber. Since previous study the right femoral line has been replaced and a new tunneled dialysis catheter has been placed with its tip terminating in the right atrium. Note is also made of another left femoral IV line the tip of which terminates in the right atrium. Findings within the skeleton most consistent with renal osteodystrophy. There is generalized anasarca. IMPRESSION: 1. Continued pneumoperitoneum, which could relate to the prior presence and subsequent removal of the peritoneal dialysis catheter. No evidence of oral contrast extravasation to suggest an enteric perforation. Enhancing peritoneal layers consistent with provided history of peritonitis. 2. Thickening of [**Known lastname **] of the small bowel and colon suggestive of ileocolitis, possibly secondary. 3. Interval removal of peritoneal dialysis catheter and placement of right femoral vein access tunnelled catheter and left femoral access PICC line, the tips of which terminate in the right atrium. 4. Bilateral pleural effusions with adjacent atelectasis. Discharge Labs: [**2157-3-10**] 06:08AM BLOOD WBC-7.6 RBC-2.59* Hgb-7.9* Hct-24.5* MCV-95 MCH-30.3 MCHC-32.0 RDW-17.0* Plt Ct-226 [**2157-3-10**] 06:08AM BLOOD PT-29.4* PTT-98.3* INR(PT)-2.8* [**2157-3-10**] 06:08AM BLOOD Glucose-111* UreaN-19 Creat-5.8*# Na-138 K-3.9 Cl-99 HCO3-33* AnGap-10 [**2157-3-10**] 06:08AM BLOOD Calcium-8.7 Phos-4.0# Mg-2.0 [**2157-3-9**] 06:18AM BLOOD calTIBC-109 Ferritn-[**2163**]* TRF-84* [**2157-3-7**] 09:31AM BLOOD PTH-239* [**2157-3-1**] 10:28AM BLOOD CRP-258.2* Brief Hospital Course: Assessment and Plan: 47 YOM with ESRD on PD, [**Month/Day/Year 1291**] AND MCR [**3-3**] to endocarditis, difficult vascular access trasnmitted to [**Hospital1 18**] MICU for mangement of ESBL klebsiella peritonitis. . # ESBL Klebsiella and GNR peritonitis: Patient remained hemodynamically stable throughout his MICU course. Culture data from the OSH shows Klebsiella oxytoca resistant to ceftaz and ampicillin. Patient was started on IV meropenem and vancomycin in addition to intraperitoneal vancomycin and meropenem. Transplant surgery removed the PD catheter on HD#2 ([**2157-3-2**]) and patient was intubated for the procedure though quickly extubated on return. Fluid from the PD catheter grew enterobacter cloacae complex senstive to meropenem. Per ID, vancomycin was discontinued and meropenmen was continued IV. Patient felt subjectively improved after removal of PD catheter on [**2157-3-2**] and he was maintained on dilaudid for pain control. A right femoral tunneled HD catheter was placed on [**2157-3-2**]. The line clotted during the initial attempted run of HD on [**3-3**]. On [**3-4**] the line was replaced on [**3-4**]. On [**3-5**], the patient spike a fever to 101 and vancomycin was restarted. Blood cultures were obtained, and after 3 days of no growth and the patient remaining afebrile, vancomycin was discontinued. Meropenem was discontinued on the day of discharge and the patient was discharge on 5-more days of ertapenem 500mg IV daily to complete a 14 day course of abx since removed of the PD catheter. . # ESRD: Initially on PD due to poor 'end-stage' vascular access issues in the past. Temporary femoral HD line was placed by IR on hospital day #2 and PD catheter was removed that same day. Hemodialysis was attempted on HD#3 but the dialysis line did not work. After a tunnel HD line was placed on HD#4 and The patient then successfully underwent HD on HD#4 and HD#5 and was started on MWF HD. He will need to comtinue 3 times weekly HD. Iron and Epo were held given active infection. These will need to be restarted per renal after discharge. . # [**Month/Day (4) 1291**]/MVR: History of St. [**Male First Name (un) 1525**] valves. Kept on heparin gtt given multiple interventions during this hospitalization. The patient was restarted on [**Male First Name (un) **] on [**2157-3-4**] and became therapeutic to 2.8 (target 2.5-3.5) on [**2157-3-10**] and heparin was discontinued. The patient was discharged on warfarin 8mg PO daily and should continue to have INR monitoring and dosing adjustment. . #.conjunctivitis- The patient developed conjunctivitis on [**2157-3-9**] and was started on Erythromycin 0.5% Ophth Oint 0.5 in both eyes TID. He was discharge to complete 5 additional days of treatment. . # HTN: Normotensive throughout hospital course. Not on medications . # GERD: The patient was started on famotadine on admission. He complained of acid reflux on the daily prior to discharge while on famotadine and was switched to omeprazole. Transition Issues: - INR monitor with a target INR of 2.5-3.5 Medications on Admission: amiodarone 200mg amitryptiline phoslo 2 tabs tid renagel 3 tabs tid asa 325mg qday levodopa/carbidopa 25/250 benadryl colace 100mg daily senna metoprolol 50 [**Hospital1 **] simethicone nepro darbopoietin 60 mcg q week . Medications on transfer: heparin gtt dilaudid 1 mg IV q4h prn pain Insulin sliding scale duonebs tylenol 650 q4h prn pain/fever zofran 4mg IV q6hours prn Ertapenam 0.5g IV q24. Discharge Medications: 1. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. warfarin 2 mg Tablet Sig: Four (4) Tablet PO Once Daily at 4 PM: adjust for goal INR 2.5-3.5. 3. calcium acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. ertapenem 1 gram Recon Soln Sig: One (1) 500mg Intravenous once a day for 5 days. 6. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1) Ophthalmic TID (3 times a day). 7. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas. 10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 12. darbepoetin alfa in polysorbat 60 mcg/0.3 mL Syringe Sig: One (1) Injection once a week. 13. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Discharge Disposition: Extended Care Discharge Diagnosis: Peritonitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname **], You were transferred to [**Hospital1 69**] for an abdominal infection. You were treated with antibiotics and the peritoneal dialysis catheter was removed. A new hemodialysis dialysis catheter was placed in your groin. You will need to continue to undergo hemodialysis on Mondays, Wednesdays and Fridays. You will need to complete 5 more days of antibiotics. Medication Changes: START taking omeprazole 20mg by mouth daily START Ertapenam 500mg intravenously daily for 5 more days START Calcium Acetate [**2146**] mg by mouth with three times a day with meals. START taking Warfarin 8 mg by mouth daily, please have this medication adjusted by your doctor START taking sevelamer CARBONATE 2400 mg three times day with meals START Erythromycin 0.5% Ointment in both both eyes three times daily for 5 additional days START camphor-menthol 0.5-0.5% lotion START docusate sodium 100 mg by mouth twice daily as needed for constipation START simethicone 80 mg by mouth up to four time daily as needed for gas START acetaminophen 325 mg 1-2 tablets as need for pain/fever up to 4 times daily STOP any other medications Followup Instructions: Please keep the following appointments: Department: TRANSPLANT CENTER When: THURSDAY [**2157-3-24**] at 1:15 PM 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 Department: TRANSPLANT CENTER When: TUESDAY [**2157-4-12**] at 9:00 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: TRANSPLANT When: TUESDAY [**2157-4-12**] at 10:00 AM With: TRANSPLANT ID [**Telephone/Fax (1) 673**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

[ "996.73", "V45.73", "567.29", "453.77", "493.90", "V12.04", "585.6", "453.75", "V15.82", "041.3", "E878.1", "786.8", "786.2", "V43.3", "E879.8", "372.30", "285.21", "041.85", "V45.11", "530.81", "996.68", "459.2", "333.94", "403.91", "V58.61" ]

icd9cm

[ [ [] ] ]

[ "86.07", "38.95", "88.51", "54.95", "54.98", "97.82", "38.97", "39.95" ]

icd9pcs

[ [ [] ] ]

11653, 11668

6886, 9948

288, 401

11724, 11724

3274, 3274

13043, 14007

2243, 2272

10397, 11630

11689, 11703

9974, 10195

11875, 12266

6379, 6863

2287, 2740

2754, 3255

12286, 13020

237, 250

457, 1795

3289, 6362

11739, 11851

10220, 10374

1817, 1963

1979, 2227

17,164

180,594

4840

Discharge summary

report

Admission Date: [**2127-2-26**] Discharge Date: [**2127-3-3**] Date of Birth: [**2082-8-11**] Sex: F Service: PLASTIC S. HISTORY OF THE PRESENT ILLNESS: This is a 44-year-old female with a history of ductal carcinoma in situ to the right breast, status post lumpectomy and radiation therapy in the year, [**2124**] with recurrence diagnosed on open surgical biopsy of [**2127-1-17**], grade III ductal carcinoma in situ who presents for right mastectomy and immediate reconstruction with free TRAM flap. PAST MEDICAL HISTORY: The patient has a past medical history significant for breast cancer right breast, hypertension, gastroesophageal reflux disease, status post lap Nissen fundoplication. MEDICATIONS: The patient takes Norvasc. ALLERGIES: The patient has no known drug allergies. HOSPITAL COURSE: On [**2127-2-26**], the patient was taken to the operating room and underwent right mastectomy, right axillary sampling with immediate reconstruction via re-TRAM flap performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The patient tolerated the procedure without complications. The patient was transferred to the surgical Intensive Care Unit, where she underwent q 15 minute flap checks via implantable Doppler monitor, as well as exterior Doppler monitor. On [**2127-2-28**] the patient was out of bed to chair. The epidural was capped and removed by the acute pain service and she was changed over to Percocet PO with good pain relief. On [**2127-3-1**], she was transferred to the floor. Foley catheter was taken out. Percocet was changed to Vicodin with better effect, and the patient was ambulating t.i.d., tolerating a regular diet. On [**2127-3-2**], the patient was noted to have a small blister to the inferolateral aspect of the right breast on the native skin without any signs of infection and a small drainage of serous fluid. On [**2127-3-3**], the patient was discharged to home with a large bra for comfort. Prescriptions for Keflex, Motrin, Colace, and a small amount of Percocet was given. The patient was advised to followup with Dr. [**First Name (STitle) **] in the clinic on Friday. Of note, throughout the entire hospital course, the patient's free TRAM flap was noted to have good capillary refill, warm to touch, and excellent implantable and exterior Doppler signals. On discharge, her flap has excellent warmth to touch, good capillary refill, and excellent Doppler signals. On [**2127-3-3**], prior to discharge, the [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drains were discontinued. Implantable Doppler catheter was cut and left in place with significant length to be pulled in followup clinic on Friday. DISCHARGE MEDICATIONS: 1. Norvasc. 2. Colace. 3. Keflex. 4. Motrin. 5. Percocet. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8332**], M.D. [**MD Number(1) 8333**] Dictated By:[**Last Name (NamePattern1) 14783**] MEDQUIST36 D: [**2127-3-3**] 08:44 T: [**2127-3-3**] 09:42 JOB#: [**Job Number **]

[ "233.0", "401.9", "780.6", "530.81" ]

icd9cm

[ [ [] ] ]

[ "85.7", "85.43" ]

icd9pcs

[ [ [] ] ]

2793, 3130

834, 2770

550, 816

31,502

195,364

42

Discharge summary

report

Admission Date: [**2174-8-6**] Discharge Date: [**2174-8-12**] Date of Birth: [**2093-11-17**] Sex: F Service: MEDICINE Allergies: Atorvastatin Attending:[**First Name3 (LF) 458**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Dialysis History of Present Illness: Pt is a 80 yo woman with h/o CAD s/p cypher DES to LCX [**2174-5-13**], severe aortic stenosis with valvular area of 0.5 cm2 despite recent aortic valvuloplasty on [**2174-5-11**], frequent hospitalizations for CHF exacerbation (last d/c [**2174-8-5**]), and ESRD recently restarted on HD who returns w/SOB. She was admitted on [**2174-7-22**] for CHF exacerbation and discharged yesterday. She was initally treated with Lasix, went into worsening renal failure, and started on hemodialysis. Her course was also complicated by upper GI bleed, of which an EGD showed multiple AVMs. She required total of 5 units of PRBCs and by discharge, HCT was stable at 26. She received her last transfusion yesterday at HD. Pt was discharged to rehab. She ate well for dinner under 2 gm of sodium diet. She report feeling warm the evening prior to admission but was afebrile. She still felt warm and diaphoretic this morning. Again, she was afebrile per her husband. She did have increased productive cough with mostly clear, occasionally blood-tinged phlegm. She then became acutely short of breath while lying down. She denied any CP, palpitations, nausea, vomiting. She asked to return to the hospital. . In the ED, her initial VS were: T98, BP 150/80, HR 130, RR 42, O2 sat 92% on ?RA. BiPap was started and her BP fell to 72/38, and Bipap was switched to NRB. She was started on neo gtt and BP came up to 130s/60s. BiPap was restarted with O2 sat of 100%. A CVL was placed int he R groin. She also received ceftazidime and vanc. She was transferred on NRB off neo. . On review of symptoms, her husband denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery. She continues to complain of leg pain for which she was taking neurotin and vicodin. . Cardiac review of systems is notable for absence of chest pain, palpitations, syncope, or presyncope. She does have dyspnea on exertion, orthopnea at baseline. She has never had ankle edema in the past. Past Medical History: - CAD--one vessel disease on cath in [**5-/2174**], s/p stent to LCx Severe AS s/p valvuloplasty [**4-/2174**] ([**Location (un) 109**] from 0.56->0.74; Grad from 24->12) - Chronic systolic CHF, EF 30-40% - HTN - strep viridans bacteremia - CRI with Cr 1.3-2.5 over last month, was on hemodialysis for one month in [**2174-4-14**] - Scoliosis with chronic back pain on vicodin - h/o MRSA from LLE trauma in [**2173-7-14**] - h/o cholelithiasis - osteoarthritis - herpes zoster - Gastritis - h/o H. pylori - Anemia--baseline Hct 26-30 - h/o right inguinal herniorrhaphy in [**2156**] - Myositis s/p muscle biopsy at [**Hospital1 112**], possibly related to statin use - s/p right nephrectomy [**2165**] for renal cell carcinoma Social History: Social history is significant for the absence of current tobacco use; she smoked [**12-15**] PPD from age 18 to age 60. There is no history of alcohol abuse; she occasionally has wine. Uses a walker; no recent falls. Family History: Father died of a heart valve problem at age 52 and 4 of her siblings had heart problems (though not valvular disease). Physical Exam: VS: T 97.2, BP 112/77, HR 71, RR 24, O2100% on NRB Gen: Elderly woman in NAD lying on left side. HEENT: Sclera anicteric. Pupils equal and sluggish in reaction to light. EOMI. Mucous membranes moist. Neck: Supple, unable to assess JVP due to positioning. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Grade III/VI systolic murmur best at LUSB. Chest: + scoliosis. Resp were unlabored, no accessory muscle use. Bibasilar crackles. No wheezes. Abd: Obese, normoactive bowel sounds, soft, nondistended, mildly diffusely tender, no HSM or tenderness. No abdominial bruits. Ext: No edema. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP Pertinent Results: [**2174-8-6**] 10:24AM cTropnT-0.09* [**2174-8-6**] 10:24AM CK(CPK)-31 [**2174-8-6**] 10:24AM GLUCOSE-249* UREA N-33* CREAT-3.4* SODIUM-137 POTASSIUM-5.0 CHLORIDE-97 TOTAL CO2-24 ANION GAP-21* [**2174-8-6**] 10:30AM PT-14.6* PTT-23.4 INR(PT)-1.3* [**2174-8-6**] 10:33AM LACTATE-2.6* K+-4.6 [**2174-8-6**] 10:45AM URINE BLOOD-LG NITRITE-NEG PROTEIN-300 GLUCOSE-NEG KETONE-TR BILIRUBIN-MOD UROBILNGN-0.2 PH-5.0 LEUK-LG [**2174-8-6**] 04:24PM PT-15.1* PTT-29.5 INR(PT)-1.3* [**2174-8-6**] 04:24PM WBC-11.7* RBC-4.11* HGB-12.3 HCT-35.1* MCV-85 MCH-29.9 MCHC-35.0 RDW-17.6* [**2174-8-6**] 04:24PM CK-MB-NotDone cTropnT-0.12* [**2174-8-6**] 04:24PM CK(CPK)-27 [**2174-8-6**] 06:08PM URINE RBC-61* WBC->1000* BACTERIA-MANY YEAST-MANY EPI-3 [**2174-8-6**] 06:08PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG [**2174-8-6**] 06:08PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.018 CXR ([**2174-8-9**]): As compared to the previous radiograph, the left-sided pleural effusion has slightly decreased in extent. At the right, there is no secure evidence of pleural effusion on today's examination. Unchanged is the cardiac silhouette. Vascular signs of overhydration are not present on today's examination. Brief Hospital Course: 80 yo woman with h/o CAD s/p cypher DES to LCX [**2174-5-13**], severe aortic stenosis with valvular area of 0.5 cm2 despite recent aortic valvuloplasty on [**2174-5-11**], frequent hospitalizations for CHF exacerbation (last d/c [**2174-8-5**]), upper GI bleed from AVMs, and ESRD recently restarted on HD who returned w/SOB, dialyzed, and discharged back to extended care facility. . # CHF Exacerbation: Patient initially presented with volume overload on CXR and acute shortness of breath, was placed on facemask, then later weaned to nasal cannula. The patient was emergently dialyzed, and subsequently her shortness of breath resolved. The patient was continued on low O2 nasal cannula, followed via serial CXR's, and was given her outpatient dose of carvedilol. . # Coronary artery disease: DES to LCx in [**2174-5-11**], other coronaries w/o obstructive disease. Patient had CP the night before admission and ECG showed J Point elevation. Patient was given O2 and cardiac enzymes were sent. Patient was chest pain free subsequently, EKG's were done which showed some minor elevations, but none concerning enough in lieu of her existing LBBB. Patient was continued on her beta blocker, CE's were followed and remained within the range of 0.11 which is her chronic level and not concerning given the lack of an acute rise, and her existing chronic kidney disease. Plavix and ASA were held given her recent upper GI bleed. . # Aortic Stenosis: Worsened after valvuloplasty in [**4-21**]. Last TTE [**7-27**] w/aortic valvular area of 0.5 cm2. No realistic percutaneous option as patient has 4 exclusion criteria for most feasible trial. . # Anxiety: Patient has had considerable anxiety on this admission and during her stay at [**Hospital 100**] Rehab. The patient was amenable to and was given a prescription for citalopram. . # ID: Pt presented with leukocytosis, though it later resolved along with the rest of her CBC values, suggesting an inaccurate measurement. Pt had been afebrile and most recent WBC has decreased to WNL. U/A was positive but contaminated and pt had long history of positive U/As with negative UCx, recently completed 5 day course of cipro. Pt recently ended course of Vancomycin for strep veridins bacteremia. Blood and Urine cultures were negative throughout admission, TTE negative for any endocarditis. . # Upper GI Bleed: Hct suspiciously high. No sig. bleeding. Continued protonix [**Hospital1 **]. . # Acute on chronic RF on Dialysis: Pt was given emergent dialysis the day of admission, was also given EPO that she was scheduled to receive. Her shortness of breath resolved with subsequent scheduled dialyses. . # Neovascular glaucoma: Patient developed severe eye pain on [**8-10**] while at dialysis. On physical exam, patient's right eye was injected, her pupil was dilated and non-reactive, and she experienced pain in right eye when shining pen light into left eye. Ophthalmology was consulted, and she was found to have neovascular glaucoma, an uncommon complication of retinal artery occlusion. Patient was started on Timolol, Alphagon, Prednisolone, and latanoprost eye drops in right eye, twice daily. She was then seen in the [**Hospital 464**] clinic where she underwent Pan-retinal phototherapy, vitrial tap and avastin injection, OD. Her eye drops were changed to a new medical regiment including iopidine, azopt, alphagan, prednisolone, atropine and erythromycin. The patient was scheduled for a follow-up appointment with Dr. [**Last Name (STitle) **] on Tuesday, [**8-16**]. Medications on Admission: Acetaminophen 325 mg Tablet PO Q6H as needed for pain. Carvedilol 25 PO BID Dextromethorphan-Guaifenesin 5 mL PO Q6H (every 6 hours) as needed for cough. Ipratropium Bromide/Albuterol neb Lorazepam 0.5 mg PO Q8H (every 8 hours) as needed. Zolpidem 5 mg PO HS (at bedtime) as needed. Docusate Sodium 100 mg PO BID (2 times a day) Bisacodyl 5 mg PO DAILY (Daily) as needed. Ferrous Sulfate 325 mg PO DAILY Lidocaine 5 %(700 mg/patch) Adhesive Patch [**12-15**] Adhesive Patch, Medicateds Topical QD as needed for pain. Hydrocodone-Acetaminophen 5-500 mg Tablet PO Q4H (every 4 hours) as needed for pain relief. Aluminum-Magnesium Hydroxide 15-30 MLs PO QID (4 times a day) as needed. Calcium Acetate 667 mg PO TID W/MEALS Polyvinyl Alcohol-Povidone 1.4-0.6 % 1-2 Drops Ophthalmic PRN (as needed). Epoetin Alfa Morphine Sulfate 1 mg IV Q2H:PRN Ondansetron 4 mg IV Q8H:PRN Pantoprazole 40 mg IV Q12H Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily): Please offer, patient may refuse. 2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day): Please offer, patient may refuse. 3. Docusate Sodium 50 mg/5 mL Liquid Sig: [**12-15**] PO BID (2 times a day). 4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours): Please offer, patient may refuse. 5. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours): Please offer, patient may refuse. 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 10. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-15**] Drops Ophthalmic every six (6) hours: Please offer, patient may refuse. 11. Zolpidem 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 12. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed: Please offer, patient may refuse. 13. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day): Please offer, patient may refuse. 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 15. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours): Please offer, patient may refuse. 16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection PRN (as needed) as needed for line flush. 17. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): Please give 10mg for 1st week (7 days), then increase to 20 as tolerated. 18. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 19. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: Acute on Chronic Congestive Heart Failure Severe Aortic Stenosis Acute on Chronic Renal Failure Secondary: [**Doctor First Name **]-[**Doctor Last Name **] Tear Osteoarthritis Central Retinal Artery Occlusion Macular Degeneration Discharge Condition: Stable, ambulating, eating and drinking without complaint. Discharge Instructions: You were admitted to the hospital because you became acutely short of breath. It was later believed that this episode was similar to other episodes of shortness of breath that you have experienced. Those experiences were due to your heart being unable to beat strongly enough through your narrowed valve and your body having an excess of fluid, which backed up into your lungs. As a result, you required dialysis, which removed much of the fluid in your lungs. In your previous admission, you were set up with Dr. [**Last Name (STitle) 120**] and Dr. [**Last Name (STitle) **]. Additionally, Dr. [**Last Name (STitle) 118**] will be able to make rounds at the [**Hospital 100**] Rehab facility to which you are going. If you continue to experience any acute shortness of breath, extreme chest pain, or severe light-headedness, please contact your primary care provider at once. In addition to the above, please weigh yourself every morning abd adhere to a 2 gm sodium diet. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2174-8-10**] 9:00 Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2174-8-11**] 3:20 Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2174-8-18**] 11:00 Completed by:[**2174-8-12**]

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icd9cm

[ [ [] ] ]

[ "39.95", "38.93", "93.90" ]

icd9pcs

[ [ [] ] ]

12325, 12391

5667, 9225

292, 303

12674, 12735

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233, 254

331, 2335

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3103, 3323

9,486

184,390

17848

Discharge summary

report

Admission Date: [**2159-12-31**] Discharge Date: [**2160-1-3**] Date of Birth: [**2090-6-11**] Sex: M Service: NEUROLOGY Allergies: Rocephin Attending:[**First Name3 (LF) 2518**] Chief Complaint: Hemorrhage Major Surgical or Invasive Procedure: None History of Present Illness: 69 year old with a history of CAD s/p CABG x and hypertension, who presented with acute onset of right facial droop at 16:27. Earlier in the day, he had complained of a headache. Wife called EMS and he was brought to [**Hospital3 **] where he was found to have a right facial droop in addition to right arm weakness. A head CT was performedand showed a left 4cm intraparenchymal bleed. Routine labs were unremarkable. He was loaded with Dilantin and transferred to [**Hospital1 18**] for further care. Since arrival, his blood pressure has been in the 150s. In review of systems (per wife), he has not had fever, nausea, vomiting, diarrhea, abdominal pain, unintentional weight loss. Past Medical History: CAD, MI x 2 s/p CABG x 2, hypertension, and diabetes Social History: Used to smoke. Drinks a whiskey or scotch a each night. Exercises daily. Wife has "memory" problems. [**Name (NI) **] lives with his wife at home Family History: Father died of a heart attack in his 50s. Mother died of leukemia in her 50s. Physical Exam: Vitals: T 96.7 HR 63 BP 152/82 RR 18 100% on RA Gen: WD/WN, comfortable, NAD. HEENT: NC/AT. Anicteric. MMM. Neck: Supple. No masses or LAD. No carotid bruits. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. No M/R/G. Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert. Follows some appendicular commands but not midline commands. Does not follow complex commands. Cannot point to the source of illumination. Will make some monosyllabic sounds but does not form any meaningful words. He is not distressed by this. Able to mimic. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2mm bilaterally in the light. Blinks to threat bilaterally. III, IV, VI: EOMI without nystagmus V, VII: Right lower facial droop. VIII: Turns head to the sound of voices. IX, X: Palatal elevation symmetrical. Gag symmetric. [**Doctor First Name 81**]: Strong shoulder shrug bilaterally XII: Tongue deviated to the left. Motor: Normal bulk bilaterally. Decreased tone in right upper extremity. Full strength in left upper, left lower, and right lower extremities. Right arm plegic. Sensation: Withdraws to pain in left upper, left lower, and right lower extremity. Reflexes: B T Br Pa Ac Right 2 2 2 2 1 Left 2 2 2 2 1 Right toe up, left toe down. Coordination and gait: unable to test Pertinent Results: [**2159-12-31**] 08:40PM BLOOD WBC-9.9 RBC-4.26*# Hgb-14.1# Hct-39.6*# MCV-93 MCH-33.2*# MCHC-35.7*# RDW-13.2 Plt Ct-227 [**2159-12-31**] 08:40PM BLOOD PT-12.2 PTT-28.5 INR(PT)-1.0 [**2159-12-31**] 08:40PM BLOOD Glucose-128* UreaN-18 Creat-1.1 Na-140 K-4.2 Cl-105 HCO3-25 AnGap-14 [**2160-1-1**] 03:30AM BLOOD ALT-37 AST-34 CK(CPK)-137 AlkPhos-52 TotBili-0.7 [**2159-12-31**] 08:40PM BLOOD cTropnT-<0.01 [**2160-1-1**] 03:30AM BLOOD CK-MB-4 cTropnT-<0.01 [**2160-1-1**] 03:30AM BLOOD Calcium-9.0 Phos-3.5# Mg-2.3 Cholest-133 [**2160-1-1**] 03:30AM BLOOD %HbA1c-6.1* [**2160-1-1**] 03:30AM BLOOD Triglyc-70 HDL-46 CHOL/HD-2.9 LDLcalc-73 [**2160-1-1**] 03:30AM BLOOD TSH-1.6 Head CT: left basal ganglia hemorrhage presumably related to hypertension. Slight interval increase in rim of surrounding vasogenic edema. Brief Hospital Course: Mr. [**Known lastname **] is a 69 year old gentleman with history of CAD s/p CABG, hypertension, who presented with acute onset of right facial droop, and later right arm plegia and aphasia (both anterior and posterior). He was found to have a left basal ganglia hemorrhage likely hypertensive in etiology. Neuro: He was admitted to the neuro ICU for closer monitoring. His basal ganglia hemorrhage was stable on admission. He was monitored on tele and had no events. He was ruled out for an MI with 2 sets of cardiac enzymes. His blood pressure was allowed to autoregulate with a goal of systolic 120-170, MAP < 130. His head of bed was maintained above 30 degress. His risk factors for stroke were checked and his A1c was 6.1. His LDL was 73. He was maintained normoglycemic and normothermic. He will need an MRI scan of the brain with and without gadolinium in [**1-20**] weeks, as an outpatient to rule out underlying mass or amyloid angiopathy. He should follow up with his primary care doctor for continued management of his hypertension, blood glucose control, and lipid checks. He should follow up with the stroke center at [**Hospital1 18**] in [**3-23**] weeks following his MRI scan. Endo: His DM was initially treated with SSI. Medications on Admission: Aspirin 81mg daily Metoprolol 25mg [**Hospital1 **] Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Insulin Regular Human 100 unit/mL Solution Sig: Per Sliding Scale Injection every six (6) hours. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO twice a day. 5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Fever or pain. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Left Basal Ganglia Hemorrhage Hypertension Diabetes Mellitus Type 2 Discharge Condition: right lower motor neuron facial droop. Slight right finger extensor weakness. Discharge Instructions: You were admitted for a hemorrhagic stroke likely related to high blood pressure. Please take all your medications as prescribed. You will need a follow up brain MRI in about 4 weeks. Call your doctor or 911 if you experience any new or worsening difficulty with speech, new weakness, numbness, tingling or any other concerning symptoms. Followup Instructions: Please see your Primary Care Doctor 1 week after discharge from rehab for monitoring of your blood pressure and blood sugars. You have a follow up appointment with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 162**] at the Stroke center at [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] building [**Location (un) **]. Please call to update your insurance information prior to the visit. Date/Time:[**2160-2-18**] 1:00 Phone:[**Telephone/Fax (1) 44**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2533**]

[ "250.00", "431", "401.9", "V45.81" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5483, 5580

3635, 4878

282, 289

5692, 5772

2797, 3471

6160, 6747

1268, 1349

4980, 5460

5601, 5671

4904, 4957

5796, 6137

1364, 1691

231, 244

317, 1010

2005, 2778

3480, 3612

1706, 1989

1032, 1087

1103, 1252

56,996

114,004

1727

Discharge summary

report

Admission Date: [**2114-2-28**] Discharge Date: [**2114-3-2**] Date of Birth: [**2046-11-11**] Sex: M Service: MEDICINE Allergies: Furosemide / Klor-Con / ZPACK / Atrovent Attending:[**First Name3 (LF) 983**] Chief Complaint: BRBRP hematuria Major Surgical or Invasive Procedure: none History of Present Illness: 67 YOM who presents with worsening B BRBPR and hematuria. He reports developing BRBPR 8-9 months ago after starting pradaxa for afib. It remained stable, but over the past 4-5 days there has been increasing blood and rectal pain along with hematuria and dysuria. He reports this was in the setting of cold symptoms. He denies melena, abdominal pain, nausea or vomiting. He had some mild shortness of breath and fatigue yesterday and today, but no CP. . In the ED, initial VS were ED 97.2 57 82/58 16 96%, and he triggered for hypotension. EKG showed sinus 60 na ni qtc 496. WBC was 20.6 and Hct was 37.7. INR was 1.3. Cr was 2.0 but improved to 1.5. Lactate 1.7. UA showed 108 wbc and many bacteria. He had a CT a/p which showed cystitis but no major bleed. He received cipro/flagyl. 2 PIVs were placed and received 2L NS. He did not receive blood. . He was seen by GI who felt that he may warrant a colonoscopy initially, but decided given his stable picture to defer for now. . On arrival to the MICU, he is comfortable and without any complaints. VS 98.3 97/58 66 16 94% RA Review of systems: (+) Per HPI (-) 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. Denies rashes or skin changes. . Past Medical History: Atrial fibrillation ED Gout HTN Hypothyroid OSA Asthma Venous stasis ulcers Social History: lives alone in [**Location (un) **]. recently separated. drinks 3 scotches/night. No hx of withdrawals. smokes 4 cigars/night. no illicits . Family History: NC Physical Exam: On admission: Vitals: 98.3 97/58 66 16 94% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, pale conjunctiva. 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: diffuse wheezes. No crackles Abdomen: obese soft, non-tender, non-distended, bowel sounds present, no organomegaly Rectal (in ED): Guiac + brown stool, external hemorroids, no obvious fissues GU: no foley Ext: warm, well perfused, 2+ pulses, 1+ edema. Multiple leg scars Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact Pertinent Results: [**2114-2-28**] 10:58AM BLOOD WBC-20.6*# RBC-3.81* Hgb-12.1*# Hct-37.7* MCV-99* MCH-31.9 MCHC-32.2# RDW-13.5 Plt Ct-139* [**2114-2-28**] 10:58AM BLOOD Neuts-73* Bands-5 Lymphs-14* Monos-7 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2114-2-28**] 10:58AM BLOOD PT-14.7* PTT-34.7 INR(PT)-1.4* [**2114-2-28**] 10:58AM BLOOD Glucose-128* UreaN-36* Creat-2.0* Na-139 K-5.8* Cl-103 HCO3-25 AnGap-17 [**2114-3-1**] 03:13AM BLOOD ALT-67* AST-39 LD(LDH)-275* AlkPhos-74 TotBili-0.5 [**2114-2-28**] 10:58AM BLOOD Calcium-7.9* Phos-5.2*# Mg-1.8 [**2114-2-28**] 12:34PM BLOOD Lactate-1.7 [**2114-2-28**] 01:56PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.016 [**2114-2-28**] 01:56PM URINE RBC-10* WBC-108* Bacteri-MANY Yeast-NONE Epi-0 [**2114-2-28**] 01:56PM URINE CastHy-27* CXR: FINDINGS: Frontal and lateral views of the chest are compared to previous exam from [**2113-3-14**]. Compared to prior, there is new central pulmonary vascular engorgement with mild cephalization of the pulmonary vasculature. There is no confluent consolidation or effusion. Cardiomediastinal silhouette is stable, as are the osseous and soft tissue structures. IMPRESSION: Findings suggestive of mild pulmonary vascular congestion without frank pulmonary edema. CT Abd/Pelvis: 1. Thickened bladder wall with surrounding stranding potentially secondary to cystitis and correlation with UA suggested. 2. There is no retroperitoneal hematoma. 3. Hypodense lesions in each kidney likely represent cysts, however, not fully characterized on nonenhanced CT scan. If desired US could help characterize. 4. Enlarged prostate. Brief Hospital Course: 67 yom with history of a.fib, on pradaxa, now presenting with worsening BRBPR and hematuria . # GI Bleed: Patient was monitored in the MICU overnight for GIB given pradaxa use. He remained normotensive throughout his MICU stay without drop in Hct. He was evaluated by GI who felt no urgent colonoscopy was needed, and symptoms were likely secondary hemorrhoidal and exacerbated by anticoagulation. He was transferred to the medical floor where he remained stable o/n. After discussion with Dr. [**Last Name (STitle) **] the patient's out- patient cardiologist, given the fact that he has been in sinus for the better part of a year and has not flipped into AFIB he was d/c'd on full dose ASA with GI f/u scheduled. . # UTI: Patient was started on ciprofloxacin for UTI as evidenced by UA and dysuria. He was subsequently switched to cefpodoxime given concern for prolonged QTc in combination with amiodarone. Micro showed a sensitive E. Coli. . # Afib: Patient remained in sinus rhythm. Anticoagulation was initially held, then switched to ASA as above. # [**Last Name (un) **]: Creatinine was 2.0 on admission, improving to 1.2 the following day and 1.0 on the day of discharge. Thought to be secondary to volume depletion. # Wheezing: Patine twas initially slightly wheezy on exam thoguht to be sedcondary to mild volume overload. The following day pulmonary exam had improved, patient was comfortable on room air. He refused scripts for inhalers at home, saying he only needs them when he is sick. . # Hypertension: Home medications initially held in the MICU, were restarted after patient demonstrated hemodynamic stability and transferred to the floor. Did well from this standpoint until discharge. Medications on Admission: albuterol prn alprazolam prn' amiodarone 200mg po daily atenolol 50mg po daily clobetasol 0.05% prn dabigatran 150mg po bid flovent 110 2 puffs [**Hospital1 **] levoxyl 100mcg daily lisinopril 40mg po daily percocet prn cialis triamterene/hctz 37.5/25 ca/Vit D fish oil MTV Discharge Medications: 1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. alprazolam 1 mg Tablet Sig: 1.5 Tablets PO QHS (once a day (at bedtime)) as needed for insomnia. 4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 5 days. Disp:*20 Tablet(s)* Refills:*0* 8. phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 days. Disp:*6 Tablet(s)* Refills:*0* 9. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 12. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. Cialis 5 mg Tablet Sig: One (1) Tablet PO prn as needed for intercourse. 14. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a day. 15. Flovent HFA 110 mcg/actuation Aerosol Sig: Two (2) puffs Inhalation twice a day. Discharge Disposition: Home Discharge Diagnosis: Lower GI bleeding c/b anticoagulation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 9861**], It has been a pleasure taking care of you in the hospital. You were admitted after you saw some blood with your bowel movements. You were observed overnight in the ICU and did quite well. We discussed your pradaxa with Dr. [**Last Name (STitle) **] who agreed that you should switch to full dose aspirin. . Please START Asiprin 325mg daily Please STOP Dabigatran(Pradaxa) Please START Cefpodoxime 200mg twice per day for 5 more days Please START Pyridium to treat you urinary symptoms Followup Instructions: Department: [**State **]When: FRIDAY [**2114-3-9**] at 9:30 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 . DR. [**Last Name (STitle) 9863**] IS WORKING ON GETTING YOU AN EARLIER APPOINTMENT AND WILL CALL YOU WITH IT . Department: DIV. OF GASTROENTEROLOGY When: TUESDAY [**2114-4-10**] at 3:30 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9864**], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage . Department: WEST PROCEDURAL CENTER When: TUESDAY [**2114-5-8**] at 12:30 PM With: WPC ROOM THREE [**Telephone/Fax (1) 5072**] Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Completed by:[**2114-3-4**]

[ "327.23", "041.49", "244.9", "584.9", "274.9", "E934.2", "455.8", "401.9", "599.0", "427.31", "599.71" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7766, 7772

4413, 6133

316, 322

7854, 7854

2785, 4390

8556, 9632

2031, 2036

6458, 7743

7793, 7833

6159, 6435

8005, 8533

2051, 2051

1465, 1752

261, 278

350, 1446

2065, 2766

7869, 7981

1774, 1852

1868, 2015

16,553

165,353

28127

Discharge summary

report

Admission Date: [**2195-2-10**] Discharge Date: [**2195-2-17**] Date of Birth: [**2137-12-3**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 4373**] Chief Complaint: Nausea/Vomiting Major Surgical or Invasive Procedure: Biliary drain replacement on [**2-16**]. History of Present Illness: Ms. [**Known firstname **] [**Known lastname **] is a 57 year old woman with history of pancreatic ca s/p Whipple procedure in [**8-/2191**], s/p cyberknife radiation [**12/2191**], c/b radiation enteritis and gastric outlet obstruction due to adhesions, s/p laparotomy [**12/2193**], s/p biliary drain and [**Year (4 digits) 68382**] placement [**11-5**] who presents with Emergency Department with 5 days of nausea and vomiting. In the ED, initial VS: T 98.7 HR 110 BP 156/80 RR 20 SpO2 96% RA. Patient was found to have glucose of 757, Na 125, HCO3 20, Cr 1.1, AG 20. ABG was obtained showing 7.38/34/100/21. She was given regular insulin 6 u IV followed by insulin gtt at 6u/hr, 2 L NS and 40 KCl. After these interventions her fsbs was 435 and she was transferred to the ICU. She remained hemodynamically stable. On arrival to the ICU, patient complains of nausea. On further questioning she reports recent increase in urination and thirst. She reports slightly increased blurred vision that she had attributed to old contacts. She denied any abdominal pain, fever, chills, change in biliary drain output, or bowel movements. She reports history of problems maintaining [**Name (NI) 68382**] function (due to dislodging and clogging) since its placement during her [**11-5**] hospital admission. She states that it was most recently replaced one month ago and this has been the longest she has gone without requiring intervention. She denies recent changes in tube feeds or medications. She denies any history of requiring insulin or oral hypoglycemics and does not monitor her glucose at home. ROS: Positive for vaginal irritation. Denies fever, chills, night sweats, headache, rash, sick contacts, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: # pancreatic ca s/p Whipple procedure [**9-2**], s/p cyberknife radiation [**1-4**] and adjuvant chemotherapy, c/b radiation enteritis and gastric outlet obstruction due to adhesions, s/p laparotomy [**12/2193**], s/p biliary drain in setting of biliary obstruction and [**Year (4 digits) 68382**] placement due to malnutrition [**11-5**] # pancreatic insufficiency # gallstone pancreatitis [**2189**] # depression # irritable bowel syndrome Social History: She has a 20-pack-year history of smoking and quit in [**Month (only) 359**] [**2193**]. She used to drink alcohol occasionally but none since her cancer diagnosis. She is accompanied today by her boyfriend, [**Name (NI) **]. She has no children. She works as a self-employed house cleaner but currently is not working. She lives in [**Location **] with her boyfriend although she does own an apartment in [**Location (un) 3493**]. Family History: Significant for mother with uterine cancer. Physical Exam: Vitals - T: 96.8 BP: 146/74 HR: 99 RR: 24 02 sat: 96% GENERAL: NAD, cachectic, axo x 3 HEENT: dry mm, EOMI, PERRL, clear op, [**Location (un) 68382**] in place and taped to face CARDIAC: tachycardic, RR, no MRG, no JVP LUNG: CTA B, nonlabored breathing ABDOMEN: mild lower abdominal distension, not tympanic, nontender, no fluid wave, bilary drains in place, dressing with minimal serosanginous drainage, bilary drains actively draining EXT: warm, dry, thin, 2+ distal pulses NEURO: no focal deficits DERM: No rashes, ulcers, skin warm and dry On discharge: Tc 97.5 Tm 99.4 BP 102/58 (SBP up to 110) HR 91-104 RR 16 98% RA BS: 215 / 100 / 77 / 115 / 275 / 208 Biliary drain: 50 left and 50 right so far today 270 right yesterday, 125 left yesterday 1.2 in, 1.2 out GEN: NAD, cachectic woman appearing older than her stated age, conversational. HEENT: Dry mucus membranes, clear oropharynx, [**Location (un) 68382**] in place / taped to face CARDIAC: RRR, no murmurs/r/g LUNG: CTAB ABDOMEN: rounded distention, firm but not tense, nontender but mild 'discomfort' to palpation diffusely, no r/g FLANK: right flank with two biliary drains (they contain brown/yellow thin trace liquid) that smell foul; ttp at drain site; small amount of pink granulation tissue extruding from the tube site, no pus EXT: thin, no edema Pertinent Results: [**2195-2-11**] WBC-10.3 RBC-3.38* Hgb-10.5* Hct-30.6* MCV-90 MCH-31.0 MCHC-34.3 RDW-15.5 Plt Ct-278 [**2195-2-10**] WBC-9.7 RBC-3.91* Hgb-11.7* Hct-36.0 MCV-92 MCH-30.0 MCHC-32.5 RDW-15.0 Plt Ct-309 [**2195-2-10**] PT-22.5* PTT-27.6 INR(PT)-2.1* [**2195-2-11**] Glucose-67* UreaN-27* Creat-0.6 Na-140 K-4.5 Cl-107 HCO3-23 AnGap-15 [**2195-2-10**] Glucose-757* UreaN-41* Creat-1.1 Na-125* K-4.8 Cl-85* HCO3-20* AnGap-25* [**2195-2-10**] Lipase-8 [**2195-2-11**] CK-MB-NotDone cTropnT-<0.01 [**2195-2-11**] Calcium-8.3* Phos-5.0*# Mg-2.2 [**2195-2-10**] Calcium-8.5 Phos-2.0*# Mg-2.2 [**2195-2-10**] Albumin-4.0 Calcium-10.2 Phos-4.3 Mg-2.5 [**2195-2-10**] Type-ART Temp-36.7 FiO2-21 pO2-100 pCO2-34* pH-7.38 calTCO2-21 Base XS--3 Intubat-INTUBATED [**2195-2-10**] Lactate-2.6* . CT ABDOMEN / PELVIS [**2195-2-11**]: 1. Post-Whipple procedure changes. Two PTC catheters in place. Stable mild left biliary duct dilatation. 2. NJ tube traverses the stomach towards the proximal loops of jejunum (biliopancreatic limb). There is no small or large bowel obstruction. 3. Mild amount of abdominal and pelvic free fluid is unchanged. 4. Interval increase in size and number of innumerable enlarged mesenteric lymph nodes. 5. Right middle lobe opacities, may represent acute infectious process--correlate clinically. . RUQ ultrasound [**2195-2-10**]: 1. No intrahepatic biliary ductal dilation. 2. Echogenic liver consistent with fatty infiltration. Other forms of liver disease and more advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on this study. . [**2-16**] Bile duct brushing: Distal common bile duct washing: ATYPICAL. Atypical glandular epithelial cells in a background of acute inflammatory cells. . [**2-16**] IR procedure:1. Cholangiograms through the existing biliary catheters as well as over the wire cholangiogram demonstrating mild dilatation of the left hepatic duct and free passage of contrast material into the small bowel through the hepaticojejunostomy. 2. Two sets of separate brushing samples were obtained for cytology, the first set from left hepatic duct and confluence of left and right hepatic ducts. The second set was from common bile duct. 3. Left external biliary catheter was placed with a modified 6 French pigtail catheter and connected to an external drainage bag. 4. A 6 French pigtail catheter was replaced on the right side, which was modified by cutting extra side holes to act as an internal-external drain. The pigtail was formed and locked inside the bowel loop. . Discharge labs: [**2195-2-17**] WBC-6.5 RBC-2.97* Hgb-9.3* Hct-28.4* MCV-96 MCH-31.3 MCHC-32.6 RDW-14.8 Plt Ct-185 [**2195-2-17**] PT-24.8* PTT-30.7 INR(PT)-2.4* [**2195-2-17**] Glucose-191* UreaN-14 Creat-0.7 Na-135 K-4.7 Cl-101 HCO3-27 AnGap-12 [**2195-2-17**] ALT-52* AST-36 LD(LDH)-141 AlkPhos-697* TotBili-2.8* [**2195-2-17**] Albumin-2.7* Calcium-8.6 Phos-3.4 Mg-2.2 Brief Hospital Course: 57 year old woman with history of pancreatic ca s/p Whipple procedure in [**8-/2191**], s/p cyberknife radiation [**12/2191**], c/b radiation enteritis and gastric outlet obstruction due to adhesions, s/p laparotomy [**12/2193**], s/p biliary drain and [**Year (4 digits) 68382**] placement [**11-5**] who presents to the Emergency Department with 5 days of nausea and vomiting. Found to have elevated glucose of 757 and be in diabetic ketoacidosis. DKA: Initial presentation of diabetes. DKA was easiliy controlled on an insulin drip and the patient was switched to lantus and SSI. [**Last Name (un) **] was consulted and made recommendations for her insulin regimen, her medication regimen was titrated to improve glucose control. Anion gap closed before transfer from ICU to the floor. Electrolytes aggressively repleted as needed. The etiology was likely related to endocrine dysfunction of the pancreas related to whipple and radiation (question of delayed pancreatic burnout). No trigger for DKA such as infection or ACS could be found. With [**Last Name (un) **] recommendations, glucose control improved. Patient given diabetic and insulin teaching, tubefeed formulation changed, provided with 'new patient' [**Last Name (un) **] appointment outpatient follow-up. Abdominal pain: likely related to DKA, improved with treatment of DKA. imaging attached in results section. Patient with some abdominal discomfort and nausea; and an episode of vomiting prompted holding and then restarting slowly of tubefeeds. After that, with blood sugar control and symptom management, patient was eating and tolerating tubefeeds on discharge, with pain resolved. Acute Renal Failure: improved to baseline with treatement of dehydration and DKA. Nutrition: The patient has an NJ tube, feedings were restarted after nausea resolved. Her NJ tube currently travels down the limb which is closest to the duodenum, rather than towards the ileum, at this point she does not seem to be suffering any adverse effects from this placement. Her symptoms were monitored during tube feeds and she was eating and tolerating tubefeeds well on discharge. Biliary tube replacement: Tubes replaced by IR without incident, patient tolerated procedure well. Hyponatremia: Resolved. Likely pseudohyponatremia secondary to elevated glucose as well as hypovolemic hyponatremia given dehydration. Elevated Alk Phos: Patient with baseline elevated alk phos in setting of biliary drain placement. Alk phos above baseline on presentation. Drains appear to be working well, replaced tubing by IR. Alk Phos downtrended. Some concern for new source of biliary obstruction or compression that may be contributing to nausea and vomiting and causing recent elevation in alk phos - but this was not verified by imaging or clinical course. Medications on Admission: Calcium daily Vitamin D 400 mg Clonazepam qam and qpm prn Compazine 10 mg po prn Creon 5 124 mg [**11-29**] caps po daily Prilosec 40 mg po daily Prozac 30 mg po daily Wellbutrin 150 mg po daily Trazodone prn insomnia Simethicone prn bloating Discharge Medications: 1. Lantus 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous once a day: Suggest to take this in the morning. If you find a fasting glucose to be less than 70, then decrease the lantus dose to 18 units daily. Disp:*3 bottles* Refills:*3* 2. Insulin Syringe 1 mL 30 x [**4-12**] Syringe Sig: One (1) Miscellaneous every 4-6 hours. Disp:*200 syringes* Refills:*2* 3. Insulin Needles (Disposable) 30 X [**4-12**] Needle Sig: One (1) Miscellaneous every 4-6 hours. Disp:*200 needles* Refills:*2* 4. Lancets Misc Sig: One (1) Miscellaneous every 4-6 hours. Disp:*200 lancets* Refills:*2* 5. One Touch Test Strip Sig: One (1) In [**Last Name (un) 5153**] every [**3-3**] hours. Disp:*200 strips* Refills:*2* 6. Insulin Lispro 100 unit/mL Solution Sig: 2 to 20 units, as described in sliding scale Subcutaneous four times a day: Please following insulin sliding scale. Disp:*3 vials* Refills:*3* 7. Please monitor fasting blood sugar before each meal and at bedtime. 8. Calcium Oral 9. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO once a day. 10. Clonazepam Oral 11. Compazine 10 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 12. Creon 5 124 mg (5,000- 18.7K-16K unit) Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 14. Fluoxetine 10 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 15. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 16. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 17. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for bloating. 18. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*28 Tablet(s)* Refills:*1* 19. Peptamen 1.5 Full Strength, 5 cans per day at 45 mL/hr with 100 mL H2O q6hours flush. 2 month supply. 20. Statlock at biliary drain, change every week. 21. 1 sharps container Discharge Disposition: Home With Service Facility: [**Hospital 5065**] Healthcare Discharge Diagnosis: Diabetic ketoacidosis Pancreatic cancer Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: You were admitted to the hospital with nausea and vomiting, and were found to have Diabetic Ketoacidosis (a very high blood sugar). Your blood sugar was controlled through medication, in the ICU and on the floor, with the assistance of the [**Last Name (un) **] Diabetes team. Your nausea and vomiting resolved with blood sugar control and medication. . You had your biliary drains assessed by the Interventional Radiology team, and they were exchanged on [**2-16**]. . Changes to your medications include: - a new insulin regimen (see attached) - morphine pills as needed for pain - a new tubefeed regimen Followup Instructions: Please attend the following appointment at [**Last Name (un) **] Diabetes Center: [**2-25**] at 3pm with Dr. [**First Name (STitle) **] and Dr. [**First Name (STitle) 3636**]. [**Location (un) **] of the [**Hospital **] Clinic. [**Telephone/Fax (1) 2384**]. . Please attend the following previously-scheduled appointment: Dr. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD (Oncology). Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2195-2-26**] at 3:30pm. . Please call Dr.[**Name (NI) 12202**] office to set-up a follow-up gastroenterology appointment: ([**Telephone/Fax (1) 2306**]. Completed by:[**2195-2-24**]

[ "V10.09", "787.01", "584.9", "564.1", "311", "263.9", "250.12", "799.4" ]

icd9cm

[ [ [] ] ]

[ "50.11", "51.12", "97.05", "87.54" ]

icd9pcs

[ [ [] ] ]

12784, 12845

7534, 10344

288, 331

12929, 12929

4580, 7137

13740, 14383

3178, 3224

10637, 12761

12866, 12908

10370, 10614

13109, 13717

7153, 7511

3239, 3789

3803, 4561

233, 250

359, 2245

12944, 13085

2267, 2710

2726, 3162

30,376

185,179

48930

Discharge summary

report

Admission Date: [**2169-7-24**] Discharge Date: [**2169-8-2**] Date of Birth: [**2095-9-28**] Sex: F Service: CARDIOTHORACIC Allergies: Bactrim / Tetracyclines / Vasotec / Isordil / Procardia Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**7-25**] Cardiac Cath [**7-26**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to Diag, SVG to OM, SVG to dRCA), Mitral Valve Repair with 26mm CE Ring History of Present Illness: 73 yo female with known severe CAD s/p RCA stent in [**2164**], HTN, hypothyroidism, presents with a chief complaint of chest pain. The pt reports that for the last week she has experienced several episodes of burning SSCP with radiation to the neck and right shoulder in the evenings while in bed before falling asleep. Prior to this she has not experienced any CP since [**2164**] when she had a stent placed. The pt would take [**12-14**] SL NTG and get relief. On the evening of admission, she again experienced pain however 3 SL NTG did not improve her sxs. No associated SOB, N/V or diaphoresis. She called 911 and was taken to the ED. There, her ECG was thought essentially unchaged from baseline. In the ED, she was started on NTG and heparin gtts and quickly became pain free. She is now admitted to cardiology for further care. Past Medical History: Coronary Artery Disease s/p stent placement in [**2164**], severe hypertension with history of hypertensive emergency, Dyslipidemia, Hypothyroidism, Peripheral Vascular Disease with Intermittent claudication, Obesity, Gout, Hiatal hernia, Fibroid uterus, Spine scoliosis and arthritis, Benign cartilage tumor (most probably an enchondroma), Severe spinal stenosis Social History: She does not smoke or drink alcohol. Quit tob >40 yrs ago. Retired real estate [**Doctor Last Name 360**]. Family History: Positive family history of early CAD in multiple relatives. Physical Exam: Vitals: T 97.4 P 60 R 18 149/70 97% on 2L Gen: Well appearing adult female, no acute distress. HEENT: PERRL, EOMI. MMM. Conjunctiva well pigmented. Neck: Supple, without adenopathy or JVD. No tenderness with palpation. Chest: CTAB anterior and posterior. Cor: Normal S1, S2. RRR. No murmurs appreciated. Abdomen: Soft, non-tender and non-distended. Mildly obese. +BS, no HSM. Extremity: Warm, without edema. Neuro: Alert and oriented. CN 2-12 intact. Motor strength intact in all extremities. Sensation intact grossly. PULSES: Right: Carotid 2+ Femoral 2+ DP 2+ Left: Carotid 2+ Femoral 2+ DP 2+ Pertinent Results: [**7-25**] Cath: 1. Selective coronary angiography of this right dominant system revealed diffuse three vessel coronary artery disease. The LMCA had a 50% stenosis at its origin, and a 70% stenosis distally. The mid LAD had a 70% stenosis, with diffuse disease distally. The Let circumflex had a 99%stenosis in the proximal and mid portions. The RCA had a 50% stenosis in the mid portion and a 80% stenosis distally. 2. Resting hemodynamic measurements revealed severe systemic arterial hypertension with a SBP ranging from 150-180 during nitroglycerine infusion. 3. There was a 50mm Hg gradient noted across a stenotic segment of the right iliac artery at the level of the aortic bifurcation. [**7-26**] Echo: Pre-CPB: This study was limited by poor gastric windows. No spontaneous echo contrast is seen in the left atrial appendage. The RV shows mild global free wall hypokinesis. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. In the face of MR, LV systolic fxn appears mildy depressed, with an EF of 45 -50%. There is hypokinesis of the inferior, infero-septal and posterior walls. There is no pericardial effusion. Post-CPB: The patient is A-Paced, on low-dose epi and ntg infusions. There is a well-seated and functioning prosthetic mitral annular ring. There is no MR [**First Name (Titles) **] [**Last Name (Titles) 3564**]. The residual peak gradient is 4, and area is 3.1. There is good RV systolic fxn. The LV systolic fxn is good, with residual inferior, inf-septal and posterior HK. Aorta intact. [**2169-8-1**] 05:07AM BLOOD WBC-9.9 RBC-2.82* Hgb-8.6* Hct-25.6* MCV-91 MCH-30.5 MCHC-33.6 RDW-14.1 Plt Ct-253 [**2169-7-28**] 02:17AM BLOOD PT-13.5* PTT-31.1 INR(PT)-1.2* [**2169-8-1**] 05:07AM BLOOD Glucose-106* UreaN-38* Creat-0.8 Na-140 K-3.4 Cl-102 HCO3-33* AnGap-8 [**Known lastname **],[**Known firstname **] [**Medical Record Number 102756**] F 73 [**2095-9-28**] Radiology Report CHEST (PA & LAT) Study Date of [**2169-8-1**] 9:45 AM [**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2169-8-1**] SCHED CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 102757**] Reason: ? effusion [**Hospital 93**] MEDICAL CONDITION: 73 year old woman with s/p cabg REASON FOR THIS EXAMINATION: ? effusion Provisional Findings Impression: LCpc TUE [**2169-8-1**] 12:59 PM PFI: Since [**2169-7-28**], right internal jugular now ends in mid SVC. Left lower lobe alveolar opacity and less marked right lower lobe opacity slightly increased. Bilateral pleural effusions mostly on the left are small and unchanged. Preliminary Report !! PFI !! PFI: Since [**2169-7-28**], right internal jugular now ends in mid SVC. Left lower lobe alveolar opacity and less marked right lower lobe opacity slightly increased. Bilateral pleural effusions mostly on the left are small and unchanged. DR. [**First Name8 (NamePattern2) 4078**] [**Name (STitle) 4079**] DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**] PFI entered: TUE [**2169-8-1**] 12:59 PM [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 102758**] (Complete) Done [**2169-7-26**] at 11:12:46 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] [**Street Address(2) 15115**] [**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2095-9-28**] Age (years): 73 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: cabg/?mvr ICD-9 Codes: 786.05, 786.51, 799.02, 440.0, 424.0 Test Information Date/Time: [**2169-7-26**] at 11:12 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: Suboptimal Tape #: 2008AW-1: Machine: aw3 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.4 cm <= 5.6 cm Aorta - Ascending: 2.8 cm <= 3.4 cm Aorta - Descending Thoracic: 2.4 cm <= 2.5 cm Findings LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. RIGHT VENTRICLE: Mild global RV free wall hypokinesis. AORTA: Normal ascending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Moderate to severe (3+) MR. TRICUSPID VALVE: Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Conclusions Pre-CPB: This study was limited by poor gastric windows. No spontaneous echo contrast is seen in the left atrial appendage. The RV shows mild global free wall hypokinesis. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. In the face of MR, LV systolic fxn appears mildy depressed, with an EF of 45 - 50%. There is hypokinesis of the inferior, infero-septal and posterior walls. There is no pericardial effusion. Post-CPB: The patient is A-Paced, on low-dose epi and ntg infusions. There is a well-seated and functioning prosthetic mitral annular ring. There is no MR [**First Name (Titles) **] [**Last Name (Titles) 3564**]. The residual peak gradient is 4, and area is 3.1. There is good RV systolic fxn. The LV systolic fxn is good, with residual inferior, inf-septal and posterior HK. Aorta intact. 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) **] [**2169-7-26**] 14:03 Brief Hospital Course: As mentioned in the HPI, Ms. [**Known lastname 1968**] was admitted from the ED with chest pain. She was brought for a cardiac cath on [**7-25**] which revealed left main and three vessel disease. She was appropriately worked up for surgery and on [**7-26**] she was brought to the operating room. Echo in OR showed moderate to severe mitral regurgitation. In addition to undergoing coronary artery bypass surgery, she also had a mitral valve repair. This procedure [**Last Name (un) 19692**] performed by Dr. [**Last Name (STitle) **]. Please see operative note for further details. Following surgery she was transferred to the CVICU for invasive monitoring in stable condition. Her chest tubes were removed and she was gently diuresed. The cardiology service saw her in consultation. By post-operative day 2 she was extubated. Her epicardial wires were removed on the following day and she was transferred to the step down floor. Her blood pressure medications were titrated up as tolerated. By post-operative day 5 she was discharged to rehab. Medications on Admission: Atorvastatin 40 mg daily, Plavix 75 mg daily, Triameterene-HCTZ 37.5-25 daily, ASA 325 mg daily, Atenolol 100 mg daily, Verapamil 300 mg daily, Amlodipine 5 mg daily, Benzapril 20 mg daily, Labetalol 400 mg [**Hospital1 **], Levothyroxine 200 mcg daily, Allopurinol 150 mg QHS, Triavil, Colace, Senna, MVI daily Discharge Medications: 1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. 2. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 7 days. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Perphenazine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 13. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 15. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 16. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 17. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [**3-19**] hours as needed. 18. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 Mitral Regurgitation s/p Mitral Valve Repair Myocardial Infarction PMH: s/p stent placement in [**2164**], severe hypertension with history of hypertensive emergency, Dyslipidemia, Hypothyroidism, Peripheral Vascular Disease with Intermittent claudication, Obesity, Gout, Hiatal hernia, Fibroid uterus, Spine scoliosis and arthritis, Benign cartilage tumor (most probably an enchondroma), Severe spinal stenosis Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**First Name (STitle) **] in 4 weeks Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] DR. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 1142**] Date/Time:[**2169-7-31**] 9:30 AM RADIOLOGY Phone:[**Telephone/Fax (1) 9045**] Date/Time:[**2169-8-24**] 10:30 AM ORTHO XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2169-10-26**] 8:00 AM [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2169-8-2**]

[ "V45.82", "553.3", "414.01", "272.4", "285.9", "788.5", "276.6", "440.21", "401.9", "E878.2", "424.0", "411.1", "274.9" ]

icd9cm

[ [ [] ] ]

[ "88.56", "36.15", "35.33", "39.61", "36.13", "37.22", "38.93" ]

icd9pcs

[ [ [] ] ]

12190, 12260

9298, 10351

331, 490

12776, 12782

2577, 4909

13293, 13818

1885, 1946

10713, 12167

4949, 4981

12281, 12755

10377, 10690

12806, 13270

1961, 2558

281, 293

5013, 9275

518, 1357

1379, 1745

1761, 1869

43,122

180,308

13573

Discharge summary

report

Admission Date: [**2101-5-12**] Discharge Date: [**2101-5-19**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1**] Chief Complaint: - abdominal pain Major Surgical or Invasive Procedure: - closure/[**Location (un) **] patch for perforated duodenal ulcer History of Present Illness: On admission: The patient is a [**Age over 90 **]-year-old female who began having intermittant generalized abdominal pain about 4 days ago. She had some mild nausea and one episode of small volume emesis, but she attributes this to her vertigo. Today, her pain increased a great deal, and became quite sharp and constant and unbearable to the point that she was crying at home. She was brought to the ED by EMS for evaluation. Her last BM was earlier today and was normal. She denies fever and chills. She does have anorexia, but she says this has been going on for some months. Past Medical History: - hypertension - palpitations - depression - vertigo - COPD/asthma - hearing loss Social History: - rare social alcohol use, denies T/D - lives in [**Location **] in senior housing Family History: - non-contributory Physical Exam: Day of Discharge: Vitals - T:97.9 BP:125/62 HR:83 RR:20 O2sat:98% on 2L NC FS:113-134 Gen: NAD, A&O x 3 CV: irregular, normal rate Resp: CTAB, no respiratory distress Abd: soft, not distended, minimal TTP Incision: C/D/I, no erythema or induration JP site: dressing C/D/I L UE: improved erythema, but still with palpable cord Pertinent Results: [**2101-5-12**] CXR: IMPRESSION: Pneumoperitoneum with bowel perforation better assessed on CT abdomen/pelvis performed within the same hour. Large left diaphragmatic hernia. Right lung base bronchiectasis may be related to chronic aspiration. . [**2101-5-12**] CT ABD/PELVIS: IMPRESSIONS: 1. Findings suggest bowel perforation, likely from the region of the pylorus/first portion of the duodenum where there is circumferential wall thickening and apparent small rent through the anterior wall. This causes large pneumoperitoneum and mild-to-moderate ascites. 2. Large, stomach- and colon-containing left diaphragmatic hernia. 3. Peripheral ground- glass opacities in the right lower lobe concerning for aspiration. 4. Few scattered sigmoid colonic diverticulae, without definite diverticulitis, thus making this less likely cause for bowel perforation. . [**2101-5-12**] WBC-7.2 Hgb-11.4 Hct-33.8 Plt Ct-420 [**2101-5-12**] Neuts-88 Bands-2 Lymphs-2 Monos-5 Eos-2 Baso-1 Atyps-0 Metas-0 Myelos-0 [**2101-5-13**] WBC-15.5 Hgb-10.8 Hct-32.5 Plt Ct-458 [**2101-5-14**] WBC-10.6 Hgb-8.4 Hct-24.9 Plt Ct-374 [**2101-5-15**] WBC-9.2 Hgb-9.1 Hct-27.2 Plt Ct-378 [**2101-5-17**] WBC-8.5 Hgb-9.5 Hct-28.5 Plt Ct-349 . [**2101-5-18**] Glucose-86 UreaN-10 Creat-0.5 Na-133 K-4.2 Cl-98 HCO3-29 [**2101-5-18**] Calcium-7.5 Phos-3.3 Mg-1.9 . [**2101-5-12**] PT-15.2 PTT-28.4 INR(PT)-1.3 [**2101-5-15**] PT-15.3 PTT-30.9 INR(PT)-1.3 [**2101-5-16**] PT-16.0 PTT-30.2 INR(PT)-1.4 [**2101-5-17**] PT-17.2 PTT-30.9 INR(PT)-1.6 Brief Hospital Course: *)Duodenal Ulcer She was taken to the operating room, where a 4mm defect in the pyloroduodenal area was noted. The defect was repaired and reinforced with an omental patch; please see the operative report for full details. Her diet was slowly advanced and on discharge she was tolerating a regular diet, albeit with the same decreased appetite she had had for several months as reported on admission. . *)Tachycardia Her post-operative course was complicated by tachycardia, which was initially thought to be atrial fibrillation. Cardiology was consulted and felt that it may be multi-focal tachycardia. She had been on verapamil as an outpatient, but was started on diltiazem during her hospitalization for acute rate control. This was maintained, as verapamil was noted to be more constipating. On discharge her heartrate was well controlled on diltiazem. . *)Cellulitis On POD#5 erythema was noted at the site of a prior infiltrated IV on her left arm. The area was marked and appeared to grow in size; vancomycin was started with subsequent improvement of the erythema. She was discharged on a course of Bactrim to complete 7 days of antibiotics, per ID curbside recommendations. . *)Disposition Physical therapists worked with her during her hospital course and recommended further therapy after discharge. She was discharged to a rehabilitation facility to continue her post-operative recovery. Her home medications, with the exception of verapamil, were re-started shortly after surgery and were continued during her hospital course. Medications on Admission: - albuterol - estrogen ring - Advair - Atrovent - meclizine - Detrol [**Name Prefix (Prefixes) **] - [**Last Name (Prefixes) 40988**] - Tylenol prn Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO QID (4 times a day) as needed for low calcium, heartburn. 4. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 5. Codeine Sulfate 15 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. 7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Inhalation twice a day. 8. Bactrim DS 160-800 mg Tablet Sig: Two (2) Tablet PO twice a day for 4 days. Disp:16 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: Perforated duodenal ulcer Post-op low urine output RUE cellulitis . Secondary: HTN, asthma/COPD, L leg cellulitis, occasional palpitations Discharge Condition: Stable. Tolerating regular diet. Pain well controlled with oral medications. Discharge Instructions: Rehab: 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: -Your staples can be removed at rehab on [**5-25**] and steri strips should be applied. -Steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after applicaiton -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. . Cellulitis (skin infection) of the left arm: - please take your antibiotics as directed - if the infection does not continue to improve, an additional antibiotic may be added (Keflex/cephalexin) - you will need a set of labs while you are taking Bactrim Followup Instructions: 1. Please call Dr.[**Name (NI) 10946**] office to make a follow up appointment in [**12-24**] weeks. . Scheduled Appointments : Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2101-9-26**] 9:20 Completed by:[**2101-5-19**]

[ "785.0", "311", "568.89", "532.50", "E878.2", "997.1", "682.3", "567.9", "401.9", "493.20", "427.31" ]

icd9cm

[ [ [] ] ]

[ "44.42" ]

icd9pcs

[ [ [] ] ]

5707, 5773

3093, 4635

275, 343

5966, 6045

1560, 3070

7920, 8229

1174, 1194

4833, 5684

5794, 5945

4661, 4810

6069, 7218

7233, 7897

1209, 1541

219, 237

371, 371

385, 953

975, 1058

1074, 1158

7,718

158,818

21691

Discharge summary

report

Admission Date: [**2138-2-11**] Discharge Date: [**2138-2-15**] Service: MEDICINE Allergies: Plavix / Shellfish / Artichoke / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 2880**] Chief Complaint: Elective Cardiac Cath Major Surgical or Invasive Procedure: Left and Right Heart Caths Stenting of origins of both common iliacs Stenting of Right External Iliac Artery History of Present Illness: 80 year old female with PVD, bilateral carotid dz s/p bilateral TIA's, left CEA X 3 ('[**12**] X 2, '[**27**]), right CEA X 1 ('[**27**]), s/p [**Country **] stenting [**12-28**], htn, dyslipidemia, left subclavian steal syndrome, who is being admitted for elective cardiac cath. The pt has left sided SSCP s radiation that occurs when she is hypertensive (occasionally BP's in the 220's/120's), but is not associated with exertion. She had a negative chemical stress test at [**Hospital 47**] hospital 7 months ago. Ms.[**Known lastname 39151**] notes "fluid" in her lungs, that her physicians are trying to determine an etiology of, thus, she is being cath'd. Currently, she is CP free and has no shortness of breath, visual changes, weakness or neurologic symptoms, other than occasional tingling, weakness and bluish discoloration of her left hand/fingers. Past Medical History: PVD s/p bilateral CEAs (L CEA '[**19**] w/ redo in '[**30**]; R CEA [**October 2128**] w/ redo in [**April 2129**]) COPD GERD mild CRI s/p hysterectomy s/p appendectomy w/ hypertensive crisis [**5-27**] C5-6 lami [**2132**] right L4-5 lami [**2132**] s/p AAA repair Social History: She is retired at age 63. Previous occpuations: drafting engineer and working on computers. Pt is divorced and lives alone. Pt is a former smoker x 35 years. No alcohol or illicit drug use. Family History: Mother deceased 84, hx of Alzheimer's. Father deceased 55 from accident. Physical Exam: Gen: NAD, A&O X 3, pleasant Heent: EOMI, PEERL, MMM, Neck: 7 cm JVP Heart: RRR, normal S1/S2. No mr. +S4. PMI non-displaced. Lungs: Scarce bibasilar crackles. Abd: Soft, nt/nd. NABS Ext: No c/c/e. Faint right femoral bruit. Equal pulses. Warm and well perfused extremities. Neuro: Normal sensation and motor LUE Pertinent Results: Cath Results: FINAL DIAGNOSIS: 1. Mild single vessel coronary artery disease. 2. Severe diastolic ventricular dysfunction. 3. Severe pulmonary hypertension. 4. Severely elevated central aortic pressure. 5. Severe distal aortic disease. 6. Severe right external iliac disease. 7. Successful distal aortic reconstruction with stenting of the origins of the common iliac arteries bilaterally. 8. Successful stenting of the right external iliac artery. COMMENTS: 1. Hemodynamic evaluation revealed mildly elevated right-sided pressures (mean RA was 8 and RVEDP was 13 mmHg), moderate to severely elevated left sided pressures (mean PCW was 22 and LVEDP was 23 mmHg), severely elevated pulmonary pressures (PA was 79/27 mmHg and the PVR was 516 dynes-sec/cm-5), and a severely elevated central aortic pressure (264/103 mmHg) with a severely elevated systemic [**Year (4 digits) 1106**] resistance (4077 dynes-sec/cm-5). The cardiac index was borderline low at 2.0 L/min/m2 (using an assumed oxygen consumption). There was no gradient across the aortic valve on pullback of the angled pigtail catheter from the left ventricle to the ascending aorta. 2. Selective coronary arteriography revealed single vessel disease. The LMCA was calcified and had an ostial 30% stenosis. The LAD was calcified and had a 50% stenosis distally. The LCX was calcified and had mild luminal irregularities. The RCA was calcified and had mild luminal irregularities. 3. Abdominal aortography revealed severe diffuse disease with evidence of prior aortic reconstruction. The right renal artery was single without critical lesions. The left renal artery was also single and arose from the repaired segment of the abdominal aorta, it was also without critical lesions. The distal aorta had severe disease extending into the iliac arteries bilaterally. 4. Right lower extremity angiography revealed a 90% stenosis at the origin of the CIA with diffuse disease extending into the EIA which also had a 90% stenosis. The IIA was occluded. The CFA, SFA, popliteal, AT, PT, and PA were all without critical lesions. 5. Left lower extremity angiography revealed an 80% stenosis at the origin of the CIA wihtout critical lesions distally. The IIA was patent with an ostial stenosis. The CFA and proximal SFA were free of angiographically significant disease. 6. Successful reconstruction of the distal aorta with simultaneous placement of a 7.0 x 58 mm Omnilink stent in the distal aorta extending into the right common iliac artery and a 7.0 x 38 mm Omnilink stent in the distal aorta extending into the left common iliac artery. Both stents were postdilated to 8.0 mm. Final angiography revealed no residual stenosis, normal flow, and no demonstrable gradient across either iliac artery. 7. Successful stenting of the distal right common iliac artery into the right external iliac artery with an 8.0 x 56 mm Dynalink stent. Final angiograohy revealed no residual stenosi, no apparent dissection, and normal flow (see PTA comments). TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 2 hours 12 minutes. Arterial time = 2 hours 00 minutes. Fluoro time = 33.0 minutes. Contrast: Non-ionic low osmolar (isovue, optiray...), vol 299 ml, Indications - Renal Premedications: ASA 325 mg P.O. Brief Hospital Course: 80 year old female with bilateral carotid disease s/p bilateral CEA's and [**Country **] stenting, htn, dyslipidemia, admitted for elective cardiac cath. 1. Hypertensive urgency/emergency: Pt was admitted for elective cardiac cath to evaluate coronaries as a potential cause of recurrent pulmonary edema. On day of admission, noted to have BP 210's/100's without evidence of end-organ damage (chest pain, ecg changes, HA, visual changes, back pain or hematuria). Given PO meds with improvement of BP to 140's/90's. During cath, found again to be hypertensive to 264/103, so admitted to CCU. There she was noted to be hallucinating, likely [**2-26**] hypertensive encephalopathy. Started on nipride drip then transitioned back to stable outpt antihypertensive regimen. Currently BP stable around 140's/80's. Will continue outpt regimen of quinapril and nadolol. 2. Elective Cardiac Cath: Found to have 30% LMCA dz and 50% distal LAD disease, with no intervention done to coronaries. However, she was noted to have severe dz at both common iliacs (90 and 80% stenoses or R & L), and 90% stenosis of right external iliac artery, each of which were stented with BMS's. Aspirin and ticlopidine (given plavix allergy) will be used for life. 3. CHF: Pt had depressed CO and increased left sided and pulmonary pressures. Etiology likely malignant hypertension causing increased afterload, decreased cardiac output causing increased L-sided filling pressures being transmitted to the pulmonary vasculature. Also, the pt was anemic 2/2 blood loss from right groin during cath, so 1U PRBC given. These 2 manuvers improved the pt's volume overloaded state. She required lasix IV X 2 and will be d/c'd on outpt dose of oral lasix. 4. Hx Left Subclavian Arterial Stenosis: Noted during prior catheterizations. She does have occasional symptoms of tingling, but her symptoms did not warrant intervention. She does not have steal syndrome and is not at risk of limb-threatening ischemia. If the pt were to need LIMA-->coronary, her subclavian would then have needed to be stented. 5. Anemia: [**2-26**] excessive blood loss from right groin during cath and epistaxis from nasal canula. Was transfused one unit PRBC and is being discharged with stable hematocrit. 6. PNA: Pt with LLL infiltrate on CXR. Afebrile, no leukocytosis and no breathing problems. [**Name (NI) **] be d/c'd on levaquin to finish a 7 day course. Discharge Disposition: Home With Service Facility: [**Hospital **] Hospice and VNA Discharge Diagnosis: Cardiac cath: LMCA 30% distal occlusion, LAD mild proximal disease Abdominal aorta with severe diffuse disease R+L renal arteries without critical lesions Occlusions of the external and internal iliac arteries Pneumonia Discharge Condition: Stable and improved Discharge Instructions: Please return to the ER or call your doctor if you have any other episodes of difficulty breathing, chest pain, weakness, or new numbness, tingling, or visual changes. Followup Instructions: Provider: [**Name10 (NameIs) **] STUDY Where: CC CLINICAL CENTER RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2138-3-18**] 1:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2138-3-18**] 3:00\n [**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**] Completed by:[**2138-2-15**]

[ "433.30", "998.11", "414.01", "496", "440.20", "416.8", "285.1", "272.4", "V12.59", "435.2", "486", "437.2", "428.0" ]

icd9cm

[ [ [] ] ]

