ChanBeDu/relevant_section_length · Datasets at Hugging Face

27,331

104,786

42946

Discharge summary

report

Admission Date: [**2121-12-13**] Discharge Date: [**2121-12-20**] Date of Birth: [**2054-11-25**] Sex: M Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 3326**] Chief Complaint: AMS, hallucinations Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 92689**] is a 67 yo male with metastatic colon cancer s/p first and second line chemotherapy now on Erbitux who was admitted on [**2121-12-13**] with mental status changes. He was then transfered to the [**Hospital Unit Name 153**] for tachycardia, tachypnea, and hypoxia. Please see moonlighter H&P on [**2121-12-13**] and [**Hospital Unit Name 153**] H&P on [**2121-12-15**] for full details. Briefly, per notes, the patient began hallucinating during the days before admission, followed by increased somnolence, incoherence, and lethargy without history of falls. Per family, he had not had any narcotics in [**1-4**] days before admission. . On arrival to the Emergency Department, VS were T 94.1; HR 102; BP 118/66; RR 18; 100 % RA. He received CT Head which was negative for bleed. Labs remarkable for worsening LFTs, hypokalemia, and mild leukocytosis with left shift. He was hydrated with 2L IVFs and given empiric Vancomycin/Clinda/Ceftazidime. . On the floor he became tachypneic and dropped his satts from 98/2L to 88/4L. He was put on a NRB on which the satts improved to 95%. He was afebrile, RR 35, HR 120, BP 130/70. He denied CP, SOB, dizziness, palpitations. Per family his MS improved last night in the ED as compared to what it was in the afternoon on the day of admission. However it worsened this afternoon and continues to be the same. He was somnolent, was waking up to answer questions and then drifting back to sleep, was AAO x 3. He was started on heparin drip for suspected PE. His ABG showed 7.56/19/64 on NRB. He was xferred to the [**Hospital Unit Name 153**] for closer monitoring. . In the [**Hospital Unit Name 153**] he was stable from a hemodynamic and respiratory standpoint and quickly was placed on RA, but he continued to wax and wane in terms of his mental status. A CTA showed no large PE (assessment for small PE limited by artifact) and he had negative LE doppler U/S's. He received a diagnostic paracentesis which did not reveal SBP. A head CT w/ and w/o contrast was negative for intracranial process. Given his negative work-up and stability, he was called out to the oncology floor. . Upon seeing the patient, he is somnolent, mildly tachypneic, oriented x 2 (his name, place). He does not intelligibly cooperate with further history other than to deny HA, abdominal pain, CP and endorse SOB. . Past Medical History: 1. Diverticulitis 2. Osteoarthritis s/p bilateral knee replacement . ONCOLOGIC HISTORY: Mr. [**Name14 (STitle) 92690**] initially presented with abdominal pain, which was not relieved with routine measures. A CT scan of the abdomen and pelvis in [**2121-5-2**] demonstrated a soft tissue mass at the base of the cecum concerning for malignancy. Because of symptoms, he was taken to the OR and a right colectomy was performed with a primary anastomosis. A liver biopsy was also performed. The pathology from the resected specimen demonstrated metastatic adenocarcinoma in the liver resection consistent with a colonic primary, and the colon lesion demonstrated a low-grade, moderately differentiated lesion in the sigmoid colon. The patient was initially treated with FOLFOX with avastin, on which he progressed. Then on capecitabine, oxaliplatin with avastin. He was most recently started on Erbitux. Social History: The patient quit smoking 26 years ago and drinks occasionally. Family History: Remarkable for an aunt who had breast cancer in her 70s, a cousin who had breast cancer, the age is unknown; and an uncle who died of some form of leukemia in his 80s. He has no brothers or sisters but has a daughter who is healthy. Physical Exam: VS: T 98.9 HR 88 (87-129) BP 103/71 (83-118/55-88) RR 30 (23-37) 99%RA GEN: Chronically ill-appearing gentleman, comfortable, in no acute distress, somnolent, and difficult to arouse. Answers some simple questions. HEENT: Mildly icteric sclerae. PERRL. LUNGS: CTA bilaterally anteriorly without w/r/r CV: HRRR, no m/r/g ABD: distended abdomen with midline surgical scar. + BS. soft, NT. mild distension + fluid wave EXT: 2+ pitting edema b/L to knees. Distal upper extremities cold bilaterally. Distal LE warm. NEU: AO x 2 (name, place). Somnolent. does not cooperate with neurological exam other than moving fingers and toes on command bilaterally. Pertinent Results: [**2121-12-13**] 10:32PM GLUCOSE-77 UREA N-20 CREAT-0.8 SODIUM-137 POTASSIUM-2.8* CHLORIDE-99 TOTAL CO2-22 ANION GAP-19 [**2121-12-13**] 10:32PM ALT(SGPT)-54* AST(SGOT)-248* LD(LDH)-750* CK(CPK)-293* ALK PHOS-797* TOT BILI-5.2* [**2121-12-13**] 10:32PM CK-MB-4 cTropnT-0.05* [**2121-12-13**] 10:32PM CALCIUM-8.0* PHOSPHATE-1.9* MAGNESIUM-2.0 [**2121-12-13**] 10:32PM WBC-11.1* RBC-3.60* HGB-11.3* HCT-34.3* MCV-95 MCH-31.4 MCHC-33.0 RDW-20.4* [**2121-12-13**] 10:32PM PLT COUNT-120* [**2121-12-13**] 10:32PM PT-18.4* PTT-33.7 INR(PT)-1.7* [**2121-12-13**] 06:55PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-15 BILIRUBIN-MOD UROBILNGN-8* PH-6.5 LEUK-NEG [**2121-12-13**] 06:55PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2121-12-13**] 06:55PM URINE HYALINE-0-2 [**2121-12-13**] 05:59PM LACTATE-3.8* [**2121-12-13**] 03:06PM GLUCOSE-94 LACTATE-4.8* NA+-134* K+-3.0* CL--94* TCO2-25 [**2121-12-13**] 03:06PM HGB-12.3* calcHCT-37 [**2121-12-13**] 02:45PM GLUCOSE-110* UREA N-22* CREAT-1.0 SODIUM-133 POTASSIUM-2.8* CHLORIDE-93* TOTAL CO2-24 ANION GAP-19 [**2121-12-13**] 02:45PM ALT(SGPT)-60* AST(SGOT)-264* CK(CPK)-280* ALK PHOS-872* AMYLASE-30 TOT BILI-5.4* [**2121-12-13**] 02:45PM LIPASE-17 [**2121-12-13**] 02:45PM CK-MB-4 cTropnT-0.05* [**2121-12-13**] 02:45PM ALBUMIN-2.4* CALCIUM-8.2* PHOSPHATE-2.7 MAGNESIUM-2.3 [**2121-12-13**] 02:45PM WBC-11.6* RBC-3.80* HGB-12.1* HCT-37.3* MCV-98 MCH-31.8 MCHC-32.4 RDW-21.6* [**2121-12-13**] 02:45PM NEUTS-85.0* LYMPHS-10.3* MONOS-4.3 EOS-0.3 BASOS-0.2 [**2121-12-13**] 02:45PM PLT COUNT-133* [**2121-12-13**] 02:45PM PT-19.2* PTT-35.1* INR(PT)-1.8* [**2121-12-17**] 05:50AM BLOOD ALT-54* AST-274* CK(CPK)-369* AlkPhos-625* TotBili-4.8* [**2121-12-17**] 05:50AM BLOOD Ammonia-65* [**2121-12-14**] 05:02PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2121-12-17**] 06:16AM BLOOD Lactate-5.9* . BCx negative x 4 UCx negative x 2 Peritoneal fluid gram stain and culture negative . [**2121-12-13**] 4:35 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST CT ABDOMEN: Visualized lung bases demonstrate small bilateral pleural effusions, and minor bibasilar atelectasis. Widespread ill-defined intrahepatic nodules and masses are grossly unchanged when compared to [**2121-10-23**], and remain consistent with metastatic disease. As before, some of these masses are situated near the liver capsule, and deform the liver surface. The overall amount of ascites within the abdomen has increased. The gallbladder, pancreas, spleen, and adrenal glands are unremarkable. Kidneys enhance and excrete contrast symmetrically. There is no hydronephrosis. There is no free intraperitoneal air. Numerous small mesenteric lymph nodes are not significantly changed. CT PELVIS: Free fluid extends into the pelvis, and within the processus vaginalis, through an inguinal hernia into the left hemiscrotum. The urinary bladder is decompressed with a Foley catheter balloon in place. There is sigmoid diverticulosis, without evidence of diverticulitis. OSSEOUS STRUCTURES: Multilevel thoracolumbar degenerative changes are similar, and there is no sign of suspicious osteolytic or sclerotic lesion. Note is again made of prior left hip surgery. IMPRESSION: 1. Unchanged appearance of widespread intrahepatic metastatic disease. 2. Increased ascites. . CT C-SPINE W/O CONTRAST [**2121-12-13**] 4:34 PM CT CERVICAL SPINE: There is no fracture, or acute cervical spine malalignment. Prevertebral and paraspinal soft tissues are normal. There is no lytic or sclerotic bony lesion. Mild degenerative change is seen at the atlantodental interface anteriorly and superiorly, likely calcification of the apical dental ligament. Facet osteophytes result in mild neural foraminal narrowing on the left at C4/5, on the right at C5/6, and also on the left at C5/6. Broad-based posterior disc bulges at C3/4 and C4/5 result in mild-to-moderate central canal stenosis. Right paracentral disc bulge at C5/6 without significant canal narrowing. Visualized lung apices are unremarkable. The visualized brain parenchyma is unremarkable. IMPRESSION: No acute cervical spine fracture or malalignment. Multilevel degenerative changes, as described above, with mild-moderate ventral canal narrowing at C3/4 and C4/5 levels. . CT HEAD W/O CONTRAST [**2121-12-13**] 4:34 PM FINDINGS: There is no intracranial hemorrhage, mass, mass effect, or evidence of acute vascular territorial infarction. There is minimal periventricular white matter hypodensity, most consistent with chronic small vessel ischemic disease. The ventricles and sulci are normal in size and configuration. There is no fracture. Visualized paranasal sinuses are normally aerated. IMPRESSION: No acute intracranial process. . CHEST (PORTABLE AP) [**2121-12-13**] 4:52 PM CHEST PORTABLE: Comparison is made to a prior examination of [**2121-5-10**]. The heart is normal in size. There is an elevated hemidiaphragm. There is some linear opacity at the right base representing mild atelectasis. The pulmonary vasculature is normal. The lungs are otherwise clear. Port-A-Cath is identified with its tip in the right atrium. There are no pleural effusions. IMPRESSION: 1. No acute intrathoracic process. No evidence for pneumonia. 2. Mild atelectasis at the right base and elevation of the right hemidiaphragm are unchanged. . ECG Study Date of [**2121-12-13**] 2:35:26 PM Sinus rhythm. Non-diagnostic small Q waves in the inferior leads. Anterolateral ST-T wave changes which are non-specific. Low QRS voltage in the precordial leads. Compared to the previous tracing of [**2121-5-26**] anterolateral ST-T wave abnormalities are new. Clinical correlation is suggested. . CHEST (PORTABLE AP) [**2121-12-14**] 6:57 PM FINDINGS: In comparison with the previous examination, there are no major relevant changes. Due to projection, the pre-existing slight elevation of the hemidiaphragms is a little more visible. No evidence of substantial pleural effusions. The size of the cardiac silhouette is within the upper range of normal. No signs of hyperhydration. Mild atelectasis at the right lung base. No opacity suggestive of pneumonia. The Port-A-Cath is in standard position. IMPRESSION: No relevant change as compared to [**2121-12-13**]. No cardiac decompensation, no overhydration, no pneumonia. . [**2121-12-15**] 3:58 PM CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN [**Name Initial (PRE) **]: Metastatic colon cancer, NG tube placement. There is comparison with the prior from [**2121-12-15**] at 2:42 p.m. The NG tube is in the proximal stomach. There is some interval worsening in the right mid and lower lobe atelectasis and pulmonary edema. No other interval change. IMPRESSION: Standard position of NG tube. Interval worsening in atelectasis and pulmonary edema. . BILAT LOWER EXT VEINS [**2121-12-15**] 4:36 PM FINDINGS: Evaluation is limited secondary to severe edema bilaterally. The SVC in the mid and distal portions on the left were difficult to visualize, though the color flow in these sections appeared normal. Additionally, the exam was limited given patient discomfort and the right tibials and peroneals on the right were not visualized. Allowing for these limitations, the common femoral, superficial femoral, and popliteal veins on both right and left lower extremities demonstrated normal flow, augmentation, compressibility, and waveforms. No intraluminal luminal thrombus was identified. IMPRESSION: Limited exam, but no evidence to suggest DVT. . CHEST (PORTABLE AP) [**2121-12-15**] 2:36 PM FINDINGS: In comparison with the study of [**12-14**], the patient has taken a slightly better inspiration. The Dobbhoff tube extends to the lower body of the stomach. . CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2121-12-15**] 12:34 AM CT OF THE CHEST WITH IV CONTRAST: There is no evidence of pulmonary embolism, although assessment of the small segmental and subsegmental pulmonary arterial branches is somewhat limited by patient respiratory motion and contrast timing. There is no acute aortic abnormality. There are a few small mediastinal lymph nodes not pathologic by CT size criteria. There are small bilateral pleural effusions and associated dependent consolidation of the lower lobes, right greater than left. A previously identified subcentimeter right lower lobe pulmonary nodule is not well evaluated as it is present in the region of consolidated lung. No new nodules are identified. Limited evaluation of the upper abdomen demonstrates a large amount of ascites. Most of the visualized liver is occupied by confluent hypodense metastatic lesions. BONE WINDOWS: No suspicious lytic or sclerotic osseous lesions are identified. IMPRESSION: 1. No pulmonary embolism. However, there is poor filling of the segmental branches for the left lower lobe. If clinically indicated, a repeated CTA could be performed for better evaluation. 2. Small bilateral pleural effusions and consolidation of a portion of the dependent lower lobes, right worse than left. 3. Large amount of ascites and evidence of significant hepatic metastatic disease. These findings, including the need for further imaging if high clinical suspicion for PE were discussed with Dr. [**First Name8 (NamePattern2) 4311**] [**Last Name (NamePattern1) 4312**] at 12:30PM on [**2121-12-15**] by Dr. [**Last Name (STitle) **]. . CT HEAD W/ & W/O CONTRAST [**2121-12-15**] 12:33 AM CT OF THE HEAD WITHOUT AND WITH IV CONTRAST: There is no evidence of hemorrhage, shift of normally midline structures, mass effect, hydrocephalus or infarction. There is mild periventricular white matter hypodensity consistent with mild chronic microvascular infarction. There is no evidence of abnormal brain parenchymal enhancement or focal mass lesion. The paranasal sinuses and mastoid air cells are clear. The visualized osseous structures are unremarkable. IMPRESSION: No acute intracranial process. No evidence of intracranial metastatic disease. Brief Hospital Course: A/P 67-year-old gentleman with metastatic colon CA presenting with AMS . # Respiratory distress: CTA negative for large PE, though could not r/o small PE. CXR showed RLL atelectasis. PNA could not be completely ruled out. Exam and CXR dont support pulm edema. No echo in the system. LENIs were negative. He was given vanc and levo as well as albuterol and atrovent nebs. All cultures were negative. He was stabilized in the [**Hospital Unit Name 153**] and transfered to the floor. . # AMS - His mental status waxed and waned during his stay. He was minimally interactive by the time he was called out of the [**Hospital Unit Name 153**] to OMED. He had no intracranial disease by CT. His AMS was likely from hepatic encephalopathy vs infection, though there was little evidence of infection. He was given antibiotics as above as well as lactulose for possible hepatic encephalopathy. Mr. [**Known lastname 92689**] also showed evidence of seizure activity in the final days of his stay. Given his poor prognosis and acute decline, his family decided to transition to CMO status. All non-comfort meds were decreased. Palliative care was consulted. He passed on [**2121-12-20**]. . # ONCOLOGIC - Patient with widely metastatic colon CA s/p failed first and second-line chemotherapy, most recently started on Erbitux. Imaging as above. He was transitioned to CMO as above. . # LE edema: stable and chronic. d/c'd lasix with CMO status. . # ELEVATED LFTs - Likely related to progression of widely metastic colon CA with known involvement of liver. No acute intra-abdominal pathology seen on Abdominal CT; cholecystitis is on differential and HIDA or U/S more sensitive for cholecystitis, but given comorbidities, patient was not a candidate for surgical intervention. . # osteoarthritis - comfort care as above . # CODE - CMO Medications on Admission: 1. Amlodipine 2.5 mg Tablet PO qd 2. Furosemide 20 mg Tablet PO qd 3. Lorazepam 0.5 mg Tablet 4. Oxycodone-Acetaminophen 5 mg-325 mg Tablet 5. Prochlorperazine Edisylate [Compazine] 10 mg Tablet Discharge Disposition: Expired Discharge Diagnosis: Primary: metastatic colon cancer AMS Discharge Condition: expired