[ "39.50", "88.48", "88.42", "37.23", "88.56", "00.55" ]

icd9pcs

[ [ [] ] ]

7986, 8048

5525, 7963

283, 393

8312, 8333

2241, 2255

8550, 9051

1804, 1879

8069, 8291

2272, 5237

8357, 8527

1894, 2222

5256, 5502

222, 245

421, 1288

1310, 1577

1593, 1788

65,541

175,047

17278+17279

Discharge summary

report+report

Admission Date: [**2113-3-24**] Discharge Date: [**2113-3-26**] Date of Birth: [**2074-1-28**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: Headache Major Surgical or Invasive Procedure: Diagnostic Cerebral Angiogram History of Present Illness: 39yo M with sudden onset headache and neck stiffness found to have SAH. Pt tood cialis 2.5mg tablet at 9pm this evening. Noted sudden onset headache and neck stiffness at 12:30am during ejaculation. He vomited several times following the onset of symptoms. Pt went to an outside hospital where head CT revealed SAH in the ambient cysterns. He was transferred to [**Hospital1 18**] for further care. At present pt reports neck stiffness. He feels generalized fatigue and a "heavyness" of his eyelids bilaterally. Denies diplopia. No vision loss. No dysarthria. No difficulty understanding or producing speech. No weakness, numbness or paresthesias. On general ROS: No recent f/c/NS, no N/V (preceding HA onset), no diarrhea, no constipation. Past Medical History: Spontaneous pneumothorax Community acquired pneumonia- summer [**2112**] Use of illicit narcotics Social History: Married, works for [**Company **], nonsmoker, drinks three drinks per day. He smokes marijuana regularly. Uses valium, which is not prescribed. He denies any other illicits or IV drug use. Family History: Father - 75yo, "healthy" Mother- healthy Paternal [**Name (NI) **] died of COPD Maternal Aunt- has migraine headaches No known family history of polycystic kidney disease or early sudden cardiac death. Physical Exam: O: T: 98.6 BP: 133/80 HR: 75 R: 18 O2Sats: 98% RA Gen: WD/WN, comfortable, NAD. HEENT: NCAT, MMM, OP clear Neck: + nuchal rigidity. 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, normal affect. Orientation: Oriented to person, place, and date. Recall: [**3-8**] 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, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. He has slight hypometric saccades to the left gaze only. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-10**] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 2---------> Left 2---------> Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Upon discharge on [**2113-3-26**], he was neurologically intact. Pertinent Results: [**2113-3-24**] 04:41AM BLOOD WBC-12.7* RBC-5.26 Hgb-14.6 Hct-43.8 MCV-83 MCH-27.8 MCHC-33.4 RDW-13.1 Plt Ct-195 [**2113-3-24**] 04:41AM BLOOD Neuts-86.0* Lymphs-9.6* Monos-3.6 Eos-0.2 Baso-0.6 [**2113-3-24**] 04:41AM BLOOD Plt Ct-195 [**2113-3-24**] 04:41AM BLOOD PT-11.5 PTT-19.6* INR(PT)-1.0 [**2113-3-24**] 04:41AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2113-3-24**] 04:41AM BLOOD estGFR-Using this CTA Head [**3-24**]: 1. Unchanged moderate volume of subarachnoid hemorrhage within the interpeduncular and prepontine cistern with effacement of the basilar cisterns, not significantly changed from the outside CT scan. There is a small volume of hemorrhage within the inferior fourth ventricle. 2. No vascular malformation or aneurysm is identified. While the findings may relate to so-called "benign perimesencephalic hemorrhage" (due to bleeding from the prepontine venous plexus), the degree of edema and mass effect is most atypical. Continued close follow-up and, possibly, catheter cerebral arteriography, as well as MR examination of the complete spine to exclude an occult spinal AVM or other source of hemorrhage, is recommended in further evaluation. The study and the report were reviewed by the staff radiologist. CT head [**3-25**]: Interval decrease in the amount of subarachnoid blood in comparison to one day prior. Similar to decreased size of ventricles Brief Hospital Course: Mr [**Known lastname 12536**] was admitted to the Neurosurgery service to the trauma ICU for close neurological monitoring. His BP was kept less than 130. He had a angiogram on [**3-24**] which showed no aneurysm. He remained neurologically stable with changes on repeat Head CT. He was ambulating independently. He remained due to bed issues only and was discharged to home on [**2113-3-26**]. Medications on Admission: Cialis and Valium Discharge Medications: 1. Acetaminophen 325 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). Disp:*60 Capsule(s)* Refills:*2* 3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: SAH-Nonanerysmal Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs. ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). ?????? After 1 week, you may resume sexual activity. ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate. ?????? No driving until you are no longer taking pain medications Followup Instructions: Please call [**Telephone/Fax (1) 1669**] to schedule a follow up visit with Dr. [**First Name (STitle) **] in 4 weeks. He will need to decide if a second angiogram will be scheduled. Completed by:[**2113-3-26**] Admission Date: [**2113-3-27**] Discharge Date: [**2113-3-30**] Date of Birth: [**2074-1-28**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 78**] Chief Complaint: Back pain Major Surgical or Invasive Procedure: cerebral angiogram History of Present Illness: HPI: 39 yo man with sudden onset headache and neck stiffness found to have SAH [**2113-3-24**]. Occured [**2113-3-24**] at 1230AM during ejactulation. Vomitted several times following onset of symptoms. Went to OSH where SAH was noted in ambient cysterns. Then transferred to [**Hospital1 18**], admitted [**3-24**] and discharged [**3-26**] with stable symptoms. Called today reporting new back pain, and asked to return for further monitoring. Back pain is distal sacral and somewhat position related. Exacerbated by lifting legs. Past Medical History: Spontaneous pneumothorax Community acquired pneumonia- summer [**2112**] Use of illicit narcotics Social History: Married, works for [**Company **], nonsmoker, drinks three drinks per day. He smokes marijuana regularly. Uses valium, which is not prescribed. He denies any other illicits or IV drug use. Family History: Father - 75yo, "healthy" Mother- healthy Paternal [**Name (NI) **] died of COPD Maternal Aunt- has migraine headaches No known family history of polycystic kidney disease or early sudden cardiac death. Physical Exam: PHYSICAL EXAM: O: T: pending BP: 140/93 HR: 77 R 10 O2Sats 97RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: [**5-7**] 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, normal affect. Orientation: Oriented to person, place, and date. Recall: [**3-8**] 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, 5 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-10**] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 2+ --------> Left 2+ --------> Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin EXAM ON DISCHARGE: Neurologically intact. No deficits Pertinent Results: DISCHARGE LABS: [**2113-3-28**] 02:19AM BLOOD WBC-7.4 RBC-4.90 Hgb-13.8* Hct-40.4 MCV-83 MCH-28.2 MCHC-34.2 RDW-13.1 Plt Ct-189 [**2113-3-28**] 02:19AM BLOOD PT-11.3 PTT-21.4* INR(PT)-0.9 [**2113-3-28**] 02:19AM BLOOD Glucose-110* UreaN-14 Creat-1.0 Na-138 K-3.9 Cl-103 HCO3-24 AnGap-15 ADMISSION LABS: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2113-3-24**] 04:41AM 12.7* 5.26 14.6 43.8 83 27.8 33.4 13.1 195 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2113-3-24**] 04:41AM 136*1 14 1.1 141 3.9 103 27 15 [**Known lastname **],[**Known firstname **] [**Medical Record Number 48396**] M 39 [**2074-1-28**] Radiology Report CTA HEAD W&W/O C & RECONS Study Date of [**2113-3-28**] 9:20 AM [**Last Name (LF) **],[**First Name3 (LF) **] J. NSURG SICU-A [**2113-3-28**] 9:20 AM CTA HEAD W&W/O C & RECONS; CT BRAIN PERFUSION Clip # [**Clip Number (Radiology) 48397**] Reason: vasospasm Contrast: OPTIRAY Amt: 110 [**Hospital 93**] MEDICAL CONDITION: 39 year old man with SAH REASON FOR THIS EXAMINATION: vasospasm CONTRAINDICATIONS FOR IV CONTRAST: None. Final Report INDICATION: Subarachnoid hemorrhage. Evaluate for vasospasm. COMPARISON: Non-contrast head CT dated [**2113-3-25**]. Head CTA and conventional cerebral angiogram dated [**2113-3-24**]. TECHNIQUE: Non-contrast head CT was obtained. CT perfusion study was performed during intravenous contrast administration. Axial multidetector CT images of the head were then obtained during administration of additional intravenous contrast, according to CTA protocol. Multiplanar two-dimensional reformatted images and volume-rendered three-dimensional reformatted images were generated. NONCONTRAST HEAD CT: Previously noted perimesencephalic subarachnoid hemorrhage has decreased in density. There is no evidence of new intracranial hemorrhage. There is no evidence of parenchymal edema, mass effect, or other signs of a large infarction. The ventricles are normal in size and configuration, without change since the previous study. There is mild mucosal thickening in the left sphenoid sinus with a small mucous retention cyst. There is mild mucosal thickening in some of the right anterior ethmoid air cells. CT PERFUSION: The mean transit time, cerebral blood volume, and cerebral blood flow appear symmetric within the imaged portion of the brain. HEAD CTA: Flow is visualized in the intracranial internal carotid and vertebral arteries, and their major branches, without evidence of occlusion. However, there is decreased caliber of the distal basilar artery, right and left superior cerebellar arteries, and the P1 segment of the right posterior cerebral artery since [**2113-3-24**]. These findings are consistent with mild vasospasm. There is no evidence of vasospasm in the anterior circulation. There is no evidence of an aneurysm or vascular malformation. IMPRESSION: 1. No new hemorrhage. 2. New mild vasospasm involving the distal basilar artery, right and left superior cerebellar arteries, and proximal right posterior cerebral artery. 3. No evidence of a large area of ischemia or infarction on the CT perfusion study. Findings reported to the neurosurgery service by Dr. [**Last Name (STitle) **] in the early afternoon of [**2113-3-28**]. DR. [**First Name11 (Name Pattern1) 95**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 96**] Approved: WED [**2113-3-29**] 9:36 AM Imaging Lab [**Known lastname **],[**Known firstname **] [**Medical Record Number 48396**] M 39 [**2074-1-28**] Radiology Report MR [**Name13 (STitle) **] W &W/O CONTRAST Study Date of [**2113-3-28**] 1:07 PM [**Last Name (LF) **],[**First Name3 (LF) **] J. NSURG SICU-A [**2113-3-28**] 1:07 PM MR [**Name13 (STitle) **] W& W/O CONTRAST; MR [**Name13 (STitle) **] W &W/O CONTRAST; MRA THORACIC SPINE Clip # [**Clip Number (Radiology) 48398**] Reason: PERIMESENCEPHALIC BLEED Contrast: MAGNEVIST [**Hospital 93**] MEDICAL CONDITION: 39 year old man with perimesencephalic bleed REASON FOR THIS EXAMINATION: MRI MRA r/o avm CONTRAINDICATIONS FOR IV CONTRAST: None. Final Report INDICATION: Perimesencephalic subarachnoid hemorrhage. Evaluate for spinal arteriovenous malformation. COMPARISON: No previous spine imaging. TECHNIQUE: Sagittal T1-weighted, T2-weighted, and STIR images of the cervical and thoracic spine were obtained, with axial T2-weighted and gradient echo images of the cervical spine, and axial T2-weighted images of the thoracic spine. Dynamic sagittal VIBE imaging of the cervical and thoracic spine was obtained during intravenous gadolinium administration per MRA protocol, and maximal intensity projections were generated. Subsequently, post-contrast T1- weighted spin echo, sagittal, and axial images of the cervical and thoracic spine were obtained. CERVICAL AND THORACIC SPINE MRA: There is no evidence of abnormal arteries or veins to suggest an arteriovenous malformation. CERVICAL SPINE MRI: Vertebral body height, alignment, and bone marrow signal are normal. There is no pathologic enhancement within the cervical spine. At C4-5, there is a small central disc protrusion, which does not contact the spinal cord. There are small uncovertebral osteophytes bilaterally, and mild narrowing of the right neural foramen. At C5-6, there is a right paracentral disc/osteophyte complex with associated flattening of the right ventral spinal cord. There is mild-to-moderate spinal canal narrowing. There are right uncovertebral osteophytes with mild narrowing of the right neural foramen. The spinal cord is normal in signal intensity. The imaged portion of the posterior fossa appears grossly unremarkable, as the known perimesencephalic subarachnoid hemorrhage is not assessed by this study. The imaged soft tissues of the neck are unremarkable. THORACIC SPINE MRI: Vertebral body height, alignment, and bone marrow signal are normal. There is no pathologic enhancement within the thoracic spine. There are no significant disc bulges. The spinal cord is normal in morphology and signal intensity. There are small bilateral pleural effusions. IMPRESSION: 1. No evidence of a vascular malformation in the cervical or thoracic spine. 2. Right paracentral disc osteophyte complex at C5-6, which slightly deforms the ventral spinal cord, without evidence of cord signal abnormality. [**Known lastname **],[**Known firstname **] [**Medical Record Number 48396**] M 39 [**2074-1-28**] Radiology Report CTA HEAD W&W/O C & RECONS Study Date of [**2113-3-30**] 9:59 AM [**Last Name (LF) **],[**First Name3 (LF) **] J. NSURG FA11 [**2113-3-30**] 9:59 AM CTA HEAD W&W/O C & RECONS; CT BRAIN PERFUSION Clip # [**Clip Number (Radiology) 48399**] Reason: 39 year old man with non aneursymal subarachnoid hemorrhage, Contrast: OPTIRAY Amt: 110 [**Hospital 93**] MEDICAL CONDITION: 39 year old man with non aneursymal subarachnoid hemorrhage,found to have mild vasospasm, please perform CTA/CTP to further evaluate. REASON FOR THIS EXAMINATION: 39 year old man with non aneursymal subarachnoid hemorrhage,found to have mild vasospasm, please perform CTA/CTP to further evaluate. CONTRAINDICATIONS FOR IV CONTRAST: None. Provisional Findings Impression: [**First Name9 (NamePattern2) 48400**] [**Doctor First Name **] [**2113-3-30**] 2:56 PM PFI: There is no evidence of hemorrhage, masses, mass effect or infarction. Again seen is a decrease in caliber of the distal basilar, bilateral superior cerebellar and P1 segment of the right PCA, essentially unchanged from [**3-28**], [**2113**] and an equivocal change compared to [**2113-3-24**]. It is unclear whether this represents a normal variant of the posterior circulation vasculature or whether there is a continued mild component of vasospasm. The CT perfusion map show no evidence of ischemia or infarction. Final Report INDICATION: 39-year-old man with non-aneurysmal subarachnoid hemorrhage who was found to have mild vasospasm. Please perform CTA/CTP for further evaluation. TECHNIQUE: Initially, contiguous axial images through the brain were obtained without IV contrast. Subsequently, axial imaging was performed from the skull base to the vertex during infusion of intravenous contrast (CT angiogram). Images were processed on a separate workstation with displays of curved reformats, volume-rendered images, and maximum intensity projection images. Additionally, CT perfusion maps were acquired with display of mean transit time, cerebral blood volume and blood flow color maps. COMPARISON: CTA of the head from [**2113-3-28**] and from [**2113-3-24**]. CT of the head from [**2113-3-25**] and cerebral angiogram from [**2113-3-24**]. FINDINGS: NON-CONTRAST HEAD CT: The previously noted perimesencephalic hemorrhage has resolved. There is no evidence of new extra-axial or intra-axial hemorrhage. No evidence of edema, mass effect, or territorial infarction is noted. The ventricles and sulci are normal in caliber and configuration. [**Doctor Last Name **]-white matter differentiation is preserved. There is unchanged mild mucosal thickening of the left sphenoid sinus with a small retention cyst, as well as mild mucosal thickening of the anterior right ethmoid air cells. CT PERFUSION: The mean transit time, cerebral blood volume and cerebral blood flow appear normal and symmetric within the imaged portion of the brain without deficits. CTA OF THE HEAD: Again seen is decreased caliber of the right vertebral artery, distal basilar artery, bilateral superior cerebellar arteries and the P1 segment of both posterior cerebral arteries. This is essentially unchanged compared to [**3-28**], [**2113**] and essentially also unchanged compared to the initial CTA from [**3-24**], [**2113**]. There is no evidence of occlusion in the intracranial arteries. The remainder of the intracranial arteries and their major branches of the vertebral and internal carotid arteries are normal without evidence of stenosis or aneurysm formation. There is no evidence of vasospasm of the anterior circulation. IMPRESSION: 1. There is no evidence of hemorrhage, mass effect or obvious infarction. 2. Again seen is a decrease in caliber of the distal basilar, bilateral superior cerebellar and P1 segment of the right posterior cerebral artery. This is essentially unchanged from [**2113-3-28**] and essentially also unchanged compared to the initial CTA from [**2113-3-24**]. This may represent a normal variant of the posterior circulation vasculature or related to a continued mild component of vasospasm. 3. The CT perfusion maps show no evidence of perfusion deficits of the limited portion of the brain imaged. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: Patient called the office on day of admission reporting new back pain, and asked to return for further monitoring. Back pain is distal sacral and somewhat position related. Exacerbated by lifting legs. He was tracked for step down unit but no beds were available therefore he was put in the sicu for close observation. His exam was stable and non focal. He underwent a CT CTA on hosp day #1 that was negative. He was transferred to the step down unit. While in the stepdown unit patient remained medically stable. He was seen in Consultation by Dr. [**Last Name (STitle) 1693**] of Neurology who thought that he was stable for discharge with a 21 day course of Nimodipine and did not require a follow up Angiogram. Medications on Admission: Cyalis, Valium prn (using but no prescribed), Tylenol, Colace, Oxycodone Discharge Medications: 1. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4 hours) for 21 days. Disp:*252 Capsule(s)* Refills:*0* 2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: [**1-7**] Capsules PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Sub Arachnoid Hemorrhage Mild vasospasm Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: Angiogram with Embolization and/or Stent placement Medications: ?????? Take Aspirin 325mg (enteric coated) once daily. ?????? Take Plavix (Clopidogrel) 75mg once daily. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs. ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). ?????? After 1 week, you may resume sexual activity. ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate. ?????? No driving until you are no longer taking pain medications What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site *SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call our office. If bleeding does not stop, call 911 for transfer to closest Emergency Room! Followup Instructions: We recommend you have a repeat angiogram in 1 month with Dr. [**First Name (STitle) **] Follow up with Dr. [**Last Name (STitle) 656**] in the Neurology Department in [**2-8**] weeks. Completed by:[**2113-4-17**]

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Discharge summary

report

Admission Date: [**2141-9-19**] Discharge Date: [**2141-9-25**] Service: VASCULAR HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 33976**] is an 85 year old white male with a past medical history significant for hypertension, benign prostatic hypertrophy and hypercholesterolemia, who presented to his primary care physician for an annual physical and was found to have a questionable pulsatile mass on examination. His work-up included ultrasound revealing 5 to 6 cm diameter abdominal aortic aneurysm. Ultimately a preoperative CT scan angiogram was performed revealing a 5 cm enhanced AP diameter infra-renal abdominal aortic aneurysm. Given the age and co-morbidities, the patient was initially evaluated for possible endovascular stenting of this, although after review of his films and consultation with the endovascular surgeons, it was determined that he in fact, did not have an appropriate aneurysm, and therefore an open repair was elected. The patient's preoperative work-up included a sestamibi which showed an ejection fraction of 50% with no ischemic changes, no defects noted. He did have a dilated left ventricular otherwise that was chronic and had been previously noted on prior stress test. Once these cleared from a cardiac standpoint, then his medical management was optimized. He then presented to the [**Hospital1 69**] for an open abdominal aortic aneurysm repair after Informed Consent was obtained in the preoperative visit with Dr. [**Last Name (STitle) 1391**]. The patient came to [**Hospital1 69**] on [**2141-9-19**], where he underwent an open abdominal aortic aneurysm repair. The case was otherwise uneventful. He did receive approximately 4 liters of Crystalloid and 500 of Cellsaver interoperatively and required two units of transfused blood. The patient tolerated the procedure well and was extubated in the Operating Room and was transferred to the surgical Intensive Care Unit for his postoperative management. PAST MEDICAL HISTORY: 1. Hypertension. 2. Gastroesophageal reflux disease. 3. Peripheral vascular disease. 4. Hyperlipidemia. 5. Benign prostatic hypertrophy. ALLERGIES: None. OUTPATIENT MEDICATIONS: 1. Accupril 40 mg p.o. q. day. 2. Norvasc 5 mg p.o. q. day. 3. Lipitor 20 mg p.o. q. day. 4. TUMS as needed. SOCIAL HISTORY: No significant ETOH; former smoker, greater than 30 pack years. Widowed and lives at home alone. He has an extended facility that helps with his care. Otherwise, at baseline, he is ambulatory and appropriate. Difficult to examine on presentation in the office. PHYSICAL EXAMINATION: He was an 88 kilogram male. Temperature was 97.9 F.; blood pressure 130/60; his pulse was 50 and sinus bradycardia. Breathing at 18 with a room air saturation of 95%. He is in no acute distress. His mucous membranes were moist. Pupils equally round and reactive to light and accommodation. Extraocular muscles are intact. His trachea was midline. He had no cervical lymphadenopathy. His neck was supple. Otherwise, his lungs were clear. His heart was regular but bradycardic. There is no murmur present. He had no carotid bruit. He had no S3 gallop. The abdomen was soft, nondistended, nontender; there was a small pulsatile mass felt between the xiphoid and the umbilicus. The patient's flanks were clear; they were nontender. He had no spinal abnormalities or step off. Peripheral vascular disease was noted for palpable femoral, popliteal, dorsalis pedis as well as posterior tibialis pulses. Feet were warm with no ulceration. There is no edema. LABORATORY: The patient's preoperative labs included hematocrit of 37.1, a BUN of 31 and a creatinine value of 1.8 with baseline renal between 1.5 and 1.7. Additionally, he did receive a preoperative cardiogram that was shown to be sinus bradycardia compared to an EKG from [**2141-1-24**]. There was some slight QT interval prolongation. There was some diffuse non-specific ST-T wave flattening as well; otherwise, negative. Preoperative chest x-ray on [**2141-9-13**], showed enlargement of left ventricular; the mediastinal and other contours are otherwise unremarkable. Pulmonary vascularity was normal. There was mild ectatic changes of the artery. Lung fields were clear. There was no pleural effusion. The soft tissue and osseous structures were otherwise unremarkable. Findings just showing the mild left ventricular enlargement but no active cardiopulmonary disease. HOSPITAL COURSE: After undergoing his open abdominal aortic aneurysm procedure, the patient was brought back to the SICU for postoperative management. On postoperative day number one, the [**Hospital 228**] hospital course was as follows: The remaining days will be summarized based on system. 1. NEUROLOGIC: The patient was slightly sedated and getting p.r.n. narcotics and PCA. He was on an epidural for pain and getting Propofol at 40. His temperature at this time was 97.7 F. He remained otherwise neurologically intact. On postoperative day number three, he was noted to be somewhat agitated and did, in fact, self extubate. He did well thereafter. He had been maintained on a ventilator for the first three days postoperatively, but after self-extubating, they were utilizing soft restraints and Haldol as needed for his agitation. It was presumed that he was having a small degree of Intensive Care Unit delirium. By the time of discharge, he had completely cleared and was alert and oriented times three, with appropriate affect. He was off any sedation and was not having any benzodiazepines, no anti-cholinergics and quiescent medications like Haldol were being utilized to control him. 2. PULMONARY: The patient was ventilated for approximately three days postoperatively and after self-extubation, he did quite well. Thereafter, he was continued on a progressive pulmonary toilet including chest physiotherapy around the clock as well as incentive spirometry and early ambulation with encouragement for coughing and deep breathing. Pre-operative chest x-rays, as stated above. His saturations at the time of discharge were 94 to 95% and he is breathing at a rate of 20. 3. CARDIOVASCULAR: His preoperative cardiac work-up is as stated previously. Postoperatively, he was given beta blockers as well as vasodilators for some after load reduction. He was supported with intravenous fluid resuscitation utilizing Swan-Ganz hemodynamic monitoring catheter. This was left in place for the first four days postoperatively to guide fluid management. The patient did well from the that standpoint. He was off of a Nitroglycerin drip by postoperative day number three. By postoperative day number six, the patient was being maintained on his Lopressor 50 twice a day, Accupril 40 mg q. day and Norvasc 5 mg q. day added back to put him on his preoperative regimen. He remained stable. Postoperative EKG showed no change from prior EKG and he was not ruled out. 4. Fluids, Electrolytes and Nutrition/ Gastrointestinal: The patient's diet was advanced once he passed flatus which occurred on postoperative day number five. He tolerated the diet well and had no evidence of nausea or vomiting. Otherwise, his electrolytes remained somewhat stable although he was relatively hypokalemic postoperatively which was aggressively repleted. At the time of discharge, his potassium was 4.1. The remainder of his electrolytes were otherwise normal. The patient was utilizing stool softeners as needed, as well as Dulcolax suppositories to incur some type of response from below, as he had not had a bowel movement in approximately four days. This ultimately occurred after gentle persuasion with the Dulcolax. The patient's weight preoperatively was 89 kilos and at discharge his weight was 90.1 kilos. The patient did in fact get Protonix for gastroesophageal reflux disease as well as ulcerative prophylaxis. 5. Genitourinary/Renal: BUN and creatinine; creatinine peaked at 2.1 and at the time of discharge was 1.9. Baseline creatinine is between 1.7 and 1.8. He was making adequate urine and his Foley catheter was removed on postoperative day six and he voided spontaneously without any difficulty. 6. Hematology / Infectious Disease: His hematocrit postoperative was 29.0. His discharge hematocrit was 34.8. He was transfused, however, for this. He received a total of 2 units of packed cells. He remained afebrile otherwise and his white blood cell count was 9.0 at the time of discharge. Infectious Disease with no issues. He was given perioperative Kefzol and for the first two days postoperative as well for prophylaxis. The patient's deep venous thrombosis prophylaxis was done utilizing subcutaneous heparin 5000 units three times a day. DISPOSITION: He was working aggressively with Physical Therapy who determined that he would be a good candidate for rehabilitation as he was having minimal ambulation and he required quite a bit of assistance. Therefore, the appropriate screenings were done. DISCHARGE STATUS: Stable, afebrile, tolerating a diet and ambulating with great deal of assistance, to go to rehabilitation. DISCHARGE MEDICATIONS: 1. Protonix 40 mg p.o. q. day. 2. Lopressor 50 mg p.o. twice a day. 3. Lasix 20 mg p.o. twice a day. 4. Haldol 1 to 2 mg intravenous q. four to six as needed for agitation. 5. Percocet 5/325, one to two tablets p.o. q. four to six p.r.n. 6. Colace 100 mg p.o. twice a day. 7. Aspirin 325 mg p.o. q. day. 8. Heparin 5000 units subcutaneously q. 12 hours. 9. Prednisolone acetate 1% ophthalmic solution, one drop o.u. three times a day left eye. 10. Accupril 40 mg p.o. q. day. 11. Norvasc 5 mg p.o. q. day. 12. Lipitor 20 mg p.o. q. day. 13. Tums as needed. DISCHARGE INSTRUCTIONS: 1. The patient will receive strengthening and conditioning, blood pressure monitoring and mood checks by the facility. 2. To see Dr. [**Last Name (STitle) 1391**] in approximately seven to 14 days, at which time he will be seen in the office. 3. At time of discharge, the patient's clips were removed and Steri-Strips. DISCHARGE DIAGNOSES: 1. Status post open infrarenal abdominal aortic aneurysm repair utilizing a Dacron grasp. 2. Hypertension. 3. Gastroesophageal reflux disease. 5. Peripheral vascular disease. 5. Hyperlipidemia. 6. Benign prostatic hypertrophy. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**] Dictated By:[**Last Name (NamePattern4) 3204**] MEDQUIST36 D: [**2141-9-25**] 13:51 T: [**2141-9-25**] 14:04 JOB#: [**Job Number **]

[ "600.0", "441.4", "276.4", "272.4", "530.81", "401.9", "443.9" ]

icd9cm

[ [ [] ] ]

[ "38.44", "38.93", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

10105, 10607

9170, 9737

4479, 9147

9761, 10084

2187, 2301

2608, 4461

122, 1978

2000, 2163

2319, 2585

45,057

130,090

53782

Discharge summary

report

Admission Date: [**2187-1-10**] Discharge Date: [**2187-1-15**] Date of Birth: [**2102-7-22**] Sex: F Service: MEDICINE Allergies: Amoxicillin Attending:[**First Name3 (LF) 2387**] Chief Complaint: Nausea/fatigue, ?anginal equivalent Major Surgical or Invasive Procedure: Cardiac catheterization and placement of 2 drug-eluting stents History of Present Illness: Ms. [**Known firstname 110384**] [**Known lastname 110385**] is a 84 yo f with h/o CAD s/p multiple MIs and PCI, HTN and Afib on coumadin who presents with acute onset nausea and weakness similar to her previous MIs. She was at home in the late morning when she suddenly felt weak, diaphoretic, lightheaded and nauseous. She had no chest pain or shortness of breath. These symptoms were similar to her previous MIs, which have manifested with nausea and not chest pain. She felt she might vomit but did not, and her son called an ambulance. Her symptoms continued on the way to the hospital, but began to resolve as she arrived to the hospital. She had some residual nausea for 1-2 hours, but her strength had returned. She had episodes of weakness Sunday and Tuesday, as though she were going to collapse, but they were not as severe and passed relatively quickly. . In the ED, initial vitals were T 96.6, HR 96 and irregular, BP 117/75, RR 18, O2 sat 100%. She received aspirin 325 mg po and zofran prior to transfer to the cardiology floor. On arrival to the cardiology floor the patient is resting comfortably. She has not had any recurrence of her symptoms. . On review of systems, she has chronic lower back and hip pain secondary to a displaced disk, for which she recently had a steroid injection and is soon to start physical therapy. She has recently had cold symptoms, with rhinorrhea and phlegm production, which she has treated with Mucinex. She denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension, Diabetes 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: LAD stent in [**2177**] and LCx stent in [**2180**]. -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: - Coronary artery disease status post MI in [**2163**], [**2176**], [**2178**], LAD stent in [**2177**] and LCx DES in [**2180**], prior angioplasty. - Diet-controlled diabetes - Hypertension - History of tonsillectomy/adenoidectomy - GERD, controlled on Prevacid - Hyperlipidemia - Status post umbilical hernia repair - Cataracts - Status post C-section - Atrial fibrillation. Social History: Lives alone in a senior complex with an elevator, independent in ADLs. Son lives nearby and helps her out. -Tobacco history: None -ETOH: rarely -Illicit drugs: none Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: T=97.8 BP=141/84 HR=84 RR=18 O2 sat=100% 2L GENERAL: WDWN female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 8 cm. No carotid bruits CARDIAC: PMI located in 5th intercostal space, midclavicular line. irregular, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Obese. No abdominial bruits. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ radial 2+ DP 1+ PT 1+ Left: Carotid 2+ Radial 2+ DP 1+ PT 1+ Pertinent Results: EKG ([**2187-1-10**]): Afib at 64bpm, normal axis, no ST-T wave changes, unchanged from prior. . Cardiac Cath (prelim report): COMMENTS: 1. Coronary angiography of this right dominant system revealed two vessel coronary artery disease. The LMCA was short and calcified. The proximal LAD had a long 70-80% calcific area of in-stent restenosis and diffuse disease distally. The LCx prior stent was widely patent without significant disease. The RCA had moderate plaquing to 50%, similar in appearance to the angiogram in [**2180**]. 2. Resting hemodynamics demonstrated mildly elevated right and left sided filling pressures (RVEDP 15 mm Hg, LVEDP 19 mm Hg). There was mild pulmonary hypertension (PASP 32 mm Hg). The systemic arterial blood pressure was low-normal (SBP 92 mm Hg). The cardiac index was mildly depressed (2.0 l/min/m2). The systemic vascular resistance was normal (SVR 1115 dynes-sec/cm5). The pulmonary vascular resistance was mildly elevated (PVR 170 dynes-sec/cm5). FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Patent prior LCx [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]. 3. Mild biventricular diastolic dysfunction. 4. Mild pulmonary hypertension. . Echo [**2187-1-15**]: The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Moderate pulmonary artery systolic hypertension. Mild mitral regurgitation. Admission labs: [**2187-1-10**] 03:20PM WBC-8.4 RBC-3.82* HGB-10.9* HCT-33.1* MCV-87 MCH-28.4 MCHC-32.8 RDW-14.8 [**2187-1-10**] 03:20PM NEUTS-69.2 LYMPHS-22.7 MONOS-5.7 EOS-2.2 BASOS-0.1 [**2187-1-10**] 03:20PM PLT COUNT-281 [**2187-1-10**] 03:20PM PT-31.0* PTT-29.7 INR(PT)-3.1* [**2187-1-10**] 03:20PM GLUCOSE-156* UREA N-21* CREAT-1.0 SODIUM-137 POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-28 ANION GAP-14 Cardiac enzymes: [**2187-1-10**] 03:20PM BLOOD cTropnT-<0.01 [**2187-1-11**] 02:35AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2187-1-11**] 06:05AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2187-1-14**] 06:24AM BLOOD CK-MB-4 cTropnT-0.02* Brief Hospital Course: 84yo F w/ history of multiple prior MIs, PCI x2, HTN and Afib presented with anginal equivalent of nausea and diaphoresis and is now s/p PCI with intraprocedural bradycardia and hypotension. . # Unstable Angina: Patient presented with unstable angina, was taken for cardiac cath [**2187-1-12**] and found to have in-stent [**46**]-80% restenosis of prior LAD stents. Rota was used during the procedure and soon thereafter dropped her HR and BP. She had overlapping [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2 placed in her mid-LAD. This change may have been from distal ischemia, though her post-procedure troponin was normal and her echocardiogram was unchanged, suggesting a transient vagal reaction. Patient recovered, but needed use of levophed to maintain her BPs and she was transferred to the CCU. Overnight in the CCU, the patient was acutely delirious, requiring 4 point restraints and IV haldol. She was weaned off of pressors and had one episode of hypotension to SBP ~50, but responded to 1L of normal saline. The morning after, her delirium had entirely resolved and her blood pressure was stable. She was transferred back to the floor. She had no further symptoms on the floor and her home antihypertensives were restarted without incident. . # RHYTHM: Arrived with Afib, rate controlled with verapamil. Anticoagulated as oupatient on coumadin. She was intermittently in afib and sinus rhythm while here. She was converted to metoprolol given her history of myocardial infarctions with good rate control. . # PUMP: Despite multiple MIs, she appears to have relatively normal pump function and is euvolemic on exam. . # Diet controlled diabetes: The patient was placed on an insulin sliding scale. . # GERD: Continued on lansoprazole. Medications on Admission: Lansoprazole 30mg daily Olmesartan/HCTZ 40/12.5mg daily Rosuvastatin 5mg daily Verapamil SR 240mg daily Warfarin 2mg MWF and 1mg TuThSaSu Aspirin 81mg Folic Acid 1gm daily Calcium Citrate Cod Liver Oil Flaxseed Oil Centrum MVI Discharge Medications: 1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 2. Olmesartan-Hydrochlorothiazide 40-12.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 3. Rosuvastatin 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 4. Warfarin 1 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO As directed: Take 2 pills Mon/Wed/Fri and 1 pill Tu/Th/Sa/[**Doctor First Name **]. 5. Aspirin 325 mg Tablet, Delayed Release (E.C.) [**Doctor First Name **]: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Folic Acid 1 mg Tablet [**Doctor First Name **]: One (1) Tablet PO DAILY (Daily). 7. Calcium Citrate Oral 8. Cod Liver Oil Oral 9. Flaxseed Oil Oral 10. Centrum Oral 11. Clopidogrel 75 mg Tablet [**Doctor First Name **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. Toprol XL 100 mg Tablet Sustained Release 24 hr [**Doctor First Name **]: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary diagnosis: Unstable angina Secondary diagnoses: Coronary artery disease Atrial fibrillation Hypertension Diet-controlled Type 2 diabetes Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You were admitted with nausea and weakness similar to your prior heart attacks. You had a cardiac catheterization done to see the arteries supplying your heart. They re-opened a blockage in one of your arteries and placed two drug-eluting stents. You went to the intensive care unit overnight because your blood pressure went very low. You recovered and are now ready to go home. . Some changes were made to your medications: - You should take clopidogrel (Plavix) once a day for at least one year or until told otherwise by your doctor. - You should take a full-dose Aspirin (325mg) once a day. - You should STOP taking diltiazem. - You should take Toprol XL (metoprolol succinate) 100mg once a day. Followup Instructions: You should follow-up with your cardiologist, Dr. [**Last Name (STitle) 11679**], within the next week. You can call his office at ([**Telephone/Fax (1) 5455**] to make an appointment that fits your schedule. Completed by:[**2187-1-18**]

[ "272.4", "414.01", "401.9", "427.31", "412", "996.72", "530.81", "V58.61", "293.0", "458.29", "V58.66", "411.1", "427.89" ]

icd9cm

[ [ [] ] ]

[ "00.46", "00.40", "37.22", "00.66", "88.56", "36.07" ]

icd9pcs

[ [ [] ] ]

9873, 9931

6630, 8405

308, 372

10120, 10120

3936, 4921

10992, 11231

3024, 3139

8682, 9850

9952, 9952

8431, 8659

4938, 5964

10264, 10969

3154, 3917

10009, 10099

2300, 2416

6394, 6607

233, 270

400, 2196

5980, 6377

9971, 9988

10134, 10240

2447, 2826

2218, 2280

2842, 3008

175

159,223

54121

Discharge summary

report

Admission Date: [**2183-10-30**] Discharge Date: [**2183-11-11**] Service: [**Last Name (un) **] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 371**] Chief Complaint: s/p fall dizziness, headache Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a [**Age over 90 **] yo M s/p unwitnessed fall down 10 steps at home. Was unattended for 2 hours, vomited x 3 at scene. Awake on EMS arrival, c/o headache, dizziness, taken by EMS to OSH, neurologically intact, found to have stable C2 fracture. Was transferred to [**Hospital1 18**] for further evaluation and stabilization and treatment. Past Medical History: Angina AAA - 7cm - scheduled for endovascular repair in ~1-2 weeks. HTN AFib PVD Aortic valve replacement - porcine - [**2177**] Pacemaker RLE bypass cataracts Social History: married, lives with wife Family History: noncontributory Physical Exam: 97.0 155/107 108 afib 18 97%RA in NAD, GCS15 PERRLA, 3-->2 bilat, 4cm Left parietal hematoma trachea midline, c-collar in place back, no deformity, no stepoff, no tenderness irreg rhythm, [**4-5**] holosystolic murmur lungs CTA bilat, normal expansion abdomen soft, nontender, nondistended, +bowel sounds extremities - weakly palpable DP bilaterally, +bilat venous statsis Left elbow & L forearm abrasions Pertinent Results: [**2183-10-30**] 09:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0 [**2183-10-30**] 09:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2183-10-30**] 09:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.011 [**2183-10-30**] 09:00PM FIBRINOGE-275 [**2183-10-30**] 09:00PM PT-20.2* PTT-35.1* INR(PT)-2.6 [**2183-10-30**] 09:00PM PLT COUNT-153 [**2183-10-30**] 09:00PM WBC-9.4 RBC-3.44* HGB-11.9* HCT-35.4* MCV-103* MCH-34.7* MCHC-33.8 RDW-14.6 [**2183-10-30**] 09:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2183-10-30**] 09:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2183-10-30**] 09:00PM AMYLASE-64 [**2183-10-30**] 09:00PM UREA N-21* CREAT-0.8 [**2183-10-30**] 09:10PM GLUCOSE-142* LACTATE-2.9* NA+-138 K+-4.8 CL--100 TCO2-30 FINDINGS: There is a type III dense fracture which extends through the body of C2 into the right lateral mass. There is a fracture line that extends into the foramen transverse sarium on the right side. The fracture fragments are minimally displaced. There is no retropulsion into the cervical spinal canal. There are prominent degenerative changes in the mid cervical spine with degenerative disk disease of C3-C7. There is also prominent facet arthropathy at these levels as well. There is high attenuation in epidural space spanning from C1-C3. This abormality is consistent with a small epidural hematoma. There is CSF attenuation remaining surrounding the cervical spinal cord. There is pronounced arterial vascular calcification and bilateral pleural effusions. There is no pneumothorax. IMPRESSION: 1. Type III dens fracture with extent into the lateral mass of C2 and involves the right foramen transverse sarium. There is a small epidural hematoma spanning from C1-C3. 2. Diffuse spondylytic changes in the mid to lower cervical spine. IMPRESSION: 1. Nondisplaced fracture through the anterior superior end plate of T2 and nondisplaced fracture of the left 8th rib. 2. No evidence of compression of the spinal cord in the thoracic spine. IMPRESSION: 1) Cholelithiasis without evidence of cholecystitis. There is no intra or extrahepatic ductal dilatation identified. However, the distal common bile duct and pancreas were not visualized due to overlying bowel gas. 2) Small septated cyst and small granuloma in the left lobe of the liver. 3) Small amount of fluid in the abdomen seen above the liver dome. Brief Hospital Course: The patient was admitted on [**2183-10-30**] transferred from an OSH with the fractures described above. He was admitted to the trauma SICU for stabilization and close monitoring. His CT head was negative for acute intercranial injury. He received FFP and vitamin K for his elevated INR (2.6). His scalp laceration was repaired with staples. He remained hemodynamically and neurologically stable in the SICU, and developed no new neurologic deficits. His motor and sensory exam was normal and remained so throughout his hospitalization. On HD4 he was transferred to the floor. On the floor, he had some episodes of agitation, mostly at night, that required haloperidol prn. On HD6 he was found to be dyspneic with decreased O2 sats to the low 90s. His chest xray showed slight fluid overload. He was given lasix 20, and nebulizer treatments, with an improvement in his respiratory status, to O2 sats in the high 90s. On HD7, he failed a swallow test, and on HD8 a PICC line was placed to provide nutrition via TPN. On HD8, he was found to be slightly jaundiced, and LFTs revealed a hyperbilirubinemia (50% direct, 50% indirect). Liver fellow was consulted. RUQ ultrasound showed cholelithiasis with no evidence of cholecystitis, normal ducts. He was started on ursodiol 300. On HD10 he self d/c'd his PICC line. Re-evaluation by the swallow consult showed that he passed for soft solids and thickened liquids. He was restarted on PO feedings with assistance. Throughout his stay on the floor, he had occasional tachycardia to the 140s, while in afib. these were treated with additional doses of IV metoprolol. He had no such tachycardia the 2 days prior to discharge, and required no additional beta-blocker. On HD12 he was started on PO medications which he tolerated well. He was seen by PT/OT, which will be continued upon discharge. He was transferred to rehab on HD 13 with follow-up with neurosurgery, and a c-collar to stay on for 12 weeks. Medications on Admission: coumadin 5/7.5 dig 0.25 atenolol 50 qd zantac 150bid isosorbide 30 [**Hospital1 **] clonopin 0.5 qd hctz 25 qd altace 5qd norvasc 10qd ntg sl prn Discharge Medications: 1. Isosorbide Dinitrate 10 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 2. Ramipril 5 mg Capsule Sig: One (1) Capsule PO QD (once a day). 3. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO QD (once a day). 4. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Location (un) 1036**] - [**Location (un) 620**] Discharge Diagnosis: Type III odontoid fracture Nondisplaced fracture through the anterior superior end plate of T2 nondisplaced fracture of the left 8th rib hyperbilirubinemia - resolving atrial fibrillation s/p fall Discharge Condition: good Discharge Instructions: Keep the cervical collar on at all times for 12 weeks. [**Month (only) 116**] be briefly removed only for bathing and head must be immobilized while collar is off. Activities as tolerated, with assitance. Small frequent meals, with assistance - soft solids, advance as tolerated. Please check LFTs (AST, ALT, AlkPhos, Total Bili, Direct Bili) in 1 week. Please call the Liver Clinic at ([**Telephone/Fax (1) 1582**] with the results. Thank you. Please check digoxin level in 1 day, and adjust dose as needed. Followup Instructions: With your primary care doctor (Dr. [**Last Name (STitle) 9385**] as needed. With the neurosurgery clinic in 12 weeks for a follow-up visit and CT scan. Please call ([**Telephone/Fax (1) 88**] as soon as possible to schedule an appointment.

[ "E880.9", "427.31", "V45.01", "401.9", "805.2", "807.01", "413.9", "428.0", "V42.2", "806.04", "574.20", "441.4", "873.0", "443.9" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.07", "99.15", "86.59" ]

icd9pcs

[ [ [] ] ]

6573, 6650

3961, 5910

305, 312

6891, 6897

1395, 3938

7454, 7698

927, 944

6106, 6550

6671, 6870

5936, 6083

6921, 7431

959, 1376

237, 267

340, 686

708, 869

885, 911

22,692

117,523

24353

Discharge summary

report

Admission Date: [**2196-5-10**] Discharge Date: [**2196-5-18**] Date of Birth: [**2133-10-14**] Sex: M Service: CARDIOTHORACIC Allergies: Nortriptyline Attending:[**Last Name (NamePattern1) 1561**] Chief Complaint: Increasing shortness of breath, found to have Left hemothorax Major Surgical or Invasive Procedure: Left thoractomy & decortication for fibrothorax History of Present Illness: 62 male esrd [**2-10**] dm s/p crt [**9-8**] w/ baseline creatinine of 2.0, s/p L thoractomy and decort for fibrothorax on [**5-12**]; transferred from [**Hospital3 **] for recurrent hemothorax. Pt was admitted [**2196-4-20**] for increasing dyspnea,s/p fall and found to have L hemothorax and underwent thoracentesis w/ removal of 300cc blood fluid. Patient discharged, then readmitted [**2196-4-29**] for increasing dyspnea. Left CT placed, w/ 400-500 cc bloody fluid. CT removed after 72 hours w/ oozing from CT site. CT scan showed recurrent homothorax w/ possible empyema. Pt then became 'septic' and transferred to [**Hospital1 18**] for further care. INR >5.0 on admission. Post-op oliguric atn with hyperkalemia now resolving. Past Medical History: s/p CRT [**9-8**], CAD,s/p CABG '[**94**], severe PVD (necesitating anti-coagulation), Hypertension, gout, hyperlipidemia Social History: lives w/ wife in [**Name (NI) 26469**] RI, very supportive family. Physical Exam: General-NAD HEENT-PERRLA, anicteric REsp- Clear, crackles @ left base, Left thoracotomy incision CV- RRR, no murmer, pulses intact, + CSM. ABD- + BS x4, NT, ND. Ext-+ pulses, well healed scars @ RLE, LLE; feet warm Neuro- A&O x3, very cooperative and pleasant Pertinent Results: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2196-5-15**] 04:45AM 7.7 3.15* 9.2* 27.5* 87 29.3 33.6 15.3 267 RCL BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [**2196-5-15**] 04:45AM 267 RCL [**2196-5-15**] 04:45AM 15.0*1 26.4 1.5 RCL 1 NOTE NEW NORMAL RANGE AS OF 12 AM [**2196-5-7**] Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2196-5-15**] 04:45AM 116* 68* 1.5* 146* 4.4 114* 25 11 RCL ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2196-5-12**] 11:06AM 235* [**2196-5-12**] 04:31AM 157 OTHER ENZYMES & BILIRUBINS Lipase [**2196-5-11**] 12:01AM 17 CPK ISOENZYMES CK-MB cTropnT [**2196-5-12**] 11:06AM 3 0.02*1 1 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI [**2196-5-12**] 04:31AM 3 <0.011 1 <0.01 RADIOLOGY Final Report ART DUP EXT LO UNI;F/U [**2196-5-17**] 8:45 AM [**Hospital 93**] MEDICAL CONDITION: 62 year old man with Fem BK [**Doctor Last Name **] on R REASON FOR THIS EXAMINATION: please do graft surveillance of RLE HISTORY: Graft surveillance for a fem below-the-knee popliteal bypass on the right. FINDINGS: No prior studies at this institution for comparison. The peak systolic velocity within native right common femoral artery is 161 cm per second and at the proximal graft anastomosis with this vessel is 73 cm per second. Graft velocities range from a minimum of 25 to a maximum of 62 cm per second. At the distal graft anastomosis, the peak systolic velocity is 76 cm per second and that within the native distal vessel is 94 cm per second. IMPRESSION: Widely patent right fem-to-tibial bypass graft. RADIOLOGY Preliminary Report CHEST (PA & LAT) [**2196-5-17**] 9:18 AM [**Hospital 93**] MEDICAL CONDITION: 62 year old man with L thoractomy -chest tubes to water seal REASON FOR THIS EXAMINATION: assess hemothorax INDICATION: Status post thoracotomy and removal of chest tube, assess for pneumothorax. PA AND LATERAL RADIOGRAPH. Comparison is made to one day earlier. FINDINGS: Two right-sided chest tubes have been removed. There is a persistent loculated hydropneumothorax at the left apex, which is unchanged from the prior studies. Skin staples are seen overlying the left side of the chest. Patchy opacification is again identified at the left lung base, which is stable in appearance. The right lung remains essentially clear. IMPRESSION: Interval removal of left-sided chest tubes. No significant change in appearance of loculated hydropneumothorax in the left upper lobe. Brief Hospital Course: Pt admitted [**2196-5-10**] from [**Hospital **] Hospital for recurrent hemothorax vs. empyema despite placement of chest tubes x2 and CT scan showing recurrent fluid. Pt on anticoagulation for PMHx of PVD, CRT ([**9-8**]). Transplant nephrology, vascular surgery, and [**Hospital **] clinic were consulted. Patient underwent Left thoracotomy [**2196-5-12**], fibrosis consolidated effusion, total Lung decortication, VATS. Findings> pleural effusion consolidated into pockets of solid vs gelatinous consistancy in L lung field. Thickened parietal pleura. 3 left chest tubes in place to sx. Pt transferred to SICU post-op, intubated, sedated, pain control w/ Fentanyl gtt, Insulin gtt; on levoquin, flagyl and vancomycin for coverage; transfused w/ 2u PRBC for hct 24, ^32 post transfusion; TF nepro started. POD#1- Pt weaned and extubated at 11am w/ + gag, good sats 5lNC. Pain control w/ fentanyl patch w/ fentanyl gtt weaned to off, no c/o of pain; OOB to chair; clear liqs tol well; I/O adquate; Insulin gtt d/c @ dinner w/ NPH/Sliding scale; po meds restarted. POD#2 D/C to floor, BS decreased at left base, CT to sx ser/sang fluid continues, no air leak, no crepitus, 4lNC, IS; tolerating po intake, BSx4po pain medication; activity advanced as tolerated/IS. Renal and [**Last Name (un) **] consults cont to follow, recs appreciated. POD#[**3-11**] Pt continues to improve, CT remain to sx; Flagyl, levo and vanco cont; RISS cont w/NPH [**Hospital1 **]. Pain control w/ Fentanyl patch and percocet po. POD#5-CT placed to water seal, then d/c later in day w/o complication. Thoracotomy dsg D&I, CT dsg site smal amt sang drainage, dsg change prn. Episode of BS of 60, treated w/ OJ + sugarx2. F/U bs 105, then dinner taken.Ambulatory. Pain control cont as above POD#6-BS crackles LUL, diminished LLL, IS cont to be encouraged and done. RLE Graft surveillance done= patent. Pt to be d/c on ASA 81 mg and plavix 75 mg qd; Po intake tolerated well. L thoracotomy site D&I, CT site bruising/eccymosis present. Ambulatiing ad lib. POD#7- NO events overnight. Pt stable for d/c to home in company of wife. Antibiotics changed to Dicloxacillin 500po qid x14 days. Patient will f/u w/ [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD, [**Location (un) **], MA. Medications on Admission: doxazosin, coumadin, prograf, prednisone, norvasc, synthroid, labetolol, alprazolam, temazepam, neurontin, sulfamethoxazole, lasix, liitor, zetia, primidone, clonidine, AASA, MVI, SSI, allopurinol Discharge Medications: 1. Doxazosin Mesylate 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 2. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Disp:*120 Capsule(s)* Refills:*0* 3. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Labetalol HCl 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 7. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*0* 8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed. Tablet(s) 10. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Primidone 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Clonidine HCl 0.2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 13. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Magnesium Citrate 1.745 g/30mL Solution Sig: One Hundred Fifty (150) ML PO QHS (once a day (at bedtime)) as needed. 16. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 17. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 19. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 20. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*100 Tablet(s)* Refills:*0* 21. Dicloxacillin Sodium 500 mg Capsule Sig: One (1) Capsule PO four times a day for 14 days. Disp:*56 Capsule(s)* Refills:*0* 22. medication Insulin- NPH Per previous regimen 23. medication Insulin- Humalog Per previous regimen 24. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO twice a day. Disp:*300 ML(s)* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: Left thoractomy & decortication for fibrothorax, recurrent hemothorax PMH: Cadaver Renal Transplant [**9-8**], Coronary Aartery Disease, severe Peripheral Vascular Disease (necesitating anti-coagulation), Hypertension, gout, hyperlipidemia Discharge Condition: good Discharge Instructions: Call Dr[**Last Name (STitle) 61679**] office ([**Telephone/Fax (1) 61680**] for: fever, chest pain, shortness of breath, increased reddness or discharge from incision site. REsume all medications as previous to hospitalization. TAke new medications as directed. [**Month (only) 116**] shower in [**1-10**] days. No tub baths for 3-4 weeks. Followup Instructions: Call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office for appointment in [**1-10**] weeks- [**Telephone/Fax (5) 61681**] [**Location (un) **] Dr, [**Location (un) 8973**], [**Numeric Identifier 17178**] Completed by:[**2196-5-18**]

[ "996.81", "584.5", "276.7", "250.40", "511.0", "401.9", "V58.67", "443.9", "286.9" ]

icd9cm

[ [ [] ] ]

[ "96.6", "34.51", "99.07", "99.04", "99.77" ]

icd9pcs

[ [ [] ] ]

9157, 9163

4288, 6573

351, 401

9447, 9453

1696, 2612

9841, 10104

6820, 9134

3485, 3546

9184, 9426

6599, 6797

9477, 9818

1415, 1677

250, 313

3575, 4265

429, 1171

1193, 1316

1332, 1400

52,598

197,463

49804+59202

Discharge summary

report+addendum

Admission Date: [**2138-12-25**] Discharge Date: [**2139-1-2**] Date of Birth: [**2084-2-15**] Sex: F Service: MEDICINE Allergies: Penicillins / Bactrim Ds Attending:[**First Name3 (LF) 1928**] Chief Complaint: necrotizing pancreatitis Major Surgical or Invasive Procedure: Feeding tube placement History of Present Illness: Mrs. [**Known lastname 104086**] is a 54-year old Spanish-speaking Ecuadorian lady who was transferred from [**Hospital3 417**] Hospital for necrotizing pancreatitis. She initially presented there on [**12-21**] with severe mid-abdominal pain, associated with vomiting and one epiosde of diarrhea. In the [**Last Name (LF) **], [**First Name3 (LF) **] abdominal CT showed gallstones and an ill-defined pancreas with peripancreatic fluid. Amylase was 4916 and lipase was >[**2129**]. She was kept NPO with IVF with IV pain control with dilaudid, but it was never fully controlled. WBC peaked at 18, but she was never febrile. No antibiotics were given as the OSH. Repeat CT scan 2 days later showed pancreatic necrosis in the pancreatic head as well as a PV and SMV thrombus. At that point imipenem, levofloxacin, and flagyl were started and GI was consulted and recommended transfer for surgical consultation. However, she needed to be transferred into the ICU for oversedation from dilaudid, responded to narcan. Overnight had several episodes of desaturation requiring BiPAP. Came off of BiPAP at 1AM the morning of transfer to the floor. Currently, she feels worse with increased back pain, but otherwise states her breathing is stable. Has abdominal pain, but controlled on medication. Is frustrated with her feeding tube that is in place. Has some mild shortness of breath, but feels better with supplemental oxygen. Past Medical History: Anxiety GERD Social History: Denies alcohol, tobacco or IVDU. Currently unemployed She lives at home in [**Doctor Last Name **] with her daughter [**Name (NI) **] Family History: no family history of diabetes but positive family history for gallstones and pancreatic cancer. She has an aunt who died from liver cancer. Physical Exam: GENERAL: Pleasant, ill-appearing hispanic female in moderate distress from abdominal and back pain. HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, tachycardic rate. Normal S1, S2. no murmurs apprecaited. LUNGS: CTAB, good air movement biaterally. ABDOMEN: hyperactive bowel sounds, soft, distended, tympanic to percussion, pain over epigastric area, radiating to back, voluntary guarding no rebound. EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3 en [**Last Name (un) **]. Appropriate. 5/5 strength throughout. [**2-14**]+ reflexes, equal BL. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant but in obvious pain Pertinent Results: wbc 17.8 ([**12-21**])--> 16.3 ([**12-22**])-->14.2 ([**12-25**]) hct 31.7 plts 211 U/A negative 139| 99| 10 --------------< 256 3.1| 32| 0.8 Ca 7.3 Mg 0.8 AST 18 ALT 21 STUDIES: RUQ: U/S [**2138-12-22**] 9mm nonmobile caclulous in BG, no wall thichening. numerous stones, CBD 3.1mm, pancreas edematous and enlarged. Repeat CT [**2138-12-24**] extensive necrotizing pancreatitis and SMV, PV thrombus. more prominent peripancreatic fluid adn induration. Spleen and kidneys nl large right and moderate left pleural effusions. CT Chest/Abd with contrast [**12-27**]: 1. No pulmonary embolus, aortic dissection, or aortic aneurysm. 2. Extensive pancreatitis with now only trace residual pancreatic enhancement, consistent with diffuse necrosis. Also noted is thrombus in the portal vein, splenic vein and superior mesenteric vein. There is no pseudocyst or aortic pseudoaneurysm. 3. Enlarged endometrial hypodensity. These findings should be correlated to the patient's menstrual history as it is atypical in a postmenopausal patient. Would recommend correlation to pelvic ultrasound. 4. Bibasilar consolidations, likely atelectatic, with adjacent pleural effusions. 5. Diffuse fatty infiltration of the liver. CXR [**12-31**]: Minimal interval improvement in bilateral pleural effusions and associated bibasilar atelectasis. MICROBIOLOGY: ([**Hospital3 **]) MRSA and VRE screen negative [**12-22**] BCX NGTD [**12-22**] UCx: <5000 GPCs, presumed contaminant Labs on discharge ([**1-2**]) CBC: [**2139-1-2**] 07:40AM BLOOD WBC-11.9* RBC-3.11* Hgb-9.4* Hct-28.6* MCV-92 MCH-30.2 MCHC-32.8 RDW-13.7 Plt Ct-680* Coags: [**2139-1-2**] 07:40AM BLOOD PT-48.4* PTT-47.8* INR(PT)-5.3* [**2139-1-1**] 03:22AM BLOOD PT-22.7* PTT-38.4* INR(PT)-2.1* [**2138-12-31**] 03:26AM BLOOD PT-13.8* PTT-65.0* INR(PT)-1.2* [**2138-12-30**] 03:21AM BLOOD PT-12.2 PTT-32.3 INR(PT)-1.0 Chemistry panel [**2139-1-2**] 07:40AM BLOOD Glucose-150* UreaN-7 Creat-0.6 Na-138 K-3.9 Cl-101 HCO3-30 AnGap-11 [**2139-1-2**] 07:40AM BLOOD Calcium-8.6 Phos-4.1 Mg-2.3 Iron Studies: [**2139-1-1**] 03:22AM BLOOD calTIBC-189* Ferritn-662* TRF-145* Brief Hospital Course: Ms. [**Known lastname 104086**] is a 54 year-old Spanish speaking female with history of GERD and asthma, who was transferred to the ICU for necrotizing gallstone pancreatitis. * Necrotizing pancreatitis - etiology is gallstone pancreatitis as stones were clearly visualized on OSH CT and abd U/S. She developed necrotizing pancreatitis as a complication of gallstone pancreatitis, as evidenced on repeat CT scan. Necrotizing pancreatitis must be closely monitored as it can lead to pancreatic infection, retroperitoneal hemorrhage and sepsis with multi-organ system failure. Surgery and GI were consulted upon admission who recommended conservative medical management and contination of meropenem. She was kept NPO and interventional radiology was consulted for NJ tube placement for parenteral nutrition since below-the-gut nutrition has shown to be beneficial in necrotizing pancreatitis. She was transferred to the floor and continued to improve. Her pain continued to decrease and was slowly able to tolerate a diet. Unfortunately, one morning she became more nauseous and her feeding tube dislodged and was finally pulled. At this point, she was able to tolerate a regular diet and so the feeding tube was not reinserted. Nutrition was reconsulted given that she was no longer on tube feeds and felt that she would be able to continue on her current diet without additional tube feeds. She will need follow up with Dr. [**Last Name (STitle) 174**] as an outpatient. Per the inpatient GI team, she will also need liver clinic follow up in the future. * SMV/portal vein/splenic vein thrombosis - nonocclusive thrombosis found on Abd CT. Most likely this is provoked in the setting of her pancreatitis, given that she also does not have a history of DVT. She was started on a heparin gtt and closely monitored given the chance of developing hemorraghic pancreatitis in the setting of her necrosis. Heme onc was consulted to help determine the length of anticoagulation. They recommended to continue anticoagulation for 6 months and to be seen in their clinic in follow up to determine if the patient should have a hypercoagulable work up. To help transition her home, she was changed from heparin gtt to lovenox. On the day of discharge her INR was 5.3 and her coumadin will be held on [**1-2**] evening. She will need daily INR checks until her INR is stable x 2 days. She should receive 2 mg of coumadin daily once her INR is back in the normal range. Her Hct is stable, but should be followed on [**1-3**] AM. * Sinus tachycardia - On arrival to the floor, her HR was stable in the 120s. Given her thromboses above, this was concerning for PE. She had a CT PE protocol which was negative, but revealed moderate bilateral pleural effusions. Over the course of her hospitalization, her HR decreased to 90s on discharge. * Pleural effusions - This is likely a result of the volume resuscitation at the OSH and ICU for her pancreatitis. This is likely [**3-17**] to the inflammation associated from the pancreatitis. Over the course of her hospitalization, her pleural effsuions decreased in size and she was able to be weaned to room air from 4L nasal cannula. She will need a follow CXR in 2 weeks to ensure resolution of her effusions. * Anemia - Hct is stable between 28-30 throughout her time on the floor. Iron studies are consistent with anemia of chronic disease, but elevated ferritin is likely the result of acute pancreatitis. Will need f/u with PMD. * Endometrial lesions - CT Abd revelaed enlarged endometrial hypodensity that will need f/u with pelvic ultrasound as outpatient. * [**Name (NI) 1068**] pt has hx depression w/ suicidal ideation. She had no suicidal ideations on this admission. Outpatient medications were continued which include paxil 20mg daily. * Asthma- Was stable on exam, without wheezing. She initially was on albuterol, but this was changed to xopenex given her tachycardia. Medications on Admission: 1. tylenol 650mg q4h PRN 2. asa 81mg daily 3. colace 100 mg [**Hospital1 **] PRN 4. nexium 40 mg daily 5. dilaudid 1 mg q4h PRN pain 6. Timentin q8 h 7. RISS 8. Xopenex 2qh PRN 9. Ativan 0.5mg IV q4 PRN 10. Lopressor 5mg q6h IV 11. singulair 10mg qhs 12. phenergan 12.5 mh q6h PRN Discharge Disposition: Extended Care Facility: [**Hospital 2971**] Rehabilitation and Nursing Center - [**Hospital1 1474**] Discharge Diagnosis: Necrotizing pancreatitis Diabetes mellitus GERD Anxiety Discharge Condition: Stable. Tolerating regular diet. Discharge Instructions: You were transferred to [**Hospital1 18**] with pancreatitis. You were initially in the intensive care unit and needed antibiotics and fluids. You were later transferred to the floor. You slowly improved and your antibiotics were discontinued and you were able to tolerate a regular diet. Because your pancreas was damaged, you were started on insulin to control your blood sugars. You will need to monitor your sugars closely at home. Please return to the hospital if you experience worsening fevers, chills, nausea, vomiting, abdominal pain, blood in your stool or other concerning symptoms. Followup Instructions: You will need to follow up with your primary care doctor Dr. [**First Name (STitle) 2631**] on [**1-12**] at 6:15 PM Provider: [**Name10 (NameIs) 191**] POST [**Hospital 894**] CLINIC Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2139-1-12**] 1:10 Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3990**], [**First Name3 (LF) **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2139-1-26**] 8:40 Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 600**] Date/Time:[**2139-1-28**] 1:00 (Surgery) Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**2139-2-9**] at 2:00 PM (Gastroenterology) Provider: [**First Name4 (NamePattern1) 569**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2139-2-20**] 10:30 Name: [**Known lastname 16868**],[**Known firstname 16869**] M Unit No: [**Numeric Identifier 16870**] Admission Date: [**2138-12-25**] Discharge Date: [**2139-1-2**] Date of Birth: [**2084-2-15**] Sex: F Service: MEDICINE Allergies: Penicillins / Bactrim Ds Attending:[**First Name3 (LF) 1458**] Addendum: Addendum: D/c Clinic: please follow up with CXR to ensure resolution of bilateral pleural effusions. If otherwise hemodynamically stable, would try lasix to help diurese fluid. Please also monitor abdominal pain to assess for uptitration of pain medication. Discharge Disposition: Extended Care Facility: [**Hospital 371**] Rehabilitation and Nursing Center - [**Hospital1 328**] [**Name6 (MD) **] [**Last Name (NamePattern4) 1459**] MD [**MD Number(2) 1460**] Completed by:[**2139-1-2**]

[ "574.20", "518.0", "511.9", "530.81", "493.90", "577.0", "249.00", "427.89", "285.29", "571.8", "300.4", "452" ]

icd9cm

[ [ [] ] ]

[ "96.08" ]

icd9pcs

[ [ [] ] ]

11867, 12106

5176, 9127

310, 335

9663, 9699

3032, 5153

10347, 11844

1996, 2138

9583, 9642

9153, 9436

9723, 10324

2153, 3013

246, 272

363, 1792

1814, 1829

1845, 1980

64,334

191,708

35669

Discharge summary

report

Admission Date: [**2201-2-5**] Discharge Date: [**2201-4-24**] Date of Birth: [**2147-10-9**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 165**] Chief Complaint: Sepsis Major Surgical or Invasive Procedure: redo sternotomy, reoperative aortic valve replacement(23mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] mechanical),xenograft root/ascending aorta reconstruction, DDD pacer implant [**4-17**] Left and right heart catheterizations, coronary angiogram dental extraction History of Present Illness: This is a 53 year-old male with a history of type II diabetes mellitus and hyperlipidemia presents with sepsis from another institution. He was found at home by EMS diaphoretic and pale with a blood pressure in the 80s. He complained at the time of 1 week of watery diarrhea. He also reported that he was in the middle of his treatment for a right foot ulcer and had been on Keflex. At the OSH, he was noted to have a WBC 17.8 with 17% bands, plts 36 and lactic acid to 6.8. He became hypotensive in OSH ED and was given 6 L NS, and started on levophed. A CXR wasfelt to be consisitent with a LLL pneumonia. He was started on vancomycin, zoysyn, flagyl, and levofloxacin. He was also noted to have a wide complex tacchycardia and was started on an amiodarone infusion. He was intubated due to lethargy. He was transferred to the [**Hospital1 18**] for further management of his sepsis. Here VS were:T 99 BP 114/61 HR 82 Sat 100% AC FiO2 100% RR 20 TV 550 PEEP 5. He was admitted to the [**Hospital Unit Name 153**] for further management of his sepsis. ROS: unable to be obtained as he is intubated and sedated. Past Medical History: prosthetic Aortic Valve endocarditis prosthetic valve aortic Regurgitation s/p aortic valve replacement [**3-29**] s/p reoperative aortic valve replacement(homograft),aortic root abscess resection [**9-28**] s/p DDD pacer implantation s/p removal infected pacemaker venous stasis ulcers hyperlipidemia insulin dependent diabetes mellitus s/p removal infected pacemaker Social History: lives with daughter on disability EtOH: 6 beers/day tobacco: denies Family History: non-contributory Physical Exam: Admission: Vitals: T: 97.5 BP: 101/56 HR: 67 RR: O2Sat: 100% FiO2 100%, RR 20 TV 550 PEEP 5 GEN: Overweight male intubated and sedated, opens eyes to commands HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: Distant heart sounds, RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTA anteriorly ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords SKIN: No jaundice, cyanosis. +Large well circumscribed ulcer along the sole of right foot. Pertinent Results: [**2201-4-23**] 05:03AM BLOOD WBC-8.7 RBC-2.81* Hgb-8.5* Hct-26.1* MCV-93 MCH-30.2 MCHC-32.5 RDW-16.9* Plt Ct-243 [**2201-4-24**] 05:15AM BLOOD PT-28.7* INR(PT)-2.9* [**2201-4-23**] 05:03AM BLOOD WBC-8.7 RBC-2.81* Hgb-8.5* Hct-26.1* MCV-93 MCH-30.2 MCHC-32.5 RDW-16.9* Plt Ct-243 [**2201-4-22**] 05:38AM BLOOD PT-33.4* PTT-92.9* INR(PT)-3.5* [**2201-4-23**] 05:03AM BLOOD PT-37.9* PTT-34.5 INR(PT)-4.1* [**2201-4-22**] 05:38AM BLOOD Glucose-86 UreaN-21* Creat-0.9 Na-143 K-4.1 Cl-104 HCO3-34* AnGap-9 [**2201-4-23**] 05:03AM BLOOD Mg-2.2 [**2201-3-25**] 05:41AM BLOOD %HbA1c-6.2* [**2201-2-11**] 04:10AM BLOOD %HbA1c-9.8* On Presentation: [**2201-2-5**] 11:20PM BLOOD WBC-32.9* RBC-4.05* Hgb-12.7* Hct-37.7* MCV-93 MCH-31.3 MCHC-33.6 RDW-14.3 Plt Ct-63* [**2201-2-5**] 11:20PM BLOOD Neuts-90* Bands-4 Lymphs-2* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-1* [**2201-2-5**] 11:20PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-NORMAL Polychr-NORMAL [**2201-2-5**] 11:20PM BLOOD PT-13.1 PTT-32.4 INR(PT)-1.1 [**2201-2-5**] 11:20PM BLOOD Glucose-509* UreaN-60* Creat-2.0* Na-128* K-4.1 Cl-97 HCO3-18* AnGap-17 [**2201-2-5**] 11:20PM BLOOD ALT-16 AST-25 CK(CPK)-19* AlkPhos-123* TotBili-1.4 [**2201-2-5**] 11:20PM BLOOD Albumin-2.2* Calcium-6.7* Phos-3.9 Mg-2.2 Micro: Blood culture: multiple cultures from [**2-5**] to [**3-15**], all negative Sputum culture x4: sparse yeast and/or OP flora. C diff x3: negative Urine culture x6: negative Urine legionella: negative [**2201-2-23**] Left pacer site culture- negative [**2201-2-6**] CATHETER TIP- negative [**2201-2-6**] FOOT CULTURE- BETA STREPTOCOCCUS GROUP B, MODERATE GROWTH. [**2201-2-6**] BRONCHOALVEOLAR LAVAGE- Gram stain 1+ polys, no growth [**2201-2-6**] Rapid Respiratory Viral Screen & Culture- negative Imaging/Pathology: TTE [**2201-2-6**]: The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is no ventricular septal defect. 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. Tricuspid regurgitation is present but cannot be quantified. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. TEE [**2201-2-10**]: No thrombus/mass is seen in the body of the left atrium. A large highly mobile, well circumscribed mass (1.6 x 1.7 cm) associated with a catheter/pacing wire is seen in the right atrium . This could be consistent with a vegetation or thrombus. There are several smaller, highly mobile mass-like structures which also appear to be attached to the pacemaker lead and are in close proximity to the inferior vena cava. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular free wall motion is normal. A homograft aortic valve is present with three aortic valve leaflets. There is a moderate-sized (1.6 x 0.6 cm) vegetation on the right coronary cusp of the aortic valve. The vegetation prolapses into the left ventricular outflow tract in diastole. The aortic root is circumferentially markedly thickened with areas of echolucency which appears consistent with abscess (versus less likely post surgical changes from prior known aortic root replacement). At least moderate (2+) aortic regurgitation is seen. The severity of regurgitation may be underestimated due to shadowing (clip [**Clip Number (Radiology) **]). The mitral valve appears structurally with mild mitral regurgitation. No mitral vegetation or mass is seen. CT Head [**2201-2-10**]: No acute intracranial process. [**2201-2-10**] CT chest/abd/pelvis: 1. Soft tissue density at the anterior aspect of the base of the aortic root may correspond to valvular vegetation seen on recent TEE. However, without cardiac gating, CT evaluation is limited by cardiac motion. 2. Small bilateral pleural effusions, and moderate bibasilar atelectasis, left greater than right. 3. Mediastinal lymphadenopathy. [**2-12**] Carotid U/S: Normal carotid study. [**2-13**] Bone Scan: Radiotracer uptake predominantly at the medial aspect of the first metatarsopalangeal joint is non-specific. [**2-16**] TTE: Compared with the TEE study (images reviewed) of [**2201-2-10**], the overall findings are similar. [**2201-2-17**] CT chest: 1. Left lower lobe consolidation associated with small amount of left pleural effusion. 2. Unchanged appearance of enlarged mediastinal and right hilar lymph nodes. 3. Mild cardiomegaly. 4. Gallstones. [**2201-2-18**] Arterial Peripheral Study: IMPRESSION: No significant peripheral [**Month/Day/Year 1106**] disease bilaterally at rest. [**2-20**] TEE: Compared with the findings of the prior study (images reviewed) of [**2201-2-10**], the mass on the pacer wire is bigger and possibly attaching to the tricuspid valve. The smaller masses previously associated to the SVC portion of the pacer wire are no longer seen. The aortic valve vegetation and severity of aortic regurgitation are similar. [**2-23**] Pacemaker lead: Fragment of fibrin and blood clot. A Gram stain is negative for bacterial organisms. - NEGATIVE FOR MALIGNANT CELLS. - Red blood cells, neutrophils, and lymphocytes. [**2-24**] TTE: Compared with the prior study (images reviewed) of [**2201-2-16**], the aortic regurgitation appears more severe (may be underestimated due to eccentricity of jet). The aortic valve vegetation is not well visualized (especially on the parasternal short-axis views). [**2-25**] TEE: Compared with the findings of the prior TEE study (images reviewed) of [**2201-2-20**], the large mass associated with the pacemaker lead in the right atrial side is now absent. Moderate sized vegetation is present on the tricuspid valve. The vegetation on the right coronary cusp of the aortic valve is smaller, but the aortic annulus is more concerning for abscess formation. The severity of aortic regurgitation and mitral regurgitation are similar. [**2-26**] CT Chest: 1. New cluster of poorly defined subcentimeter right apical lung nodules, consistent with either an infectious or inflammatory etiology. Although potentially related to septic emboli, localized apical distribution is unusual for this entity. 2. Worsening left lower lobe consolidation/atelectasis. 3. Increasing moderate partially loculated left pleural effusion and new small right pleural effusion. 4. New asymmetric ground glass and septal thickening likely due to hydrostatic pulmonary edema. 5. Enlarging mediastinal lymph nodes, likely related to CHF or infection. Attention to these nodes on a future followup CT may be helpful to document resolution. [**2-27**] Foot x-ray: Bilateral soft tissue ulcers on the plantar aspects of the forefeet. Questionable lucency and cortical irregularity of the right sesamoid bone on the plantar aspect adjacent to the ulcer that could possibly represent osseous infectious involvement. [**2-28**] TTE: Compared with the prior study (images reviewed) of [**2201-2-25**], the vegetation on the right coronary cusp of the aortic valve is larger. The heterogeneous thickening at the aortic annulus is thicker. The focal echolucency at the base of the inter-atrial septum is similar and is very likely to be an abscess. The degree of aortic regurgitation has increased. There may be perforation of the right coronary cusp. The degree of mitral regurgitation has increased and the LV cavity appears slightly more dilated. The previously seen mass on the tricuspid valve is still present but image quality precludes exact comparison of size. [**3-9**] Skin bx: Leukocytoclastic vasculitis. [**3-10**] TEE: Compared with the prior study (images reviewed) of [**2201-2-28**], the vegetation on the right coronary cusp of the aortic valve is smaller. The heterogeneous thickening around the aortic annulus and at the base of the inter-atrial septum are similar. The degree of aortic regurgitation is similar. Destruction of the non-coronary cusp is now evident. There is a highly mobile mass in the right atrium near the IVC which was not seen on the prior study. [**3-10**] TTE: Compared with the prior study (images reviewed) of [**2201-2-24**], the severity of aortic regurgitation is increased (4+). Estimated pulmonary artery pressures are elevated (previously indeterminate). [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname 177**] [**Hospital1 18**] [**Numeric Identifier 81152**]Portable TTE (Complete) Done [**2201-4-20**] at 11:25:02 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] [**Street Address(2) 15115**] [**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2147-10-9**] Age (years): 53 M Hgt (in): 69 BP (mm Hg): 123/47 Wgt (lb): 283 HR (bpm): 70 BSA (m2): 2.40 m2 Indication: Pericardial effusion. Valvular heart disease. ICD-9 Codes: V43.3, 424.1 Test Information Date/Time: [**2201-4-20**] at 11:25 Interpret MD: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1661**], RDCS Doppler: Full Doppler and color Doppler Test Location: West Echo Lab Contrast: None Tech Quality: Suboptimal Tape #: 2009W008-0:13 Machine: Vivid [**7-1**] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *4.9 cm <= 4.0 cm Left Atrium - Four Chamber Length: *6.3 cm <= 5.2 cm Right Atrium - Four Chamber Length: *6.1 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.9 cm <= 5.6 cm Left Ventricle - Ejection Fraction: >= 55% >= 55% Aorta - Sinus Level: 3.1 cm <= 3.6 cm Aorta - Ascending: 3.2 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.9 m/sec <= 2.0 m/sec Aortic Valve - LVOT pk vel: 1.36 m/sec TR Gradient (+ RA = PASP): *28 mm Hg <= 25 mm Hg Findings This study was compared to the prior study of [**2201-3-10**]. LEFT ATRIUM: Dilated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic function (LVEF>55%). Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. No resting LVOT gradient. RIGHT VENTRICLE: RV not well seen. Paradoxic septal motion consistent with conduction abnormality/ventricular pacing. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). Normal AVR gradient. Trace AR. [The amount of AR is normal for this AVR.] MITRAL VALVE: Mildly thickened mitral valve leaflets. No mass or vegetation on mitral valve. TRICUSPID VALVE: Tricuspid valve not well visualized. Mild [1+] TR. Borderline PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal image quality - body habitus. Conclusions The left atrium is dilated. The right atrium is moderately dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. A bioprosthetic aortic valve prosthesis is present. The transaortic gradient is normal for this prosthesis. Trace aortic regurgitation is seen. [The amount of regurgitation present is normal for this prosthetic aortic valve.] The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: poor technical quality due to patient's body habitus. Bioprosthetic AVR with normal gradients and no evidence of vegetation (transthoracic echo cannot exclude). Left ventricular function is probably normal, a focal wall motion abnormality cannot be fully excluded. The right ventricle is not well seen. Based on [**2198**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis IS recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. If clinically suggested, the absence of a vegetation by 2D echocardiography does not exclude endocarditis. Compared with the prior study (images reviewed) of [**2201-3-10**], a bioprosthetic AVR has replaced. Electronically signed by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2201-4-20**] 17:04 CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 81153**] Reason: f/u effusions/consolidation Final Report TYPE OF EXAMINATION: Chest PA and lateral. INDICATION: Status post redo of aortic valve replacement and ascending aorta. Followup for effusion and consolidation. FINDINGS: AP and lateral chest views were obtained with patient in sitting upright position. Available for comparison is a preceding single AP chest view of [**2201-4-20**]. The patient is status post sternotomy and aortic valve repair (redo) of [**2201-4-17**]. Status post sternotomy, ring-shaped metallic structure of aortic valve prosthesis and multiple thin wires for epicardial electrodes in place as before. High positioned diaphragms and basal pulmonary densities obscure heart shadow which probably is enlarged. Right lung base has cleared up considerably and is now almost same as appeared on preoperative chest examination of [**4-15**]. No new infiltrates are present. The left-sided retrocardiac density representing a mixture of atelectasis and some residual postoperative pleural thickening remains, but has improved moderately in comparison with the next preceding single chest view examination of [**2201-4-20**]. No new parenchymal abnormalities are seen and the accessible pulmonary vasculature does not demonstrate edema pattern. No pneumothorax identified in the apical areas. The lateral view now obtained for the first time after the recent operation demonstrates some parenchymal density in the left lower lobe posterior segment, not noted on the preoperative examination. IMPRESSION: Further improvement of postoperative changes. Right base almost completely clear. Left-sided residual atelectasis and infiltrate remaining and further followup recommended. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Initials (NamePattern5) 3250**] [**Last Name (NamePattern5) 3251**] Brief Hospital Course: PREOPERATIVE COURSE: 1. Sepsis: The patient was initially covered with vancomycin, pipercillin / tazobactam, levofloxacin, and metronidazole given an unclear source of his sepsis. He was meeting SIRS criteria with WBC, fever, HR, and initial PaCO2. Initial concern was for pneumosepsis but given questionable history of diarrhea and/or abdominal pain he was covered for C. diff and HAP. Surveillance cultures were drawn but have been consistently negative however initial blood cultures at [**Location (un) **] did yield Group B Strep. The patient did proceed on to have a bronchoscopy, which revealed no impressive infiltrate, purulence, or organisms. Urine exam did not reveal pyuria and cutlures were negative. Other possible sources of his bacteremia considered were intra-abdominal abcess and his foot ulcers (though these were probed and did not have deep tracts). Finally, the patient did, by report, pull one of his own teeth a week PTA and thus a dental abcess was considered. After bronchoscopy was not consistent with pneumonia and given the patient's persistently benign belly exam his pipercillin/tazobactam and metronidazole were stopped. Levofloxacin was continued for a CAP course and the patient remained on vanco for GPC bacteremia until culture data revealed these were GBS at which time in consultation with ID he was switched to Penicillin G. On presentation the patient was on norepinephrine to support blood pressures though this was weaned off on [**2201-2-9**]. Scan of chest and abdomen was negative for occult abcess. Given history of valve surgeries and other foreign body placement in the heart he had TTE and TEE as discussed below. It was felt that cause of bacteremia and sepsis was related to endocarditis with bacteremia most likely from foot ulcers since positive blood cx at OSH and foot wound cx both growing group B strep. Endocarditis treated as below. 2. Endocarditis: Given that this patient has a history of endocarditis and valvular surgery with a bioprosthesis the ICU team remained concerned about the possibility of an endocarditis. A TTE was obtained on [**2201-2-6**] that did not show any vegetations but this was not an ideal exam and given clinical picture and organism it was felt necessary to further evaluate with TEE. On [**2201-2-10**] a TEE was obtained that showed multiple large vegetations on his pacemaker wires and aortic valve leaflets as well as concern for an aortic root abscess. Given concern for further interference with conduction system due to progressive infection and probable need to d/c pacer leads cardiology requested the patient be transferred to the CCU on [**2201-2-11**]. ID and CT surgery were involved with case discussion. Patient was continued on Gentamicin and Pencillin. Antibiotics later changed to just penicillin given concern that gent was contributing to renal failure. PCN was subsequently changed to ceftriaxone [**2201-3-12**] given concern for causing leukocytoclastic vasculitis. Pacemaker wires were taken out after long discussion with ID/EP/CT surgery with the thought that patient was unlikely to have operation in the next several weeks and that the curative potential with medical therapy alone would likely be insufficient. As per CT surgery, dental consult was requested for surgical clearance. Oral surgery recommended 4 teeth extraction prior to OR and patient was resistant to this especially in the setting of not having definitive OR time planned currently. He subsequently had 4 teeth extraction on [**2201-3-4**]. Ongoing discussions with CT surgery continued and they refused to take patient to OR given high perioperative mortality risk. Due to concern that patient had change in clinical status on [**2201-3-1**] with hypotension and complaints of nausea and chest discomfort, he was urgently intubated for repeat TEE. Serial TEEs showed progression of AI and development of likely abscess (as outlined in results) as well as destruction of non coronary cusp. He developed signs and symptoms of heart failure and volume overload as discussed below. ID recommended continuing CTX indefinitely and following weekly CBC, LFTs, ESR, CRP. Ultimately, his case was re-presented at CT surgery conference on [**2201-3-16**], where they decided to perform AVR on [**3-31**]. Prior to surgery, he underwent a pre-op cardiac catheterization which showed clean coronaries. 3. Acute diastolic heart failure: Pt developed signs and symptoms of volume overload on [**2201-3-8**] with shortness of breath, increased oxygen requirement and lower extremity edema. Echo showed preserved EF, no WMA and worsening AI. CHF most likely secondary to worsening valvular disease. He was diuresed with lasix IV, intermittently on lasix gtt then transitioned to PO torsemide with improvement in symptoms, although remained on a small amount of supplemental oxygen for comfort. 4. Respiratory failure: The patient was intubated for lethargy and acidosis initially and was given 8 L on his presentation to help maintain his BP's. This undoubtedly contributed to his continued hypoxemic respiratory failure. He was advanced to pressure support with stable ventilation and oxygenation. On transfer to the CCU patient was still intubated but off pressors. Patient was extubated successfully. He was reintubated [**2201-3-1**] transiently for 48 hours for urgent TEE and subsequently extubated without adverse effect or complication. 5. Wide Complex Tachycardia: At the outside hospital the patient was noted to be in a wide complex tachycardia and initially there was concern that this was ventricular tachycardia so the patient was put on amiodarone gtt. On arrival to ICU this was reassessed and pacer spikes were visible and cardiology agreed this was most likely his V-paced rhythm. Amiodarone was stopped and rhythm did not reoccur. He remained V paced at 80. HR was initially set at 60 but increased to 80 to improve forward flow and cardiac output. As above, EP placed temp wire. 6. Diabetes: The patient had an anion gap at the outside hospital but this was closed by his arrival here. Nevertheless he continued to have elevated BGs in the 200's to 300's range. He was transitioned to subcutaneous insulin with initially reasonable control of BGs. Unfortunately, these began to worsen again so on [**2201-2-11**] he was transitioned back to insulin drip prior to his transfer to the CCU. Patient was again switched to SC insulin once he was extubated and eating. He later had some symptomatic hypoglycemia (50s-60s), so his glargine dose was lowered from 40 units to 38 units qhs. However, he was hyperglycemic in the evenings so he was transitioned to NPH 20U in the am and 15U in the pm. Subsequently, the BG were still not controlled [**First Name8 (NamePattern2) **] [**Last Name (un) **] was consulted and recommended restarting lantus. His FSBS were better controlled thereafter. 7. Hyponatremia: The patient was hyponatremic at presentation presumably in the setting of diarrhea and hypovolemia. This resolved in the setting of hydration. 8. Thrombocytopenia: The patient was initially thrombocytopenic presumebly due to his sepsis. This resolved as his infection was treated. 9. Anemia: Anemia most likely secondary to inflammation. Blood loss may also have been initial component given initial gastroccult + NGT secretions while intubated. He had no further evidence of GIB and remained guaiac negative subsequently. He had persistently low retic count with elevated ferritin. He was treated with pantoprazole 40 mg PO Q12H and transfused for HCT <25. He received a total of 6 PRBC trasnfusions throughout hospital course ([**2-12**], [**2-15**], [**2-17**], [**2-24**] and [**3-1**] x2). HCT subsequently remained stable around 25. 10. Rash: Patient developed a symmetric erythematous nonblanching maculopapular rash on bilateral lower extremities on [**2201-3-8**]. Dermatology was consulted and biopsy was done which was consistent with leukocytoclastic vasculitis. Given timing of rash, they felt it was most likely secondary to endocarditis but infectious disease was concerned that rash was from PCN so they recommended changing abx to ceftriaxone which was done. Rash continued to improve and he did not develop any new lesions. 11. Depression: Patient had persistent flat affect with s/s depression. He intially was not interested in seeing psychiatry but was later agreeable. Psychiatry was consulted who felt symptoms were a combination of delirium and dementia. They recommended sertraline and methylphenidate which were started and uptitrated. The methylphenidate was later stopped per patient request, as he noted blurry vision. 12. Foot ulcers: Pt had bilateral foot ulcers (R>L) which grew GBS and were felt to be source of endocarditis. He was followed by podiatry who recommended daily wet to dry dsg changes. At time of discharge, they did not believe ulcers were infected. His activity was restricted to FWB on left and partial weight bearing on RLE. 13. Acute on chronic renal insufficiency: Pt developed acute on chronic renal insufficiency with elevated creatinines on 2 occasions during hospital course. His creatinine trended up to 1.8-2.[**1-26**] which was felt to be secondary to gentamicin. Creatinine subsequently improved briefly after genatmicin was discontinued. Creatinine then rapidly trended up again to peak 3.6 on [**3-2**]. Nephrology was consulted who felt acute on chronic renal failure likely secondary to ATN from brief hypotension on [**2201-2-27**] when pt appeared more ill and was intubated. It may also have been from septic emboli. Creatinine subsequently improved but remained around 1.9 as a new baseline, likely from decreased renal perfusion with CHF and in then up to 21 with aggressive diuresis. 14. FEN: Patient with poor PO intake and low albumin. Patient was not meeting his nutritional needs with his current diet but PO intake slowly improved. Albumin low to mid 2s most of hospital stay, but was increased to 3.1 on [**2201-3-14**]. 15. LE edema: Patient developed 2+ pitting edema to legs with bilateral erythema and bullae over anterior of tibias. Patient was followed by wound care which improved with diuresis and dressing changes. INTRAOPERATIVE COURSE: On [**4-17**], Dr. [**First Name (STitle) **] performed redo sternotomy, redo aortic valve replacement with reconstruction of aortic root and ascending aorta, with placement of dual chamber pacemaker. Given patient inpatient stay was greater than 24 hours prior to surgery, Vancomycin was give for perioperative antibiotic coverage. For surgical detail, please refer to operative note. POSTOPERATIVE COURSE: Following the operation, he was brought to the CVICU on Levophed and Epinephrine but in stable condition. Within 24 hours, he awoke neurologically intact and was extubated without incident. EP interrogation found a properly functioning dual chamber [**Company 1543**] pacemaker with an underlying of sinus rhythm with 2:1 block. Over several days, he gradually weaned from inotropic support. He maintained stable hemodynamics and transferred to the telemetry floor on postoperative day four. Over the next several days the patient had an uneventful post-operative course. On POD 7 he was discharged to rehabilitation. He is to have 1 week of IV antibiotics followed by an indefinate course of oral antibiotics post discharge. Follow up as directed. Medications on Admission: Zocor 40 Lisinopril 5 Metformin 850 [**Hospital1 **] Keflex 500 QID Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 4. Ammonium Lactate 12 % Liquid Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 5. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical PRN (as needed). 6. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 9. Petroleum Jelly Gel Sig: One (1) Topical [**Hospital1 **] (2 times a day). 10. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. Insulin Glargine 100 unit/mL Solution Sig: Thirty Two (32) units Subcutaneous at bedtime. 12. Insulin Lispro 100 unit/mL Solution Sig: as directed Subcutaneous every four (4) hours: Per sliding scale. 13. Warfarin 1 mg Tablet Sig: as directed Tablet PO once a day: target INR 2.5-3.5 Patient to receive 3 mg on [**4-24**] then as directed at rehab. 14. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for SBP<100 HR<60. 16. Sodium Chloride 0.9 % 0.9 % Solution Sig: daily and prn ML Injection PRN (as needed) as needed for line flush: 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. 17. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO twice a day: while taking lasix. 18. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day. 19. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig: Two (2) gms Intravenous Q24H (every 24 hours): continue through [**5-1**] then Cefuroxime 500mg Q12 hrs. 20. Cefuroxime Axetil 500 mg Tablet Sig: One (1) Tablet PO Q 12 hours: start [**5-2**]: after Ceftriaxone course completed. Discharge Disposition: Extended Care Facility: [**Hospital6 25759**] & Rehab Center - [**Location (un) **] Discharge Diagnosis: prosthetic Aortic Valve endocarditis prosthetic aortic Regurgitation s/p aortic valve replacement [**3-29**] s/p reoperative aortic valve replacement(homograft),aortic root abscess resection [**9-28**] s/p DDD pacer implantation s/p removal infected pacemaker venous stasis ulcers hyperlipidemia insulin dependent diabetes mellitus s/p removal infected pacemaker Discharge Condition: good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month, and while taking narcotics No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] I. [**Telephone/Fax (1) 80567**] Appointment in [**7-3**] days PCP [**Last Name (NamePattern4) **] [**1-27**] weeks Dr [**First Name8 (NamePattern2) 1370**] [**Last Name (NamePattern1) 28949**]([**Location (un) 11269**]) [**Telephone/Fax (1) 76254**] Please call for all appointments Provider:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13447**],MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2201-5-26**] 10:30 Provider:[**Name10 (NameIs) **] [**Name11 (NameIs) 3628**](NHB) Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2201-5-6**] 8:15 Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2201-5-6**] 9:00 Formal outpatient polysomnogram (please order at [**Hospital1 **]-[**Location (un) 620**]) Outpatient f/u in Sleep Disorders Center [**Telephone/Fax (1) 55570**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2201-4-24**]

[ "443.81", "250.52", "311", "285.9", "357.2", "362.02", "E930.8", "276.0", "250.62", "250.82", "446.29", "996.61", "486", "518.81", "707.15", "E930.0", "250.72", "327.23", "427.31", "429.89", "584.5", "780.09", "785.52", "428.31", "585.9", "294.8", "E878.1", "995.92", "272.4", "459.81", "V53.31", "276.1", "427.1", "584.9", "287.5", "250.12", "038.0", "428.0" ]

icd9cm

[ [ [] ] ]

[ "37.23", "37.77", "33.24", "86.22", "39.59", "23.19", "96.04", "39.63", "86.28", "37.89", "96.6", "88.72", "96.72", "39.61", "35.22", "37.33", "89.45", "37.72", "34.91", "38.93", "38.91", "37.83", "86.11", "88.56" ]

icd9pcs

[ [ [] ] ]

31765, 31851

18015, 29433

284, 574

32258, 32265

2884, 17992

32805, 33921

2229, 2247

29552, 31742

31872, 32237

29459, 29529

32289, 32782

2264, 2865

237, 246

602, 1734

1756, 2127

2143, 2213

5,979

198,678

25128

Discharge summary

report

Admission Date: [**2147-6-30**] Discharge Date: [**2147-7-20**] Date of Birth: [**2095-7-1**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1973**] Chief Complaint: GI bleed, respiratory failure Major Surgical or Invasive Procedure: EGD at outside hospital History of Present Illness: 51 y.o. male with history of alcholism, HTN, hypercholesterolemia who is now being transferred from OSH for further work-up of severe GIB. . Patient has a history of severe alcoholism, reporting up to 7 shots of Tequilla per day and recently went on a drinking binge for approximately 13 days prior to presentation to [**Hospital3 12748**]. During this time, he is reported to have become progressively weaker and had one episode of hematemesis. He additionally is reported to have aspirated his emesis, though his sister knows of no resultant fevers, cough, SOB and denies any recent travel or sick contacts. [**Name (NI) **] largely isolated himself during this time so little is known of the events that took place. He was urged to go to the hospital at several times, to include when he experienced hematemesis, but patient denied. He has a history of poor follow-up with doctors. Patient finally presented to [**Hospital6 3105**] on [**6-29**] where he was initially hypoxic, tachypneic and hypotensive to SBP in the 60s. He was urgently intubated, started on pressors and admitted to the ICU for further management. . During this hospitalization, patient was found to be in renal failure with BUN of 288 and creatinine of 19.9. He also had a metabolic acidosis from renal failure and lactic acidosis from presumed, prolonged hypoxia/hypoperfusion. Since he was aniuric in this setting, HD was initiated through a temporary groin line. Additionally, an EGD was performed given history of alcoholism and report of hematemesis and hypoxia on presentation and this revealed an esophageal ulcer that was injected with 10 ccs of epinephrine and clipped x 2. It was felt that this would only be a temporizing measure so patient was sent to [**Hospital1 18**] for further evaluation, namely from IR and thoracics. . Upon arrival to [**Hospital1 18**], patient was intubated, sedated and on Levophed, Neosynephrine and Vasopressin. An a-line was placed and stat imaging showed bilateral lung infiltrates and dilateld loops of small bowel. A repeat EGD was performed on [**7-7**], which demonstrated a clipped GE jxn ulcer, and a few gastric fundus ulcers, all were nonbleeding. After careful discussion wtih GI and surgery, an OG tube was placed as a last resort to decompress the small bowel. Patient received 1 unit of PRBCs, 1 unit of platelets as well as 1 unit of FFP. Past Medical History: Alcoholism CAD HTN Hyperlipidemia History of Vicodin abuse, on Methadone DVT and PE s/p IVC filter DM Depression Suicidal Ideations Obesity Chronic Renal Failure (creatinine of 1.3 - 1.7 in '[**44**]) Social History: History of tobacco (1 ppd x 30 years), ETOH with several Tequilla shots/day, but no history of DTs, history of Vicodin abuse, on Methadone. Used to live with wife and 3 children and own his own furniture store; recently, his wife divorced him and placed a restraining order, banning him from the househould. His mother wishes to claim gaurdianship over him. At this point, the patient does not have a certain household to which he would ultimately be discharged. Mother/sister have attempted Section 35 last fall, which was unsuccesful. Family History: NC Physical Exam: VS: T - 97.7, BP - 106/52, HR - 112, RR - 19, O2 - 89% AC 550/24/8/1 GEN: Blood oozing from mouth, sedated, intubated, nonresponsive HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection, anicteric, OP clear, MMM, Neck supple, no LAD, no carotid bruits CV: RRR, nl s1, s2, no m/r/g PULM: CTAB, no w/r/r with good air movement throughout ABD: soft, markedly distended and tympanic to percussion, decreased BS EXT: warm, dry, +2 distal pulses BL, no femoral bruits Pertinent Results: KUB ([**7-1**]): Single portable view of the abdomen without prior imaging for comparison reveals multiple distended loops of small bowel. There is relative paucity of gas within the colon. Findings are suggestive of possible mechanical small-bowel obstruction. IVC filter and right-sided femoral central venous catheter incidentally identified. CXR ([**7-1**]): Endotracheal tube has been placed with tip terminating 4 cm above the carina. Left internal jugular catheter has been placed with tip terminating in the proximal-to-mid superior vena cava, with no pneumothorax. Right PICC has apparently been removed. Cardiac silhouette is mildly enlarged, and there is new combined alveolar and interstitial pulmonary edema, likely due to fluid overload, accompanied by small bilateral pleural effusions. Mild-to-moderate gastric distension has developed with prominence of the gastric folds noted. Abdominal U/S ([**2147-7-3**]): 1. Echogenic liver consistent with fatty infiltration. Other forms of liver disease and more advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on this study. 2. No gallstones and no signs of cholecystitis. No biliary dilatation. 3. Mild splenomegaly. 4. Trace of ascites. 5. No hydronephrosis. TTE ([**2147-7-3**]): The left atrium is elongated. A patent foramen ovale is present with right-to-left passage of microbubbles post Valsalva release, but no flow at rest. . Mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The aortic valve leaflets appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Right ventricular cavity enlargement with free wall hypokinesis. Mild symmetric left ventricular hypertrophy with preserved global systolic function. Patent foramen ovale. EEG ([**2147-7-2**]): Abnormal portable EEG due to the abnormal background consisting of disorganized low voltage fast activity with admixed theta and delta frequency activity in the posterior regions bilaterally. The findings are consistent with a moderate to severe encephalopathy and suggestive of dysfunction of bilateral subcortical or deep midline structures. Medications, metabolic disturbance, and infection are among the common causes of the encephalopathy, but there are others. There were no areas of prominent focal slowing although encephalopathic patterns can sometimes obscure focal findings. There were no clearly epileptiform features. No electrographic seizure activity was noted. If of clinical interest, the study can be repeated in absence of sedative medicatoins for a better assessment of the background. EGD [**7-7**]: Impression: Normal mucosa in the esophagus Ulcer in the gastroesophageal junction Erythema and congestion in the stomach compatible with gastritis Ulcers in the fundus No gastric or esophageal varicies were seen. Normal mucosa in the duodenum Recommendations: [**Hospital1 **] proton pump inhibitor check H. Pylori serology Treat for H. Pylori if biopsy positive Repeat EGD if acutely rebleeds EGD in [**8-22**] weeks Additional notes: Source of bleeding appears to be gastric ulcers. BILAT LOWER EXT VEINS ([**2147-7-10**]): No deep venous thrombosis in right or left common femoral, superficial femoral, or popliteal veins. CXR ([**2147-7-10**]): Single AP chest radiograph compared to [**2147-7-9**] shows slight improvement in the perihilar edema. Bibasilar atelectasis and small left pleural effusion persist. The cardiomediastinal contour is stable. Right IJ central venous catheter terminates within the proximal SVC. ET tube terminates 4.7 cm above the carina. NG tube courses below the diaphragm, the tip has been excluded. RUQ Ultrasound ([**2147-7-7**]): 1. Fatty liver with associated perihepatic ascites and a small right effusion. 2. No evidence of gallbladder or biliary disease. [**2147-7-14**] 07:50AM BLOOD WBC-5.1 RBC-2.95* Hgb-8.9* Hct-26.5* MCV-90 MCH-30.2 MCHC-33.6 RDW-14.8 Plt Ct-155 [**2147-7-13**] 04:21AM BLOOD WBC-3.7* RBC-2.80* Hgb-8.7* Hct-25.0* MCV-89 MCH-31.1 MCHC-34.8 RDW-14.7 Plt Ct-121* [**2147-7-12**] 01:07AM BLOOD WBC-2.6* RBC-2.75* Hgb-8.3* Hct-24.4* MCV-89 MCH-30.1 MCHC-33.9 RDW-14.8 Plt Ct-97* [**2147-7-2**] 03:50AM BLOOD WBC-25.4* RBC-3.07* Hgb-9.7* Hct-27.3* MCV-89 MCH-31.6 MCHC-35.6* RDW-15.8* Plt Ct-60* [**2147-7-1**] 12:05AM BLOOD WBC-18.2*# RBC-3.08* Hgb-9.5* Hct-27.5* MCV-89 MCH-31.0 MCHC-34.7 RDW-15.5 Plt Ct-108*# [**2147-6-30**] 10:48PM BLOOD WBC-8.4 RBC-2.92* Hgb-9.0* Hct-25.4*# MCV-87# MCH-30.7 MCHC-35.2* RDW-15.3 Plt Ct-49*# [**2147-7-9**] 03:07AM BLOOD PT-13.2 PTT-29.2 INR(PT)-1.1 [**2147-7-1**] 09:40AM BLOOD PT-15.4* PTT-39.8* INR(PT)-1.4* [**2147-6-30**] 10:48PM BLOOD PT-15.7* PTT-45.7* INR(PT)-1.4* [**2147-7-3**] 04:38AM BLOOD Fibrino-405* [**2147-7-2**] 03:50AM BLOOD Fibrino-381 D-Dimer-4995* [**2147-7-14**] 07:50AM BLOOD Glucose-86 UreaN-12 Creat-1.3* Na-143 K-3.3 Cl-111* HCO3-23 AnGap-12 [**2147-7-13**] 04:21AM BLOOD Glucose-89 UreaN-14 Creat-1.4* Na-142 K-3.1* Cl-109* HCO3-26 AnGap-10 [**2147-7-1**] 09:40AM BLOOD Glucose-234* UreaN-82* Creat-6.3* Na-139 K-4.3 Cl-102 HCO3-20* AnGap-21* [**2147-7-1**] 12:05AM BLOOD Glucose-166* UreaN-80* Creat-6.2* Na-138 K-4.5 Cl-106 HCO3-16* AnGap-21* [**2147-6-30**] 10:48PM BLOOD Glucose-126* UreaN-82* Creat-6.2*# Na-139 K-3.9 Cl-105 HCO3-20* AnGap-18 [**2147-7-9**] 03:07AM BLOOD ALT-27 AST-32 AlkPhos-405* TotBili-1.2 [**2147-7-7**] 04:09AM BLOOD ALT-31 AST-40 LD(LDH)-155 AlkPhos-582* TotBili-2.1* [**2147-7-1**] 12:05AM BLOOD ALT-28 AST-42* CK(CPK)-143 AlkPhos-108 Amylase-310* [**2147-6-30**] 10:48PM BLOOD ALT-27 AST-39 CK(CPK)-153 AlkPhos-100 TotBili-1.6* [**2147-7-7**] 04:09AM BLOOD GGT-587* [**2147-7-6**] 04:00AM BLOOD Lipase-51 [**2147-7-1**] 12:05AM BLOOD Lipase-589* [**2147-7-14**] 07:50AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.7 [**2147-7-13**] 04:21AM BLOOD Calcium-8.1* Phos-3.5 Mg-1.7 [**2147-7-9**] 03:07AM BLOOD Albumin-2.5* Calcium-7.7* Phos-3.2 Mg-1.9 [**2147-7-5**] 04:30AM BLOOD Albumin-2.2* Calcium-7.7* Phos-3.2 Mg-1.8 [**2147-6-30**] 10:48PM BLOOD Albumin-2.8* Calcium-6.3* Phos-4.6* Mg-1.6 [**2147-7-6**] 04:00AM BLOOD calTIBC-134* Ferritn-637* TRF-103* [**2147-7-1**] 12:05AM BLOOD Triglyc-247* [**2147-7-3**] 08:18AM BLOOD Prolact-22* [**2147-7-3**] 05:42PM BLOOD PTH-62 [**2147-7-2**] 11:37AM BLOOD Cortsol-42.4* [**2147-7-2**] 09:46AM BLOOD Cortsol-28.7* [**2147-7-3**] 08:18AM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE HBcAb-POSITIVE HAV Ab-NEGATIVE [**2147-7-3**] 08:18AM BLOOD HCV Ab-NEGATIVE [**2147-7-10**] 02:40PM BLOOD Type-ART Temp-37.7 Rates-/23 Tidal V-400 FiO2-40 pO2-83* pCO2-39 pH-7.48* calTCO2-30 Base XS-5 Intubat-INTUBATED Vent-SPONTANEOU [**2147-7-10**] 03:43AM BLOOD Type-ART Temp-37.1 FiO2-40 pO2-110* pCO2-38 pH-7.50* calTCO2-31* Base XS-6 [**2147-7-9**] 03:16AM BLOOD Type-ART Temp-36.8 PEEP-10 FiO2-50 pO2-119* pCO2-41 pH-7.44 calTCO2-29 Base XS-4 Intubat-INTUBATED [**2147-7-8**] 07:20PM BLOOD Type-ART Temp-36.2 pO2-88 pCO2-32* pH-7.51* calTCO2-26 Base XS-2 Intubat-INTUBATED [**2147-7-6**] 01:00PM BLOOD Type-ART Temp-37.2 pO2-76* pCO2-41 pH-7.41 calTCO2-27 Base XS-0 Intubat-INTUBATED [**2147-7-4**] 06:31PM BLOOD Type-ART Temp-36.1 Rates-24/ Tidal V-480 FiO2-50 pO2-116* pCO2-32* pH-7.41 calTCO2-21 Base XS--2 Intubat-INTUBATED [**2147-7-1**] 03:11AM BLOOD Type-ART Temp-36.4 Rates-26/ Tidal V-550 PEEP-22 pO2-64* pCO2-43 pH-7.20* calTCO2-18* Base XS--10 Intubat-INTUBATED Vent-CONTROLLED [**2147-7-1**] 02:24AM BLOOD Type-ART Temp-36.4 Rates-/20 Tidal V-830 PEEP-24 FiO2-100 pO2-66* pCO2-40 pH-7.24* calTCO2-18* Base XS--9 AADO2-620 REQ O2-99 Intubat-INTUBATED Vent-SPONTANEOU [**2147-6-30**] 11:29PM BLOOD Type-ART Rates-22/6 Tidal V-550 PEEP-8 FiO2-100 pO2-49* pCO2-48* pH-7.26* calTCO2-23 Base XS--5 AADO2-629 REQ O2-100 -ASSIST/CON Intubat-INTUBATED [**2147-7-3**] 12:37AM BLOOD Lactate-2.2* [**2147-7-1**] 03:11AM BLOOD Lactate-2.5* [**2147-6-30**] 10:53PM BLOOD Lactate-2.3* [**2147-7-9**] 04:31PM BLOOD freeCa-1.06* [**2147-7-6**] 01:00PM BLOOD freeCa-1.15 [**2147-7-1**] 03:15PM BLOOD freeCa-0.86* [**2147-7-1**] 10:12AM BLOOD freeCa-0.82* [**2147-7-10**] 02:00AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 [**2147-7-1**] 02:36AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.009 [**2147-7-10**] 02:00AM URINE Blood-LG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.5 Leuks-NEG [**2147-7-1**] 02:36AM URINE Blood-LG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2147-7-10**] 02:00AM URINE RBC-[**11-30**]* WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2 [**2147-7-1**] 02:36AM URINE RBC-[**6-20**]* WBC-[**3-15**] Bacteri-FEW Yeast-NONE Epi-0-2 [**2147-7-10**] 02:00AM URINE CastGr-0-2 [**2147-7-7**] 04:35AM URINE AmorphX-RARE [**2147-7-3**] 06:34PM URINE Hours-RANDOM Creat-75 TotProt-55 Prot/Cr-0.7* URINE CULTURE (Final [**2147-7-11**]): NO GROWTH. Blood Culture, Routine (Pending, [**2147-7-10**]). GRAM STAIN (Final [**2147-7-10**]): [**11-4**] PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2147-7-12**]): SPARSE GROWTH OROPHARYNGEAL FLORA. CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2147-7-10**]): FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. HELICOBACTER PYLORI ANTIBODY TEST (Final [**2147-7-10**]): NEGATIVE BY EIA. (Reference Range-Negative). Blood Culture, Routine (Final [**2147-7-13**]): NO GROWTH. WOUND CULTURE Catheter Tip (Final [**2147-7-8**]): No significant growth. Brief Hospital Course: 51 y.o. male with history of alcoholism, being transferred from [**Hospital3 1443**] Hospital post GI Bleeding with intervention with hypotensive shock, requiring multiple pressors, admitted to MICU initially, stabilized, then stabilized for discharge on the floor. 1. Hemorrhagic Shock: Initially likely due to hypovolemia from bleeding esophageal ulcer s/p EGD with injection and poor PO intake, however remained hypotensive despite injection of ulcer and had received IVF and PRBCs for resuscitation. At OSH, he was started on pressors given persistent hypotension and although he had no elevated WBC or fever, patient received Zosyn, Vancomycin and Ceftazidime while there. He was intubated in the MICU. He received 1 unit FFP, 2 bags of platelets upon [**Hospital **] transfer to [**Hospital1 18**] and was transfused a total of 5 Units of PRBCs with hematocrit stable thereafter. He was continued on zosyn/vancomycin upon transfer to [**Hospital1 18**] out of concern for hospital acquired pneumonia. With stability in his hematocrit and continued antibiotics, pressors were discontinued, the patient was extubated and was transferred to the general medicine floor where his BPs remained stable. # Acute blood loss anemia due to gastrointestinal bleeding due to gastric ulcer: GI was consulted and performed EGD which revealed a row of a few non-bleeding ulcers in the fundus and gastritis without active bleeding. He was transfused blood products as outlined above and his hematocrit remained stable thereafter. H. pylori antibody was negative. He was continued on [**Hospital1 **] PPI, upon d/c his hematocrit had stabilized to approx 25. He will need repeat EGD in [**8-22**] weeks from scope on [**7-7**]. # Acute Respiratory Distress Syndrome: ARDS by definition thought secondary to pancreatitis vs. aspiration event vs. Hospital Acquired Pneumonia. Was initially placed on ARDSNet ventilation however patient became markedly hypoxic in this setting. Nitric oxide was used without effect. He was thereafter placed prone with good effect on his oxygention. Following initial prone positioning and supination thereafter, his oxygenation improved markedly. He was continued on vancomycin/zosyn for presumed HAP and oxygenation improved dramatically with antibiotics and subsequent diuresis for volume overload. He was weaned from the ventilator without complications on [**7-10**]. On the general medical floor, he was weaned off nasal O2 to room air without complication. # Acute Renal Failure on CKD III, Acute Tubular Necrosis: Requiring initiation of HD at OSH for oliguric/anuric renal failure though secondary to ATN from prolonged hypoxia/hypoperfusion. Presented from OSH with femoral HD line in place, however was nonfunctioning thought mainly secondary to elevated intraabdominal pressures on presentation. During his course electrolytes remained stable not requiring HD and UOP picked up. Lasix was used to supplement autodiuresis to which he responded well. His renal function continued to improve in this setting at which point he was transferred to the medical floor, where his lasix was discontinued. His Cr stabilized to his baseline value of 1.3. # Altered mental status/Delirium: There was concern per family that patient had experienced seizure activity at OSH however d/w OSH staff denies this. He remained largely unresponsive even to painful stimuli on presentation so EEG was checked which showed encephalopathy but no evidence of epileptiform activity. While weaning his sedation, he became increasingly responsive following simple commands and post extubation he was verabl and responded to commands. Upon discharge he was AOx3, and at his presumed baseline. # Substance Dependence Alcohol: Reportedly without h/o DTs and withdrawal seizures. Versed was used for sedation and he was without evidence of withdrawal while on versed. He was continued on folate and thiamine. After extubation, social work was consulted for continued EtOH abuse. He was tapered off Ativan upon D/C without complication. In the past he has apparently taken disulfiram, however, this was not resumed as an inpatient. He also had some difficulty sleeping (chronic), and required prn trazodone. He was not sent home with any of these medications as it was determined that his PCP would best be able to address the needs for this medicine. # CAD: Cardiac enzymes negative on presentation. Lipitor, BB, and ACEI were initially held in the setting of his clinical instability and the BB and ACEI were restarted without event. His aspirin was held in the setting of GI bleed. Ultimately, in the hospital he was resumed on lisinopril 30mg daily, metoprolol tartrate 75mg tid, amlodipine 10mg daily. Upon discharge his lipitor was held, as it was not resumed during his hospital course. This medicine should be resumed by the patient's PCP if it is clinically warranted. # Benign Hypertension: Antihypertensive mediations were held on presentation given shock. Lasix was used preferentially over BB and ACEI given goal to diurese and ARF. Ultimately, before discharge, he was resumed on lisinopril 30mg daily, metoprolol tartrate 75mg tid, amlodipine 10mg daily. Additionally, we began HCTZ 25mg PO daily. As an outpatient he is instructed to take ToprolXL 200mg daily, lisinopril 30mg daily, amlodipine 10mg daily. # Hyperlipidemia: He was not resumed on his home statin, but was given a prescription for it upon discharge. This should be followed-up as an outpatient with his PCP to determine whether the medicine should be resumed. # Fevers, Bacterial Pneumonia: The patient was afebrile at discharge with a WBC of 6.5. Final cultures were negative. Due to hypotension and fevers in the ICU, the patient was started briefly on vanc/zosyn but has been off the medicine since [**7-9**]. No non-infectious etiologies of fever such as meds, rheum issues were found; lower-extrem noninvasive doppler studies were also negative. # Anemia: HCT around 25 and stable. Should followup as an outpatient to ensure continued resolution. # Social Work: Has been following pt, saw pt [**7-12**] - spend significant time talking to sister/mother/social worker regarding [**Name2 (NI) 63020**] and gaurdianship. initially, the mother and sister planned to go to court on mon [**7-17**], to file for guardianship in order to place him at a long term rehab for addictions that (avoiding [**Location (un) 1475**], as the patient had filed for a Section 35 in fall [**2146**]). However, the attending physician and medical team did not believe that the patient was mentally or physically incapacitated, and thus would not endorse the document. After close work with social work and case management, and several lengthy discussions with the patient, family, and members of the healthcare team, it was decided that the patient would go to his mother's home with the condition of strict rules, namely, no EtOH whatsoever, and to only smoke outside of the home. He was also instructed at length to go to alcohol/addiction rehab meetings daily, occupy himself productively with many of his creative hobbies (woodworking, guitar, etc), and attend daycare programs for his own health. He was also told that he would be sent to a homeless shelter if he did not cooperate. Finally, his ex-wife has allowed him to visit the home during the daytime only so that he can do his woodwork, etc; however, he must return home at night - again, there is to be no EtOH whatsoever. # Physical Thearpy: At discharge the patient was walking with occasional assistance/walker. PT has cleared patient to go home without the need for physical rehab. Medications on Admission: Thiamine Toprol Norvasc Lipitor Lantus w/ Insulin SS Iron Lisinopril Felodipine MVI Discharge Medications: 1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. Disp:*1 1* Refills:*2* 2. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation every six (6) hours as needed. Disp:*1 1* Refills:*2* 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 6. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Multivitamins Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. Disp:*30 Tablet, Chewable(s)* Refills:*2* 8. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 10. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 11. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 12. Lantus 100 unit/mL Solution Sig: 15unit Subcutaneous at bedtime. Disp:*1 month's supply* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: Primary: alchohol addiction, massive upper GI bleed, hypotension, hypoperfusion/hypoxemia, acute renal failure, ARDS Secondary: CAD, HTN, DVT, CKD, DM, depression Discharge Condition: minimal ambulation, tolerating POs, afebrile Discharge Instructions: You were hospitalized due to alcohol intoxication and binge drinking, which caused a major bleed from your esophagus leading to low blood pressure, kidney dysfunction, and lung dysfunction. Initially, you were at [**Hospital6 3105**] in the intensive care unit (ICU) to manage these complications. In that ICU you were intubated, and on medicines to raise your blood pressure. You had a endoscopic gastroduodonoscopy (EGD) to help stop the bleeding from the ulcer in your esophagus. You were then transferred to [**Hospital3 **] Deaconness ICU for further treatment of your bleeding and the complications mentioned above - he you were initially intubated, had a feeding tube, and received 1 unit of blood, platelets, and fresh-frozen plasma since your blood counts, blood clotting system was depleted. You also had a repeat EGD here which demonstrated multiple nonbleeding ulcers. In the ICU you improved and were taken off the breathing tube, blood pressure raising medicines, and your kidneys began to regain function. At this point, you were transferred to the general medical floor where each one of your complications improved each daily until they became stable. Since you were on a breathing tube and sedated for many days, you became weak, and required physical therapy to regain strength. You also were found to have a minimally symptomatic toe ulcer, which you should follow up with your primary care doctor. At this point, given your improved health and personal circumstances, you will be discharged to home. Please take all medications as prescribed below. According to your recount, you take Lantus 15 units at night, and check your blood sugar twice a day; however, please followup with your primary care doctor to ensure that this is indeed the best regimen for you. We have also made some changes to your blood pressure medications so it is important that you follow our prescriptions precisely, and followup with your primary care doctor closely. Your followup appointments are listed below. If you experience chest pain, shortness of breath, lightheadedness, fainting, or any other new or concerning symptoms, call your doctor or return to the emergency room for evaluation. Followup Instructions: Please attend your appointment on [**2147-8-2**], 2pm, [**Hospital Ward Name 23**] bldg floor 6, with your new primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at the [**Hospital 18**] [**Hospital6 733**] ([**Telephone/Fax (1) 250**]). Please attend your appointment for a repeat EGD (endoscopy) on Mon, [**8-21**], at 830AM, please call [**Telephone/Fax (1) 463**] for additional questions. Please schedule alcohol addiction rehab based on a program of your choice. You were given several options and information from the social worker.

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icd9cm

[ [ [] ] ]

[ "99.05", "99.07", "39.95", "45.13", "38.91", "99.04", "96.72", "38.93" ]

icd9pcs

[ [ [] ] ]

23259, 23265

14060, 21714

344, 369

23474, 23521

4068, 14037

25765, 26426

3563, 3567

21849, 23236

23286, 23453

21740, 21826

23545, 25742

3582, 4049

275, 306

397, 2769

2791, 2993

3009, 3547

11,668

118,425

15114+56617

Discharge summary

report+addendum

Admission Date: [**2128-8-24**] Discharge Date: [**2128-9-16**] Date of Birth: [**2054-5-13**] Sex: F Service: ADMITTING DIAGNOSES: 1. Sarcoma DISCHARGE DIAGNOSIS: 1. Status post posterior pelvic exenteration for HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old woman G5, P1-0-1-4 who presented to the hospital for vaginal bleeding, initially presented to [**Hospital3 1280**] Hospital on [**8-22**] where she required multiple units of blood for vaginal bleeding. Her hematocrit was as low as 25 on admission there. Her CT scan was significant for a rectovaginal [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **] to the Gyn/Onc service for further. A needle biopsy performed demonstrated high grade sarcoma versus poorly differentiated carcinoma. During her hospital course up until the time she was operated upon, she had a lot of vaginal bleeding requiring pad changes at least every three hours. She was admitted and underwent a posterior pelvic exenteration on [**2128-9-2**]. She had received 6 units of packed red blood cells in the Operating Room. Postoperatively, patient was transferred to the Intensive Care Unit. Postoperatively, she was ruled out for an myocardial infarction. She was extubated on postoperative day #3 without any complications. While in the Intensive Care Unit, she was transfused 2 more units to a total of 8 units throughout, 6 units since being in the Operating Room. She had one episode of hypotension 77/40, but after a normal saline bolus, her blood pressure went to 123/52. While in the Intensive Care Unit, she was placed on dopamine and propofol which were weaned off. She was started on ampicillin, Flagyl and levofloxacin which she was on for seven days. For the first seven days postoperatively, she was continued on those antibiotics. Her white count was as high as 17.4, but it trended down daily and she was taken off the antibiotics on [**9-11**] and her Foley was also removed. She was NPO. For pain control, first she was on epidural which fell out and she was then placed on a Dilaudid PCA. When she was on the floor, she was given Demerol and Vistaril. The patient did have one episode of supraventricular tachycardia for 28 beats prior to being transferred from the Intensive Care Unit to the floor. She was therefore started on Lopressor 25 mg [**Hospital1 **]. She was on telemetry and the telemetry was discontinued after the patient demonstrated normal sinus rhythm for several days. On [**9-11**], postoperative day #8, a nasogastric tube was placed. A PICC was also placed. The patient had over [**2126**] cc of bilious emesis, but once the nasogastric tube was placed, the patient felt much better. The nasogastric tube was left in place for four days. Once the nasogastric tube was removed, the patient was able to tolerate solid po's without any difficulty. Her last set of labs, her white count was 9.5, hemoglobin 10.7, hematocrit 32.2, platelets 584, sodium 141, potassium 3.7, chloride 105, bicarbonate 27, BUN 10, creatinine 0.4, glucose 104. Her electrolytes were monitored daily. She had been on TPN while she was NPO. First, she was on PPN and then she was on TPN. Her TPN was discontinued once she was able to tolerate po's. On exam, her stoma was pink. Her ostomy was putting out bilious drainage. Ostomy nurse came and taught the patient as well as her two daughters how to care for the stoma. The patient is to be transferred to [**Hospital3 1280**] for rehabilitation. She is to follow up with Dr. [**First Name (STitle) 1022**] in two weeks. She was sent home with all her ostomy care supplies, as well as Percocet and Motrin for pain relief and Lopressor. Her JP drain was removed as well as her staple prior to discharge. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4871**] Dictated By:[**Last Name (NamePattern1) 30184**] MEDQUIST36 D: [**2128-9-16**] 07:54 T: [**2128-9-16**] 09:20 JOB#: [**Job Number 44105**] Name: [**Known lastname 8070**],[**Known firstname **] Unit No: [**Unit Number 8071**] Admission Date: Discharge Date: [**2128-9-16**] Date of Birth: Sex: F Service: ADDENDUM: PAST MEDICAL HISTORY: 1. Fibroids. 2. Ejection fraction of 55%. 4. Cystoscopy, [**8-25**]. PAST SURGICAL HISTORY: History is as above. SOCIAL HISTORY: The patient is married. The patient denies any alcohol, drug, or tobacco use. FAMILY HISTORY: Noncontributory. PAST PSYCHIATRIC HISTORY: Thyroid nodule removal. PHYSICAL EXAMINATION: Examination on discharge revealed the following: Vital signs: Temperature 98.3, blood pressure 118/68, heart rate 72, respirations 18, saturation 96% on room air. JP put out 300 cc. Ostomy put out 1050 cc. The patient was in no acute distress. LUNGS: Lungs were clear to auscultation bilaterally. HEART: Regular rate and rhythm. ABDOMEN: Soft, nontender, nondistended with good bowel sounds. Stoma was pink. Ostomy revealed bilious drainage. Incision was clean, dry, and intact. DR.[**First Name (STitle) **],[**First Name3 (LF) **] 16-314 Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2128-9-16**] 07:57 T: [**2128-9-16**] 09:27 JOB#: [**Job Number 8072**]

[ "171.6", "427.1", "263.9", "599.0", "458.2" ]

icd9cm

[ [ [] ] ]

[ "57.32", "38.93", "68.8", "99.15", "70.24", "46.13" ]

icd9pcs

[ [ [] ] ]

4563, 4633

185, 236

4426, 4448

4656, 5368

265, 4307

4329, 4402

4465, 4546

79,348

175,848

9091

Discharge summary

report

Admission Date: [**2182-8-9**] Discharge Date: [**2182-8-21**] Date of Birth: [**2130-8-26**] Sex: F Service: MEDICINE Allergies: Penicillins / Fentanyl Attending:[**Male First Name (un) 5282**] Chief Complaint: hematemesis Major Surgical or Invasive Procedure: intubation, extubation History of Present Illness: Ms. [**Known lastname **] is a 51 yo woman with PMH significant for MELD 20 EtOH cirrhosis c/b esophageal varices, encephalopathy, and ascites, EtOH abuse with history of DTs, and asthma admitted to the MICU for hematemesis. The patient woke this morning with and found blood coming from her mouth. The patient also notes diarrhea, abdominal pain and headache. The patient was found in the field to be confused with a bottle of alcohol and unable to provide a history. She was transferred to [**Hospital1 18**] ED. Of note, the patient was admitted to [**Hospital1 18**] from [**Date range (1) 31378**] for shortness of breath secondary to a large pleural effusion, EtOH withdrawl, alchohol hepatitis, and acute on chronic pancreatitis. . In the [**Hospital1 18**] ED, VS 137/77, HR 92-100, RR 20-30, 99% on face mask. The patient was intubated for airway protection. An OGT revealed 5cc of bright red blood and the patient was guaiac positive. Octreotide and PPI were started. Hepatology was consulted. Pt was given vanco and pip/tazo over concern for right lung field white out and ceftriaxone for SBP prophylaxis. The patient was then transferred to the MICU for further management. . ROS: Unable to obtain. Past Medical History: 1. Alcoholic cirrhosis: Diagnosed in [**2178**], course has been compicated by esophageal varices, ascites, and hepatic encephalopathy 2. Chronic pancreatitis 3. Alcohol abuse: h/o DTs 4. Asthma: Patient has required intubation on prior hospitalizations 5. Uterine and cervical cancer: s/p hysterectomy in [**2166**] Social History: Patient lives alone. She has one son who lives in [**State 15946**] and is involved with legal troubles. She had a significant male partner for 8 years who died sudden 3 years ago with ICH. As a result, this has been extremely difficult for her and her alcohol consumption has continued to increase. Usually drinks mixed drinks with vodka - unable to say how many per day, but at least 4. Smokes 1/2ppd for many years. Denies IVDU Family History: Mother- died in 70s from GI bleeding [**1-21**] alcohol abuse Father- died in 70s from some type of cancer, also had alcohol abuse Physical Exam: vs: temp 99.3 F, BP 149/82, HR 120 (sinus tachy on monitor), O2 sat 94-100% on 4 L NC Gen: lethargic, easily arousable by verbal stimuli, Ox3, + asterixis HEENT: Scleral icterus, small pupils 2mm/PERRLA, intact EOM CV: Nl S1+S2, no m/r/g Pulm: Decreased breath sounds on right base, dullness to percusion, + upper airway and upper lung fields with exp wheeze, Rales bil Abd: patient guarding during abdominal exam, abdomen distended, tender to palpation on epigastric area, +BS x4, Ext: Trace edema bilaterally. Neuro: lethargic and resposive to verbal stimuli, CNII-XII intact, able to follow commands Skin: Spider angioma GU: foley to BSD with dark yellowish/brownish urine Pertinent Results: [**2182-8-9**] 10:59PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]->1.050* [**2182-8-9**] 10:59PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-4* PH-6.5 LEUK-NEG [**2182-8-9**] 10:59PM URINE RBC-7* WBC-12* BACTERIA-NONE YEAST-NONE EPI-0 [**2182-8-9**] 09:20PM TYPE-ART TEMP-35.8 PO2-301* PCO2-44 PH-7.31* TOTAL CO2-23 BASE XS--4 INTUBATED-INTUBATED [**2182-8-9**] 09:04PM GLUCOSE-127* UREA N-5* CREAT-0.4 SODIUM-138 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-21* ANION GAP-16 [**2182-8-9**] 09:04PM CALCIUM-7.6* PHOSPHATE-3.8 MAGNESIUM-2.0 [**2182-8-9**] 09:04PM WBC-10.1 RBC-2.73* HGB-9.4* HCT-29.8* MCV-109* MCH-34.6* MCHC-31.7 RDW-19.6* [**2182-8-9**] 04:23PM LACTATE-2.4* [**2182-8-9**] 04:15PM ALT(SGPT)-70* AST(SGOT)-176* ALK PHOS-112 TOT BILI-9.5* DIR BILI-4.7* INDIR BIL-4.8 [**2182-8-9**] 04:15PM LIPASE-136* [**2182-8-9**] 04:15PM ALBUMIN-3.3* CALCIUM-8.4 PHOSPHATE-3.7 MAGNESIUM-2.3 [**2182-8-9**] 04:15PM NEUTS-59.9 LYMPHS-25.7 MONOS-8.6 EOS-5.1* BASOS-0.7 Micro: URINE CULTURE (Final [**2182-8-9**]): ESCHERICHIA COLI. >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. ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | ENTEROCOCCUS SP. | | AMPICILLIN------------ =>32 R <=2 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- R CEFTRIAXONE----------- =>64 R CEFUROXIME------------ =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S <=16 S PIPERACILLIN---------- =>128 R PIPERACILLIN/TAZO----- <=4 S TETRACYCLINE---------- =>16 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R VANCOMYCIN------------ <=1 S . Studies: CTH: no significant change from prior study or acute process. . Chest Xray: Large right sided pleural effusion compared to the xray from recent admission that had small pleural effusion on.... 2nd x-ray; ET Tube in place. . CT Abdomen/pelvis [**8-4**]: 1. Diffuse thickening of mucosal folds throughout the jejunum. Although thickened folds may be seen from portal hypertension, usually the right colon shows the most prominent fold thickening in that scenario. Findings may accordingly be more consistent with an infectious or inflammatory process. Hemorrhage and ischemia are felt less likely particularly given selective jejunal involvement, but please correlate with INR, platelets and recent clinical course. The major mesenteric arteries and veins are not optimally assessed, but appear patent. Please correlate with clinical findings. 2. Known cirrhosis of the liver with small amount of free peritoneal fluid. 3. Right moderate pleural effusion. . US abdomen [**2182-8-1**] Limited Doppler study due to bowel gas establishing patent left and right portal veins with a new hepatofugal flow. Cirrhotic-appearing liver with minimal ascites and right pleural effusion as well as borderline splenomegaly. . EGD [**3-28**]: 4 cords of grade 1 varices at the lower third of the esophagus Erythema, congestion and mosaic appearance in the whole stomach compatible with portal hypertensive gastropathy Abnormal mucosa in the duodenum. 2 small nonbleeding ulcers were seen in duodenum. . EGD [**2-25**]: Mosaic pattern; erythematous in the fundus and body compatible with congestive gastropathy (biopsy) Ulcers in the duodenal bulb Polyps in the duodenal bulb and second portion of duodenum (biopsy) Otherwise normal EGD to third part of the duodenum Brief Hospital Course: Ms. [**Known lastname **] is a 51 yo woman with PMH significant EtOH cirrhosis c/b esophageal varices, encephalopathy, and ascites, hepato hydrothorax, EtOH abuse, asthma admitted for questionable hematemesis and was found to have E.coli ESBL UTI transferred out from MICU on [**2182-8-10**] now with improved mental status. . ALCOHOL HEPATITIS/Cirrhosis: Given AST:ALT ratio >2:1, this was likely secondary to EtOH cirrhosis. Discriminant function of decreased from 60s->49->51. Her LFTs and t bili trended down to ALT/AST 41/88 (from 60/155 on admission) and tbili 6.7 (from 12.2 on admission). She was continued lactulose and ursodiol, and started rifaxamin [**8-14**]. She was also restarted on diuretics, spirolactone 100mg and lasix 40mg Qday on [**8-15**]. She was on SBP prophylaxis with meropenem which was transitioned to nitrofurantoin ([**8-19**]). At time of discharge her MELD was 20. . CHANGE MS: Pt was lethargic in the first 3 days of admission. She was on CIWA protocol and on dilaudid IV, both were d/ced given that patient was lethargic. As per addiction nurse who has been following her she was hospitalized for 9 days up to [**8-5**] and only had 3 days of drinking prior to readmission on [**8-9**], so less likely to be DTs. Mental status overall improved after stopping ativan and dilaudid. During her admission, she was emotionally distressed, crying and threatening to leave AMA; she was seen by social work on this admission. Her mood improved over hospitalization. Options for alcohol rehabilitation were discussed, however the patient ultimately stated she wanted to go home to her sisters with plans for rehab in the future. . CHRONIC PAIN: Pt has been taking narcotics for several years. There is a note on OMR that pt had been getting narcotics from multiple providers. She was started on low dose methadone 5mg [**Hospital1 **] and titrated up to 10mg which alleviated the pain but made her feel nauseous. Pain control was an issue given that the patient has a history of narcotic seeking. She was transitioned to oxycodone on discharge, given the side effects of methadone. . ANEMIA/Hematemesis: This was related to gastritis in the setting alcohol intake as recent EGD which showed gastritis and small ulcers. Hct 33->26.3 in the setting of hydration. Hct trended down from 23->19.9 ([**8-15**]) and patient received 2 units of PRBCs. Her PPI was changed to [**Hospital1 **], she did not experience any further bleeds, and her hct remained stable at 30. . Wheezing/Pleural effusion: Patient intubated ([**8-10**]) for airway protection in setting of hematemesis. Patient received vanco and pip/tazo for aspiration/nosocomial pneumonia at admission which was then changed to meropenem for ESBL UTI. She also has large pleural effusion on right lower lobe and has history of asthma. Patient with diminished LS on right base, exp wheezes and prolonged exp phase. She had a right lung thorocentesis on [**8-12**] with a total of 2.5 L of fluid removed. She was on prednisone for her lung issues and was tapered from 20-> 15-> 10 ->5 , and finished last dose on day of discharge. Her respiratory status has overall improved, no wheezing, diminished BS at base and crackles on the right. This also improved with prednisone taper, nebulizers, and diurectics (lasix 40mg and spirolactone 100mg) which were restarted on [**9-14**]. Her meropenem was transitioned to nitrofurantoin for total of 14 days. . UTI: urine culture from [**2182-8-5**] demonstrated ESBL E.coli. Final sensitivity panel which shows resistant to amp, unasyn, cefalosporins and senstive to gent, meropenem, nitrofurantoin, zozyn , trobamycin. Patient was started on Meropenem ([**8-10**]) and was transitioned to nitrofurantoin ([**8-19**]). . Pancreatitis: Patient with acute on chronic pancreatitis during last admission in setting of EtOH abuse, c/o epigastric pain. Pain was started on methadone and switched to oxycodone (see above). She was restarted on pacreatic enzymes on [**8-14**]. . EtOH abuse: Pt with history of DTs, last drink on day of admission. She was without drinking for 9 days since she was hospitalized up to [**8-5**] and was readmitted on [**8-9**]. Pt initally stated that she would like to go to rehabilitation facility, did not want hospice care. The severity of her clinical condition was discussed with her and she was told of the morbidity associated with continued drinking. She verbalized understanding. She also has plans to stay with her sister for while until she is more stable. She was continued on Thiamine, folate, MVI . HYPONATREMIA: Patient had her Na trended down during this admission. This was due cirrhosis and possibly pre-renal causes given that she had decreased PO intake. She was given albumin and encouraged to have food and fluids. Na is 132 at time of discharge. . Medications on Admission: Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID Fluticasone-Salmeterol 250-50 mcg/Dose [**Hospital1 **] Pantoprazole 40 mg Tablet daily Thiamine HCl 100 mg Tablet daily Folate 1 mg daily MVI daily Ursodiol 300 mg daily Tramadol 50 mg po Q12H Albuterol MDI Q4H prn Nadolol 20 mg daily Bactrim 1 tab po bid x7 days Discharge Medications: 1. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). Disp:*qs ML(s)* Refills:*2* 6. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*3* 8. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Spironolactone 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 11. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 12. Nitrofurantoin (Macrocryst25%) 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 12 days: Until [**9-2**]. Disp:*24 Capsule(s)* Refills:*0* 13. Amylase-Lipase-Protease 48,000-16,000- 48,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*30 Cap(s)* Refills:*2* 14. Nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 15. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO four times a day for 7 days. Disp:*30 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Alcoholic Hepatitis Hepatic Hydrothorax Urinary tract infection Secondary: Alcoholism Alcoholic liver disease Chronic pain Chronic pancreatitis Discharge Condition: Stable Discharge Instructions: You were admitted with alcoholic hepatitis, which is inflammation of your liver secondary to alcohol use. You have improved while in the hospital, but the condition can be fatal if you continue to drink alcohol. During your hospitalization you also were found to have fluid around your lung secondary to your liver disease, and a urinary tract infection. We tried to remove the fluid, but it continues to come back. This process is also related to continued alcohol intake. Your urinary infection was treated with antibiotics. . We made the following changes to your medications: 1. Continue your ursodiol, folate, thiamine, lactulose, albuterol, fluticasone-salmeterol, and nadolol 2. Stop pantoprazole, and start omeprazole 40mg twice daily for your stomach 3. Start rifaximin 400mg three times a day 4. Start Furosemide 40mg daily and spironolactone 200mg daily to reduce the fluid in your lungs 5. Start magnesium supplements for your leg cramps 6. Start Macrobid 100mg twice a day for 12 days for your UTI . Please consider alcoholic rehabilitation on discharge. If you continue to drink alcohol, you liver disease may progress to a fatal condition. . If you develop any further episode of blood in your vomit, confusion, or any other concerning symptoms, please return to the emergency department to be evaluated. Followup Instructions: Please follow up with your PCP on discharge. Completed by:[**2182-8-23**]

[ "305.1", "577.0", "577.1", "276.1", "572.2", "571.2", "303.01", "599.0", "535.01", "789.07", "456.21", "V10.42", "511.89", "572.3", "338.29", "518.82", "285.29", "493.90", "305.50", "041.4" ]

icd9cm

[ [ [] ] ]

[ "34.91", "94.62", "38.93", "38.91", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

14114, 14120

7083, 11914

298, 322

14318, 14327

3217, 7060

15701, 15777

2373, 2505

12287, 14091

14141, 14297

11940, 12264

14351, 14907

2520, 3198

14936, 15678

247, 260

351, 1564

1586, 1905

1921, 2357

31,802

153,432

1448+55292

Discharge summary

report+addendum

Admission Date: [**2150-1-14**] Discharge Date: [**2150-1-22**] Date of Birth: [**2106-11-1**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2024**] Chief Complaint: nausea, vomiting, SOB Major Surgical or Invasive Procedure: none History of Present Illness: 42 F w/ metastatic Breast Ca (liver, brain, bone, lung) undergoing radiation therapy to the brain (last [**2150-1-13**]), recent chemotherapy (in [**Month (only) **] treated with abraxan), on decadron. She presented to [**Hospital 1474**] hosp last night with N/V, chills, SOB. At [**Hospital1 **] ED her initial vitals were significant for- T 99.9 BP 67/52, pulse 143, RR 20, 02sat 85% on RA -> 98% NRB. She was given 3.5L of NS, decadron 8mg, zosyn 3.375mg , vancomycin 1g and started on levophed (BP refractory to 2L of IVF). Her CXR showed bilateral hilar infiltrates. Her initial labs were significant for a WBC count was 1.1 (60% neut, 30% bands- ANC 660), HCT 39.2, plts 166. A UA showed some protein but otherwise was unimpressive. In the OSH ICU, Her BP was supported by levophed (4mg/min) and continuous IVF. Her 02 sats were 97-100% on an NRB. Her abx. were changed to ceftazidine/cipro/vanc for neutropenic sepsis. She was continued on Dex 4mg po q6hrs. A KUB was done [**3-14**] N/V, which showed a lack of bowel gas. A Her family req. transfer to [**Hospital1 18**]. She was intubated for airway protection and a R subclavian central line was placed ([**2150-1-13**]). Past Medical History: - Metastatic breast cancer dx'ed 13 years ago s/p mastectomy/reconstruction R breast and chemotherapy Navelbine and Avastin in 8/[**2147**]. Poor response to treatment with Gemzar. She then had a response to Xeloda but did not respond to her most recent therapy, which was Doxil. Then CMF treatment in [**9-16**]. Now on abraxane, first dose 10/9. - Hypercholesterolemia - Adjustment d/o Social History: [**Known firstname 8368**] is married. Works as a CPA. She denies tobacco, alcohol, or drug use. Family History: Non-Contributory Physical Exam: VS: Temp: 96.6 BP: 122/73 HR: 88 RR: O2sat AC 500/12 fi02 0.50 peep 5 GEN: intubated, sedated HEENT: ET tube placed. PERRL. RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g ABD: NT/ND, bowel sounds are hypoactive, soft abdomne, well healed surgical scar. EXT: WWP, 2+ DP SKIN: no rashes Pertinent Results: [**2150-1-15**] 04:00AM BLOOD WBC-1.4*# RBC-3.26*# Hgb-8.3*# Hct-26.7* MCV-82 MCH-25.5* MCHC-31.1 RDW-19.9* Plt Ct-52*# Neuts-57 Bands-27* Lymphs-9* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 NRBC-1* [**2150-1-16**] 04:01AM BLOOD WBC-2.5*# RBC-3.44* Hgb-8.8* Hct-28.2* MCV-82 MCH-25.6* MCHC-31.2 RDW-19.7* Plt Ct-66* [**2150-1-15**] PT-18.8* PTT-30.7 INR(PT)-1.7* [**2150-1-15**] Fibrino-676* FDP-40-80 [**2150-1-16**] 04:01AM BLOOD Gran Ct-2160* [**2150-1-16**] 04:01AM BLOOD Glucose-121* UreaN-17 Creat-0.3* Na-138 K-3.8 Cl-111* HCO3-20* AnGap-11 [**2150-1-15**] 04:00AM BLOOD ALT-243* AST-985* AlkPhos-489* Amylase-68 TotBili-0.8 [**2150-1-16**] 04:01AM BLOOD Calcium-9.9 Phos-1.5* Mg-2.9* [**2150-1-14**] 03:44PM BLOOD Type-ART Temp-35.8 Rates-[**1-16**] Tidal V-450 PEEP-5 FiO2-50 pO2-147* pCO2-23* pH-7.44 calTCO2-16* Base XS--5 -ASSIST/CON Intubat-INTUBATED [**2150-1-15**] 08:13AM BLOOD Type-ART Temp-37.2 Tidal V-350 PEEP-5 FiO2-50 pO2-172* pCO2-25* pH-7.43 calTCO2-17* Base XS--5 Intubat-INTUBATED Vent-SPONTANEOU [**2150-1-14**] 03:44PM BLOOD Lactate-2.0 Brief Hospital Course: 43 yo F w metastatic breast ca undergoing radiation therapy. Transferred from an OSH where she presented with hypotension, hypoxia, fever c/w septic shock that resolved quickly with IVF and broad spectrum ABX. . # Septic shock: Unclear source. Pt. had bilateral infiltrates on CXR. Was treated with broad spectrum abx given trend towards neutropenia, now resolved. Also given stress dose steroids as had been on dexamethasone in the past for brain mets. Hypotensive in MICU requiring 2L NS. Her ANC was 666 at time of transfer concerning for functionl neutropenia. Per family pt. mounted a fever to 99.8 on decadron. Has difficulty with swallowing recently and may have aspirated. Prelim Sputum gram stain was positive for GPCs and patient was started on vancomycin. However subsequent culture revealed oropharyngeal flora. Patient improved quickly, including respiratory status, supporting aspiration pneumonitis picture. Patient stabilized and was transferred to OMED service. Repeat CXR improved over course of 1 day, supporting aspiration diagnosis and all antibiotics were discontinued. All cultures remained negative. . # neutropenia: Resolved. Most likely differential includes medications, viral illness (EBV, CMV?), bacterial illness, ARDS. [**Month (only) 116**] also be manifestation of depressed marrow response to sepsis given chemotherapy 3 weeks ago. Counts recovered over hospital course without intervention. . # respiratory distress: Presented to OSH with SOB. Required a NRB to maintain 02 sats. She was intubated for airway protection for transport as well as for ongoing respiratory distress. Her CXR was significant for diffuse bilateral infiltrates. However, there was no clear consolidation. Was on ARDS NET protocol overnight. Patient was extubated without difficulty. Repeat CXR following day was clear, pointing toward a diagnosis of aspiration pneumonia. Patient did well satting 100% on RA after transfer out of MICU. . # Altered Mental Status: Patient has baseline abullia secondary to brain metastases. Was not responding to questions after extubation. However over the course of several days, patient's mental status improved back to baseline. Unclear if this was related to drugs, brain mets, depression. Likely a combination of all three. Celexa dose was increased. # Nausea/vomiting: Pt. was recently hosp for N/V/dehydration. Per family- she was doing well until the afternoon of [**2149-12-14**] when she started to exp. n/v. She has also had poor PO intake recently. A KUB at [**Hospital1 1474**] was significant for lack of bowel gas. Also, this could be a side effect of radiation or due to her metastatic disease- increased intracranial pressure from brain mets. - antiemetics as needed. (compazine/zofran/ativan). . # Brain metastasis: Diagnosed by MRI on [**2149-12-25**]. Undergoing radiation therapy (last treatment [**2150-1-13**]). Patient completed radiation treatment while in house. Began steroid taper on day of discharge. . # Breast ca: Completed XRT for brain metastases whie in house. No other intervention was completed. . # Anemia: Anemia of chronic disease. Hematocrit was followed daily and patient did not require transfusion. . # Hypercholesterolemia: continued on simvastatin. # Depression: Affect appeared flat and concern for underlying element of depression. Celexa was titrated up to 30mg PO daily. . # CODE STATUS: Changed to DNR/DNI per husband's request when patient was nonresponsive. . # Communication: husband- [**Telephone/Fax (1) 8627**] (cell) home [**Telephone/Fax (1) 8628**]. . Medications on Admission: Home medications: COMPAZINE 10 mg qday Citalopram 20mg qday DEXAMETHASONE 4 mg [**Hospital1 **] DILAUDID 2 mg qhs EMEND 125 mg (1)-80 mg (1)-80 mg (1)--1 capsule(s) by mouth as directed percocet prn LORAZEPAM 1 mg prn PROTONIX 40 mg qdaily TESSALON PERLE 100 mg tid prn Tussionex [**Hospital1 **] ZOCOR 20 mg qdaily prn ZOFRAN 8 mg tid prn . Transfer medications: vancomycin 1g iv q12hrs ceftazidine 2g iv q12hrs ciprofloxacin 400mg iv q12hrs dexamethasone 4mg po q6hrs benzanoate 100mg po tid celexa 20mg po qdaily simvastatin 20mg po qdaily zofran 8mg po tid protonix 40mg po qdaily ativan 1mg po qhs prn levophed iv drip compazine 10mg iv q6hrs prn Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Atovaquone 750 mg/5 mL Suspension Sig: One (1) PO DAILY (Daily). 5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 6. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed. 7. Lorazepam Intensol 2 mg/mL Concentrate Sig: 0.5 mL PO qHS:PRN as needed for insomnia. 8. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 9. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 10. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 11. Ondansetron 4 mg IV Q8H:PRN 12. Pantoprazole 40 mg IV Q24H 13. Dexamethasone 2 mg Tablet Sig: Per taper Tablet PO Per taper: On [**11-7**]: 4mg PO qAM, 2mg PO qPM; On [**11-10**]: 2mg PO qAM, 2mg PO qPM; On [**1-27**]: D/C steroids. 14. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). Discharge Disposition: Extended Care Facility: [**Hospital 8629**] East Region Discharge Diagnosis: Primary: Aspiration Pneumonia Secondary: Metastic Breast Cancer Discharge Condition: Good, satting 100% on RA, afebrile Discharge Instructions: You were transferred to this hospital with respiratory distress and shock. You were intubated and in the intensive care unit. You quickly recovered and were transferred to the oncology floor. All antibiotics were discontinued as you were much improved. You completed your radiation treatments. . Your dose of celexa was increased to 30mg daily. . Please follow up with your regularly scheduled appointments. . Please return to the emergency room or call your doctor if you develop any worrisome symptoms such as shortness of breath, chest pain, fever, chills. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2150-1-26**] 9:30 Please call Dr. [**Last Name (STitle) 19**] at [**Telephone/Fax (1) 8630**] to set up a follow up appointment. Name: [**Known lastname 1202**],[**Known firstname 1203**] Unit No: [**Numeric Identifier 1204**] Admission Date: [**2150-1-14**] Discharge Date: [**2150-1-22**] Date of Birth: [**2106-11-1**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1205**] Addendum: Patient vomited once after receiving tessalon perles in chocolate pudding. Had some coughing afterward. Patient given sublingual zyprexa and ativan with relief. No further episodes of vomiting. On exam, VS stable, chest was clear, patient in NAD. She was held overnight for evaluation. Patient appeared well in AM and was discharged to rehab. Discharge Disposition: Extended Care Facility: [**Hospital 1206**] East Region [**Name6 (MD) **] [**Last Name (NamePattern4) 1207**] MD [**MD Number(1) 1208**] Completed by:[**2150-1-22**]

[ "198.3", "197.7", "198.5", "785.52", "285.22", "288.00", "038.9", "518.81", "995.92", "V10.3", "197.0", "507.0" ]

icd9cm

[ [ [] ] ]

[ "96.71", "92.29" ]

icd9pcs

[ [ [] ] ]