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Discharge summary

report

Admission Date: [**2113-6-15**] Discharge Date: [**2113-6-20**] Date of Birth: [**2031-6-5**] Sex: M Service: MEDICINE Allergies: Vancomycin Attending:[**First Name3 (LF) 425**] Chief Complaint: infected PPM Major Surgical or Invasive Procedure: lead and pacemaker extraction Temporary pacer Pacer insertion left chest History of Present Illness: Mr [**Known lastname **] is an 82-yo man with complete heart block s/p dual chamber [**Company **] pacemaker [**10/2101**] with RV lead revision [**2-/2112**] and recent device infection in [**1-/2113**], hypertension, dyslipidemia, GERD, and BPH, who presented today with continued device infection for lead and device extraction. The procedure was prolonged due to significant fibrosis of the pacer leads, and he was noted to have purulent material that was extracted and sent to the microbiology lab for analysis. Given his history of complete heart block and hypotension with his ventricular escape rhythm, a temporary screw-in external pacemaker was placed in the right IJ. Intra-operative TEE was unremarkable, but he did require Neosynephrine in the OR for hypotension that was thought to be due to the prolonged anesthesia. Given the significant infection, the wound was left open, to close by secondary intention, with plan to treat with IV antibiotics over the weekend and re-implant a pacemaker next week. . With regards to the recent device infection in [**2113-1-12**], this was initially treated with IV vancomycin, but that was discontinued due to development of fever and rash. He was instead treated with a full course of IV linezolid. The site was noted to have significantly improved, and he was seen in [**Hospital **] clinic at the end of [**Month (only) 404**] at which point the site was considered to be healed. Per the patient, the site was stable for over 3 months, but he then developed a new area of erythema over the left lateral aspect of the pocket, with blistering. He was seen for this complaint in [**Hospital **] clinic on [**2113-6-7**]. He denies any fevers or chills but has been experiencing pain at the pacemaker site with his usual activity. His WBC was 5.1 with a normal differential on [**2113-6-12**], and he was admitted today for lead and device extraction for continued infection versus new pocket site infection. . On arrival to the CCU, the patient was hypotensive with SBP in the 60s. He received a 200cc NS IVF bolus with improvement to the 90s. He complains of left-sided chest pain as well as pain and tingling in his fingers bilaterally, left worse than right. There is no weakness or numbness of the hands. The pains are intermittent. ECG showed V-pacing at 60 bpm. STAT TTE showed no obvious effusion or depressed ventricular function, and STAT CXR was also unremarkable. His external pacemaker rate was increased from 60 to 80 bpm. IV Linezolid was started for possible septicemia. He did not require any further IVF or vasopressor support. . 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. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: None. -PERCUTANEOUS CORONARY INTERVENTIONS: None. -PACING/ICD: [**2101**] ([**Company 1543**] Sensi SEDR01) 3. OTHER PAST MEDICAL HISTORY: * Complete heart block status post initial permanent pacemaker implantation in [**2101**] with subsequent RV lead revision and generator change in [**2112-2-12**] (Dual Chamber [**Company 1543**] Sensia SEDR01). * Device infection in [**2113-1-12**], initially treated with IV vancomycin, which was discontinued due to development of fever and rash. Then treated with full course of IV linezolid. * Hypertension. * Hyperlipidemia. * GERD. * BPH. Social History: He is married with five grown children. He does not smoke and drinks only on occasion. No illicit drug use. He is a retired landscaper. Family History: His father died of emphysema, and his mother had diabetes. All five grown children are well and healthy. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: T= 95.8F, BP= 68/43, HR= 60, RR= 18, O2 sat= 100% 4L NC. GENERAL: WD/WN elderly man in NAD. Oriented x3. Mood, affect appropriate. HEENT: NC/AT. PERRL/EOMI. Sclera anicteric. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. MMM, OP clear. NECK: Supple, JVP not measurable [**2-13**] RIJ temporary pacer. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RRR, normal S1-S2, but muffled heart sounds. No m/r/g. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NT/ND. No HSM or tenderness. No abdominial bruits. EXTREMITIES: WWP, no c/c/e. No femoral bruits. SKIN: No rashes or lesions. NEURO: Awake, A&Ox3, moving all extremities appropriately. PULSES: Right: Femoral 2+ DP 1+ Radial 1+ Left: Femoral 2+ DP 1+ Radial 1+ Pertinent Results: [**2113-6-15**] 05:51PM BLOOD WBC-10.9# RBC-3.32* Hgb-10.0* Hct-29.6* MCV-89 MCH-30.1 MCHC-33.8 RDW-13.8 Plt Ct-202 [**2113-6-15**] 05:51PM BLOOD PT-14.7* PTT-28.7 INR(PT)-1.3* [**2113-6-15**] 05:51PM BLOOD Glucose-137* UreaN-20 Creat-0.8 Na-141 K-3.7 Cl-111* HCO3-20* AnGap-14 [**2113-6-15**] 05:51PM BLOOD Calcium-7.6* Phos-2.9 Mg-1.6 [**2113-6-20**] 09:00AM BLOOD WBC-7.8 RBC-3.29* Hgb-10.0* Hct-29.4* MCV-89 MCH-30.4 MCHC-34.1 RDW-14.2 Plt Ct-222 [**2113-6-19**] 06:20AM BLOOD PT-12.7 PTT-21.8* INR(PT)-1.1 [**2113-6-20**] 09:00AM BLOOD Glucose-169* UreaN-23* Creat-1.0 Na-139 K-4.4 Cl-102 HCO3-29 AnGap-12 [**2113-6-19**] 06:20AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.0 [**2113-6-15**] 1:45 pm SWAB LEFT SHOULDER. GRAM STAIN (Final [**2113-6-15**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Preliminary): SENSITIVITIES REQUESTED BY DR. [**First Name (STitle) 488**] . STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. ANAEROBIC CULTURE (Final [**2113-6-19**]): NO ANAEROBES ISOLATED. Blood Cx [**6-16**] and [**6-17**] NGTD ECHO [**6-15**] The left atrium is markedly dilated. The left atrium is elongated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. There is moderate global left ventricular hypokinesis (LVEF = 35 - 40 %). The right ventricle displays mild to m oderate global free wall hypokinesis. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid leaflets and pulmonic leaflets are not well seen. There is a trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results in the operating room at the time of the study. After lead extraction, there were no significant changes and no signs of an enlarging pericardial effusion. ECHO [**6-15**] There is symmetric left ventricular hypertrophy. The left ventricular cavity is very small. Left ventricular systolic function is hyperdynamic (EF>75%). There is no pericardial effusion. CXR: [**2113-6-20**] Since yesterday, right-sided dual-chamber pacemaker still ends in expected position. There is no pneumothorax. Small bilateral pleural effusion increased, still tiny. Hyperinflation is unchanged. The cardiomediastinal silhouette is stable. There is no other change. ECG: Baseline artifact. Sinus or atrial paced or ventricular paced rhythm. Since the previous tracing of [**2113-1-23**] atrial pacing is probably new at a faster rate. Brief Hospital Course: 82-yo man with complete heart block s/p dual chamber pacemaker with RV lead revision and recent device infection who presented with continued device infection for lead and device extraction, found to have significant infection of the pacer pocket and lead fibrosis, now s/p external temporary pacemaker placement and awaiting treatment with IV antibiotics prior to re-implantation of permanent pacemaker. . # Infected pacemaker - He was seen for this complaint in [**Hospital **] clinic on [**2113-6-7**]. He denies any fevers or chills but has been experiencing pain at the pacemaker site with his usual activity. His WBC was 5.1 with a normal differential on [**2113-6-12**], and he was admitted on [**6-15**] for lead and device extraction. On arrival to the CCU, the patient was hypotensive with SBP in the 60s. He received a 200cc NS IVF bolus with improvement to the 90s. He complained of left-sided chest pain as well as pain and tingling in his fingers bilaterally, left worse than right. There is no weakness or numbness of the hands. The pains are intermittent. ECG showed V-pacing at 60 bpm. STAT TTE showed no obvious effusion or depressed ventricular function, CXR was also unremarkable. His external pacemaker rate was increased from 60 to 80 bpm. He was started on IV Linezolid. He did not require any further IVF or vasopressor support. The patient underwent pacer and lead extraction on [**2113-6-15**] without complication. A temporary pacer was also placed after removal. The patient remained stable and blood cx were NGTD. He was seen by ID who recommended 2 weeks of linezolid from pacer extraction [**2113-6-15**]. The patient had a new pacemaker placed on [**2113-6-19**] without complication. CXR showed no PTX and leads in proper position. His wound culture eventually grew coag-neg staph. The patient will have both ID and EP follow-up with weekly labs. The patient remained afebrile and pacemaker was working properly. # complete heart block (rhythm) - See above for management of pacemaker. The patient had his lead and pacer extracted on [**2113-6-15**]. A temporary external pacemaker in right IJ was placed. He was monitored on tele. A new pacemaker was placed on [**2113-6-19**] without complication. # coronaries - The patient has no known CAD or findings of CAD on ECG. He remained chest pain free. He was continued on home ASA. . # pump - The patient had an intra-op EF 35-40% with moderate global LV hypokinesis. He remained clinically euvolemic. # hypertension - The patient's anti-hypertensives were intially held secondary to his hypotension. Once his pressures had stabilzed he was restarted on lisinopril 10mg and home metoprolol succinate 12.5mg at the time of discharge. # dyslipidemia - stable, continued home statin . # diabetes - stable, continued home Actos and ISS. He was also continued on a diabetic diet. # GERD - stable, continued home H2B # BPH - His flomax was initally held secondary to hypotension, but restarted once stable. Medications on Admission: Lisinopril 20mg daily Lovastatin 20mg daily Metoprolol succinate 12.5mg daily Actos 15mg daily Zantac 150mg daily PRN Flomax 0.4mg daily Aspirin 325 mg daily Vitamin C 500mg daily Vitamin B12 500mcg daily Glucosamine-Chondroitin 500mg-400mg daily Loratadine 10mg QHS Multivitamin daily Aleve 220mg daily PRN Vitamin E 400unit daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO four times a day as needed for pain. 3. Lovastatin 20 mg Tablet Sig: One (1) Tablet PO daily (). 4. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for indigestion. 6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO once a day. 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Vitamin E 400 unit Tablet Sig: One (1) Tablet PO once a day. 9. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Loratadine 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 11. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Outpatient Lab Work Please draw CBC on [**2113-6-27**] when pt comes to see Dr. [**Last Name (STitle) **], call results to the ID fellow Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 432**] 15. Outpatient Lab Work Please check CBC by VNA on [**2113-7-4**] and call results to ID fellow, Dr. [**Last Name (STitle) **] at [**Hospital1 18**] at [**Telephone/Fax (1) 432**]. 16. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 9 days: last day [**2113-6-28**]. Disp:*18 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Community VNA, [**Location (un) 8545**] Discharge Diagnosis: Complete Heart Block Pacemaker site infection Discharge Condition: stable. Discharge Instructions: You had a pacemaker pocket infection that necessitated the pacemaker to be removed and another pacemaker was placed on the right side of your chest. You are on Linezolid antibiotic to treat this infection. You will be seen by Dr. [**Last Name (STitle) **] in 1 week to look at the new pacemaker and the old pacemaker site. While you are on the antibiotics, you will need to have weekly labs checked. This can be done by the VNA. A plastic surgeon saw your left chest wound. They feel that it will heal well and deferred care to Dr. [**Last Name (STitle) **]. New medicines: 1. Linezolid: an antibiotic to treat the pocket infection. Please follow the dietary restrictions given to you by Dr. [**Last Name (STitle) **]. 2. Please decrease your Lisinopril to 10 mg at night. This may be increased again by Dr. [**Last Name (STitle) **]. . Please do not take any showers until Dr. [**Last Name (STitle) **] tells you to. You may take a bath and wash your hair but don't get the pacer dressings wet. If the dressings fall off, cover with dry sterile gauze and tape. NO lifting more than 5 pounds with your right arm, no lifting that arm over your head. . Please call Dr. [**Last Name (STitle) **] if you have any fevers, chills, sweating, increasing redness or pain at either pacer site, light headedness, chest pain or any other worrying symptoms. Followup Instructions: DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2113-6-27**] 11:00 . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2113-6-27**] 12:20 . Primary Care: PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 20**] [**Name Initial (NameIs) **]. Phone: [**Telephone/Fax (1) 77179**] Date/Time: Please make an appt to be seen in [**2-14**] weeks. Completed by:[**2113-6-20**]

[ "996.61", "600.00", "250.00", "041.11", "426.0", "458.29", "E878.1", "530.81", "401.9", "682.2", "272.4", "E947.9" ]

icd9cm

[ [ [] ] ]

[ "37.87", "37.89", "37.78", "37.77", "37.76", "00.14", "88.72" ]

icd9pcs

[ [ [] ] ]