10847, 11044

3568, 5529

337, 343

9177, 9214

2474, 3545

9822, 10824

2101, 2119

7832, 8988

9090, 9156

7155, 7155

9238, 9799

2134, 2455

7173, 7497

276, 299

7519, 7809

371, 1558

5544, 7129

1580, 1970

1986, 2085

50,744

155,409

36444

Discharge summary

report

Admission Date: [**2152-4-29**] Discharge Date: [**2152-5-9**] Date of Birth: [**2094-3-10**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: agitation and fall Major Surgical or Invasive Procedure: None History of Present Illness: 58yo M discharged from the neurology service on [**4-28**] following complete L PCA infarction now returning from rehab following a fall from bed, admitted to the medicine service, now having fallen from bed again and found to be unresponsive. Pt was found on the ground at [**Hospital3 **] earlier today, and was sent to [**Hospital1 18**] ED for head CT. His examination was reportedly consistent with prior exams, head CT revealed a large L PCA infarct. He was admitted to the medicine service for further care. At 5am this morning patient was found on the ground next to his bed again and was noted to be unresponsive. Neurology was consulted. The patient was minimally responsive, unable to provide a ROS or history. Please refer to details of recent admission from yesterday's note. The patient was taken for STAT CTA head and neck to rule out a recurrent posterior circulation vascular event. There was no evidence for vessel occlusion or cut-off. Pt was transferred to the neurology ICU and Neurology ICU service for further care and monitoring. No evidence for ICH noted on CT following fall on coumadin. Reconstructions of the CTA neck showed no evidence of fracture. Past Medical History: L PCA infarct as described previously- etiology unclear if cardioembolic versus possible L vert dissection. Pt was briefly on coumadin and plavix. discharged on coumadin monotherapy. s/p pacemaker implantation for symptomatic bradycardia 2 weeks ago. Social History: worked as a law administrator. Has never smoked. Married, 2 daughters Family History: Non-contributory Physical Exam: T 98, BP 134/78, HR 78, R 17, 97% RA Gen- eyes closed, in bed, unresponsive to sternal rub. HEENT: bilateral frontal contusions with fresh blood present. anicteric sclera Neck- no carotid or vert bruits CV- RRR, no MRG Pulm- CTA B Abd- soft, ND, BS+ Extrem- no CCE, warm Neurologic Exam: MS- no response to sternal rub. CN- pupils minimally reactive, L 3-->2.5, R 5-->4.5mm, absent Doll's, + blinks to threat, intact gag. Motor/Sensory- slowly withdraws R UE and R LE to noxious in plane of bed, more briskly withdraws LUE and LLE in plane of the bed to nailbed pressure only. Reflexes: 3+ R [**Hospital1 **], [**Last Name (un) **], patellar,2+ L [**Hospital1 **], [**Last Name (un) **], patellar Plantar response upgoing on the right, mute on the left. Pertinent Results: [**2152-4-28**] 04:35AM WBC-6.9 RBC-4.11* HGB-12.8* HCT-35.1* MCV-85 MCH-31.0 MCHC-36.4* RDW-12.5 [**2152-4-28**] 04:35AM PT-20.6* PTT-26.6 INR(PT)-1.9* [**2152-4-28**] 04:35AM GLUCOSE-95 UREA N-18 CREAT-0.8 SODIUM-141 POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-24 ANION GAP-14 [**2152-4-28**] 04:35AM CALCIUM-9.3 PHOSPHATE-3.7 MAGNESIUM-2.3 [**2152-4-28**] 10:00PM CK-MB-3 [**2152-4-28**] 10:00PM cTropnT-<0.01 [**2152-4-28**] 10:00PM CK(CPK)-218* [**2152-4-29**] 05:07PM LACTATE-0.6 [**2152-4-29**] 07:59AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-6.5 LEUK-NEG [**2152-4-29**] 07:59AM URINE RBC-[**1-27**]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2152-4-30**] 02:05AM BLOOD ESR-33* [**2152-4-30**] 02:06AM BLOOD CRP-4.2 EKG: NSR [**4-28**] CT head: 1. Evolving left PCA territory infarct. No intracranial hemorrhage. 2. Small left frontal subgaleal hematoma. [**4-28**] CT c-spine: 1. No fracture. 2. Mild cervical spondylosis with grade 1 C5 on C6 retrolisthesis, likely degenerative. [**4-29**] CTA: 1. Evolving left posterior cerebral artery infarct involving the left thalamus, posterior occipital lobe, and left side of the mid brain. 2. No significant abnormalities on CT angiography of the neck without vascular occlusion or stenosis. 3. Improved left posterior cerebral artery irregularity with no evidence of occlusion on CT angiography of the head. 4. Right pulmonary artery thrombus is partially visualized CT PE and Abd, pelvis: CTA chest with CT abdomen and pelvis found no occult malignancy. There is embolism within the branches of the right pulmonary artery which might be chronic in origin. There was also enlargement and hypodense filling defects of the right common femoral vein and right external iliac veins are concerning for acute DVT in this area. There is also Colonic pandiverticulosis. CTA CNS on 6/ 10/ 09: less evident hypodensity in the left PCA territory with less evident hypodensities in the left pons and midbrain. no new areas of infarct. no hemorrhage. hypoplastic right vertebral, otherwise normal COW. Brief Hospital Course: 58yo M with prior L PCA infarction and cerebellar infarction now with two episodes of "falling" from bed followed by unresponsiveness. The patient at present is comatose. Anisocoria and right hemiparesis are consistent with prior exams. CTA brain did not show a recurrent cerebral event. Hence patient's markedly impaired diminished level of consciousness is perhaps related to seizure. Pt's falls from bed may relate to motor activity associated with seizure, but has yet to be witnessed. Mr [**Known lastname 34393**] was admitted to the neurology ICU, Attending Dr. [**Last Name (STitle) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and monitored with q1h neuro checks, tele, cardio/resp monitoring. Neuro: Pt woke up more and improved after 1mg IV ativan consistent with diagnosis of seizure. He was able to say his last name, say the correct year, and show two fingers with the left hand. He received Keppra 1,000mg IV x 1, then started 1,000mg IV BID thereafter. Routine EEG after keppra load did not show any sign of ongoing seizure and lab evaluation with troponin/CK, LFT's, repeat Chem 10, CBC was wnl with stable hct. Head CT was negative for new stroke or bleeding. Over the course of the following 2 days he remained somnolent but easily arousable, briskly following simple motor commands, dysarthric, oriented to [**Location (un) 86**] and name only. His opthalmoplegia worsened. His right eye had minimal abduction and barely any adduction. The right eye had minimal upward and downward movements. The left eye did not abduct or adduct, and barely made any vertical movements. His continued disorientation and somnolence was attributed to post ictal state and medication effect from keppra and ativan/Seroquel which he was requiring for agitation. Upon transfer from the ICU to the floor, ativan was stopped and he was placed on a standing order of Seroquel 25mg qhs to improve his sleep/wake cycle. Heme: Incidental LUL PE was found on CTA neck. Hypercoagulability/malignancy work-up was initiated given multiple thrombi involving multiple organ systems while therapeutic on coumadin. INR was monitored and coumadin decreased from 7.5mg to 6mg given rapidly increasing INR. There were no active cardiovascular, respiratory (he was stable on room air w/o tachypnea despite the PE seen on CT), infectious, or renal issues. At his family's request his code status was changed to DNR/DNI. Neurology floor course: CTA chest with CT abdomen and pelvis found no occult malignancy. There is embolism within the branches of the right pulmonary artery which might be chronic in origin. There was also enlargement and hypodense filling defects of the right common femoral vein and right external iliac veins are concerning for acute DVT in this area. There is also Colonic pandiverticulosis. On [**5-3**] at 7:20am, Dr. [**Last Name (STitle) 1794**] noted that his mental status had worsened. He received a CTA CNS on 6/ 10/ 09: less evident hypodensity in the left PCA territory with less evident hypodensities in the left pons and midbrain. no new areas of infarct. no hemorrhage. hypoplastic right vertebral, otherwise normal COW. We informed the family that he might be having new small vessel strokes in the pons or midbrain which could not be detected by CT scans. MRI is not possible due to his pacemaker. The family declined the possibility of consulting cardiology about stopping the pacemaker and then pursuing an MRI study. He was afebrile, had no leukocytosis and a UA was negative. EEG on [**4-2**] showed no epileptic activity. On 06/ 11/ 09 his family decided to make him CMO. Medications on Admission: 1. Simvastatin 40 mg daily 2. Ranitidine HCl 150 mg [**Hospital1 **] 3. Warfarin 6 mg daily Discharge Medications: 1. Morphine Concentrate 20 mg/mL Solution Sig: Two (2) PO Q2H (every 2 hours) as needed for pain signs. 2. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q4H (every 4 hours) as needed for anxiety. 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital1 656**] family hospice Discharge Diagnosis: Seizure Probable new pontine stroke. Secondary: PCA stroke Pulmonary embolus DVT Discharge Condition: The patient has been made CMO. He is receiving ativan and morphine as required. Discharge Instructions: You were readmitted to the hospital after a fall followed by unresponsiveness. You had another similar episode after admission and were transferred to the neurology ICU for presumed seizure and were treated for with keppra. Once transferred to the neurology floors, your mental status worsened and there was the suspicion that you may have had a new stroke in the pons. We did not obtain an MRI because your PPM needed to be stopped by cardiology previously. At this point, our family decided to not pursue the route of full care and decided for DNR, DNI status to then make you CMO. Followup Instructions: Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**] Date/Time:[**2152-6-14**] 2:00

[ "E884.4", "434.91", "780.39", "412", "427.31", "438.83", "784.5", "374.30", "873.42", "438.20", "V66.7", "415.19", "368.46", "V45.01", "438.7", "438.19" ]

icd9cm

[ [ [] ] ]

[ "96.6" ]

icd9pcs

[ [ [] ] ]

8999, 9060

4898, 8536

342, 349

9185, 9268

2753, 3563

9902, 10068

1940, 1958

8679, 8976

9081, 9164

8562, 8656

9292, 9879

1973, 2245

284, 304

377, 1562

3572, 4875

2262, 2734

1584, 1837

1853, 1924

19,338

103,482

45223

Discharge summary

report

Admission Date: [**2198-3-12**] Discharge Date: [**2198-3-22**] Date of Birth: [**2147-7-28**] Sex: M HISTORY OF PRESENT ILLNESS: This is a 50 year old male with a history of HIV, Hepatitis C, intravenous drug abuse and poly-substance abuse, who was admitted from an outside hospital with continued mental status changes after being [**2198-3-9**]. He was taken initially to [**Hospital 1474**] Hospital where he was given Narcan for presumed opiate overdose. He became awake and agitated following the Narcan and was admitted to the [**Hospital 1474**] Hospital Intensive Care Unit with the diagnosis of acute renal failure and rhabdomyolysis. His creatinine at that time was 13.2 and he had an initial CK of 14,000. He was treated with intravenous fluids, urine His mental status continued to be abnormal as he demonstrated both agitation and excessive somnolence. He was transferred to [**Hospital1 69**] on [**3-12**], for further evaluation of change in mental status after he had become progressively lethargic and unresponsive to questions at [**Hospital 1474**] Hospital. Of note, he was treated with Tequin for a three-day course at [**Hospital 1474**] Hospital for a urinary tract infection. On arrival to [**Hospital1 69**], the patient was noted to have a temperature of 100.2 F., and an examination notable for delirium, nuchal rigidity, and questionable right sided weakness. Head CT scan showed a 6 mm left posterior frontal hemorrhage. Lumbar puncture showed approximately 1400 red blood cells and one white blood cell. The patient was placed on empiric Acyclovir for coverage of HSV encephalitis pending results of HSV PCR from cerebrospinal fluid. An MRI and MRA study was consistent with focal leukoencephalopathy of toxic, HIV, PML or other origin. In the Medical Intensive Care Unit, the patient received a five day course of Fluconazole for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 564**] albicans urinary tract infection. He defervesced. He was transfused with a total of three units of blood for a hematocrit of 20. He was treated aggressively for hypertension including diastolic hypertension. An EEG performed in the Intensive Care Unit showed encephalopathic but not epileptiform activity. On [**3-19**], he was transferred to the ACOVE Service for continued care. REVIEW OF SYSTEMS: Negative for headache, visual changes, shortness of breath, cough, chest pain, back pain, abdominal pain. PAST MEDICAL HISTORY: 1. Human Immunodeficiency Virus diagnosed in [**2194**]; recent CD4 count 309; HIV viral load less than 50. 2. Intravenous drug abuse with cocaine and heroin. 3. Poly-substance abuse. 4. Status post laparotomy for abdominal stab wound. 5. Herpes zoster in [**2194-8-14**]. ALLERGIES: No known drug allergies. MEDICATIONS: (Outpatient) 1. Neurontin 600 mg p.o. three times a day. 2. Zerit 40 mg p.o. twice a day. 3. Sulfamethoxazole. MEDICATIONS: (Transfer from Intensive Care Unit) 1. Prevacid 30 mg p.o. twice a day. 2. Multivitamin one p.o. q. day. 3. Nystatin 5 cc swish and swallow twice a day. 4. Folate 1 mg p.o. q. day. 5. Thiamine 100 mg p.o. q. day. 6. Ativan 1 mg p.o. twice a day. 7. Dyazide 50/25 q. day. 8. Lisinopril 40 mg p.o. q. day. 9. Haldol 5 mg p.o. twice a day. 10. P.R.N. Tylenol, Lomotil, Haldol, Ativan. SOCIAL HISTORY: Positive for marijuana, cocaine, heroin, alcohol use. The patient is married with three children. He is currently unemployed. PHYSICAL EXAMINATION: At admission, temperature 101.2 F.; heart rate 90; blood pressure 150/92; respirations 14; pulse oximetry 98% on room air. Generally, somnolent but arousable African American male not following commands. HEENT: Pupils equally round and reactive to light. Dry mucous membranes. Neck: Nuchal rigidity present. Lungs: Coarse breath sounds bilaterally with no wheezes. Cardiovascular: Regular rate and rhythm, without murmurs, rubs or gallops. Abdomen: Laparotomy scar present. Soft, nontender, nontender. Bowel sounds present. Liver palpated at the right costal margin. Extremities: Warm without edema. A left groin line is intact. Foley catheter is present. There is an NG tube. Neurologic: Somnolent and minimally arousable. Unable to follow simple commands. Grossly intact strength and sensation throughout. Reflexes two plus bilaterally. LABORATORY STUDIES: (At admission) white blood cell count of 5.7, hematocrit of 23.9, platelets 152, 68% neutrophils, 21% lymphocytes. PT 13.7, PTT 32.5, INR 1.3. Sodium 148, potassium 3.3, chloride 115, bicarbonate 23, BUN 27, creatinine 1.0. Arterial blood gas is 7.47/29/86 on room air. ALT 82, AST 249, alkaline phosphatase 55, total bilirubin 1.1, calcium 7.7, albumin 2.9, magnesium 1.9. EKG normal sinus rhythm at 95 beats per minute, without ischemic changes. Urinalysis: Cloudy, specific gravity 1.010, large blood, 100 protein, pH 7.0, moderate leukocytes, 26 red cells, 110 white cells, no bacteria, no epithelial cells. Chest x-ray: No evidence of pneumonia. Other laboratory studies: Serum tox screen positive for opiates. Direct COOMBS test negative. LD 557, total bilirubin 1.0, haptoglobin less than 20, fibrin split products 10 to 40, D-Dimer 500 to 1000, fibrinogen 206, B12 491, folate 5.6. Iron 110, total iron binding capacity 221, ferritin 280. ESR is 4. Reticulocyte count 3.0. HOSPITAL COURSE: This is a 50 year old male with history of HIV, Hepatitis C, intravenous drug and poly-substance abuse who was admitted with persistent mental status changes from [**Hospital 1474**] Hospital on [**2198-3-12**], for continued care. 1. Mental status: The patient was noted to be somnolent and unable to follow simple commands and unable to answer questions on admission. The differential diagnosis of meningitis, HSV encephalitis, subarachnoid hemorrhage, seizure activity or post-ictal state, or toxic metabolic ingestion were considered. Given the patient's admission fever, nuchal rigidity and questionable right sided neurologic findings, a lumbar puncture was performed showing 1405 red blood cells and one white blood cell. At this point, a differential was considered that included subarachnoid hemorrhage or HSV encephalitis. Acyclovir was empirically started on [**3-13**] and an HSV PCR was sent from the cerebrospinal fluid. A head CT scan showed a 6 mm left posterior frontal hemorrhage. A Neurologic consultation was obtained and recommended MRI/MRA, which showed diffuse white matter, T2 hyperintensity, involving the cerebral and cerebellar white matter, brain stem, internal capsule. These findings were considered to be consistent with a toxic demyelinating process, HIV leukoencephalopathy or progressive multi-focal leukoencephalopathy. An EEG was performed showing left temporal lobe slowing, but no evidence of epileptiform activity. There were encephalopathic findings. On [**3-18**], Acyclovir was discontinued when the HSV PCR from cerebrospinal fluid result was negative. During the Intensive Care Unit course, the patient required Haldol, Ativan and at one point, restraints for patient's safety. The patient was transferred from the Intensive Care Unit to the ACOVE Unit on [**3-19**]. He continued to demonstrate clearing of his mental status over the next 48 hours and at the time of discharge, had returned to his baseline mental status. 2. Infectious Disease: HIV - The patient was noted to have a recent viral load of less than 50 and a CD4 count in the 300s, and so these levels were not repeated. His HIV medications were held on admission per his primary care physician's request, and then restarted on [**3-21**]. Urine - The patient was noted to have a urinary tract infection at [**Hospital 1474**] Hospital treated with Tequin and was also noted to have a urinary tract infection on admission to the Intensive Care Unit at [**Hospital1 188**]. He was initially treated with Ceftriaxone from [**3-12**] through [**3-15**], as it was presumed to be bacterial. Ceftriaxone was discontinued on [**3-15**], and Fluconazole was started for a five-day course at that time when urine cultures showed 100,000 colonies of [**Female First Name (un) 564**] albicans. Blood - The patient was treated between [**3-14**] and [**3-15**], with Vancomycin when one out of four blood cultures bottles grew Gram positive cocci. The Vancomycin was discontinued when the identification showed coagulase negative Staphylococcus. The patient also had a positive serum RPR. At the time of this dictation, a quantitative RPR is pending at the State Laboratory. Cerebrospinal fluid - At the lumbar puncture, the patient had 1,405 red blood cells and one white blood cell. HSV PCR was negative; Cryptococcal antigen negative; [**Male First Name (un) 2326**] virus PCR is pending at the time of this dictation. There was no viral, bacterial, fungal growth from the cerebrospinal fluid culture at the time of this dictation. On [**3-21**], the Infectious Disease Service was consulted regarding need for continued Acyclovir therapy. Infectious Disease recommended no further treatment with Acyclovir as there was a very low suspicion that the mental status changes were of HSV origin. Stool - The patient was found to have diarrhea during Intensive Care Unit stay. It was thought that this was possibly due to opiate withdrawal. Stool studies were negative for infectious etiologies. 3. Renal: The patient initially presented at the outside hospital with acute renal failure and rhabdomyolysis. The patient returned to baseline renal function and had resolving rhabdomyolysis at the time of his admission to [**Hospital1 346**]. 4. Gastrointestinal: The patient was noted on admission to have a trans-aminitis consistent with chronic alcohol abuse. He also presented, as mentioned, with diarrhea which was thought to be due to opiate withdrawal as his stool studies where negative. He was noted to have guaiac positive stool during the admission. He was prophylaxed with Protonix initially and then changed to Prevacid after he developed thrombocytopenia. Otherwise, he tolerated a regular diet and had no further gastrointestinal issues. 5. Genitourinary: Note is made that the patient was treated during his entire hospital course for a total of two urinary tract infections with yeast. This may require outpatient follow-up. 6. Hematologic: The patient was noted to have an anemia at admission which was thought to be multi-factorial related to but not limited to HIV, HIV medications, nutritional deficiencies and alcohol abuse. Iron studies were consistent with anemia of chronic disease. The patient was transfused a total of three units of packed red blood cells for a hematocrit of 20, beginning on [**3-16**]. There were some abnormalities of the hemolysis labs suggesting hemolysis, but this was thought to be due to possible effect of blood transfusion. 7. Cardiovascular: At a concern that the patient may have had endocarditis, a transthoracic echocardiogram was performed on [**3-15**], which showed an ejection fraction of greater than 55% and no obvious vegetations. The patient was also noted to be hypertensive at times during the Intensive Care Unit stay and his blood pressure was successfully controlled by the time of discharge with Lisinopril and Dyazide. 8. Nutrition: The patient tolerated a regular diet which was supplemented with a multivitamin, supplemental thiamine and folate. 9. Musculoskeletal: The patient developed bilateral elbow abrasions as well as a coccyx abrasion secondary to profound agitation during Intensive Care Unit admission. These abrasions were dressed with Duoderm and will be dressed as an outpatient by visiting nurses. 10. Psychiatric: A Code Purple was called on the morning of [**3-19**], when patient became agitated, began swearing and attempted to leave the hospital. The patient was treated with Haldol for acute delirium. Per the Psychiatry Consult Service, the patient was continued on Haldol for agitation as well as restraints, given that he was unable to be re-oriented successfully. He was also maintained on a sitter for periods of the hospital stay. Per Psychiatry recommendations, a TSH was sent which was normal. In terms of the patient's poly-substance abuse, he is to be followed at the [**Hospital 96653**] Health Center as an outpatient as he has declined inpatient therapy at this time. CONDITION AT DISCHARGE: Stable. DISCHARGE STATUS: The patient is being discharged to home. DISCHARGE INSTRUCTIONS: 1. Diet regular. 2. Activity as tolerated. DISCHARGE DIAGNOSES: 1. Mental status change. 2. Human Immunodeficiency Virus. 3. Hepatitis C. 4. Poly-substance abuse. 5. Intravenous drug abuse. 6. Leukoencephalopathy of uncertain origin. 7. Hypertension. 8. Acute renal failure. 9. Rhabdomyolysis. MEDICATIONS AT DISCHARGE: 1. Multivitamin one p.o. q. day. 2. Dyazide 50/25 p.o. q. day. 3. Lisinopril 40 mg p.o. q. day. 4. Kaletra 3 capsules p.o. twice a day. 5. Didanosine 400 mg p.o. q. day. 6. Stavudine 40 mg p.o. twice a day. 7. Vitamin C 500 mg p.o. twice a day. 8. Zinc 220 mg p.o. q. day. 9. Oxycodone 10 mg p.o. q. four to six hours p.r.n. pain.1 week supply6 ONLY 10. Neurontin 600 mg p.o. three times a day or as directed. 11. Duoderm CGF to bilateral elbows and coccyx, change q. 48 hours, normal saline cleansing at dressings changes; extra thin Duoderm to the right ear, change q. 48 hours. FOLLOW-UP INSTRUCTIONS: 1. Dr. [**First Name (STitle) **] [**Name (STitle) 2340**], [**Hospital1 69**] Neurology, [**4-25**], at 03:00, in [**Hospital Ward Name 23**], [**Location (un) 858**]. 2. [**Hospital 96653**] Health Center, phone number [**Telephone/Fax (1) 75084**]55, with Dr. [**Last Name (STitle) 724**], within one to two weeks. 3. Follow-up with Dr. [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) **] after [**5-7**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 17014**], M.D. [**MD Number(1) 17015**] Dictated By:[**Last Name (NamePattern1) 737**] MEDQUIST36 D: [**2198-3-22**] 15:11 T: [**2198-3-22**] 18:44 JOB#: [**Job Number 96654**]

[ "305.51", "V08", "305.61", "112.2", "303.91", "584.9", "728.89", "323.9", "070.54" ]

icd9cm

[ [ [] ] ]

[ "38.93", "03.31" ]

icd9pcs

[ [ [] ] ]

12644, 12896

5415, 5652

12577, 12623

3516, 5397

12910, 13501

2365, 2472

147, 2345

5668, 12467

13525, 14239

2494, 3347

3364, 3493

42,900

109,264

39679

Discharge summary

report

Admission Date: [**2185-8-1**] Discharge Date: [**2185-8-2**] Date of Birth: [**2102-8-31**] Sex: F Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 2901**] Chief Complaint: pericardial effusion/tamponade Major Surgical or Invasive Procedure: none History of Present Illness: Patient is a 82 y/o female with PMHx CAD who presents from [**Hospital **] hospital with concern of pericardial effusion/tamponade. The patient had a pacemaker placed 1 month ago by Dr. [**Last Name (STitle) 23246**]. She had been feeling well until approximately 1 week ago when she suddenly had the onset of decreased energy, fatigue, decreased taste, a burning sensation in her stomach, and loose stools. She had a routine check-up with her cardiologist today who sent her to the ED after hearing her symptoms. In the [**Location (un) **] ED, her vital signs were 98.8 73 122/53 22 94% RA. She had an echo performed which showed a pericardial effusion and concern for tamponade. She was transferred to [**Hospital1 18**] for further management. On review of systems, she does admit to ~1 month of [**3-2**] sharp, substernal chest pain with no radiation as well as dyspnea that she would get when she walked up stairs. It would dissipate with rest. She also admits to having trouble breathing when she lies flat and has been sleeping in an inclined chair the past 2 weeks. There has also been increased ankle swelling. She did have chest pain last night, for which she took 2 sublingual nitros. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of palpitations, syncope or presyncope. Past Medical History: -Hypertension -PACING/ICD: Pacer placed 1 month ago with Dr. [**Last Name (STitle) 23246**] [**Name (STitle) 87455**] Social History: -Tobacco history: 1ppd x20 yrs, quit 20 yrs ago -ETOH: 1 glass wine daily -Illicit drugs: denies Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Mother with renal cell cancer. Physical Exam: GENERAL: elderly female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. mild conjunctival pallor. NECK: Supple with JVP to jawline, no carotid bruits, no LAD CARDIAC: PMI located in 5th intercostal space, midclavicular line. irregular rate, rhythm, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Decreased breath sounds left lung base,with b/l crackles ABDOMEN: Soft, non-distended. +bowel sounds, scar anterior abdomen. mild tenderness to deep palpation, suprapubic. No guarding/rebound. EXTREMITIES: 2+ pitting edema bilaterally to mid calf, 2+ DP/PT pulses. Pertinent Results: [**2185-8-1**] 11:42PM URINE HOURS-RANDOM UREA N-500 CREAT-92 SODIUM-LESS THAN POTASSIUM-36 CHLORIDE-LESS THAN [**2185-8-1**] 11:42PM URINE OSMOLAL-294 [**2185-8-1**] 09:30PM GLUCOSE-104* UREA N-62* CREAT-2.4* SODIUM-133 POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-20* ANION GAP-17 [**2185-8-1**] 09:30PM estGFR-Using this [**2185-8-1**] 09:30PM CALCIUM-8.7 PHOSPHATE-5.4* MAGNESIUM-2.6 [**2185-8-1**] 09:30PM WBC-8.9 RBC-3.52* HGB-10.1* HCT-30.4* MCV-86 MCH-28.7 MCHC-33.2 RDW-14.2 [**2185-8-1**] 09:30PM NEUTS-76.8* LYMPHS-13.2* MONOS-7.9 EOS-1.9 BASOS-0.1 [**2185-8-1**] 09:30PM PLT COUNT-400 [**2185-8-1**] 09:30PM PT-23.1* PTT-35.1* INR(PT)-2.2* Brief Hospital Course: 82 y/o female with CAD, paroxysmal atrial fibrillation who presents from [**Hospital **] hospital after echo showed pericardial effusion with signs of tamponade and clinically stable with pulsus of 8. ECHO showed: The left atrium is elongated. The left ventricular cavity size is normal. Overall left ventricular systolic function appears preserved. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is a large sized pericardial effusion. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. Patient was monitored overnight. She was kept NPO. INR was reversed with vitamin K, with INR 2.2 on transfer. Anti-hypertensives and anticoagulants were held. All home meds except simvastatin were held. Patient was given IVF since Urine lytes showed pre-renal with Na < 10. She was also found to have normocytic anemia, with Hct 28.7 on transfer. Medications on Admission: Simvastatin 80mg Nifedipine 90mg Aspirin 81mg Isosorbide dinitrate 30mg Lisinopril 40mg NitroSL 0.4mcg PRN Furosemide 20mg Metoprolol 50mg Coumadin 2.5mg Colchicine 0.6mg TIDPRN Discharge Medications: TRANSFER MEDICATIONS: Simvastatin 80 mg PO/NG DAILY Discharge Disposition: Extended Care Facility: [**Hospital6 **] Discharge Diagnosis: pericardial effusion Discharge Condition: alert and oriented clinically stable Discharge Instructions: You were admitted for pericardial effusion. Your medications were held and you were given IV fluids. You are being transferred to another hospital for further care. Followup Instructions: Transfer to outside hospital. Will need f/u with PCP after discharge [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

[ "585.9", "403.90", "V45.01", "V58.61", "428.33", "592.0", "414.01", "427.31", "423.3", "285.9", "428.0", "423.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5295, 5338

3725, 4989

297, 303

5402, 5440

3040, 3702

5655, 5857

2263, 2382

5217, 5217

5359, 5381

5015, 5194

5464, 5632

2397, 3021

227, 259

5240, 5272

331, 1988

2010, 2130

2146, 2247

46,414

172,689

38141

Discharge summary

report

Admission Date: [**2109-5-13**] Discharge Date: [**2109-5-20**] Date of Birth: [**2048-5-22**] Sex: M Service: CARDIOTHORACIC Allergies: Iodine-Iodine Containing Attending:[**First Name3 (LF) 922**] Chief Complaint: relatively asymptomatic ( single episode described in HPI) Major Surgical or Invasive Procedure: [**2109-5-13**] 1. Bentall procedure with a 29-mm [**Company 1543**] Freestyle Xenograft root with coronary button reimplantation. 2. Coronary bypass grafting x3 of left internal mammary artery, left anterior descending coronary; reverse saphenous vein single-graft from the aorta to the distal right coronary artery; as well as reverse saphenous vein single-graft from the aorta to the second obtuse marginal coronary artery. 3. Replacement of ascending aorta and hemiarch with a 30-mm Dacron graft using deep hypothermic circulatory arrest. 4. Endoscopic right vein harvesting. History of Present Illness: 60 yo male with 5.3 cm asc. aortic aneurysm revealed on CT when hospitalized. Had ER visit for N/V/diaphoresis/ angina radiating into left arm in [**Month (only) 116**]. Stress echo was mildly abnormal, but scan showed aortic root and ascending aortic aneurysm. Pt lives in [**State **] and NH and presents for surgical eval. Past Medical History: asc. aortic aneurysm NIDDM dyslipidemia renal calculi obesity pyloric stenosis (repaired at 3 days old) hemorrhoids gastric ulcer ulcer ventral/umbilical hernia colon polyps Social History: Lives with son and his mother in [**Name (NI) **]; significant other lives in their [**Name (NI) **] home Occupation:computer engineer Tobacco: 5 PY Hx; quit 35 yrs ago ETOH:1-2 drinks per month Family History: sister had thoracic aortic aneurysm repaired at age 50; mother with CABG at age 60 Physical Exam: Pulse:85 Resp: 20 O2 sat: 97% RA B/P Right: 142/85 Left: 146/89 Height: 6'0" Weight:260# General:obese, NAD Skin: Dry [x] intact [] HEENT: PERRLA [x] EOMI [x]anicteric sclera,OP unremarkable Neck: Supple [x] Full ROM [x]no JVD Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur- 4/6 SEM radiates throughout precordium and into carotids Abdomen: Soft [x] non-distended [] non-tender [x] bowel sounds + [x] obese, large ventral and umbilical hernia; no HSM/CVA tenderness Extremities: Warm [x], well-perfused [x] Edema-none Varicosities: None [x] Neuro: Grossly intact; MAE [**4-3**] strengths; nonfocal exam Pulses: Femoral Right: 2+ Left:2+ DP Right: 2+ Left:2+ PT [**Name (NI) 167**]: 2+ Left:2+ Radial Right: 2+ Left:2+ Carotid Bruit: murmur radiates into both carotids Pertinent Results: [**2109-5-18**] 11:55AM BLOOD WBC-7.1 RBC-3.23* Hgb-9.8* Hct-29.0* MCV-90 MCH-30.3 MCHC-33.7 RDW-14.9 Plt Ct-199 [**2109-5-18**] 11:55AM BLOOD Glucose-223* UreaN-27* Creat-1.1 Na-139 K-3.5 Cl-95* HCO3-34* AnGap-14 [**2109-5-18**] 09:15AM BLOOD Glucose-214* UreaN-27* Creat-1.0 Na-139 K-3.7 Cl-97 HCO3-33* AnGap-13 Intra-op echo [**2109-5-13**] PRE-CPB:1. The left atrium is mildly dilated. No thrombus is seen in the left atrial appendage. 2. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is mildly depressed (LVEF= 40 %). 3. Right ventricular chamber size and free wall motion are normal. 4. The aortic root is moderately dilated at the sinus level. The ascending aorta is markedly dilated The aortic arch is moderately dilated. The descending thoracic aorta is moderately dilated. 5. The aortic valve is bicuspid. There is no aortic valve stenosis. Moderate (2+) aortic regurgitation is seen and is eccentric. 6. The mitral valve appears structurally normal with trivial mitral regurgitation. Dr. [**Last Name (STitle) 914**] was notified in person of the results. POST-CPB: On infusion of phenylephrine. AV pacing initially for heart block. Well-seated valve conduit in the aortic position with no stenosis, no AI. MR is 1+. LVEF = 45% with inferior hypokinesis. Aortic contour is normaol post decannulation. Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [**2109-5-13**] where the patient underwent bentall, hemiarch replacement and CABG x 3. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. He developed post-op bradycardia and atrial fibrillation and was evaluated by EP. Low dose beta blocker was recommended, as well as temporary pacing. The patient was transferred to the telemetry floor for further recovery. Rhythm stabilized, and pacing wires were discontinued. Chest tubes were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 7 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home in good condition with appropriate follow up instructions. He is from [**State **], but will be staying in New [**Location (un) **] for the month following discharge. He will see Dr. [**Last Name (STitle) 39975**] in [**Location (un) 3844**] for cardiology follow up. Medications on Admission: Byetta 10 mcg inj. [**Hospital1 **] Glipizide 10 mg [**Hospital1 **] Lovastatin 40mg daily Metformin 1000 mg [**Hospital1 **] Multivitamin daily fish oil 1 gm [**Hospital1 **] ASA 81 mg daily C0-Q-10 300 mg daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 2. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Byetta 10 mcg/0.04 mL Pen Injector Sig: One (1) Subcutaneous twice a day. 5. Lovastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): 200mg [**Hospital1 **] x 2 weeks, then 200mg daily until further instructed. Disp:*60 Tablet(s)* Refills:*2* 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 2 weeks. Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) **] vna Discharge Diagnosis: aortic root/ascending aortic aneurysm, coronary artery disease s/p Bentall, hemiarch replacement, CABGx3 [**2109-5-13**] Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: Provider: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2109-6-18**] 2:00 Please call to schedule appointments Cardiology in [**Location (un) 3844**] Dr. [**Last Name (STitle) 39975**] ([**Telephone/Fax (1) 84379**]‎ [**2109-6-6**] 3:40pm, 1 [**Doctor First Name **] Way, [**Location (un) 5450**], [**Numeric Identifier 85099**] Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) 2946**] [**Telephone/Fax (1) 85100**] on return to [**State **] **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:[**2109-5-20**]

[ "424.1", "278.00", "413.9", "250.00", "441.2", "997.1", "746.4", "E878.2", "518.0", "427.81", "414.01" ]

icd9cm

[ [ [] ] ]

[ "36.12", "38.45", "35.39", "39.61", "35.21", "36.15" ]

icd9pcs

[ [ [] ] ]

7294, 7349

4125, 5622

350, 961

7514, 7670

2712, 4102

8372, 9101

1744, 1829

5886, 7271

7370, 7493

5648, 5863

7694, 8349

1844, 2693

251, 312

989, 1317

1339, 1515

1531, 1728

80,757

162,599

26889

Discharge summary

report

Admission Date: [**2180-11-18**] Discharge Date: [**2180-11-22**] Date of Birth: [**2127-9-23**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4282**] Chief Complaint: Chills Major Surgical or Invasive Procedure: None History of Present Illness: A 53 year old lady with metastatic breast CA 9 weeks s/p Chemo presented to the ED after experiencing chills the evening prior to admission after starting the day's TPN. She then later developed a fever to 101.9 and was recommended to come to the ED by the oncologist on call. . In the ED, initial vs were: 101.4 165 82/43 18 97%RA Patient was given 5-6 L NS; Vancomycin, Zosyn, Fluconazole and a femoral line was placed. She also received Toradol for pain control. Given her hypotension, she was started on Norepinephrine, Dopamine and Phenylephrine and Dexamethasone for blood pressure support. Her respiratory and mental statuses remained uncompromised. . Of note, the patient had a R hickman placed 2 weeks prior to initate TPN. She is also 1 day s/p therapeutic paracentesis with "many" bottles of fluid removed. . On the floor, the patient appears pale and mildy uncomfortable and reports generalized pain. She denies dyspnea, chest pain, line pain or abdominal pain, and reports that her belly is softer after paracentesis. She denies any cough, sinus pain, congestion. She is not chilled at this time. The patient reports chronic constipation with 5 episodes of non-bloody diarrhea the day prior to admission; all secondary to an obstructive colonic mass. Past Medical History: -Metastatic Breast Cancer Oncologic History: - [**8-3**] - initially diagnosed after finding breast lump - [**8-3**] - s/p partial mastectomy and lymph node dissection in [**8-3**] with negative nodes and clean margins - [**12-3**] - s/p radiation therapy - initially declined chemotherapy in [**2176**] - [**3-5**] - found to have breast cancer metastatic to liver with associated ascites - [**Date range (1) 66166**] - received 5 cycles taxotere and cytoxan; 6th cycle taxotere only due to bladder irritation related to cytoxan; excellent response to chemotherapy - [**8-5**] - started on xeloda for maintenance - [**5-6**] - progression of hepatic and peritoneal disease, started on doxil - [**7-6**] - started clinical trial with cisplatin and PARP inhibitor for metastatic triple negative breast cancer; unfortunately she had to withdraw from the study due to thrombocytopenia - [**10-6**] - started weekly taxotere Social History: Lives with her husband and 2 daughters. Former [**Company 378**] consultant, business owner. 5pkyr history, quit Family History: Father - died at age 63 from CVA Mother - Glaucoma Physical Exam: Vitals: T: 99.3 BP: 101/46 P: 154 R: 17 O2: 95% RA General: Alert, oriented, mildly uncomfortable HEENT: Pale conjunctive, dry mucous membranes. Neck: supple, JVP not elevated, no LAD Lungs: Occasional wheezes, otherwise clear to auscultation bilaterally CV: S1 & S2 rapid without appreciable murmur, difficult given rate. Hickman on R Subclavian with mild erythema surrounding line insertion. Abdomen: tight and distended, nontender, bowel sounds present. No masses palpable. No hepatosplenomegaly, but difficult given tight abdomen. GU: foley & R femoral line in place Ext: warm, well perfused, 2+ pulses, no edema At discharge: VSS, afebrile Gen: in chair, NAD HEENT: Clear OP, MMM NECK: Supple, No LAD, No JVD CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops LUNGS: CTA, BS BL, No W/R/C ABD: Soft, tender to deep palpation in the RUQ and mid periumbilical area, no rebound or guarding, mildly distended. NL BS. No HSM EXT: No edema. 2+ DP pulses BL SKIN: No lesions NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [**12-31**]+ reflexes,equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**2180-11-18**] 08:44PM LACTATE-7.6* [**2180-11-18**] 08:20PM GLUCOSE-211* UREA N-36* CREAT-1.1 SODIUM-137 POTASSIUM-3.0* CHLORIDE-98 TOTAL CO2-21* ANION GAP-21* [**2180-11-18**] 08:20PM ALT(SGPT)-20 AST(SGOT)-33 LD(LDH)-527* CK(CPK)-43 ALK PHOS-753* TOT BILI-0.7 [**2180-11-18**] 08:20PM LIPASE-8 GGT-72* [**2180-11-18**] 08:20PM CK-MB-1 cTropnT-<0.01 [**2180-11-18**] 08:20PM CALCIUM-7.6* PHOSPHATE-2.5* MAGNESIUM-1.7 [**2180-11-18**] 08:20PM WBC-13.6* RBC-2.79* HGB-9.1* HCT-26.4* MCV-95 MCH-32.6* MCHC-34.4 RDW-17.2* [**2180-11-18**] 08:20PM NEUTS-95* BANDS-1 LYMPHS-4* MONOS-0 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2180-11-18**] 08:20PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL ENVELOP-1+ [**2180-11-18**] 08:20PM PLT COUNT-86* [**2180-11-17**] 02:00PM WBC-14.7*# RBC-2.68* HGB-8.7* HCT-25.5* MCV-95 MCH-32.3* MCHC-33.9 RDW-16.7* [**2180-11-17**] 02:00PM PLT SMR-LOW PLT COUNT-94*# [**2180-11-17**] 02:00PM PT-14.9* PTT-35.0 INR(PT)-1.3* [**2180-11-17**] 02:00PM GRAN CT-[**Numeric Identifier 16227**]* [**2180-11-21**] 07:35AM BLOOD WBC-25.4* RBC-3.12* Hgb-9.6* Hct-27.6* MCV-89 MCH-30.7 MCHC-34.7 RDW-17.4* Plt Ct-24* [**2180-11-20**] 03:02AM BLOOD Neuts-93* Bands-2 Lymphs-1* Monos-2 Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-1* [**2180-11-20**] 03:02AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-OCCASIONAL Schisto-OCCASIONAL Bite-OCCASIONAL [**2180-11-21**] 06:15PM BLOOD Plt Ct-61*# [**2180-11-21**] 07:35AM BLOOD Glucose-185* UreaN-23* Creat-0.6 Na-137 K-2.9* Cl-107 HCO3-22 AnGap-11 [**2180-11-21**] 07:35AM BLOOD ALT-22 AST-24 AlkPhos-169* TotBili-0.6 [**2180-11-21**] 07:35AM BLOOD Calcium-6.9* Phos-1.6* Mg-2.1 [**2180-11-20**] 05:39AM BLOOD Type-ART pH-7.43 . CT CHEST/ABDOMEN AND PELVIS [**2180-11-19**] IMPRESSION: 1. Progression of metastatic disease involving the left pelvic serosal implant as well as right abdominal omental caking. 2. Worsening large bowel obstruction, with transition point in the sigmoid colon at the region of serosal implant. 3. Decrease in omental caking within the left mid and left anterior abdomen. 4. Interval decrease in size of hepatic lesion. Using son[**Name (NI) 493**] guidance, an appropriate spot for paracentesis was selected in the right lower quadrant, and the skin was marked. The skin was prepped and draped in the usual sterile fashion. 1% buffered local lidocaine was administered. A 5 French [**Last Name (un) 11097**] catheter was inserted into the peritoneal cavity and 2.8 liters of brown fluid was removed Abdominal ultrasound: 1. Liver vessels patent. 2. Distended gallbladder with small amount of pericholecystic fluid. 3. Liver lesion seen on recent CT are not demonstrated well on this study, due to difference in technique, and the patient unable to cooperate Labs at discharge: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 25.4* 3.19* 9.7* 29.0* 91 30.6 33.5 17.3* 69* PT 13.11 PTT 31.5 INR 1.1 Glucose UreaN Creat Na K Cl HCO3 AnGap 153* 19 0.6 139 3.2* 110* 22 10 Albumin Calcium Phos Mg 2.1* 6.7* 2.0* 2.0 Blood Culture, Routine (Final [**2180-11-22**]): CITROBACTER FREUNDII COMPLEX. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 66167**] [**2180-11-18**]. ENTEROBACTER GERGOVIAE. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 286-0135K [**2180-11-18**]. [**2180-11-19**] 11:30 am BLOOD CULTURE Blood Culture, Routine (Pending) Brief Hospital Course: A 53 year old lady with metastatic breast CA currently between chemo cycles presenting with sepsis of indeterminate source. . 1) Septic Shock: Mrs. [**Known lastname 1022**] [**Last Name (NamePattern1) 66168**] hypotensive, tachycardic with leukocytosis on multiple pressors with likely sources including Hickman catheter infection (Bacterial or fungal given TPN); secondary or spontaneous bacterial peritonitis given recent tap, without fluid to be sent. Initially received vanc, zosyn, fluconazole. Received crystalloid and blood fluid rescussiation. Levophed and dopamine were needed for pressor support, and were successfully weaned. It was decided to administer stress dose hydrocortisone given chronic dexamethasone. The indwelling port was thought to be the nidus of her infection. Initial cultures eventually grew out citrobacter and enterobacter. The patient defervesced and was transferred to the floor, where she continued to improve. Her primary oncologist had a discussion regarding removal of Hickman catheter, and given the direction of care towards comfort, it was decided not to remove the port but to treat through it. The patient received a gentamicin lock at the time of discharge for additional anti-microbial therapy. . 2) Metabolic/Lactic Acidosis: The patient's lactate was elevated initially from hypoperfusion which improved with blood pressure and fluid support. . 3) Anemia, thrombocytopenia: At recent baseline. Patient showed good response to blood transfusion. . 4) Metastatic Breast Ca: The patient has chronic/constant pain but otherwise no active issues. She also has an obstructive bowel mass preventing any PO intake. Fentanyl Tp and Oxycodone home regimen were used for pain control. . Medications on Admission: Senna 8.6 mg PO BID PRN Colace 100mg PO BID Megestrol 40mg/mL PO daily Caltrate-600 Plus Vitamin D3 600-400 mg-unit PO BID Fentanyl 100 mcg/hr Patch Q72hr Oxycodone 20-30mg PO Q3prn Pain Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Morphine Concentrate 20 mg/mL Solution Sig: [**5-17**] ml PO q1-2 as needed for pain, shortness of breath. Disp:*1 bottle* Refills:*2* 4. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal once a day. Disp:*10 patches* Refills:*0* 5. Ciprofloxacin 500 mg/5 mL Suspension, Microcapsule Recon Sig: Five (5) Suspension, Microcapsule Recon PO every twelve (12) hours for 14 days. Disp:*140 Suspension, Microcapsule Recon(s)* Refills:*0* 6. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: [**12-31**] Tablet, Rapid Dissolves PO every eight (8) hours. Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 3005**] Hospice Discharge Diagnosis: Primary Gram Negative Bacteremia . Secondary Breast Cancer Discharge Condition: stable, afebrile Discharge Instructions: You were admitted to the hospital because you were having fevers. You were found to have an infection in your blood stream which was treated with antibiotics. You were found to have a low platelet numbers so you received a platelet infusion. . We are discharging you on an antibiotic called ciprofloxacin. Please take 5mL of this liquid medication twice daily for 14 days. . Please return to the hospital or call your doctor if you experience any nausea, diarrhea, headache, fever, chills, constipation, light headedness, blurry vision, abdominal pain, bleeding, changes in your bowel movements of any other symptoms that are concerning to you. Followup Instructions: MD follow up needed Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 14688**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2180-11-27**] 12:00 Provider: [**Name10 (NameIs) 17246**] [**Name11 (NameIs) **], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2180-11-28**] 2:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4285**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 22**] Date/Time:[**2180-12-1**] 11:00

[ "790.7", "V10.3", "197.6", "287.5", "276.2", "E879.8", "787.02", "338.3", "511.81", "041.85", "197.7", "285.9", "789.59", "999.31", "785.50" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.04", "99.15", "99.05" ]

icd9pcs

[ [ [] ] ]

10455, 10513

7683, 9419

324, 330

10616, 10635

4042, 6948

11329, 11832

2721, 2773

9656, 10432

10534, 10595

9445, 9633

10659, 11306

2788, 3409

3423, 4023

278, 286

6967, 7660

358, 1629

1651, 2574

2590, 2705

47,547

190,553

37393+58147

Discharge summary

report+addendum

Admission Date: [**2105-8-31**] Discharge Date: [**2105-9-6**] Date of Birth: [**2033-12-6**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 165**] Chief Complaint: unstable angina Major Surgical or Invasive Procedure: left heart catheterization, coronary angiogram insertion of intra aortic balloon urgent coronary artery bypass grafting History of Present Illness: Ths=is 71 yesar olfd white male underwent eluting stents/PCI to mid circumflex vessel in [**2102**]. He recently had an abnormal stress test (surveillance) and was scheduled for catheterization. He, however, presented with the acute onset on angina ti [**Hospital3 417**] Hospital on [**8-29**]. Enzymes were flat and he was transferred for catheterization. 95% left main stenosis was found and he had some pain in the lab, propmting a balloon to be placed with stabilization. Surgical evaluation was requested for urgent revascularization. Past Medical History: Hypertension hyperlipidemia benign prostatic hypertrophy right carpal tunnel surgery noninsulin dependent diabetes gastroesophageal reflux hiatal hernia paroxysmal atrial fibrillation migraines Social History: Occupation:Retired HVAC mechanic for [**Company 22957**] Cigarettes: Smoked no [x] yes [] Other Tobacco use:denies ETOH: denies Illicit drug use:denies Last Dental Exam:a few months ago, see dentist every 6 months Lives with:alone, but stays with girfriend most of the time Contact: [**Name (NI) **] (girlfriend) Phone #[**Telephone/Fax (1) 84066**] Family History: Family History:Premature coronary artery disease- mother died at age 57 from MI; brother CABG [**51**] [**Name2 (NI) **]:Caucasian Physical Exam: Physical Exam Pulse:70 Resp:14 O2 sat:99/2L B/P 174/68 Height:5'7" Weight:158 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [] Extremities: Warm [x], well-perfused [x] Edema [] _____ IABP in R groin Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: IABP Left: 2+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: no Left: no Pertinent Results: [**2105-8-31**] 06:40PM BLOOD WBC-5.2 RBC-4.32* Hgb-13.3* Hct-37.6* MCV-87 MCH-30.8 MCHC-35.3* RDW-12.6 Plt Ct-116* [**2105-8-31**] 06:40PM BLOOD Glucose-162* UreaN-14 Creat-1.1 Na-137 K-3.7 Cl-104 HCO3-27 AnGap-10 [**2105-8-31**] 06:40PM BLOOD ALT-19 AST-32 LD(LDH)-156 AlkPhos-58 TotBili-0.5 [**2105-9-6**] 07:20AM BLOOD WBC-9.2 RBC-3.11* Hgb-9.3* Hct-28.0* MCV-90 MCH-29.9 MCHC-33.2 RDW-13.6 Plt Ct-180 [**2105-9-6**] 07:20AM BLOOD UreaN-30* Creat-1.2 Na-136 K-4.1 Cl-99 CXR [**9-4**] Since [**2105-9-2**], bilateral lower lung atelectasis, left more than right, has improved. Moderate left and minimal right pleural effusions are unchanged. No new lung opacities of concern. Heart size is top normal. Patient is status post median sternotomy with intact sternal sutures for CABG. Mediastinal and hilar contours are stable. TTE: PRE-BYPASS: -No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. -No atrial septal defect is seen by 2D or color Doppler. -There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. -Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). -Doppler parameters are most consistent with Grade I (mild) left ventricular diastolic dysfunction. -There are three aortic valve leaflets. No aortic regurgitation is seen. -The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. -There is no pericardial effusion. - IABP was in too far (in arch) it was repositioned (pulled back to distal to 1-2 cm distal to left sc) Dr. [**Last Name (STitle) **] was notified of the results. POSTBYPASS: -The patient is on no inotropic infusions. -Biventricular function is unchanged. -There is trace mitral regurgitation. -No aortic regurgitation is seen -The aorta is intact post-decannulation -IABP in good position with tip 1-2 cm distal to left sc artery Brief Hospital Course: As noted in present illness section, left main stenosis was found and an intra aortic balloon was placed. The following day ([**9-1**]) he went to the Operating Room where revascularization was performed. The balloon was retained and he required low dose Neo Synephrine. The balloon was removed the evening of surgery due to malposition (hemodynamics were stable). He was extubated the following morning, CTs were removed and Neo Synephrine was weaned off. He transferred to the floor on POD #3. Beta blocker and Lasix were begun as was Amiodarone for atrial ectopy and his history of paroxysmal atrial fibrillation. Physical Therapy was consulted for strength and mobility. His creatinine bumped slighly but is returning to baseline, he continues to need to be diuresed. His lisinopril should be restarted when appropriate. Wires were removed according to protocol. The [**Location (un) 1661**]-[**Location (un) **] drain was removed. On pod#5 he was ready for discharge to Life Care Center rehab West-[**Location (un) **]. Follow-up instructions reviewed. Of note his left upper thigh is very ecchymotic and extends to just above left knee, it has not changed in 48 hrs and his Hct has been stable. Medications on Admission: Aspirin 325 mg daily Finasteride 5 mg daily Combivent 2 puffs 4X/daily Lisinopril 5 mg daily Prazosin 2 mg twice daily Propanolol 160 mg daily Zocor 80 mg daily. Pantoprazole 40 mg daily Hyoscyamine 0.125 mg at night Discharge Medications: 1. hyoscyamine sulfate 0.125 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual HS (at bedtime). 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 3. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 6. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. prazosin 2 mg Capsule Sig: One (1) Capsule PO twice a day. 9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 4 days: then decrease to 400mg daily for 1 week, then 200mg daily until seen by cards. 10. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours). 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 15. hyoscyamine sulfate 0.125 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual HS (at bedtime). 16. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 17. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): increase once off amiodarne. 18. prazosin 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 19. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 20. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 21. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 22. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 23. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 24. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 25. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 1 weeks: then decrease to 40mg po daily x1 week then reevaluate. Discharge Disposition: Extended Care Facility: Life Care Center of [**Location 15289**] Discharge Diagnosis: unstable angina left main coronary artery disease gastroesophageal reflux benign prostatic hypertrophy noninsulin dependent disabetes mellitus hyperlipidemia paroxysmal atrial fibrillation s/p carpal tunnel release hypertension hyperlipidemia s/p coronary stenting s/p coronary artery bypass grafts 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. Left thigh very ecchymotic extending to just above the knee Edema +[**12-14**] generalized Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon:Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 170**]on [**10-5**] @1:15pm Cardiologist:Dr. [**Last Name (STitle) 7047**] ([**Telephone/Fax (1) 8725**]office will call with appt. Wound Check [**9-15**] @ 11:00 Please call to schedule appointments with: Primary Care Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 28095**]) in [**3-17**] 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** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2105-9-6**] Name: [**Known lastname 13369**],[**Known firstname 126**] M Unit No: [**Numeric Identifier 13370**] Admission Date: [**2105-8-31**] Discharge Date: [**2105-9-6**] Date of Birth: [**2033-12-6**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 265**] Addendum: Revised med list: aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 4 days: then decrease to 400mg daily for 1 week, then 200mg daily until seen by cards. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO Q12H (every 12 hours). docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). hyoscyamine sulfate 0.125 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual HS (at bedtime). glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): increase once off amiodarne. prazosin 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 1 weeks: then decrease to 40mg po daily x1 week then reevaluate. Print Options Discharge Disposition: Extended Care Facility: Life Care Center of [**Location 2075**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**] Completed by:[**2105-9-6**]

[ "412", "414.01", "458.29", "327.23", "530.81", "287.5", "V45.82", "427.89", "411.1", "401.9", "V17.3", "V15.84", "250.00", "346.00", "272.4", "427.1", "553.3", "600.00" ]

icd9cm

[ [ [] ] ]

[ "39.61", "37.61", "36.15", "88.56", "36.12" ]

icd9pcs

[ [ [] ] ]

13126, 13311

4456, 5664

292, 414

8958, 9254

2427, 4433

10094, 13103

1606, 1724

5933, 8525

8636, 8937

5690, 5910

9278, 10071

1739, 2408

237, 254

442, 990

1012, 1207

1223, 1575

31,573

148,606

33294

Discharge summary

report

Admission Date: [**2167-5-17**] Discharge Date: [**2167-5-18**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 495**] Chief Complaint: hemoptysis, respiratory distress Major Surgical or Invasive Procedure: mechanical ventilation History of Present Illness: Mr. [**Known lastname 77287**] is an 88 yo man with metastatic colon ca, previously on home hospice who was admitted with altered mental status, hemoptysis. His family saw the patient having respiratory distress, hemoptysis, and called EMS. On route, the patient was intubated, and initially was started on pressors for hypotension. Past Medical History: 1)Metastatic colon ca: s/p resection in [**2164**] complicated by leak; underwent ileostomy but hospital course complicated by septic shock. He then underwent reverse ileostomy. He has known metastases to liver and lung. Completed last cycle of chemotherapy on [**2167-3-14**] with 5-FU. 2)CAD s/p stent in [**2161**] and [**2163**] at [**Hospital6 2561**] 3)Atrial fibrillation 4)Hx of pulmonary embolism/DVT in R leg in [**2164**] on Coumadin 5)Hx of respiratory failure s/p tracheostomy 6)Anxiety Social History: Lives with wife and daughter. [**Name (NI) 3003**] tobacco use, quit 15 years ago. No current alcohol or IVDA. Family History: NC Physical Exam: Gen: eldery male, intubated, not responsive CV: difficult to asses; coarse mechanical BS. regular Lungs: coarse sounds with rhonci bilaterally; mechanical breath sounds Abd: soft, NT, normal BS Ext: 1+ BLE edema Neuro: sedated, not following commands. downward going toes bilaterally Pertinent Results: [**2167-5-18**] 05:24AM BLOOD WBC-8.8 RBC-3.37* Hgb-10.4* Hct-31.0* MCV-92 MCH-30.8 MCHC-33.5 RDW-14.4 Plt Ct-260 [**2167-5-18**] 05:24AM BLOOD Neuts-83.7* Lymphs-11.0* Monos-4.4 Eos-0.7 Baso-0.2 [**2167-5-18**] 05:24AM BLOOD PT-27.8* PTT-36.4* INR(PT)-2.8* [**2167-5-18**] 05:24AM BLOOD Glucose-78 UreaN-16 Creat-0.8 Na-141 K-3.6 Cl-106 HCO3-26 AnGap-13 [**2167-5-18**] 05:24AM BLOOD ALT-11 AST-31 LD(LDH)-231 AlkPhos-117 Amylase-46 TotBili-0.4 [**2167-5-18**] 05:24AM BLOOD Albumin-2.6* Calcium-8.0* Phos-2.6*# Mg-1.6 [**2167-5-17**] 07:45PM BLOOD Digoxin-0.4* [**2167-5-18**] 04:00AM BLOOD Lactate-1.7 [**2167-5-17**] 08:09PM BLOOD Lactate-4.6* [**2167-5-17**] 08:24PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011 [**2167-5-17**] 08:24PM URINE Blood-NEG Nitrite-NEG Protein-500 Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2167-5-17**] 08:24PM URINE RBC-[**12-24**]* WBC-[**4-8**] Bacteri-FEW Yeast-NONE Epi-[**4-8**] TransE-0-2 RenalEp-0-2 [**2167-5-17**] 08:24PM URINE CastGr-0-2 CastHy-[**12-24**]* [**2167-5-17**] 7:50 pm BLOOD CULTURE #2. **FINAL REPORT [**2167-5-23**]** Blood Culture, Routine (Final [**2167-5-23**]): NO GROWTH Time Taken Not Noted Log-In Date/Time: [**2167-5-17**] 8:25 pm URINE Site: CATHETER **FINAL REPORT [**2167-5-18**]** URINE CULTURE (Final [**2167-5-18**]): NO GROWTH. Brief Hospital Course: 88 yo male with metastatic colon cancer a/w respiratory distress, hemoptysis, altered mental status, intubated en route to ICU. # Respiratory Distress: The patient was at home on hospice prior to admission. He developed respiratory distress, hemoptysis, and altered mental status which concerned his family to call EMS. En route to the hospital, the patient was intubated. He also was briefly on pressors once he was sent from the ED to the ICU. There was no apparent source of infection. The patient's family did not want to continue mechanical ventilation or pressors, therefore the following day, these measures were stopped. The patient expired shortly afterwards from respiratory arrest. Medications on Admission: Digoxin 0.125mg PO daily Sotalol 80mg PO TID Fluoxetine 10mg PO daily Prevacid 30mg PO daily Coumadin 1mg PO daily Remeron 7.5mg PO QHS Iron PO BID Multivitamin with minerals Oxycodone 5mg PO Q6H PRN Potassium 20mEQ PO daily Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: Metastatic Colon Cancer Respiratory Failure Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired

[ "427.31", "V58.61", "786.3", "518.81", "197.7", "V45.82", "V12.51", "197.0", "414.01", "V10.05" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

4156, 4165

3147, 3848

302, 326

4252, 4261

1685, 3124

4317, 4327

1359, 1364

4124, 4133

4186, 4231

3874, 4101

4285, 4294

1379, 1666

230, 264

354, 690

712, 1214

1230, 1343

31,439

114,626

50612

Discharge summary

report

Admission Date: [**2136-8-14**] Discharge Date: [**2136-8-21**] Date of Birth: [**2064-3-15**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: nausea/vomiting Major Surgical or Invasive Procedure: Attempted temporary pacing wire placement (unsuccessful) Foley catheter History of Present Illness: 72 year old female with h/o severe ventricular dysfunction (EF 10%) secondary to polysubstance abuse and HIV (dx [**2116**] on [**Year (4 digits) 2775**], last CD4 359), 2+ MR, on methadone maintenance who presents with nausea, bradycardia, acute on chronic renal failure with potassium of 6.0. Patient states she has been fatigued recently but denies shortness of breath, chest pain, orthopnea and leg swelling. On day of presentation to ED, she began vomiting, non-bloody non-bilious. . Patient was recently admitted to [**Hospital1 18**] from [**Date range (1) 105348**]/07 with CHF exacerbation, swan was placed that admission and she was diuresed. Elevated troponin at the time thought secondary to demand. She was started on amiodarone for runs of VTach and continued on digoxin. She states she has been compliant with her medications. . ED: sbp 80's, which is baseline. Given insulin, 1amp D50, atropine, calcium gluconate 1g, sodium bicarbonate 50mEq for potassium 6.0. Given ondansetron. EKG likely junctional brady with retrograde p waves. . On review of symptoms, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. Other review of symptoms negative aside from above. . In the ED, the patient was afebrile with SBP in the 80-90s. She had nausea and was noted to have HR in the 30s junctional vs av delay. Now being transferred to floor for further mgmt. . On arrival to the CCU, she was feeling tired (hadn't slept all night) but no CP, shortness of breath, dizziness or LH. . On review of symptoms, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. Other review of symptoms negative aside from above. . Cardiac review of systems is notable for absence of chest pain, shortness of breath, palpitations, syncope or presyncope. Past Medical History: 1. HIV- Diagnosed in [**2116**], has taken [**Year (4 digits) 2775**] therapy intermittently. Stopped taking her pills three months ago because stated she had foamy vomit every time she took them. CD4 274, VL<50 in [**12-10**] 2. CHF- EF 10% 7/07 followed by Dr. [**First Name (STitle) 437**] 3. HCV- VL >700K in [**12-9**], not a good candidate for interferon therapy or liver biopsy per gi note in 04. 4. mild COPD- PFTs [**7-/2129**] showed a normal study 5. IVDU--last abuse heroin several days ago, skin popping 6. Arthritis 7. chronic pancreatitis 8. ventricular tachycardia Social History: Has 20 grandchildren, tobacco: [**4-8**] cig/day, 40 py Heavy EtOH in past. States that last used heroin in the past few days (skin popping) and also used cocaine in the last month. Family History: NC Physical Exam: VS: 96.2F HR 30 BP 86/50 RR 16 100%/2Ln.c. Gen: Cachectic female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple, thin. CV: PMI located in 7th intercostal space, midclavicular line. Distant heart sounds, regular rhythm, normal S1, S2. [**3-13**] holosystolic murmur at apex. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Crackles at right base, left base clear. Abd: Soft, ND, mild TTP epigastrium and RUQ with hepatomegaly. No abdominal bruits. Ext: no LE edema bilaterally. Skin: Multiple well healed lesions from h/o drug abuse Pulses: Right: 1+ DP Left: 1+ DP Pertinent Results: 7/13/7. CXR. Stable severe cardiomegaly. New mild-to-moderate pulmonary edema accompanied by small bilateral new pleural effusion. [**2136-8-14**]. Digoxin level 3.8 [**2136-8-16**]. Dig level 2.5 [**2136-8-17**]. Dig level 2.1 [**2136-8-18**]. Dig level 1.5 Brief Hospital Course: 72 yo female with severe ventricular dysfunction (EF 10%) secondary to polysubstance abuse and HIV (last CD4 359) who presented with bradycardia secondary to digoxin and amiodarone toxicity. . # Rhythm: Found to be bradycardic to 30's in ED in setting of digoxin toxicity with amiodarone and hyperkalemia contributing. Patient had been started on amiodarone at her last hospitalization due to runs of VTach. Pacer pads were placed but she did not require transcutaneous pacing. An isoproterenol drip was started which increased her Heart rates to 50's-60's (although initially remained in junctional rhythm). Digoxin and amiodarone were held. An attempt was made to place a temporary pacing wire, but this attempt was unsuccessful because of thrombosed veins. The isoprotenenol drip was stopped on [**8-18**]. Patient will not go home on amiodarone and will go home on Digoxin 0.125 mg qod. . # Pump: EF 10% on last echo ([**2136-8-3**]). She appeared euvolemic on admission so lasix was held. She developed increased shortness of breath and CXR was consistent with pulmonary edema, so patient was diuresed with lasix. A foley catheter was placed to monitor accurate I/Os. Digoxin and ACEI were held. ACEI will be held until she follows up in clinic with Dr. [**First Name (STitle) 437**]. # CAD: No evidence of active ischemia during admission. Normal perfusion images in [**2133**]. # HIV: Last CD4 359 in 04/[**2136**]. Patient requested that her [**Year (4 digits) 2775**] therapy be stopped as she felt that this made her nauseated and gave her abdominal discomfort. Her PCP was [**Name (NI) 653**] and made aware that the [**Name (NI) 2775**] was stopped. Her bactrim prophylaxis was continued. She will follow-up with her PCP [**2136-8-23**] to discuss further treatment options. # Polysubstance abuse: Last use [**6-10**] mos PTA. Continued with methadone 90mg. # ARF on CRI: Baseline creatinine 1.3-1.5. Now ARF on CRI; likely secondary to bradycardia and low EF in setting of digoxin toxicity. Held lasix and ACEI initially. Creatine continues to trend towards baseline with return of home lasix dose. #) Hyperkalemia: likely [**3-9**] ARF on CRI. Held ACEI. Avoided Calcium in setting of digoxin toxicity. Monitored frequent electrolytes. Treated with kayxalate as needed. She will have her potassium monitored on [**8-22**] at the rehab facility. #) Anticoagulation: Patient started on coumadin given poor LV function and risk of clot formation. Continued coumadin at decreased dose with sub-therapeutic INR. Prior to discharge to rehab, coumadin was increased to 5mg daily. Her INR will be checked on [**8-22**] at rehab and coumadin will be adjusted by Dr. [**First Name (STitle) 437**]. Medications on Admission: 1. Amiodarone 400mg [**Hospital1 **] 2. Digoxin 0.125 mcg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY 3. Emtricitabine-Tenofovir 200-300 mg po daily 4. Furosemide 100mg po bid 5. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 6. Lisinopril 20 mg PO DAILY 7. Methadone HCl 90 mg PO DAILY 8. Sulfameth/Trimethoprim DS 1 TAB PO BID 9. Warfarin 2 mg PO HS Discharge Medications: 1. Methadone 10 mg Tablet [**Hospital1 **]: Nine (9) Tablet PO DAILY (Daily). 2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 4. Furosemide 20 mg Tablet [**Last Name (STitle) **]: Five (5) Tablet PO BID (2 times a day). 5. Digoxin 125 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every other day: Start on Tuesday, [**2136-8-21**]. 6. Coumadin 2.5 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO once a day: Please have your INR checked on [**2136-8-22**]. Results faxed to Dr. [**First Name8 (NamePattern2) 401**] [**Last Name (NamePattern1) 437**]. 7. Outpatient Lab Work Please have your PT/PTT/INR as well as a chem 7 (electrolytes, creatinine, BUN) checked on Wednesday, [**2136-8-22**]. Fax results to Dr. [**First Name8 (NamePattern2) 401**] [**Last Name (NamePattern1) 437**] at ([**Telephone/Fax (1) 49261**]. Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: Digoxin toxicity resulting in bradycardia Congestive heart failure Coronary artery disease Discharge Condition: afebrile, comfortable on room air Discharge Instructions: Your foley catheter was removed just prior to discharge to rehab. Please perform a voiding trial on the day of admission to rehab. . Please stop taking Amiodarone and lisinopril. Please resume taking digoxin 0.125 mg every other day starting on Tuesday, [**2136-8-21**]. . Please take coumadin at 5 mg daily. Your INR will be checked on Wednesday, [**8-22**]. Results will be faxed to Dr.[**Name (NI) 3536**] office. . Please resume the rest of the medications you were on prior to admission, including lasix 100 mg twice per day. Please call your primary physician or return to the emergency room should you develop any of the following symptoms: nausea/vomiting, chest pain, difficulty breathing, or any other concerns. Followup Instructions: Please keep your appointment to see Dr. [**Last Name (STitle) **] on Thursday, [**2136-8-23**] at 2:30 pm. Call [**Telephone/Fax (1) 3581**] if there is a problem with this appointment. You should discuss restarting your HIV medications at this appointment. Please see DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] on [**2136-8-27**] at 3:30 PM. Call [**Telephone/Fax (1) 3512**] if there is a problem with this appointment.

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icd9cm

[ [ [] ] ]

[ "38.94" ]

icd9pcs

[ [ [] ] ]

8565, 8638

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3294, 4043

241, 258

398, 2454

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3075, 3259

81,579

109,770

7918

Discharge summary

report

Admission Date: [**2103-8-7**] Discharge Date: [**2103-9-23**] Date of Birth: [**2056-3-4**] Sex: F Service: MEDICINE Allergies: Compazine Attending:[**First Name3 (LF) 3913**] Chief Complaint: Hypercalcemia Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname 4003**] is a 47 year old woman who carries a diagnosis of HTLV-associated adult T-Cell leukemia/lymphoma who presents from routine clinic appointment with hypercalcemia, with a corrected calcium of 15.5. She received a liter of normal saline, but no bisphosphonate, and was subsequently admitted to the floor. . She was recently hospitalized from [**2103-7-11**] through [**2103-8-4**], also for hypercalcemia with acute mental status changes, which was attributed to progression of her hematologic malignancy. Following IV hydration and zometa, her calcium normalized, and she underwent treatment with [**Hospital1 **] cycle 1. Her post-chemo course was unfortunately complicated by DIC requiring multiple cryoprecipitate, C. dif colitis, CMV viremia, and a severe abdominal pain requiring bowel rest with TPN. She developed a LLL pnuemonia towards the end of her hospitalization and was discharged on a 10 day course of levaquin in addition to home TPN. . Since her discharge, Ms. [**Known lastname 4003**] has been slowly regaining her strength, noting persistent fatigue which has acutely worsened today. She denies acute confusion or mental status changes which accompanied her previous hypercalcemic episode. She notes no pain or paresthesias or tetany. Her last hospitalization was complicated by severe abdominal pain requiring bowel rest- she remains on home TPN and has been tolerating light meals due to a sense of fullness. She also had CXR evidence of LLL pneumonia and had been discharged on levaquin, which she has taken. She had also developed C.dif, and CMV viremia, which had been maintained on PO flagyl x 14d and valganciclovir in the outpatient setting. . On review of systems, the patient denies fevers, chills, nausea, vomiting, diarrhea, malaise, rigors, abdominal pain, blood in the stools, shortness of breath, cough, dysuria, hematuria, paresthesias, weakness. Past Medical History: Stage [**Doctor First Name **] mycosis fungoides (Cutaneous T-cell lymphoma, stage IV 1A) with transformation to CD-30 positive large cell lymphoma and development of HTLV-1 Adult T-cell Leukemia Lymphoma . - [**10-29**]: The patient developed a pruritic, papular rash. She was seen in the internal medicine and dermatology clinics on several occasions and was treated with antibiotics, triamcinolone, clobetasol, and IV triamcinolone w/ no improvement. - [**2100-3-12**]: Skin Bx 1: LLE: Superficial and deep perivascular lymphohistiocytic infiltrate with perivascular and interstitial eosinophils consistent with a hypersensitivity rxn. Scabies neg. - [**2100-7-13**]: Skin Bx 2: Atypical superficial and deep dermal lymphoid infiltrate containing CD30-positive cells and showing epidermotropism. PCR analysis for the T-cell receptor gamma gene showed two sharp bands with a migration pattern suggestive of a clonal rearrangement. - [**2100-8-24**]: [**Hospital **] clinic: WBC 10.6 with 57% Lymphocytes S??????zary cells. Immunophenotypic analysis -> expanded T-cell population with increased CD4:CD8 ratio (15) and loss of CD7. Due to her high count of circulating S??????zary cells, she was felt to have Stage [**Doctor First Name 690**] mycosis fungoides. - [**2100-9-8**] CT scan: Infiltrating, hypo-enhancing lesion in the R. kidney (?infiltrating neoplasm vs pyelonephritis) compatible w/ lymphomatous involvement of the kidney but was not present on a follow-up scan on [**2101-1-21**]. - [**9-30**]: Photopheresis therapy through an indwelling central venous catheter, placed due to poor venous access. - [**2101-1-5**]: Skin Bx 3: CTCL with large-cell transformation. - [**2101-1-10**]: Interferon alpha at 3M units 3x/wk given w/ with photopheresis every other week and PUVA. - [**2101-1-26**]: Interferon alpha increased to 6Munits 3x/wk; PUVA was d/ced [**12-26**] side effects. - [**2101-2-23**]: Interferon alpha decreased to 4.5Munits 3x/wk on [**2101-2-23**] b/c fatigued. Photopheresis was d/ced when catheter removed due to a line infection (last treatment [**2101-3-10**]). - [**2101-8-4**]: The patient presented for a follow-up evaluation with clear evidence of disease progression. Interferon alpha was increased to 6M units three times weekly and bexarotene was started at 150mg daily, decreased to 75mg daily due to poor tolerability. - [**2101-8-25**]: Mtx added to interferon alpha and bexarotene and the dose was up-titrated to 45mg weekly. - [**2101-10-18**]: Hospital admission for severe lower extremity pain at the site of new, large, papular skin lesions. Biopsy showed cutaneous T-cell lymphoma with large cell transformation, involving the panniculus with an unusual angiocentric pattern. The patient was prescribed vorinostat 400mg daily (started [**2101-10-27**]) with continuation of interferon alpha 6M units TIW. Due to thrombocytopenia, interferon alpha was decreased to 3M units 3x/wk. - [**2101-12-22**]: Cycle 1 Day 1 liposomal doxorubicin plus gemcitabine. Vorinostat and interferon alpha were d/ced. Side Effect: severe palmar-plantar erythrodysesthesia [**12-26**] to liposomal doxorubicin. - [**2102-1-17**]: Cycle 1 Day 1 bortezomib plus gemcitabine, dose-reduced during Cycle 2 due to neutropenia. - [**2102-2-9**] 3M units TIW Interferon alpha restarted - [**2102-3-9**]: Due to the observation that peripheral T-cells contained floret-like nuclei, immunophenotypic analysis was performed on peripheral blood, revealing findings consistent with involvement by patient's known T cell lymphoproliferative disorder as well as CD25 co-expression in a significant population of the neoplastic CD3+ lymphocytes, suggesting a diagnosis of HTLV-1 associated lymphoma. PCR for HTLV-1 DNA was positive. - [**2102-5-26**]: Following a treatment break, the patient was started on pentostatin 4mg/m2 weekly x4 doses with reinitiation of interferon alpha at 3Munits 3x/wkly , increased to 3M units 5x/wkly. She d/ced therapy after 2 cycles in [**7-2**] in favor of a Chinese herbal preparation she received in [**Location (un) 4708**]. - [**2102-8-18**]: Evaluation in the [**Hospital 18**] [**Hospital 3242**] clinic: good candidate for allo SCT. - [**2102-9-26**]: CT scan: s/p 3 mo off therapy: stable to improved disease: lymph nodes in the chest, abdomen, and pelvis, are stable to decreased in size since [**2102-7-28**], with no new pathologic LAD identified. Decreased size of the previously enlarged spleen, now within normal limits in size. - [**2102-12-25**] Initiation of ONTAK therapy Cycle 1 [**2102-12-25**], Cycle 2 [**2103-1-15**], Cycle 3 [**2103-2-5**], Cycle 4 [**2103-2-26**], Cycle 5 [**2103-6-4**], Cycle 6 [**2103-7-2**] - [**2103-4-26**]: 2 weeks of total skin electron beam therapy at the [**Hospital3 2358**] under the care of Dr. [**First Name4 (NamePattern1) 3403**] [**Last Name (NamePattern1) **]. Therapy was held [**2103-5-18**] through [**2103-5-24**] [**12-26**] fatigue. She received a single dose on Friday [**2103-5-25**]. - [**2103-5-29**]: Hypercalcemia: IVF and Zometa. - [**2103-5-29**]: Treatment Discussion: Re: Total Skin Electron Beam Therapy: Progressive Disease and Difficulty tolerating therapy. Decision to resume ONTAK therapy with intention of initiating auto-transplant as she demonstrates response. -[**2103-7-11**]: admitted for AMS in the setting of hypercalcemia, which was thought to be due to progression of ATLL. Started [**Hospital1 **] [**7-11**], complicated by c dif, CMV viremia, DIC. Social History: The patient is from [**Location (un) 4708**]. She moved to the U.S. 11 years ago. She is married and has two children. She denies past or current tobacco, etoh or illicit drug use. Family History: Mother had an MI. Her father with CAD. Physical Exam: VS: T98.9 BP128/86 P109 RR18 Sa02100RA GENERAL: Fatigued appearing female in no acute distress HEENT: EOMI, PERRLA, white plaques along lateral left border of tongue, pharyngeal wall nonerythematous without exudates PULMONARY: Minimal bibasilar crackles, otherwise clear to auscultation CARDS: RRR, normal S1, S2, 3/6 systolic ejection murmur. no rubs or gallops. ABDOMEN: soft, nondistended, positive bowel sounds, mild tenderness to palpation of the RUQ which is chronic, no rebound tenderness or guarding. EXTREMITIES: nonedematous, 2+ PT, DP pulses bilaterally NEUROLOGIC: CN II-XII intact bilaterally. Strength 5/5 throughout though deconditioned. Sensation to soft touch intact throughout. DTRs depressed. SKIN: no rashes or lesions appreciated. Pertinent Results: ADMISSION LABS: . [**2103-8-7**] 11:30AM PT-15.1* PTT-35.9* INR(PT)-1.3* [**2103-8-7**] 11:30AM PLT COUNT-129*# [**2103-8-7**] 11:30AM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ [**2103-8-7**] 11:30AM NEUTS-38* BANDS-3 LYMPHS-45* MONOS-6 EOS-0 BASOS-0 ATYPS-8* METAS-0 MYELOS-0 [**2103-8-7**] 11:30AM WBC-16.9* RBC-2.57* HGB-8.5* HCT-25.5* MCV-99* MCH-32.9* MCHC-33.2 RDW-17.9* [**2103-8-7**] 11:30AM ALBUMIN-2.9* CALCIUM-14.6* PHOSPHATE-7.2*# MAGNESIUM-2.2 [**2103-8-7**] 11:30AM ALT(SGPT)-14 AST(SGOT)-26 ALK PHOS-209* TOT BILI-0.4 [**2103-8-7**] 11:30AM GLUCOSE-103* UREA N-34* CREAT-1.1 SODIUM-145 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-31 ANION GAP-13 [**2103-8-7**] 06:57PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2103-8-7**] 06:57PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007 [**2103-8-7**] 09:48PM CALCIUM-14.1* . IMAGING: CXR [**2103-8-12**]: Cardiac size is normal. ET tube tip is in a standard position 3.8 cm above the carina. Right PICC tip is in the mid SVC. Left subclavian catheter tip is in the proximal SVC. There is no pneumothorax. New bibasilar opacities, left greater than right, are a combination of pleural effusions and atelectasis. Superimposed infection on the left cannot be totally excluded. NG tube tip is in the stomach. . HEAD MRI [**2103-8-12**]: FINDINGS: There is mild prominence of sulci and ventricles inappropriate for patient's age. There is no midline shift or mass effect. There is no hydrocephalus. There is no acute infarct seen on diffusion images. Following gadolinium, there is no abnormal parenchymal, vascular or meningeal enhancement identified. In particular, there is no leptomeningeal enhancement seen. Soft tissue changes are visualized in the paranasal sinuses due to mucosal thickening. Diffuse low signal is identified within the bony structures, which could be secondary to marrow hyperplasia. It should be noted that on FLAIR images, increased signal identified at the sulci at the convexity is secondary to these images were obtained following gadolinium. IMPRESSION: No acute infarcts or enhancing brain lesions are identified. No mass effect or hydrocephalus. Other findings as described above. . PORTABLE ABDOMEN [**2103-8-12**]: NG tube tip is in the stomach. There is no evidence of bowel obstruction. Nondistended air-filled large bowel loops are seen. There are no pathologic intraabdominal calcifications. . CT Torso: [**2103-8-27**] 1. No evidence of pulmonary embolus or acute aortic syndrome. 2. Interval development of right middle upper lobe airspace consolidation most consistent with pneumonia, with additional focus of opacity in the left perihilar region, possibly representing additional focus of infection, although enlargement of left hilar lymph nodes is difficult to exclude. Followup imaging following treatment to ensure resolution is recommended. 3. Splenomegaly. 4. Retroperitoneal adenopathy, grossly stable from [**2103-6-24**]. 5. No intra-abdominal explanation for fever. Colon is diffusely fluid-filled but thin-walled and without associated inflammatory change. There is no loculated fluid collection or abscess identified. 6. Diffuse soft tissue anasarca. . Bronchial Embolization: [**2103-9-4**]. IMPRESSION: Uncomplicated embolization of the right bronchial artery with 300-500 micron Embospheres until stasis was achieved. . CT Head [**2103-9-17**]. No acute hemorrhagic mass seen, nor large area of edema or mass effect on non-contrast head CT. However, for evaluation of subtle process, MRI before and after IV gadolinium would be recommended for more sensitive evaluation. . Peripheral Blood Analysis: Flow Analysis: INTERPRETATION More than 99% of the peripheral blood lymphocytes are CD4-positive subset with co-expression of CD3, CD2, CD5. They have loss of expression of CD7. About half of these T-cells also express CD25. These immunophenotypic findings and the presence of "floret-like cells" in peripheral blood smear are consistent with involvement by patient's known "Adult T cell leukemia/lymphoma". . Microbiology: Major Studies/Findings listed here: [**2103-9-4**] 4:49 pm BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final [**2103-9-4**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2103-9-6**]): NO GROWTH, <1000 CFU/ml. LEGIONELLA CULTURE (Final [**2103-9-11**]): NO LEGIONELLA ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2103-9-4**]): 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 [**2103-9-5**]): NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Final [**2103-9-17**]): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2103-9-5**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Final [**2103-10-3**]): No Cytomegalovirus (CMV) isolated. [**2103-8-28**] 1:43 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE, RIGHT MIDDLE LOBE. GRAM STAIN (Final [**2103-8-28**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2103-8-30**]): NO GROWTH, <1000 CFU/ml. POTASSIUM HYDROXIDE PREPARATION (Final [**2103-8-29**]): NO FUNGAL ELEMENTS SEEN. This is a low yield procedure based on our in-house studies. TEST REQUESTED BY PULMONARY FELLOW [**Numeric Identifier 28457**] [**2103-8-29**]. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2103-8-29**]): NEGATIVE for Pneumocystis jirovecii (carinii).. FUNGAL CULTURE (Final [**2103-9-14**]): YEAST. NOCARDIA CULTURE (Final [**2103-9-17**]): NO NOCARDIA ISOLATED. ACID FAST SMEAR (Final [**2103-8-29**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. . [**2103-8-28**] 11:31 am SPUTUM Site: EXPECTORATED Source: Expectorated. **FINAL REPORT [**2103-9-14**]** GRAM STAIN (Final [**2103-8-28**]): <10 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final [**2103-8-30**]): RARE GROWTH Commensal Respiratory Flora. YEAST. RARE GROWTH. FUNGAL CULTURE (Final [**2103-9-14**]): YEAST. . [**2103-8-12**] 11:24 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2103-8-14**]** GRAM STAIN (Final [**2103-8-12**]): <10 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final [**2103-8-14**]): Commensal Respiratory Flora Absent. YEAST. SPARSE GROWTH. . [**2103-8-21**] 9:31 pm URINE Source: CVS. **FINAL REPORT [**2103-8-23**]** URINE CULTURE (Final [**2103-8-23**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ 4 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R . Test Result Reference Range/Units ASPERGILLUS ANTIGEN 6.5 H <0.5 . Test ---- Fungitell (tm) Assay for (1,3)-B-D-Glucans Results Reference Ranges ------- ---------------- 358 pg/mL Negative Less than 60 pg/mL Indeterminate 60 - 79 pg/mL Positive Greater than or equal to 80 pg/mL Brief Hospital Course: In brief, Ms. [**Known lastname 4003**] was a 47 year old lady with a diagnosis of HTLV-1 associated Adult T cell leukemia/lymphoma who initially presented with hyerpcalcemia. Her hospital course was complicated by Mental Status changes which after ICE therapy necessitating an admission to the ICU without any acute evidence of an intracranial process. Her hospital course at this time was also complicated by persistent ATLL, hypercalcemia, renal tubular acidosis, acute renal failure, C. Diff colitis, and CMV viremia. Subsequently she developed hypoxic respiratory failure secondary to invasive aspergillosis with pulmonary hemorrhage. She underwent a pulmonary embolization procedure and a second intubation and ICU stay. Upon returning to the floor, no additional therapeutic intervention was started for her ATLL. Her mental status continued to deteroirate, and she stopped taking PO. Due to disease progression in addition to a persistent fungal infection and concern for aspiration goals of care were discussed with her family. Due to her poor prognosis, she was made DNR/DNI, and subsequently CMO. She passed peacefully on [**2103-9-23**]. Medications on Admission: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:*28 Tablet(s)* Refills:*0* 5. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for nausea, anxiety. 6. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 7. Doxepin 25 mg Capsule Sig: [**11-25**] Capsules PO once a day. 8. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO twice a day. 9. Pyridoxine 100 mg Tablet Sig: Four (4) Tablet PO once a day. 10. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. 12. Benadryl Oral 13. Levaquin 750 mg Tablet Sig: One (1) Tablet PO once a day for 9 days. Disp:*9 Tablet(s)* Refills:*0* 14. Line flush order Sodium chloride 5-10ml pre- and post infusion Heparin 10units/ml [**12-29**] ml infused as a final flush 15. Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for nausea. Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Deceased. Discharge Condition: None Discharge Instructions: None Followup Instructions: None Completed by:[**2103-10-17**]

[ "528.01", "E933.1", "276.1", "286.6", "790.8", "284.89", "484.6", "275.42", "588.89", "V49.86", "348.39", "202.10", "276.2", "518.81", "117.3", "079.51", "584.9", "200.70", "078.5", "486", "787.01", "008.45" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04", "38.91", "33.22", "99.15", "33.24", "03.31", "99.25", "39.79", "96.72" ]

icd9pcs

[ [ [] ] ]

20023, 20032

17594, 18752

282, 288

20085, 20091

8789, 8789

20144, 20180

7961, 8001

19994, 20000

20053, 20064

18778, 19971

20115, 20121

8016, 8770

15143, 17571

229, 244

316, 2228

8805, 14009

2250, 7746

7762, 7945

23,707

118,330

5346

Discharge summary

report

Admission Date: [**2153-2-26**] Discharge Date: [**2153-3-4**] Date of Birth: [**2092-4-12**] Sex: F Service: MEDICINE Allergies: Compazine / Droperidol / Gadolinium-Containing Agents / Demerol / Morphine / Haldol Attending:[**First Name3 (LF) 1674**] Chief Complaint: MCDS Flare. Major Surgical or Invasive Procedure: ICU stay, no invasive monitoring History of Present Illness: 60 W with long hx of frequent hospital admissions for degranulation syndrome (MCDS), most recently admitted here at [**Hospital1 18**] from [**0-0-**] for same, presents with shortness of [**Year/Month 1440**] consistent with her usual flares of MCDS. Patient says that she noticed some redness in her face and neck 2-3 days ago. She tried to increase her home dose of benadryl but wasn't able to keep the medication down secondary to nausea. She also notes increased chest and abd pain, pruritis, nausea and vomiting, all of which is consistent with her usual flares of MCDS. The patient used her epi pen at home as she usually does. In ED she received benadryl 50mg iv x 1, solumedrol 80mg IV x 1, IV dilaudid, zofran, ativan, and albuterol and combivent nebs. She was admitted to the ICU for close monitoring. By the time she arrived in the ICU, she was comfortable, breathing quietly, and dozing in bed. She says that she has been hospitalized at [**Hospital1 336**] since her last admission here, with a MRSA infection in her L hand. She also notes that she's had some superficial tongue pain and was started on nystatin swish and swallow by her ID doctor. Past Medical History: Mast cell degranulation syndrome (MCDS) Depression/anxiety Bipolar disorder MI in [**2147**] after receiving cardiac arrest dose epi instead of anaphylactic dose epi HTN Erosive osteoarthritis GERD, gastritis and esophagitis on recent EGD [**2151-1-8**] Paradoxical Vocal Cord Dysfunction viewed on fiberoptic laryngoscopy Anemia, iron studies c/w AOCD Hemorrhoids EGD with vegetable bezoar (?[**12-7**]) Status post hysterectomy and oophorectomy h/o MRSA infection (porthacath associated) portacath placed [**3-8**] - d/c'd [**2-3**] MRSA infection portacath placed [**2151-6-9**] MRSA left arm infection; now is cast . Social History: Pt is divorced. Lives alone. She works as an ER tech in [**Hospital3 **]. No tobacco or EtOH or illicit drugs. Son is HCP [**Telephone/Fax (1) 21738**] Family History: Mother died of MI @ 76, Sister w/ breast cancer and bilateral mastectomy. Physical Exam: T: 98.3 BP: 130/67 P: 95 RR: 18 O2 sat: 95% on 2 L NC Gen: patient appears relaxed, no itching or evidence of acute distress HEENT: perrla, eomi, MMM, OP clear, no evidence of thrush Neck: supple Cor: RRR, S1S2, no M/R/G Pulm: inspiratory wheezes B/L throughout lung fields, poor air movement Abd: soft, obese, diffusely tender to palpation, no rebound or involuntary guarding. Ext: no c/c/e, 2+ dp bilaterally Skin: no rashes noted Pertinent Results: [**2153-2-26**] 02:05PM BLOOD WBC-10.5# RBC-4.79# Hgb-13.5# Hct-40.9# MCV-85 MCH-28.2 MCHC-33.0 RDW-13.4 Plt Ct-400 [**2153-2-27**] 02:52AM BLOOD WBC-8.3 RBC-3.96* Hgb-11.0* Hct-33.5* MCV-85 MCH-27.8 MCHC-32.8 RDW-13.3 Plt Ct-312 [**2153-2-28**] 04:00AM BLOOD WBC-7.8 RBC-4.07* Hgb-11.4* Hct-34.2* MCV-84 MCH-28.0 MCHC-33.3 RDW-13.1 Plt Ct-328 [**2153-2-26**] 02:05PM BLOOD Neuts-68.2 Lymphs-26.1 Monos-5.2 Eos-0.4 Baso-0.2 [**2153-2-28**] 04:00AM BLOOD Neuts-88.2* Lymphs-8.4* Monos-3.3 Eos-0.1 Baso-0 [**2153-2-28**] 04:00AM BLOOD PT-11.7 PTT-24.8 INR(PT)-1.0 [**2153-2-26**] 02:05PM BLOOD Glucose-138* UreaN-12 Creat-0.9 Na-146* K-3.7 Cl-109* HCO3-23 AnGap-18 [**2153-2-27**] 02:52AM BLOOD Glucose-131* UreaN-11 Creat-0.7 Na-142 K-4.2 Cl-111* HCO3-24 AnGap-11 [**2153-2-28**] 04:00AM BLOOD Glucose-143* UreaN-14 Creat-0.7 Na-142 K-3.9 Cl-110* HCO3-25 AnGap-11 [**2153-2-28**] 04:00AM BLOOD ALT-14 AST-14 LD(LDH)-191 AlkPhos-85 TotBili-0.1 [**2153-2-27**] 02:52AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.2 [**2153-3-1**] 12:35PM BLOOD TRYPTASE-PND CXR [**2153-2-26**] Single bedside AP examination labeled "upright at 18:10" is compared with recent study dated [**2153-1-25**]; the overall appearance is essentially unchanged. The right-sided port-a-cath reaches the cavo-atrial junction, as before. The lungs remain well-inflated and clear. The cardiomediastinal silhouette and pulmonary vessels are within normal limits and there is no pleural effusion. Heavily calcified left hilar and AP window nodes related to old granulomatous disease are redemonstrated. IMPRESSION: No acute process; old granulomatous disease. CHEST (PORTABLE AP) [**2153-2-28**] FINDINGS: In comparison with the study of [**2-26**], there is again no evidence of acute cardiopulmonary disease. Right subclavian catheter extends to the lower portion of the SVC. Brief Hospital Course: 59 y.o. woman with h/o Mast Cell Degranulation Syndrome presented with typical MCDS symptoms including SOB, pruritis, chest and abdominal pain, admitted to MICU for close monitoring, then transferred to medical floor after management of acute attacks. # Mast Cell Degranulation Syndrome: The patient was admitted to the medical intensive care unit. Per her protocol, when her acute flares occurred, she was given zofran, dilaudid, solu-medrol, albuterol nebs, O2 by NC, epinephrine, ativan and benadryl. She had flares multiple times daily during her ICU admission. Attacks seemed to be related to emotional stressors; thus, psychiatry was consulted for assistance in managing anxiety, who recommended that she continue her outpatient medications. Additionally, allergy was consulted, who recommended increasing her solu-medrol dose to 120 mg from 80 mg for her flares. She was also started on prednisone 40 mg daily for improved management of her flares. She was transferred to the medicine floor after stabilization, and she had no other flares. # Hypertension: Continued diltiazem. # Depression/anxiety/bipolar: Psych and anxiety issues seemed to instigate some of her acute flares. She was continued on her outpatient medications of Cymbalta, Seroquel, Adderall, and Ativan prn. Psychiatry was consulted as noted above. # Urinary Tract Infection: While in the hospital, the patient was found to have a urinary tract infection. She was treated with one dose of Meropenem and once the resistance pattern of the infection was determined, her antibiotics were changed to Cefpodoxime. She was discharged with instructions to take Cefpodoxime 200mg twice per day for a total of 5 days. # Postmenopausal symptoms: Held premarin while in hospital. # Osteoarthritis: Continued plaquenil. **FULL CODE** Medications on Admission: gastrocrom "3 amps" qid (oral cromylin 100mg q6) cardizem CD 180mg po qday premarin 0.3 daily atarax 25mg po bid zantac 300mg po daily cymbalta 60mg po qhs plaquenil 200mg po bid adderal xr 15mg po qday fexofenadine 180mg po bid omeprazole 20mg po bid ambien 10mg po prn zofran 8mg po prn zyflo 600 mg QID Zaditen 1 mg [**Hospital1 **] asmanex 2 puffs [**Hospital1 **] dilaudid 4mg po prn fioricet prn epi-pen Discharge Medications: 1. Gastrocrom 100 mg/5 mL Solution Sig: One Hundred (100) mg PO every six (6) hours. 2. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 3. Premarin 0.3 mg Tablet Sig: One (1) Tablet PO once a day. 4. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Adderall XR 15 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 9. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 11. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. 12. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 13. Zyflo 600 mg Tablet Sig: One (1) Tablet PO four times a day. Tablet(s) 14. Asmanex Twisthaler 220 mcg (120 doses) Aerosol Powdr [**Hospital1 **] Activated Sig: Two (2) puffs Inhalation twice a day. 15. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed. 16. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 17. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours: do not operate heavy machinery or drive after you take this medication. Disp:*15 Tablet(s)* Refills:*0* 18. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every [**4-8**] hours as needed. 19. zaditen Sig: One (1) mg twice a day: continue as before. 20. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 5 days. Disp:*20 Tablet(s)* Refills:*0* 21. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for headache. Tablet(s) Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. Mast Cell Activating Syndrome 2. Urinary tract infection Secondary Diagnosis: 1. Hypertension 2. Depression/Anxiety 3. Osteoarthritis Discharge Condition: Stable. Ambulating with O2 sats 99-100%. Tolerating medications by mouth and no recent Mast Cell Degranulation Syndrome flares. Afebrile. No dysuria. Discharge Instructions: You were admitted for a mast cell activation syndrome flare. You were treated according to your protocol and improved. Your oxygen level was 99-100% on room air while walking. While in the hospital, you were found to have a urinary tract infection. You were treated with one dose of Meropenem and once the resistance pattern of your infection was determined, you were changed to Cefpodoxime. ***Please take the Cefpodoxime 200mg twice per day for a total of 5 days.*** Please continue your home medications as prescribed. You have been given a new prescription for ativan for nausea. Do not operate heavy machinery or drive when you are taking this medication. Please make all your medical appointments. If you have any of the following symptoms, please call your doctor or go to the nearest ER: fever>101, chest pain, shortness of [**Month/Day (3) 1440**], intractable nausea/vomiting, abdominal pain, or any other concerning symptoms. If you notice any burning when you urinate or increased urinary frequency, please follow up with your primary care provider for [**Name Initial (PRE) **] repeat urine culture. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2153-4-24**] 4:00 Provider: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2153-6-4**] 1:30 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**] Completed by:[**2153-3-5**]

[ "285.29", "786.50", "530.81", "V02.59", "300.4", "338.4", "401.9", "722.10", "715.30", "041.4", "279.8", "296.80", "V09.0", "599.0" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

9092, 9098

4819, 6635

355, 389

9299, 9455

2960, 4796

10625, 11042

2415, 2491

7095, 9069

9119, 9119

6661, 7072

9479, 10602

2506, 2941

304, 317

417, 1583

9220, 9278

9138, 9199

1605, 2228

2244, 2399

29,658

146,894

32250

Discharge summary

report

Admission Date: [**2194-1-15**] Discharge Date: [**2194-2-6**] Date of Birth: [**2115-1-20**] Sex: M Service: CARDIOTHORACIC Allergies: Rythmol / Florinef Acetate / Percocet / Amiodarone Attending:[**First Name3 (LF) 922**] Chief Complaint: Fatigue Major Surgical or Invasive Procedure: [**2194-1-17**] Minimal Invasive MAZE procedure, Left Atrial Appendage resection, LV epicardial lead placement [**2194-1-16**] Cardiac Catheterization History of Present Illness: 78 y/o male with PAF first diagnosed in [**2188**] who underwent PVI in [**2189**] and [**2190**]. His PAF has recently increased in frequency and has become fairly symptomatic. With symptoms that include fatigue, dyspnea on exertion, occ. shortness of breath at rest and dizziness. Past Medical History: Paroxysmal Atrial Fibrillation s/p Pulmonary Vein Isolation [**2189**] and [**2190**], Pacemaker placement [**2189**], Coronary Artery Disease s/p PCI/Stent to LAD and RCA in [**2189**] and [**2190**], Mitral Valve Prolapse, Hypercholesterolemia, Prostate cancer, Sciatica, s/p Appendectomy, s/p Hernia Repair Social History: Quit smoking 37 yrs ago after 60pk yr history. Social ETOH use. Family History: NC Physical Exam: VS: 60 18 144/80 Gen: NAD well-nourished Skin: Skin intact with left subclavian pacing wire protruduing under skin HEENT: EOMI, PERRL Neck: Supple, FROM, -JVD, -carotid bruit Chest: CTAB -w/r/r Heart: RRR -c/r/m/g Abd: Soft, NT/ND +BS Ext: Warm, well-perfused, -edema, superficial left leg varicosities Neuro: MAE, A&0 x 3, non-focal Pertinent Results: [**2194-2-6**] 06:50AM BLOOD WBC-9.9 RBC-2.85* Hgb-8.9* Hct-26.8* MCV-94 MCH-31.2 MCHC-33.1 RDW-14.0 Plt Ct-840* [**2194-2-6**] 06:50AM BLOOD PT-19.5* INR(PT)-1.8* [**2194-2-5**] 11:00AM BLOOD PT-22.3* PTT-26.6 INR(PT)-2.1* [**2194-2-6**] 06:50AM BLOOD Plt Ct-840* [**2194-2-4**] 11:40AM BLOOD PT-23.6* PTT-27.5 INR(PT)-2.3* [**2194-2-3**] 02:06AM BLOOD PT-34.7* PTT-34.1 INR(PT)-3.7* [**2194-2-2**] 07:36AM BLOOD PT-35.9* PTT-34.1 INR(PT)-3.8* [**2194-2-1**] 12:49AM BLOOD PT-31.3* PTT-33.0 INR(PT)-3.2* [**2194-1-31**] 02:32PM BLOOD PT-35.3* PTT-31.8 INR(PT)-3.7* [**2194-1-31**] 01:30AM BLOOD PT-28.4* PTT-31.4 INR(PT)-2.9* [**2194-1-30**] 02:08AM BLOOD PT-18.0* PTT-26.7 INR(PT)-1.6* [**2194-1-29**] 09:41AM BLOOD PT-15.0* PTT-57.8* INR(PT)-1.3* [**2194-1-29**] 02:22AM BLOOD PT-14.4* PTT-105.2* INR(PT)-1.3* [**2194-1-28**] 04:54AM BLOOD PT-12.9 PTT-61.4* INR(PT)-1.1 CHEST (PA & LAT) [**2194-2-5**] 3:09 PM CHEST (PA & LAT) Reason: eval for pleural effusions [**Hospital 93**] MEDICAL CONDITION: 79 year old man s/p LAA resection REASON FOR THIS EXAMINATION: eval for pleural effusions TWO VIEW CHEST COMPARISON: [**2194-2-4**]. INDICATION: Pleural effusion assessment. FINDINGS: Small right pleural effusion is without change. No left pleural effusion is evident. Multifocal pulmonary opacities show slight interval improvement with residual opacities, most marked in the upper lobes. These are superimposed upon underlying changes of emphysema. Cardiomediastinal contours are unchanged. Pacing device remains in standard position. IMPRESSION: Slight improvement in upper lobe predominant pneumonia. No change in small right pleural effusion. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 75397**]TTE (Focused views) Done [**2194-1-21**] at 3:43:17 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 177**] [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2115-1-20**] Age (years): 79 M Hgt (in): 69 BP (mm Hg): 116/63 Wgt (lb): 152 HR (bpm): 71 BSA (m2): 1.84 m2 Indication: ?Tamponade. ICD-9 Codes: 423.3 Test Information Date/Time: [**2194-1-21**] at 15:43 Interpret MD: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Test Type: TTE (Focused views) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Doppler: Limited Doppler and color Doppler Test Location: West Echo Lab Contrast: None Tech Quality: Adequate Tape #: 2008W000-0:00 Machine: Vivid [**6-16**] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 4.0 cm <= 4.0 cm Left Ventricle - Ejection Fraction: >= 55% >= 55% Findings This study was compared to the prior study of [**2194-1-16**]. LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. LEFT VENTRICLE: Overall normal LVEF (>55%). RIGHT VENTRICLE: Moderately dilated RV cavity. Borderline normal RV systolic function. Abnormal septal motion/position consistent with RV pressure/volume overload. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild (1+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Characteristic rheumatic deformity of the mitral valve leaflets with fused commissures and tethering of leaflet motion. No MVP. Mild mitral annular calcification. Mild thickening of mitral valve chordae. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Indeterminate PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Physiologic (normal) PR. PERICARDIUM: Trivial/physiologic pericardial effusion. Effusion circumferential. Conclusions The left atrium is normal in size. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is moderately dilated with borderline normal function. 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. The mitral valve shows characteristic rheumatic deformity. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. The effusion appears circumferential. IMPRESSION: Trivial pericardial effusion without echo signs of tamponade. Moderately dilated right ventricle with borderline normal function. Overall LV function is normal. Mild mitral and moderate tricuspid regurgitation. Compared with the prior study (images reviewed) of [**2194-1-16**], the findings are similar. Brief Hospital Course: Mr. [**Known lastname 31**] was admitted pre-operatively for cardiac work-up and initiation on Heparin secondary to patient being on Coumadin. He underwent usual work-up and also had cardiac cath on [**1-16**] which revealed no significant coronary artery disease. Prior to surgery he was medically managed and then brought to the operating room on [**1-17**] where he underwent a minimal invasive maze procedure with left atrial appendage ligation. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Later on op day he was weaned from sedation and awoke neurologically intact. On post-op day one he was restarted on his pre-operative medications and transferred to the telemetry floor for further care. On post-op day two his chest tubes were removed. He remained in sinus rhythm post-operatively. Coumadin was titrated for a therapeutic INR. On POD #4 he had a pulseless arrest and was transferred to the ICU, he vomited/aspirated and was intubated. It was thought to be a vagal episode. Brochoscopy was performed and emesis cleared. He was started on empiric broad spectrum antibiotics. He remained intubated. Bronchoscopy was again performed on [**1-22**] and a mucous plug was removed. PA catheter was placed to assess volume status given oliguria. His pressors were weaned to off by POD #7. He continued lung protective ventilation and his vent settings were weaned. He had atrial fibrillation for which he was started on heparin and coumadin. He was extubated on POD #12. He as initially confused at times, but improved. He was transferred back to the floor on POD #13. His aspiration pneumonia resolved and his antibiotics were completed. He improved greatly, and progressed well with PT and was ready for discharge home on POD #20. Dr. [**Last Name (STitle) **] with continue to follow his Coumadin and INR. Medications on Admission: Diltiazem 180mg qd, Aspirin 325mg qd, Metoprolol XL 100mg qd, Lipitor 20mg qd, Flomax 0.4mg qd, Fish Oil 1000mg qd, Coumadin 5mg qd except 2.5mg on Friday (last dose [**1-11**]), Nitro SL prn Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Lopressor 100 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*0* 3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0* 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 6. Ferrous Gluconate 300 mg (35 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 weeks. Disp:*7 Tablet(s)* Refills:*0* 8. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 1 weeks. Disp:*21 Capsule(s)* Refills:*0* 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 10. Diltiazem HCl 360 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0* 11. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 12 days: until follow up with Dr. [**Last Name (STitle) 914**]. . Disp:*24 Tablet(s)* Refills:*0* 12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 12 days: while on lasix. Disp:*12 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 13. Warfarin 1 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 days: INR to be checked [**1-/2115**] with results to Dr. [**Last Name (STitle) **]. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital **] Hospice and VNA Discharge Diagnosis: Paroxysmal Atrial Fibrillation s/p Minimal Invasive MAZE procedure, Left Atrial Appendage resection, LV epicardial lead placement PMH: Pulmonary Vein Isolation [**2189**] and [**2190**], Pacemaker placement [**2189**], Coronary Artery Disease s/p PCI/Stent to LAD and RCA in [**2189**] and [**2190**], Mitral Valve Prolapse, Hypercholesterolemia, Prostate cancer, Sciatica, s/p Appendectomy, s/p Hernia Repair Discharge Condition: Good Discharge Instructions: 1)Please shower daily. No baths. Pat dry incisions, do not rub. 2)Avoid creams and lotions to surgical incisions. 3)Call cardiac surgeon if there is concern for wound infection. 4)No driving while taking narcotics. Followup Instructions: [**Hospital Ward Name 121**] 6 for wound check in 2 weeks Dr. [**Last Name (STitle) 914**] in 4 weeks Dr. [**Last Name (STitle) **] or [**Doctor Last Name **] in [**1-12**] weeks Dr. [**Last Name (STitle) 8026**] in [**12-11**] weeks Completed by:[**2194-2-6**]

[ "V45.01", "427.5", "518.82", "394.1", "427.31", "V45.82", "V10.46", "507.0", "272.0", "788.20", "933.1", "997.1" ]

icd9cm

[ [ [] ] ]

[ "37.27", "33.23", "37.74", "88.56", "96.04", "37.22", "96.05", "96.72", "96.6", "89.60", "37.33" ]

icd9pcs

[ [ [] ] ]

10624, 10686

6561, 8473

323, 475

11139, 11145

1590, 2560

11408, 11671

1217, 1221

8715, 10601

2597, 2631

10707, 11118

8499, 8692

11169, 11385

1236, 1571

276, 285

2660, 6538

503, 787

809, 1120

1136, 1201

5,199

141,389

17926

Discharge summary

report

Admission Date: [**2204-9-21**] Discharge Date: [**2204-10-14**] Date of Birth: [**2137-7-10**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 983**] Chief Complaint: Anemia, hyperglycemia Major Surgical or Invasive Procedure: None History of Present Illness: 67yo M PMHx CHF (EF25%), DM, CAD s/p CABG+PCI, LV thrombus on coumadin, p/w FS 500 at home. Per patient report, his blood sugars have been "harder to control lately", despite compliance w insulin 70/30 regimen and diet; reports feeling well, denies fevers, chest pain, dyspnea, cough, abdominal pain, nausea, vomiting, dysuria. . On presentation to [**Hospital1 18**] ED, initial vital signs were 97.7 102 194/64 16 100%RA. Exam significant for hemodynamic stability, guaiac positive brown stool. Labs were significant for WBC 11.6, Hct 21.7 (was 38 5months ago), platelets 212, Cr 2.7, INR 4.7. EKG demonstrated SR at 97 w LBBB unchanged from prior. CXR did not demonstrate acute abnormalities. GI was notified and opted to see patient on Monday. Patient was transfused 2 units blood and was admitted to MICU given concern for his history of CAD and poor EF in setting of GI bleed and resuscitation; vital signs prior to transfer were 98.6 92 160/44 26 97%RA. . On arrival to the floor, vital signs were 95 97/73 18 99%RA. Patient was comfortable, denied chest pain, SOB, HA; on further questioning, patient reported 2 recent episodes of black stools; on review of systems, patient reported several episodes of dark stools recently, but was unable to elaborate further. He denied fever, chills, night sweats. Denied headache, cough, shortness of breath, chest pain/pressure, palpitations, or weakness; denied nausea, vomiting, diarrhea, constipation, abdominal pain; denied recent weight loss or gain; denied dysuria, frequency, or urgency. Past Medical History: - CHF (EF 25%) - Severe CAD s/p CABG in [**2196**] and PCI in [**2199**] - LV thrombus on coumadin - Diabetes - Dyslipidemia - Hypertension - CKD (Baseline Cr = 2.6) - VF arrest [**2196**] s/p ICD placement - s/p bilateral SFA stenting - s/p L common femoral to below-knee popliteal artery bypass with non-reversed right saphenous vein Social History: Lives with wife, immigrated from Caribbean approximately 40 years ago. Retired construction worker. -Tobacco history: Denies -ETOH: Denies -Illicit drugs: Denies Family History: Mother died at age 45 of stroke; father w DM, HTN, died at age 70. Two brothers with coronary artery disease, one died [**2200**] at age 59 from MI. Physical Exam: Vitals: 95 97/73 18 99%RA General: Comfortable, NAD HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, no JVD, no LAD Lungs: CTA bilaterally, no wheezes, rales, ronchi CV: RRR, no murmurs, rubs, gallops Abdomen: soft, NT/ND, naBS, no rebound/guarding, no HSM Ext: WWP, 2+ DP/PT [**Name (NI) **], 1+ DP/PT [**Name (NI) **] (baseline) 2+ radial b/l, no c/c/e Pertinent Results: Select Laboratory Data: CBC [**2204-9-21**] 07:30PM BLOOD WBC-11.6* RBC-2.90*# Hgb-7.2*# Hct-21.7*# MCV-75* MCH-24.8* MCHC-33.1 RDW-17.7* Plt Ct-212 [**2204-9-22**] 05:45AM BLOOD WBC-11.2* RBC-3.19* Hgb-8.6* Hct-25.4* MCV-80* MCH-27.0 MCHC-33.9 RDW-17.5* Plt Ct-167 [**2204-9-26**] 09:59PM BLOOD WBC-12.7* RBC-2.82* Hgb-8.4* Hct-24.2* MCV-86 MCH-29.9 MCHC-34.9 RDW-16.7* Plt Ct-147* [**2204-9-27**] 01:22AM BLOOD WBC-12.9* RBC-2.55* Hgb-7.8* Hct-22.1* MCV-87 MCH-30.6 MCHC-35.3* RDW-15.8* Plt Ct-118* [**2204-9-28**] 08:05PM BLOOD Hct-26.9* [**2204-9-29**] 02:03PM BLOOD Hct-26.1* [**2204-9-30**] 02:53PM BLOOD WBC-15.0* RBC-3.26* Hgb-9.7* Hct-28.4* MCV-87 MCH-29.8 MCHC-34.3 RDW-15.5 Plt Ct-191 [**2204-10-6**] 01:55AM BLOOD WBC-12.8* RBC-3.41* Hgb-9.8* Hct-28.6* MCV-84 MCH-28.9 MCHC-34.4 RDW-16.0* Plt Ct-245 [**2204-10-9**] 07:35AM BLOOD WBC-16.5* RBC-3.33* Hgb-9.5* Hct-27.9* MCV-84 MCH-28.6 MCHC-34.0 RDW-16.4* Plt Ct-289 [**2204-10-14**] 07:10AM BLOOD WBC-8.5 RBC-3.26* Hgb-9.3* Hct-27.0* MCV-83 MCH-28.6 MCHC-34.6 RDW-16.6* Plt Ct-507* [**2204-10-6**] 08:05AM BLOOD WBC-12.3* RBC-3.43* Hgb-9.9* Hct-29.6* MCV-87 MCH-29.0 MCHC-33.6 RDW-15.9* Plt Ct-251 . Chemistry [**2204-9-21**] 07:30PM BLOOD Glucose-278* UreaN-68* Creat-2.7*# Na-136 K-3.8 Cl-104 HCO3-26 AnGap-10 [**2204-9-29**] 02:53AM BLOOD Glucose-133* UreaN-76* Creat-4.1* Na-145 K-4.0 Cl-110* HCO3-24 AnGap-15 [**2204-10-1**] 03:37PM BLOOD Glucose-160* UreaN-63* Creat-2.7* Na-155* K-3.4 Cl-120* HCO3-26 AnGap-12 [**2204-10-9**] 07:35AM BLOOD Glucose-130* UreaN-44* Creat-3.0* Na-141 K-4.3 Cl-105 HCO3-27 AnGap-13 [**2204-10-14**] 07:10AM BLOOD Glucose-65* UreaN-39* Creat-2.5* Na-136 K-4.3 Cl-103 HCO3-24 AnGap-13 . Cardiac enzymes [**2204-9-21**] 07:30PM BLOOD CK-MB-4 cTropnT-0.06* [**2204-9-22**] 05:45AM BLOOD CK-MB-4 cTropnT-0.06* [**2204-9-29**] 02:00PM BLOOD cTropnT-0.40* proBNP-5133* [**2204-9-29**] 09:50PM BLOOD cTropnT-0.37* [**2204-9-30**] 07:44AM BLOOD CK-MB-2 cTropnT-0.37* . LFTs [**2204-9-21**] 07:30PM BLOOD LD(LDH)-229 CK(CPK)-137 TotBili-0.1 [**2204-10-5**] 05:56AM BLOOD ALT-17 AST-40 LD(LDH)-557* AlkPhos-61 TotBili-1.8* DirBili-0.6* IndBili-1.2 [**2204-10-6**] 08:05AM BLOOD ALT-22 AST-43* LD(LDH)-539* AlkPhos-66 TotBili-1.4 [**2204-10-7**] 06:47AM BLOOD ALT-25 AST-36 LD(LDH)-500* AlkPhos-61 TotBili-1.2 . Lactate [**2204-9-26**] 12:37PM BLOOD Lactate-2.4* [**2204-9-27**] 01:36AM BLOOD Lactate-0.8 [**2204-10-8**] 05:54PM BLOOD Glucose-141* Lactate-1.0 Na-136 K-4.8 . Microbiology Blood cultures 8/25, [**10-4**]: NG Blood culture [**10-8**] BACTEROIDES FRAGILIS GROUP 2/4 bottles Blood cultures 9/7, [**10-11**]: No growth to date Urine culture [**9-27**]: No growth Urine culture KLEBSIELLA PNEUMONIAE, ENTEROBACTER CLOACAE SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | ENTEROBACTER CLOACAE | | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S =>64 R CEFTRIAXONE----------- <=1 S =>64 R CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- 32 S 32 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S C. Diff toxin [**2204-10-9**]- negative . Studies . CXR PA and LAT ([**2204-10-9**]) In comparison with study of [**10-8**], there is continued enlargement of the cardiac silhouette without evidence of elevated pulmonary venous pressure in a patient with previous CABG procedure and elevated right hemidiaphragm. No evidence of acute focal pneumonia. The study and the report were reviewed by the staff radiologist. . CT Abdomen and Pelvis ([**2204-9-26**]) CT ABDOMEN: A few patchy airspace opacities in the lung bases are nonspecific but could represent early infection. A punctate granuloma is present in the left base. There is no pleural effusion. The heart is top normal in size without pericardial effusion. Relative myocardial [**Name2 (NI) 13215**] to the blood pool is compatible with severe anemia. Punctate calcification in the cardiac apex is likely related to known LV thrombosis. A linear calcification paralleling the left lateral ventricular wall may represent calcification in papillary muscles. There is moderate-to-severe multivessel coronary arterial calcification as well as aortic valve calcification. Postoperative changes of CABG are demonstrated. There is a small amount of perihepatic ascites. There is a long segment of sigmoid colon with significant mural thickening and likely intramural hemorrhage associated with increased density and stranding in the mesocolon extending into the anterior pararenal space and lateral conal fascial. There is an unusual appearance of blood in the sigmoid colon and rectum with a hematocrit level in the rectum and a convex superior edge. While this looks in many places to be intraluminal, it could be mural. There is additional stranding in the mesorectal fat posterior to the rectum which may represent a second site of hemorrhage more distally. There is no pneumatosis or pneumoperitoneum. Proximal colon to the level of mid descending colon appears within normal limits. Proximally the small bowel loops appear extremely collapsed. A small hiatal hernia is noted. The liver demonstrates no focal lesion. A few dependent hyperdense stones are seen in the gallbladder. The spleen, pancreas, and adrenal glands are unremarkable. A hyperdense hemorrhagic cyst measuring 12 mm in the right kidney is unchanged. Punctate hyperdensities in bilateral kidneys predominantly represent vascular calcifications. There is no mesenteric or retroperitoneal adenopathy. Moderate atherosclerotic disease involves the infrarenal aorta. Vascular patency cannot be evaluated without contrast. A small umbilical hernia is noted without evidence of obstruction. CT PELVIS: The bladder and distal ureters appear within normal limits. There is no inguinal or pelvic sidewall adenopathy. Rectal and mesorectal abnormalities are as described before. BONE WINDOW: The patient is status post median sternotomy with intact wires. No focal concerning osseous lesion. IMPRESSION: 1. Intramural and intraluminal rectosigmoid hemorrhage with mesenteric and retroperitoneal involvement. No frank perforation or pneumatosis. Patient is status post colonoscopy. 2. Stranding in the mesorectal fat could be a second site of hemorrhage more distally in the region of the rectum. 3. Patchy airspace opacities in the lung bases may represent early infection. 4. Stable hyperdense right renal cyst. 5. Cholelithiasis. 6. Severe anemia, coronary arterial disease, LV thrombosis, and papillary muscle calcification. . CT Abdomen Pelvis ([**2204-9-27**]) FINDINGS: CHEST: The base of the heart is enlarged, no pericardial effusion is detected. Status post CABG. Calcifications are seen along the course of the LAD. Tiny calcification is seen within the apex of the left ventricle consistent with old thrombosed aneurysm. Subsegmental dependent atelectasis are seen. The ground-glass opacities that were seen on previous examination is now less clearly identified. No pleural effusion is detected. ABDOMEN: Nasogastric tube is seen, the tip is oriented in the stomach. Again seen a long segment of sigmoid colon with significant mural thickening and intramural/intraluminal hemorrhage associated with stranding and hemorrhage in the mesentery that surrounds it. There is an interval increase in the amount of hemorrhage distending the rectal and sigmoid lumen. Hemoperitoneum of heterogeneous density (with the appearance of a sentinel clot) has increased markedly in the interval as well (2:68). There is no pneumatosis or pneumoperitoneum. The proximal colon to the level of the mid descending colon appears within normal limits. The small bowel shows no gross pathology and there are no signs of small-bowel obstruction. There is increased hemoperitoneum in the perihepatic and perisplenic region. The noncontrast appearance of the liver, spleen, the pancreas and the adrenals are within normal limits. The gallbladder is distended, there are no signs of intra- or extra-biliary duct dilatation. A hyperdense lesion that may represent a hemorrhagic cyst but cannot be fully characterized in the absence of IV contrast is seen in the inferior pole of the right kidney with no gross change from previous examination. A small non specific hypodense region that measures 8 mm is seen in the posterior upper pole of the right kidney. Atherosclerotic calcification along the course of the aorta. PELVIS: A Foley catheter is seen within the urinary bladder. No lymphadenopathy is observed within the pelvis. Hemorrhage distends the rectum and there is hemoperitoneum in the pelvis as described. BONY WINDOW: No suspicious lytic or sclerotic lesion is seen. IMPRESSION: 1. Progression of intra-abdominal and pelvic hemorrhage, including increased hemoperitoneum in the pelvis and upper quadrants, increased hemorrhage distending the rectosigmoid lumen as well as increased intramural hemorrhage in the sigmoid colon wall. No pneumatosis or signs of bowel obstruction are seen. 2. Probable right lower pole hyperdense renal cyst, unchanged, and stable indeterminate 8 mm hypodensity in right upper pole. These could be further evaluated with ultrasound when clinically appropriate. . CT Abdomen Pelvis [**2204-10-8**] FINDINGS: Interval decrease in the sigmoid colon wall thickening and in the intramural/intraluminal hemorrhage. The involved sigmoid segment is shorter in the current examination. Decreased amount of fluid/hemorrhage in the left mesenterium. The fat stranding that was seen along the course of the sigmoid colon has decreased in severity. No signs of bowel obstruction. Foley catheter is seen within the urinary bladder. The prostate is of no gross pathology. No lymphadenopathy is detected within the pelvis. No suspicious lytic or sclerotic lesion is observed within the visualized bones. IMPRESSION: 1. Interval decrease in the sigmoid colon wall thickening along with decrease in the size of the intramural/intraluminal hemorrhage. 2. The involved sigmoid colon is improved in comparison to previous examination. 3. The hemoperitoneum has significantly decreased in size. . TTE ([**2204-9-26**]) The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed (LVEF= 35-40 %). No masses or thrombi are seen in the left ventricle. The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2204-4-9**], left ventricular function is probably similar but technical limitations may have led to underestimation of the LVEF in the prior report. . TTE ([**2204-9-29**]) The left ventricular cavity size is normal. There is mild to moderate regional left ventricular systolic dysfunction with inferior and inferolateral hypokinesis. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) 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. Compared with the prior study (images reviewed) of [**2204-9-26**], left ventriuclar systolic function appears similar. Regional wall motion abnormalities are similar with slight differences in appearance likely due to differences in technical quality of the images. . TTE ([**2204-10-10**]) The left atrium is mildly dilated. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild to moderate regional left ventricular systolic dysfunction with hypokinesis of the inferior, infero-lateral walls and apex (LVEF 40%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. No vegetation/mass is seen on the pulmonic valve. Compared with prior study dated [**2204-9-29**], findings are similar. No vegetations or abscessess identified. . Renal US([**2204-10-10**]) The right kidney is normal in size measuring 10.2 cm. Note is made of a well-circumscribed hypoechoic 1.7 x 1.3 x 1.4 cm lesion in the lower pole corresponding to the hyperdense lesion on prior CT. There is no internal vascularity. While imaging is limited by acoustic window, findings are consistent a cyst probably containing some internal debris and a single thin septation. The left kidney is within normal limits measuring 10.6 cm. No focal lesion identified. No hydronephrosis identified in either kidney. IMPRESSION: 1. Findings consistent with a mildly complex cyst corresponding to prior CT abnormality in the lower pole of the right kidney. Suggest follow up ultrasound in 6 months to assess continued stability. 2. No stones or hydronephrosis. . Brief Hospital Course: 67 yo male with complicated cardiac history including CAD s/p CABG ([**2196**]), DES to RCA and protected OMCA ostium in [**2199**] and sCHF with EF 35-40% who p/w lethargy, melena, and hyperglycemia thought to have GI bleed complicated course including hemoperitoneum managed medically w/ bowel rest and decompression, as well as acute on chronic renal failure and UTI/ bacteremia . # Microcytic Anemia - Pt a/w Hct 21 (most recent prior values 34-38), guaiac pos brown stool; despite patients history of significant CAD, patient asymptomatic on presentation; guaiac pos stool in setting of microcytic anemia was concerning for GI loss especially in patient on coumadin, ASA, plavix; It was unclear if this would be lower or upper GI source. There was concern that chronic issues may also be at play, such as poor erythropoiesis [**3-7**] CKD, chronic inflammation. The patient's hematocrit drifted down to nadir 22. He was also started on IV protonix 40mg daily for concern of possible upper GI bleed. GI was following the patient with plan to perform EGD and colonoscopy after bowel prep on Monday, [**2204-9-24**] did not show a clear source of bleeding. As the EGD did showed gastritis he was transitioned to PO Protonix 40 daily which was continued at the time of discharge. His post colonoscopy course was complicated by hemoperitoneum requiring admission to the MICU with transfer to the SICU as described below. In total the patient received 10 units of PRBCS and 2 units of PRBCs. He continued to note intermittent small amounts of bright red blood per rectum which surgery felt was likely residual blood from his intramural hematoma. His HCT remained stable while on the floor and was 27 at the time of discharge. Though the initial source of bleeding remained unclear bleeding had subsided at the time of discharge and there was no clear plan for future repeat scope, though if bleeding were to recur would consider capsule endoscopy to r/o small intestine as the source of bleeding. . # Hemoperitoneum: As above the pt was admitted to the Medical ICU on [**9-26**] for medical management of bowel perforation versus hemorrhage after colonoscopy. Pt complaining of increased abodominal pain,CT demonstrated intraabdmonial and pelvic hemorrhage - hemoperitoneum in the pelvis and upper quadrants, hemorrhage in the rectosidmoi lumen, and intramural hemorrhage of the sigmoid wall, without no evidence of pneumoperitoneum. Surgery was following, and IR and GI were aware. He received a total of 10 units of PRBCs and 4 units of FFP over this hospitalization. Repeat CT in the setting of increased abdominal distension showed an increase in the size of the blood collection and the patient was transferred to the Surgical ICU on [**9-27**]. He was not felt to be a good operative candidate for surgical intervention therefore he was managed with bowel rest and gastric decompression. Bladder pressures were increased in the 20-30s however clinically the patient denied pain and was making urine which was made abdominal compartment syndrome unlikely. He continued to improve, his diet was advanced to clears and then full liquids without incident. He had a few non bloody stool and was determined to be stable to go to be transferred to the floor. On the floor his HCT remained stable and he was tolerating a full diet with improvement in abodominal distention. The patient did have residual suprapubic tenderness and began to pass small amounts of blood per rectum however a third CT showed resolution of his hemoperitoneum. # Supratherapeutic INR - on coumadin for LV thrombus, but w INR 4.7 on admission, uncertain etiology. The coumadin was held and INR gradually drifted down to 1.0. However, it began to trend upward again while on the floor and vitamin K was given PO due to the patients high risk for bleeding. His increased INR was felt to likely be due to poor nutritional status as the patient also had a low albumin. Repeat TTE showed no LV therefore coumadin was not restarted. . # Hyperglycemia - Pt reporting elevated sugars at home ~500 without recent change in diet or change in medications; no anion gap; no signs infection on CXR; EKG of limited use given LBBB; no CP to indicate ACS, although given DM, atypical presentation of ACS is possible but cardiac enzymes were trended and ultimately negative. Urinalysis was negative for infection. The patient was maintained on sliding scale insulin with addition of home 70/30 as oral intake increased. Blood sugars remained elevated and his morning 70/30 was increased to 20 units with some improvement in glucose control. . # Chronic sCHF - Patient appeared euvolemic on exam so his carvedilol was continued. This was increased from 25 to 50 mg [**Hospital1 **] for better blood pressure and rate control His diuretics were initially continued but were eventually held in the setting of increasing creatinine. However his home lasix was resumed prior to discharge. His home spironolactone was not restarted. Patient was instructed to discuss restarting his medication with his PCP. . # Acute on Chronic renal failure: Patient had CKD with known baseline creatinine of 4.0. Over the course of this admission his creatinine peaked at 4.0. It was initally trending downward on transfer to the floor however then increased to 3.0. Urine lytes and FeNa (3.3%) were consistent with a intrinsic or post renal etiology. The patient was noted to have increasing suprapubic abdominal pain and placement of a foley drained 500 mL of urine suggesting a post renal etiology to the increased creatinine. Renal US did not show hydronephrosis. The patient failed post void trials and the foley remained in place as below. His creatinine trended downward and was at baseline at the time of discharge. . #Hypertension: Pt initially hypotensive with SBP in the 100s in the setting of GI bleed. Now hypertensive with blood pressures as high as the 160s the SICU. He was continued on home Hydralazine, carvediol was increased to 50 mg [**Hospital1 **], lasix and spironolactone. However, diuretics were eventually held in the setting of rising creatinine. As below lasix was restarted prior to discharge but spironolactone was not. . #Leukocytosis, Fever: While in the ICU the patient was noted to have a leukocytosis with high of 22.1. Urine and blood cultures were negative. There was a concern for bacterial translocation from the gut and the patient was started on broad spectrum antibiotics with linezolid and zosyn. The patients WBC trended downward and antibiotics were discontinued as no source of infection was identified. The patient continued to have intermittent fevers on the floor,CXR unconcerning for PNA, c.diff was negative. Blood and urine cultures were both positive for GNR and ultimately grew Bacteroides Fragailis in the blood, Klebsiella Pneumonaie and Enterbacter clocacae in the urine. Repeat TTE was done to r/o endocarditis in the setting of a murmur on exam was negative. He was initially started on broad spectrum gram negative/anaerobic coverage with cefepime and flagyl and then transitioned to PO cipro flagyl to complete a 2 week course from his first negative culture on [**2204-10-10**]. . # Urinary retention: The patient was noted to have urinary retention as above in the setting of a UTI. Patient was having increasing suprapubic pain as well as urinary incontinence so a foley was placed and drained 500 mL of urine. Post foley void trials were attempted on 2 occasions unsuccessfully. Patient was started on tamsulosin and discharged with a foley in place to f/u with [**Date Range **] as an outpatient regarding discontinuing the foley. . # Hypernatremia: Patient noted to have sodium of 155 while in the ICU believed to be secondary to free water deficit in the setting of poor intake. He was initially managed with free water flushes. On transfer to the floor his sodium was corrected slowly with D5W. Given his poor cardiac function the patient was monitored closely for signs of fluid overload. Sodium trended downward and fluids were discontinued as the patient increased his oral fluid intake. At the time of discharge his sodium was 136. # CAD - The patient was continued on atorvastatin and carvedilol, aspirin and plavix were held in the setting of an acute bleed. He was noted to have elevated cardiac enzymes over the course of the hospitalization (tropoinin to 0.95) felt to reflect demand ischemic. These trended downward and the patient denied any chest pain or shortness of breath. EKGs remained unchanged and echo showed left ventricular function that was similar to what was seen on a TTE done in [**4-13**]. He was monitored on telemetry throughout admission and was noted to have a lot of ventricular ectopy. Prior to discharge he was restarted on aspirin 81 mg, atorvastatin 80 mg, and carvediolol at an increased dose as above. His plavix was not restarted at the time of discharge. . # h/o LV Thrombus - The patient's coumadin was initially held for supratherapeutic INR. Repeat TTE showed no evidence of thrombus therefore coumadin was not restarted. . #HLD: Patient was continued on home atorvastatin for most of his admission and at the time of discharge. . Transitional issues -Pt remained full code throughout this hospitalization -Pt will follow-up with his PCP, [**Name10 (NameIs) **] [**Name11 (NameIs) **]/U renal US in 6 months to assess incidentally noted R kidney cyst Medications on Admission: Warfarin 5mg PO QD Plavix 75 mg PO QD Carvedilol 25 mg PO BID Folic Acid 1 mg PO BID Lipitor 80 mg PO QD Aspirin 81 mg Furosemide 80 mg PO QD 15 units insulin NPH & regular human (70-30) [**Hospital1 **] Discharge Medications: 1. hydralazine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. carvedilol 25 mg Tablet Sig: Two (2) Tablet PO twice a day. Disp:*120 Tablet(s)* Refills:*2* 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 12 days. Disp:*12 Tablet(s)* Refills:*0* 8. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*0* 9. furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. insulin NPH & regular human 100 unit/mL (70-30) Suspension Sig: as instructed below units Subcutaneous twice a day: 20 units q am, 15 units q pm . 11. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 12 days. Disp:*36 Tablet(s)* Refills:*0* 12. Outpatient Physical Therapy please evaluate and treat Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnosis: GI Bleed Hemoperitoneum Urinary tract infection Bacteremia Acute on Chronic Renal failure Urinary retention . Secondary Diagnoses: Diabetes Hypernatremia Chronic systolic heart failure 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 letting us take part in your care at [**Hospital1 771**]. You came to the hospital because you were having difficulty controlling your blood sugars. In the emergency department, you had blood tests that showed your red blood cell count was low and blood was detected in your stool. You were admitted to the Medical ICU and received blood. Your stomach pain got worse and CT scan showed you had bleeding in your abdomen. You got more blood and your blood counts were stable. Your INR was very high when you came into the hospital. This lab test estimates how high your coumadin level is. When it is too high you are at an increased risk of spontaneous bleeding. Plavix is another medication you were taking which also prevents blood clotting, but works through a different mechanism than coumadin. It can raise your risk of developing bleeding in your gastrointestinal tract. Because of the bleeding you just developed your Plavix was stopped. While you were in the hospital, you had an upper endoscopy and a colonoscopy to identify the source of your bleeding. Neither of these showed a source of bleeding, which indicates the bleeding is coming from your small intestine, which can be evaluated with a capsule endoscopy (small camera that you swallow). You should follow up with your Primary Care Doctor to arrange this test. You were also found to have an infection in your urine and blood. You were started on antibiotics for this infection. You will need to continue these antibiotics for 12 days. The following changes were made to your medications You were started on the following new medications: STARTED Cipro 750mg by mouth qday for 12 days STARTED Flagyl 500mg by mouth every 8 hours for 12 days STARTED Pantoprazole 40mg by mouth once a day STARTED Tamsulosin 0.4mg by mouth at night STOPPED Plavix 75mg by mouth once a day STOPPED Coumadin 5mg by mouth once a day HELD Sprionolactone 50mg by mouth 3 times a day INCREASED Carvediol to 50 mg [**Hospital1 **] CHANGED Insulin to: 70/30 20 units every morning 70/30 15 units every evening Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. You should review your medication changes with your primary care doctor at your next appointment. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] C. Location: [**Hospital **] MEDICAL ASSOCIATES Address: [**Location (un) 11142**], [**Location (un) **],[**Numeric Identifier 11143**] Phone: [**Telephone/Fax (1) 11144**] Appt: The office is working on an appt for you in the next week and will call you at home with an appt. If you dont hear from them in 2 business days, please call them directly to book an appt. [**Telephone/Fax (1) 159**] Department: SURGICAL SPECIALTIES When: MONDAY [**2204-10-22**] at 1:30 PM With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 164**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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Discharge summary

report

Admission Date: [**2166-8-10**] Discharge Date: [**2166-8-14**] Date of Birth: [**2117-10-9**] Sex: F Service: MEDICINE Allergies: Beta-Blockers (Beta-Adrenergic Blocking Agts) Attending:[**First Name3 (LF) 5037**] Chief Complaint: Fever, Back pain, Nausea Major Surgical or Invasive Procedure: None History of Present Illness: This is a 48 year old female with renal transplant in [**2164**] secondary to Type 1 DM who has had two renal transplants, most recently a living related donor in [**10/2164**], HCV, and recurrent UTIs who presents with signs and symptoms of a UTI. She presented with one day of fever to 104, back pain and nausea which is typical for her UTI. She was at the beach and there is a question of if she was taking in enough fluids per her sister. [**Name (NI) **] also is supposed to straight cath four times per day and per the sister only does it twice a day. She has a history of UTIs in the past. Because her symptoms were consistent with a UTI she came to the ED. . In the ED, initial vs were: 97.7 128 117/64 20 99. A UA was found to have 50 WBC. WBC was 19 and initial lactate was 3.3. Lactate trended down to 1.5. Cr 1.9. (from 1), Na was 131 (down from 135). Patient was given 1 g tylenol and vancomycin and cefepime. Tackro level was 4.7. Renal U/S and chest XR were normal. On transfer 102.1 171/97 118 97% RA, this is after 2L NS and 3rd one hanging. She was rigoring and appears ill. Pt has a 20G in right AC. . Past Medical History: -Diabetes type 1 with neuropathy nephropathy -end-stage renal disease status post MI -status post living-related renal transplant in [**2145**], repeat living related transplant on [**2164-11-6**] from her brother -hep C with mildly elevated liver function tests.Biopsy shows grade I disease. -Recurrent UTIs in the past, neurogenic bladder with self catheterization QID -hypertension. - PVD s/p stenting - s/p amputation R hallux - [**Hospital1 **]-v pacer implantation for paroxysmal AV block [**2165-10-21**] Social History: Lives w/ her husband and son; never smoked; does not drink alcohol or use illicit drugs. Previously worked in commercial banking, but does not currently work. Is supposed to be off of her feet in wheelchair but reports she does walk around the house. Husband works full time but is able to return home frequently to her pt. Family History: non-contributory Physical Exam: Physical Exam on [**2166-8-13**]: Vitals: T: 97.3 (max 98.6) BP: 173/96 (150s-180s/60s-90s) P: 80s-90s R: 20 O2: 97% RA General: Pleasant, watching TV in street clothes, NAD HEENT: Sclera anicteric, MMM, oropharynx clear Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, +tenderness to palpation mid abdomen, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, Trace edema. B/l LE wounds dressed gauze that was not removed. Pertinent Results: [**2166-8-10**] 10:45AM BLOOD WBC-19.8*# RBC-3.75* Hgb-11.4* Hct-34.6* MCV-93 MCH-30.5 MCHC-32.9 RDW-14.2 Plt Ct-173 [**2166-8-11**] 04:23AM BLOOD WBC-13.0* RBC-3.07* Hgb-9.7* Hct-28.8* MCV-94 MCH-31.7 MCHC-33.7 RDW-14.1 Plt Ct-132* [**2166-8-13**] 03:22AM BLOOD WBC-6.0 RBC-3.14* Hgb-9.9* Hct-29.5* MCV-94 MCH-31.5 MCHC-33.5 RDW-13.8 Plt Ct-127* [**2166-8-10**] 10:45AM BLOOD Neuts-93.6* Lymphs-2.9* Monos-3.2 Eos-0.1 Baso-0.2 [**2166-8-13**] 03:35AM BLOOD PT-11.9 PTT-27.7 INR(PT)-1.0 [**2166-8-10**] 10:45AM BLOOD Glucose-297* UreaN-31* Creat-1.9* Na-131* K-5.0 Cl-97 HCO3-21* AnGap-18 [**2166-8-11**] 05:34PM BLOOD Glucose-237* UreaN-22* Creat-1.4* Na-135 K-4.8 Cl-107 HCO3-16* AnGap-17 [**2166-8-13**] 03:22AM BLOOD Glucose-196* UreaN-17 Creat-1.2* Na-134 K-4.4 Cl-113* HCO3-17* AnGap-8 [**2166-8-10**] 08:05PM BLOOD ALT-39 AST-43* LD(LDH)-199 AlkPhos-108* TotBili-0.4 [**2166-8-12**] 07:27AM BLOOD ALT-28 AST-37 CK(CPK)-22* AlkPhos-86 TotBili-0.4 [**2166-8-11**] 01:23PM BLOOD CK-MB-2 cTropnT-<0.01 [**2166-8-11**] 05:34PM BLOOD CK-MB-2 cTropnT-0.02* [**2166-8-12**] 12:30AM BLOOD CK-MB-2 cTropnT-0.03* [**2166-8-12**] 07:27AM BLOOD CK-MB-2 cTropnT-0.03* [**2166-8-10**] 08:05PM BLOOD Albumin-3.3* Calcium-8.5 Phos-2.3* Mg-1.7 [**2166-8-12**] 12:30AM BLOOD Calcium-9.1 Phos-1.5* Mg-1.8 [**2166-8-13**] 03:22AM BLOOD Calcium-9.7 Phos-2.5* Mg-2.7* [**2166-8-11**] 05:34PM BLOOD TSH-2.1 [**2166-8-11**] 05:34PM BLOOD Free T4-0.97 [**2166-8-10**] 10:45AM BLOOD tacroFK-4.7* [**2166-8-11**] 04:23AM BLOOD tacroFK-6.4 [**2166-8-13**] 03:22AM BLOOD tacroFK-12.3 [**2166-8-12**] 12:50AM BLOOD Lactate-1.4 STUDIES: RENAL U/S [**2166-8-10**]: Normal grayscale and Doppler evaluation of left lower quadrant renal transplant. . KUB [**2166-8-12**]: FINDINGS: Mildly distended loops of small bowel are noted. No air-fluid levels are observed. Air is noted within the colon. S-shaped scoliosis of the lumbar spine is stable since the film in [**2164-10-31**]. Degenerative changes of the lumbar spine are noted with the remainder of the imaged osseous structures being unremarkable. A right-sided pacemaker is noted. There are surgical clips noted in the abdominal and pelvic area that are unchanged from the comparison study. IMPRESSION: Mildly distended loops of small bowel with air in the colon. This could be ileus but cannot rule out early or partial small bowel obstruction. Please note that the exam is limited by motion . U/S [**2166-8-12**]: IMPRESSION: No evidence of DVT of the right upper extremity. Brief Hospital Course: 48 year old femmale with renal transplant in [**2164**] secondary to Type 1 DM who has had two renal transplants, most recently a living related donor in [**10/2164**], HCV, and recurrent UTIs who presents with signs and symptoms of a UTI. #) Urinary tract infection and acute renal failure: The patient appeared septic in the emergency room and was transferred to the MICU immediately. In the MICU, the patient was found to have Ecoli UTI and started on Ciprofloxacin with good response. Renal ultrasound showed no evidence of pyelonephritis. Creatinine improved from admission to 1.2. Etiology of renal failure thought to be a combination of pre-renal etiology with damage from chronic UTIs. Patient advised to take Lasix 20 mg daily for three days on discharge per renal recommendations. . #) HTN: During MICU stay on [**8-11**], the patient was hypertensive to 200's, not responsive to iv hydral or nitro paste. During episode she had left sided chest pain with HTN, EKG paced, but some STD in v3-v4. She was given ASA, morphine, wasn't able to get beta blocker secondary to previous bradycardia; a repeat EKG showed improvement. Patient was started on nitro gtt for refractory hypertension and blood pressure control. On [**8-11**] patient had small rise in troponin (to 0.02) in the setting of hypertensive emergency. Her hypertenison resolved, the nitro gtt was stopped; patient was transitioned to hydralazine and then restarted on her home diovan dose for discharge. #) Wide complex tachycardia: Pt developed a change in her rhythm from native sinus rhythm to a paced rhythm (there was some initial concern for VT, for which pt received amiodarone 150 mg x 2, however VSS throughout the entire time). EP was consulted on [**8-12**] given concerning paced rhythm - noted pacer to be functioning properly. Further wide complex tachycardia was A-sensing V-pacing [**3-4**] paroxysmal AV node block. . #) Diabetic foot ulcers: Wound care saw the pt and did not feel that there was any obvious sign of infection of her heels where she has diabetic ulcers. . #) Arm swelling: On [**8-12**] patient had R upper extremity swelling ultrasound performed without DVT. Medications on Admission: Plavix 75mg PO daily Lantus 20units qHS Lispro sliding scale Reglan 5mg PO BID Cellcept 250mg PO BID Omeprazole 20mg PO daily Pravastatin 80mg PO daily Prednisone 5mg PO daily Bactrim SS 1tab PO daily Prograf 4mg PO BID Diovan 40mg PO daily ASA 81mg PO daily Colace 100mg PO BID Discharge Medications: 1. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 2. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every 12 hours). 10. Lantus 100 unit/mL Cartridge Sig: Twenty (20) units Subcutaneous at bedtime. 11. lispro Sig: According to home sliding scale according to home sliding scale. 12. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 12 days: Please take for 12 more days with last dose on [**8-26**]. . Disp:*24 Tablet(s)* Refills:*0* 13. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 3 days: Please take this for three days with last dose on [**8-17**]. 14. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. 15. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Primary Diagnosis: Urinary Tract Infection End Stage Renal Disease Hypertension Secondary Diagnosis: Type I Diabetes Chronic Hepatitis C Neurogenic Bladder [**Hospital1 **]-v pacer implantation for paroxysmal AV block [**2165-10-21**] Diabetic Foot Ulcers 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 because you were having fever, back pain and nausea which was suspicious for a UTI. In the hospital, we did find that you had a UTI and this was treated with Ciprofloxacin. While you were in the ICU, you had some very elevated blood pressures but these were controlled with medications. Your pacemaker was checked in the ICU as well and this was shown to be functioning properly. Our wound care team followed you throughout your stay and did not think that your foot wounds were infected. . In summary: We ADDED Lasix 20 mg once daily- you should take this for three days. We ADDED Cipro 500 mg twice daily for 12 days-- last dose on [**8-26**] Followup Instructions: Please go to the following outpatient appointments as scheduled: . 1. Provider (Urology): Please call [**Telephone/Fax (1) 18725**] to make an appt with Dr. [**Last Name (STitle) 365**]. 2. Provider (Primary Care): Please call [**0-0-**] to make a followup appointment with your PCP, [**Name10 (NameIs) **],[**Name6 (MD) **] [**Name8 (MD) **] MD at the [**Hospital1 **] OF [**Hospital1 420**] . 3. Provider(Cardiology): [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2166-8-19**] 9:00 . 4. Provider (Nephrology): Dr. [**Last Name (STitle) 4090**] at [**Last Name (un) **]-- [**8-27**] at 8:30 (appointment on [**8-19**] cancelled) . 5. Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3628**] (NHB) Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2166-9-10**] 2:15 . 6. Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3628**] (NHB) Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2166-9-10**] 3:15 . 7. Provider (Nephrology): Dr. [**Last Name (STitle) 27211**] [**10-14**] at 1:20 PM [**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]

[ "357.2", "E878.0", "V45.01", "412", "583.81", "070.54", "403.90", "250.61", "599.0", "427.89", "250.41", "V58.67", "707.14", "596.54", "038.42", "995.92", "996.81", "585.9", "584.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9392, 9467

5542, 7711

331, 338

9768, 9768

3010, 5519

10655, 11829

2383, 2401

8041, 9369

9488, 9488

7737, 8018

9951, 10632

2416, 2991

267, 293

366, 1489

9590, 9747

9507, 9569

9783, 9927

1511, 2025

2041, 2367

27,567

195,766

45685+58843

Discharge summary

report+addendum

Admission Date: [**2186-7-24**] Discharge Date: [**2186-8-1**] Date of Birth: [**2118-6-17**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5880**] Chief Complaint: Abdominal cramping and 4-5 episodes of vomiting Major Surgical or Invasive Procedure: Exploratory laporotomy, lysis of adhesions, appendectomy, small bowel resection, and ileocecal anastomosis. History of Present Illness: 68 year old female with a history of colon cancer status post LAR with colostomy. Was treated with chemotherapy and radiation. Presented with nausea vomiting and abdominal cramping. No fever, no chills, no blood in emesis or ostomy output. Past Medical History: Hypothyroid Hysterectomy Lap cholecystectomy Low anterior resection for Rectal cancer End colostomy TAH Social History: Lives in [**Location 17065**] with husband, no tobacco or EtOH Physical Exam: 68 y/o female in NAD Lungs: CTA bilaterally CV: Regular rate and rhythm, no murmur ABD: Ostomy left lower quadrant, ND, NT, +BS, midline incision with steristrips, no drainage, wound in right lower quadrant from removed JP drain no drainage no skin erythema Neuro: A&O X3 Skin: Warm and Dry Pertinent Results: [**2186-7-31**] 06:10AM BLOOD WBC-9.2 RBC-2.84* Hgb-8.6* Hct-25.7* MCV-91 MCH-30.3 MCHC-33.4 RDW-14.2 Plt Ct-257# [**2186-7-28**] 12:19AM BLOOD PT-11.2 PTT-29.3 INR(PT)-0.9 [**2186-8-1**] 06:45AM BLOOD Glucose-113* UreaN-10 Creat-0.5 Na-139 K-3.8 Cl-103 HCO3-27 AnGap-13 [**2186-8-1**] 06:45AM BLOOD Calcium-7.8* Phos-3.4 Mg-1.8 CT Abd/Pelvis [**2186-7-25**] IMPRESSION: 1. Compared to [**Month (only) 547**], proximal small bowel loops are more dilated with a more abrupt caliber change noted in the presacral region. Small bowel fecalization proximal to this transition point and small pockets of free fluid are also new. Stool and air within the colon suggest that this either represents partial obstruction or early complete obstruction. 2. Unchanged right-sided renal hypoattenuating lesions, likely cysts but too small to characterize. TTE [**7-25**]: IMPRESSION: Hyperdynamic left ventricular function with severe resting left ventricular outflow tract gradient and impaired relaxation pattern. Possible systolic anterior motion of the mitral valve. Cannot exclude hypertrophic cardiomyopathy as left ventricular wall thickness cannot be reliably assessed. Recommend follow-up TTE when patient extubated. Brief Hospital Course: Patient was admitted to trauma service from the ER on [**2186-7-24**] with a small bowel obstruction. She was taken to the OR the evening of [**7-24**] and underwent exploratory laparotomy, lysis of adhesions, small bowel resection, ileocecal anastamosis, and an appendectomy. Post operatively she was transferred to the SICU intubated and sedated. In the SICU she received and arterial line in the right radial artery. In the SICU she had a TTE which showed "hyperdynamic left ventricular function with severe resting left ventricular outflow tract gradient and impaired relaxation pattern. Possible systolic anterior motion of the mitral valve." She was successfully weaned from the ventilator and extubated on [**2186-7-26**]. She required neosynephrine in the SICU to maintain afterload. Neo was weaned on [**2186-7-28**]. She was transferred to the floor on [**2186-7-28**]. On the floor she had some burping and minimal ostomy output. This improved over the next 3 days with return of adequate ostomy output. Her JP drain was removed on [**2186-7-31**] without problems. [**Name (NI) **] [**Name2 (NI) 14073**] were removed on [**2186-8-1**] and she was dischared to home on her home medications in addition to percocet 5/325 and colace. Instructed to call PCP if she developed a fever greater than 101.5, pain that is uncontrollable, or drainage from her incisions. Medications on Admission: 1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO once a day: resume home dose. 2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a day: resume home dose. Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO once a day: resume home dose. 2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a day: resume home dose. 3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): resume home dose. 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 5. Colace 50 mg Capsule Sig: One (1) Capsule PO once a day: to soften stool. Disp:*30 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Recurrent small bowel obstruction Discharge Condition: Stable Discharge Instructions: Continue home medications and ostomy care. Call primary care provider if you have a fever greater than 101.5, pain that is uncontrollable with your pain medication, drainage from your incision. Followup Instructions: Follow up wtih Dr. [**Last Name (STitle) **] on [**2186-8-15**]. Please call ([**Telephone/Fax (1) 29931**] for appointment. Name: [**Known lastname 15522**],[**Known firstname 1463**] T Unit No: [**Numeric Identifier 15523**] Admission Date: [**2186-7-24**] Discharge Date: [**2186-8-1**] Date of Birth: [**2118-6-17**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 813**] Addendum: Patient discharged with home PT care Discharge Disposition: Home With Service Facility: [**Hospital 136**] Homecare [**First Name11 (Name Pattern1) 801**] [**Last Name (NamePattern4) 815**] MD [**MD Number(2) 816**] Completed by:[**2186-8-1**]

[ "244.9", "272.0", "V10.05", "560.81", "276.8", "V44.3" ]

icd9cm

[ [ [] ] ]

[ "45.72", "47.19", "54.11", "54.59", "96.07", "38.91", "45.93" ]

icd9pcs

[ [ [] ] ]