13278, 13348

8349, 11347

282, 357

13438, 13448

5406, 6263

14841, 15305

4287, 4507

11730, 13255

13369, 13417

11373, 11707

13472, 14818

4522, 5387

3524, 3639

230, 244

6298, 8326

385, 3416

3670, 4118

3438, 3504

4134, 4271

26,218

112,911

29923

Discharge summary

report

Admission Date: [**2151-3-9**] Discharge Date: [**2151-4-8**] Date of Birth: [**2109-2-5**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 99**] Chief Complaint: abdominal pain, transfer from OSH with pancreatitis Major Surgical or Invasive Procedure: Endotracheal intubation Peripherally inserted central catheter Subclavian vein central venous line Internal jugular vein central venous line Arterial line Tracheostomy Percutaneous gastro-jejunostomy tube History of Present Illness: 42M with h/o hypertension, otherwise healthy now transferred form [**Location (un) **] for severe pancreatitis. He presented initially to [**Location (un) **] on [**2151-3-7**] with 1 day h/o nausea and non-bilious, non-bloody vomiting and intense mid epigastric pain. There was diarrhea on the day PTA as well. He noted fevers and chills. In the ED at [**Location (un) **], he was noted to be hypotensive, though rapidly responded to aggressice IVF and his BP was soon in the 90s and tachy to 130s rr 20 96% RA. Initial labs showed WBC 19.4, hct 48.2, plt 269. amylase 3228, lipase [**Numeric Identifier **]. transaminases nl and t bili 0.8. Of note, cr up to 1.6 from a normal baseline. ABG 7.33/45/52. CT Abd showed pancreatic edema with extensive pancreatic inflammation, no free air, pseudocyst. ABD US showed no gallbladder thickening, stones, or ductal dilatation. Pt was admitted to ICU for aggressive IVF. His hospital course was otherwise unremarkable. Past Medical History: HTN Tobacco abuse Asthma Social History: smoking 1ppd x 20 years, rarely drinks alcohol nothing recently. no drug use. Family History: pt was adopted. Physical Exam: VS: Temp: 99 BP: 183/102 HR: 129 RR: 20 O2sat: 93 5L NC GEN: appearing uncomfortable HEENT: MM dry, OP clear RESP: CTAB CV: RR, S1 and S2 wnl, no m/r/g ABD: distended abd, TTP diffusely. typanitic to percussion. EXT: non-pitting LE edema Genital: scrotal edema. Pertinent Results: Admission labs: 143 110 17 --------------< 163 4.0 26 0.8 Ca: 7.4 Mg: 1.9 P: 1.5 ALT: 19 AP: 58 Tbili: 1.1 Alb: 3.1 AST: 50 LDH: 850 [**Doctor First Name **]: 345 Lip: 490 . 13.1 15.3 >----< 180 38.0 PT: 14.0 PTT: 28.6 INR: 1.2 . Discharge Labs: [**2151-4-8**] 04:40AM BLOOD WBC-9.6 RBC-3.25* Hgb-8.8* Hct-29.0* MCV-89 MCH-27.1 MCHC-30.5* RDW-14.9 Plt Ct-344 [**2151-4-8**] 04:40AM BLOOD PT-14.8* PTT-61.9* INR(PT)-1.3* [**2151-4-8**] 04:40AM BLOOD Glucose-107* UreaN-15 Creat-0.6 Na-142 K-3.6 Cl-102 HCO3-29 AnGap-15 [**2151-4-8**] 04:40AM BLOOD ALT-57* AST-31 AlkPhos-90 Amylase-49 TotBili-0.3 [**2151-4-8**] 04:40AM BLOOD Lipase-28 [**2151-4-8**] 04:40AM BLOOD Calcium-9.1 Phos-4.0 Mg-2.1 . Micro: [**3-13**], [**3-20**], [**3-21**] blood cultures: coag neg staph [**3-29**], [**3-30**], [**4-4**] sputum: MSSA other blood, urine, and sputum cultures NGTD c diff negative x 6 . Radiology: CXR [**2151-3-9**]: Interval development of mild-to-moderate pulmonary edema. KUB [**2151-3-9**]: Nonspecific bowel gas pattern. . CT Abd [**2151-3-7**] OSH: Pancreatic edema with extensive pancreatic inflammation, no free air, pseudocyst. . ABD US [**2151-3-8**]: no gallbladder thickening, stones, or ductal dilatation [**3-10**] ECHO: The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. There is no valvular aortic stenosis. The increased transaortic gradient is likely related to high cardiac output. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . [**3-26**] ECHO: no vegetations . [**3-11**]: CT abdomen/pelvis: 1. More than 50% areas of non-enhancement within pancreatic bed consistent with necrosis. No pseudocyst or abscess is seen within the pancreatic bed. No biliary ductal dilatation of pancreatic dilatation is seen. 2. Non occlusive thrombus of superior mesenteric vein is noted. 3. Extensive fluid accumulation within the abdominal cavity predominantly anterior to the stomach and in the anterior pararenal space. . [**3-24**]: CT abdomen/pelvis: 1) Pancreatic pseudocyst measuring 13.7 cm x 5 cm with significant inflammation and fat stranding noted in the peripancreatic area. 2) Bilateral pleural effusions with associated atelectasis. 3) Sigmoid diverticulosis without evidence of diverticulitis. 4) Bilateral inguinal hernias. . [**3-31**]: CT chest/abdomen/pelvis: 1. Extensive pancreatic necrosis with large pancreatic fluid collection, probably slightly increased since the prior study. 2. Bilateral moderate pleural effusions with compressive atelectasis. 3. Multiple lower lobe lung nodules some of which are tree-in-[**Male First Name (un) 239**] in configuration and may represent an infectious process versus aspiration. 4. Stable bilateral large fat containing inguinal hernias. 5. Filling defects versus contrast mixing in the bilateral internal jugular veins. Ultrasound could be performed to exclude thrombus. 6. Fluid collection next to the left adrenal gland versus small adrenal lesion. . [**4-6**]: CXR: Interval decrease in the bibasilar pleural effusion. Otherwise, stable as compared to yesterday. . [**4-8**]: CT abdomen/pelvis: pending Brief Hospital Course: 42M h/o hypertension, presents with idiopathic acute necrotizing pancreatitis with pseudocyst. Hospital course by problem: . # Pancreatitis: Etiology unclear on presentation (no h/o EtOH abuse, no stones on RUQ U/S, normal Ca2+, only mildly elevated TG, no trauma). Perhaps medication related (lisinopril, HCTZ) or viral. CT abdomen as above demonstrated extensive pancreatitis. Followup film showed pseudocyst formation. There was no abscess seen in either film. Patient was followed closely/daily by both the GI service and pancreatic surgery service. They participated actively in his management. His disease, although severe, was not deemed necessary for surgical repair. Instead, we provided supportive care with respiratory ventilation, nutritional needs, and prophylactic management. Amylase and lipase normalized by [**3-13**]. He aggressively treated with IVF early in his hospital course. We maintained his UOP greater than 100cc/h. He then mobilized his third-spaced fluid and we assisted with his diuresis. The prolongation of his ventilatory requirements was largely [**3-5**] elevated intraabdominal pressures and significant pulmonary edema. PEG-J tube was placed by IR for tube feeds. After extubation, he was started on POs which he tolerated well with no increase in serum pancreatic enzymes. Consider pancreatic enzyme replacement if develops steatorrhea. A repeat abdominal CT scan was performed prior to discharge per surgery. Followup with Dr. [**Last Name (STitle) **] in 2 weeks (he would like to be called if not tolerating POs, develops abdominal pain, or requires re-admission to the hospital). . # Hypoxic Respiratory Failure: Patient was intubated on [**3-10**]. Given bilateral infiltrates seen on CXR, he was initially ventilated under ARDS-net protocol with use of an esophageal balloon pump to monitor pleural pressures and a triadyne bed for rotational support. His PEEP was initially high but we weaned down gradually over the course of several weeks. It was thought that his PEEP requirements were [**3-5**] large abdominal girth from third spacing. This improved with diuresis and we weaned him down to more typical vent settings. Received diamox transiently for metabolic alkalosis. He also developed VAP and completed a 7 day course of vanc/cefepime with improvement in his secretions. Noted to have wheezing and was given combivent inhalers and nebulized steroids with improvement. Given the prolonged intubation a tracheostomy was performed by thoracic surgery. He was succesfully weaned off of the ventilator. . # ID: Patient spiked temperatures as high as 103.9 intermittently throughout his hospital course. Given concerns for GNR assoc with his pancreatitis, he was treated with meropenem on [**3-10**] for a seven day course. This was discontinued. Superinfected pseudocyst also possible but abd CT unchanged. Thereafter he had three blood cultures which grew coag neg staph thought to be [**3-5**] a central line infection. We pulled the right IJ and treated with vancomycin for a 14 day course. We also repeated an echo which showed no evidence of vegetations. His fever curve improved but then developed increased secretions and fever likely due to VAP. Sputum eventually grew MSSA. He completed a 7 day course of vanc/cefepime and remained afebrile with decraesed secretions and his respiratory status improved significantly. . # SMV Thrombosis: Noted incidentally on CT scan ([**3-15**]) and heparin gtt started. Data suggests that the SMV thrombosis is commonly associated with severe pancreatitis and often resolves with resolution of the pancreatic inflammation. We treated with heparin gtt with strict parameters (ptt goal of 55-60). Coumadin started [**4-5**] (Goal INR [**3-6**]), continue to follow INR at rehab facility. Will need 6 months anticoag per surgery. Repeat CT abdomen performed prior to discharge and will followup with surgery. . # Functional bowel obstruction: On [**3-20**], patient was given lactulose for no stool output. He then had bilious vomitting. It was promptly noted that his rectal tube was poorly positioned. It was replaced and he had significant stool output. His feeding tube had to be repositioned and we restarted his tube feeds without issue. . # Tachycardia: The patient was persistently tachycardic in the 100-110s. His HR was greater than 130s on admission and responded to IVF as he was intravascularly dry. Once euvolemic, he was treated with metoprolol to control tachycardia and hypertension (baseline HTN at home with mx meds). This was discontinued in the setting of aggressive diuresis and he remained largely in the HR of 100-110s. . # Hypertension: On multiple BP meds at home which were discontinued. As his clinical status improved, he became more hypertensive and was started on metoprolol with good effect. Given that his pancreatitis was possibly BP med-related, would avoid thiazides and ACEi. . # Anemia: Patient had drop in his hct to low 20s in setting of acute illness and aggressive IVF. On [**3-23**], his Hct dropped to 19. He had no obvious source of bleeding. He was transfused with improvement. His heparin was held for several days until hct stabilization. We also urgently obtained a CT abdomen to assess for intraabdominal fluid/blood collection which was not seen. Hct remained stable throughtout the rest of the hospital stay. . # Sedation: Patient required significant doses of versed and fentanyl for sedation. As we weaned down on the PEEP, we also weaned down on the sedation and was started on fentanyl patch to avoid withdrawal. He tolerated this well. The fentanyl patch can be weaned off slowly. . # Transaminitis: He developed elevated LFTs on [**3-25**]. Thought [**3-5**] meds vs tube feeds. We limited his tylenol intake and did not see other med source for hepatotoxicity. We trended this over several days with improvement. Likely [**3-5**] tube feeds vs. meds. LFTs normalized. . # Hyperglycemia: Elevated blood sugars, possibly due to pancreatic endocrine dysfunction. Initially on insulin gtt then transitioned to standing NPH and RISS with good control. . # FEN: Trophic tube feeds were started. The patient recieved PEG-J by IR [**4-1**]. He will need to have the T-clips surrounding the PEG-J tube removed on [**4-11**] (see sheet included with d/c summary for instructions). He was restarted on POs slowly on [**4-5**] with good tolerance and can be increased to soft regular diet [**4-9**] as tolerated. Tube feeds should be discontinued once PO intake is adequate. . # Access: PICC . # Contact: Wife [**Name (NI) 8513**] [**0-0-**], [**Name (NI) 5321**] [**Name (NI) 71501**] (mom) [**Telephone/Fax (1) 71502**] Medications on Admission: asa 81 atenolol 100" felodipine 10' HCTZ 25' lisinopril 20' zantac 50' Discharge Medications: 1. Acetaminophen 325 mg Tablet [**Telephone/Fax (1) **]: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Albuterol 90 mcg/Actuation Aerosol [**Telephone/Fax (1) **]: 6-8 Puffs Inhalation Q4H (every 4 hours) as needed for wheeze. 3. Clonazepam 0.5 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO BID (2 times a day) as needed. 4. Docusate Sodium 50 mg/5 mL Liquid [**Telephone/Fax (1) **]: Two (2) PO BID (2 times a day). 5. Dolasetron Mesylate 12.5 mg IV Q8H:PRN 6. Fentanyl 50 mcg/hr Patch 72HR [**Telephone/Fax (1) **]: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 7. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 8. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution [**Telephone/Fax (1) **]: One (1) sliding scale Intravenous ASDIR (AS DIRECTED): goal PTT 55-60, discontinue when INR [**3-6**]. 9. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Day (3) **]: Six (6) Puff Inhalation Q4H (every 4 hours). 10. Lactulose 10 g/15 mL Syrup [**Month/Day (3) **]: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 12. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO BID (2 times a day). 13. Budesonide 0.5 mg/2 mL Solution for Nebulization [**Last Name (STitle) **]: One (1) ML Inhalation [**Hospital1 **] (2 times a day). 14. Quetiapine 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for insomnia. 15. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 16. Warfarin 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily): goal INR [**3-6**]. 17. Insulin NPH Human Recomb 100 unit/mL Suspension [**Month/Day (3) **]: Thirty Eight (38) units Subcutaneous qam: 36 units qpm. 18. Insulin Regular Human 300 unit/3 mL Insulin Pen [**Month/Day (3) **]: One (1) sliding scale Subcutaneous four times a day. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: Primary: Necrotizing pancreatitis with pseudocyst Acute respiratory distress syndrome Ventilator associated pneumonia Superior mesenteric vein thrombosis . Secondary Hypertension Asthma Hyperglycemia Discharge Condition: Good, afebrile, stable respiratory status, tolerating food Discharge Instructions: Please take all medications as prescribed. . Call your doctor or return to the ED immediately if you experience worsening chest pain, shortness of breath, nausea, vomiting, sweating, fevers, chills, bleeding, or other concerning symptoms. Followup Instructions: You are scheduled for the following appointments. Please contact the [**Name2 (NI) 11686**] provider with any questions or if you need to reschedule. Surgery: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 2833**] Date/Time:[**2151-5-7**] 8:00.

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icd9cm

[ [ [] ] ]

[ "96.72", "96.04", "46.32", "96.6", "38.93", "99.15", "31.1", "38.91", "99.04" ]

icd9pcs

[ [ [] ] ]

14605, 14679

5595, 5691

362, 569

14923, 14984

2035, 2035

15271, 15576

1721, 1738

12417, 14582

14700, 14902

12322, 12394

15008, 15248

2300, 5572

1753, 2016

271, 324

5719, 12296

597, 1562

2051, 2284

1584, 1610

1626, 1705

46,202

198,651

39736

Discharge summary

report

Admission Date: [**2167-9-2**] Discharge Date: [**2167-9-5**] Date of Birth: [**2121-4-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2901**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac catheterization with bare metal stent to the left anterior descending coronary artery History of Present Illness: 46 year old man with hypertension that has not been under treatment, admitted to [**Hospital3 4107**] with chest pain. Apparently had been having pain since yesterday but was able to go to sleep. Woke up this morning with continued chest pain, [**11-1**] with radiation to left arm and shoulder upon arrival to ER. EKG with bigeminy and anterior ST elevation. Treated with heparin, integrilin, 15mg lopressor, lipitor 80mg, plavix 600, asa 81 x 4, SL nitro. BP 170/115 upon arrival, down after some meds. Had [**8-1**] pain upon leaving. Had tea and toast at 7am. Transfer to cath lab. Troponin pending. Cath showed flush occluded LAD at ostium. Flow restored and 3.0x18mm bare metal stent placed. Given lasix 20 IV x 1 post-op. To CCU for monitoring. . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: heartburn with ibuprofen Social History: -Tobacco history: none -ETOH: glass of wine with dinner -works as electrician, walks a lot at work. Family History: Mother and father both passed away from liver cancer history of early age MIs and strokes on mothers side siblings have HTN Physical Exam: GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: Sclera anicteric. EOMI. no oral lesions. NECK: Supple, JVP not elevated. CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: clear to auscultation anteriorly ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No edema, distal pulses present. right groin nontender, no bruising, no bruits SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: [**2167-9-2**] 02:58PM GLUCOSE-173* UREA N-15 CREAT-0.9 SODIUM-138 POTASSIUM-3.3 CHLORIDE-105 TOTAL CO2-23 ANION GAP-13 [**2167-9-2**] 02:58PM CK(CPK)-9313* [**2167-9-2**] 02:58PM CK-MB-GREATER TH cTropnT-GREATER TH [**2167-9-2**] 02:58PM CALCIUM-8.4 PHOSPHATE-3.4 MAGNESIUM-1.4* [**2167-9-2**] 02:58PM WBC-12.8* RBC-4.78 HGB-14.3 HCT-40.0 MCV-84 MCH-29.9 MCHC-35.7* RDW-13.3 [**2167-9-2**] 02:58PM NEUTS-92* BANDS-1 LYMPHS-3* MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2167-9-2**] 02:58PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2167-9-2**] 02:58PM PLT COUNT-185 [**2167-9-2**] 02:58PM PT-15.0* PTT-150* INR(PT)-1.3* [**2167-9-2**] 11:58AM GLUCOSE-164* UREA N-12 CREAT-0.8 SODIUM-140 POTASSIUM-3.2* CHLORIDE-108 TOTAL CO2-22 ANION GAP-13 [**2167-9-2**] 11:58AM estGFR-Using this [**2167-9-2**] 11:58AM WBC-13.3* RBC-4.25* HGB-13.2* HCT-36.2* MCV-85 MCH-31.0 MCHC-36.5* RDW-13.3 [**2167-9-2**] 11:58AM PLT COUNT-205 Brief Hospital Course: 46 year old man with questionable history of hypertension presenting to outside hospital with chest pain, found to have anterior STEMI, s/p cath with bare metal stent placed in LAD. Cath showed flush occluded LAD at ostium. Flow restored and 3.0x18mm bare metal stent placed. Received integrellin infusion for 18 hours. Started on aspirin 325 mg, atovastatin 80 mg, metoprolol 25 mg [**Hospital1 **], lisinopril 5 mg daily, Clopidogrel 75 mg PO DAILY, and coumadin. ECHO demonstrated: severe regional left ventricular systolic dysfunction with akinesis of the mid to distal anterior septum and anterior wall. The apical segments and apex are also akinetic. The inferior septum and lateral wall are milldy hypokinetic. HgbA1C was 5.3. Lipid panel: TC 201, LDL 116, HDL 52. Patient remained hemodynamically stable with no recurrence of chest pain. He will be discharged on aspirin, statin, metoprolol, lisinopril, plavix, and coumadin, and will have follow-up with both his PCP and [**Name Initial (PRE) **] cardiologist. Medications on Admission: none 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). Disp:*30 Tablet(s)* Refills:*2* 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:*30 Tablet(s)* Refills:*2* 5. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours) for 3 days. Disp:*6 syringe* Refills:*2* 6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Outpatient Lab Work Please check INR on [**2167-9-7**] and call results to Dr. [**Last Name (STitle) 1637**] at [**Telephone/Fax (1) 14655**] 9. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual every 5 minutes: do not take more than 2 tablets, call Dr. [**Last Name (STitle) **] for any chest pain. Disp:*25 tablets* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: ST Elevation Myocardial Infarction Acute systolic dysfunction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had chest pain and a large heart attack. You were brought to to the cardiac catheterization lab at [**Hospital1 18**] and a bare metal stent was placed in your left anterior descending artery. You will need to take Aspirin and Plavix every day for at least 3 months and possibly longer. do not stop taking aspirin or Plavix or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr. [**Last Name (STitle) 1637**] tells you to. this is very important to prevent the stents from clotting off and having another heart attack. You will see Dr. [**Last Name (STitle) **] in [**Hospital1 **] in about 6 weeks as well. . New medicines: 1. Aspirin 325 mg to prevent blood clots in the stents 2. Plavix 75 my daily to prevent blood clots in the stents 3. Warfarin (coumadin) to prevent blood clots from forming in your heart. Dr. [**Last Name (STitle) 1637**] will tell you how much coumadin to take on Monday. 4. Lovenox twice daily injections: to use until the coumadin level is therapeutic. 4. Lisinopril: to control your blood pressure and help your heart recover from the heart attack. 5. Metoprolol Succinate 50 mg: to lower your heart rate and help your heart recover from the heart attack. . You will need to get your INR (coumadin level) drawn on Monday [**9-7**]. Please go to the admitting office at [**Hospital3 **] and they tell them there is a lab slip waiting from Dr.[**Doctor Last Name **] office. We also wrote you a prescription for blood work in case there is a problem. Dr. [**Last Name (STitle) 1637**] will get the blood results and will tell you how much coumadin to take from then on and whether you can stop taking the Lovenox. Weigh yourself every morning, call Dr. [**Last Name (STitle) 1637**] if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. Followup Instructions: Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] When: Friday [**2167-9-11**] at 10AM Location: [**Hospital **] MEDICAL OFFICE BLDG Address: [**Street Address(2) 4472**] [**Apartment Address(1) **], [**Hospital1 **],[**Numeric Identifier 9331**] Phone: [**Telephone/Fax (1) 14655**] Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] When: Tuesday [**2167-10-13**] 8:30am (Please arrive at 8:15am) Address: [**Street Address(2) 32216**] [**Hospital1 **], MA Phone: [**Telephone/Fax (1) 70676**] option 1 (it is the radiology dept but that is correct) [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

[ "414.01", "401.9", "410.11", "429.9" ]

icd9cm

[ [ [] ] ]

[ "36.06", "00.40", "37.22", "00.45", "99.20", "88.53", "88.56", "00.66" ]

icd9pcs

[ [ [] ] ]