5604, 5819

2516, 3897

361, 471

4776, 4785

1276, 2493

5027, 5581

4114, 4617

4719, 4755

3923, 4091

4809, 5004

965, 1257

274, 323

499, 743

765, 870

886, 950

12,581

107,814

52536+59434+59435

Discharge summary

report+addendum+addendum

Admission Date: [**2106-1-25**] Discharge Date: Service: Critical Cardiac Care Unit HISTORY OF PRESENT ILLNESS: The patient is an 81 year old male with cardiomyopathy, hypertension, diabetes Type 2, status post recent cardiac admission for catheterization in the setting of increased shortness of breath. The patient has clean coronary arteries, positive cardiomyopathy with an ejection fraction of about 30%, clinically right heart failure, symptoms greater than left heart failure who notes bilateral minimal activity secondary to lower extremity pain and swelling, increased over the past four to five days with increased scrotal/penis edema, no dosing changes and no medical noncompliance. PAST MEDICAL HISTORY: Coronary artery disease, cardiomyopathy, congestive heart failure, atrial fibrillation, status post pacer in [**2103**], patient with prostate cancer, embolic cerebrovascular accident, lymphedema, chronic renal insufficiency, degenerative joint disease, and hypertension and diabetes Type 2 MEDICATIONS ON ADMISSION: Amiodarone 200 mg once a day; Protonix 40 mg once a day; Aspirin 325 once a day; Colace; Lopressor 12.5 twice a day; insulin sliding scale, NPH 25 q. AM; Hydralazine 400 mg four times a day; Imdur 30 mg twice a day; Lasix 80 mg twice a day; Coumadin 5 mg once a day, alternating with 7 mg once a day, on alternating days. ALLERGIES: The patient with allergies to Penicillin, Sulfa drugs, intravenous dye and shellfish. SOCIAL HISTORY: No tobacco or alcohol history. REVIEW OF SYSTEMS: No weight loss, no fever, nightsweats or anorexia, no blurry vision, diplopia and no tinnitus, sinus pain or sore throat. No chest pain or palpitations, positive lower extremity edema, positive fatigue, no orthopnea or paroxysmal nocturnal dyspnea. Positive dyspnea on exertion. Positive cough, dry, no nausea or vomiting, hematemesis, positive hematochezia, no abdominal diarrhea, constipation, no easy bruising, no dysuria or hematuria, no rash, no pruritus, no change in skin or hair, positive energy loss, positive weakness in extremities. No back pain, no vertigo, no dizziness. PHYSICAL EXAMINATION: Blood pressure is 164/90, heartrate 72, weight 268 lbs, blood sugar 143, 96% oxygen saturation on 2 liters, afebrile. The patient is alert and oriented times three. Head, eyes, ears, nose and throat shows pupils are equal, round, and reactive to light and accommodation. Mucous membranes dry. Neck is supple, no left anterior descending. Respiratory, slight bibasilar crackles, nonlabored breathing. Cardiovascular, regular rate and rhythm via pacer, no mitral regurgitation, normal pulses. Abdomen, soft, normoactive bowel sounds, soft nontender, nondistended, no rebound or guarding. Lower extremities are 2+ edema. Cranial nerves II through XII intact. LABORATORY DATA: Labs on admission from [**1-25**], sodium 136, potassium 4.1, chloride 100, bicarbonate 22, BUN 65, creatinine 2.9, glucose 161, white blood cells 6, hematocrit 32.6, platelets 136, PT 25.3, INR 4.5, PTT 44.4, ALT 20, AST 41, alkaline phosphatase 28, albumin 2.7, calcium 8.6, phosphorus 3.8, magnesium 2.0, amylase 33, CK 157, MB 5. Catheterization on [**2105-12-18**] showed normal coronaries, moderate systolic and diastolic ventricular dysfunction, moderate pulmonary hypertension. Blood cultures times two are pending, urine culture is pending. Echocardiogram shows paced rhythm at 70 with left bundle branch block. No changes from [**2105-12-31**]. Chest x-ray shows cardiomyopathy with overt congestive heart failure. Basal small effusions. IMPRESSION/PLAN: An 81 year old with nonischemic cardiomyopathy who presents with increased scrotal edema, pain in the lower extremities, increased lower extremity edema, decreased exercise tolerance, acute and chronic renal failure. Cardiovascular - Evaluate the cause of cardiomyopathy, congestive heart failure, unclear. Pulmonary hypertension, question pulmonary function tests. Need for pulmonary evaluation. Continue to diurese. The patient should be 1 liter negative over 24 hour period. Check right atrial saturation at rest. Continue with Hydralazine, Imdur, Aspirin, Amiodarone, Coumadin, beta blocker. Renal - Acute and chronic renal insufficiency, workup not suggested of urinary tract infection. Continue Lasix. Suspect chronic low flow state secondary to cardiomyopathy. Kidneys with mild prerenal status at baseline, avoid nephrotoxic drugs. Check eos, consider renal ultrasound. Genitourinary - Evaluate scrotal edema, meticulous skin care to avoid ulcerations and breakdown. History of anemia, workup baseline, check iron studies, reticulocyte count if not done. Endocrinology - Check fingersticks q.i.d. NPH dose as above. Physical therapy consult please. HOSPITAL COURSE: The patient was transferred from the [**Hospital Ward Name 8559**] Acove [**Hospital1 **] to the Coronary Care Unit for management of his worsening edema and congestive heart failure for Swan-Ganz catheter and intravenous Milrinone therapy. There was an 82 year old male with multiple medical problems, congestive heart failure with an ejection fraction of 40% by echocardiogram with moderately elevated right-sided pressures, no wall-motion abnormalities, clean indices by recent catheterization, diabetes Type 2, atrial fibrillation status post pacer who has had many recent admissions for congestive heart failure exacerbation. The patient was recently 202d, admitted to [**Hospital6 2018**] for symptoms of congestive heart failure accentuated by prominent lower extremity edema. At that time he was ruled out by myocardial infarction, diuresed and switched from an ACE inhibitor to Hydralazine in the setting of an elevated creatinine. The patient was discharged to rehabilitation on [**2106-1-5**] until five days ago prior to admission on [**2106-1-25**]. He presented with evaluation with worsening lower extremity edema and new scrotal edema. On presentation he denied any chest pain, shortness of breath, fevers, chills, nausea, vomiting or diarrhea. The patient denied dietary indiscretions, not certain. He noted he has been taking his medications as described. The patient's review of systems were essentially negative, no orthopnea or paroxysmal nocturnal dyspnea as above. The patient denied palpitations. He has never smoked nor drank alcohol. The patient was initially admitted to the [**Hospital Ward Name 8559**], Acove Service for management of congestive heart failure. Summary of the first few days as follows - He was ruled out for an myocardial infarction by enzymes. He had no telemetry event. Chest x-ray read as no evidence of failure. Repeat echocardiogram showed an increased ejection fraction of 40%, up from 30% in [**Month (only) 956**] with mild mitral regurgitation, 1+, moderate tricuspid regurgitation 2+ and no PCD. The patient managed on increasing doses of Lasix and Zaroxolyn to a maximum of Lasix 200 mg b.i.d. with Zaroxolyn before each use with difficulty keeping him negative, given his rise in creatinine. The patient had lower extremity dopplers negative for deep vein thrombosis, abdominal ultrasound was negative for hepatosplenomegaly, ascites, portal hepatic obstruction and PPD dilation. The kidneys were within normal limits without enlargement and/or hydronephrosis. Bilateral pleural effusions were incidentally noted. Renal was consulted and they recommended diuresis and plus/minus possible ultrafiltration if there was no response to the diuresis. Eos were positive, Phena 1%, dopplers negative. Congestive Heart Failure Service was consulted and they recommended aggressive diuresis with Lasix alone as tolerated. They initiated Digoxin workup for etiology of pulmonary hypertension and possible sleep apnea evaluation. The patient was transferred to the CCU on [**2106-2-2**] for tailored therapy with Milrinone plus/minus Natrecor. MEDICATIONS ON ADMISSION TO CCU: 1. Trazodone 25 to 50 prn 2. NPH 16 q. AM 3. Colace 100 mg b.i.d. 4. Digoxin .125 q.o.d. 5. Epogen 5000 units subcutaneously three times a week 6. Imdur 30 mg q.d. 7. Lasix 200 mg b.i.d. 8. Zaroxolyn SOCIAL HISTORY: The patient lives with his oldest daughter. [**Name (NI) **] does not smoke or use alcohol. PHYSICAL EXAMINATION TO CCU: General, alert and oriented times three in no acute distress. Head, eyes, ears, nose and throat showed normocephalic, atraumatic, pupils are equal, round, and reactive to light and accommodation, oropharynx clear. No jugulovenous distension, no thyromegaly or bruits. Pulmonary, bibasilar rales one third of the way up, no wheezes, rales or rhonchi. Cardiovascular, regular rate and rhythm, I/VI systolic murmur best heard at the left upper sternal border with no radiation. Abdomen, obese, nontender, nondistended, normoactive bowel sounds, no fluid. Scrotum, marked edema with 1 by 3 cm upper superior skin breakdown with necrotic base, no erythema. Extremities, bilateral lymphedema associated with chronic venous stasis skin changes. No calf tenderness, pitting edema of thighs. Pulses trace, nonpalpable. LABORATORY DATA ON ADMISSION TO CCU: White blood cell count 6.4, hematocrit 29.1, platelets 166, sodium 137, potassium 3.1, chloride 98, bicarbonate 28, BUN 95, creatinine 3.0, glucose 161. Arterial blood gases was 7.51 PH, 38 carbon dioxide and 70 oxygen. INR is 2.3. While in the CCU the patient had a right internal jugular cordis placed and Swan-Ganz catheter placed, will initiate chemotherapy with Nasreotide, Natrecor, continue drops and aspirin/Amiodarone, anticoagulate with Coumadin for atrial fibrillation and hold off on calcium channel blockers, diuretics and beta blockers for now. Follow inputs and outputs strictly and follow Swan-Ganz catheter numbers. Lower extremity edema, the patient with a history of lymphedema and congestive heart failure. Findings were negative, no evidence of cellulitis. Check feasibility if given lymphogram. Check abdominal computerized tomography scan to rule out intra-abdominal large vessel clot, elevate legs as much as possible. Hematology, anemia of chronic disease, versus low epo state from chronic renal failure, hold off on transfusion, given no coronary artery disease. Overall fluid status, overloaded for now. Check AM hematocrit. Continue Epogen. Consider increasing dose. Transfuse if hemodynamic but unstable. Renal, acute and chronic renal failure, likely multifactorial, possible interstitial nephritis with positive urine eos versus aggressive diuresis, versus worsening intrinsic diabetic nephropathy. Dopplers negative for post obstructive causes. Renally dose all medications. Continue to check electrolytes for now. Fluids, electrolytes and nutrition, we will recheck potassium after AM repletion of potassium to 3.1. Goal inputs and outputs is to be 1 to 1.5 liters negative. Continue cardiac diet and diabetic diet. Protonix and Colace. The patient is a full code. The patient has a left arterial line placed, a right internal jugular with Swan-Ganz catheter and right peripheral intravenous. Swan-Ganz catheter measurements on admission to CCU are as follows: CVT 26, PA pressure 58/23 with a mean of 36, wedge pressure 17, cardiac output by thick 13.8 with cardiac index of 5.66. SVR was 968. The patient seen by Dermatology on day #2 of CCU. The patient's lower extremity lesions are consistent with elephantiasis verrucosa nostra. This is a variable severe lymphedema, recommended topical emollient b.i.d./Aquaphor with Pneumoboots or other compression treatment for congestive heart failure. The patient on admission to the CCU was started on Natrecor at 180 mcg intravenous bolus and then .9 microgram drip per minute. The patient was given Lasix 80 mg intravenously for diuresis. Lopressor was restarted at 12.5 b.i.d. The patient's low hematocrit was given transfusion 1 packed red blood cells. Diamox was started 250 mg b.i.d. for bicarbonate diuresis with alkalosis. Nutrition was consulted. Nutritions recommendations for 700 cc free water, Respalor at 50 cc/hr for 24 hours. Check laboratory data and replete electrolytes prn. Consider nasogastric tube placement. The patient on day #2 of CCU doing well, diuresed approximately 400 cc after the first day. Lasix drip was started for diuresis. Anticoagulations were held due to INR of 2.7. The patient will continue to receive blood transfusions for the low hematocrit of 27.9. The patient still remains total volume overloaded, diuresis continued. More packed red blood cells to increase narcotic pressure for better diuresis. Increase Natrecor drip. The patient on day #3, continue Natrecor at present dose. The patient is without good diuresis. Continues to be fluid overloaded. Lasix drip at 20 mg/hr. [**2106-2-5**], Swan-Ganz catheter #s reveal PA pressure 57/24, wedge pressure 21, cardiac output 15.1, cardiac index of 6.11 with SVR of 262, PA saturation 84. Arterial blood gases 7.41 pH/46 CO2 and 99 for O2. The patient's inputs and outputs on day #3 was positive 50 cc. [**2-5**], Diamox was discontinued as alkalosis resolved. The patient had hematocrit stable, status post packed red blood cell transfusion. Hematocrit 31.9, above 30 which was the goal. Swan-Ganz catheter was discontinued. On [**2106-2-5**] the patient doing well, diuresing well. The patient was negative 2 liters overnight. The patient was responding to Natrecor and Zaroxolyn and Lasix. Swan-Ganz catheter was removed. The patient had slight metabolic alkalosis but will be given potassium repletion. If this does not improve, we will readd Diamox. The patient's blood saturations prior to pulling Swan-Ganz catheter showed superior vena cava, first measurement 82%, second measurement 80%; right arterial first measurement 80%, second measurement 82%; right ventricle first measurement 85%, second measurement 81%; [**MD Number(3) 108502**] measurement 91, second measurement 90 with a mixed VNS oxygen saturation, first measurement 79% second 84%. The patient on [**2106-2-8**] in the CCU, overnight events, no deep vein thrombosis via lower extremity ultrasound. The patient diuresing well overnight, -1.7 liters. Hemodynamically the patient is stable, diuresing well. Current regimen still on Natrecor and Lasix as well as Zaroxolyn. The patient was started on heparin intravenously, Diamox was restarted. Psychiatry was consulted for depression evaluation. The patient on [**2-9**], overnight events had a fever to 102.8 with hypertension, culture grew out gram positive cocci. The patient was shown to have Methicillin-resistant Staphylococcus aureus via blood culture. Line was pulled. The patient was started on Vancomycin 750 mg intravenously and Levaquin 250 mg intravenously q. 24 hours. The patient's urine culture from [**2106-2-10**] showed less than 10,000 organisms. Recent blood culture showed no growth. The patient's right internal jugular culture showed mixed bacterial types, greater than 3 colonies. The patient's sputum culture on [**2106-2-8**] showed no predominance of respiratory pathogens, moderate oropharyngeal Flora growth and moderate growth of Staphylococcus aureus coagulase positive. The patient had right upper quadrant ultrasound on [**2106-2-9**] which showed a right pleural effusion without evidence of ascites. The patient on [**2106-2-10**] in the CCU Nasreotide and diuretics discontinued. The patient continued to autodiurese effectively with -730 cc on this day inputs and outputs. Diamox was discontinued for now. Ongoing ultrasound showed results as above. The patient subsequently failed a swallowing study and nasogastric tube was placed for tube feeds. The patient on [**2106-2-11**] was transferred from the CCU to a regular cardiac floor. The patient on [**2-11**] continues to improve, is 1 liter negative on that date, over 6 liters negative total for his hospital stay per care view notes. The patient now is showing a free water deficit of approximately 3 liters. The patient now will be repleted with D5/W intravenously as well as free water via his nasogastric tube. The patient continues to autodiurese well, watching his potassium closing and replete as needed. The patient's Methicillin-resistant Staphylococcus aureus positive blood culture, he is being continued on Vancomycin and recultured. The patient is on tube feeds, doing well. The patient was started on Remeron 50 mg p.o. q.h.s. per Psychiatry for depressive symptoms. The patient on [**2-12**], put back on Diamox for alkalosis. The patient continues to need free water for hyponatremia, sodium up to 150 on [**2106-2-12**]. This will be monitored per renal and we will continue to use free water to bring down this hyponatremia. Vancomycin peak and troughs were checked closely. The patient was changed to 1 gm q. 24 hours. The patient on [**2106-2-12**] with noted low platelets at 87. The patient had HIT thrombocytopenia workup. DIC labs were sent as well as coagulation screen. Discussed with the patient and the patient's daughter the possible need for right heart catheterization with biopsy to explore potential causes of right ventricular failure. The patient's right upper quadrant ultrasound as stated before showed no ascites. Computerized tomography scan of the abdomen showed small nodule of liver consistent with cirrhosis, questionably caused by right ventricular failure. Currently continue workup for possible cirrhosis. AST and ALT are within normal limits on this day. The patient's laboratory data for possible causes of thrombocytopenia showed FTP of 80-100, D-dimer of greater than [**2103**], fibrinogen 221, haptoglobulin 67. The patient will be monitored for possible DIC picture. The patient's platelets up to date at 100 up from 87, trending upward. They will be monitored. The patient's platelets will be checked again in the afternoon. The patient's sodium dipping down to 148, now back up, elevated at 150. Will continue to use free water via nasogastric tube which is working well and that replete the intravenous fluid, D5/W for a free water deficit of approximately 4 liters at this point. The patient's blood cultures on [**2106-2-12**] show as again positive for Methicillin-resistant Staphylococcus aureus, continue on Vancomycin. Blood cultures are pending from [**2-12**], times two, no growth to date. The patient's diuretics have all been discontinued. The patient's creatinine seems to be improving, down to 2.5 from previously 2.7. Patient's pulmonary status, pneumonia/effusion, the patient continues to be Vancomycin and Levofloxacin. Vancomycin dose now at 1 gm q. 36 hours for an elevated peak. Will be rechecked to follow this and may be redosed as needed. The patient's HIT has been sent pending. The patient continues on Remeron for depression with slight improvement in affect. The patient continues on tube feeds with good residuals. End of summary up until [**2106-2-14**], patient's continued care to be dictated for dates following [**2106-2-14**] up until possible date of discharge. [**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D. Dictated By:[**Last Name (NamePattern1) 4724**] MEDQUIST36 D: [**2106-2-20**] 18:02 T: [**2106-2-20**] 19:56 JOB#: [**Job Number 108503**] Name: [**Known lastname 5181**], [**Known firstname 63**] Unit No: [**Numeric Identifier 17744**] Admission Date: [**2106-2-15**] Discharge Date: [**2106-3-23**] Date of Birth: [**2024-2-4**] Sex: M Service: ADDENDUM: This is an addendum starting [**2106-2-15**]. 1. CARDIOVASCULAR: The patient admitted initially for worsening congestive heart failure and was sent to the Coronary Care Unit for diuresis with a Swan-Ganz catheter for [**Location (un) **] therapy. The patient was aggressively diuresed to the point of developing hypernatremia and dehydration with worsening renal function. Eventually, the patient was discharged to the floor. From a cardiovascular standpoint, the patient remained stable for the rest of his stay; however, when the patient developed a respiratory arrest in the hospital on [**2106-2-23**] the patient subsequently became hypotensive requiring multiple pressors. Likely the patient had sepsis physiology. A Swan-Ganz catheter was reintroduced in the Coronary Care Unit which showed the patient having elevated cardiac output and decreased systemic vascular resistance consistent with septic physiology. The patient was started on broad spectrum antibiotics and was put on multiple pressors including Levophed and pitressin. However, after further discussion with the patient's daughters, the patient was able to be made comfort measures only and pressors were discontinued, and the patient remained off pressors until expiration. 2. PULMONARY: Again, the patient was doing well until hypoxic respiratory arrest on [**2106-2-23**] thought secondary to an aspiration episode. The patient also with large bilateral pleural effusions. The patient underwent bilateral thoracentesis which revealed a transudative fluid secondary to congestive heart failure or malnutrition with low oncotic pressure. The patient was initially intubated after his respiratory arrest; however, again, after discussion with the family, the patient had a terminal extubation and was then able to maintain decent saturations with a nonrebreather and finally face mask. The patient was started on a morphine drip for comfort. Unfortunately, the patient eventually developed a respiratory arrest and expired. 3. INFECTIOUS DISEASE: The patient initially treated for a line sepsis with vancomycin. However, again, after the patient's hypoxic arrest on [**2-23**], the patient became hypotensive; likely secondary to aspiration and multiorgan system failure. The patient was covered with broad spectrum antibiotics. No organisms were cultured. Again, after discussion with the patient's daughters, antibiotics were withdrawn and the patient was made comfortable. The patient expired on [**2106-3-4**]. Time of death at 7:07 p.m. The patient had been on a morphine drip titrated to comfort prior to expiration. A family meeting was held with both daughters who agreed to this treatment course. One daughter was present at the bedside at the time of expiration. Autopsy was offered but refused. [**Name6 (MD) 116**] [**Name8 (MD) 117**], M.D. [**MD Number(1) 118**] Dictated By:[**Name8 (MD) 7039**] MEDQUIST36 D: [**2106-3-23**] 17:37 T: [**2106-3-23**] 18:55 JOB#: [**Job Number 17745**] Name: [**Known lastname 5181**], [**Known firstname 63**] Unit No: [**Numeric Identifier 17746**] Admission Date: Discharge Date: Date of Birth: Sex: M Service: ADDENDUM: This addendum will cover the patient's course while on the regular medical floor, [**2106-2-15**]. The patient was transferred to the regular medical floor from the Coronary Care Unit service. He had aggressive oral and dental care, which resulted in improved respiratory performance. The patient was still an aspiration risk, so a PEG tube was placed on [**2106-2-26**]. Status post placement of the PEG tube, the patient did well. He was not being fed through the PEG tube. The patient developed respiratory distress on the evening of [**2-26**]. He was intubated that night and taken back to the Coronary Care Unit Service, where the care was again assumed by Dr.[**First Name8 (NamePattern2) **] [**Name (STitle) 3970**] who will dictate the patient's remaining Coronary Care Unit course until the patient's time of death. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 17747**] Dictated By:[**Last Name (NamePattern1) 6341**] MEDQUIST36 D: [**2106-4-1**] 09:57 T: [**2106-4-1**] 12:05 JOB#: [**Job Number **]

[ "416.0", "486", "428.0", "584.9", "996.62", "427.31", "038.11", "608.86", "799.1" ]

icd9cm

[ [ [] ] ]

[ "96.72", "43.11", "96.6", "34.91", "96.04" ]

icd9pcs

[ [ [] ] ]

1050, 1472

4797, 8155

2152, 4779

1541, 2129

124, 708

731, 1023

8172, 23972

73,997

195,629

36296

Discharge summary

report

Admission Date: [**2164-3-21**] Discharge Date: [**2164-3-29**] Date of Birth: [**2094-2-10**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2836**] Chief Complaint: Abdominal pain associated with hyperkalemia and acute renal failure. Major [**First Name3 (LF) 2947**] or Invasive Procedure: None History of Present Illness: Pt is a 70 y/o F who presents from [**Hospital3 **] with hyperkalemia, acute renal failure, and abdominal tenderness. The patient denies any abdominal pain although she has had anorexia for 3-4 days. She denies fever, chills, nausea, vomiting, cough, sore throat, rhinorrhea, chest pain, shortness of breath, dysuria, hematuria, BRBPR, no change in BM's although now diarrhea since kayexylate, dysuria, hematuria, travel, sick contacts, strange foods. In addition to no abdominal pain she denies shoulder, back, and leg pain. The ER called as patient has significant abdominal tenderness in setting of renal failure. The patient has received kayexylate, Ca, and bicarb for her hyperkalemia. No peaked T waves on EKG. Brief Hospital Course: Ms. [**Known lastname 82238**] was admitted to the [**Known lastname **] ICU on [**2164-3-21**]. Her potassium at the time of admission was 5.6, and she was treated with calcium gluconate, kayexalate, and sodium bicarbonate for the hyperkalemia. Her EKG was negative for T-wave changes. Her creatinine at time of admission was found to be 5.7, and her urine was positive for E.coli. She was started on empiric ciprofloxacin and flagyl and kept strict NPO and hydrated with IV fluids. A CT scan at time of admission showed the following: Hypodense cystic lesion in the head of the pancreas with associated calcification. This finding may represent a benign cyst or cystic neoplasm. Associated pancreatic ductal dilatation, common bile duct dilatation and gallbladder distention is also noted. On [**3-22**] she was transferred from the ICU to the floor and had a right upper quadrant abdominal ultrasound which showed the following: 1. Distended gallbladder, however no son[**Name (NI) 493**] evidence of cholecystitis. 2. Prominent CBD measuring up to 9 mm. 3. Both the gallbladder distention and CBD dilation may be related to the pancreatic head lesion seen on CT, and a multiphasic CT or MRI of the abdomen is recommended when feasible. On [**3-23**] - [**3-25**], her stool was found to be positive for c.diff and she was continued on IV cipro/flagyl, hydration and NPO status. Her potassium was normalized at 3.7 and creatinine was 2.9. A CA [**73**]-9 was 19, and CEA was 3. On [**3-26**] she underwent endoscopic ultrasound and biopsy of the pancreatic cyst. Cyst fluid was negative for malignant cells with cyst fluid amylase 165 and CEA 655. On [**3-27**] she was advanced to a clear diet. Ciprofloxacin was discontinued, and she was transitioned to PO medications. On [**3-28**] she was advanced to a regular diet without difficulty. She complained of left foot pain and was started on a 5-day course of prednisone for likely gout flare in her left great toe; pain improved later that day. On [**3-29**] she was tolerating a regular diet, ambulating and voiding without assitance, pain was well controlled. She was continued on Flagyl for cdiff with resolutions of loose stools. Follow-up was scheduled as outlined below. Medications on Admission: Nicotine 21mg/24hr patch top daily, Prilosec 20mg PO daily, Lidocaine patch 5% top. daily, Advair Diskus 250/5 1 puff [**Hospital1 **], Lisinopril 10mg PO BID, Iron 325mg PO daily, Hydralazine 25mg PO TID, Lopressor 50mg TID, Norvasc 5mg PO BID, Thiamine 100mg PO daily, MVI 1 PO daily, Folate 1mg Po daily, Colace 100mg PO BID, Albuterol MDI 90mcg/inh 2 puffs QID PRN Discharge Medications: 1. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily) for 14 days. Disp:*14 Patch 24 hr(s)* Refills:*0* 2. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) patch Transdermal once a day: Start once Nicotine 21mg/24hour patches completed. Disp:*14 patches* Refills:*1* 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) inhalation Inhalation [**Hospital1 **] (2 times a day). 4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO three times a day. 6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply for 12 hours, off for 12 hours. 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation four times a day as needed for shortness of breath or wheezing. 9. Lopressor 50 mg Tablet Sig: One (1) Tablet PO three times a day. 10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. 11. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 15. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 16. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 17. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 7 days. Disp:*21 Tablet(s)* Refills:*0* 18. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 3 days. Disp:*9 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 7571**]VNA Discharge Diagnosis: 1. Head of pancreas mass 2. Pancreatic duct and common bile duct dilatation 3. Acute renal failure likely secondary to UTI 4. Clostridium Difficile Discharge Condition: Stable Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**4-8**] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Followup Instructions: MRI ([**Hospital1 **] [**Last Name (Titles) 517**] Clinical Center Building) Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2164-4-4**] 7:40 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1239**], [**Name Initial (NameIs) **].O. Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2164-4-4**] 1:00 Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SPECIALTIES CC-3 (NHB) Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2164-4-4**] 4:00 Completed by:[**2164-3-29**]

[ "590.80", "496", "V10.3", "041.4", "008.45", "276.2", "274.9", "577.8", "276.7", "577.9", "576.8", "584.9" ]

icd9cm

[ [ [] ] ]

[ "52.11", "45.13" ]

icd9pcs

[ [ [] ] ]

5770, 5824

1182, 3432

6016, 6025

7526, 8093

3852, 5747

5845, 5995

3458, 3829

6049, 7503

275, 409

437, 1159

20,133

186,599

48150

Discharge summary

report

Admission Date: [**2164-4-12**] Discharge Date: [**2164-4-17**] Date of Birth: [**2108-12-6**] Sex: F Service: MEDICINE Allergies: Percocet Attending:[**First Name3 (LF) 896**] Chief Complaint: weakness and upper back pain Major Surgical or Invasive Procedure: None History of Present Illness: 55 YO F w IDDM1 s/p renal transplant with recurrent ESRD, non-ischemic cardiomyopathy with EF 30% s/p [**Hospital1 **]-v ICD placement, chronic Hepatitis C, OSA with recent admission for unresponsiveness [**2-8**] hypoglycemia who presents now with weakness. The patient reports feeling generalized weakness for the past week and has not been performing her ADLs as usual. She reports poor appetite and nausea, but has been having normal bowel movements and denies abdominal pain. The night prior to presentation, the patient vomited non-bloody bilious emesis x2. Although she continued to have nausea earlier this morning, she was able to hold down soup and a [**Location (un) 6002**] today. She denies fevers/chills, weight loss, myalgias or arthralgias, chest pain, or changes in her stable dyspnea with walking up 5 stairs. Denies sick contacts. She reports having prior similar symptoms during her prior episodes of pneumonia. Patient went to dialysis today and came to ED after undergoing a full dialysis session. Of note, the patient reports episodes of intermittent nausea and dry heaves for the past several weeks, and has notified her medical providers of this, who attributed her symptoms to her labile [**Location (un) **] pressures and dialysis sessions. She reports decreased activity and energy since re-starting hemodialysis [**10/2162**], but reports the past week has been an acute worsening. Upon arrival to the ED, 98.9 65 183/78 18 95% ra. Exam notable for pain across top of back with tense muscles. No cough. Labs notable for creatinine of 3.8 and troponin of 0.14, INR of 1.8 and anion gap of 16. Lactate was 2.8EKG reportedly at rate of 68, Vpaced, with unchanged morphology. CXR showed increase in size of her chronic right sided effusion and so she was given ceftriaxone and azithromycin. VS on transfer: 96.5 64 151/84 18 95% on 2L. Upon arrival to the floor, the patient reports improvement of her nausea and reports feeling better after receiving antibiotics in the ED. Past Medical History: - s/p placement of right upper extremity arteriovenous graft [**2162-10-19**] with recent revision 11/[**2163**]. L fistula did not mature. -Type 1 DM, since age 20 -Dilated non-ischemic cardiomyopathy, EF 30% by echo [**11/2163**] -Biventricular ICD placement, [**7-/2162**] -Hypertension -ESRD s/p transplant in [**2152**], undergoing evaluation for possible second transplant; currently on HD -Hepatic fibrosis, of unknown cause - worked up at [**Hospital1 3278**] -Intracranial right ICA aneurysm, s/p clipping [**2159-5-16**] -s/p C4-5 and C5-6 anterior decompression and fusion after MVA [**2157**] -s/p discectomy at C6-C7 and fusion in [**2157**], with instrumentation removal and reinsertion on [**2159-9-28**] -Ulnar nerve impingement bilaterally -GERD -Asthma as a child -Sleep apnea, unable to tolerate CPAP -s/p right carpal tunnel release -s/p rotator cuff repair -Resting tremor -h/o CMV in [**2155**] Social History: No tobacco, quit 14 years ago after having previously smoked 1ppd x27 years. Occasional alcohol and no drug use. Lives with a son and daughter-in-law. She is divorced, has 2 children and 9 grandchildren. Family History: Sister died of [**Name (NI) 11398**]. Many other family members on maternal side with diabetes, including grandmother and aunt. [**Name (NI) **] with breast cancer. Physical Exam: Vitals: 97.8 144/67 60 18 96%2L FS 361 General: Alert, oriented, no acute distress. HEENT: Sclera anicteric, [**Name (NI) 5674**] Neck: supple, JVP to mandible at 45 degrees CV: RRR, systolic murmur loudest at LUSB. Lungs: CTAB with decreased BS at right lung base to mid lung field and bronchial breath sounds at RML and RLL. Abdomen: soft, non-tender, non-distended. Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis, 2+ pitting edema b/l Pertinent Results: Admission labs: [**2164-4-12**] 05:30PM GLUCOSE-181* UREA N-26* CREAT-3.8*# SODIUM-136 POTASSIUM-4.1 CHLORIDE-94* TOTAL CO2-25 ANION GAP-21* [**2164-4-12**] 05:38PM LACTATE-2.8* [**2164-4-12**] 05:30PM ALT(SGPT)-121* AST(SGOT)-162* LD(LDH)-408* ALK PHOS-228* TOT BILI-2.0* DIR BILI-0.9* INDIR BIL-1.1 [**2164-4-12**] 05:30PM LIPASE-15 [**2164-4-12**] 05:30PM cTropnT-0.13* [**2164-4-12**] 05:30PM ALBUMIN-4.0 CALCIUM-9.7 PHOSPHATE-4.6* MAGNESIUM-1.9 [**2164-4-12**] 05:30PM WBC-4.7 RBC-4.27 HGB-13.8 HCT-42.5 MCV-100* MCH-32.4* MCHC-32.5 RDW-18.4* [**2164-4-12**] 05:30PM NEUTS-82.8* LYMPHS-12.4* MONOS-3.8 EOS-0.4 BASOS-0.5 [**2164-4-12**] 05:30PM PLT COUNT-206 [**2164-4-12**] 05:30PM PT-19.5* PTT-29.9 INR(PT)-1.8* [**2164-4-12**] 05:15PM WBC-5.3 RBC-4.42# HGB-14.3 HCT-45.3# MCV-103* MCH-32.4* MCHC-31.6 RDW-18.0* [**2164-4-12**] 05:15PM NEUTS-79.2* LYMPHS-14.2* MONOS-5.5 EOS-0.3 BASOS-0.7 [**2164-4-12**] 05:15PM PLT COUNT-195 Hep C VL - not detected Micro: All BCx - no growth or NGTD ascitic fluid cx - no growth Imaging: CXR [**4-12**]: IMPRESSION: Unchanged moderate right pleural effusion. Abdominal US with dopplers [**4-13**]: IMPRESSION: 1) Findings again suggestive of congestive hepatopathy (nutmeg liver) with cardiomegaly and marked dilatation of the IVC and hepatic veins as well as probable third spacing within the gallbladder wall. No vascular thrombosis is present. 2) Unchanged cholelithiasis and probable cholesterol polyps within the gallbladder. Interval increase in the degree of biliary sludge within the gallbladder lumen. 3) Echogenic atrophic kidneys consistent with known underlying renal disease. Moderate to large right pleural effusion. TTE [**4-16**]: The left ventricular ejection fraction is <40%, a threshold for which the patient may benefit from a beta blocker and an ACE inhibitor or [**Last Name (un) **]. Based on [**2160**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Brief Hospital Course: 55 year-old female with history of Type I DM, sCHF (EF 30%) s/p ICD, ESRD s/p failed transplant and OSA who presented with a couple of weeks of worsening fatigue and nausea and transaminitis on labs s/p episode of hypotension/hypothermia without identified cause whose symptoms resolved. Active issues: # Episode of hypotension and hypothermia: The morning after admission, the patient developed an episode of hypotension with SBPs in the 60's and hypothermia with a temperature of 91. She was given IVF, started on vanc and cefepime, and transferred to the MICU. EKG showed only slight T wave changes and cardiac enzymes were negative. BP normalized by time of transfer and no further IVF given. Bear hugger was applied and her temperature normalized. U/S of graft site showed no fluid collection. Diagnostic and therapeutic thoracentesis performed with IP team with 1200mL serosanguinous drainage. CXR after [**Female First Name (un) 576**] showed small R apical PTX. Catheter left in place overnight for continued drainage and pulled in AM. Patient otherwise stable and transferred back to medical floor. Her antibiotics were slowly stopped without change in her clinical status. Cultures have been negative. Abd US did show chronic gallbladder wall thickening and cholelithiasis, however no dilatation of her common bile duct. Surgery was consulted due to concern that her decompensation could have been from a biliary source, but the surgery team did not feel a cholecystecomty was indicated as there was no evidence of inflammation of the gallbladder on the abdominal US. Cultures were still pending at time of discharge. # Weakness/nausea/transaminitis: Her initial symptoms were nonspecific. A biliary source was worked up as above. Symptoms improved over her hospital course and her transaminitis trended downward. Hep C VL was negative. # Hypertension: In the setting of hypotension her antihypertensive medications were all held. As she improved, her [**Female First Name (un) **] pressure mediations were slowly added back and she was discharged on her home regimen of metoprolol, nifedipine, isosorbide [**Name (NI) 101507**], and [**Name2 (NI) 101508**]. Inactive issues: # ESRD: She was dialyzed per her home schedule (T/Th/Sat) and continued on prednisone (for her failed transplant), sevelamer, and nephrocaps. # Non-ischemic Cardiomyopathy: She was continued on Digoxin and Metoprolol per home regimen. # DM: BS generally well controlled except for one elevated BS last night. - Continue SSI and Glargine per home regimen. # Dyslipidemia: The patient was continued on pravastatin. CODE: Full Communication: Patient. Daughter [**Telephone/Fax (1) 101509**]. Son-in-law [**Name (NI) 101510**] [**Telephone/Fax (1) 101511**]. Transitions of care: - follow up pending [**Telephone/Fax (1) **] cultures Medications on Admission: - digoxin 125 mcg Tablet Sig: One (1) Tablet PO QTUESDAY - prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). - hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q8H - insulin glargine 100 unit/mL (3 mL) Insulin Pen 6u qam, 3u qpm. - insulin lispro 100 unit/mL Insulin Pen Subcutaneous four times a day: Please resume insulin sliding scale. - isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr PO DAILY - metoprolol succinate 100 mg Tablet Sustained Release 24 hr daily - pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY - ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO DAILY - B complex-vitamin C-folic acid 1 mg Capsule PO DAILY - nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). - sevelamer carbonate 800 mg Two (2) Tablet PO TID W/ MEALS - torsemide 100 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO QTUES (every Tuesday). 3. hydralazine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. insulin glargine 100 unit/mL Solution Sig: 6 units qam, 3 units qpm . Subcutaneous . 5. insulin lispro 100 unit/mL Solution Sig: sliding scale . Subcutaneous four times a day. 6. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 7. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 8. pravastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 9. ranitidine HCl 15 mg/mL Syrup Sig: Seventy Five (75) mg PO DAILY (Daily). 10. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 11. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO DAILY (Daily). 12. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 13. torsemide 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Primary: Malaise Hypotension and hypothermia of unknown cause Secondary: End-stage kidney disease on dialysis Systolic heart failure Type I Diabetes 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 due to fatigue and nausea. The day after admission you had an episode where your [**Telephone/Fax (1) **] pressure and temperature dropped. You were given IV fluids, antibiotics, and sent to the medical ICU for monitoring. Your [**Telephone/Fax (1) **] pressure and temperature improved and no infectious sources of your episode were identified. Your [**Telephone/Fax (1) **] pressure medications were slowly added back and you were eventually taken off the antibiotics. Medication changes: No changes were made to your medications. Continue your outpatient medications as prescribed. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Department: CARDIAC SERVICES When: MONDAY [**2164-5-28**] at 2:30 PM With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2164-4-19**]

[ "038.9", "E878.0", "V45.4", "780.65", "V58.65", "V45.02", "V45.11", "070.54", "V15.82", "V58.67", "403.91", "425.4", "575.10", "573.0", "286.7", "511.9", "571.5", "530.81", "250.01", "785.52", "327.23", "995.92", "996.81", "585.6", "428.23", "512.1", "E879.8", "285.21", "428.0" ]

icd9cm

[ [ [] ] ]

[ "34.91", "39.95" ]

icd9pcs

[ [ [] ] ]

11224, 11230

6312, 6601

298, 305

11424, 11424

4170, 4170

12313, 12649

3519, 3685

10079, 11201

11251, 11403

9180, 10056

11575, 12084

3700, 4151

12104, 12290

229, 260

6616, 8501

333, 2339

8518, 9078

4187, 6289

11439, 11551

9099, 9154

2361, 3280

3296, 3503

73,713

124,621

50309

Discharge summary

report

Admission Date: [**2147-10-8**] Discharge Date: [**2147-10-25**] Date of Birth: [**2096-10-22**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2485**] Chief Complaint: hypoxia, cough Major Surgical or Invasive Procedure: Percutaneous tracheostomy under direct bronchoscopic visualization. Intubation R IJ R radial arterial line History of Present Illness: The patient is a 50 yo paraplegic female (T2 injury following MVC [**1-5**]) who has a history of recurrent UTIs and pneumonias who presents with a productive cough and hypoxia x a few hours. The patient is currently intubated and sedated so the husband provides the history. He states that over the past 14 days she has been treated for a UTI by her PCP with keflex and macrobid. The day prior to her admission [**2147-10-7**] her abx course had finished and in the a.m. of [**10-8**] she had a productive cough, productive of brown sputum. Her husband stated that her face would turn red while coughing and he checked her O2 sat and it was 82%. He started her on 5L of nasal cannula oxygen and brought her to the ER. She was stable for the 45 minute car ride in without coughing. She did not complain of any other symptoms to her husband. [**Name (NI) **] symptoms of UTI are usually of color change of her urine, a change in the odor of her urine and sometimes delerium, none of which she had during this episode. She had no fevers or chills that the husband is aware of. In the ER she was 83% on 5L. She improved to 96% on a non rebreather. She has 2 PIV 20g in hand and a R IJ in place. She has had a persistent low BP of 80s and she was started on levophed and her BPs improved. She had rec'd 4 L of IVF in the ER. Her Tmax was 101.8 rectally. She rec'd vanc, zosyn, and tylenol in the ER for likely pneumonia. Past Medical History: 1. T1-T2 paraplegia following MVC [**1-5**] 2. Recurrent UTIs 3. HCV, viral load suppressed after 3 months of therapy 4. H/o recurrent PNAs 5. Anxiety 6. DVT in [**2142**] -IVC filter placed in [**2142**] 7. Pulmonary nodules 8. Hypothyroidism 9. Chronic pain 10. Chronic gastritis 11. H/o obstructive lung disease 12. Anemia of chronic disease Social History: The patient currently lives at home wiht her husband and 2 children, ages 15 and 22. Former 35 packyear smoker. Denies current tobacco or alcohol use. Family History: Non-contributory. Physical Exam: Vitals: T: 98.0 BP: 122/65 P: 98 CVP 8 AC 380 x 28 PEEP 10 FiO2 50% General: intubated, sedated, responds appropriately to verbal stimuli HEENT: Sclera anicteric, MMM Neck: supple, JVP not elevated, no LAD Lungs: Crackles heard R>L with decreased breath sounds on RLL. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, moderately-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Imaging: CXR ([**10-8**]): FINDINGS: The right IJ line has been slightly retracted and is now at the SVC just above the right atrium. Again seen is moderate right pleural effusion. There is bilateral alveolar infiltrates, left greater than right. This appears to have progressed slightly; however, there is improved aeration at the left base. CXR ([**10-24**]): FINDINGS: The tracheostomy and right IJ line both appear unchanged from previous study. An endogastric tube courses inferiorly below the GE junction The tip of an IVC filter is seen at the edge of the field of view. There has been interval placement of a left PICC whose tip rests in the lower SVC. The heart size is at the large end of normal but unchanged from previous study. The mediastinal contours are also unchanged. Overall the lungs are clear with no focal or lobar consolidation. There is no pleural effusion or pneumothorax. Admission labs: [**2147-10-8**] 05:35PM GLUCOSE-126* UREA N-13 CREAT-0.5 SODIUM-134 POTASSIUM-5.8* CHLORIDE-103 TOTAL CO2-20* ANION GAP-17 [**2147-10-8**] 05:35PM CALCIUM-9.4 PHOSPHATE-3.1 MAGNESIUM-1.9 [**2147-10-8**] 05:35PM WBC-10.8# RBC-4.01*# HGB-11.1* HCT-34.5* MCV-86 MCH-27.6 MCHC-32.0 RDW-15.6* [**2147-10-8**] 05:35PM NEUTS-81.8* BANDS-0 LYMPHS-12.5* MONOS-4.5 EOS-0.7 BASOS-0.6 [**2147-10-8**] 05:35PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2147-10-8**] 05:35PM PLT SMR-NORMAL PLT COUNT-177 [**2147-10-8**] 05:35PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.024 [**2147-10-8**] 05:35PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-MOD [**2147-10-8**] 05:35PM URINE RBC-[**4-6**]* WBC-21-50* BACTERIA-MOD YEAST-NONE EPI-[**4-6**] TRANS EPI-0-2 [**2147-10-8**] 04:44PM LACTATE-1.9 [**2147-10-8**] 07:25PM TYPE-ART PO2-99 PCO2-53* PH-7.34* TOTAL CO2-30 BASE XS-0 [**2147-10-8**] 11:48PM TYPE-ART PO2-195* PCO2-75* PH-7.14* TOTAL CO2-27 BASE XS--5 [**2147-10-8**] 08:22PM POTASSIUM-3.6 Labs at time of discharge: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2147-10-24**] 06:15AM 6.9 2.88* 7.9* 24.8* 86 27.4 31.8 16.7* 254 BASIC COAGULATION PT PTT INR(PT) [**2147-10-24**] 06:15AM 12.4 27.3 1.0 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 [**2147-10-24**] 06:15AM 89 7 0.2* 138 4.1 102 29 CHEMISTRY Calcium Phos Mg [**2147-10-24**] 06:15AM 8.7 3.6# 1.9 Microbiology: [**2147-10-19**] BLOOD CULTURE -PENDING [**2147-10-19**] BLOOD CULTURE -PENDING [**2147-10-19**] BLOOD CULTURE -PENDING [**2147-10-19**] BLOOD CULTURE -PENDING [**2147-10-19**] URINE CULTURE - No growth [**2147-10-18**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL; LEGIONELLA CULTURE-PRELIMINARY; FUNGAL CULTURE-PRELIMINARY {YEAST} [**2147-10-18**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL; LEGIONELLA CULTURE-PRELIMINARY; FUNGAL CULTURE-PRELIMINARY [**2147-10-17**] MRSA SCREEN MRSA SCREEN- Negative [**2147-10-13**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST- Negative [**2147-10-13**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {YEAST} [**2147-10-10**] Influenza A/B by DFA DIRECT INFLUENZA A ANTIGEN TEST- negative; DIRECT INFLUENZA B ANTIGEN TEST- Negative [**2147-10-9**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {KLEBSIELLA PNEUMONIAE}; FUNGAL CULTURE-FINAL {YEAST} [**2147-10-9**] BLOOD CULTURE - No growth [**2147-10-9**] BLOOD CULTURE - No growth [**2147-10-9**] URINE CULTURE - No growth [**2147-10-9**] URINE CULTURE - No growth [**2147-10-8**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {KLEBSIELLA PNEUMONIAE, STAPH AUREUS COAG +} [**2147-10-8**] BLOOD CULTURE - No growth [**2147-10-8**] BLOOD CULTURE - No growth Brief Hospital Course: # Hypoxia and respiratory failure: Patient presented with respiratory distress, and was found to have recurrent RLL pneumonia. Sputum culture grew out klebsiella. Patient was intubated on arrival to the ICU floor as respiratory status worsened and arterial gas concerning. Patient was put on levofloxacin and her pneumonia and respiratory status improved. She was extubated on [**10-15**], and was doing well despite copious amount of secretions. However, 2 hours after the extubation, patient complained of acute pleuritic RUQ. Stat CXR showed worsening right pleural effusion, and RLL and RML collapse. The team discussed the necessity of re-intubation given new right lung collapse/plugging and inability to cough, and plan of tracheostomy in a couple of days, pt refused. Her oxygen saturation remained good for the rest of the night. Repeat CXR the next morning showed worsened right lung collapse to the point of complete right lung collapse, but patient continued to do well with intermittent CPAP supports despite the completely collapsed right lung. On [**10-18**], pt requested that she be re-intubated in the afternoon as she was more dyspneic on non-rebreather. Anesthesiology came and intubated her. Soon afterwards, patient had bradycardia and went into PEA, and pt was coded. Patient was resuscitated with CPR, 3 epi and 2 atropine, 1 amp bicarb, 5u insulin and 1amp dextrose. During the code, it was difficult to bag patient, indicating central airway was plugged. After about 4min, her pulse returned, patient was intially hypertensive with SBP in 170s, tachycardic at 150s with SVT, possibly AVNRT. she became hypotensive with SBP in the 80-90s as well. Patient was bronch'd immediately, copious secretions were suctioned, and post-bronch cxr showed part of the right lung re-opened up. Following bronch, BP and HR improved. Vancomycin and cefepime were started together with levofloxacin, which were discontinued after 72 hours of no growth in culture. Patient continued to improve since re-intubation. Tracheostomy was placed on [**10-20**], and patient tolerated the procedure well. On discharge to rehab on [**10-24**], patient was doing well on trach mask with minimal ventilator support. . # Sepsis: Patient met the criteria for sepsis. The source of infection was most likely pulmonary with evidence of pneumonia. She required pressors on and off in the initial part of her admission, and was off pressor during the later part of her stay in ICU. Early goal-directed therapy was employed and her MAP was maintained above 65, CVP above [**9-13**], UOP > 30cc/hr and ScvO2 > 70%. . # Anemia: Patient has chronic normocytic anemia, with baseline hct in the 25-30 range. During her stay in ICU, she was hemodynamically stable with no obvious sources of bleeding. B12, iron, folate studies were within normal limits. Patient's hematocrit was stable throughout her stay here in ICU and did not require an blood product transfusion. . # Mild metabolic alkalosis: Patient presented with mild metabolic alkalosis which was most likely due to contraction alkalosis. It resolved with IVF. . # T2 Paraplegia: Home pain regimen with baclofen, methadone and lyrica were continued. . # Depression: Outpatient management with Celexa 40mg was continued. . # Prophylaxis: Patient was put on subutaneous heparin for DVT prophylaxis. She received IV PPI for stress ulcer prevention. . # Code: Full (discussed with patient) . # Communication: Patient and husband [**Name (NI) **] were updated daily on patient progress. Medications on Admission: Baclofen 10 mg po tid Citalopram 40 mg po daily Methadone 5 mg po tid Levothyroxine 75 mcg po daily Omeprazole 20 mg po bid Pregabalin 75 mg po bid Pregabalin 75 mg po daily Calcium Carbonate 500 mg po tid Senna 8.6 mg [**Hospital1 **] prn constipation Docusate Sodium 100 mg po bid Clonazepam 2 mg Tablet po qhs Polyethylene Glycol po daily prn constipation Oxycodone-Acetaminophen 5-325 mg q8hrs prn pain Trazodone 50 mg po qhs Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) Injection TID (3 times a day). 2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Hospital1 **]: [**2-3**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day (2) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 4. Bismuth Subsalicylate 262 mg/15 mL Suspension [**Month/Day (2) **]: Fifteen (15) ML PO TID (3 times a day) as needed for dyspepsia. 5. Citalopram 20 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO DAILY (Daily). 6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 7. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Two (2) PO BID (2 times a day). 8. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. Methadone 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day). 10. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). 11. Oxycodone 5 mg/5 mL Solution [**Last Name (STitle) **]: One (1) PO Q4H (every 4 hours) as needed for pain. 12. Tramadol 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 13. Polyethylene Glycol 3350 17 gram/dose Powder [**Last Name (STitle) **]: One (1) PO DAILY (Daily) as needed for constipation. 14. Pregabalin 75 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2 times a day). 15. Baclofen 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day). 16. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: [**3-7**] PO Q6H (every 6 hours) as needed for fever, pain. 17. Clonazepam 1 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for anxiety/insomnia. 18. Acetylcysteine 20 % (200 mg/mL) Solution [**Month/Day (3) **]: 1-10 MLs Miscellaneous Q6H (every 6 hours) as needed for thick secretions. 19. Trazodone 50 mg Tablet [**Month/Day (3) **]: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 20. Clonazepam 1 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO QID (4 times a day). 21. Chlorhexidine Gluconate 0.12 % Mouthwash [**Month/Day (3) **]: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary - Klebsiella pneumonia Pulseless electrial activity (PEA) arrest Sepsis Secondary - Paraplegia Hypothyroidism Anemia of chronic disease Hepatitis C Discharge Condition: On trach with vent support. Failed speech and swallow so with dobhoff tube. Awake, alert, oriented, continued anxiety. Discharge Instructions: You were admitted to the hospital due to severe pneumonia. You had a prolonged hospital course complicated by respiratory failure and right lung collapse requiring a tracheostomy to be placed. Your medications have been changed. Please call you doctor or present to the Emergency Department if you develop worsening respiratory distress, shortness of breath, chest pain or any other symptom that concerns you. Followup Instructions: You should follow up with your primary doctor within one week after discharge from the rehab

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icd9cm

[ [ [] ] ]

[ "38.91", "96.71", "96.72", "31.1", "96.04", "33.24", "96.05", "38.93", "96.6", "93.90", "99.60" ]

icd9pcs

[ [ [] ] ]

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49894+59197

Discharge summary

report+addendum

Admission Date: [**2116-3-30**] Discharge Date: [**2116-4-7**] Date of Birth: [**2057-8-25**] Sex: F Service: TRANS [**Doctor First Name 147**] HISTORY OF PRESENT ILLNESS: This is a 58 year old woman with end-stage renal disease secondary to membranous glomerular nephritis. She has been on hemodialysis for the past four years previous to admission. She presented to [**Hospital1 346**] on [**2116-3-30**], for a kidney transplant when a donor organ became available. She has no history of peritoneal dialysis. She denies any recent chest pain, shortness of breath, change in bowel habits, evidence of melena or bright red blood per rectum. PAST MEDICAL HISTORY: 1. Hypothyroidism. 2. Hepatitis C. 3. End-stage renal disease on hemodialysis as described in the History of Present Illness. 4. Hypertension. 5. Status post hysterectomy in [**2110**]. MEDICATIONS ON ADMISSION: 1. Norvasc. 2. Zestril. 3. Renagel. 4. Quinine. 5. Nephrocaps. 6. Levoxyl. 7. B12. PHYSICAL EXAMINATION: On admission, Ms. [**Known lastname **] is a well appearing woman appearing her stated age. Temperature is 97.2 F.; pulse is 98; blood pressure is 198/80; respiratory rate is 18. Pupils were equal, round and reactive to light. Extraocular muscles are intact. Sclerae are anicteric. She has no jugular venous distention and no cervical lymphadenopathy. Her lungs are clear to auscultation bilaterally. Her heart is regular rate and rhythm without evidence of murmur. Her abdomen is soft, slightly distended without any evidence of organomegaly or ascites. Rectal examination is no masses and guaiac negative. Extremities are warm with palpable dorsalis pedis pulse bilaterally. HOSPITAL COURSE: Mrs. [**Known lastname **] was admitted to the Transplant Service and on the day of admission was brought to the Operating Room whereupon she received a cadaveric renal transplant. The procedure was performed by Dr. [**Last Name (STitle) **] assisted by Dr. [**Last Name (STitle) 104233**]. The procedure was performed under general anesthesia with an estimated 50 cc of blood loss. During the procedure she received 2.6 liters of Crystalloid and made 25 cc of urine. Please see previously dictated operative note for more details. The patient tolerated the procedure well, was extubated in the Operating Room and transferred to the Post-Anesthesia Care Unit. Mrs.[**Hospital 104234**] hospital course was relatively uncomplicated. After the Operating Room she was admitted to the Surgical Intensive Care Unit so that she could be monitored more closely in her postoperative period. On postoperative day one, she was transferred from the Intensive Care Unit to the Patient Care Floor without incident. She was placed on the standard regimen of immunosuppression therapy including CellCept starting at 1000 mg for the first three days and then titrated down to 500 mg thereafter. She was on a sliding steroid taper such that she was tapered down to 20 mg of Solu-Medrol and then Prednisone on postoperative day number seven. She will remain on the 20 mg a day. She received three doses of 100 mg of anti-Thymoglobulin, followed by two doses of 50 mg. She was started on Rapamune on postoperative day number five. During the rest of this hospitalization, she was slow to make urine and, in fact, required hemodialysis during her postoperative period. However, on postoperative day number six, she made 300 cc of urine. Mrs. [**Known lastname **] complained of epigastric discomfort for several days and, in fact, vomited on postoperative day number six. Because of this episode of nausea and vomiting, she was ruled out for myocardial infarction by serial enzymes. Also, an EKG was obtained which was unchanged from baseline EKG. She is on Protonix 40 mg p.o. q. day for her epigastric discomfort. On postoperative day number six, she complained of dysuria. For this, she was placed on Ciprofloxacin and started on a five day course. CONDITION AT DISCHARGE: Stable. DISCHARGE DISPOSITION: To home. DISCHARGE DIAGNOSES: 1. Status post cadaveric renal transplant. 2. Urinary tract infection. MEDICATIONS ON DISCHARGE: 1. Levoxyl 125 micrograms p.o. q. day. 2. Protonix 40 mg p.o. q. day. 3. Percocet 1 to 2 tablets p.o. q. four to six hours p.r.n. 4. Colace 100 mg p.o. twice a day. 5. Ganciclovir 500 mg p.o. q.o.d. 6. Bactrim Single Strength 1 tablet p.o. q. day. 7. CellCept [**Pager number **] mg p.o. four times a day. 8. Prednisone 20 mg p.o. q. day. 9. Rapamune 5 mg p.o. q. day. 10. Amphojel 30 mg p.o. q. eight hours. 11. Nystatin Swish and Swallow. 12. Ciprofloxacin 500 mg p.o. q. day. 13. Ditropan 5 mg p.o. twice a day. DISCHARGE INSTRUCTIONS: 1. The patient will follow-up with Dr. [**Last Name (STitle) **] in the Transplant Surgery Clinic. 2. Follow-up for her Rapamune levels, blood work has been arranged. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3598**], MD [**MD Number(1) 3599**] Dictated By:[**Last Name (NamePattern1) 6355**] MEDQUIST36 D: [**2116-4-7**] 18:25 T: [**2116-4-7**] 10:59 JOB#: [**Job Number **] Name: [**Known lastname 16846**], [**Known firstname **] W Unit No: [**Numeric Identifier 16847**] Admission Date: [**2116-3-30**] Discharge Date: [**2116-4-10**] Date of Birth: [**2057-8-25**] Sex: F Service: Transplant Surgery ADDENDUM: On the day prior to anticipated day of discharge, Ms. [**Known lastname **] began complaining of epigastric pain. The pain became very severe and was accompanied by emesis times one. A subsequent endoscopy on hospital day eight revealed a very large ulceration at the gastroesophageal junction. This was biopsied. At the time of discharge this pathology was not finalized. However, initial report supported changes consistent with acute esophagitis. There was no evidence of viral change. For this, she was treated with Protonix, and she was started on Valcyte 450 mg p.o. q.d. to cover both cytomegalovirus and herpes simplex virus. By postoperative 11, Ms. [**Known lastname **] was stable to tolerate adequate oral intake and was ready to be discharged to home. Additionally, during this interval, sensitivities from urine cultures previously sent revealed she had in fact grown out Enterobacter cloacae from her urine. This was sensitive to levofloxacin and ciprofloxacin. She was to be discharged home on 10 additional days of levofloxacin 250 mg p.o. q.d. All previously dictated medications, discharge diagnoses, and instructions remained the same except for the aforementioned changes. [**First Name4 (NamePattern1) 168**] [**Last Name (NamePattern1) 1030**], MD [**MD Number(1) 1031**] Dictated By:[**Last Name (NamePattern1) 2383**] MEDQUIST36 D: [**2116-4-9**] 19:26 T: [**2116-4-11**] 07:47 JOB#: [**Job Number **]

[ "070.51", "276.7", "530.2", "285.9", "041.85", "585", "599.0", "244.9", "530.12" ]

icd9cm

[ [ [] ] ]

[ "55.69", "45.16", "39.95" ]

icd9pcs

[ [ [] ] ]

4034, 4044

4065, 4139

4165, 4690

905, 996

1724, 3984

4714, 6907

1019, 1706

4000, 4009

190, 665

687, 879

82,202

179,900

9953

Discharge summary

report

Admission Date: [**2110-12-12**] Discharge Date: [**2110-12-17**] Date of Birth: [**2065-5-17**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3043**] Chief Complaint: Right flank pain. Major Surgical or Invasive Procedure: None History of Present Illness: 45 yo man with HIV/AIDS (last CD4 7 in [**10/2110**]) presenting with right lower thorax, pain for last 4-5 days. Pain is sharp, pleuritic, non-radiating. No diarrhea, hematuria, dysuria. Patient endorses decreased oral intake in last 5 to 6 days, though it is not clear why. Also with subjective fevers and chills relieved by acetaminophen. Also with headache in last week. History notably absent for any cough, sputum production, dyspnea, and chest pain. Was admitted to [**Hospital1 18**] from [**11-13**] to [**11-15**] for hypotension and fever attributed to PCP pneumonia as patient was thought to be non-compliant with prescribed treatment course. Was discharged on [**11-15**] with planned course of prednisone and Bactrim ending on [**11-21**], which he states he did take. He also states that shortly after discharge he had an episode of similar pleuritic chest pain and was evaluated in the ED (not at [**Hospital1 **]) and told everything was ok, after which the pain resolved. The pain then recurred. He denies other associated symptoms including cough, sob, fevers, chills, doe, leg swelling, nausea, vomitting, sore throat, myalgias, arthralgias. He denies sick contacts, lives alone, has not travelled. He has worked a few shifts at a gas station but denies being exposed to ill contacts via this. He is not fully aware of the names of his medications, and likely was not taking all of them but does claim to at least be taking some of them (see medication section for details). He does not recall taking bactrim at a ppx dose after completing treatment in [**Month (only) **]. He did receive a seasonal influenza vaccine, though did not get vaccinated for H1N1. Currently his pain is improved from presentation, rated [**2111-4-13**], for which he does not want medication. Upon presentation to the ED: T 99.4, HR 89, BP 123/73, RR 18, O2Sat 98% RA. CXR was concerning for multilobar pneumonia and thus patient was given Bactrim DS three tabs, prednisone 40 mg PO, Vancomycin 1 g IV, Cefepime 1 g IV, levofloxacin 750 mg IV. EKG was intially concerning for lateral ST segment elevations in setting of slight trop rise to 0.02 and thus cardiology was called. They felt EKG consistent with J-point elevation and trop likely attributable to decreased renal clearance. Patient was initially destined for medical floor bed and was seen by admitting hospitalist who was worried about tachypnea to 30s and thus patient was deemed to need ICU level of care. Vitals prior to transfer to the ICU were: HR 82, BP 128/68, RR 30, O2Sat 96% RA. In the ICU he remained stable, with mild tachypnea but no respiratry distress. He was continued on broad spectrum antibiotics, including vancomycin, cefepime, levofloxacin, osteltamivir, and bactrim. He had a flu swab and an induced sputum, but not until [**2110-12-13**] am. ROS: + for frontal HA without photophobia, meningismus or confusion for 10 days, constipation intermittently without blood or melena, last bm today, and rash on left arm since [**10-17**], unchanged, but otherwise negative except as noted above. Past Medical History: 1. HIV/AIDS, initially diagnosed in [**2102**], with a history of multiple OIs, last CD4 7, (1%), VL 453,000 2. Kaposi Sarcoma 3. CKD (baseline creatinine 1.5-2.0) 4. HIV-induced ITP 5. History of HBV infection 6. History of pericarditis with tamponade physiology (remote) 7. Disseminated histoplasmosis 8. PCP [**Name Initial (PRE) 11091**] [**10-17**], re-treated [**11-17**] Social History: Patient moved from [**Country 15800**] 8 years ago. He lives alone. He works as a cashier. Quit tobacco 3 years ago, previously smoked 3 cig/day x 15 years. 1 alcoholic drink/week. Denies past/current illicit drug use. Sister lives near by, other family still in [**Country 15800**]. Family History: Denies any family history. Physical Exam: VS: Tm 100.9 Tc 96.0 HR 81 BP 120/70, RR 28 O2Sat 89% RA -> 97% 2L GEN: Thin, well appearing man in NAD HEENT: PERRL, EOMI, oral mucosa moist, oropharynx benign NECK: Supple, JVP flat LYMPH: No post occipital, cervical chain, axillary, or inguinal [**Doctor First Name **] THORAX: Slightly tachypneic with shallow breathing, R>L bibasilar rales, decreased breath sounds at both bases, patient tender to palpation of lower right mid-axillary line, n wheezes or rhonchi, not using acceessory muscles CARD: RRR, nl S1, nl S2, no M/R/G ABD: BS+, soft, non-tender, non-distended, no rebound or guarding, no HSM, no CVA tenderness EXT: no C/C/E SKIN: Multiple scabbed lesions across extremities, back with scarring and skin hyperpigmentation NEURO: Oriented x 3, CN II - XII intact, BLE strength 5/5 PSYCH: Mood and affect appropriate Pertinent Results: Admit labs: CBC: WBC-1.5* HGB-12.5* HCT-37.3* RDW-16.8* PLT COUNT-268; diff: NEUTS-56 BANDS-0 LYMPHS-36 MONOS-4 EOS-0 BASOS-0 ATYPS-4* METAS-0 MYELOS-0 BMP: GLUCOSE-101 UREA N-16 CREAT-1.7* SODIUM-135 POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-23 LFT: ALT(SGPT)-9 AST(SGOT)-32 LD(LDH)-557* CK(CPK)-182* ALK PHOS-74 TOT BILI-2.6* LIPASE-34 [**Doctor First Name 33339**]-1.3 CK-MB-1 cTropnT-0.02* Coags: PT-12.8 PTT-26.3 INR(PT)-1.1 URINE: BLOOD-NEG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 RENAL EPI-0-2 ABG: PO2-118* PCO2-26* PH-7.47* TOTAL CO2-19* Micro: Blood cx pending x2 [**12-12**] CXR: Bilateral ill-defined patchy airspace opacities, most likely due to multifocal pneumonia; PCP should be considered in this HIV positive individual. ECG: NSR (76), nl axis, intervals, J P elevation V2, TWI V3-V6 (old). [**2110-12-15**] 1:36 pm Influenza A/B by DFA Source: Nasopharyngeal swab. **FINAL REPORT [**2110-12-15**]** DIRECT INFLUENZA A ANTIGEN TEST (Final [**2110-12-15**]): Negative for Influenza A. DIRECT INFLUENZA B ANTIGEN TEST (Final [**2110-12-15**]): Negative for Influenza B. Brief Hospital Course: 45 yo M with HIV/AIDS (last CD4 7 in [**10/2110**]) presenting with right flank pain for last three days. #. Pneumonia: Radiographically impressive, and likely his pleuritic chest pain co-relates with his infection. He is at high risk for recurrence of PJP given was not taking his prophylactic Bactrim and may or may not be compliant with his HAART and known to have very low CD4 (LDH also very elevated c/w PJP). Additionally at risk for CAP and was hospitalized within the past month so HAP. Was initially on broad spectrum antibiotics (including cefepime, vancomycin, levofloxacin, and oseltamivir). ID was consulted for assistance with management. DFA for flu was negative and oseltamivir was discontinued. Cefepime and vancomycin were also discontinued as he improved (and in the absence of any discovered bacterial etiologies). He will complete a 7 day course of levofloxacin for community-acquired pneumonia. He will continue on Bactrim until [**1-2**] along with a prednisone taper (40mg [**Hospital1 **] through [**12-17**], 40mg daily through [**12-22**], and 20mg daily through [**1-2**]). #. Right chest pain: Pleuritic, likley related to acute infection. Improved with treatment of pneumonia. #. HIV/AIDS: Recent CD4 of 7 ([**2110-10-31**]). High risk for OI, likely not taking [**Month/Day/Year 33337**] as prescribed including HAART and prophylaxis. He was continued on his home regimen of Atazanavir, Ritonavir, Tenofovir, and Zidovudine. Prophylactic azithromycin and itraconazole were continued, and he will require Bactrim prophylactically once he completes his treatment course. #. CKD: stage III, at recent baseline, monitor, renally dose [**Month/Day/Year 33337**]. #. Leukopenia: not neutropenic, stable, likley related to HIV vs. medications. #. Anemia: normocytic, at recent baseline though this is relatively new for him. Guaiac negative. #. Positive blood culture (coag negative Staph): From ED, likely contaminant. He was briefly continued on vancomycin, and all follow up blood cultures were negative. #. Electrolyte abnormalities. Sodium was borderline low (130 at discharge) and bicarbonate was low throughout the admission (18 at time of discharge; [**Month/Day/Year **] not elevated); no anion gap. He was encouraged to drink plenty of fluids, and this should be followed closely as outpatient. Full code. EMERGENCY CONTACT: [**Name (NI) **] [**Name (NI) 33342**], Mother ([**Telephone/Fax (1) 33343**]) Medications on Admission: 1) Nystatin 100,000 unit/mL Suspension 5 mL PO QID - states was taking 2) Azithromycin 1200 mg PO QSUN - does not recall taking 3) Betamethasone Dipropionate 0.05 % Cream [**Hospital1 **]:PRN - uses on left arm 4) Itraconazole 200 mg PO BID - thinks he was taking 5) Atazanavir 200 mg Two Capsule PO DAILY - thinks he was taking 6) Ritonavir 100 mg PO DAILY - thinks he was taking 7) Tenofovir Disoproxil Fumarate 300 mg Tablet PO DAILY - thinks he was taking 8) Zidovudine 100 mg Three Capsule PO BID probably not taking 9) Docusate Sodium 100 mg PO BID 10) Senna 8.6 mg PO BID 11) Trimethoprim-Sulfamethoxazole 160-800 mg Tablet PO DAILY (patient reports that he was not taking prophylactic dose after finishing treatment dose) Discharge Medications: 1. Cyanocobalamin 250 mcg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Itraconazole 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Disp:*120 Capsule(s)* Refills:*2* 4. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK ([**Doctor First Name **]). Disp:*8 Tablet(s)* Refills:*2* 5. Atazanavir 200 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 6. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Zidovudine 100 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day). 9. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: Two (2) Tablet PO Q8 HOURS () for 17 days: last day [**2111-1-2**]. Disp:*102 Tablet(s)* Refills:*0* 10. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO once a day: please start this medication on [**1-2**] after you finished taking 2 tablets three times per day. Disp:*30 Tablet(s)* Refills:*2* 11. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 2 days. Disp:*2 Tablet(s)* Refills:*0* 12. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day: take two tablets in the evening of [**12-17**]; then take 2 tablets once daily for five days (ending [**12-22**]); then take one tablet daily for 11 days (ending [**1-2**]). Disp:*22 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: PCP Pneumonia, HIV, chronic kidney disease. Discharge Condition: Stable vital signs, on room air. Discharge Instructions: You were admitted with pneumonia (pneumocystis pneumonia), please take all medications as prescribed and keep all follow up appointments. . We confirmed all your medications with your pharmacy. Please take all four of your HIV medications, in addition to the new medications prescribed. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1207**], MD Phone:[**Telephone/Fax (1) 4775**] Date/Time:[**2110-12-22**] 10:30 . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7449**], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2111-2-13**] 9:00

[ "285.29", "784.0", "518.82", "486", "V58.65", "585.3", "288.50", "176.1", "136.3", "V15.81", "276.1", "042", "510.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10990, 10996

6320, 8769

335, 342

11084, 11119

5054, 6297

11455, 11766

4162, 4190

9550, 10967

11017, 11063

8795, 9527

11143, 11432

4205, 5035

278, 297

370, 3444

3466, 3845

3861, 4146

15,046

116,990

50744

Discharge summary

report

Admission Date: [**2190-2-4**] Discharge Date: [**2190-2-22**] Date of Birth: [**2124-2-1**] Sex: F Service: MEDICINE Allergies: Tetracyclines / Zinc Attending:[**First Name3 (LF) 689**] Chief Complaint: Sepsis and respiratory failure Major Surgical or Invasive Procedure: Endotracheal intubation Placement of arterial line History of Present Illness: 59 year old female with a h/o Castleman's disease s/p splenectomy, recurrent aspiration PNA necessitating recent PEG placement on [**11-11**] who presents from [**Hospital1 599**] after her HHA called EMS for lethargy and altered mental status. Home health aide notes that pt had large watery bowel movement on the day of admission. States that pt has been eating cheesecake and pudding, though she is aware and has been instructed by multiple MDs to remain NPO due to aspiration. On EMS arrival, she was febrile to 102F, and hypotensive to 80/50 with HR 70-80s. After 300mL NS in the field, BP increased to 90s. . In the ED she had a temp of 101.1F, HR 78, RR 16, and BP 100/65 initially and was found to have a RLL PNA on CXR, with lactate of 2.5, given 4L NS for concern of early sepsis, developed worsening respiratory distress, desaturation to 88% on 4L, and was intubated. A left subclavian CVL was placed, she was found to have copious secretions, with frequent suctioning. She was given vancomycin, ceftriaxone, and flagyl in the ED after BCx were drawn Past Medical History: -Castleman's disease since [**2175**], followed by Dr. [**Last Name (STitle) 410**]. Hx mediastinal LAD, but these were FDG negative on [**2188**] PET. Also with diffuse centrilobular and tree-in-[**Male First Name (un) 239**] opacities on last couple of chest CTs, unchanged. Last seen by Dr. [**Last Name (STitle) 410**] [**3-7**], who did not wish to pursue biopsy of these nodes at that time. -s/p splenectomy -Hx of anaplastic thyroid cancer as adolescent s/p thyroidectomy and subsequent hypothyroidism -Esophageal web and dysmotility s/p esophageal dilation -Recurrent aspiration pneumonia; last admission [**Date range (1) 17594**], 5/13-5-20; s/p course of Imipenem for most recent episode; *[**5-22**] sputum culture grew [**Month/Year (2) **] -Chronic R olecranon bursitis and MRSA osteomyelitis of R olecranon s/p multiple debridement (most recent one on [**5-13**]) -Hx of MRSA pneumonia -Bipolar disorder with hx of suicide attempt -PVD -HTN -GERD, hx perforated ulcer in past -Seizure disorder (reportedly had generalized seizure several years ago assoc. with hypoglycemia, none since, no meds) -s/p R hip fracture with failed ORIF and redo at [**Hospital1 2025**] -hx of Grave's dz with ophthalmopathy -Osteoporosis -Herpes Zoster -PFT ([**2189-5-4**]) w/ restrictive pattern: FVC 62% FEV1 65% FEV1/FVC 105% Social History: Living at home with HHA. No [**Month/Day/Year **], no IVDU. Family History: NC Physical Exam: vitals on arrival to ICU: T 98.9 107/32 70 19 98% AC 450x16/1.0/10 PE: Gen: sedated, intubated HEENT: MM dry Neck: no JVD CV: RRR, nl S1/S2, no m/r/g Lungs: coarse breath sounds anteriorly Abd: soft, NT/ND, +BS, PEG in place with no surrounding erythema or drainage Extr: no edema, warm, bounding pulses Brief Hospital Course: # sepsis - Given history, this was thought to be most likely secondary to aspiration pneumonia, given thick white sputum suctioned on secretion, which grew strep pneumo, MRSA, and GNR which were ultimately speciated as klebsiella. Blood cultures were negative for growth on multiple occasions. Was on levophed for two days, which was then weaned off. Was also found to have an inadequate response to [**Last Name (un) 104**] stim test, and was given a seven day course of hydrocortisone and fludrocortisone. Completed 14-day course of vancomycin and zosyn. Initially treated with Levofloxacin as well for double-coverage of gram negative organisms, but was d/c'ed after consulting with infectious disease team. Was also initially empirically treated with flagyl for c. difficile colitis due to reported diarrhea prior to admission by her caretaker. Flagyl was d/c'ed after 3 days once stool samples were negative for c. diff x 3. Orthopedic surgery was also consulted after chest CT revealed a chronic sternoclavicular posterior dislocation with associated fluid collection. It was not thought that this was a source of infection, and ortho did not advise any intervention during this admission. Ms. [**Known lastname 14**] had significant improvement in her clinical status and, although Klebsiella sensitive only to carbapenems was ultimately speciated from her sputum approximately 10 days into her course,it was decided not to treat for this, since it did not appear to be clinically significant. Given pt's history of Castleman's disease, it was also recommended that Ms. [**Known lastname 14**] receive a pneumovax vaccination prior to d/c, given risk of sepsis with encapsulated organisms. . # hypoxic respiratory failure - Ms. [**Known lastname 14**] was initially intubated with hypoxic respiratory failure, thought to be due to aspiration pneumonia. Due to concerns that pleural effusions seen on chest Xrays and CT represented an empyema rather than transudative fluid secondary to aggressive fluid resuscitation, a R thoracentesis was done. Analysis of pleural fluid was consistent with a transudative etiology, and pleural fluid culture was negative for growth. After approximately a week of weaning and pressure support trials, Ms. [**Known lastname 14**] was extubated. Unfortunately, she quickly experienced hypoxia, dyspnea and stridor, and failed racemic epi and heliox. Pt initially indicated that she did not wish to be reintubated. After discussions with her and her power of attorney, however, it was ascertained that reintubation was acceptible to her, and this was quickly done. Given possible laryngeal edema as etiology, was placed on three days prednisone. She was also aggressively diuresed, as she was grossly overloaded for the course of stay due to aggressive volume resuscitation in response to sepsis, and failure to extubate was thought to be partly attributable to pulmonary edema. After three days, Ms. [**Known lastname 14**] was doing well on pressure support and several SBTs, and she was extubated. She did well following this, and was transferred to the floor satting well on 4L NC. . # Sedation: Ms. [**Known lastname 14**] was kept alert but comfortable with Versed and Fentanyl. This was weaned off once extubated. She experienced some mild signs and symptoms of narcotic withdrawal, and was placed back on a fentanyl drip transiently, and restarted on her home dose of fentanyl patch, which had been held during her early ICU course. Her fentanyl drip was then titrated to off. . # hypothyroidism - Ms. [**Known lastname 14**] was continued on her home dose of levothyroxine. . # Bipolar disorder - Was continued on her home doses of lamotrigine and venlafaxine . # FEN/GI - Ms. [**Known lastname 14**] received tube feeds through her PEG during the course of her stay. Nutrition service was consulted for assistance in monitoring her nutritional status. After extubation, she continued to be kept NPO secondary to aspiration risk. . # Access - An arterial line and L subclavian line were placed at admission. These were d/c'ed, and a PICC placed [**2-9**] for continued antibiotic delivery. Medications on Admission: 1. Levofloxacin 250 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q24H (every 24 hours). 2. Metronidazole 500 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO TID (3 times a day). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Metoclopramide 10 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 5. Senna 8.6 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a day) as needed. 6. Acetaminophen 325 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 7. Venlafaxine 37.5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a day). 8. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 9. Levothyroxine Sodium 100 mcg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 10. Ipratropium Bromide 0.02 % Solution [**Month/Year (2) **]: One (1) Inhalation Q6H (every 6 hours). 11. Albuterol Sulfate 0.083 % Solution [**Month/Year (2) **]: One (1) Inhalation Q6H (every 6 hours). 12. Amlodipine 5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 13. Atenolol 100 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 14. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Month/Year (2) **]: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 15. Gabapentin 300 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO HS (at bedtime). 16. Guaifenesin 100 mg/5 mL Syrup [**Month/Year (2) **]: 5-10 MLs PO Q6H (every 6 hours) as needed. 17. Enoxaparin 40 mg/0.4mL Syringe [**Month/Year (2) **]: One (1) Subcutaneous DAILY (Daily). 18. Polysaccharide Iron Complex 150 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO DAILY (Daily). 19. Zolpidem 5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO HS (at bedtime) as needed. 20. Fentanyl 75 mcg/hr Patch 72HR [**Month/Year (2) **]: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 21. Docusate Sodium 100 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO BID (2 times a day) as needed. 22. Oxycodone 5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q4H (every 4 hours) as needed. 23. Dolasetron 12.5 mg/0.625 mL Solution [**Month/Year (2) **]: One (1) Intravenous Q8H (every 8 hours) as needed. Discharge Disposition: Home With Service Facility: Caritas VNA Discharge Diagnosis: Primary - aspiration pneumonia, sepsis, respiratory failure, CHF Secondary - macrocytic anemia, hypothroidism Discharge Condition: 96% on 2L Discharge Instructions: - continue with medications as prescribed - DO NOT EAT BY MOUTH AS YOU ARE AT A HIGH RISK FOR ASPIRATION - call your PCP if you have any fevers Followup Instructions: Provider: [**Name10 (NameIs) **],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] & MINERAL-CC7 (SB) Date/Time:[**2190-3-22**] 11:30 Call your PCP to schedule an appointment. Completed by:[**2190-2-23**]

[ "244.0", "785.52", "427.1", "785.6", "443.9", "401.9", "296.7", "V44.1", "038.9", "584.9", "428.0", "530.81", "995.92", "507.0", "518.81" ]

icd9cm

[ [ [] ] ]

[ "96.72", "96.6", "96.04", "34.91" ]

icd9pcs

[ [ [] ] ]

9828, 9870

3253, 7401

309, 362

10025, 10037

10229, 10485

2897, 2901

9891, 10004

7427, 9805

10061, 10206

2916, 3230

239, 271

390, 1456

1478, 2804

2820, 2881

13,061

163,814

20502

Discharge summary

report

Admission Date: [**2118-1-26**] Discharge Date: [**2118-1-28**] Date of Birth: [**2069-1-2**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1973**] Chief Complaint: melena Major Surgical or Invasive Procedure: EGD (Endoscopic Gastroduodenoscopy) History of Present Illness: The pt is a 49M w/ new onset lightheadedness and melena. He had been having intermittent abdominal pain for about 2 months, describing an achy, cramping feeling in the periumbilical area. He had not had nausea or vomiting. He did note a metallic taste in his mouth. The pain was not relieved with food, and he only had mild relief with an antacid. Over the past several days the pain had somewhat intensified. He also notes during the past week episodes of dizziness, especially when he stands up. He went to play hockey but felt very short of breath and tired. No headaches, chest pain, palpitations. About five days ago he noticed very dark "ink blot"-colored stools which he has had since then. His last bowel movement was 11am today. He reports recent use of NSAIDs over the last 2-3 months, having taken 600mg Advil about twice a week on average for back pain. . In his PCP's office today, he had guaiac-positive stools. His Hct measured in the office was 29, down from a baseline of 42 one year ago. He was subsequently sent to the ED. . In the ED, 2 large bore IVs were placed. His Hct was 27.3. He was evaluated by GI who recommended immediate EGD, after which he was transferred to the [**Hospital Unit Name 153**]. On arrival to the [**Hospital Unit Name 153**], EGD was performed which showed 2 duodenal ulcers that were cauterized. 3U PRBC were hung, given Hct of 22.4 on arrival to the unit. Past Medical History: discectomy [**2114**] Social History: Married w/ 2 children. He is the CEO of a software company. He is a non-smoker, rare EtOH Family History: father with "stomach ulcers" Physical Exam: VS: 97.3, 103/66, 52, 20, 99 Gen: alert, interactive, NAD, pleasant gentleman in NAD HEENT: PERRL, EOMI, OP clear, MMM, anicteric Neck: supple, no JVD, no LAD Lungs: CTAB CV: RRR, nl S1S2, no m/r/g Abd: +BS, soft, nontender, nondistended, -R/G Ext: warm and well-perfused, no c/c/e, DP/PT pulses 2+ b/l Neuro: AAOx3, nonfocal Pertinent Results: CXR: normal EKG: NSR@66, nl axis, nl int, non-specific TWI lead III [**2118-1-28**] 07:25AM BLOOD WBC-8.9 RBC-3.79* Hgb-11.6* Hct-33.0* MCV-87 MCH-30.5 MCHC-35.1* RDW-15.2 Plt Ct-322 [**2118-1-27**] 04:14AM BLOOD WBC-9.8 RBC-3.32*# Hgb-10.4*# Hct-28.8*# MCV-87 MCH-31.4 MCHC-36.2* RDW-15.2 Plt Ct-267 [**2118-1-26**] 07:49PM BLOOD WBC-8.8 RBC-2.51* Hgb-7.8* Hct-22.4* MCV-90 MCH-31.0 MCHC-34.6 RDW-14.4 Plt Ct-298 [**2118-1-27**] 04:14AM BLOOD PT-13.3* PTT-29.5 INR(PT)-1.2* [**2118-1-28**] 07:25AM BLOOD Glucose-91 UreaN-11 Creat-1.2 Na-137 K-4.5 Cl-102 HCO3-28 AnGap-12 [**2118-1-28**] 07:25AM BLOOD Calcium-9.3 Phos-3.6 Mg-2.3 EGD: Esophagus: Normal esophagus. Stomach: Normal stomach. Duodenum: Mucosa: Localized erythema and nodularity of the mucosa with no bleeding were noted in the duodenal bulb compatible with duodenitis. Excavated Lesions A few cratered ulcers ranging in size from 2mm to 5mm were found in the posterior bulb and anterior bulb. A clot suggested recent bleeding. [**Hospital1 **]-CAP Electrocautery was applied for hemostasis successfully. Impression: Ulcers in the posterior bulb and anterior bulb (thermal therapy) Erythema and nodularity in the duodenal bulb compatible with duodenitis Brief Hospital Course: Patient admitted noted to have HCT 22 with melena, brought to ICU with appropriate recuscitation including 2 large bore IV's, IV hydration and 2units PRBC. An EGD was performed, which was sig for Duodenitis/Ulcers with Acute Blood Loss Anemia which were cauterized. Patient was observed in the ICU, with good response to transfusions. Patient required 1 further unit PRBC post procedure. No further bleeding was noted, patient was then transferred to floor. Repeat HCT's rose to 33. Patient placed on high dose PPI therapy. H. Pylori serologies, and Gastrin level Sent, both pending. I d/w PCP regarding [**Name Initial (PRE) **]/u of studies. Patient concerned about back pain, and NSAIDs so he was given tramadol as a trial with instructions on starting carefully. Medications on Admission: Meds: ASA 81 mg, Propecia Allergies: NKDA Discharge Medications: 1. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day for 3 weeks: Take 30-45 mins prior to meal. Disp:*42 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 2. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 30 doses. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Duodenitis with ulcer Low Back Pain Discharge Condition: Good Discharge Instructions: Return to the hospital if you experience lightheadedness, black tarry stools (although you may experience these for several days after the procedure), blood in the stool, nausea/vomitting, fevers or chills. Do not take NSAIDS (Motrin/Ibuprofen, Aleve/Naproxen, Aspirin) without talking with your doctor. Tylenol is safe We are given you some tablets of Tramadol (ultram) which can cause mild lightheadedness, you should not take your first dose in situations where this would be a problem until you see how you react Followup Instructions: Please make an appointment with your [**First Name8 (NamePattern2) **] [**Last Name (Titles) 903**],[**First Name3 (LF) 251**] J. [**Telephone/Fax (1) 904**] for the next 1-2 weeks. He will need to follow up your H. Pylori Tests

[ "E935.9", "285.1", "532.40" ]

icd9cm

[ [ [] ] ]

[ "99.04", "44.43" ]

icd9pcs

[ [ [] ] ]

4827, 4833

3600, 4369

321, 359

4912, 4918

2354, 3577

5485, 5716

1962, 1993

4461, 4804

4854, 4891

4395, 4438

4942, 5462

2008, 2335

275, 283

387, 1794

1816, 1839

1855, 1946

26,709

118,461

43001

Discharge summary

report

Admission Date: [**2179-8-24**] Discharge Date: [**2179-8-31**] Date of Birth: [**2118-2-26**] Sex: M Service: MEDICINE Allergies: Macrolide Antibiotics / Ambien Attending:[**First Name3 (LF) 2297**] Chief Complaint: fevers, chills Major Surgical or Invasive Procedure: Sacral decubitus ulcer debridment PICC line History of Present Illness: Mr. [**Known lastname 92808**] is a 61 M with a h/o of DM and recent epidural abscess due to MSSA s/p laminectomy and T2-T12 washout who comes in for workup of fever and leukocytosis at his rehab facility. Of note, at the time of his recent discharge from [**Hospital1 18**] on [**2179-7-27**] he had a WBC count of 16 with productive cough but was afebrile. He was transferred on nafcillin (Started [**7-18**] planned 6 week course). He was initially transferred to [**Hospital **] Rehab, but subsequently transferred to [**Hospital 100**] Rehab. The patient was feeling well until [**8-19**] when he developed fevers, shaking chills, and sweats. A CXR was obtained on [**8-19**] with questionable LLL "haziness" per report. Blood cultures from [**8-19**] reportedly grew coag negative staph in [**2-9**] bottles and vancomycin was administered. He was started on flagyl on [**8-19**] as well due to diarrhea. He had a repeat spine CT on [**8-20**] at [**Hospital1 112**] that by report did not show evidence of worsening infection. His RUE PICC line was removed on [**8-22**] and a midline was placed in the LUE on [**8-22**]. Levofloxacin and flagyl were added for additional empiric coverage, apparently on [**8-22**]. Over the weekend his temperature was as high as 102, and he experienced malaise with poor appetite. He has a foley catheter, but has not noticed any abdominal or suprapubic tenderness. He does have R sided back discomfort that dates to time of his operation in [**7-15**] and has not worsened. He has been incontinent since his previous hospitalization, with continuing loose stools that have been heme+. He denies any cough, headache, neck stiffness, photophobia, nausea, vomiting, rash. He does have decubitus buttock wounds that are painful. In the ED, he received 4L IVFs and given nafcillin, flagyl, ceftazidime, and vancomycin. Past Medical History: Epidural abscess [**7-15**] due to MSSA s/p laminectomy Diabetes MI s/p CABG 5 years PTA Chronic back pain neuropathy- unable to feel the bottom of his feet gout obstructive sleep apnea Social History: No EtoH since CABG, heavy smoker 50 years x 2ppd, lives with girlfriend. [**Name (NI) **] used intranasal cocaine, no IVDA Family History: non contributory Physical Exam: T 98.4 P 82 BP 107/58 RR 25 O2 95% 2L, 92% RA General: morbidly obese man in no acute distress, nontoxic appearing HEENT: sclera white, conjunctiva pink, oropharynx without lesions, PEARL, EOMI Neck: No adenopathy appreciated, supple CV: Regular rate S1 S2 I/VI SEM at base Pulm: Lungs clear on anterior exam Abd: Obese +BS, nontender, one linear superficial wound without exudate or significant erythema under panus Extrem: Hyperpigmented c/w venous stasis, 2+ pitting edema bilaterally. No peripheral stigmata of endocarditis Neuro: Alert and interactive, unable to move lower extremities, ~T10 sensory level to light touch, CN intact Back: large 20+ cm decubitus ulcer with black eschar . . Pertinent Results: [**2179-8-24**] 06:25AM GLUCOSE-90 UREA N-32* CREAT-1.1 SODIUM-140 POTASSIUM-3.5 CHLORIDE-103 TOTAL CO2-25 ANION GAP-16 WBC-19.1* RBC-3.07* HGB-8.6* HCT-27.1* MCV-88 MCH-27.9 MCHC-31.6 RDW-17.8* NEUTS-90.3* BANDS-0 LYMPHS-4.3* MONOS-2.6 EOS-2.5 BASOS-0.3 HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-1+ STIPPLED-1+ FRAGMENT-OCCASIONAL PLT SMR-HIGH PLT COUNT-498* URINE: COLOR-LtAmb APPEAR-Clear SP [**Last Name (un) 155**]-1.020 BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM URINE RBC-6* WBC-22* BACTERIA-MOD YEAST-FEW EPI-<1 URINE MUCOUS-RARE [**8-20**] WBC 17.1 90% N 0 bands noted, [**8-21**] WBC 16.6 89% N 0 bands noted, [**8-22**] WBC 16.5 90% N 0 bands noted, [**8-23**] WBC 20.7 [**8-24**] UA sm leuks, lg bld, tr prot, neg nitr, 6 rbcs, 22 wbc, mod bact [**8-23**] CXR IMPRESSION: Very limited study, which, in comparison to the series of recent studies dating to [**2179-7-13**], demonstrates no definite new airspace process. There is evidence of previous cardiac surgery with no gross CHF. [**8-20**] noncontrast CT spine due to study limitations can't exclude epidural abscess or mass effect, but no definite evidence of epidural abscess or high grade dural sac compression is present. small fluid collection in subQ tissues, ?small seroma. . CULTURE DATA [**8-27**] VRE from sacral ulcer (swab) [**8-27**] Tissue Bx: -- {KLEBSIELLA PNEUMONIAE, ENTEROCOCCUS SP., STAPHYLOCOCCUS, COAGULASE NEGATIVE, PSEUDOMONAS AERUGINOSA, GRAM NEGATIVE ROD #3, ENTEROCOCCUS SP.}; ANAEROBIC CULTURE-PRELIMINARY {ANAEROBIC GRAM NEGATIVE ROD(S)} . [**8-23**] C. diff negative x1 [**Hospital1 18**] [**8-23**] urine NGTD [**Hospital1 18**] [**8-23**] blood NGTD [**Hospital1 18**] [**8-22**] blood, from PICC: NGTD [**8-23**] stool: NGTD [**8-20**] C. diff negative x1 [**7-24**] C. diff negative [**7-21**] wound MSSA (ses to gent, oxacillin, bactrim; resistant to levoflox, erythromycin, penicillin) 6/5 blood MSSA ([**Last Name (un) 36**] to gent, oxacillin; resistant to levoflox, erythromycin) . ([**2179-8-21**]) ECG Sinus rhythm. Left axis deviation with left anterior fascicular block. Right bundle-branch block. Probable left atrial abnormality. Low QRS voltages in the precordial leads. Compared to tracing of [**2179-7-22**] frequent premature ventricular complexes have resolved. . ([**2179-8-27**]) CHEST X-Ray: The tip of the right IJ line lies in the lower SVC. The heart remains enlarged with evidence of prior CABG. No failure is seen. IMPRESSION: Right IJ line in lower SVC. ([**2179-8-31**]) WBC-15.7* RBC-3.07* Hgb-8.8* Hct-27.5* MCV-90 MCH-28.7 MCHC-32.0 RDW-17.0* Plt Ct-503* Neuts-87* Bands-1 Lymphs-5* Monos-3 Eos-1 Baso-0 Atyps-1* Metas-1* Myelos-1* Glucose-101 UreaN-20 Creat-0.7 Na-146* K-4.3 Cl-110* HCO3-31 AnGap-9 ALT-8 AST-9 LD(LDH)-251* CK(CPK)-38 AlkPhos-69 TotBili-0.2 BLOOD Calcium-7.9* Phos-3.3 Mg-2.0 . Brief Hospital Course: This 61M diabetic with recent history of MSSA epidural abscess is admitted for workup of fevers and leukocytosis while on nafcillin. (1) Fevers and leukocytosis -- Patient presented with complicated decubitus ulcer after laminectomy for an MSSA epidural abcess. He was treated empirically with broad spectrum antibiotics and underwent debriedment of his wound by plastic surgery. Therapy was narrowed after organisms were isoloated from the wound culture. Blood cultures however have no growth to date. His presentation is very concerning for osteomyelitis and Infectious diseases has recommended a prolonged treatment course of antibiotics. Initially, he was treated with vancomycin, meropenem and daptomycin, but after Vanc Resistant Enterococcus (VRE) was isolated, Infectious Diseases has recommended treating with a single [**Doctor Last Name 360**]; Tigecycline, loading dose of 100mg IV followed by 6 week course of Tigecycline 75mg IV, to be started at nursing home. Infection is clearly worsnened by fecal contamination. During admission, a mushroom rectal catheter was pleace which patient tolerated well. This is likely to improve would hygiene and may prevent surgical intervention to perform a diverting colectomy at this time with ongoing infection, malnutrition and challenging positioning restraints. Plastic surgery has been continuously involved in this case and did not recommed further debriedment during this hospitalization, but would like for patient to follow up in their clinic. *** Infectious diseases would like to have weekly labs drawn: CBC, ESR, CRP, BUN, Creatinine to be faxed to their office, ([**Telephone/Fax (1) 1353**]. They will also follow up in their outpatient clinic. . 2. Hypotension/Anemia: During procedure, patient became hypotensive and had Hct drop. He Received 3Units of PRBC, 2U FFP to correct a 5pt HCT drop (19.5). He was transfered to the MICU where he was quickly weaned off pressors and had stabilization of Hct. No further hypotension or signs of bleeding with stable Hct. . (3) Diarrhea/loose stools: A problem at presentation, now with Negative C diff and Mushroom catheter in place. . (4) Diabetes: Coverage was maintained with lantus and sliding scale regular insulin. . (5) CAD: We continued outpatient ASA, beta blocker and statin but held [**Last Name (un) **]. Will defer further management to outpatient primary care doctor. . (6) Chronic back pain: Pain was controlled with tylenol/oxycodone with good results. . (7) OSA: CPAP mask given every night but patient only tolerated it sporadically. Did not make any changes on outpatient settings. . (8) PPX: Ulcer prophylaxis with H2 blocker. DVT prophylaxis was achieved with weight adjusted Lovenox, 40mg SQ [**Hospital1 **] per published protocol by [**Last Name (un) 92809**] et [**Doctor Last Name **],(Obes [**Doctor First Name **] 12,[**2174**], 19-24). . (9) FEN: diabetic diet was maintained along with protein supplementation due to a low albumin on admission. . (10) Access: Right IJ was placed during admission in addition to left midline. The latter was replaced by a double lumen PICC line on ([**2179-8-31**]) . (11) Contact: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18933**], [**First Name8 (NamePattern2) 622**] [**Last Name (NamePattern1) 40027**] was contact[**Name (NI) **] at ([**Telephone/Fax (1) 92810**]. . (12) Code: Patient remained full code throughout admission Medications on Admission: Senna [**Hospital1 **] Acetaminophen 325mg Q4-6HPRN lactulose Q8H PRN Nicotine patch Famotidine Nystatin PO qid Morphine SR 60mg [**Hospital1 **] Morphine 15mg Q4-6hrs Lasix 40mg daily Nafcillin 2gm IV Q4H Metoprolol 50mg TID Zolpidem 10mg QHS Heparin TID Lidocaine patch Ipratropium Q4-6H Insulin glargine and regular sliding scale. Metoprolol tartrate 50mg TID Zolpidem 10mg QHS PRN Lidocain patch Albuterol Q4H PRN Ipratropium Bromide Discharge Medications: 1. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 4. Sodium Hypochlorite 0.5 % Solution Sig: One (1) Appl Miscellaneous ASDIR (AS DIRECTED). 5. Daptomycin 1600 mg IV Q24H VRE 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 7. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 8. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 10. Meropenem 1000 mg IV Q6H 11. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO DAILY (Daily) for 14 days. 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 15. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 16. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 17. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for pruritis. 19. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous at bedtime. 20. Regular Insulin Sliding Scale Regular Insulin Sliding Scale 21. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 22. Tigecycline 50 mg Recon Soln Sig: Two (2) Recon Soln Intravenous ONCE (Once) for 1 doses. 23. Tigecycline 50 mg Recon Soln Sig: 1.5 Recon Solns Intravenous Q12H (every 12 hours) for 6 weeks: 75mg twice a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: PRIMARY: 1. sacral decubitus ulcer 2. ESBL UTI 3. hypotension 4. anemia SECONDARY - Epidural abscess [**7-15**] due to MSSA s/p laminectomy - incontinent of urine and stool now, unable to move lower extremities with ~T10 sensory level - Diabetes - MI s/p CABG 5 years PTA - Chronic back pain - neuropathy- unable to feel the bottom of his feet - gout - obstructive sleep apnea Discharge Condition: hemodynamically stable, afebrile Discharge Instructions: You were admitted for a sacral decubitus ulcer. You will be treated with antibiotics which you will continue when you are at rehab. Please take all medication as prescribed. Keep all appointments listed below. If you have any medical questions or concerns, please call your doctor. If you have fever, you need to call your doctor or go to the emergency room. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] your [**Last Name (STitle) 3390**]: [**Name Initial (NameIs) 3390**]: [**Last Name (LF) **],[**First Name3 (LF) 569**] S [**Telephone/Fax (1) 16963**] Please make an appointment within 2 weeks. Please follow up with Infectious Disease. Please see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] who saw you in the hospital: Friday [**9-10**] at 10:30am. [**Last Name (NamePattern1) 54538**]. Please follow up with Neurosurgery about your epidural abscess: Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 9151**], MD Phone:[**Telephone/Fax (1) 1669**] Date/Time:[**2179-9-7**] 10:00 . Please have weekly labs drawn and faxed as requested above (please see brief hospital course, problem 1).

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icd9cm

[ [ [] ] ]

[ "38.93", "99.04", "83.45", "93.90", "77.49", "99.07" ]

icd9pcs

[ [ [] ] ]

12165, 12231

6306, 9731

306, 352

12653, 12688

3356, 6283

13100, 13887

2608, 2626

10220, 12142

12252, 12632

9757, 10197

12712, 13077

2641, 3337

252, 268

380, 2242

2264, 2452

2468, 2592

4,784

185,700

17385

Discharge summary

report

Admission Date: [**2112-7-25**] Discharge Date: [**2112-8-2**] Date of Birth: [**2052-12-3**] Sex: M Service: CARDIAC SURGERY HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This is a 59-year-old gentleman who presented to an outside hospital in [**2112-5-5**] with a dry cough, found to be in atrial flutter. Further workup revealed endocarditis with vegetations on his mitral valve and severe mitral regurgitation. Subsequent blood cultures were positive for corynebacterium. The patient was treated with IV antibiotics and referred to Dr. [**Last Name (Prefixes) **] for replacement of his mitral valves. Cardiac catheterization showed mild pulmonary hypertension and no significant coronary artery disease. Echocardiogram showed an ejection fraction of greater than 55%, mildly thickened aortic leaflets, trace aortic insufficiency, mitral valve leaflets mildly thickened, moderate sized vegetations on the anterior leaflet of the mitral valve, 4+ mitral regurgitation and 1+ tricuspid regurgitation. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Rheumatoid arthritis. 4. History of bacterial endocarditis. 5. Mitral valve prolapse. 6. Recent onset of atrial flutter. PREOPERATIVE MEDICATIONS: 1. Sulindac. 2. Plaquenil. 3. Arrova. 4. Prednisone prn. 5. Lipitor. 6. Lasix. 7. Toprol XL. 8. Lisinopril. 9. Amiodarone. ALLERGIES: Penicillin and sulfa, both of which cause rash. PREOPERATIVE PHYSICAL EXAMINATION: This is a well-nourished and well-developed male in no apparent distress, appears slightly younger than stated age. Skin is without rashes or lesions. HEENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Normal mucosa, normal dentition. Neck is supple without jugular venous distention. No thyromegaly. Chest was clear to auscultation bilaterally, no wheezes, rales, or rhonchi. Heart is regular, rate, and rhythm, S1, S2 with 3/6 systolic murmur heard best at apex, no rubs. Abdomen is soft, nontender, nondistended, no guarding, rebound, or rigidity. Extremities are warm, no edema, no cyanosis. Cranial nerves II through XII are grossly intact. No motor or sensory deficits. HO[**Last Name (STitle) **] COURSE: The patient was admitted to [**Hospital1 346**] on [**2112-7-25**] for a minimally invasive mitral valve replacement with Dr. [**Last Name (Prefixes) **]. Patient had a 33 mm mosaic porcine valve placed through a minimally invasive surgery. Patient tolerated the procedure well. Please see operative note for further details. The patient was transferred to the Intensive Care Unit on a Neo-Synephrine drip. Patient was weaned the next day from mechanical ventilation on his first postoperative evening. The Neo-Synephrine was weaned. In the afternoon of postoperative day #1, the patient converted from sinus rhythm to atrial flutter, which he tolerated well. Patient's chest tubes were removed without incident. Patient was transferred from the Intensive Care Unit to the regular floor on postoperative day #2. On postoperative day #3, the patient ambulated with Physical Therapy and was able to walk 500 feet and climb one flight of stairs, was cleared for discharge to home from a Physical Therapy standpoint. On postoperative day #3, the Electrophysiology Service was consulted for patient's atrial flutter. Their recommendation was for the patient to be taken to the Catheterization Laboratory for a flutter ablation and cardioversion. Patient was on Heparin infusion at this time for anticoagulation. The patient was taken to the Catheterization Laboratory on postoperative day #4, where he underwent A-flutter ablation and conversion into sinus rhythm with first degree A-V block. The patient tolerated the procedure well. The Electrophysiology Service recommended discontinuing the patient's amiodarone after the flutter ablation due to his age, they felt that it would be better if the patient were on an anti-arrhythmic with fewer long-term side-effects. However, since the patient's electrocardiogram at that time showed sinus rhythm, first degree A-V block with a right bundle branch block plus or minus a left anterior fascicular block, it was decided that patient would not be placed on any anti-arrhythmics at this time and will follow up with his cardiologist, Dr. [**Last Name (STitle) 1295**] in one month for further monitoring of his rhythm and further decisions about his rhythm would be made by Dr. [**Last Name (STitle) 1295**]. It is also recommended that if the patient required further anti-arrhythmic therapy, the patient should be considered for a permanent pacer for his A-V node conduction delay. The patient was restarted on Heparin and Coumadin was begun for anticoagulation. By postoperative day #8, patient's INR was therapeutic at 2.2, and the patient was cleared for discharge to home. CONDITION ON DISCHARGE: Pulse 82 sinus rhythm with first degree A-V block, blood pressure 100/64, respiratory rate 14 and on room air oxygen saturation 96%. Neurologically, the patient is alert, awake, oriented x3. Heart is regular, rate, and rhythm without murmur or rub. Lungs are clear bilaterally without wheezes, rales, or rhonchi. Abdomen is soft, nontender, nondistended. Patient is tolerating a regular diet. The incision in his right chest is clean and dry without erythema. The Steri-Strips are intact. LABORATORY DATA: White blood cell count 7.4, hematocrit 31.4, platelet count 319. Sodium 143, potassium 4.2, chloride 109, bicarb 27, BUN 16, creatinine 1.0, glucose 88. PT 18.2, INR of 2.2. Patient has no peripheral edema. DISCHARGE DIAGNOSES: 1. Status post minimally invasive mitral valve replacement with a 33 mm mosaic valve. 2. Postoperative atrial fibrillation/atrial flutter. 3. Status post atrial flutter/ablation. DISCHARGE MEDICATIONS: 1. Colace 100 mg po bid. 2. Zantac 150 mg po bid. 3. Aspirin 81 mg po q day. 4. Percocet 5/325 1-2 tablets po q4h prn. 5. Lipitor 20 mg po q day. 6. Coumadin 2.5 mg po on [**8-2**] and [**8-3**]. INSTRUCTIONS: The patient is to followup with Dr.[**Name (NI) 39613**] [**Hospital 197**] Clinic on [**8-4**] for PT/INR and further Coumadin dosing. The patient is not being discharged home on any beta blockers or anti-arrhythmics. Patient is to followup with Dr. [**Last Name (STitle) 1295**] in two weeks, and at that time patient will be evaluated for initiation of this therapy. CONDITION ON DISCHARGE: Good. FO[**Last Name (STitle) **]: The patient is to followup with Dr.[**Name (NI) 39613**] [**Hospital 197**] Clinic on [**8-4**] at 11 am. Patient is to followup with Dr. [**Last Name (STitle) 1295**] in two weeks, and the patient is to followup with Dr. [**Last Name (Prefixes) **] in one month. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 16172**] MEDQUIST36 D: [**2112-8-2**] 10:08 T: [**2112-8-2**] 10:09 JOB#: [**Job Number 48632**]

[ "E878.2", "426.11", "714.0", "997.1", "401.9", "416.8", "427.32", "427.31", "424.0" ]

icd9cm

[ [ [] ] ]

[ "35.23", "37.26", "37.34", "37.27", "39.61", "89.68" ]

icd9pcs

[ [ [] ] ]

5662, 5842

5865, 6450

1251, 1449

1472, 4891

1058, 1225

6475, 7041

16,718

191,175

25828

Discharge summary

report

Admission Date: [**2128-7-14**] Discharge Date: [**2128-7-16**] Date of Birth: [**2054-5-10**] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 1145**] Chief Complaint: STEMI Major Surgical or Invasive Procedure: Cardiac Catheterization s/p 2 stents placed to mid LAD and PTCA to LCx History of Present Illness: HPI: 74 yo man with PMH significant for CAD s/p MI and PTCA [**34**] years ago and HTN presented to ED c/o vague epigastric discomfort since 1 pm on [**7-13**], which gradually spread across chest and was [**10-25**] sharp in quality. Patient called 911. In ED, was able to be made pain-free with SLNTG. Afterwards, SBP dropped to 80s, but initial EKG without ischemic changes and 1st set CEs negative. While in ED, developed sudden onset of sharp L-sided CP, different from presenting abdominal pain. Patient was diaphoretic and SBP down to 70s. New EKG showed STE anteriorly --> given fluid boluses and aspirin, plavix, morphine, heparin gtt, integrillin gtt and brought to cath lab. Temporary Wenkebach noted (no rhythm strips available). In cath lab, given 1 mg Atropine with improvement in BP and HR but converted to A fib per cath report. Cath revealed 2VD with mLAD 80% s/p 2 cypher stents and dLCx 80-90% s/p PTCA. RHC showed RA 10, RV 45/10, PCWP 22, CO 4.5, CI 2.3 L/min/m2 and LVEF 45-50%. Angioseal placed. Patient denied CP, SOB after cath. . ROS negative for DOE, orthopnea, PND or LE edema. Past Medical History: PMH: - HTN - CAD s/p MI with PTCA ? to PDA in [**2117**] - GERD (hiatal hernia x 35 years) - MVP - PVCs, ectopy - seminoma s/p L orchiectomy Social History: - lives in [**Location 49506**], here in [**Location (un) 86**] visiting son. Originally from South [**Country 480**]. Denies tobacco use, occ EtOH. - walks 3 km 3x/week Family History: - Father CAD s/p MI and death age 76 - Mom - colon CA age 81 - Sister - CAD - Brother - HTN Physical Exam: T 97.7 BP 116/52 HR 84 15 100% on 2L NC Drips: integrillin GEN - NAD, A&Ox3 HEENT - PERRL, EOMI, OP clear NECK - JVD 10 cm, supple, no LAD HEART - regularly irregular, normal rate, no mrg LUNGS - CTAB anterlaterally ABD - soft, NT/ND, NABS EXT - no edema . Pertinent Results: [**2128-7-14**] 08:21PM LACTATE-1.6 [**2128-7-14**] 05:13PM GLUCOSE-124* UREA N-11 CREAT-0.8 SODIUM-135 POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-22 ANION GAP-13 [**2128-7-14**] 05:13PM CK(CPK)-1747* [**2128-7-14**] 05:13PM CK-MB-142* MB INDX-8.1* cTropnT-3.15* [**2128-7-14**] 05:13PM CALCIUM-8.0* PHOSPHATE-2.8 MAGNESIUM-1.8 [**2128-7-14**] 05:13PM HCT-31.4* [**2128-7-14**] 11:00AM CK(CPK)-2602* [**2128-7-14**] 11:00AM CK-MB-258* MB INDX-9.9* cTropnT-6.41* [**2128-7-14**] 11:00AM PLT COUNT-228 [**2128-7-14**] 01:12AM ALT(SGPT)-41* AST(SGOT)-195* CK(CPK)-2123* ALK PHOS-67 AMYLASE-74 TOT BILI-0.8 [**2128-7-14**] 01:12AM LIPASE-24 [**2128-7-14**] 01:12AM WBC-11.2* RBC-4.05* HGB-12.3* HCT-35.2* MCV-87 MCH-30.3 MCHC-34.8 RDW-13.2 [**2128-7-13**] 07:40PM D-DIMER-360 [**2128-7-13**] 07:40PM PT-12.6 PTT-27.7 INR(PT)-1.1 CXR [**2128-7-13**] IMPRESSION: No evidence of an acute cardiopulmonary abnormality. EKG [**2128-7-13**] Sinus rhythm Bigeminal PACs Left axis deviation Lateral ST-T changes are nonspecific No previous tracing EKG [**2128-7-13**] Sinus rhythm Ventricular couplets Long QTc interval Left axis deviation Intraventricular conduction delay Anterior ST segment elevation may be due to injury Lateral ST-T changes offer additional evidence of ischemia Changes may be due to metabolic effect Since previous tracing of [**2128-7-13**], ST segment elevation and ventricular premature complex are new Clinical correlation is suggested Catherterization [**2128-7-13**] 1. Coronary angiography of this right dominant system revealed severe two vessel coronary artery disease. The left main coronary artery had a 20% stenosis. The LAD had an 80% stenosis in the mid-vessel and a small D2 had an 80% ostial stenosis. The LCX had a 90% stenosis in the mid to distal segment. The RCA had mild diffuse luminal irregularities. 2. Resting hemodynamics revealed mildly to moderately elevated right sided filling pressures (mean RA pressure was 8 mm Hg and RVEDP was 12 mm Hg). Pulmonary artery pressures were mildly to moderately elevated (PA pressure was 40/20 mm Hg). Left sided filling pressures were moderately elevated (mean PCW pressure was 22 mm Hg and LVEDP was 25 mm Hg). Central arterial pressure was normal (aortic pressure was 121/76 mm Hg). Cardiac index was mildly depressed (at 2.3 L/min/m2). There was no significant gradient upon pullback of the catheter from the left ventricle to the ascending aorta. 3. Left ventriculography revealed an ejection fraction of 45% with anterolateral hypokinesis. No mitral regurgitation was noted. 4. Successful PTCA and stenting of the LAD with two overlapping 3.0 mm Cypher drug-eluting stents. Final angiography showed no residual stenosis, no dissection and normal flow (see PTCA comments). 5. Successful PTCA of the LCX with a 2.0 mm balloon. Final angiography showed a 20% residual stenosis, no dissection and normal flow (see PTCA comments). 6. Successful closure of right femoral arteriotomy with AngioSeal device. ECHO [**2128-7-14**] 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. Moderately depressed LVEF. No resting LVOT gradient. No LV mass/thrombus. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic root diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is moderately depressed with hypokinesisi of the mid to distal anterior wall, septum and apex. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No 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. IMPRESSION: Moderately reduced LVEF will regional dysfunction c/w CAD [**2128-7-14**] Abdominal U/S IMPRESSION: 1. No abdominal aortic aneurysm. 2. The gallbladder contains tiny echogenic foci, some of which likely represent polyps, but a few of which may represent tiny stones. The gallbladder is otherwise unremarkable. 3. Probable cyst at the liver dome. 4. Simple cyst of the left kidney. [**2128-7-14**] Abdominal CT CT OF THE ABDOMEN WITHOUT CONTRAST: There are small bilateral pleural effusions with minimal bibasilar atelectasis. There are calcifications seen along the pleural surface of the right lung base suggesting prior infection. The visualized heart and pericardium are unremarkable. A low-density rounded focus is seen within the lateral right lobe of the liver which is suspicious for a neoplastic implant. A small calcification is seen within the dome of the liver posteriorly, likely residual of prior granulomatous infection. No suspicious lesions are identified within the liver. The gallbladder is filled with oral contrast and is unremarkable. The stomach wall appears mildly thickened. The spleen, adrenal glands, and intra- abdominal loops of small and large bowel are unremarkable. There is fullness in the tail of the pancreas. The left kidney contains a rounded low- density focus, likely a cyst. The right kidney is unremarkable. Neither kidney displays hydronephrosis. There is no pathologically enlarged mesenteric or retroperitoneal lymphadenopathy. There is no free air or free fluid within the abdomen. Calcifications are seen within the abdominal aorta and its branches. CT OF THE PELVIS WITH CONTRAST: The rectum, sigmoid colon, distal ureters, bladder, prostate, and seminal vesicles are unremarkable. There is no evidence for free or focal fluid, such as a retroperitoneal hematoma. There is no pathologically enlarged inguinal or pelvic lymphadenopathy. Again, calcifications are seen within the arterial vasculature. BONE WINDOWS: There are no suspicious lytic or blastic osseous lesions. CT REFORMATS: Coronal and sagittal reformatted images confirm the axial findings. IMPRESSION: 1. No evidence for retroperitoneal hematoma or evidence of bleeding within the abdomen or pelvis to explain the patient's dropping hematocrit. 2. Small subcapsular implant within the liver which is suggestive of a metastatic disease. In the context of a thickened gastric wall, this is concerning for gastric carcinoma. Furtehr evalyuation with endoscopy or upper GI is recommended. 3. Fullness within the pancreatic tail. A mass cannot be excluded on this no- contrastenhanced examination and contrast enhanced CT scan is recommended to definitively characterize this. 4. Small bilateral pleural effusions with minimal bibasilar atelectasis. Brief Hospital Course: 1) STEMI - Mr. [**Known lastname 951**] presented with epigastric pain that evolved to 10/10 chest pain, treated with SLNG. The chest pain recurred, accompanied by sweating and hypotension, and he was noted to have ST elevations in anterior leads and increased troponins. He was taken emergently to cath where he was found to have 2 vessel disease with mLAD 80% stenosis s/p 2 cypher stents and dLCx 80-90% stenosis s/p PTCA. RHC showed mildly elevated filling pressures and normal CO/CI, with a LVEF of 45-50% (see report). Post cath course was complicated by hypotension and bradycardia, though to be d/t vagal surge, and required atropine to maintain hemodynamics. CK peaked at 2602. Patient was placed on appropriate CAD medications including ASA, atorvastatin, metoprolol, captopril, and plavix. No anticoagulation was intitiated d/t an EF >40. 2) Epigastric pain - Mr. [**Known lastname 951**] presented initially with epigastric pain, but this resolved during cath. The pain returned shortly after catheterization, accompanied by nausea, bradycardia, and hypotension. Laboratory evaluation of the epigastric pain revealed normal transaminases, amylase, and lipase. An abdominal U/S was unremarkable. Stress dose PPI's gave little relief, and continued epigastric pain in the setting of a falling HCT precipited an abdominal CT, which demonstrated no RP hematoma or evidence of bleed. However, a lesion within the liver was documented, as well as a thickened gastric wall and fullness within the pancreatic tail (see reports). The findings were discussed with the patient and it was decided that he would follow up with his PCP in [**Name9 (PRE) 49506**] to further evaluate the abdominal CT findings. At the time of discharge the patient was pain free on a pantoprazole 40 mg PO and sucralfate. 3) FEN - Hyponatremia to a Na of 130 was thought to be d/t either SIADH in the setting of acute pain/epigastric discomfort (supported by Uosm>100) or dehydration (UNa>20). The patient was free water restricted and monitored closely and his Na had improved by discharge. No symptoms of hyponatremia noted. Mr. [**Known lastname **] diet was progressed slowly after resolution of epigastric discomfort, and he was couseled regarding the importance of a heart healthy diet. 4) Code - Full 5) Dispo - PT saw the patient prior to discharge. He will go home with family and return to [**Location (un) 49506**] in approximately 1 week, where he will follow up with his own physicians regarding his cardiac and GI issues. Medications on Admission: Aspirin 75 mg po qd Norvasc 5 mg po qd Zantac prn Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 7. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: STEMI with 2 vessel disease to LAD and LCx Discharge Condition: Good Discharge Instructions: 1) Please take all of your medications as prescribed 2) Please call if you have chest pain, worsening shortness of breath while active, shortness of breath at rest, weight gain > 5 lbs, edema of lower extremeties, fever, or worsening epigastric pain. Followup Instructions: 1) Cardiology - Make an appointment with your cardiologist at home in [**2-19**] weeks to discuss all of your medications and any symptoms that you may have. 2) PCP [**Name Initial (PRE) **] [**Name10 (NameIs) **] an appointment with your PCP at home in [**2-19**] weeks to discuss any symptoms that you may have, as well as the findings on abdominal CT scan so that you may decide if further workup is warranted/desired.

[ "410.11", "275.3", "V17.3", "997.1", "427.89", "V16.0", "285.9", "412", "V45.77", "793.4", "530.81", "458.29", "E879.0", "V45.82", "401.9", "276.1", "414.01" ]

icd9cm

[ [ [] ] ]

[ "37.23", "88.53", "36.05", "36.07", "99.20", "88.56" ]

icd9pcs

[ [ [] ] ]

13104, 13110

9611, 12151

302, 375

13197, 13203

2279, 9588

13503, 13928

1891, 1985

12251, 13081

13131, 13176

12177, 12228

13227, 13480

2000, 2260

257, 264

403, 1521

1543, 1686

1702, 1875

20,577

115,141

47892+59039

Discharge summary

report+addendum

Admission Date: [**2184-4-21**] Discharge Date:[**2184-4-27**] Date of Birth: [**2125-5-16**] Sex: M Service: [**Location (un) 259**] MEDICINE CHIEF COMPLAINT: Fevers and chills, called out from Surgical Intensive Care Unit on [**4-23**]. HISTORY OF PRESENT ILLNESS: This is a 58 year-old male with a history of end stage renal disease on hemodialysis, history of chronic right foot infections, status post left below knee amputation and a history of thrombosed right upper extremity AV fistula, status post left IJ tunnel PermaCath with a history of GI bleed and ischemic colitis, History of IVDU who was initially admitted from the hemodialysis center as an outpatient where developed fevers, hypotension and altered mental status. He was subsequently admitted to the Intensive Care Unit where he received intravenous fluids and Dopamine drip for less than 12 hours. The patient was pancultured at the time for suspected sepsis and blood cultures on [**4-21**] grew out 2 out of 4 bottles showing gram positive cocci in pairs and clusters and a foot culture with gram stain showing 3+ positive cocci and 2+ gram negative rods. In addition, his right foot was noted to be malodorous with pus and he is treated empirically with Vancomycin and meropenem and one dose of ceftazidime. Podiatry was consulted and recommended right foot amputation, but patient adamantly refused and so was subsequently transferred to the floor medicine team, with further evaluation from podiatry and possible surgical foot debridement. Patient also had chronic left shoulder pain. Shoulder and neck films in the unit showed that the patient had no acute pathology that explained the shoulder pain. On the morning of transfer the patient was being dialyzed. He wa s awake, alert and had no complaints of shortness of breath, chest pain, light headedness or dizziness. Patient notes chronic left shoulder pain with no radiation. Denies night sweats, fevers or chills. Denies nausea, vomiting or diarrhea. PAST MEDICAL HISTORY: 1) End stage renal disease on hemodialysis. 2) History of thrombosed right upper extremity AV fistula. 3) Status post left IJ PermaCath tunneled. 4) Diabetes mellitus type 2. 5) Hepatitis B. 6) Hypertension. 7) Ischemic colitis with GI bleed. 8) Tuberculosis in the past. 9) Status post left below knee amputation. 10) Multiple right foot infections. 11) History of drug use. 12) Congestive heart failure with an ejection fraction of 55 percent and normal wall motion. 13) History of VR and MRSA. MEDICATIONS ON ADMISSION: Norvasc 10 mg p.o. q day, multivitamin, folate 1 mg p.o. q day, Renagel 800 mg p.o. t.i.d., NPH 40 units q P.M., 60 units q A.M., insulin sliding scale, Epogen 30,000 units subcutaneous three times weekly, Vicodin p.r.n., aspirin 81 mg p.o. q day, Coumadin 1 mg p.o. q day, Protonix 40 mg p.o. q day, Neurontin 100 mg p.o. b.i.d. and methadone 100 mg p.o. q day. PHYSICAL EXAMINATION: Temperature 97.9, blood pressure 128/78, heart rate of 90, respiratory rate of 16, satting 98 percent on room air. In general, this was a gentleman who was awake, alert on hemodialysis, chronically ill appearing in no apparent distress. Oropharynx is clear. No jugular venous distention, no masses in the neck. Chest: Tunneled right catheter with dressing clean, dry and intact. Decreased breath sounds bilaterally. Coronary regular rate and rhythm. Abdomen soft, nontender, nondistended, positive bowel sounds. Extremities: Status post left below knee amputation. Right foot with 3+ edema with dressing clean, dry and intact. Neurologic alert and oriented times three, moved all extremities spontaneously. HOSPITAL COURSE: 1. Sepsis: Patient was transferred to the Intensive Care Unit after three days for hypotension. Patient was resuscitated with intravenous fluids as well as Dopamine for less than 12 hours as above. Culture data showed bacteremia that was persistent. The patient was maintained on Vancomycin dose by levels and meropenem. Patient underwent a foot debridement on [**4-23**] by podiatry for further evaluation and debridement of his wound. Podiatry had recommended a right foot amputation for optimal control. However, the patient adamantly refused and did not want his other foot amputated as well. Patient up to the date of this discharge summary had no growth to date on his surveillance cultures from [**4-23**] and [**4-25**]. 2. Right foot infection: Podiatry was managing this patient in terms of his foot infection. The patient underwent operating room surgical debridement on [**4-23**] that was uncomplicated. Cultures are still pending. The patient was maintained on Vancomycin and Meropenem. 3. End stage renal disease on hemodialysis: Renal was consulted in management of this patient. Patient was dialyzed Monday, Wednesday and Friday, was continued on phos lowering agents. Patient was also maintained on 1 mg of Coumadin at night for prophylactic use for his tunnel catheter. 4. Diabetes mellitus: The patient was maintained on his NPH. [**Last Name (un) **] was consulted in management of the patient. They recommended alternating his NPH for optimal control. The patient was maintained on a regular sliding scale with q.i.d. blood glucose fingers. 5. Cardiology: The patient had an ejection of 55%, question diastolic dysfunction. Given the fact that he is hypotensive his antihypertensive medications were held during this hospital stay until his blood pressure normalized. 6. Chronic pain: The patient had a history of chronic pain as well as history of intravenous drug use and possible heroin use. Patient was maintained on his outpatient doses of methadone and p.r.n. Vicodin postoperatively. Also for chronic right shoulder pain. 7. Anemia: The patient with anemia of chronic disease and end stage renal disease. Patient was transfused for hematocrit of less than 28 percent. Patient got one unit of packed red cells at dialysis on [**4-23**] and was maintained on his Epogen shots three times weekly at hemodialysis. 8. Constipation: Patient was maintained on Colace, Senna and Dulcolax. 9. Prophylaxis: Patient was maintained on proton pump inhibitor and Pneumoboots. 10. Code: Patient was maintained on full code. The remainder of the hospital course will be dictated by the next intern who will be covering for this patient. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 9755**] Dictated By:[**Last Name (NamePattern1) 5227**] MEDQUIST36 D: [**2184-4-25**] 22:03 T: [**2184-4-25**] 22:31 JOB#: [**Job Number 101057**] Name: [**Known lastname 16230**], [**Known firstname 77**] Unit No: [**Numeric Identifier 16231**] Admission Date: [**2184-4-21**] Discharge Date: [**2184-4-28**] Date of Birth: [**2125-5-16**] Sex: M Service: The addendum covers the period of hospitalization between [**4-26**] and [**2184-4-28**]. HOSPITAL COURSE: 1. Sepsis: During this period of time the patient remained afebrile without any complaints. His blood culture from [**4-21**] grew staph coag positive, and gram stain from his right foot ulcer showed staph guaiac positive and proteus and Mirabilis. The patient was maintained on Vancomycin and Ceftazidime. Both medications were administered at the time of hemodialysis. 2. Diabetes mellitus: The patient was continued on insulin therapy with NPH and regular insulin sliding scale as recommended by [**Last Name (un) 616**] consult. 3. Access: A femoral line had been placed on the patient. The line was removed on [**2184-4-26**]. Apparently the patient has no intravenous access. His only intravenous medications are Ceftazidime and Vancomycin, both of which were administered during hemodialysis. DISCHARGE INSTRUCTIONS: The patient should follow up with his primary care physician within [**Name Initial (PRE) **] week. Also he should follow up with the Podiatry Service on Monday [**2184-5-3**] at which point further management will be decided. DISCHARGE STATUS: To extended care facility. DISCHARGE CONDITION: Stable. DISCHARGE DIAGNOSES: 1. Sepsis. 2. End stage renal disease on hemodialysis. 3. Ulcers/infection. 4. Diabetes mellitus, insulin dependent. DISCHARGE MEDICATIONS: 1. Protonix 40 mg po q.d. 2. Gabapentin 100 mg po b.i.d. 3. Multivitamins one cap po q.d. 4. Folic acid 1 mg po q.d. 5. Methadone 100 mg po q.d. 6. Nephrocaps one capsule po q.d. 7. Tylenol 325 to 650 mg po q 4 to 6 hours prn. 8. Sevelamer 3200 mg po t.i.d. 9. Warfarin 1 mg po q.h.s. 10. Colace 100 mg po b.i.d. 11. Senna one tablet po b.i.d. 12. Bisacodyl 10 mg po/pr q.d. prn for constipation. 13. Hydrocodone/Acetaminophen one to two tabs po q 4 to 6 hours prn for pain. 14. Insulin sliding scale with 60 units of NPH at breakfast and regular insulin sliding scale with q.i.d. finger sticks. 15. Ceftazidime 1 gram q hemodialysis (with each hemodialysis session). 16. Vancomycin with each hemodialysis session dosed by levels drawn prior to hemodialysis. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4273**], M.D. [**MD Number(1) 4274**] Dictated By:[**Last Name (NamePattern1) 3221**] MEDQUIST36 D: [**2184-4-28**] 10:09 T: [**2184-4-28**] 10:12 JOB#: [**Job Number 16232**]

[ "038.10", "428.0", "403.91", "070.54", "995.91", "682.8", "730.07", "730.17", "707.15" ]

icd9cm

[ [ [] ] ]

[ "77.69", "78.69", "86.04", "39.95" ]

icd9pcs

[ [ [] ] ]

8167, 8176

8197, 8319

8342, 9396

2576, 2940

7030, 7844

7869, 8145

2963, 3681

181, 261

290, 2017

2040, 2549

63,048

179,674

34089

Discharge summary

report

Admission Date: [**2169-7-3**] Discharge Date: [**2169-7-10**] Date of Birth: [**2092-6-12**] Sex: M Service: SURGERY Allergies: Cipro Attending:[**First Name3 (LF) 3376**] Chief Complaint: local recurrence of [**First Name3 (LF) 499**] ca Major Surgical or Invasive Procedure: segmental colectomy, excision of retroperitoneal mass, psoas muscle, L nephrectomy/adrenalectomy History of Present Illness: 76-year-old male referred for evaluation for his recently diagnosed prostate cancer. His previous oncologic history is significant for [**First Name3 (LF) 499**] cancer, which was diagnosed in [**2158**], at which time he underwent a left colectomy followed by adjuvant chemotherapy with 5-FU and leucovorin. He was doing well until [**2165-11-23**] when he had a recurrence of the original anastomosis. He underwent neoadjuvant chemotherapy with FOLFOX and Avastin followed by a second partial colectomy followed by radiation and FOLFIRI. He underwent a surgery at [**Hospital6 **], and at the time there no intervention was deemed indicated and in terms of the ureter. He subsequently underwent serial PET scans. The CT scan in [**2166**] revealed hydronephrosis and his creatinine at that time increased to 2.2. Discussion of the stent was mentioned per his son, however, the urologist at [**Hospital6 **] did not think it was indicated at that time. He subsequently saw a urologist in [**Doctor Last Name 40074**]in [**Month (only) **] of this year, and a small stent was placed. He had a repeat PET scan in [**2169-5-23**] that revealed increase in activity in the left retroperitoneum and the patient was referred to surgical service for resection. Past Medical History: HTN CAD [**Year (4 digits) 499**] cancer BPH Past surgical: L ureteral stent, colectomy x 2, coronary atherectomy + angioplaty Social History: The patient works as an optometrist in [**Doctor Last Name 26532**]. He is married. He used to smoke 1 pack a day for 30 years, but quit in [**2149**]. He occasionally has a glass of beer, does not use any other drugs. Family History: He had a paternal uncle with [**Name2 (NI) 499**] cancer. Father with [**Name2 (NI) 499**] cancer at age 57 and CAD. He died at 72 from coronary artery disease. Mother had pancreatic cancer. Sister is healthy and two sons that are healthy. Physical Exam: Vitals stable T-98.6, HR-58, BP-144/58, RR-18, 94% on 2L, desats to 85-88% on RA with activity GEN: NAD, A&O x 3 CVS: RRR no m/r/g Pulm: Decreased b/l breath sounds no w/r/r Abd: S/nt/nd + BS x 4 Wound: C/D/I, Surgical Midline abdominal OTA with staples Extrem: no c/c/e Pertinent Results: [**2169-7-5**] 09:25AM BLOOD Glucose-89 UreaN-23* Creat-2.1* Na-139 K-5.0 Cl-107 HCO3-27 AnGap-10 [**2169-7-9**] 08:34AM BLOOD Glucose-130* UreaN-13 Creat-1.8* Na-143 K-3.4 Cl-104 HCO3-27 AnGap-15 . PAthology: Descending [**Month/Day/Year 499**], left kidney, left adrenal gland, and psoas muscle (A-O): 1. Recurrent colonic adenocarcinoma, moderately differentiated, involving the wall of the [**Month/Day/Year 499**], encasing the left ureter and invading the left psoas muscle. Tumor extends to within 0.3 cm of the deep resection margin of the psoas muscle. 2. Ureteral margin and colonic resection margins uninvolved by carcinoma. 3. Kidney and ureter with hydronephrosis, chronic inflammation, and atrophy due to obstruction of ureter by tumor. Adrenal gland with no malignancy identified. 4. One lymph node with no malignancy identified (0/1). II) Lymph nodes left para-aortic (P-Q): Two lymph nodes with no malignancy identified (0/2). III) [**Month/Day/Year **], true proximal margin (R): No malignancy identified. IV) [**Month/Day/Year **], anastomotic donut (S): No malignancy identified. . [**2169-7-5**] 09:25AM BLOOD WBC-11.2* RBC-3.03* Hgb-9.2* Hct-27.4* MCV-90 MCH-30.5 MCHC-33.8 RDW-14.7 Plt Ct-194 [**2169-7-10**] 04:32AM BLOOD Glucose-102 UreaN-13 Creat-1.6* Na-143 K-3.5 Cl-108 HCO3-26 AnGap-13 [**2169-7-10**] 04:32AM BLOOD Calcium-7.9* Phos-2.1* Mg-2.0 Brief Hospital Course: [**2169-7-3**]: Pt admitted to the ICU after his procedure. He was extubated and remained NPO, IVF. PT had a small increase in CR s/p nephrectomy. [**2169-7-4**]: PT had episodes of desaturations to the mid 80s. CXR obtained which showed small left pleural effusion. PT was given Lasix 10 mg with good diuresis. IVF were decreased. That evening patient again desaturated to the high 70s while sleeping. He was placed on CPAP on 8 L NC with improved saturations. All other VS stable, ABG reassuring. [**7-5**]: Patient did well. CXR in am showed increased atelectasis in LLL, mild pulmonary edema and b/l small effusions. Pt continued treatment with CPAP at night. Cr continued to mildly increase. Pt consulted. [**7-6**]: PT had desaturations with PT to the upper 70 off the face mask with recovery of saturations to 91-92% with supplemental O2. Pt kept on sips while awaiting return of bowel function. [**7-7**]; Pulmonary consult. [**7-8**]: PT had O2 saturations >92% on 3 L NC. Further diuresis with 20 mg of Lasix x 2 with good response. [**7-9**]: Pt worked with physical therapy maintaining O2 sats >88% while on flat surfaces, corrected to > 92% with 1L NC. PT sats 87% on 1 L while stair climbing. PT again treated with 20 mg of Lasix. [**7-10**]: Lasix 20mg IV ordered, patient refused due to long drive home, and due to adequate urine output. PT discharged home with services and on supplemental pulsed oxygen. Follow-up appointment with Dr. [**Last Name (STitle) **] and Pulmonology arranged. Medications on Admission: amlodipine 7.5', lipitor 10', valsartan 160', ASA 81' Discharge Medications: 1. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain: [**Doctor Last Name **] if sedated or breathing at a rate under 10 breath per minute. Disp:*45 Tablet(s)* Refills:*0* 6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours) as needed for pain/fever: Do not exceed 4gm/24hr. Discharge Disposition: Home With Service Facility: VNA of [**Doctor Last Name **] Discharge Diagnosis: Primary: Respiratory distress [**Doctor Last Name **] cancer Renal failure Hypertension . Secondary: CAD, s/p angioplasty x2 ([**2155**]), HTN, BPH, PE Discharge Condition: Requiring oxygen during day, CPAP at night ambulating with assistance tolerating oral intake Pain well controlled with oral medication Requiring oxygen during day, CPAP at night ambulating with assistance tolerating oral intake Pain well controlled with oral medication Requiring oxygen during day, CPAP at night ambulating with assistance tolerating oral intake Pain well controlled with oral medication Discharge Instructions: General: . 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: -Your staples will be removed at your follow-up appointment with Dr. [**Last Name (STitle) 1120**]. -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.Follow up with Dr. [**Last Name (STitle) 1120**] [**Telephone/Fax (1) 160**] in [**12-25**] weeks 2.Provider: [**First Name8 (NamePattern2) 8913**] [**Last Name (NamePattern1) 8914**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2169-7-27**] 11:00 3. Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD,PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 22**] Date/Time:[**2169-7-27**] 11:00 4. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10921**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2169-7-27**] 11:00 NEITHER DICTATED NOR READ BY ME Completed by:[**2169-7-10**]

[ "585.9", "V45.82", "185", "403.90", "799.02", "518.0", "198.1", "198.89", "997.3", "414.01", "197.6", "153.8", "591" ]

icd9cm

[ [ [] ] ]

[ "55.51", "45.94", "40.3", "59.00", "99.77", "45.79" ]

icd9pcs

[ [ [] ] ]

6322, 6383

4074, 5592

314, 413

6579, 6988

2666, 4051

8521, 9153

2114, 2359

5696, 6299

6404, 6558

5618, 5673

7012, 8167

8182, 8498

2374, 2647

225, 276

441, 1706

1728, 1857

1873, 2097

5,102

119,479

29809+57663

Discharge summary

report+addendum

Admission Date: [**2179-1-18**] Discharge Date: [**2179-1-30**] Date of Birth: [**2109-9-24**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: Intraventricular blood Major Surgical or Invasive Procedure: Intraventricular drains History of Present Illness: 69 y/o male found wedged between cabinet and stove on [**1-18**] He went to outside hospital where he had head CT demonstrating large right frontal ICH with blood tracking into the 4th ventricle. The patient then came to this institution for neurosurgery care. Past Medical History: Diagnosed with Diabetes on [**10-26**] Arthritis of knees and hips but took no NSAIDs (No ho of seizures) Social History: Retired civil engineer. HO ETOH abuse x 30+ years. Drinks 2-3 shots of whisky/night or [**12-22**] whisky beverages and [**1-23**] beers/night. Family denies daytime ETOH consumption. No tobacco,or drug history. Family History: Mother had polycythemia and was on coumadin Father died of emphysema Sister with multiple medical illnesses but no ho ICH Physical Exam: O: Tm: 100.8 Tc: 98 BP: 118-154 / 55-68 HR: 71-89 RR: 15-23 O2Sat.100%: I/Os:1410/107 AC PIP 23 PEEP 5 x R15 Gen: intubated off sedation HEENT: Pinpoint pupils midline Neck: C-collar in place Lungs: CTA bilaterally. No R/R/W. Cardiac: RRR. S1/S2. No M/R/G. Abd: Soft, D, no BS. Generous spleen size, no hepatomegaly Extrem: Warm and well-perfused. edema noted Neuro: Mental status: Intubated, off sedation. Does not rouse with sternal rub or pain Cranial Nerves: I: Not tested II: Pupils 2 mm and min reactive to light mm bilaterally. Does not blink to threat III, IV, VI: Did not Doll's with intubation/c-collar V, VII: Corneal's intact VIII: deferred IX, X: Per nurse gag and cough present [**Doctor First Name 81**]: deferred XII: deferred Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. RUE: Has minimal flexion at wrist with deep pain. RLE: Spont moves. LLE: Spont moves though minimal. LLE: no movement with deep pain Reflexes: 2 plus reflexes UE bilat. 1 plus reflexes bilat patella and AJ. Grasp reflex absent. Toes upgoing bilaterally. Pertinent Results: [**2179-1-18**] 09:23PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 TRANS EPI-0-2 [**2179-1-18**] 09:23PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-1000 KETONE-50 BILIRUBIN-NEG UROBILNGN-0.2 PH-6.0 LEUK-NEG [**2179-1-18**] 09:23PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.028 [**2179-1-18**] 09:23PM FIBRINOGE-535* [**2179-1-18**] 09:23PM PT-13.3* PTT-25.2 INR(PT)-1.2* [**2179-1-18**] 09:23PM PT-13.3* PTT-25.2 INR(PT)-1.2* [**2179-1-18**] 09:23PM PLT COUNT-187 [**2179-1-18**] 09:23PM WBC-9.5 RBC-4.10* HGB-14.9 HCT-42.1 MCV-103* MCH-36.4* MCHC-35.4* RDW-13.1 Brief Hospital Course: The patient is a 69-year-old gentleman who was admitted to the [**Hospital **] [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] from an outside hospital. The patient had presented with a change in mentation. He was found on outside hospital CT scan to have an intraparenchymal hemorrhage with extension to the ventricle, across the ventricle, an extensive intraventricular clot, hydrocephalus with distention of the temporal wounds. The patient was transferred [**Hospital **] [**Hospital **] Medical Center for management. The patient had incipient herniation. Therefore, an emergent left-sided high frontal EVD was placed in the ER, follow up head CT showed good placement of drain. He was started on Mannitol, Decadron and Dilantin A Stroke Neurology consult was obtained on day one they recommended, cont Mannitol 25 g IV q6h, Dexamethsone 4 mg IV q8h, Phenytoin 100 mg IV q6h ,RISS SBP goals less than 160 and MAPs <130, and keeping the patient. Normothermia/Normoglycemia A hematology consulted due the patients frequency of nose bleed and numerous blood studies were sent which were all normal. An MRI rule out any underlying lesions and CTA rule out an anuersymal source for the bleed. On hospital day 2 the patients EVD clotted off and a new EVD was placed, and [**Hospital1 **] TpA was started throughout the hospitalization. The patients neurologic exam remained poor he would move left arm spontaneously which improved daily where he moved it more frequently. Initially he would only withdraw his right hand to pain and his legs. Prior to being made CMO he spontaneoulsy moving all his extremities except his right arm which would withdraw to pain. We discussed the grave prognosis with his family and had multiple meetings with social work and daily updates they wanted to proceed with full care knowing the possible outcome may be nursing home care. Mr [**Known lastname **] had CT scans showing resolving blood in ventricular system. On [**1-23**] he began developing persistent fevers eventually cultures grew out moraxecella out of his sputum, ID was eventually consulted and he was started on Vancomycin for his ventriculostomy drain and thought would provide better coverage for his fevers, other sources of fever were ruled out and he was thought to have a central fever. On [**1-28**] the family was approached about giving Mr [**Known lastname **] a PEG and Trach and they decided not to proceed with those procedures and to make him CMO. On [**1-29**] he was extubated and over the course of the next day he expired on the evening of [**1-30**]. Medications on Admission: Metformin Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: IPH and IVH Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None Completed by:[**2179-1-30**] Name: [**Known lastname 11998**],[**Known firstname **] J Unit No: [**Numeric Identifier 11999**] Admission Date: [**2179-1-18**] Discharge Date: [**2179-1-30**] Date of Birth: [**2109-9-24**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 599**] Addendum: Please note and ID consult was obtained for this patient due to persistent fevers which started on [**2179-1-23**]. He had a presumed Ventilator associated pneumonia and was started on Levaquin. He eventually grew out moraxecella out of his sputum. We do feel he had a componenent of central fever and ventilator associated pneumonia. Discharge Disposition: Expired [**Name6 (MD) **] [**Last Name (NamePattern4) 603**] MD [**MD Number(2) 604**] Completed by:[**2179-2-16**]

[ "853.05", "250.00", "331.4", "780.6", "303.91", "V66.7", "348.4", "999.9", "560.9", "482.83", "E849.0", "996.75", "E884.2" ]

icd9cm

[ [ [] ] ]

[ "99.10", "96.6", "96.04", "96.72", "02.42", "02.39" ]

icd9pcs

[ [ [] ] ]

6504, 6650

2904, 5498

342, 368

5651, 5661

2271, 2881

5714, 6481

1035, 1158

5558, 5564

5617, 5630

5524, 5535

5685, 5691

1173, 1541

280, 304

396, 659

1638, 2252

1556, 1622

681, 789

805, 1019

81,827

166,523

41149

Discharge summary

report

Admission Date: [**2189-4-1**] Discharge Date: [**2189-4-5**] Date of Birth: [**2118-7-22**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 22964**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: Cardiac catheterization, with 2 drug eluting stents placed in the mid-left anterior descending artery. History of Present Illness: 70 yo M with PMH of HTN, HLD and recent admission (d/c [**2189-3-7**])for syncope attributed to orthostasis without appropriate heart response secondary to medications and beta blockade who presented to ED with four days of worsening SOB, chest fullness, diaphoresis. Normally has excellent exercise tolerance and walks 3 miles a day, but over last several days, becaome SOB just walking in his house. He reports no antecedent symptoms such as fever, chills, or recent URI. He denied sputum production or cough at the time of admission. Triggered on arrival for tachycardia to 154 and found to be in AF with RVR. . In the ED, initial VS 96.8 154 143/99 24 97% RA, received iv dilt with good hr response and got dilt 60mg po x1. Labs with metabolic gap acidosis, lactate normal, normal WBC with slight left shift, BNP >21,000, trop 0.03 with normal CK. CXR with large RML infiltrate, treated with CTX and azithro for CAP. VS prior to transfer. 1L IVF. EKG with flipped Tw v2-v6. Developed worsening hypoxia and O2 requirement increased to 4L nc, crackles on exam, got 20iv lasix. VS prior to transfer: 98.2 102 138/97 92% on 2L, 89%L on RA. . ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. . He was subsequently found to have TWI on his ECG on the lateral leads and he underwent ECHO to determine whether or not need needs to undergo emergent Cath. He does not have a previous Echo in the [**Hospital1 18**] system. . Upon evaluation on the floor, he endorsed the history given above but became acutely short of breath and desated to the mid 80's during a rectal exam, and became cyanotic. He was sat upright with an improvement in his O2 sat to the low 90s. His HR at the time was in the 100's with an ECG that showed a NSR at 97 with [**Female First Name (un) **] lateral TWI in V3-V6. He was given 40 mg IV lasix, and an ABG was 7.48/32/81/ on NBR. . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: None -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: Hypertension Hyperlipidemia H/O EtOH abuse Social History: Lives alone. Has a significant other, widower. Drinks 2-3 "good" size hard liquor drinks a night, sometimes more. No h/o withdrawal, is interested in cutting back. Does not remember the last day he did not have something to drink. Denies any history of DTs. He goes to the liquor store twice a week for to purchase a fifth of alcohol. Tobacco quit 22 years ago. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. . Physical Exam: On admission: VS: T=98.2 BP=124/84 HR=92 RR=18 O2 sat= 92 4L (with drop noted above) GENERAL: Labored breathing, uncomfrortable Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 20 cm. + Hepatojugular reflex. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Speaking in short sentences, pursed lipped breathing when lying flat, No dullness to percusion, bronchovesicular sounds with crackles at the bases, with left sided wheezes. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Guiac negative. Notable small round prostate, posterior compressable hemorrhoid. No palpable masses. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, small healed excoriations PULSES: Right: Carotid 1+ Left: Carotid 1+ Pertinent Results: Admission: [**2189-3-31**] 11:30PM BLOOD WBC-8.7# RBC-3.99* Hgb-13.6* Hct-41.5 MCV-104* MCH-34.0* MCHC-32.7 RDW-15.7* Plt Ct-127* [**2189-3-31**] 11:30PM BLOOD PT-15.0* PTT-25.0 INR(PT)-1.3* [**2189-3-31**] 11:30PM BLOOD Glucose-163* UreaN-18 Creat-0.9 Na-139 K-4.0 Cl-95* HCO3-18* AnGap-30* [**2189-3-31**] 11:30PM BLOOD ALT-35 AST-62* CK(CPK)-120 AlkPhos-126 [**2189-3-31**] 11:30PM BLOOD CK-MB-5 proBNP-[**Numeric Identifier 42759**]* [**2189-3-31**] 11:30PM BLOOD Calcium-9.6 Phos-4.1 Mg-1.7 [**2189-4-1**] 04:55AM BLOOD VitB12-1195* Folate-GREATER TH [**2189-4-5**] 06:35AM BLOOD Triglyc-100 HDL-72 CHOL/HD-2.3 LDLcalc-77 [**2189-4-1**] 04:55AM BLOOD TSH-1.9 [**2189-4-4**] 07:55AM BLOOD HIV Ab-NEGATIVE . Discharge: [**2189-4-5**] 06:35AM BLOOD WBC-4.8 RBC-3.87* Hgb-13.2* Hct-37.6* MCV-97 MCH-34.1* MCHC-35.1* RDW-14.7 Plt Ct-174 [**2189-4-5**] 10:40AM BLOOD PT-14.2* PTT-23.2 INR(PT)-1.2* [**2189-4-5**] 06:35AM BLOOD Glucose-101* UreaN-31* Creat-1.1 Na-135 K-3.6 Cl-93* HCO3-31 AnGap-15 [**2189-4-2**] 06:04AM BLOOD ALT-23 AST-31 CK(CPK)-41* AlkPhos-91 TotBili-1.1 [**2189-4-3**] 05:15AM BLOOD CK-MB-3 [**2189-4-2**] 06:04AM BLOOD CK-MB-3 cTropnT-0.02* [**2189-4-5**] 06:35AM BLOOD Calcium-9.1 Phos-4.5 Mg-1.8 Cholest-169 . CT Chest: IMPRESSION: . 1. Moderate right and small left lower lobe consolidations, consistent with pneumonia. 2. Medial ground-glass opacity, smooth gravity dependent intralobular septal thickening and bilateral pleural effusions, consistent with pulmonary edema. 3. Coronary arterial calcification. The study and the report were reviewed by the staff radiologist. . Cath: COMMENTS: 1. Selective coronary angiography in this left dominant system demonstrates single vessel disease. The left anterior descending contains a long 90% lesion in the mid-vessel. The left main contains no angiographically apparent disease, and circumflex contains minor disease only. The right coronary is a small non dominant vessel that is free of angiographically apparent disease. 2. Hemodynamics demonstrate a low cardiac output with elevated biventricular filling pressures. 3. Successful PTCA/stenting of mid LAD with overlapping 2.5 X 18 mm and 2.5 X 23 mm PROMUS DES, post dilated to 2.75 mm with NC balloon at high pressure. (details under PTCA comments). Final angiogram showed 0% residual stenosis in the stent, no dissection and normal flow. . FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Mild systolic and diastolic ventricular dysfunction. 3. Successful PTCA/stenting of mid LAD with overlapping PROMUS DES. 4. Aspirin 325 mg daily for 1 month, then 81 mg daily 5. Plavix 75 mg daily for > 3-6 months as tolerated. . ECHO: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is severe regional left ventricular systolic dysfunction with severe hypokinesis to akinesis of the distal two-thirds of the ventricle and preservation of the basal septum and inferior walls. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve is mildly thickened (?#) with no aortic stenosis or regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. IMPRESSION: Severe regional left ventricular dysfunction c/w multivessel CAD, large wrap-around LAD territory lesion, or Takotsubo cardiomyopathy. Moderate pulmonary hypertension. Mildly dilated thoracic aorta. Brief Hospital Course: 70 year old male with history of alcohol abuse, HTN, hyperlipidemia who presents with congestive heart failure and new onset AF with TWI and depressed systolic EF [**1-7**] mid-LAD lesion, complicated by acute onset hypoxic respiratory distress. . # Hypoxic respiratory distress: The patient was initially admitted to the general cardiology service, but was found to have an increasing oxygen requirement, prompting transfer to the CCU. Upon admission, he was started on a furosemide drip with a robust response, improving his oxygenation. His CXR was consistent with pulmonary edema, but also had multifocal infiltrates. He was initially started on broad spectrum antibiotic coverage for HCAP, but he did not develop any systemic signs or symptoms to suggest pneumonia so these were stopped. Given his effective diuresis and uptrending creatinine with decreased oxygen requirement, further treatments were discontinued. We had some concern over his multifocal infiltrates and paucity of symptoms pointing to PCP as [**Name Initial (PRE) **] potential diagnosis, so we decided to test him for HIV to rule out causes for immunosuppression. We also sent a urinary streptococcal antigen that was negative. He underwent diuresis and Cath with an intervention to his LAD, subsequently weaned to RA. . # Depressed systolic Function/Acute systolic CHF [**1-7**] ischemia: He had globally depressed systolic function on TTE (with EF of 20-25%) and he had concerning TWIs in the anterolateral region (V3-V6) with biphasic T waves in V1 and V2. He was taken for cardiac catheterization, which showed a 90% mid-LAD lesion and 2 drug-eluting stents were placed. Though this culprit lesion is a good reason for the depressed EF and pulmonary edema, there is also concern for a depressed systolic function from alcohol-induced cardiomyopathy in the long-term from heavy EtOH use. He should continue on ASA indefinitely, Plavix for at least 1 year, high-dose atorvastatin, and B-blocker/ACE-i on discharge. His ACE-i was held until his creatinine returned to baseline and he was discharged home on 5 mg Lisinopril. Due to the apical akinesis on his ECHO he was started on anti-coagulation with Warfarin. His plan was to have his PCP follow his INR, and have a repeat echo in 6 weeks to 3 months to evaluate his cardiac function. . INACTIVE ISSUES . # HTN: After diuresis he was noted to have systolic blood pressures in the 130's-140's with diastolic blood pressures in the 90's. Given his CAD, he was started on metoprolol in addition to after load reduction with Acei. If his echo continues to show a depressed EF he will need to start spironolactone as an outpatient. . # [**Last Name (un) **]: He had a mild bump in his CR while he was hospitalized and diuresed prior to discharge his Cr was 1.1. . # Anemia: He had a mild drop in his HgB while on heparin, and his HgB prior to discharge was 13.2. He will need follow up as an outpatient while he is on anti-coagulation. # Alcohol Abuse: Currently a heavy drinker requiring biweekly purchases of alcohol. He did not require any medications, as he did not score on the CIWA scale. He was continued on thiamine, B12, and folate. Social work was consulted and provided resources for alcohol abstinence. . # Dyslipidemia: Last LDL was 98. He was continued on high-dose atorvastatin during his hospitalization and was continued after discharge . # Afib with RVR: He was found to have Afib with RVR when he was admitted to the hospital the resolved after he was admitted for an acute systolic heart failure exacerbation in the setting of a Left dominant LAD lesion. He had 1-2 episodes of SVT on Tele when he was admitted, but they were asymptomatic and he was HD throughout. . TRANSITIONAL ISSUES . # Follow-up: He will follow-up with [**Hospital1 18**] outpatient cardiology and is in the process of transferring his care over to a PCP affiliated with [**Hospital1 18**]. Medications on Admission: lansoprazole 30 mg sucralfate 1 gram qid. aspirin 81 mg multivitamin thiamine 100 mg folic acid 1 mg cyanocobalamin 1,000 mcg Discharge Medications: 1. aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. sucralfate 1 gram Tablet [**Hospital1 **]: One (1) Tablet PO QID (4 times a day). 3. thiamine HCl 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. cyanocobalamin (vitamin B-12) 100 mcg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 5. folic acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. multivitamin Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 7. atorvastatin 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. clopidogrel 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Outpatient Lab Work Please check PT/INR on [**2189-4-6**] and [**2189-4-8**] and fax results to Dr. [**Last Name (STitle) 29146**] [**Name (STitle) 5861**]. FAX: [**Telephone/Fax (1) 29155**] PHONE: [**Telephone/Fax (1) 29149**] 10. ranitidine HCl 150 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO twice a day. 11. metoprolol succinate 50 mg Tablet Extended Release 24 hr [**Telephone/Fax (1) **]: One (1) Tablet Extended Release 24 hr PO once a day. Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 12. lisinopril 5 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. warfarin 5 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAYS ([**Doctor First Name **],MO,TU,WE,TH,FR,SA). Disp:*15 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Non ST elevation myocardial infarction Pulmonary edema Secondary diagnosis: Hypertension Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 5433**], It was a pleasure taking part in your care at [**Hospital1 18**]. You were admitted with shortness of breath, due to fluid build up in your lung. We believe that this was due to a decrease in your heart function from a blockage in one your coronary arteries. You underwent a catheterization that opened up this artery with 2 stents. We gave you medications to help get this fluid out of your lungs and your shortness of breath improved markedly. We have made the following changes to your medications: START clopidogrel (Plavix) 75mg daily for at least one year START atorvastatin START thiamine, folate, and B12 supplementation START warfarin START Aspirin take for the rest of your life START Metoprolol START Lisinopril START ranitidine START sucralfate Please call your PCP if your weight increases by more than 3 lbs. Followup Instructions: Primary Care: Your primary care doctor's office will call you to make an appointment in the next 1-2 days. If you do not hear from them, please call [**Telephone/Fax (1) 29149**] to make an appointment. You will need to seen in [**2-7**] days. PCP: [**Name10 (NameIs) 29146**] [**Name11 (NameIs) 5861**] Phone: [**Telephone/Fax (1) 29149**] You will also need your blood drawn tomorrow ([**2189-4-6**]) to determine your INR and have your coumadin dose adjusted if necessary. Cardiology: Please call [**Hospital1 18**] Cardiology clinic for follow up. You need to be seen within the next 1-2 weeks. PHONE: ([**Telephone/Fax (1) 2037**] Completed by:[**2189-4-8**]

[ "285.9", "427.31", "414.01", "514", "410.71", "428.0", "584.9", "305.01", "401.9", "272.4", "518.82", "428.21" ]

icd9cm

[ [ [] ] ]

[ "00.66", "00.46", "94.62", "37.23", "36.07", "99.20", "88.56", "00.40" ]

icd9pcs

[ [ [] ] ]