5826, 5832

3552, 4581

324, 419

5938, 5938

2517, 3529

7916, 8656

1919, 2045

4636, 5803

5853, 5917

4607, 4613

6088, 7893

2060, 2498

274, 286

447, 1736

5953, 6064

1758, 1784

1800, 1903

20,131

119,884

47730

Discharge summary

report

Admission Date: [**2152-8-27**] Discharge Date: [**2152-8-28**] Date of Birth: [**2099-4-20**] Sex: F Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 1850**] Chief Complaint: cc: Dyspnea/Hypoxia/Hypotension Major Surgical or Invasive Procedure: none History of Present Illness: HPI: This 53 year old female with a past history of CHF, DM, recurrent PEs was transfered from NH after she was noted to be hypoxic. On 4L NC her O2 sats ranged from 88-92%. She has reported a persistent non-productive cough, at breakfast she vomited a small amount of cereal but reported no nausea. She also had large loose stools. Of note she is on Coumadin for a history of PEs, she was found to have an INR on [**8-25**] of >10 so 5mg SC Vitamin K was given. Upon arrival here there were no medical records available. She was able to respond to a few questions she denied CP, SOB, said that her current breathing was her baseline. Her vitals upon arrival were Temp 98.5, HR 90, BP 80/palp, 87% on RA, 93% on NRB. Her BP continued to remain low and she was started on peripheral dopa. She was intubated secondary to her hypoxia. Pulmonary emboli was high on the differential so they got a stat Echo which showed right heart strain. She was treated with tPA. She continued to have hard to control pressures, she was treated with Levophed, Vasopressin, and Dopamine. She was also given 125 mg Hydrocortisone given her adrenal insufficiency. Records from [**Hospital1 756**] indicate that she was hospitalized there in [**Month (only) 216**] for Pulmonary hypertension and CHF at that time CXR and chest CT showed pulmonary edema, bilateral LENIs were negative for DVTs. There she was diuresed for presumed heart failure, treated with Levofloxacin, Vancomycin and Gentamicin. She had positive cultures for MRSA on [**7-17**] with no source found for bacteremia. . Past Medical History: PMHx: 1. Adrenal hypoplasia (on replacement steroids) 2. Arthritis 3. Renal insufficiency (baseline Cr 2.5) 4. Obesity 5. CHF, right sided, pulmonary hypertension Echo [**4-30**] with RVH, pulm HTN EF 60%, right heart catheterization on [**7-20**] which showed severe pulmonary hypertension, low CO and CI 6. DM 7. History of PEs on Coumadin 8. Presumed schizoaffective disorder 9. Depression 10. OSA 11. Hypothyroidism 12. GERD 13. Osteoarthritis . Social History: Lives in [**Name (NI) **], sister is health care proxy Family History: unknown Physical Exam: Physical exam Temp 98.5 pulse 109 BP 90/64 RR 22 98% on A/C Tv 450, RR 22, 100% FIO2 Gen: intubated, sedated, unresponsive female HEENT: PERRL, ET tube in place Lungs: upper airway rhonchi CV: RRR, nl S1S2, exam limited by respiratory noises Abd: obese, non-tender, decreased BS Ext: trace edema, lt femoral line in place with some bruising and oozing around it Pertinent Results: Lab results: [**2152-8-27**] 07:28PM BLOOD WBC-22.0*# RBC-4.55 Hgb-11.4* Hct-38.5 MCV-85 MCH-25.1* MCHC-29.7* RDW-25.0* Plt Ct-282# [**2152-8-27**] 02:45PM BLOOD WBC-13.4* RBC-4.66 Hgb-11.6* Hct-37.9 MCV-81* MCH-24.9* MCHC-30.6* RDW-25.2* Plt Ct-186 [**2152-8-27**] 02:45PM BLOOD Neuts-83.7* Lymphs-9.5* Monos-5.3 Eos-1.3 Baso-0.1 [**2152-8-27**] 10:12PM BLOOD PT-20.2* PTT-81.4* INR(PT)-2.9 [**2152-8-27**] 02:45PM BLOOD D-Dimer-1310* [**2152-8-27**] 09:38PM BLOOD CK(CPK)-35 [**2152-8-27**] 02:45PM BLOOD CK(CPK)-20* [**2152-8-27**] 02:54PM BLOOD Lactate-3.5* Na-130* K-3.8 Cl-95* calHCO3-21 [**2152-8-27**] 09:45PM BLOOD Hgb-12.1 calcHCT-36 EKG: sinus rhythm, nl axis, flipped Ts V1-V2, flattened T waves throughout, very variable baseline, no old to compare, no ST changes. . CXR: IMPRESSION: Examination markedly limited by overlying soft tissue. However, probable left lower lobe opacity. Mediastinal shift to the left. . Echo: Technically difficult study, limited parasternal views demonstrated preserved LV function, significant RA and RV dilatation, bowing of interventricular septum consistent with acute pulmonary hypertension and RV strain. Brief Hospital Course: This 53 year old female with history of CHF, DM, PEs in the past and subtherapeutic INR presented with hypoxia and hypotension. Echo and hypoxia consistent with pulmonary emboli, was lysed with tPA in the ED. Other possible causes of hypoxia included pneumonia, CXR showed LLL opacity which is consistent with this, or CHF, less likely given no evidence of this on CXR and normal LV function on Echo, however could be diastolic. She was treated with Vanco, Flagyl, Levofloxacin for Pneumonia and possible sepsis. She was afebrile, however WBC elevated with increased neutrophils, and LLL opacity on CXR. She was treated with fluid gently given concern for fluid overload. She was continued on nebulizers. She was supported on the ventilator, initially on PEEP of 10 and FIO2 of 100. Her cardiac enzymes were cycled, if her condition was due to an MI she was already getting tPA. A repeat CXR was sent which showed no evidence of pneumothorax. Upon arrival to the MICU her family was contact[**Name (NI) **] and they stated that she was DNR/DNI and would not have wanted to be on life support. They came into the hospital and a conversation was held with them and with Dr. [**Last Name (STitle) 57046**] at [**Hospital1 756**] and it was come to the understanding that she would not have wanted the aggressive care which she received. It was decided to withdraw pressure support. This was done and she expired at 12:15AM on [**2152-8-28**]. . Other issues on hospitalization: 1. Hypotension - most likely from PE vs. Sepsis from PNA. She was treated on Dopamine, Levophed, and Vasopressin. These were discontinued pending conversation with the family. Stress steroids were given history of Addison's and thus adrenal insufficiency. Propofol was avoided as this will drop pressures and we avoided giving too much fluid given history of CHF. 2. DM - Patient had some hypergylcemia upon arrival to the MICU, has a history of insulin dependant diabetes. She was covered with insulin drip. . 3. Addison's disease - patient on steroids at home. She was covered with stress dose steroids here. . 4. Thyroid insufficiency - Continued synthroid . 5. Renal insufficiency - Continued Renagel . 6. CHF - Continued Spironolactone . 7. GERD - Continued Protonix . 8. FEN - IV fluid at maintenance - repleted lytes prn . 9. PPx - Anticoagulate with heparin - PPI Medications on Admission: Medications on tranfer MVI Iron 325 daily Lasix 160mg PO daily Hydrocortisone 20mg PO qAM, 10mg PO qPM Levothyroxine 100mcg PO daily Protonix 40mg PO daily Spironolactone 50mg PO daily Advair discus 1 puff [**Hospital1 **] Colchicine 0.6mg daily Colace Lactulose Rhinocort 2 sprays [**Hospital1 **] Senna Renagel 400mg TID Trazadone 50mg PO qHS Novolog insulin sliding scale, 3 units novolog qAM, 6 units Lantus qPM NH information: Diet - honey thick Aspiration precautions CPAP setting 5 at night Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: N/A Discharge Condition: expired Discharge Instructions: none Followup Instructions: none [**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**] MD [**MD Number(2) 1851**]

[ "785.59", "244.9", "593.9", "995.92", "255.4", "415.19", "428.0", "518.81", "486", "038.9" ]

icd9cm

[ [ [] ] ]

[ "96.71", "38.93", "96.04", "99.10", "00.17" ]

icd9pcs

[ [ [] ] ]

7041, 7050

4096, 6464

329, 335

7097, 7106

2914, 4073

7159, 7282

2507, 2516

7013, 7018

7071, 7076

6490, 6990

7130, 7136

2531, 2895

257, 291

363, 1945

1967, 2419

2435, 2491

6,448

134,410

4904

Discharge summary

report

Admission Date: [**2119-9-26**] Discharge Date: [**2119-10-3**] Date of Birth: [**2052-6-1**] Sex: F Service: MEDICINE Allergies: Morphine / Haldol Attending:[**First Name3 (LF) 19836**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Intubation History of Present Illness: 67 yo female with CHF/COPD d/c'd on [**8-22**] after hospitalization for CHF and UTI who presented to ED on [**2119-9-26**] with flash pulmonary edema likely secondary to hypertensive emergency requiring intubation for hypoxic respiratory failure and found to have a persistent UTI. The patient denied CP, f/c, n/v. No home 02 requirement. . At presentation in the [**Name (NI) **], pt was persistently hypoxic to the 70s despite increasing oxygenation. She was placed on nitro gtt for inital BPs >200 [**3-18**] medication noncompliance. Max BP in ED 257/108. She was also given CTX/levaquin for question of PNA on CXR along with + UA, IV steroids, nebs, and lasix. Her BNP was elevated at ~7000. After stabilization, the patient was transferred to the MICU. . MICU COURSE. Captopril and hydralazine were added to her home BP regimen, and nitro drip was weaned off on [**9-28**]. She was diuresed 2L over length of stay with IV lasix. She was extubated on [**2119-9-28**]. She was found to have an E.coli UTI. She was continued on ceftriaxone. There was concern regarding her mental status while intubated. A head CT was performed and was unremarkable. . At time of MICU call-out, she denied SOB, chest pain, nausea, vomiting, diarrhea. No orthopnea or PND. She reported feeling as though her respiratory status was at baseline. Past Medical History: Cardiac Risk Factors: + Diabetes, + Dyslipidemia, + Hypertension . Cardiac History: CABG: none . Percutaneous coronary intervention ([**2-/2115**]): 1. One vessel coronary artery disease --> LCX (90% lesion), LAD modest diffuse dz, RCA 50% stenosis 2. Successful PTCA/stent of the proximal and distal LCX. 3. Normal left ventricular function. (EF 60%) 4. Resting hemodynamics showed mild pulmonary hypertension and a low-normal cardiac output. . OTHER PAST MEDICAL HISTORY: CAD: NSTEMI [**2-17**] s/p PCI w/ DES to proximal and distal LCX. CHF (diastolic dysfunction w/ EF >55%, 1+ AR and trivial MR, 2+ TR) DM 2, diet controlled Hypercholesterolemia Hypertension Pulm HTN- moderate H/o rheumatic heart disease w/ mild AR Chronic renal insufficiency Lung disease: ? COPD vs. restrictive pattern on spirometry in [**2113**] and pulmonary nodules. History of pulmonary embolus in [**2080**], while taking oral contraceptives, s/p IVC "interruption procedure") [**Year (4 digits) **] [**Year (4 digits) 20441**] Schizoaffective disorder H/o thyroiditis H/o seizure disorder from infancy to age of 17 Social History: She lives alone. Her daughter, [**Name (NI) **], lives nearby and visits her frequently and helps her managing her medications. Currently uses walker for walking. Has home nurse [**First Name (Titles) **] [**Last Name (Titles) **] her regularly for daily activity as well; Tobacco abuse: 30 pyrs, still smoking, social drinker; no illicit drugs Currently in rehab, s/p R total knee replacement Family History: CAD in mother at age 68. No history of coagulation problems in her family. Physical Exam: VS: 99.4 (99.8) 146/60 81 12 94% on 5L FSBS 111 Gen: Pleasant female eating breakfast in bed, NAD, asking to go home HEENT: PERRL, EOMI, NCAT, MMM and I NECK: no JVD, no bruits CV: no MRG, nl S1, S2, RRR Chest: CTA bl Abd: soft, NT/ND, +BS Ext: no CCE skin: intact, no rashes or jaundice Neuro: CN2-12 grossly intact, moving all 4 extremities, sensation intact, oriented to person, place and time Rectal and bladder foleys inplace and draining Pertinent Results: [**2119-9-26**] 10:07AM PLT COUNT-386# [**2119-9-26**] 10:07AM NEUTS-72.9* LYMPHS-20.3 MONOS-5.3 EOS-1.3 BASOS-0.3 [**2119-9-26**] 10:07AM WBC-5.6 RBC-3.44* HGB-10.8* HCT-33.7* MCV-98 MCH-31.5 MCHC-32.1 RDW-17.2* [**2119-9-26**] 10:07AM CK-MB-NotDone proBNP-7233* [**2119-9-26**] 10:07AM cTropnT-0.02* [**2119-9-26**] 10:07AM CK(CPK)-64 [**2119-9-26**] 10:07AM GLUCOSE-105 UREA N-9 CREAT-1.0 SODIUM-143 POTASSIUM-3.3 CHLORIDE-106 TOTAL CO2-28 ANION GAP-12 [**2119-9-26**] 11:39AM URINE RBC-0-2 WBC-21-50* BACTERIA-MANY YEAST-NONE EPI-0-2 [**2119-9-26**] 11:39AM URINE BLOOD-NEG NITRITE-POS PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [**2119-9-26**] 11:39AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017 [**2119-9-26**] 11:39AM URINE GR HOLD-HOLD [**2119-9-26**] 11:39AM URINE HOURS-RANDOM [**2119-9-26**] 02:20PM TYPE-ART PO2-62* PCO2-46* PH-7.40 TOTAL CO2-30 BASE XS-2 [**2119-9-26**] 08:06PM URINE MUCOUS-RARE [**2119-9-26**] 08:06PM URINE HYALINE-10* [**2119-9-26**] 08:06PM URINE RBC-41* WBC-39* BACTERIA-NONE YEAST-NONE EPI-<1 [**2119-9-26**] 08:06PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-MOD [**2119-9-26**] 08:06PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.014 [**2119-9-26**] 08:06PM CK-MB-NotDone cTropnT-0.01 [**2119-9-26**] 08:06PM CK(CPK)-65 Cultures: Urine - [**9-26**]: URINE CULTURE (Final [**2119-9-29**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 16 I CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- 32 I PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R Imaging: EKG [**9-26**]: Sinus rhythm. Short P-R interval. Mild Q-T interval prolongation. Since the previous tracing of [**2119-8-20**] atrial premature beats are no longer seen. CXR [**9-26**]: The exam is technically limited by patient rotation. However, the left hemidiaphragm is obscured by a region of increased opacity at the left lung base, which could reflect atelectasis. Overall, the pulmonary vasculature is engorged, with diffusely increased parenchymal opacity, consistent with mild-moderate edema. The cardiomediastinal silhouette remains markedly enlarged, overall unchanged. There is no pneumothorax. Cervical spine fusion hardware is stable. Soft tissue and bony structures are otherwise unremarkable. IMPRESSION: Moderate pulmonary edema. CT head [**9-28**]: There is no evidence of hemorrhage, edema, masses, mass effect or infarction. The ventricles and sulci are normal in caliber and configuration. No fractures are identified. CONCLUSION: Normal study. [**10-1**]: The patient has been extubated. The film is less rotated and in a slightly more lordotic position. There is no focal consolidation and the lateral CP angles are sharply delineated. Pulmonary vascular markings are normal. Mild cardiomegaly is demonstrated. Some prominence of the right paratracheal soft tissues may be related to tortuous vessels. IMPRESSION: No obvious radiographic explanation for fever spikes. Brief Hospital Course: 67F with diastolic CHF, COPD, HTN, RA transferred out of the MICU after brief intubation for respiratory failure due to hypertensive emergency also found to have resistant E.coli UTI. . ## Respiratory Failure: Acute onset hypoxic respiratory failure. PNA unlikely with lack of sputum production, cough, clear CXR. PE unlikely despite remote history of PE as patient is not hypotensive or tachycardic. History most consistent with flash pulmonary edema in the setting of known diastolic dysfunction. The patient was diuresed, her BP controlled with multiple meds including a nitro drip and she was successfully extubated morning of [**9-29**]. She was weaned off oxygen and tolerated sats in the low 90s on room air. . ## Hypertension: BP meds were adjusted to create the easiest dosing schedule. Initially, the patient was on nitro gtt with prn hydralazine and home BB and CCB. She was weaned off and placed on TID isordil which was transitioned back to imdur prior to d/c home. Captopril was added as an afterload reducer and titrated to patient BP. This was converted to lisinopril for easier dosing schedule. She was continued on her home BB and CCB, amlodipine. Amlodipine dosage was increased from 5 to 10 mg. . ## UTI: Initially treated with cipro but patient demonstrated fevers and sensitivities returned showing resistance to cipro but sensitivity to CTX. Patient was switched to CTX and thereafter to cefpodoxime for a total 7 day course to be completed as an outpatient. . ## COPD:No evidence on exam for COPD exacerbation. Patient maintained on home albuterol PRN and advair with PRN nebs. . ## CHF:As above, was treated with diuresis, BP control, and afterload reduction. . ## Pulmonary artery hypertension: Severe per last TTE [**6-22**]. No evidence for PE on CTA done at same time. Unclear etiology due to left heart failure vs pt's RA. Consider repeating TTE as an outpatient after stabilized to evaluate interval change in [**Last Name (un) 6879**], may need RHC in future. . ## DM2: Diet controlled at home. Patient was maintained on sliding scale with minimal insulin needs. . ## [**Last Name (un) **] [**Last Name (un) 20441**]: Etanercept held due to acute illness. Home sulfasalazine and plaquenil were continued. . ## CAD: History of NSTEMI in [**2115**] s/p DES, per OMR, no longer on plavix. Cardiac enzymes negative and ECG unchanged. No evidence of ACS. Patient was continued on home statin and aspirin. . ## Hypercholesterolemia: Home statin was contined. . ## Schizoaffective d/o: Home cymbalta and seroquel were contined. On [**10-3**], the patient was felt stable for discharge as her blood pressure was well-controlled on her new regimen and she was tolerating room air without difficulty. She was therefore discharged in good condition with scheduled follow up. Medications on Admission: albuterol amlodipine 10mg daily atorvastatin 80mg QHS Duloxetine 20mg daily Enteracept 50mg SC QWeek Fludrocortisone 0.1mg daily Fluticasone/Salmeterol 250/50 [**Hospital1 **] Folic Acid Furosemide 20mg daily Vicodin Hydroxychloroquine 200mg daily Isosorbide mononitrate 30mg daily Lisinopril 5mg daily Metoprolol tartrate 50mg [**Hospital1 **] Pantoprazole 40mg daily Quetiapine 50mg [**Hospital1 **] Sulfasalazine 1g daily Asa 81mg daily Ferrous sulfate 325mg daily MVI Discharge Medications: 1. Famotidine 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q24H (every 24 hours). 2. Atorvastatin 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime). 3. Quetiapine 25 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times a day). 4. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 5. Duloxetine 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Sulfasalazine 500 mg Tablet [**Hospital1 **]: Two (2) Tablet PO QAM (once a day (in the morning)). 7. Sulfasalazine 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO QPM (once a day (in the evening)). 8. Hydroxychloroquine 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 9. Amlodipine 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 10. Furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Hospital1 **]: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 12. Cefpodoxime 100 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q12H (every 12 hours) for 3 days. Disp:*12 Tablet(s)* Refills:*0* 13. Lisinopril 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 14. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day. Discharge Disposition: Home With Service Facility: Caregroup VNA Discharge Diagnosis: Hypertensive Crisis with flash pulmonary edema E.coli urinary tract infection Acute on Chronic Diastolic 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: Please attempt to restrict fluids to 2 liters daily to minimize your risk of fluid overload. You were admitted to the hospital because your blood pressure was very high. This placed strain on your heart. Because of the heart strain, fluid backed up in your lungs. This caused you to be unable to oxygenate properly and resulted in your intubation. You were aggressively diuresed with extra lasix to get the extra fluid off of your lungs and your blood pressure medications were changed to better manage your blood pressure. You have a follow up appointment on [**10-19**] with Dr. [**Last Name (STitle) 9006**] at which time there may be additional changes to your medication regimen. Until that time, you should take the medications as indicated on this discharge paperwork. In addition, you were found to have a urinary tract infection. You were treated with antibiotics and should complete the course of oral antibiotics as prescribed. You expressed interest in additional home services while in the hospital and Dr. [**Last Name (STitle) 9006**] thought you may benefit from assistance with meal provision such as via meals on wheels. Someone will contact you on [**10-4**] with details on how this can be arranged. Please call your PCP or come to the hospital if you experience severe headache, chest pain, increased shortness of breath, decreased urination, or any other symptoms of concern. Followup Instructions: [**2119-10-13**] 10:00am [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD Phone:[**Telephone/Fax (1) 1228**] [**2119-10-13**] 12:30pm [**Doctor First Name 11595**] (RHEUM LMOB) [**Doctor Last Name 11596**] Phone:[**Telephone/Fax (1) 2226**] [**2119-10-19**] 11:50 [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 250**] [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD, [**MD Number(3) 19838**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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38569

Discharge summary

report

Admission Date: [**2151-4-5**] Discharge Date: [**2151-4-15**] Date of Birth: [**2086-10-12**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3227**] Chief Complaint: Fall Major Surgical or Invasive Procedure: None History of Present Illness: This is a 64 year old man who was reported to have fallen out of a parked car on friday [**2151-4-2**] and over the weekend began to develop increasing lethargy and agitation. The day of admission his mental status declined and he became increasingly combative and as a result was taken to an OSH for evaluation. At the OSH he was initially febrile to 104 and on Head Ct was found to have subarachnoid and subdural blood as well as bilateral frontal contusions. He was treated prophylactically for meningitis at the OSH and received Acyclovir, penicillin, Dilantin, Ativan, Vancomycin, and Rocephin. He was transferred to [**Hospital1 18**] for further management and was combative upon arrival to the ED and was subsequently nasally intubated for airway protection. Past Medical History: Dyslipidemia, Hypertension, Cholecystectomy Social History: Married, lives at home with Wife. + ETOH Family History: NC Physical Exam: On Admission: O: T: 104.7 BP: 176/78 HR:110 R 28 O2Sats 99% Gen: intubated and sedated HEENT: no hemotympanum, CSF otorrhea or rhinorrhea appreciated on exam. Pupils: PERRL EOMs unable to assess Neuro: Mental status: intubated and sedated Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2mm to 1mm bilaterally. III-XII: unable to assess Motor: Moves all extremities spontaneously prior to sedation for intubation Sensation: withdraws briskly to painful stimuli Toes downgoing bilaterally Coordination: unable to assess On discharge: He is awake, alert, oriented except to name of hospital. At times uncoperative with exam but not focal neurologic deficit. Pain on ROM Left knee and with superior/anterior patellar palpation. Pertinent Results: CT head [**2151-4-5**]: 1. Bifrontal contusions with slight increase in surrounding edema. Mild increase in left temporal edema. 2. Unchanged bilateral subarachnoid and subdural hemorrhage. 3. Stable skull fracture. CT C-spine [**2151-4-5**]: The cervical spine demonstrates normal alignment. There is no evidence of fracture or subluxation. Mild multilevel degenerative changes with posterior disc osteophyte formation, especially at C3-4 place the patient at high risk for cord-ligamentous injury. There is minimal narrowing of the spinal canal at C3-4 and C4-5 due to posterior disc osteophyte formation. An endotracheal tube and NG tube are partially imaged. Mucosal thickening and secretions are likely secondary to intubation. Bilateral tonsilliths are seen. IMPRESSION: No evidence of acute fracture or malalignment of the cervical spine. CT Cspine [**2151-4-6**]: 1. Minimal increase of the edema surrounding bilateral frontal contusions without evidence of midline shift or herniation. 2. Unchanged intraparenchymal, subarachnoid and subdural hematoma. 3. No evidence of new hemorrhage, or infarction CT Torso [**2151-4-6**]: 1. Nondisplaced left ninth rib. No other acute injury is noted within the abdomen and pelvis. 2. Consolidation of the lung bases. Small bilateral pleural effusions. 3. Sigmoid colon diverticulosis with no signs of diverticulitis. CT head [**2151-4-13**]: 1. Interval evolution of bifrontal hemorrhagic contusions with surrounding edema. 2. No evidence of midline shift or herniation. Improvement in subarachnoid and subdural hemorrhage. 3. No evidence of new hemorrhage or infarction. NOTE ADDED IN ATTENDING REVIEW: There is prominence of the extra-axial CSF spaces at the frontovertex, left more than right. While this may simply reflect underlying bifrontal atrophy (more conspicuous with resolution of more acute injury), thin subdural hygromas are not excluded. X-ray Left Knee [**2151-4-14**]: There is a small left knee joint effusion. There is no acute fracture or malalignment. There is no significant degenerative arthropathy seen on these nonweightbearing radiographs. Enthesophyte along the anterosuperior aspect of the patella at the quadriceps tendon insertion is noted. There are vascular calcifications in the thigh and popliteal fossa. Brief Hospital Course: Mr. [**Known lastname **] was admitted to [**Hospital1 18**] on [**2151-4-5**]. Serial CT head imaging was performed. There was blossoming of the contusions as expected. He was in a cervical collar. He was intubated. A CIWA scale was in place to prevent ETOH withdrawal. The patient's mental status improved over the next few days. Neurology was consulted for ?meningitis and seizure management. They recommended and LP which the wife refused. The patient improved with antibiotics. His cervical spine was clinically cleared once the patient was awake and not confused. Neurology recommended a 10-day course of empiric therapy to treat the aspiration pneumonia. He was evaluated by speech therapy for a swallow eval and cognition, although there was no overt aspiration, they did make diet modifications given his inattentiveness secondary to his head injury. The patient was agitated and required restraints since he was a high fall risk given his traumatic brain injury. PT and OT recommended rehab. Vancomycin trough were followed and medication changes were made as needed. He was receiving Vanc/Cef via a PICC line. He complained of Left knee pain with movement on palpation. X-ray imaging on [**4-14**] showed a small joint effusion and a patellar bone spur. This was discussed with orthopedics via phone and they reviewed the imaging. Elevation, ice, ace wrap and weight bearing as tolerated were recommended. Serial electrolytes did not reveal significant abnormalities. He was transferred to rehab on [**2151-4-17**]. His antibiotic regimen is due to end on [**4-17**]. The PICC line will no longer be needed after IV antibiotics are discontinued. Medications on Admission: unknown Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 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. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical DAILY (Daily) as needed for rash. 5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Lorazepam 2 mg/mL Syringe Sig: 0.5 mg Injection Q4H PRN () as needed for agitation. 7. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig: Two (2) g Intravenous Q12H (every 12 hours): Until [**2151-2-17**]. 11. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) g Intravenous Q 12H (Every 12 Hours): Until [**2151-4-17**]. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Bifrontal cerebral contusions Cerebral Edema Bilateral subarachnoid and subdural hemorrhage Closed skull fracture Pleural Effusions Rib fracture Aspiration Pneumonia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: You have a follow-up CT scan at 1:00 pm on [**5-13**] in the [**Hospital 12837**] Clinic Center on the [**Location (un) 470**]. Follow-up with Dr. [**First Name (STitle) **] at 1:30 pm on [**5-13**] in the [**Hospital Unit Name 3269**] [**Hospital Unit Name 12193**]. Call [**Telephone/Fax (1) 1669**] with questions. Follow-up with Dr. [**Last Name (STitle) 12332**] and Dr. [**Last Name (STitle) **] in the neurology clinic on [**2151-5-13**] at 4:30 pm. The office is on [**Hospital Ward Name 23**] 8 on the [**Hospital Ward Name 516**]. Call [**Telephone/Fax (1) 541**] if you need to reschedule. Completed by:[**2151-4-15**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

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6851

Discharge summary

report

Admission Date: [**2112-5-17**] Discharge Date: [**2112-5-21**] Date of Birth: [**2032-1-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2641**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 11605**] is a 80yo male with PMH significant for HTN, systolic dysfunction, atrial fibrillation, and hypothyroidism. He presented to the ED with increasing SOB on [**5-17**]. Per notes, his dyspnea was acute in onset (~1 day). He also admits to having a productive cough over the past few months. In the ED he was found to be in afib w/RVR, hypotensive, and febrile to 102.6. Given hypotension he was thought to be in cardiogenic shock and then started on dobutamine. He was given Lasix/nitro spray with improvement in lung exam. He was initially started on Ceftriaxone/azithromycin which was changed to Levofloxacin prior to being transferred to the floor. Past Medical History: 1)Hypertension 2)Hypertrophic CM with severe LV dysfunction: [**4-/2112**] TTE with ef 35% 3)MR: 2+ on [**4-/2112**] 4)TR: 2+ on [**4-/2112**] 5)Atrial fibrillation and aflutter s/p ablation [**2108**] 6)Sick sinus with pacer placed [**10/2105**] 7)GERD 8)Hypothyroidism 9)Depression Social History: He is a retired sales man with no smoking history. + EtOH 2 drinks/week. Denies any use of illicit drugs. He lives with his wife in [**Hospital3 **]. Family History: NC Physical Exam: vitals T 98.6 BP 141/73 AR 77 RR O2 sat Gen: Pleasant male, NAD, lying in bed HEENT: MMM Heart: distant heart sounds Lungs: diffuse rhonchi, scattered crackles Abdomen: soft, NT/ND, +BS Extremities: 1+ bilateral edema, 2+ DP/PT pulses bilaterally Pertinent Results: Laboratory results: [**2112-5-17**] 09:10AM BLOOD WBC-7.9 RBC-4.65 Hgb-14.3 Hct-42.5 MCV-91 MCH-30.8 MCHC-33.8 RDW-15.3 Plt Ct-202 [**2112-5-21**] 07:45AM BLOOD WBC-4.9 RBC-4.08* Hgb-12.5* Hct-37.2* MCV-91 MCH-30.7 MCHC-33.6 RDW-15.1 Plt Ct-147* [**2112-5-21**] 07:45AM BLOOD PT-18.2* PTT-31.8 INR(PT)-1.7* [**2112-5-17**] 09:10AM BLOOD Glucose-166* UreaN-17 Creat-1.5* Na-144 K-3.8 Cl-108 HCO3-23 AnGap-17 [**2112-5-17**] 11:00AM BLOOD ALT-13 AST-22 AlkPhos-77 Amylase-33 TotBili-0.5 [**2112-5-17**] 09:10AM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 25882**]* [**2112-5-17**] 09:10AM BLOOD cTropnT-<0.01 [**2112-5-17**] 11:00AM BLOOD Calcium-7.9* Phos-3.0 Mg-2.0 Relevant Imaging: 1)Cxray ([**2112-5-17**]): Right pulmonary edema and small increased bilateral pleural effusions. 2)ECHO ([**2112-5-18**]): Overall left ventricular systolic function is moderately depressed. EF~35%. 3)LE doppler ([**2112-5-18**]): No evidence of DVT. Brief Hospital Course: Mr. [**Known lastname 11605**] is a 80yo male with PMH as listed above presents with acute dyspnea. 1)Respiratory distress: Patient presented with acute onset dyspnea. Combination of new onset afib w/RVR likely causing him to flash and productive cough suggestive of an underlying pneumonia. Also has component of CHF w/EF~35%. He was initally started on Ceftriaxone and Azithromycin for presumed pneumonia but was changed to Levofloxacin which he should continue for the next 10 days. He also received PRN nebulizer treatments with rapid improvement in his respiratory status. He was continued on home regimen of Lasix 20mg PO with appropriate diuresis. Patient may require 1-2L supplemental oxygen. 2)CHF: Patient has history of systolic CHF with depressed EF~35%. Likely contributed to acute respiratory decompensation. He was seen by cardiology on admission and recommended diuresis. Close to euvolemic at time of discharge and diuresing appropriately on current regimen of Lasix with close monitoring of his I/O's. He was continued on Lasix, beta-blocker, and ace-inhibitor. 3)Atrial fibrillation: Patient has history of aflutter s/p ablation. On admission found to be in AF w/RVR but converted back to NSR but now back in AF. Likely caused him to flash resulting in his acute respiratory distress. Coumadin was initially held given supratherapeutic INR but then restarted at time of discharge. INR on discharge is 1.7. Patient discharged on Coumadin 4mg and titrated up if necessary to keep INR between [**2-27**]. He was also continued on Amiodarone 200mg [**Hospital1 **]. 4)Hypertension: Patient on Lisinopril and Metoprolol at home which was continued during this hospital admission. 5)GERD: Continue Pantoprazole 6)Hypothyroidism: Continue Levothyroxine Medications on Admission: Medications on transfer: Levofloxacin 750mg IV Q48H, day 2 Albuterol neb prn Ipratropium neb prn Lisinopril 10mg PO daily Amiodarone 200mg PO daily Metoprolol 25mg PO BID Warfarin 2mg PO QHS Furosemide 20mg daily Levothyroxine 75mcg daily Vitamin D 400 unit daily Citalopram 10mg daily Pantoprazole 40mg daily Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment Inhalation Q6H (every 6 hours). 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. Albuterol Sulfate 0.083 % Solution Sig: One (1) treatment Inhalation Q4H (every 4 hours). 5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Coumadin 4 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Extended Care Facility: Bostonian - [**Location (un) 86**] Discharge Diagnosis: Primary diagnoses: 1)Dyspnea 2)Congestive heart failure 3)Atrial fibrillation Secondary diagnoses: 1)Hypertension 2)Hypothyroidism 3)GERD 4)Depression Discharge Condition: Stable Discharge Instructions: 1)Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. 2)Please take all medications as listed in the discharge instructions. 3)Please schedule follow-up with your primary care physician within the next 1-2 weeks after being discharged from the hospital. 4)You are being discharged on Coumadin. Your INR on discharge is 1.7. You will need close monitoring of your INR which should be between [**2-27**]. 5)If you experience any fevers, chills, chest pain, SOB, dizziness or any other concerning symptoms please return to the emergency room. Followup Instructions: 1)Provider: [**Name10 (NameIs) **] CALL Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2112-7-14**] 9:00 2)Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2112-10-27**] 8:30 3)Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 902**] Date/Time:[**2112-10-27**] 9:00

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icd9cm

[ [ [] ] ]

[ "00.17" ]