14182, 14188

8419, 12349

323, 427

14356, 14356

4717, 7088

15396, 16064

3588, 3706

12526, 14159

14209, 14209

12375, 12503

7105, 8396

14507, 15021

3721, 3721

3044, 3117

15050, 15373

264, 285

455, 2936

14305, 14335

14228, 14284

3736, 4698

14371, 14483

3148, 3193

2958, 3024

3209, 3572

14,838

113,962

3906+3907+55522

Discharge summary

report+report+addendum

Admission Date: [**2191-2-7**] Discharge Date: [**2191-2-20**] Date of Birth: [**2137-1-17**] Sex: F Service: CHIEF COMPLAINT: Spinal metastases. HISTORY OF THE PRESENT ILLNESS: The patient is a 54-year-old white female with recent new upper lobe mass in the left lung, liver masses, as well as spine metastases seen on the recent MRI. She had several weeks of severe low back pain associated with bilateral lower extremity weakness, left greater than right. She also complained of left shoulder weakness and numbness. She denied any GU or GI incontinence. She was referred for an MRI by her PCP and was found to have multiple vertebral metastases. REVIEW OF SYSTEMS: Positive for chronic shortness of breath times the past two months. On review of systems, the patient denied any fevers, chills, nausea, vomiting, diarrhea. She has a history of constipation. No bright red blood per rectum or melena. The patient does have a decreased appetite, no abdominal pain, no chest pain. Minimal cough. PAST MEDICAL HISTORY: 1. Ovary removal with endometriosis. 2. Status post phyllodes tumor with a wide excision in [**2186**]. She had a normal mammogram in [**2190**]. 3. History of oophorectomy. MEDICATIONS ON ADMISSION: 1. Zoloft. 2. Wellbutrin. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: She is a former teacher. She has a 27-year-old son in [**Name (NI) **]. Two packs per day since age 18. Two glasses of wine per day. No drug use. FAMILY HISTORY: Notable for a family history of lung cancer in her father. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 96.4, pulse 91. The blood pressure was 164/94, respirations 18, saturating 97% on room air. General: The patient was a pleasant female in no acute distress. Alert and oriented times three. HEENT: The pupils were equal and reactive to light. The extraocular muscles were intact, 3 to 2 mm bilaterally. The neck was supple. Heart: Regular rate and rhythm. Lungs: The lungs were with diffuse wheezing bilaterally. Abdomen: Positive bowel sounds, soft, nontender, nondistended. Extremities: With no edema, clubbing, or cyanosis. Neurological: The patient had cranial nerves II through XII intact, 5/5 strength bilaterally. Sensation grossly intact. LABORATORY DATA UPON ADMISSION: White count 4.6, hematocrit 30.9, platelets 101,000. Sodium 138, K 3.0, chloride 95, bicarbonate 27, BUN 19, creatinine 0.6, glucose 114, calcium 10.7, ALT 171, AST 90, alkaline phosphatase 217, lipase 53, total bilirubin 0.4, free calcium 1.36. HOSPITAL COURSE: The patient had a hospital course which is notable by systems as follows. 1. HEMATOLOGY/ONCOLOGY: The patient is a 54-year-old female with a left upper lobe lung mass with multiple liver and bony metastases in the spine seen by imaging studies over the last month. The ultimate diagnosis of small cell lung cancer was made and the patient had been treated with cisplatin and etoposide. In further detail, the patient had a CT scan on [**2191-2-4**] of the chest, abdomen, and pelvis. The CT of the chest, abdomen, and pelvis at this time showed a new large mass in the left upper lobe of the lung concerning for lung cancer. There were multiple liver masses concerning for metastatic disease. The lung mass in the upper lobe measured approximately 5 by 10 by 6.5 cm. There was also a precarinal lymph node measuring 13 mm. The patient also had an MR of the cervical lumbar spine. The MR of the cervical and lumbar spine dated [**2191-2-6**] were notable for diffuse marrow signal abnormalities, indicative of marrow hypoplasia or infiltrative processes. Focal signal abnormalities involving L1, L3, and L4 vertebra were seen consistent with metastatic disease. Degenerative changes in the lumbar spine lesion were noted as well. In regards to the cervical spine, the study was limited since only sagittal T2 images could be obtained because of patient discomfort. This was a limited examination but on a sagittal T2 weighted images of the cervical area, there were no foci or abnormal signal intensities in these regions. Further hematology/oncology workup included a bone marrow biopsy on [**2191-2-10**]. The bone marrow biopsy showed that the aspirate was almost entirely infiltrated with neoplastic cells with high nucleocytoplasmic ratio. The biopsy slides also showed marrow packed with approximately 90% of the trabecular space infiltrated by malignant cells showing scant amount of cytoplasm. By immunohistochemistry, the cells were diffusely positive for pankeratin and exhibit extremely weak diffuse immunoreactivity for synaptophysin. They were negative for chromogranin. The remaining of the 10% of the space had positive cellularity of 80% with trilineage hematopoiesis and increased M:E ratio. Finally, of note, the patient had her left upper lobe lung biopsy which showed cells consistent with small cell carcinoma. The corresponding bronchial washings obtained with the biopsy were positive for malignant cells consistent with small cell carcinoma. The cells were positive for cytokeratin, very rare tumor cells were positive for chromogranin. The cells were negative for LCA. This was on the bronchial brushings. Since diagnosis, the patient had received chemotherapy with cisplatin and etoposide. The patient received 80 mg per meter squared of cisplatin on day number two and 80 mg per meter squared of etoposide on days one, two, and three. Since the treatment with the chemotherapy, the patient had afterwards become neutropenic with white blood cell count of approximately 0.3. During the hospital course, the patient had received blood cell transfusions with red blood cells. She also had platelet transfusion for low platelets as well. 2. PULMONARY: The patient, during her hospital course, presented with a left upper lobe nodule. During the hospital course, she had episodes of desaturation and hypoxia. Her 02 saturations on [**2191-2-7**] had gone down to the mid 80s on room air which had improved to the low 90s on nasal cannula. She had a CT angiogram at that time which revealed no evidence of PE; however, the study was somewhat limited due to motion artifact. In addition, the CT angio revealed a large left upper lobe mass and hilar adenopathy which had been seen on previous CTs. The mass almost surrounded the left pulmonary artery, nearly compressing it. In addition, on the CT, there were new patchy bilateral opacities predominantly in the upper lung zones. At this time, the patient was noted to have a temperature to 101.7 and had been started on a ten day course of levofloxacin and clindamycin for the infiltrate and fever. Otherwise, regarding the remainder of the patient's pulmonary course, she had undergone bronchoscopy on [**2191-2-9**]. The left upper trunk was noted to be occluded with an overlying mucosal abnormality and the lower trunk was significantly narrowed, probably due to extrinsic compression. To the lower trunk was an additional abnormal white nodular area. The valvular segments were patent. The left upper lobe occlusion/mucosal abnormality was brushed. Following the brushing, there was significant bleeding with rapid clot formation of that nodule. At the end of the procedure, the left main stem was almost completely occluded by clot. Given these findings, the patient was transferred to the MICU for further observation. A repeat bronchoscopy showed complete obstruction of the left main stem bronchus with multiple clots. These clots were resectioning the mass completely and included the left upper lobe bronchus. Since then, the patient had been noted to have an increase in shortness of breath and increasing tachypnea with 02 saturations decreasing to the mid 80s on 6 liters which had improved on nonrebreather. Chest x-ray at that time revealed partial clot to the left upper lobe and interstitial involvement of the right lung field. The patient had been transferred to the MICU for further evaluation of her respiratory status. The patient's respiratory status had improved with continuing her treatment of the pneumonia as well as some diuresis. She had an echocardiogram performed at the bedside to further evaluate the etiology of the patient's shortness of breath. The echocardiogram had a left ventricular systolic function low normal at 50-55%, mild 1+ aortic regurgitation, mild 1+ mitral regurgitation. There was mild pulmonary artery systolic hypertension with this study. The patient's pulmonary status had improved during this hospital course and oxygen had been decreased as she had tolerated this. 3. INFECTIOUS DISEASE: The patient is a 54-year-old female who presented during this hospital course on her second day with increasing shortness of breath and new upper lobe infiltrates seen on CT. The infiltrates showed that there were patchy bilateral infiltrates, predominantly in the upper lung zones. There may have been a pulmonary edema; however, given that the patient spiked a fever at this time, the development of the pulmonary infiltrates had developed, she had been started on levofloxacin and clindamycin for a ten day course for treatment of a potential aspiration pneumonia. Otherwise, during this hospital course, the patient's infectious disease status had been notable for the development of herpetic lesions which have been on her lower back. The patient has had these lesions in the past. She had been started on Valtrex for these lesions. The patient had developed thrush in her mouth and had been started on fluconazole for the thrush. After the patient had completed her treatment course with levofloxacin and clindamycin for the pneumonia, she developed a fever to 102.1 on [**2191-2-18**] in the evening. At this time, the patient had been neutropenic with a white blood cell count of 0.3. For febrile neutropenia, she had been started on cefepime and Flagyl for coverage of febrile neutropenia. At this time, the patient had significant diarrhea associated with this. A chest x-ray at this time revealed the persistent left hilar mass with collapse of the left upper lobe; however, the remainder of the lung fields were well aerated and the opacities previously seen on the right side were not observed and there was interval improvement of the pleural effusion on the left side. Of note, this is a preliminary discharge and will be addended upon the patient's discharge. Dictated By:[**Last Name (NamePattern4) 17418**] MEDQUIST36 D: [**2191-2-20**] 02:58 T: [**2191-2-20**] 15:19 JOB#: [**Job Number 17419**] Admission Date: [**2191-2-7**] Discharge Date: [**2191-3-7**] Date of Birth: [**2137-1-17**] Sex: F Service: ADDENDUM TO PREVIOUS DISCHARGE SUMMARY: HOSPITAL COURSE: 1. Small cell lung cancer: Following the patient receiving became febrile neutropenic. She was treated with G-CSF which was discontinued on [**2-28**] after her white blood cell count was greater than 5000. The patient experienced increasing shortness of breath during her stay and was believed to have a postobstructive pneumonia. Follow-up chest x-ray and CT scan demonstrated similar size of a tumor, but collapse of the left upper lobe. This was felt likely syndrome of inappropriate diuretic hormone. These are felt to be indicative of treatment failure and the patient had her chemotherapy regimen changed. On [**3-3**], the patient received cisplatin, as well as CTT11, which she will also receive again on [**3-10**]. The patient also was seen by Radiation Oncology and started on palliative radiation to the left upper lobe with hopes of re-expanding the patient's lung. The patient did have mild improvement in her symptoms and will await response for chemotherapy. 2. Pulmonary: Patient's collapse of left upper lobe was concerning for worsening of her lung cancer. This became most pronounced on her chest x-ray following the resolution of her neutropenia. Patient had been on cefepime for the febrile neutropenia. The new white out on chest x-ray and white blood cell count was felt to be likely to a postobstructive pneumonia. Patient was changed from cefepime to vancomycin and Flagyl as the patient grew Methicillin resistant Staphylococcus aureus from her sputum and >....<to cover anaerobes given the postobstructive nature. Pulmonary was consulted regarding antibiotics choices, as well as the need for repeat bronchoscopy. They felt given her prognosis and mild symptoms, that bronchoscopy would not be helpful for her at this time. She will complete a ten day course of vancomycin and Flagyl and will be followed for change in her symptoms. 3. Infectious Disease: A. Postobstructive pneumonia as above. B. Genital herpes: Patient had outbreak of herpes around her and was treated with a course of Valacyclovir, as well as topical acyclovir. At the time of this dictation, the patient's symptoms are improving and she is starting to heal. Will continue on topical acyclovir until the lesions are completely healed over. C. Thrush: Patient had been started on fluconazole on [**2-16**] for thrush and dysphagia. Patient has completed a several day course with resolution of her thrush that primarily occurred following the resolution of her neutropenia. However, two days after discontinuation of her fluconazole, patient again developed thrush. Patient was started on nystatin swish and swallow, which she did not tolerate and was switched to clotrimazole troch, which provided good relief of her thrush. 4. Thrombocytopenia: Patient's platelet count remained low on admission. She received one unit of platelets on the 26th. She never experienced any spontaneous bleeding and eventually had an increase in her platelets on her own. This was felt to be the result of some improvement in her bone marrow disease and the resolution of her hematopoiesis. 5. Anemia: Patient remained anemic during her hospital stay. She received a total of ten units through [**3-3**]. The patient's anemia was felt to be likely secondary to marrow replacement by the small cell lung cancer. 6. Hyponatremia: The patient developed hyponatremia during her hospital stay. On [**2-26**], this was treated with normal saline with no effect. Patient was then started on fluid restriction and had laboratories sent which demonstrated that the patient had syndrome of inappropriate diuretic hormone. This is a common findings in people with small cell lung cancer, but likely to represent progression of the patient's disease. At the time of this dictation, the patient's sodium is 129 and creeping upward. She should remain on fluid restriction until her sodium improves. 7. Electrolytes: Hyponatremia as above. Patient also remained severely hypokalemic and hypomagnesemic during her hospital course. She had no obvious gastrointestinal losses or other losses to these electrolytes. Patient required frequent repletion; these need to be followed closely. NEXT DICTATION WILL BE COMPLETED BY THE NEXT INTERN. MARK [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 3282**] Dictated By:[**Name8 (MD) 17420**] MEDQUIST36 D: [**2164-3-26**] 02:58 T: [**2164-3-26**] 13:52 JOB#: [**Job Number 17421**] Name: [**Known lastname 68**], [**Known firstname 565**] Unit No: [**Numeric Identifier 2778**] Admission Date: [**2191-2-7**] Discharge Date: [**2191-3-7**] Date of Birth: [**2137-1-17**] Sex: F Service: The following is an addendum to the previous discharge summary. DISCHARGE MEDICATIONS: 1. Protonix 40 mg po q day. 2. Sertraline 250 mg po q day. 3. Morphine sulfate sustained release 75 mg po bid. 4. Morphine sulfate immediate release 15-30 mg po q3-4h prn pain. 5. Viscus lidocaine 20 cc po tid prn pain. 6. Docusate sodium 100 mg po bid. 7. Acyclovir ointment 5% applied tid to effected areas. 8. Combivent inhaler. 9. Flagyl 500 mg po x1 more dose. 10. Clotrimazole troche po 4x a day. 11. Calcium carbonate 500 mg po tid. DISCHARGE CONDITION: Good. DISCHARGE STATUS: Home after being cleared by Physical Therapy for being safe for home. DISCHARGE DIAGNOSES: 1. Status post oophorectomy with endometriosis. 2. Status post phyllodes tremor with wide excision in [**2186**]. 3. Small cell lung cancer status post cisplatin and etoposide in [**2191-1-26**] - multiple liver metastases as well as lumbar metastases in L1, L3, and L4 vertebra. 4. Mucosal abnormalities in the upper trunk of the left bronchus with clots found on bronchoscopy. 5. Mild pulmonary artery systolic hypertension on echocardiogram done in [**2191-1-26**]. 6. Presumed postobstructive pneumonia. 7. Thrush on this admission. 8. Herpes simplex in the mouth and lips. 9. Fever and neutropenia. 10. Methicillin-resistant Staphylococcus aureus from the sputum. 11. Genital herpes treated with valaciclovir as well as topical acyclovir. 12. Thrombocytopenia. 13. Anemia. 14. Hyponatremia with a diagnosis of syndrome of inappropriate diuretic hormone (SIADH). FOLLOW-UP PLANS: The patient is to followup for radiation therapy Monday through Friday with the Radiation Oncology Division. She is to also followup on [**3-10**] for her next dose of CPT11. MARK [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1432**] Dictated By:[**Name8 (MD) 74**] MEDQUIST36 D: [**2191-3-15**] 21:18 T: [**2191-3-16**] 05:50 JOB#: [**Job Number 2779**]

[ "507.0", "E878.8", "197.7", "253.6", "284.8", "998.11", "112.0", "162.3", "198.5" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.25", "33.24", "92.29", "41.31" ]

icd9pcs

[ [ [] ] ]

16128, 16225

1522, 1603

16246, 17114

15665, 16106

1254, 1337

10808, 15642

17132, 17566

695, 1028

147, 675

2341, 2589

1050, 1228

1354, 1505

41,350

159,848

55013

Discharge summary

report

Admission Date: [**2194-9-30**] Discharge Date: [**2194-10-12**] Date of Birth: [**2173-1-27**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 165**] Chief Complaint: left flank pain, chest pain, shortness of breath (CCU admission for RA thrombus) Major Surgical or Invasive Procedure: Right atrial mass resection [**2194-10-1**] History of Present Illness: Mr. [**Known lastname **] is a 21y/o gentleman with AIHA s/p splenectomy on steroids and Danazol, IgA deficency (likely transforming into CVID) with h/o portal vein thrombosis, left renal vein infarct, and pulmonary embolus now on Enoxaparin, as well as steroid-induced DM2 who presented to the ED with left flank pain, chest pain, and shortness of breath. His recent baseline is that he is quite sedentary but can normally climb a few flights of stairs with no problems if needed. His HR since [**2194-6-8**] has been 100-110. But for the past 2 days he has had chest pain: mild discomfort at his left side and his left frontal chest that becomes moderate and sharp with deep breathing. There are no associated symptoms. The pain does not radiate. In addition, he notes worsened left flank pain "like the pain I had with the kidney blood clot." Has noted worsening dyspnea on exertion to the point that he can't walk even a few steps before feeling short of breath. He went to his PCP's office who was concerned by his symptoms so EMS was called and he was taken to [**Hospital 1562**] Hospital. EMS found his VS to be: BP 152/92, HR 116, RR 18, POx 95%RA. At [**Hospital 1562**] Hospital, his VS were: rectal T 100.1, BP 122/95, HR 104, RR 18, POx 96% 2L NC. His labs were notable for WBC 26 (96% PMN, 1% bands). Blood cultures were sent and he received Levofloxacin 500mg IV in case of pneumonia (though CXR was clear). Received 1L NS. Was transferred to [**Hospital1 18**] due to medical complexity. In the [**Hospital1 18**] ED, his initial VS were: pain [**3-18**], T 95, HR 106, BP 148/103, RR 22, POx 91%RA-->96% 2L NC. Labs were notable for WBC 27.9 (N:94 Band:1 L:1), Hct 40.6, plt 373. BUN 14, Cr 1.0, K 5.2. Lactate 0.8. Serum tox screen was negative. EKG revealed NSR, rate 93, old TWI in III. Due to suspicion for PE, CTA was performed that revealed bilateral subsegmental PEs in the lung bases, but also a large filling defect in the RA that was suggestive of a near occlusive RA thrombus. In addition, he had left renal vein thrombus. Cardiac Surgery was consulted and recommended anticoagulation and consideration for possible thrombectomy. Cardiology Fellow performed a limited TTE which showed a limited view of the RA, but no evidence of RV strain. He was started on a Heparin gtt, as well as receiving Dilaudid 1mg IV x3 for chest discomfort. Received 1L NS in the ED here. He was never hemodynamically unstable but given his large clot burden he was admitted to the CCU for monitoring. Cardiac surgery was consulted for mass/ clot excision. Past Medical History: PAST MEDICAL HISTORY: IgA deficiency Coombs(+) autoimmune hemolytic anemia s/p splenectomy [**3-/2194**] Pulmonary embolism Portal vein thrombosis Renal vein thrombosis (left) History of pneumonia: in setting of pulmonary embolism diagnosis C.diff Mild bilateral sensorineural hearing loss since childhood s/p tonsillectomy s/p b/l tympanostomy tubes as a child Detailed hematologic history: -[**9-/2193**]: diagnosed with AIHA, IgA deficiency -->on high-dose steroids (can't taper [**1-9**] anemia) -[**3-/2194**] splenectomy -[**3-/2194**] PE, portal vein thrombosis --> started Warfarin -[**6-/2194**] renal vein thrombosis, C.diff --> continued on steroids but also started Danazol as a steroid-sparing [**Doctor Last Name 360**] -[**6-/2194**] bone marrow biopsy negative for underlying malignant process, given his history of IgA deficiency (likely in evolution to CVID) -->changed to Lovenox 1mg/kg [**Hospital1 **] Social History: -Home: Lives in [**Location 6598**] with his paternal grandfather. His mother lives in [**Name (NI) 8449**] and father lives in [**State 85653**]. Has 3 brothers and 3 sisters who are all out of state. His HCP is his maternal aunt [**Name (NI) **]. -Occupation: He is not currently working. -Tobacco history: He quit smoking after he was hospitalized here. -ETOH: Very rare use. -Illicit drugs: None. Family History: No early CAD or sudden cardiac death. Immune deficiency on his mother's side. Pt's maternal aunt has common variable immune deficiency complicated by Burkitt's lymphoma previously treated. [**Name (NI) 1094**] mother, maternal cousin also with immunodeficiency. Great-grandmother with breast cancer, grandfather with skin cancer. Physical Exam: ADMISSION EXAM VS: T 98.3, HR 118, BP 154/101, RR 18, SpO2 94% RA General: obese young man, no respiratory distress HEENT: moon facies with acne; PERRL, pink conjunctivae, no xanthelasma, MMM without pallor or cyanosis Neck: Normal carotid upstrokes, no carotid bruits, no jugular; obese with buffalo hump venous distention, no goiter Lungs: Clear, normal effort (though some breaths are truncated due to chest discomfort) Heart: S1 and S2, regular, tachycardic, PMI nondisplaced and no RV heave Abd: Soft, obese, NTND, NABS, no organomegaly, normal aorta without bruit Ext: No c/c/e, normal femoral and pedal pulses Skin: No ulcers, no rash; has scattered pink/purple striae on thighs and abdomen Neuro: alert, oriented x3, depressed mood and appropriate affect Pertinent Results: CTA CHEST AND CT ABDOMEN/PELVIS [Preliminary Report] [**2194-9-30**] 1. Bilateral subsegmental pulmonary embolism. No evidence of pulmonary infarct or right heart strain. 2. Large right atrial filling defect concerning for near occlusive thrombus. Recommend further evaluation with echo. 3. Otherwise, stable exam with atrophic left kidney and stable severe hydronephrosis and hydroureter extending to the level of the mid ureter likely due to thrombus. Previously noted main portal vein thrombus appears completely resolved. TEE [**2194-10-1**] PRE-BYPASS: No thrombus is seen in the left atrial appendage or left atrium. There is a large approximately 3 x 5 cm mass in the right atrium that originates on the free wall and partially obstructs right ventricular diastolic inflow. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). The right ventricle displays low normal free wall contractility. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results prior to incision. POST-BYPASS: Overall biventricular systolic function is unchanged. The right atrial mass has been excised. Mitral and aortic valve function are unchanged. There is some increase in the degree of tricuspid regurgitation and is now bordering on moderate. There is no evidence of aortic dissection in images obtained. Brief Hospital Course: Mr. [**Known lastname **] is a 21 year old gentleman with AIHA s/p splenectomy, IgA deficency (likely transforming into CVID) with h/o portal vein thrombosis, left renal vein infarct, and pulmonary embolus (on Enoxaparin, steroids and Danazol), as well as steroid-induced DM2 who presented to the ED with left flank pain, chest pain, and shortness of breath in the setting of known left renal vein thrombus, new PE, and incidental finding of large intracardiac thrombus for which he was admitted to the CCU. On TEE he was found to have very large mobile RA clot so he went to Cardiac Surgery. The patient was brought to the Operating Room on [**2194-10-1**] where the patient underwent excision of large right atrial thrombus. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. Hematology continued to follow closely. He was initially anti-coagulated with Heparin and transitioned to Lovenox. He developed sternal drainage and was started on Cefazolin in the setting of Diabetes and chronic steroid therapy. Blood cultures were sent and initially grew gram positive cocci. Antibiotics were adjusted to Vancomycin and the infectious disease service recommended continuing this medication until [**2194-10-16**]. He was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on post-operative day eleven the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home in good condition with appropriate follow up instructions and IV antibiotics. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q12H [ppx for HSV while on steroids] 2. Danazol 200 mg PO BID [HAS ONLY BEEN TAKING DAILY INSTEAD OF [**Hospital1 **]] 3. Enoxaparin Sodium 120 mg SC Q12H 4. GlipiZIDE 2.5 mg PO DAILY [HAS NOT BEEN TAKING] 5. Pantoprazole 40 mg PO Q24H 6. PredniSONE 25 mg PO DAILY 7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 8. FoLIC Acid 5 mg PO DAILY [HAS NOT BEEN TAKING] Discharge Medications: 1. Acyclovir 400 mg PO Q12H ppx for HSV while on steroids 2. Danazol 200 mg PO BID [HAS ONLY BEEN TAKING DAILY INSTEAD OF [**Hospital1 **]] 3. Enoxaparin Sodium 120 mg SC Q12H 4. FoLIC Acid 5 mg PO DAILY [HAS NOT BEEN TAKING] 5. GlipiZIDE 2.5 mg PO DAILY [HAS NOT BEEN TAKING] 6. Pantoprazole 40 mg PO Q24H 7. PredniSONE 25 mg PO DAILY 8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 9. Aspirin 81 mg PO DAILY RX *aspirin [Ecotrin Low Strength] 81 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 10. HYDROmorphone (Dilaudid) 4-6 mg PO Q3H:PRN pain RX *hydromorphone 2 mg [**1-10**] tablet(s) by mouth every three hours Disp #*40 Tablet Refills:*0 11. Metoprolol Succinate XL 200 mg PO DAILY RX *metoprolol succinate 200 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 12. Furosemide 40 mg PO DAILY Duration: 10 Days RX *furosemide 40 mg one tablet(s) by mouth daily Disp #*10 Tablet Refills:*2 13. Vancomycin 1500 mg IV Q 8H Duration: 4 Days end date: [**10-16**] RX *vancomycin 750 mg two 750mg bags for total 1500mg Q8 Disp #*24 Bag Refills:*0 Discharge Disposition: Home With Service Facility: VNA Assoc. of [**Hospital3 **] Discharge Diagnosis: Right atrial mass PMH: -Bilateral hearing loss -IgA deficiency -Coombs(+) autoimmune hemolytic anemia s/p splenectomy [**3-/2194**] -Pulmonary embolism -Portal vein thrombosis -History of pneumonia Past Surgical History:s/p splenectomy [**3-/2194**] Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up [**Year (4 digits) 648**] 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** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**], [**2194-10-16**] 10:00 Surgeon Dr. [**Last Name (STitle) **] [**2194-11-4**] at 1:15p [**Telephone/Fax (1) 170**] Cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 696**] [**2194-11-6**] at 10:00a [**Hospital Ward Name 23**] 7 CBC w diff, panel 7, t.bili, retic count, haptoglobin to be checked one week after discharge with results faxed to Dr. [**Last Name (STitle) **] at [**Hospital3 **] Oncology ([**Telephone/Fax (1) 79150**] and phoned to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of [**Hospital1 18**] Heme/Onc([**Telephone/Fax (1) 112319**] Please call to schedule the following: Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] R. [**Telephone/Fax (1) 31293**] in [**3-13**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2194-10-12**]

[ "V58.61", "397.0", "E932.0", "389.9", "283.0", "V12.51", "V12.55", "V45.79", "V15.82", "493.90", "249.00", "279.01", "429.89", "415.19" ]

icd9cm

[ [ [] ] ]

[ "38.97", "37.33", "39.61", "88.72" ]

icd9pcs

[ [ [] ] ]

10968, 11029

7263, 9386

391, 437

11324, 11480

5570, 7240

12365, 13536

4437, 4770

9877, 10945

11050, 11249

9412, 9854

11504, 12342

11271, 11303

4785, 5551

271, 353

465, 3051

3095, 3998

4014, 4421

1,946

159,092

4881+4882

Discharge summary

report+report

Admission Date: [**2174-10-17**] Discharge Date: [**2174-11-7**] Date of Birth: [**2117-8-17**] Sex: F Service: MEDICINE CHIEF COMPLAINT: Abdominal pain. HISTORY OF PRESENT ILLNESS: This is a 57 year old female with complicated past medical history including L4-L5 osteomyelitis with VRE on Linezolid, pancytopenia secondary to Linezolid, who presents with a four day history of nausea and vomiting and abdominal pain. The pain was worse postprandially. It did not radiate. There was no hematemesis, no bright red blood per rectum, no melena, however, she did have diarrhea. She denies fever, but did have subjective chills, no shortness of breath, chest pain or dysuria. PAST MEDICAL HISTORY: 1. Status post L4-L5 fusion and laminectomy with an osteomyelitis in the same region with Vancomycin resistant Enterococcus. 2. Anemia felt to be secondary Linezolid. 3. Guaiac positive stool on her previous admission. 4. Hypertension. 5. Osteoarthritis. 6. History of peptic ulcer disease. 7. Migraines. 8. Depression. 9. Hypothyroidism. 10. Status post cervical spine fusion. 11. History of tibial fracture, status post motor vehicle accident. 12. History of urinary tract infection. 13. B12 deficiency. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Lopressor 25 mg three times a day. 2. Iron Sulfate 325 mg once daily. 3. Colace 100 mg twice a day. 4. Protonix 40 mg once daily. 5. Oxycodone 10 mg p.o. q4hours p.r.n. 6. Miconazole Powder. 7. B12 injection monthly. 8. Linezolid 600 mg p.o. twice a day. 9. Levoxyl 175 mcg daily. 10. Imipramine 50 mg p.o. q.h.s. SOCIAL HISTORY: The patient does not smoke and does not drink. She denies intravenous drugs. She lives alone. She is a former cashier. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: On admission, temperature is 98.1, heart rate 102, blood pressure 107/73, respiratory rate 18, oxygen saturation 100% in room air. In general, the patient is in no acute distress. Head, eyes, ears, nose and throat examination - The pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Dry mucous membranes. No jugular venous distention and no lymphadenopathy. The neck is supple. Cardiovascular is regular rate and rhythm, no murmurs, rubs or gallops. Lungs are clear to auscultation bilaterally. The abdomen shows positive bowel sounds, positive extract tenderness, no rebound, no guarding. Extremities - no lower extremity edema, palpable dorsalis pedis bilaterally. Back - no costovertebral angle or spinal tenderness. LABORATORY DATA: On admission, hematocrit was 18.0, white blood cell count 6.0, platelet count 114,000. Sodium 138, potassium 2.4, bicarbonate 16, blood urea nitrogen 25, creatinine 1.3, glucose 68, calcium 9.9, magnesium 1.7, phosphorus 2.7, lactate 4.1. ALT, AST, total bilirubin, and alkaline phosphatase normal. Amylase 1892, lipase 1480. Chest x-ray showed no evidence for pneumonia. Abdominal CT scan showed enlargement and edema of the head of the pancreas compatible with focal pancreatitis. Further near complete resolution of the retroperitoneal fluid collection and stranding at the L4-L5 level. Further reduction in fluid collection at the posterior abdominal wall over the surgical site of L4-L5 and decrease in anterior abdominal wall soft tissue fluid collection at the base of the surgical incision. HOSPITAL COURSE: 1. Pancreatitis - The patient was admitted to the Medicine service and was made NPO. She was placed on aggressive intravenous fluid hydration and had serial electrolytes monitored and repleted. The patient's pancreatitis resolved clinically after several days, however, no etiology for the patient's pancreatitis could be determined. The patient had a normal calcium level, normal triglycerides. There was no evidence of stones in the gallbladder or common bile duct. The common bile duct was not dilated on abdominal ultrasound. The patient was not a consumer of alcoholic beverages. It was felt that the etiology of the pancreatitis may have been viral or idiopathic. Despite the patient's pancreatitis resolving clinically and resolving based on amylase and lipase, the patient continued to have persistent mild epigastric tenderness and nausea. She was unable to eat secondary to these complaints and it was felt that she may be having mild persistent pancreatitis. She was started on total parenteral nutrition and received approximately one week of total parenteral nutrition. 2. Anemia - The patient was felt to have an anemia secondary to Linezolid marrow suppression. She had a reticulocyte count of 0.3 on her last admission, however, she did have guaiac positive stools on her previous admission. During this hospitalization, the patient's stools were initially guaiac negative, however, over the course of admission, they became guaiac positive. The patient underwent an esophagogastroduodenoscopy to evaluate for nausea and vomiting which revealed only mild gastritis. It is recommended that the patient have an outpatient colonoscopy, however, she will need to have serial hematocrit checks followed weekly, and she may need outpatient blood transfusions and/or Epogen injections as she will be on Linezolid for life time therapy. 3. VRE osteomyelitis - The patient was admitted on Linezolid and will need to remain on Linezolid therapy for the rest of her life as she has a severe osteomyelitis with spinal prostheses in place. 4. [**Female First Name (un) 564**] line infection and sepsis - The patient developed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 564**] line infection which resulted in tachycardia and resultant flash pulmonary edema requiring admission to the Medical Intensive Care Unit. She was initially felt at high risk for pulmonary embolism after developing tachycardia and acute hypoxia, however, she had a chest CTA which was negative for pulmonary embolus. She was initially started on AmBisome when her blood cultures grew [**Female First Name (un) 564**], however, once the species was revealed to be parapsilosis, the patient was changed over to Fluconazole 400 mg p.o. once daily. She will complete a fourteen day course of Fluconazole therapy ending on [**2174-11-15**]. An ophthalmology consultation was called to evaluate the patient for Candidal eye infection, however, she did not have any evidence of eye involvement with her [**Female First Name (un) 564**] infection. The patient responded well to antifungal therapy and was transferred back to the medical floor within 72 hours. 5. Urinary tract infection - The patient had a Klebsiella urinary tract infection. She was treated with a course of Levofloxacin. 6. Depression - The patient was felt to be clinically depressed. She was seen by the inpatient psychiatry service who recommended continuing the patient on her nightly Imipramine. The patient should have outpatient psychiatry follow-up. She was never felt to be severely depressed and was never suicidal or homicidal. 7. Hypothyroidism - The patient was continued on her Levoxyl. 8. Hypertension - The patient was started on Metoprolol 25 mg p.o. twice a day and her blood pressure should be followed up as an outpatient as her medication regimen may need adjustment. 9. Nausea - The patient complained of occasional nausea, however, she had a normal abdominal ultrasound, a normal abdominal CAT scan, that showed resolved pancreatitis, and an esophagogastroduodenoscopy which showed only mild gastritis. The patient's nausea was felt to be secondary to this mild gastritis and gastroesophageal reflux disease. However, there was also felt to be a component of psychosomatic pain and nausea. The patient will be discharged on p.o. Compazine 10 mg p.o. q6hours p.r.n. 10. Social - The patient was eager to return home, however, she was felt to be unsafe to return home as her p.o. intake was relatively poor and she had to be closely monitored. In addition, she was felt to lack the motivation to be able to adequately care for herself and she will require skilled nursing facility or acute rehabilitation on discharge. 11. Pericardial effusion - The patient was found to have a pericardial effusion on abdominal CAT scan. This was further evaluated with an echocardiogram which revealed only a small nonclinically significant pericardial effusion. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To rehabilitation facility. DISCHARGE INSTRUCTIONS: Please follow-up with primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], [**Telephone/Fax (1) 20371**], in one week. DISCHARGE DIAGNOSES: 1. Pancreatitis. 2. Acute anemia. 3. Hypokalemia. 4. Hypophosphatemia. 5. Hypocalcemia. 6. Depression. 7. VRE osteomyelitis. 8. Vitamin K deficiency, coagulopathy. 9. Nausea. 10. Gastritis. 11. [**Female First Name (un) 564**] sepsis, Candidal line infection/pulmonary edema. 12. Pericardial effusion. 13. Urinary tract infection. 14. Anxiety. 15. Malnutrition. 16. Vitamin B12 deficiency. 17. Pneumonia. MEDICATIONS ON DISCHARGE: 1. Vitamin B12 injection monthly. 2. Levoxyl 125 mcg daily. 3. Clonazepam 0.5 mg p.o. twice a day. 4. Ambien 5 mg p.o. q.h.s. p.r.n. 5. Vitamin D 400 units daily. 6. Protonix 40 mg daily. 7. Imipramine 50 mg p.o. q.h.s. 8. Linezolid 600 mg p.o. twice a day. 9. Metoprolol 25 mg p.o. twice a day. 10. Ativan 0.5 mg p.o. q6hours p.r.n. 11. Fluconazole 400 mg p.o. once daily until [**2174-11-15**]. 12. Compazine 10 mg p.o. q6hours p.r.n. for nausea. 13. Multivitamin daily. 14. Colace 100 mg p.o. twice a day. 15. Senna one tablet p.o. twice a day. DR [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] 12.986 Dictated By:[**Last Name (NamePattern1) 9609**] MEDQUIST36 D: [**2174-11-6**] 15:14 T: [**2174-11-6**] 16:43 JOB#: [**Job Number 20372**] Admission Date: [**2174-10-17**] Discharge Date: [**2174-11-8**] Date of Birth: [**2117-8-17**] Sex: F Service: This is the addendum for the discharge summary dictated for [**2174-11-7**]. The patient remained stable through the remainder of hospital course and her discharge was delayed by a day, because of placement issues. The patient was discharged with the same plans and medications as outlined on the discharge summary dated [**2174-11-7**]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**] Dictated By:[**Name8 (MD) 6906**] MEDQUIST36 D: [**2174-11-8**] 05:52 T: [**2174-11-11**] 20:19 JOB#: [**Job Number 20373**]

[ "577.0", "276.2", "117.9", "996.67", "599.0", "730.18", "996.62", "518.81", "284.8" ]

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32573

Discharge summary

report

Admission Date: [**2183-9-22**] Discharge Date: [**2183-10-1**] Date of Birth: [**2138-5-31**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 473**] Chief Complaint: Abdominal Pain Gallstone Pancreatitis Major Surgical or Invasive Procedure: None History of Present Illness: This is a 45 year old male transferred to [**Hospital1 18**] with a diagnosis of acute pancreatits, felt to be gallstone etiology. He was admitted to an outside hospital on [**2183-9-20**] complaining of 2 days of back pain and multiple hours of severe abdominal pain which had awoken him from sleep. His pain at the time was associated with nausea and vomiting, but no fever, chills, diarrhea, melena. At the time of his initial evaluation, his ALT/AST were 88/78, amylase/lipase were 3821/>3000 respectively. Abdominal CT scan demonstrated an edematous pancrease surrounding fat stranding and gallstones. His most recent LFT's ([**9-22**]) were normal and his A/L decreased to 729 and 2384. His admission WBC was 20.6 and is currently 15.1. Follow-up CT scan done earlier today demostrates interval worsening of the peripancreatic inflammation and edema and formation of new ascities. Past Medical History: Hypertriglyceridemia, hypothyroidism PSH: vasectomy, anal fistulotomy Social History: Occasional ETOH Denies tobacco Physical Exam: PE: 100.9, 116, 178/86, 16, 96% RA Gen: Alert + O x 3, in apparent discomfort, but not toxic or ill appearing. CV: Regular rhythn, tachycardia Chest: lungs clear bilat. Abd: firm, distended and tympanitic, tender on palpation in the mid-epigastric without rebound or guarding Ext: No peripheral edema Pertinent Results: [**2183-9-22**] 09:48PM BLOOD WBC-14.0* RBC-4.17* Hgb-12.4* Hct-35.8* MCV-86 MCH-29.8 MCHC-34.6 RDW-13.8 Plt Ct-286 [**2183-9-23**] 04:41AM BLOOD WBC-13.1* RBC-3.86* Hgb-11.4* Hct-33.7* MCV-87 MCH-29.7 MCHC-33.9 RDW-13.9 Plt Ct-247 [**2183-9-23**] 04:41AM BLOOD PT-14.7* PTT-34.3 INR(PT)-1.3* [**2183-9-23**] 04:41AM BLOOD Glucose-98 UreaN-7 Creat-0.6 Na-135 K-4.2 Cl-100 HCO3-27 AnGap-12 [**2183-9-22**] 09:48PM BLOOD ALT-19 AST-18 AlkPhos-49 Amylase-290* TotBili-0.5 [**2183-9-23**] 04:41AM BLOOD ALT-17 AST-15 AlkPhos-47 Amylase-208* TotBili-0.4 [**2183-9-22**] 09:48PM BLOOD Lipase-150* [**2183-9-23**] 04:41AM BLOOD Lipase-99* [**2183-9-23**] 04:41AM BLOOD Albumin-2.6* Calcium-7.8* Phos-2.0* Mg-1.8 . [**2183-9-26**] 07:31AM BLOOD WBC-17.6* RBC-3.89* Hgb-11.4* Hct-33.9* MCV-87 MCH-29.2 MCHC-33.5 RDW-13.7 Plt Ct-367 [**2183-9-29**] 06:28AM BLOOD WBC-27.6* RBC-4.24* Hgb-12.2* Hct-37.0* MCV-88 MCH-28.8 MCHC-32.9 RDW-13.7 Plt Ct-506* [**2183-9-29**] 06:28AM BLOOD Glucose-115* UreaN-10 Creat-0.9 Na-135 K-4.6 Cl-94* HCO3-29 AnGap-17 [**2183-9-29**] 06:28AM BLOOD ALT-35 AST-30 AlkPhos-93 Amylase-44 TotBili-0.7 [**2183-9-25**] 05:26AM BLOOD ALT-14 AST-12 AlkPhos-62 Amylase-46 TotBili-0.4 [**2183-9-29**] 06:28AM BLOOD Lipase-29 [**2183-9-26**] 07:31AM BLOOD Lipase-17 [**2183-9-29**] 06:28AM BLOOD Calcium-9.0 Phos-4.5 Mg-2.8* . ABDOMEN U.S. (COMPLETE STUDY) [**2183-9-23**] 3:23 PM IMPRESSION: 1. Diffusely increased liver echogenicity consistent with fatty infiltration. Other forms of liver disease and more severe forms of liver disease including significant fibrosis or cirrhosis cannot be excluded on this study. Suspicion for this is increased given the presence of splenomegaly. 2. Splenomegaly (14 cm). 3. Heterogeneous echogenicity of the pancreas and (tail not seen), which may be consistent with pancreatitis. No evidence of peripancreatic fluid or pseudocyst. 4. Cholelithiasis. 5. Small right pleural effusion. . CT PELVIS W/CONTRAST [**2183-9-27**] 2:38 PM IMPRESSIONS: 1. Severe pancreatitis, with necrosis of the pancreatic body, but no evidence of associated vascular complication or discrete collection to suggest pseudocyst. 2. Cholelithiasis. 3. Small simple left pleural effusion. Trace pericardial fluid. 4. Diffuse fatty infiltration of the liver. . Brief Hospital Course: This is a 45 year old male with gallstone pancreatit1s trasferred to [**Hospital1 18**] for care. He was admitted to the ICU for one night of close monitoring and then moved to the [**Hospital1 **]. Pain: He was ordered for a Dilaudid PCA. He was using this appropriately. Once tolerating clears, he was switched to PO meds. Pancreatitis: He was NPO/IVF. He was resuscitated with aggressive IVF. We obtained a US on HD 2. This showed diffusely increased liver echogenicity consistent with fatty infiltration. Other forms of liver disease and more severe forms of liver disease including significant fibrosis or cirrhosis cannot be excluded on this study. Suspicion for this is increased given the presence of splenomegaly (14 cm). Heterogeneous echogenicity of the pancreas and (tail not seen), which may be consistent with pancreatitis. No evidence of peripancreatic fluid or pseudocyst. Cholelithiasis. Small right pleural effusion. The ERCP team evaluated the patient and felt he did not need a ERCP at this time due to his Amylase and Lipase trending down. He went for repeat CT on [**2183-9-27**] and this showed Severe pancreatitis, with necrosis of the pancreatic body, but no evidence of associated vascular complication or discrete collection to suggest pseudocyst. Cholelithiasis. Clincally he look good and he was not complaining of pain. We were able to advance his diet from clears to a low fat diet on [**2183-9-29**]. Leukocytosis: His WBC was 27.6K on [**9-29**]. A repeat WBC was 20. He was assymptomatic. FEN: He was started on clears and we slowly advanced his diet along. He was still quite distended on HD 4 and was reporting +flatus. He had a bowel movement prior to discharge. Hypertension: He was hypertensive to the SBP 160's. He was treated with Lopressor and Hydralizine. Medications on Admission: Gemfibrozil, levothyroxine 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. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 3. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Gallstone Pancreatitis Leukocytosis Discharge Condition: Good Tolerating a diet Pain well controlled Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to amubulate several times per day. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 468**] in 2 weeks on Monday [**2183-10-13**]. Call [**Telephone/Fax (1) 2835**] to schedule an appointment. Completed by:[**2183-10-1**]

[ "244.9", "288.60", "789.59", "272.1", "577.0", "574.20" ]

icd9cm

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icd9pcs

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8046

Discharge summary

report

Admission Date: [**2158-7-26**] Discharge Date: [**2158-8-23**] Date of Birth: [**2100-4-27**] Sex: F Service: NEUROLOGY Allergies: Latex Attending:[**First Name3 (LF) 2569**] Chief Complaint: left-sided weakness and dysarthria Major Surgical or Invasive Procedure: EVD placement and removal intubation with subsequent extuabtion [**8-9**]. Tracheostomy placement [**8-9**] PEG placed [**8-21**] History of Present Illness: 58 RHW with HTN was brought to ED for evaluation. She was travelling in T- Train this pm around 6 pm. She was noted to be suddenly dysarthric and not able to move her left side by the co passengers. She was crying in pain due to severe headache. 911 was called. Her Blood pressure at the scene was above 220/100. She was given morphine 4 mg IVand hydralazine 10 mg. She was taken to OSH. At OSH, Blood pressure was 195/100. Labs : WBC 6.6, Hb 13, Plt 291. Chem 7 was normal. INR 1.1. CT head showed right thalamic bleed. She was transfered to [**Hospital1 18**] for evaluation. Code stroke was called. In the [**Hospital1 18**] ED, he was still complaining of severe HA and was yelling at everyone in the room. She was very uncooperative and agitated. Per husband, she is stressed out secondary to financial reasons lately. Past Medical History: Hypertension Social History: Lives with husband,drinks significant amount of alcohol and smokes more than a pack per day. Four children living in area. No drug abuse. Her husband reports that she has been very stressed about her job ([**Location (un) 86**] Market) because she was recently transferred to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 392**] location and she does not drive. Family History: Strokes in multiple members Physical Exam: ON ADMISSION: Vitals: BP 205/100, HR 90, RR 18, 100 RA General: agitated and yelling, non cooperative. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR,occasional PVCs nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, yelling at everyone. can tell the name but not the place or date. not Able to relate history. Language is not fluent with impaired repetition. grossly intact comprehension. Naming impaired. Speech was dysarthric. Able to follow both midline and appendicular commands on right, difficulty following commands on left. neglect on the left and gaze deviation to the right side. When shown her lefrt hand, says its not her hand. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF seems to have some deficits on extreme left visual field. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: Left sided facial droop VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally. XII: Intact. -Motor: Normal bulk, tone, power throughout on right side. flaccid paraesis on left UE and LE. withdraws to pain on left. -Sensory: difficult to test on left side, though withdraws to pain. -DTRs: 2 plus on right, absent on left. Plantar response was extensor on left, flexor on right. . . Discharge exam: Alert E4 VT but can write M6 Tired and withdrawn Left hemiplegia with withdrawal in LLE and no movement in LUE Tracheostomy and PEG tube Abdomen - soft, mild upper abdominal tenderness and present bowel sounds Pertinent Results: Admission labs: [**2158-7-26**] 07:50PM BLOOD WBC-7.4 RBC-4.56 Hgb-14.2 Hct-40.8 MCV-90 MCH-31.2 MCHC-34.8 RDW-14.4 Plt Ct-368 [**2158-7-26**] 07:50PM BLOOD Neuts-52.8 Lymphs-40.6 Monos-2.7 Eos-3.0 Baso-0.8 [**2158-7-26**] 07:50PM BLOOD PT-11.6 PTT-23.9 INR(PT)-1.0 [**2158-7-26**] 07:50PM BLOOD Glucose-100 UreaN-17 Creat-0.7 Na-143 K-3.3 Cl-109* HCO3-23 AnGap-14 [**2158-7-26**] 07:50PM BLOOD Calcium-9.5 Phos-2.8 Mg-2.2 . Other pertinent labs: [**2158-8-20**] 12:50PM BLOOD PT-13.2 PTT-27.1 INR(PT)-1.1 [**2158-8-14**] 05:55AM BLOOD ALT-56* AST-24 AlkPhos-106* TotBili-0.3 [**2158-7-26**] 07:50PM BLOOD cTropnT-<0.01 [**2158-7-29**] 02:30AM BLOOD cTropnT-<0.01 [**2158-8-14**] 05:55AM BLOOD Albumin-3.8 Calcium-9.7 Phos-3.2 Mg-2.1 [**2158-7-27**] 03:54AM BLOOD Calcium-9.4 Phos-3.7 Mg-2.2 Cholest-219* [**2158-7-27**] 03:54AM BLOOD Triglyc-91 HDL-56 CHOL/HD-3.9 LDLcalc-145* [**2158-7-27**] 03:54AM BLOOD %HbA1c-5.8 eAG-120 [**2158-7-26**] 07:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . Osmolality and electrolytes [**2158-8-18**] 02:50PM BLOOD Glucose-77 UreaN-21* Creat-0.5 Na-129* K-4.5 Cl-93* HCO3-25 AnGap-16 [**2158-8-18**] 02:50PM BLOOD Osmolal-270* [**2158-8-18**] 11:04PM URINE Osmolal-616 [**2158-8-18**] 11:04PM URINE Hours-RANDOM Na-117 K-28 Cl-111 Urea-779 . Discharge labs: [**2158-8-23**] 05:50AM BLOOD WBC-6.0 RBC-3.31* Hgb-10.5* Hct-29.3* MCV-88 MCH-31.8 MCHC-36.0* RDW-13.4 Plt Ct-351 Glucose-123* UreaN-16 Creat-0.6 Na-125* K-4.2 Cl-87* HCO3-30 AnGap-12 Calcium-9.7 Phos-4.0 Mg-1.6 . Other urine: [**2158-7-26**] 08:10PM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-NEG amphetm-NEG mthdone-NEG . CT HEAD W/O CONTRAST Study Date of [**2158-7-27**] 12:54 AM FINDINGS: There has been marked interval increase in size of a right thalamic hematoma, which now measures 3.6 x 2.8 cm axially (2A:17). There is new blood extension into the right lateral ventricle with new slight leftward midline shift (2A:16). A trace amount of blood products is seen within the occipital [**Doctor Last Name 534**] of the left lateral ventricle (2A:15) and the fourth ventricle (2a:10). The suprasellar and quadrigeminal cisterns remain preserved. No new hemorrhage or large vascular territorial infarction is seen. IMPRESSION: Interval marked enlargement of a right thalamic hematoma, with lateral and 4th intraventricular extension and new mild leftward shift of midline structures. CT HEAD W/O CONTRAST Study Date of [**2158-7-28**] 2:19 PM Again noted is a right thalamic hemorrhage with intraventricular extension. A right frontal approach ventriculostomy catheter terminates in the left lateral ventricle appropriately. There is a small amount of subarachnoid hemorrhage in the right frontal region at the burr hole site. The ventricles and sulci are normal in size and configuration. The visible paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: Unchanged right thalamic hemorrhage with intraventricular extension and small amount of subarachnoid hemorrhage at burr hole entry site. No new areas of hemorrhage noted. . CT NECK W/O CONTRAST (EG: PAROTIDS) Study Date of [**2158-8-7**] 8:44 AM IMPRESSION: 1. Short (approximately 1.5 cm) segmental circumferential mural edema involving the subglottic trachea, commencing 2 cm inferior to the level of the true vocal cords, which may correspond to the findings on examination. No associated extrinsic compression upon or compromise of the endotracheal tube. 2. Laryngeal skeleton is grossly intact, with no discrete evidence of fracture of the laryngeal or arytenoid cartilages. . CHEST (PORTABLE AP) Study Date of [**2158-8-7**] 4:20 AM Both lungs are clear. No consolidation or pulmonary edema Improved left pleural effusion. . CHEST (PORTABLE AP) Study Date of [**2158-8-14**] 5:02 PM FINDINGS: In comparison with study of [**8-11**], the nasogastric tube extends to the distal stomach. Vague area of increased opacification in the retrocardiac region. Although most likely reflecting atelectasis, in the appropriate clinical setting, the possibility of supervening aspiration cannot be excluded. No evidence of vascular congestion. Tracheostomy tube remains in place. . Cardiology: ECG Study Date of [**2158-7-26**] 8:14:14 PM Sinus rhythm. Non-specific ST-T wave changes. No previous tracing available for comparison. Read by: [**Last Name (LF) **],[**First Name3 (LF) **] P. Intervals Axes Rate PR QRS QT/QTc P QRS T 92 188 88 372/428 71 -17 -21 . ECG Study Date of [**2158-8-9**] 11:16:02 AM Sinus bradycardia. Otherwise, normal tracing. Compared to the previous tracing of [**2158-7-26**] the rate is slower and ST-T wave abnormalities are no longer present. Read by: [**Last Name (LF) 2052**],[**First Name3 (LF) 2053**] J. Intervals Axes Rate PR QRS QT/QTc P QRS T 51 184 78 414/398 64 -4 4 Brief Hospital Course: Primary diagnoses: Right thalamic hemorrhage likely hypertensive in origin s/p EVD removal Tracheostomy [**3-1**] laryngeal edema and then collapse of the arytenoid cartilage Poor swallow post ICH s/p PEG . Secondary diagnoses: Ventilator-associated pneumonia with Pseudomonas on sputum Hyponatremia Hypertension Hyperlipidemia . . . 58 RHW with HTN was brought to the ED for evaluation of sudden onset left sided weakness and dysarthria. On examination, she had dysarthria, left sided neglect, left facial droop and left hemiplegia. Patient was significantly hypertensive (BP above 200/100) and CT head showed bleed in right thalamus. This was felt to be a primary hypertensive bleed. Patient was treated in the ICU and decompensated, requiring EVD insertion and intubation. ICPs were not significantly elevated and s/p EVD removal [**8-5**] and extubation with tracheostomy due to laryngeal edema on [**8-9**]. ICU course was complicated by VAP per [**8-3**] sputum Cx and was treated with 14 days of broad spectrum antibiotics. Patient continued to have severe left hemiplegia although patient was later more alert and able to appropriately respond to questions with head nodding and writing. Patient had problems with bleeding around tracheostomy and general surgery reviewed and this settled following sealant. S&S were unable to assess swallow due to secretion issues on taking the cuff down. Given continued secretion problems ENT to follow-up and re-assess tracheostomy as out-patient. Patient had PEG on [**2158-8-21**] and pain control post-procedure. Patient developed hyponatremia and this was felt likely SIADH in addition to diuretic use based on serum/urine Osm and electrolytes and patient was started concentrated PEG feed and hydrochlorothiazide was stopped. Patient was discharged to rehab on [**2158-8-23**]. Patient has neurology follow-up. NEURO: Patient with HTN presented with sudden onset left sided weakness and dysarthria. On examination, she had dysarthria, left sided neglect, left facial droop and left hemiplegia. Initial head CT at [**Hospital6 1597**] showed 2x2cm R thalamic hemorrhage. At [**Hospital1 18**], head CT showed enlargement to 3.6 x 2.8 cm with lateral and 4th intraventricular extension and new mild leftward shift of midline structures. Patient was significantly hypertensive (BP above 200/100) and ICH was felt to be a primary hypertensive bleed. Initial ED neuro exam was significant for agitation and yelling but not following commands, and L hemiparesis of face, arm and leg. Patient was transferred to the ICU. Patient then deteriorated and her consciousness level declined. Repeat head CT showed interval enlargement of ICH and neurosurgery was consulted emergently. Patient was treated with mannitol and however, as follow-up CT showed persistent evolution with intraventricular extension, an EVD was placed on [**7-27**]. She was intubated and sedated with propofol. The patient was observed closely in the neuro ICU. ICP remained low/normal, and EVD drained blood tinged CSF. The EVD was removed [**8-5**]. Sedation was weaned. The patient's neuro exam improved so that she was alert and able to follow commands on R side when off sedation. Minimal withdrawal to noxious on left side which did not significantly improve during her stay. Patient was often very withdrawn and low in mood and 20 mg was started on [**8-11**] for augmentation of rehab. Patient was extubated with tracheostomy due to laryngeal edema on [**8-9**]. Patient continued to have severe left hemiplegia although patient was later more alert and able to appropriately respond to questions with head nodding and writing. We addressed risk factors and there were no events on telemetry. BP has been well controlled on the floor. HbA1c was 5.8%. Lipid panel showed Chol 219 and LDL 149. Neurosurgery removed staples on [**8-17**]. S&S were unable to assess swallow due to secretion issues on taking the cuff down. Currently much better communication and writing very well. Given continued secretion problems ENT to follow-up and re-assess tracheostomy in 4 weeks. Patient had PEG on [**2158-8-21**]. Patient has neurology follow-up on [**2158-9-29**]. . CV: BP was initially controlled with nicardipine drip. This was weaned off prior to intubated, and BP then was controlled with PO home medications and hydralazine prn. Home hydrochlorothiazide was stopped due to hyponatremia. . PULM: The patient was intubated on [**7-27**] due to sedation. Extubation was attempted twice with the aid of steroids, furosemide, and fiberscope but was unable to be completed first due to laryngeal edema and then collapse of the arytenoid cartilage. ENT was consulted for evaluation but they saw no structural damage to the cartilage. Tracheostomy was placed [**8-9**]. Treated for VAP since [**8-6**] and sputum from [**8-3**] grew pseudomonas sensitive to cefepime and received a 14 day total antibiotic course. Patient had oozing from around her tracheostomy and general surgery were consulted and felt no intervention was required. Oozing settled post surgiseal plug. S&S were unable to assess swallow due to secretion issues on taking the cuff down. General surgery removed sealant around tracheostomy. Given continued secretion problems ENT to follow-up and re-assess tracheostomy on [**2158-9-20**]. . # Hyponatremia: Patient has had low Na since [**8-17**]. At lowest 126, currently 128. Seemed to improve with IVF. Currently euvolemic. High urine Osm 616 vs serum Osm 270 UNa 117. Likely SIADH and was started on concentrated PEG feed and hydrochlorothiazide was stopped. Discharge Na 125. To check electrolytes regularly at rehab to ensure correct formulation for Na level and to monitor hyponatremia. # ID: The patient was noted to be febrile with leukocytosis [**7-31**]. She was pan-cultured but all cultures were negative. On [**8-3**] a sputum culture grew pseudomonas. [**8-6**] Zosyn and Cipro were started for VAP. Cipro was stopped and replaced later that day by Tobramycin. [**8-9**] both Zosyn and Tobramycin were stopped and Cefepime was started in its place based on sensitivities. Patient was treated with a 14 day course of antibiotics which were stopped on [**8-20**]. . # GI: Given her neurological status, an NG tube was placed for nutrition and she was given tube feeds. Speech and swallow saw her on [**8-11**] and was unable to complete the eval due to secretions. PEG tube was placed [**2158-8-21**] and pain post-procedure was treated with PRN oxycodone. . # Renal: Hyponatremia as above. Na on discharge 125. Renal function stable. . # Endo: No prior history of DM. HbA1c 5.8%. Blood glucose monitored and remained controlled on HIS. . # Psych: Patient likely reactive depression and was apathetic and at times tearful but latterly more alert and communicative. Started citalopram in ICU and there is scope to increase dose. . . Code: FULL code . Communication: Husband: [**Telephone/Fax (1) 28763**] (home) [**Telephone/Fax (1) 28764**] (cell) . . Transitional issues: S/p tracheostomy - to be reviewed by ENT as above as an out-patient S/P PEG - some pain at site. Benign exam. Monitor pain and giving PRN oxycodone Hyponatremia - Na 125 on discharge. Will need to be closely monitored and PEG feed altered accordingly Medications on Admission: HCTZ 25 mg once per day Diltiazem- XR 120 mg once per day. According to her husband she in taking 60mg twice per day. Discharge Medications: 1. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for dry eye. 2. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day) as needed for dvt prophylaxis. 3. senna 8.8 mg/5 mL Syrup Sig: Five (5) ML PO BID (2 times a day). 4. docusate sodium 50 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 4-6 Puffs Inhalation Q4H (every 4 hours) as needed for SOB, wheezing. 6. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for erythema, irritation. 7. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 10. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H (every 6 hours): Started on [**8-22**] post peg; can be discontinued or made PRN. 11. oxycodone 5 mg/5 mL Solution Sig: One (1) PO Q4H (every 4 hours) as needed for pain: For pain related to PEG. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Thalamic hemorrhage, likely hypertensive. Secondary Diagnosis: Hypertension Hyperlipidemia Pseudomonas Pneumonia Hyponatremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Neurologic: Left hemiparesis. Follows commands on the right. Can communicate via writing, but this is often non-sequitor. Tracheostomy and PEG in place. Followup Instructions: We made the following appointments for you. You shodul also see your PCP on discharge. . Department: OTOLARYNGOLOGY (ENT) When: WEDNESDAY [**2158-9-20**] at 11:15 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], M.D. [**Telephone/Fax (1) 41**] Building: LM [**Hospital Unit Name **] [**Location (un) 895**] Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE . Department: NEUROLOGY When: FRIDAY [**2158-9-29**] at 2:30 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD [**Telephone/Fax (1) 2574**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

[ "305.1", "311", "331.4", "342.02", "997.31", "784.51", "348.5", "996.75", "478.6", "401.9", "041.7", "253.6", "599.71", "272.4", "E879.8", "431" ]

icd9cm

[ [ [] ] ]

[ "02.39", "43.11", "31.1", "96.72", "96.6", "33.22", "99.10", "33.29" ]

icd9pcs

[ [ [] ] ]

17189, 17259

8603, 8810

302, 433

17430, 17430

3746, 3746

17720, 18586

1734, 1764

16046, 17166

17280, 17323

15903, 16023

5075, 8580

2788, 3499

1779, 1779

8831, 15604

3515, 3727

15625, 15877

228, 264

461, 1288

17344, 17409

3762, 4171

4193, 5059

1793, 2321

17445, 17697

1310, 1325

1341, 1718

26,544

139,805

8075+55909

Discharge summary

report+addendum

Admission Date: [**2110-11-14**] Discharge Date: [**2110-12-5**] Date of Birth: [**2041-11-27**] Sex: M Service: MICU ADMISSION DIAGNOSIS: 1. Respiratory failure. 2. CV instability. HISTORY OF PRESENT ILLNESS: Patient is a 68-year-old male with a history of type 2 diabetes who presented with a history of subjective chills times one day prior to admission. On the PM of admission per report, the patient's eyes "glazed over" during dinner. The patient had nausea, positive fever / chills, positive shortness of breath, positive facial flushing. No vomiting, abdominal pain or sick contacts or suspect food. Per report, the patient was driving erratically to dinner and once tripped. The family took the patient to the emergency room where his temperature was 101.2 F, respiratory rate of 20, blood pressure 165/82. The patient was saturating at 89% on room air. The patient was reportedly stable until he developed an episode of lip smacking and became unresponsive with rigors "neuro curbsided and doubted there were seizures". Patient was 75% on nonrebreather, withdrawing to pain and was intubated secondary to decreased O2 saturation and airway protection. ABG at that time was 7.24 / 73 / 76 with a lactate of 1.2. Patient was covered with Ceftriaxone, Vancomycin and admitted to the MICU (source family, ER resident). In the MICU, the patient was febrile with a temperature of 103.0 F, blood pressure 180/130 to 85/40, pulse 123, respiratory rate 12, 96% on ventilation, AC 700 by 12, fio2 of 0.6. PHYSICAL EXAMINATION: In general the patient was an intubated and sedated elderly man with small minimally reactive pupils with mild conjunctival irritation. The right TM was clear. The left not visualized. ET and OT tubes were in place. Patient was flushed. CV: Tachycardia, regular rate and rhythm, S1, S2, no murmurs, rubs, or gallops. Respiratory: Breath sounds bilaterally, right greater than left. Anterior greater than posterior, lower lung volume symmetric, negative rales. Abdomen: Positive bowel sounds, soft, no masses. Rectal: Heme positive grossly brown stool. Extremities: Pulses intact, warm, mild follicular rash on chin, mild edema, no cyanosis or clubbing. Neuro: Toes down, normal ................, patient non-responsive. PAST MEDICAL HISTORY: 1. Type 2 diabetes. 2. Hypercholesterolemia. 3. Status post disc surgery. 4. Chronic sinusitis. 5. History of "difficulty swallowing". 6. Hemorrhoids. SOCIAL HISTORY: Patient is married, no alcohol use, no intravenous drug use. Remote tobacco history. Patient is retired. HOME MEDICATIONS: 1. Metformin 1 gram b.i.d. 2. Zestril 5 mg q.d. 3. Glyburide 10 mg b.i.d. 4. Lipitor 10 mg q.d. 5. Ibuprofen for pain. ALLERGIES: No known drug allergies. LABORATORY ON ARRIVAL: White blood cell count 11.1, hematocrit 45, platelets 207. Sodium 147, potassium 4.8, chloride 104, bicarbonate 27, BUN 24, creatinine 1.1, glucose 171. PT 23.2, PTT 13.2, INR 1.2. AST 28, ALT 28, alkaline phosphatase 85, TB of 0.5. ER arterial blood gas 7.24 / 73 / 76 on face mask. Urinalysis negative, RBCs three to five. Chest x-ray notable for poor inspiration, diaphragm not visualized, wide mediastinum. EKG normal sinus rhythm, normal axis, question of left atrial abnormality. [**11-15**] head CT Scan negative intracranial pathology, left maxillary sinus opacified. [**11-16**] abdominal CT Scan of the torso showed bilateral atelectasis, no effusion, spinal degenerative joint disease. Echo [**11-18**] showed left atrium, long axis dimension of 4.2 cm, TR gradient of 28 mgHg, inclusion left atrium mildly dilatated, left ventricular wall thickness, cavity size and systolic function normal. LVEF of greater than 55%, mild AV stenosis, trivial MR, mild pulmonary hypersystolic hypertension, trivial physiologic pericardial effusion. Impression: Mild aortic stenosis, preserved global biventricular systolic function with no pathologic valvular regurgitation seen. CSF fluid from [**11-17**]: White blood cells 33, RBCs 0, polys 11, lymphs 61, monos 26, eos 2 from bottle #3. From bottle #1 white blood cells 32, red blood cells 0, polys 25, lymphocytes 46, monos 28, eosinophils 1. From CSF from [**12-3**] from tube #4 with white blood cells [**Pager number **], RBCs 760, polys 0, lymphs 87, monos 10, eos 3. From tube #1 with white blood cells 10, RBCs 515, polys 0, lymphs 93, monos 3. [**11-17**] protein was 87. glucose was 131. From [**12-3**] protein 138, glucose 131. CK #1 1437, troponin less than 0.3, CK MB of 5. CK #2 1240, troponin less than 0.5, CK MB 3. CK #3 352, CK MB of 1. CK level on [**12-1**] was 352. Blood cultures 12/03 catheter tip with no growth. [**11/2110**] blood culture pending. [**11-30**] coag negative, staph one out of two bottles. [**11-21**] blood culture no growth. [**11-20**] blood culture no growth. [**11-18**] blood culture no growth. [**11-16**] blood culture no growth. [**12-2**] sputum consistent with corny bacterium and Propionibacterium species. Sputum from [**11-24**] gram negative rods, rare consistent oropharyngeal flora, pseudomonas, aeruginosa sparse growth. Sputum [**11-21**] no microorganisms seen. Sputum [**11-21**] contaminated oropharyngeal secretions. Respiratory culture from [**11-23**] negative. Sputum [**11-18**] oropharyngeal secretions, negative. Sputum [**11-16**] negative. Urine culture [**12-1**] no growth. Urine culture [**11-21**] no growth. Urine culture [**11-19**] no growth. H.pylori from [**11-28**] negative. Clostridium difficile from [**11-28**] negative. [**11-18**] Legionella urine antigen negative. [**11-17**] PCR result for HSV positive. CT Scan of the chest [**11-18**], impression 1) trace bilateral pleural effusions with bibasilar atelectasis, 2) no evidence of interstitial lung disease, 3) apparent access collapse of left main stem bronchus as well as portions of the trachea suggestive of tracheobronchial malaise. MRI [**11-18**], impression confluent T2 hyperintensity in the anterior medial aspect of the right temporal lobe and much of the right insula with questionable subtle T2 hyperintensity in the medial left ................. and portion of the insula. Slight mass effect pattern. Abnormalities compatible with clinically suspected herpes encephalitis. MRI [**11-28**] since previous MRI study [**11-18**], there has been further progression of right temporal lesion with extension to the right frontal lobe and slightly increased mass effect and edema. Findings consistent with clinical diagnosis of herpes encephalitis. No evidence of hydrocephalus. EEG of [**12-1**], abnormal EG to slow background with additional bursts of delta frequency slowly seen suggestive dysfunction of the deep midline structures which could be seen with an encephalopathic process. No electrographic seizures recorded during the tracing. [**11-21**] EEG, abnormal EEG to slow background with additional bursts of slowing. In additional there are periodic sharp discharges from the right frontal region suggestive of focal destructive legion. [**11-19**] EEG, abnormal EEG due to slow background with occasional bursts of generalized slowing suggestive of dysfunction of the deep midline structure consistent with an encephalopathic process. Head CT Scan [**11-14**], impression no evidence of acute intracranial hemorrhage or edema. Well circumscribed high attenuation focus in a completely opacified left maxillary sinus. Chest x-ray [**12-3**] new left PICC line tip is double-backed approximately 7 mm within the left brachiocephalic vein, unchanged cardiomegaly. [**11-30**] portal chest with no change in appearance of mild diffuse interstitial edema, nonspecific increased intensity persists in the left base without change. Chest x-ray of [**11-17**] mild congestive heart failure worsened since exam from previous day, bilateral pleural effusion. [**11-16**] with no evidence of pneumonia, pneumothorax with no previous films for comparison. HOSPITAL COURSE: 1. INFECTIOUS DISEASE / MENTAL STATUS CHANGE / HSV ENCEPHALITIS: On admission patient empirically covered with Ceftriaxone and Vancomycin for empiric meningitis coverage and Ceftriaxone and Azithromycin for pneumonia coverage. The patient was pan cultured. An LP was attempted, but unsuccessful secondary to significant spinal stenosis. On [**11-15**] the patient experienced rapid blood pressure decline which necessitate aggressive fluid resuscitation and pressors with stress dose steroids provided. By [**11-17**], the patient demonstrated clinical improvement. Patient self extubated himself in the AM and was alert and communicative by writing, however during the day, the patient deteriorated with confusion and somnolence. The patient was reintubated on [**11-17**] in the PM. An LP was performed by Interventional Radiology. CSF results came back later with a white blood cell count of 3.3, red blood cell count of 0, clear and colorless, protein 87, glucose 81. Tube #1 white blood cell count of 32, RBCs of 0. Acyclovir was initiated on [**11-18**]. A MRI was performed on the brain on [**11-18**]. The MRI showed increased intensity in the temporal uncal ................ lower lobe consistent with HSV encephalitis. An EEG was also performed consistent with HSV encephalitis. Subsequent PCR from the lumbar puncture was positive for HSV. Throughout hospitalization, the patient continued to be intermittent febrile. Numerous blood cultures, sputum cultures and x-rays were performed. Notable findings include a chest x-ray demonstrative of a left lower lobe pneumonia versus atelectasis. Therefore a 14 day course of Zosyn was initiated for possible pneumonia / tracheobroncheolitis. The sputum was also positive for pseudomonas sensitive to Zosyn. Subsequent sputum and blood cultures were negative for growth. A repeat LP was performed on [**2110-12-3**]. Tubes were positive for white blood cells of [**Pager number **], RBCs 760 with 0 polys and 87 lymphs. White blood cell [**Pager number **], RBCs 515, polys 0, lymphs 93. It was felt that the elevated white blood cell count was secondary to encephalitis. The gram stain was notable for no organisms and the fluid culture was pending. The patient's overall mental status declined. Respiratory failure was felt to be secondary to HSV encephalitis and a 21 day course of Acyclovir was continued throughout his hospital course. 2. RESPIRATORY FAILURE: Patient intubated on [**11-15**] for respiratory failure. Patient self extubated himself on [**11-17**]. He was reintubated that evening for control of continued respiratory decline. The patient has been ventilated. On discharge patient well ventilated on pressor support. Vent mask ventilation had been attempted several times most recently on [**12-3**] and [**12-4**]. A trach was placed on [**2110-11-25**]. 3. NEURO: Patient has been comatose through the majority of his hospitalization. Neuro exam notable for intermittent spontaneous opening of eyes. Over the last two days, patient has opened eyes to commands, moved head bilaterally to individual voices, able to smile and intermittently follow commands with right hand and wiggle right toes. Hospitalization complicated by episodes of seizures (left arm / leg and right arm / right face). Patient was placed on Dilantin. Originally, the patient continued to have seizures despite supratherapeutic level. However there was also question of right arm jerking. An EEG performed demonstrated lack of seizure activity hence the Dilantin level was decreased and the phenytoin level was allowed to drift down. On discharge, the patient was placed 200 mg IV b.i.d. dose of Phenytoin. Phenytoin level should be checked at outpatient facility every other day. Free Phenytoin level should be obtained as the phenytoin level is a less accurate level than free phenytoin level. 4. DIABETES: Type 2 diabetes with uncontrolled glucose level. The patient was originally placed on an insulin drip. Patient transitioned to b.i.d. NPH insulin scale. On [**12-5**] patient transferred to home medications of Metformin and Glyburide with insulin sliding scale. Insulin should be addressed at an outpatient facility. 5. GASTROINTESTINAL: J tube placed on [**11-26**]. By discharge patient tolerated tube feeds at 80 cc an hour. Note was made of the [**Location (un) **] ulcer. H.pylori was negative. 6. CARDIAC: Patient ruled out initially given elevated CK levels. CK levels subsequently went down. Patient also obtained echo given evidence of possible heart failure on chest x-ray. Results demonstrated LV ejection fraction of greater than 55% with some pulmonary systolic hypertension. The patient's ins and outs should be kept equal. 7. PROPHYLAXIS: Patient on heparin / IV Protonix. 8. CODE: Full. 9. ACCESS: Throughout hospitalization patient had A line and right IJ. Both were discontinued prior to discharge and PICC line was placed for IV antibiotics. DISCHARGE DIAGNOSIS: 1. HSV encephalitis. 2. Chronic sinusitis. 3. Respiratory failure. 4. Coma. DISCHARGE STATUS: Discharged to rehab facility. CONDITION ON DISCHARGE: Fair. DISCHARGE MEDICATIONS: 1. Albuterol neb solution, one neb IH q. three to four p.r.n. 2. Ibuprofen 200 to 400 mg p.o. NG q. four to six home p.r.n. 3. Acyclovir 950 mg IV q. eight. Continue through [**12-10**]. 4. Milk of Magnesia 30 mg p.o. q. six hours p.r.n. constipation. 5. Bisacodyl 10 mg p.r. q.d. p.r.n. constipation. 6. Heparin 5000 subcu q. eight hours. 7. Potassium chloride 40 mEq per 100 ml for K less than 3.5. 8. ............... sodium liquid 100 mg p.o. b.i.d. 9. ................. suspension 0.5 ml p.o. q.i.d. p.r.n. swish and swallow. 10. Glyburide 10 mg p.o. b.i.d. 11. Metformin 1000 mg p.o. b.i.d. 12. Phenytoin 200 mg IV q. 12 hours. 13. Lansoprazole oral solution 30 mcg NG q.d. p.r.n. 14. Acetaminophen 325 mg ................. p.r. q. six for fever. FOLLOW UP: Patient will follow up with neurologist, Dr. [**Last Name (STitle) 28841**] within one month. Patient will follow with primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 28842**] [**Name (STitle) 1683**] within one month. REHAB CARE: Patient should have appropriate pulmonary toilet for trach. Patient should have appropriate tube feeds and GI care for J tube. Patient should have Physical Therapy and Occupational Therapy. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**] Dictated By:[**Last Name (NamePattern1) 201**] MEDQUIST36 D: [**2110-12-5**] 12:51 T: [**2110-12-5**] 13:25 JOB#: [**Job Number 28843**] Name: [**Known lastname 5049**], [**Known firstname 116**] Unit No: [**Numeric Identifier 5050**] Admission Date: [**2110-11-14**] Discharge Date: [**2110-12-10**] Date of Birth: [**2101-11-28**] Sex: M Service: 1. Neurologic. Over the past four days patient has improved neurologically. He is currently responding to his name by opening his eyes, moving his head, tracking objects from the side of the room and intermittently following commands including "squeeze your right hand" and "wiggle your right toes." The phenytoin dose was decreased to 200 mg IV q.eight to obtain a therapeutic free Dilantin level. The phenytoin level should be monitored every few days as an outpatient in the rehab facility. Should seizures stop, phenytoin may be discontinued in the future. 2. Diabetes control. Patient was switched from NPH to his home glyburide and metformin with an aggressive sliding scale of insulin. 3. Respiratory status. Respiratory failure. Patient was able to maintain 12 hour periods of tracheal mask ventilation. 4. Ins and outs. Patient is slightly positive given his IV fluids. Therefore, we added Lasix 10 mg p.o. q.d. dose. Patient's ins and outs should be monitored as an outpatient to maintain a net even ins and outs flow. Lasix may be discontinued. DISCHARGE MEDICATIONS: 1. Albuterol nebs. 2. Ibuprofen 200 to 400 mg p.o. NGT p.r.n. 3. Acyclovir 950 mg IV q.eight hours, the last day being [**12-10**]. 4. Milk of magnesia 30 mg p.o. q.six hours p.r.n. 5. Bisacodyl 10 mg p.r. q.d. p.r.n. 6. Heparin 5000 units subcu q.eight hours. 7. Nystatin suspension 0.5 mg p.o. q.i.d. p.r.n. 8. Glyburide 10 mg p.o. b.i.d. 9. Metformin 1000 mg p.o. b.i.d. 10. Phenytoin 200 mg IV q.eight. 11. Lansoprazole 30 mcg NG q.d. p.r.n. 12. Acetaminophen 325 p.r.n. fever. 13. Sliding scale insulin 10 mg p.o. q.d. 14. Baby aspirin q.day. The patient will be transferred to UVO. Please see prior discharge summary for followup care. DR.[**Last Name (STitle) **],[**First Name3 (LF) 126**] 11-685 Dictated By:[**Last Name (NamePattern1) 3021**] MEDQUIST36 D: [**2110-12-10**] 08:41 T: [**2110-12-10**] 08:39 JOB#: [**Job Number 5051**]

[ "276.1", "473.9", "054.2", "428.0", "780.39", "518.81", "272.0", "038.9", "250.02" ]

icd9cm

[ [ [] ] ]

[ "96.72", "31.1", "96.6", "96.04", "43.11", "03.31", "33.23" ]

icd9pcs

[ [ [] ] ]

16071, 16961

13058, 13189

8043, 13037

2622, 8026

14020, 16048

1564, 2299

160, 206

235, 1541

2321, 2479

2496, 2604

13214, 13221