icd9pcs

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Discharge summary

report

Admission Date: [**2193-1-6**] Discharge Date: [**2193-1-11**] Date of Birth: [**2108-8-31**] Sex: F Service: MEDICINE Allergies: Sulfadiazine Attending:[**First Name3 (LF) 19836**] Chief Complaint: Nausea and vomiting Major Surgical or Invasive Procedure: Central venous line placement and removal History of Present Illness: This is an 84 year old female with a history of insulin dependant diabetes and hypertension who presented to the ED with complaints of vomiting. This morning she awoke feeling nauseous and consequently vomited; she also endorsed chest pain but no associated abdominal pain. In the ED, she was noted to have bradycardia to the 30s-40s. An EKG revealed sinus bradycardia with PR intervals of 0.3 s suggestive of 1st degree heart block, suggesting both sinus node and AV node dysfunction. She continued to endorse nausea. Her blood pressures were stable in the low 100s. She was mentating well; however her electrolytes revealed an acidosis. Venous blood gas showed a pH of 7.15 with a bicarb of 14; anion gap of 19. Lactate was 6.7. Blood sugar was 450. No urine output was available for determination of ketones. WBC count was noted to be near 14 with no bands. Given persistent bradycardia, a right IJ was placed and a dopamine infusion was initiated with improvement in her heart rates. She was admitted to the MICU for hypoperfusion in the setting of bradycardia with concern for cardiogenic hypotension or evolving sepsis. At time of transfer, she was complaining of palpitations however her vitals were essentially unchanged. . Of note, in [**2192-7-26**] she was admitted for cardiogenic presyncope secondary to bradycardia in the setting of diltiazem at high doses (240 mg daily). During this hospitalization she also had chest pressure which resolved with treatment of esophageal reflux. She was discharged on a lower dose of diltiazem. However, on a follow up appointment in [**Month (only) 1096**] [**2191**], she met with her nephrologist Dr [**First Name (STitle) 10083**] who recommended increasing diltiazem back to 300 mg given severe proteinuria. She did meet with her PCP, [**Name10 (NameIs) **] [**Last Name (STitle) 9006**], in [**Month (only) 404**] to see if this increase again dropped her heart rate - but on this meeting in [**Month (only) 404**], her HR tolerated the increased diltiazem dose. Also of note, her renal function has been slowly deteriorating over the past several years from a baseline of 1.3 to a new baseline of 2.1, felt to be secondary to diabetic nephropathy. Past Medical History: Hypercholesterolemia Hypertension Osteoporosis Diabetes Mellitus type 2 Diagnosed [**2155**] Microalbuminuria s/p Appendectomy Social History: Lives by herself, able to achieve most ADLs. Her daughter comes periodically to assist. No visiting nurse. She denies smoking history, alcohol history. She was formerly an artist and is now retired. She speaks Mandarin, Cantonese, and some English. Family History: Non-Contributory Physical Exam: ADMISSION PHYSICAL EXAM: VS: HR 50, BP 110/70, temp 97.9, RR 12, O2 sat 93% 2 L Gen: Chinese female, appearing well, pleasant, in no apparent distress Cardiac: Nl s1/s2, RRR Pulm: lungs clear to auscultation in anterior lung fields Abd: soft, nontender, nondistended, with normoactive bowel sounds Ext: no edema noted . DISCHARGE PHYSICAL EXAM: VS: 98.6, 100.1, 160/77 (137-171/71-89), 89 (83-96), 18, 99RA Gen: Chinese-speaking female, NAD, looking better HEENT: Echymoses overlying chin and inferior to left eye are resolving Card: Regular rate, regular rhythm, no m/r/g Pulm: No respiratory distress, minimal crackles at bases, perhaps some decreased breath sounds in RLL area Abd: very soft, non-tender in lower quadrants, NABS, no organomegaly, no CVA tenderness Ext: no edema noted, pulses 2+ throughout Pertinent Results: ADMISSION LABS: . [**2193-1-6**] 04:57PM BLOOD WBC-13.2* RBC-2.95* Hgb-8.4* Hct-27.3* MCV-93# MCH-28.7 MCHC-30.9*# RDW-16.0* Plt Ct-256 [**2193-1-6**] 04:57PM BLOOD Neuts-84.1* Lymphs-12.9* Monos-2.1 Eos-0.5 Baso-0.4 [**2193-1-6**] 04:57PM BLOOD PT-10.7 PTT-30.5 INR(PT)-1.0 [**2193-1-6**] 04:57PM BLOOD Glucose-456* UreaN-52* Creat-3.2* Na-132* K-5.3* Cl-102 HCO3-11* AnGap-24* [**2193-1-6**] 04:57PM BLOOD ALT-145* AST-297* AlkPhos-113* TotBili-0.2 [**2193-1-6**] 04:57PM BLOOD Lipase-50 [**2193-1-6**] 04:57PM BLOOD cTropnT-<0.01 [**2193-1-6**] 04:57PM BLOOD Albumin-3.7 Calcium-8.6 Phos-6.3*# Mg-2.1 [**2193-1-6**] 09:23PM BLOOD Acetone-NEGATIVE [**2193-1-6**] 04:57PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2193-1-6**] 04:54PM BLOOD Glucose-418* Lactate-6.7* K-4.3 [**2193-1-6**] 04:54PM BLOOD Glucose-418* Lactate-6.7* K-4.3 [**2193-1-6**] 11:57PM BLOOD freeCa-1.02* [**2193-1-7**] 04:39AM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.010 [**2193-1-7**] 04:39AM URINE Blood-SM Nitrite-NEG Protein-100 Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD [**2193-1-7**] 04:39AM URINE RBC-5* WBC-52* Bacteri-FEW Yeast-NONE Epi-1 [**2193-1-7**] 04:39AM URINE Hours-RANDOM Creat-59 Na-70 K-42 Cl-57 TotProt-173 Prot/Cr-2.9* . PERTINENT LABS: . [**2193-1-8**] 03:21AM BLOOD Ret Aut-1.8 [**2193-1-7**] 04:23AM BLOOD ALT-190* AST-350* LD(LDH)-504* AlkPhos-82 TotBili-0.2 [**2193-1-6**] 04:57PM BLOOD cTropnT-<0.01 [**2193-1-7**] 01:01AM BLOOD CK-MB-2 cTropnT-0.01 [**2193-1-8**] 03:21AM BLOOD calTIBC-99* Hapto-169 Ferritn-529* TRF-76* [**2193-1-6**] 09:23PM BLOOD Acetone-NEGATIVE [**2193-1-7**] 04:23AM BLOOD TSH-1.5 [**2193-1-6**] 04:57PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2193-1-6**] 04:54PM BLOOD Glucose-418* Lactate-6.7* K-4.3 [**2193-1-7**] 04:39AM URINE RBC-5* WBC-52* Bacteri-FEW Yeast-NONE Epi-1 . DISCHARGE LABS: . [**2193-1-11**] 07:05AM BLOOD WBC-8.6 RBC-2.82* Hgb-8.2* Hct-24.5* MCV-87 MCH-29.0 MCHC-33.4 RDW-16.3* Plt Ct-199 [**2193-1-11**] 07:05AM BLOOD Glucose-110* UreaN-36* Creat-2.5* Na-141 K-3.5 Cl-107 HCO3-23 AnGap-15 [**2193-1-11**] 07:05AM BLOOD ALT-51* AST-21 [**2193-1-11**] 07:05AM BLOOD Calcium-8.4 Phos-5.0* Mg-1.7 . MICRO/PATH: . BCx x 2 [**1-6**]: No growth UCx [**1-7**]: No growth MRSA Screen [**1-6**]: No MRSA . IMAGING/STUDIES: . CXR Portable [**1-6**]: IMPRESSION: Mild upper zone redistribution of pulmonary vascularity suggesting pulmonary venous hypertension, mild cardiomegaly, and slight bibasilar atelectasis suspected, but no evidence for pneumonia. . CT Head non-con [**1-6**]: IMPRESSION: No evidence of acute intracranial process. . CT Abd/Pelv [**1-6**]: IMPRESSION: 1. Right lower lobe consolidation likely due to pneumonia. 2. Cholelithiasis and sludge/bile within the gallbladder. No evidence of cholecystitis. 3. Colonic diverticulosis. 4. Atherosclerotic calcification of the aorta. 5. No evidence of retroperitoneal hemorrhage. . TTE [**2193-1-7**]: Conclusions: The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is at least 15 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 structurally normal. 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. Pulmonary artery hypertension. Mild mitral regurgitation. . Compared with the prior study (images reviewed) of [**2192-8-16**], the estimated PA systolic pressure is higher. . CXR PA/LAT [**1-8**]: IMPRESSION: PA and lateral chest compared to [**1-6**]: . Previous mild pulmonary edema has cleared, pulmonary and mediastinal vascular engorgement have cleared, but small bilateral pleural effusions, reflecting previous cardiac decompensation, have increased. Heart size top normal. Right jugular line ends in the mid SVC. Brief Hospital Course: 84F with a hx of DM2, HTN, and AV node dysfunction (type 1 heart block) presenting with pneumonia and cardiogenic shock from calcium channel blocker toxicity. . ACTIVE DIAGNOSES: . #Calcium Channel Blocker Toxicity/Cardiogenic Shock: This patient was admitted to the MICU for evaluation and treatment of cardiogenic shock from calcium channel blocker toxicity characterized by symptomatic bradycardia to the 30's and hypotension to as low as 80's/50's, and hyperglycemia to 400+. She had been on diltiazem for a long period of time and was admitted recently for pre-syncope thought to be the result of bradycardia from high dose diltiazem which was reduced at the time of discharge. Weeks prior to the current admission, her diltiazem dose was increased to 300mg daily by one of her outpatient providers (she has a history of intermittent medication noncompliance). She has had chronic PR prolongation suggesting AV node conduction disease. She had an elevated lactate, elevated creatinine (see ATN below), and moderate transaminitis thought to be related to hypotension and presented with nausea and vomiting. She was started on dopamine drip to augment heart rate and was weaned off on HD#2. TTE was obtained which showed preserved function and mild MR. [**Name14 (STitle) 16835**] were negative. Toxicology was consulted and followed while in the MICU. Her diltiazem was held and her pressure returned to a robust level with resolution of her bradycardia. Her ATN, lactic acidosis, and transaminitis resolved (see below) and she was discharged on amlodipine, valsartan, and chlorthalidone with PCP and outpatient cardiology follow-up to aid in selecting an effective antihypertensive regimen that would not lead to symptomatic bradycardia. . #Community Acquired Pneumonia: Pt described subjective fevers/chills at home but no clear history given of cough prior to admission. She was found to have a RLL consolidation on CT abd/pelv which we re-confirmed with CXR, and was initially started on broad spectrum antiobiotics which were narrowed to ceftriaxone/azithromycin. Of note, it was considered a possibility that she may have aspirated from the N/V that occurred from her symptomatic bradycardia. She was discharged with PO azithromycin to continue a 7-day total course. She had mild abdominal pain in her bilateral lower quadrants when coughing thought to be muscle strain/soreness from coughing. Her blood cultures negative. . # Acute Tubular Necrosis on Chronic Kidney Disease: Baseline creatinine was 2.1 on recent outpatient nephrology visit and peaked at 3.2 during this admission. FENA was measured at 2.8 and thought to be consistent with mild ATN from hypotension and poor perfusion. Following discontinuation of her CCB, she had adequate pressures and experienced excellent UOP on HD#2 thought to be consistent with post-ATN diuresis and her Cr fell to 2.5 on the day of discharge. Her valsartan was re-started. . # Transaminitis: Patient had moderate transanitis to the 300 range which resolved gradually to almost wnl's by the day of discharge. CT showed no focus of inflammation of liver, only cholelithiasis. This was felt to represent mild shock-liver from hypotension. . CHRONIC DIAGNOSES: . # Hypertension - Patient has had difficult to control hypertension with intermittent episodes of symptomatic bradycardia and reports of intermittent medication non-compliance. She was discharged with max dose amlodipine, valsartan, and 50mg daily of chlorthalidone and was still occasionally in the 160's systolically in the hospital. She was referred for outpatient cardiology follow-up to aid in managing her hypertension further. . #DM2: Stable. She was maintained with decent glycemic control on reduced doses of her home Novolog 70/30. She was discharged with 15U QAM, 7U QPM, and a very gentle HISS with nursing teaching with the help of a cantonese interpreter. . # Hyperlipidemia- Stable. She was continued on her home simvastatin. . # Osteoporosis - Stable. She was discharged on her home alendronate. . # Normocytic Anemia - Patient was found to have chronic normocytic anemia with iron studies suggestive of anemia of chronic disease and hemolysis labs were negative. She had no signs of bleeding. Her anemia was felt to likely be related to her CKD. . TRANSITIONAL ISSUES: . -CODE STATUS: She was full-code during this admission. . -Home Services: Patient adamantly refused home services despite being asked on multiple occasions by multiple people. . -HTN: This patient has outpatient PCP and cardiology [**Name9 (PRE) 702**] for assistance in managing her HTN. We suggest extreme caution in re-initation of nodal agents such as beta blockers and CCB's but it seems that she has previously been able to tolerate them at lower doses. . -Anemia: Unclear cause. Could be due to her CKD or other causes. Further workup deferred to outpatient setting. Medications on Admission: ALENDRONATE - (Prescribed by Other Provider) - 70 mg Tablet - 1 tablet by mouth once a week. Take with a full glass of water. Do not lie down within one hour after taking the medication. ATORVASTATIN [LIPITOR] - 10 mg Tablet - 1 Tablet(s) by mouth once a day DILTIAZEM HCL - (Dose adjustment - no new Rx) - 300 mg Capsule, Ext Release 24 hr - 1 capsule by mouth once a day INSULIN ASP PRT-INSULIN ASPART [NOVOLOG MIX 70-30] - (Prescribed by Other Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 3636**]; Dose adjustment - no new Rx) - 100 unit/mL (70-30) Solution - 31 units qam 11 units qpm VALSARTAN [DIOVAN] - 320 mg Tablet - 1 Tablet(s) by mouth once a day ASPIRIN - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day CALCIUM CITRATE - 250 mg calcium Tablet - 2 tablets by mouth twice a day CHOLECALCIFEROL (VITAMIN D3) - (OTC) - 1,000 unit Tablet - 2 tablets by mouth once a day AMLODIPINE - 5 mg Tablet - 1 tablet by mouth once a day at bedtime Discharge Medications: 1. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 2. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. insulin asp prt-insulin aspart 100 unit/mL (70-30) Solution Sig: Fifteen (15) units Subcutaneous Every morning. 4. insulin asp prt-insulin aspart 100 unit/mL (70-30) Solution Sig: Seven (7) units Subcutaneous at bedtime. 5. valsartan 320 mg Tablet Sig: One (1) Tablet PO once a day. 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. calcium citrate 250 mg calcium Tablet Sig: Two (2) Tablet PO twice a day. 8. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 9. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 10. chlorthalidone 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 11. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. Disp:*2 Tablet(s)* Refills:*0* 12. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever: Do not take more than 3 grams daily. Disp:*30 Tablet(s)* Refills:*0* 13. dextromethorphan-guaifenesin 10-100 mg/5 mL Liquid Sig: [**4-4**] MLs PO Q6H (every 6 hours) as needed for cough. Disp:*1 bottle* Refills:*0* 14. insulin aspart 100 unit/mL Solution Sig: One (1) 2-14 units Subcutaneous four times a day: Please administer 3 times daily prior to meals using the provided sliding scale. Disp:*1 units* Refills:*0* . The following is your Humalog (insulin aspart) sliding scale: Glucose Level Breakfast Lunch Dinner Bedtime 0-70 Please drink some juice or take glucose pills and eat a meal 71-100 0 0 0 0 101-150 2 2 2 0 151-200 4 4 4 0 201-[**Telephone/Fax (2) 39965**]-300 8 8 8 4 301-350 10 10 10 6 [**Telephone/Fax (2) 39966**] 12 8 400+ 14 14 14 10 If your sugar is greater than 400, please call your doctor Discharge Disposition: Home Discharge Diagnosis: PRIMARY: -Cardiogenic shock from calcium channel blocker toxicity -Community Acquired Pneumonia versus Aspiration Pneumonia -Acute tubular necrosis -Hypertension . Secondary: -Diabetes mellitus type 2 insulin dependent Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [**Known lastname **], . It was a pleasure taking care of you! You were admitted to [**Hospital1 18**] for evaluation and treatment of nausea and vomiting and were found to have a dangerously low heart rate from your diltiazem as well as pneumonia. Your diltiazem medication was held, you were monitored in the intensive care unit, given fluids and antibiotics and your condition improved. You were evaluated further on the floor and your condition continued to progressively get better. You had a fast heart rate (not dangerously fast) which was likely due to pneumonia, deconditioning (being sick in the hospital), and withdrawal from the diltiazem which is gradually improving. . You still have remaining issues with your blood pressure. You blood pressure levels are higher than we would like but no dangerously so. Given your significant troubles with your heart rate we are referring you to see a cardiologist as an outpatient to make some medication adjustments. . The following changes have been made to your medications: -STOP Diltiazem (do not take this medication unless told to do so by your primary care doctor or cardiologist) -DECREASE your Novolog 70/30 to 15 units in the morning and 7 units at night, please monitor your blood sugars and keep track of these measurements so that your primary care doctor can make adjustments -START Humalog (Insulin Aspart) prior to meals and at bedtime according the the sliding scale provided -START Azithromycin 250mg by mouth once daily for 2 more days -START Chlorthalidone 50mg by mouth once daily -START Tylenol 325-650mg by mouth every 6 hours as needed for pain (do not take more than 3 grams daily) -START Dextromethorphan/Guaifenesin sugar free cough syrup 1 dose by mouth every 6 hours as needed for cough -Continue taking your other home medications as directed . Please follow-up with your appointments below. . The following is your Humalog (insulin aspart) sliding scale: Glucose Level Breakfast Lunch Dinner Bedtime 0-70 Please drink some juice or take glucose pills and eat a meal 71-100 0 0 0 0 101-150 2 2 2 0 151-200 4 4 4 0 201-[**Telephone/Fax (2) 39965**]-300 8 8 8 4 301-350 10 10 10 6 [**Telephone/Fax (2) 39966**] 12 8 400+ 14 14 14 10 If your sugar is greater than 400, please call your doctor Followup Instructions: Department: [**Hospital3 249**] When: TUESDAY [**2193-1-15**] at 10:10 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: WEDNESDAY [**2193-2-13**] at 11:20 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD, [**MD Number(3) 19838**] Completed by:[**2193-1-14**]

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Discharge summary

report+addendum

Admission Date: [**2165-4-7**] Discharge Date: [**2165-5-30**] Date of Birth: [**2105-6-10**] Sex: F Service: [**Last Name (un) **] CHIEF COMPLAINT: Question ischemic bowel, Tylenol toxicity and acute liver failure. HISTORY OF PRESENT ILLNESS: The patient presented on [**2165-4-7**] as a 59 year-old female with diabetes mellitus, chronic renal insufficiency, depression admitted to the [**Hospital3 35813**] Center on [**4-4**] after she was found unresponsive and found to have a Tylenol overdose with a level of 123 with resulting acute liver injury and metabolic acidosis. She became unresponsive the day prior to admission and was intubated and required Levophed for hypotension and was started on Zosyn for questionable pneumonia. Patient had a high lactate and was profoundly hypotensive and acidotic and a CT of her abdomen was obtained and contained pneumatosis and was concerning for ischemia and surgical consult was obtained on [**2165-4-7**] after hepatology had already seen the patient and assessed her medical condition. The patient was housed in the medical intensive care unit at this time. PAST MEDICAL HISTORY: Is significant for Tylenol overdose, depression, hypertension, cerebrovascular accident, chronic renal insufficiency, peripheral vascular disease, peptic ulcer disease and pericardial effusion. PAST SURGICAL HISTORY: Cholecystectomy [**84**] years ago. ALLERGIES: No known drug allergies. MEDICATIONS: Protonix, Norvasc, Plavix, aspirin, Glipizide, Neurontin, amitriptyline, Lopressor, Zocor and Lantus. SOCIAL HISTORY: Former smoker, lives with daughter. MEDICATIONS IN HOUSE: At time of presentation Levophed .108 and insulin, lactulose, Mucomyst, vitamin K, fludrocortisone, hydrocortisone, Zosyn, Pepcid, Flagyl. PHYSICAL EXAMINATION: Vital signs on admission temperature was 100.6, 83 in sinus rhythm, 108/50, 18, 97% on CVP 11. She had respiratory rate of 18 at 40% with blood gases 7.32, 22, 154, 12 and -12. She was intubated. Pupils were reactive. Coarse breath sounds bilaterally. She was regular rate and rhythm. Abdomen was obese, soft. She had an upper midline incision. Her extremities were well perfused. White count on admission 22.3, hematocrit 27.9, platelets 241. PT 19.4, PTT 37.2, INR 2.4. Chemistries: 142, 3.9, 105, 10, 62, 5.7 and 125. Urinalysis showed moderate leukocyte esterase with large white count. ALT 24, 13, AST was 26, 78, alkaline phosphatase 115, total bilirubin .6, amylase of 84, lipase was also normal. CK was 766, MB was 20, troponin was .21. Albumin was 2, acetaminophen was 27.7, cortisol was 49.4, lactate was 5.7 at time of presentation. Chest x-ray showed left circumferential cardiac opacity. CT of the abdomen showed thickening of the ascending, transverse and descending colon. Rectum was spared with pneumatosis in the ascending colon. CT of her head showed no hemorrhage, multiple hypodensities consistent with prior infarct. In summary, patient is a 59 year-old female in multisystem organ failure and acidosis admitted with a Tylenol overdose. The patient has encephalopathy and renal failure and respiratory failure with hypotension which could have been a possible cause for her bowel ischemia. Patient's clinical condition improved, however, somewhat. By hospital day 2 she was off of pressors and was now on Zosyn and Flagyl for antibiotic prophylaxis with a lactate that had dome down to 4.3. Operating room was postponed for that day. Renal continued to see patient throughout her hospital course as did hepatology team. On hospital day 3 patient had decreasing transaminases, however, increasing white count and green surgery service was consulted at that time under Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] care with the clinical scenario of hypotension in the setting of an intubated patient where clinical examination was not accurate and CT scan finding of pneumatosis with high white count and high lactate. Patient was taken to the operating room for an exploratory laparotomy. For operative details please operative note. Grossly, however, patient was found to have a large amount of dead nonviable bowel and underwent total colectomy on [**2165-4-9**]. After surgery patient went to the Intensive Care Unit on [**2165-4-9**] in critical condition. Due to the patient's unresponsiveness neurology was consulted on [**4-10**] and did an EEG which showed diffuse encephalopathy without focal slowing and they suggested that patient had likely suffered a significant anoxic brain injury during the hypotensive event intraoperatively which was evidenced by parallel end organ damage, kidney, liver and bowel. Patient continued in the unit of [**2165-4-10**] and continued to become more acidotic receiving bicarb. Patient had an MRI of her head which showed probable anoxic encephalopathy and patient had ventilator weaned to CPAP by hospital day 6. Patient continued to do well on the ventilator but mental status was still not clear. Patient started on hemodialysis and tolerated it well by [**2165-4-14**]. Had large ileostomy output. Patient was thought by renal to have acute and chronic kidney injury and remained off of pressors at this time. Trial of extubation was done on [**2165-4-16**]. Patient extubated well without event. On [**2165-4-15**] stroke consult continued consult on patient and patient was transferred to the floor on [**2165-4-18**] without event. Patient was started on tube feeds 30 cc an hour on [**2165-4-18**]. Physical therapy continued to see patient throughout the case. Patient developed bilateral pleural effusions with E coli, urosepsis on [**2165-4-19**] treated appropriately. CT of the abdomen and pelvis was obtained. No signs of infection were found. Psychiatry followed up consultation seeing patient [**2165-4-18**] and patient continued to tolerate hemodialysis well. Patient was started on HEP-locked IV and renal diet on [**2165-4-20**]. C difficile x3 were sent and were negative. White count was increasing on [**2165-4-18**]. Nutrition continued to see patient throughout her hospital course. Patient developed a pelvic abscess and underwent drainage. Wound VAC was placed and was changed on a q 3 day basis growing on MRSA. Patient was on vancomycin essentially 2 week course and was discontinued from the vancomycin [**2166-5-20**]. Lines were changed. Tips were sent for culture. Patient continued to tolerate dialysis. Zosyn was added for abscess cavity drainage. Wound care nurses were seeing patient for ostomy care. Patient went back to the operating room on [**2165-5-12**] for wound debridement and ostomy revision and exploration of the wound by Dr. [**Last Name (STitle) 816**]. It was uneventful. Patient's wound VAC was then replaced and continued to be changed on q.d. basis. Vancomycin and Levaquin were given for culture and sensitivity of urinary tract infection and MRSA. Vancomycin was just on a level low maintenance after hemodialysis. Patient was continued to be screened for rehabilitation. Patient went to the operating room on [**2165-5-21**] for Perm-A-Cath placement. Patient ultimately improved. Antibiotics were discontinued on [**2165-5-30**]. Dermatology was first consulted on [**2165-5-20**] for continued itching because of what was thought to be Levaquin and patient was pretreated with Benadryl. Patient was awaiting bed to rehabilitation from [**2165-5-22**] onwards. Patient continued to tolerate dialysis well with no further issues and was discharged to rehabilitation on [**2165-5-30**] after PICC line was placed. DISCHARGE DIAGNOSIS: Liver failure. Pneumatosis. Unviable colon. Status post total colectomy. Status post wound debridement and ostomy creation and debridement. Status post VAC placement. Status post renal failure. Status post drug overdose. Status post depression. Status post hemodialysis catheter placement and wound abscess. DISCHARGE MEDICATIONS: Tylenol 650 p.o. q 4 to 6 hours p.r.n. pain. Albuterol nebulizer. Vitamin C 500 mg p.o. once daily. Bisacodyl 10 mg p.r.n. at bedtime. Potassium 1 gram IV q.d. to be discontinued on [**2165-5-31**]. Benadryl 50 mg IV q 6. Anzemet 25 mg IV q 8. Heparin 5,000 units subcutaneously t.i.d. Hydroxyzine 50 mg p.o. q 6. Insulin sliding scale. Ipratropium bromide. Procef 50 mg p.o. once daily. Loperamide 4 mg p.o. b.i.d. Lepra 75 mg p.o. t.i.d. ________ Sarna lotion. Triamcinolone Vancomycin 1 gram IV q.d. that was discontinued and zinc sulfate 220 mg p.o. q.d. Patient did well postoperatively and was discharged to rehabilitation [**2165-5-30**] under the care of Dr. [**First Name (STitle) **] and is to follow up with Dr. [**First Name (STitle) **] in two weeks. To call with any concerns. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**] Dictated By:[**Doctor Last Name 9174**] MEDQUIST36 D: [**2165-5-30**] 10:58:08 T: [**2165-5-30**] 12:51:45 Job#: [**Job Number 60640**] Name: [**Known lastname 11061**],[**Known firstname 1972**] Unit No: [**Numeric Identifier 11062**] Admission Date: [**2165-4-7**] Discharge Date: [**2165-6-6**] Date of Birth: [**2105-6-10**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2800**] Addendum: Patient stayed at [**Hospital1 8**] pending rehab bed. During the past week, she has been stable. Hemodialysis has continued without event. [**Last Name **] problem has been persistent pruritus attributed to the antibiotics that she had been on (Ceftazidime/vancomycin). Benadryl and vistaril have provided some relief in addition to triamcinolone tp tid. The pigtail catheter that was in presacral abscess was self d/c'd by the patient. Her wbc has trended down to 16.3 on [**2165-6-6**]. The abdominal wound appears smaller with granulation tissue. Wound vac has been changed every three days. Last changed on [**2165-6-6**]. The post pyloric feeding was replaced on [**2165-6-5**] after patient removed. Placement was confirmed. During this hospitalization, she was followed by psychiatry. Last exam was [**2165-6-5**]. Previously, she had expressed suicidal ideation, but this was not felt to have real intent, but more an expression of her frustration at prolonged hospitalization. She was followed by Drs. [**First Name (STitle) **] and [**Name5 (PTitle) 11063**]. Most recent labs are as follows: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2165-6-6**] 07:50AM 16.3* 3.95* 11.2* 36.0 91 28.4 31.2 17.1* 198 DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos [**2165-6-6**] 07:50AM 64.3 23.9 3.2 8.2* 0.4 RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy Polychr Ovalocy Schisto Stipple Tear Dr [**Last Name (STitle) 11064**] Bite [**2165-6-6**] 07:50AM 3+ 1+ 1+ 1+ BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [**2165-6-6**] 07:50AM 198 BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino [**2165-4-16**] 03:44AM 648* Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2165-6-6**] 07:50AM 160* 54* 4.8* 140 5.6* 105 20* 21* ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili IndBili [**2165-6-6**] 07:50AM 38 32 254* 0.3 OTHER ENZYMES & BILIRUBINS Lipase [**2165-5-26**] 07:15AM 41 CPK ISOENZYMES CK-MB MB Indx cTropnT [**2165-4-9**] 03:10AM NotDone1 0.16*2 ADDED [**Doctor Last Name **] [**2165-4-9**] 11:50AM 1 NotDone CK-MB NOT PERFORMED, TOTAL CK < 100 2 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2165-6-6**] 07:50AM 3.3* 10.4* 2.8 HEMATOLOGIC calTIBC Ferritn TRF [**2165-5-5**] 10:00AM 191* 1311 Patient was discharged to [**Hospital 2653**] Rehab Hospital in [**Location (un) 11065**], MA. Vitals signs were stable. She was alert and oriented. Discharge Medications: 1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Loperamide HCl 2 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 4. Lansoprazole 15 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 7. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. 8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily): until [**5-24**]. 10. Acetaminophen 160 mg/5 mL Elixir Sig: One (1) PO Q4-6H (every 4 to 6 hours) as needed. 11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 12. Insulin Regular Human 100 unit/mL Solution Sig: follow sliding scale Injection every six (6) hours. 13. Dolasetron Mesylate 12.5 mg IV Q8H:PRN 14. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical TID (3 times a day) for 1 weeks: resolving drug rash. 15. Hydroxyzine HCl 25 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 16. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 17. Pramoxine 1 % Lotion Sig: One (1) application Topical [**Hospital1 **] () for 1 weeks. 18. Diphenhydramine HCl 25 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) as needed. 19. Dilaudid 1 mg/mL Solution Sig: 0.5 mg Injection prn q8: premed prior to wound vac and ostomy change prn. 20. Clotrimazole-Betamethasone 1-0.05 % Cream Sig: One (1) Appl Topical HS (at bedtime) for 4 days. Discharge Disposition: Extended Care Facility: [**Hospital 2653**] Rehab [**First Name11 (Name Pattern1) 399**] [**Last Name (NamePattern4) 2801**] MD [**MD Number(1) 401**] Completed by:[**2165-6-6**]

[ "038.8", "276.2", "348.1", "250.40", "403.91", "995.92", "785.52", "682.2", "557.0", "E950.0", "965.4", "693.0", "570", "567.2", "482.41", "518.81", "998.59", "569.89", "584.5" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.6", "99.04", "39.95", "54.91", "48.5", "38.95", "86.22", "99.15", "45.8", "00.17" ]

icd9pcs

[ [ [] ] ]

13920, 14130

12029, 13897

7596, 7905

1377, 1569

1809, 7574

171, 239

268, 1135

1158, 1353

1586, 1786

18,318

128,140

29728

Discharge summary

report

Admission Date: [**2118-12-9**] Discharge Date: [**2119-1-20**] Date of Birth: [**2066-2-13**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5880**] Chief Complaint: 52M unrestrained driver s/p high-speed rollover motor vehicle crash on [**2118-12-8**]. Major Surgical or Invasive Procedure: 1) exploratory laparotomy [**12-9**] 2) R tube thoracostomy [**12-9**] 3) closed reduction R acetabular fracture [**12-9**] 4) placement of R femoral traction pin [**12-9**] 5) open reduction/internal fixation B acetabular fractures [**12-28**] 6) inferior vena cava filter placement (R femoral approach) [**1-6**] 7) endoscopic esophagogastric-duodenoscopy [**1-6**] 8) percutaneous pericardiocentesis 9) continuous [**Last Name (un) **]-venous hemofiltration 10) open tracheostomy [**1-6**] 11) open reduction/internal fixation R distal humerus fracture [**1-6**] 12) replacement open tracheostomy [**1-6**] 13) electrocardioversion [**1-7**] 14) transesophageal echocardiography [**1-7**] 15) CT-guided R pleural drainage catheter placement [**1-16**] History of Present Illness: 52M unrestrained driver s/p high-speed rollover motor vehicle crash on [**2118-12-8**]. He was ejected from vehicle approximately 20 feet. No loss of conscious at the scene but was in considerable respiratory distress. Therefore, pt was intubated at the scene and transported to [**Hospital 8641**] Hospital for initial evaluation. At [**Location (un) 8641**], the patient had persistently elevated peak airway pressures in the 50s and was tachycardic despite appropriate resuscitation. Initial imaging demonstrated multiple pelvic fractures, multiple R rib fractures, R renal hematoma. As there was no Orthopedic Trauma service at [**Location (un) 8641**], the patient was trasferred to [**Hospital1 18**] for further management. Past Medical History: 1) hypertension 2) non-insulin dependent diabetes mellitus Social History: NA Family History: NA Physical Exam: Neuro: intubated/sedated HEENT: [**1-20**] bilat pupils; 2 cm lac over R eyebrow; no palpable stepoffs to R eye with stable midface grossly; no malocclusion of jaw; TM clear bilaterally; trachea midline and mobile; no stepoffs of cervical spine CVS: tachycardic; no M/R/G Resp: coarse BS bilaterally; chest movement symetrical Abd: soft, distended, abrasions over RUQ; normal rectal tone without gross blood; prostate in normal position Ext: Pertinent Results: [**2119-1-20**] 02:07AM BLOOD WBC-5.7 RBC-3.26* Hgb-8.7* Hct-27.6* MCV-85 MCH-26.7* MCHC-31.6 RDW-15.9* Plt Ct-489* [**2119-1-19**] 04:29AM BLOOD WBC-6.1 RBC-3.14* Hgb-8.7* Hct-26.3* MCV-84 MCH-27.8 MCHC-33.2 RDW-15.7* Plt Ct-474* [**2119-1-17**] 01:27AM BLOOD WBC-6.3 RBC-3.02* Hgb-8.4* Hct-25.6* MCV-85 MCH-27.6 MCHC-32.7 RDW-15.9* Plt Ct-399 [**2119-1-16**] 01:00AM BLOOD WBC-7.4 RBC-2.94* Hgb-8.3* Hct-25.7* MCV-87 MCH-28.2 MCHC-32.2 RDW-16.0* Plt Ct-372 [**2119-1-15**] 02:48AM BLOOD WBC-7.4 RBC-2.83* Hgb-8.1* Hct-24.7* MCV-88 MCH-28.6 MCHC-32.7 RDW-16.1* Plt Ct-385 [**2119-1-14**] 02:01AM BLOOD WBC-9.0 RBC-2.84* Hgb-8.3* Hct-25.1* MCV-88 MCH-29.1 MCHC-33.0 RDW-15.9* Plt Ct-356 [**2119-1-20**] 02:07AM BLOOD PT-19.5* PTT-26.4 INR(PT)-1.9* [**2119-1-19**] 04:29AM BLOOD PT-19.3* INR(PT)-1.8* [**2119-1-18**] 10:51AM BLOOD PT-18.0* INR(PT)-1.6* [**2119-1-20**] 02:07AM BLOOD Glucose-122* UreaN-19 Creat-0.5 Na-138 K-4.1 Cl-103 HCO3-27 AnGap-12 [**2119-1-19**] 04:29AM BLOOD Glucose-118* UreaN-19 Creat-0.5 Na-137 K-4.0 Cl-102 HCO3-28 AnGap-11 [**2119-1-17**] 01:27AM BLOOD Glucose-120* UreaN-20 Creat-0.6 Na-138 K-4.1 Cl-104 HCO3-27 AnGap-11 [**2119-1-16**] 01:00AM BLOOD Glucose-118* UreaN-21* Creat-0.7 Na-141 K-3.6 Cl-106 HCO3-25 AnGap-14 [**2119-1-15**] 02:48AM BLOOD Glucose-102 UreaN-23* Creat-0.7 Na-140 K-3.8 Cl-106 HCO3-26 AnGap-12 [**2119-1-14**] 02:01AM BLOOD Glucose-118* UreaN-25* Creat-0.7 Na-139 K-3.5 Cl-105 HCO3-28 AnGap-10 [**2119-1-13**] 03:15AM BLOOD Glucose-118* UreaN-26* Creat-0.7 Na-144 K-3.8 Cl-107 HCO3-30 AnGap-11 [**2118-12-31**] 02:20AM BLOOD ALT-49* AST-159* AlkPhos-75 Amylase-63 TotBili-0.6 [**2118-12-30**] 02:20PM BLOOD CK(CPK)-1781* [**2118-12-30**] 02:22AM BLOOD ALT-46* AST-156* CK(CPK)-2382* AlkPhos-70 TotBili-0.6 [**2118-12-29**] 05:08PM BLOOD ALT-49* AST-154* AlkPhos-70 TotBili-0.6 [**2118-12-24**] 02:01AM BLOOD ALT-108* AST-82* AlkPhos-62 TotBili-0.9 [**2118-12-22**] 02:40AM BLOOD ALT-130* AST-75* AlkPhos-72 Amylase-111* TotBili-0.9 [**2118-12-21**] 02:30AM BLOOD ALT-144* AST-107* AlkPhos-76 Amylase-134* TotBili-0.9 [**2118-12-20**] 02:04AM BLOOD ALT-127* AST-110* AlkPhos-75 TotBili-1.2 [**2118-12-22**] 02:40AM BLOOD Lipase-79* [**2118-12-21**] 02:30AM BLOOD Lipase-131* [**2118-12-14**] 12:50AM BLOOD Lipase-85* [**2119-1-20**] 02:07AM BLOOD Calcium-7.9* Phos-2.9 Mg-2.2 [**2119-1-19**] 04:29AM BLOOD Calcium-7.9* Phos-2.8 Mg-2.1 [**2119-1-17**] 01:27AM BLOOD Calcium-8.3* Phos-2.8 Mg-2.1 [**2119-1-20**] 02:07AM BLOOD Calcium-7.9* Phos-2.9 Mg-2.2 [**2119-1-19**] 04:29AM BLOOD Calcium-7.9* Phos-2.8 Mg-2.1 [**2119-1-17**] 01:27AM BLOOD Calcium-8.3* Phos-2.8 Mg-2.1 [**2119-1-16**] 01:00AM BLOOD Calcium-7.3* Phos-2.8 Mg-2.0 [**2119-1-15**] 02:48AM BLOOD Albumin-2.4* Calcium-8.5 Phos-3.6 Mg-2.1 Iron-8* [**2119-1-1**] 02:12AM BLOOD TSH-3.1 [**2118-12-17**] 02:00AM BLOOD T4-3.7* T3-41* [**2119-1-12**] 09:48PM BLOOD Vanco-16.7 [**2119-1-12**] 01:19PM BLOOD Vanco-30.2* [**2119-1-12**] 08:08AM BLOOD Vanco-18.0 [**2119-1-11**] 08:18PM BLOOD Vanco-19.1 [**2119-1-11**] 11:00AM BLOOD Vanco-12.2 [**2119-1-11**] 06:33AM BLOOD Vanco-14.0 [**2118-12-8**] 11:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2119-1-15**] 03:29AM BLOOD Type-ART pO2-144* pCO2-43 pH-7.44 calTCO2-30 Base XS-5 [**2119-1-14**] 01:38PM BLOOD Type-ART Temp-37.2 Rates-/22 PEEP-5 pO2-62* pCO2-44 pH-7.43 calTCO2-30 Base XS-3 Intubat-INTUBATED [**2119-1-13**] 03:32PM BLOOD Type-ART pO2-169* pCO2-45 pH-7.46* calTCO2-33* Base XS-7 [**2119-1-13**] 12:07PM BLOOD Type-[**Last Name (un) **] pH-7.48* Comment-GREEN TUBE [**2119-1-13**] 03:27AM BLOOD Type-ART pO2-74* pCO2-47* pH-7.46* calTCO2-34* Base XS-8 [**2119-1-12**] 01:26PM BLOOD Type-ART pO2-91 pCO2-43 pH-7.45 calTCO2-31* Base XS-4 [**2119-1-12**] 06:26AM BLOOD Type-ART Temp-37.6 Rates-/20 Tidal V-520 PEEP-5 FiO2-40 pO2-87 pCO2-42 pH-7.49* calTCO2-33* Base XS-7 Intubat-INTUBATED Vent-SPONTANEOU [**2119-1-15**] 03:29AM BLOOD freeCa-1.15 [**2119-1-14**] 01:38PM BLOOD freeCa-1.12 [**2119-1-13**] 12:07PM BLOOD freeCa-1.01* [**2119-1-13**] 03:27AM BLOOD freeCa-1.13 [**2119-1-12**] 01:26PM BLOOD freeCa-1.05* [**2119-1-12**] 06:26AM BLOOD freeCa-1.09* Brief Hospital Course: 52 year-old male admitted here from [**Hospital 8641**] Hospital on [**2118-12-9**] s/p unrestrained MVA, ejected 20 feet. He was conscious at the scene, but intubated for respiratory distress with high peak airway pressures. The pt sustained a R kidney injury with a retroperitoneal hematoma, R hemothorax, hemoperitoneum, and multiple fractures (Bilateral acetabular fracture with right hip subluxation pelvic, rib, and multiple fractures involving lateral wall of the right maxilla and the right orbital floor with herniation of the orbital fat into the right maxillary sinus). Pt has undergone exploratory laparotomy and right tube thoracostomy [**12-8**], closed reduction of right acetabular fracture [**12-9**], ORIF of right both column acetabular fracture [**12-28**], and Trach/PEG on [**1-6**] with replacement of Trach on same day due to displacement. His course has been complicated by cardiac tamponade s/p pericardiocentesis, sepsis, respiratory failure, pre-renal non-oliguric ARF, atrial flutter, and hyponatremia. Neurology consult on [**2118-12-29**] also indicates pt presented with critical illness myopathy. A pig tail catheter was placed on [**1-17**] for large pleural effusions in pt's L chest which was subsequently removed prior to discharge. Swallow Assessment showed The pt had intermittent signs of aspiration at the bedside with thin liquids and nectar thick liquids, but no return was seen with tracheal suctioning and the pt does have a baseline cough. He would be able to follow compensatory strategies, and am therefore recommending he be seen for a Fiberoptic Endoscopic Evaluation of Swallowing (FEES) at the bedside tomorrow for further evaluation. At discharge pt. recommended for pureed solids with a small amount of ice chips. At discharge, pt tolerating trach masks, remains non-weight bearing 10 weeks total. Medications on Admission: 1) diovan 2) HCTZ 3) clonidine Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 3. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2 times a day). 4. Albuterol 90 mcg/Actuation Aerosol Sig: 6-8 Puffs Inhalation Q4H (every 4 hours) as needed. 5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. 6. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical DAILY (Daily). 7. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Papain-Urea 830,000-10 unit/g-% Ointment Sig: One (1) Appl Topical DAILY (Daily). 11. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q3H as needed for breakthrough pain. 12. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for anxiety/agitation. 13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours) as needed for pain. Patch 72HR(s) 15. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 16. Albuterol Sulfate 0.083 % Solution Sig: One (1) NEB Inhalation Q6H (every 6 hours) as needed. 17. Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB Inhalation Q6H (every 6 hours) as needed. 18. Metoclopramide 5 mg/mL Solution Sig: Ten (10) mg Injection Q6H (every 6 hours). Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: 1) R hemothorax/hemoperitoneum 2) cardiac tamponade 3) cardiac failure 4) line sepsis 5) pneumonia 6) ARDS/prolonged respiratory failure 7) dislodged tracheostomy tube 8) R pleural effusion 9) non-oliguric acute renal failure 10) atrial flutter/fibrillation 11) hyponatremia 12) bilateral acetabular fractures 13) comminuted distal R humeral fracture 14) R scapholunate ligament rupture 15) R renal laceration 16) anemia requiring blood transfusion 17) multiple rib fractures 18) R maxillary sinus fracture 19) R inferior orbital wall fracture 20) R transverse process fractures of L3,4 and 5 21) critical illness myopathy Discharge Condition: stable Discharge Instructions: Ortho: 1) NWB BLE w/PROM, NWB RUE w/PROM and volar splint R wrist 2) weekly pelvic film on mondays To Rehab. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] in Trauma clinic in 1 month or as convenient by appointment. Call [**Telephone/Fax (1) 6429**] for an appointment. You will need to follow up with Orthopedics at [**Telephone/Fax (1) 1228**] and Neurology [**Telephone/Fax (1) 44**]. Go to rehab. take all medications as directed. Monitor for any signs of infection or concerning symptoms such as chest pain, shortness of breath or fevers.

[ "038.11", "285.1", "423.0", "401.9", "V64.41", "870.8", "E816.0", "868.03", "998.2", "276.1", "861.21", "805.4", "519.02", "428.0", "807.00", "996.62", "427.32", "250.00", "802.4", "842.09", "812.42", "808.0", "511.9", "995.92", "584.5", "787.91", "359.81", "802.6", "866.12", "518.5", "482.41", "860.2" ]

icd9cm

[ [ [] ] ]

[ "38.7", "37.0", "31.1", "79.39", "33.22", "38.95", "34.04", "79.19", "44.61", "97.23", "34.91", "79.61", "38.93", "99.62", "39.95", "79.31", "54.11", "08.81", "43.19", "96.72", "96.6", "38.91", "99.04" ]

icd9pcs

[ [ [] ] ]

10233, 10280

6720, 8578

403, 1160

10947, 10956

2528, 6697

11115, 11551

2041, 2045

8660, 10210

10301, 10926

8604, 8637

10980, 11092

2060, 2509

275, 365

1188, 1923

1945, 2005

2021, 2025

8,231

111,643

49373

Discharge summary

report

Admission Date: [**2119-1-3**] Discharge Date: [**2119-1-7**] Date of Birth: [**2043-2-2**] Sex: F Service: MEDICINE Allergies: Penicillins / Codeine / Heparin Agents Attending:[**First Name3 (LF) 905**] Chief Complaint: melena Major Surgical or Invasive Procedure: None History of Present Illness: 75yo woman with history of DM2, HTN, CAD s/p CABG, diastolic CHF with EF of 60-65%, and past GI bleeding with AVMs on EGD and colonoscopy now presents with melena. On day of admission, she had presented to the [**Hospital1 18**] day care unit where she was to have teh patency of her AV fistula evaluated. There, it was noted that her Hct was down to 21. She was referred to the ED. In the ED, she had a dark bowel movement that was guaiac positive. Initial vitals in the ED were 99.4, 81, 133/44, 28, and 95% on 2L NC; FS 166. There, she felt well with no complaints of chest pain, shortness of breath, abdominal pain, lightheadedness or any other complaints. In Emergency department, a right IJ triple lumen catheter was placed given difficult peripheral access, she was given albuterol/atrovent nebs x 1, protonix 40mg IV x 1, and one unit PRBC. She refused an NG lavage. She remained hemodynamically stable throughout. On review, she does report that she has had dark stools and mild diffuse abdominal pain for the past two days. She had no hematemesis or BRBPR. . In ED, she was seen by Nephrology, who recommended starting Epogen at 10,000 units MWF, continuing lasix at 80mg daily, transfusing only 2units PRBC given risk for volume overload, and to perform a fistulogram when she is stable. They noted that there is no need for urgent hemodialysis. She was also seen by Gastroenterology, who recommended (in light of her refusal of NG lavage and Endoscopy) serial q4h hematocrits, holding ASA, protonix [**Hospital1 **]. Will follow. Past Medical History: 1. CRI [**3-2**] HTN and DM nephropathy, with baseline creatinine ~4.3 2. h/o GI bleeding: . - [**11-2**] EGD: Angioectasias in the stomach body Erythema and friability in the stomach compatible with gastritis Angioectasia in the distal duodenum and/or proximal jejunum Otherwise normal egd to jejunum . - [**11-2**] colonoscopy: Erythema in the whole colon There was no evidence of blood in colon. There were no AVMs but visualization was somewhat limited by stool. ( does have h/o cecal AVM's). 3. Throbocytopenia (HIT)- in [**2116**], plts dropped from 130-160 to 80-90 4. MRSA endocardiitis ([**12-31**]) 5. Coronary artery disease; status post coronary artery bypass graft times two and status post myocardial infarction in [**2103**] and [**2113**]. 6. CHF EF 60-65% (diastolic) 7. DM2 on insulin 8. HTN, hyperlipidemia 9. Paroxysmal atrial fibrillation (no anticoagulation) 10. PUD, Barrett's esoph 11. Asthma 12. Hypothyroidism 13. Osteoarthritis 14. s/p CCY 15. Anemia with baseline ~27, thought related to GIB and CRI Social History: Primarily Spanish speaking, wheelchair bound and lives alone but cared for entirely by her daughter. She denies EtOH, tobacco, and drugs. Patient has 8 children, 40 grandchildren and one great-grandaughter. Family History: CAD and DM Physical Exam: vitals: 97.5, 74, 130/43, 20, 99% on 2L nc . gen: alert, oriented, no acute distress heent: sclera anicteric, oropharynx clear neck: supple, full range of motion; left IJ in place cv: RRR, no m/r/g resp: good air movement; diffuse end-expiratory wheezing bilaterally abd: soft, obese, normoactive bowel sounds. Non-tender. No HSM. extr: 1+ symmetric lower extremity edema; 1+ pedal pulses bilaterally neuro: non-focal Pertinent Results: Chest film (ap): cardiomegaly with vascular redistribution. Left IJ with tip in likely brachiocephalic vein. [**2119-1-3**] 09:00AM WBC-6.6 RBC-2.24*# HGB-7.2*# HCT-21.7*# MCV-97 MCH-32.0 MCHC-33.1 RDW-18.3* [**2119-1-3**] 09:00AM NEUTS-73.2* LYMPHS-18.0 MONOS-7.1 EOS-1.6 BASOS-0.2 [**2119-1-3**] 03:45PM GLUCOSE-169* UREA N-57* CREAT-3.9* SODIUM-137 POTASSIUM-3.4 CHLORIDE-97 TOTAL CO2-27 ANION GAP-16 [**2119-1-3**] 03:45PM ALBUMIN-2.7* CALCIUM-8.1* PHOSPHATE-3.1 MAGNESIUM-1.8 Brief Hospital Course: 75yo woman with recurrent GI bleeding secondary to AVM who presented with melena and Hct drop from baseline of 30's to 21. She was hemodynamically stable on arrival. GI was consulted, but the patient refused NG lavage, as well as endoscopy. She was admitted to the MICU where she was monitored with Q4 hour Hct. She was transfused a total of 2units PRBC's. Her Hct trended from 21.7 --> 28.2 after transfusion, and stabilized in the mid-high 20's. Her coagulopathy was corrected and she received DDAVP. She was also started on Procrit. Hematology was consulted and recommended continued following of Hct, and also suggested possible thalidomide or estrogen for treatment of chronic AVM bleeding. The medicine team was reluctant to start estrogen given her high risk of clot formation (HIT, obesity, etc.). Eventually, she was given another 2 units PRBC's to bring her Hct above 30. Dialysis was not intitiated on this admission. The patient will follow up with renal as an outpatient for initiation of dialysis. She will also follow up with GI as an outpatient for monitoring of her chronic GI bleeding, and for the possibilty of thalidomide therapy vs. estrogen. . Medications on Admission: 1. Levothyroxine 175 mcg 2. Atorvastatin 40 mg 3. toprol xl 25mg 4. Fluticasone 110 mcg 2 puffs [**Hospital1 **] 5. Ipratropium Bromide 18 mcg 2 puffs QID 6. Pantoprazole 40 mg 7. Furosemide 80 mg daily 8. Insulin Regular 9. Aspirin 81 mg 10. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 14 days. Discharge Medications: 1. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2* 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 5. Epoetin Alfa 10,000 unit/mL Solution Sig: 10,000 units Injection QMOWEFR (Monday -Wednesday-Friday): To be set up by your nephrologist. Disp:*3 inj* Refills:*2* 6. Atrovent 18 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation four times a day. Disp:*1 unit* Refills:*2* 7. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 9. Hectorol 0.5 mcg Capsule Sig: Two (2) Capsule PO once a day. Disp:*60 Capsule(s)* Refills:*2* 10. Thalidomide 100 mg Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* 11. Outpatient Lab Work Please check CBC and Chem 7 on Monday [**2119-1-9**] Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: 1) Gastrointestinal bleeding 2) Coagulopathy 3) End Stage Renal Disease 4) Thrombocytopenia 5) Diabetes Discharge Condition: Stable, improved from the time of admission Discharge Instructions: Please return to the ER or call your doctor if you experience further bleeding per rectum, black stool, chest pain, difficulty breathing, or dizziness. You should take all medications as prescribed. Please come back if you present any new skin abnormality or anything you notethat is different from usual. Followup Instructions: 1) Please call your primary care doctor (Dr. [**Last Name (STitle) 20670**] for a follow up appointment within one week following discharge. . 2) Please call Dr. [**Last Name (STitle) 1860**] (Nephrology) for a follow up appointment at ([**Telephone/Fax (1) 773**]. . 3) Please call [**Hospital **] clinic to make a follow up appointment with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 2427**] after discharge at ([**Telephone/Fax (1) 33689**]. [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

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icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

6982, 7039

4166, 5346

302, 309

7187, 7233

3652, 4143

7588, 8142

3185, 3198

5715, 6959

7060, 7166

5372, 5692

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3213, 3633

256, 264

337, 1884

1906, 2942

2958, 3169

23,054

123,049

23133

Discharge summary

report

Admission Date: [**2175-2-4**] Discharge Date: [**2175-2-12**] Date of Birth: [**2144-12-16**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: S/p high speed MVC Major Surgical or Invasive Procedure: L Humerus ORIF 2/14 L Medial Malleolus ORIF [**2-6**] Intubation and mechanical ventilation in Trauma SICU History of Present Illness: 30yoM out drinking, as well as taking amphetamines and marijuana, with his wife's brothers; then was an ejected passenger in MVC at 100mph. GCS 3 at scene, pos LOC, GCS 6 at OSH, GCS 3T in [**Hospital1 18**] ED. Extracted and brought to OSH where intubated, Head/ abdomen/ chest CTs were negative. Transfered to [**Hospital1 18**] for further trauma management. Past Medical History: ADD, untreated Social History: alcohol on weekends unemployed wife, 1 child of his (lives with mother), 3 kids of hers two brothers in law in same accident, similarly impaired Family History: N/A Physical Exam: 154/64, 101, intubated R temporal hematoma R hyphema R lip lac PER but not reactive Ccollar in place CTAB slightly [**Month (only) **] on L soft nt nd bs wnl stable pelvis rectal nl tone, no gross blood wwp extremities, left ankle ecchymoses, left shoulder abrasions/ecchymoses back no stepoffs neurologic GCS 3 intubated Pertinent Results: [**2175-2-4**] 08:11AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2175-2-4**] 08:11AM URINE RBC->50 WBC-[**2-25**] BACTERIA-RARE YEAST-NONE EPI-0-2 [**2175-2-4**] 08:11AM PT-13.5 PTT-21.8* INR(PT)-1.1 [**2175-2-4**] 08:11AM WBC-26.1* RBC-4.58* HGB-13.3* HCT-38.7* MCV-85 MCH-29.0 MCHC-34.2 RDW-13.7 [**2175-2-4**] 08:11AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG [**2175-2-4**] 08:11AM ASA-NEG ETHANOL-124* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2175-2-4**] 10:28PM HCT-34.6* [**2175-2-6**] 02:46AM BLOOD WBC-16.1* RBC-3.40* Hgb-9.9* Hct-28.8* MCV-85 MCH-29.0 MCHC-34.3 RDW-13.7 Plt Ct-257 [**2175-2-8**] 06:00AM BLOOD WBC-13.7* RBC-3.09* Hgb-8.6* Hct-26.4* MCV-86 MCH-27.9 MCHC-32.6 RDW-13.9 Plt Ct-311 [**2175-2-8**] 04:15PM BLOOD Hct-26.7* [**2175-2-9**] 05:50AM BLOOD Hct-26.9* [**2175-2-8**] 06:00AM BLOOD Glucose-111* UreaN-10 Creat-0.7 Na-136 K-3.8 Cl-102 HCO3-27 AnGap-11 CT mandible [**2-4**] IMPRESSION: No fracture detected. There are swelling and hematoma about the superior aspect of the right orbit, with a small amount of extension into the lateral extraconal fat. CT chest/abd/pelvis [**2-4**] IMPRESSION: 1. Stranding at the root of the mesentery at the origin of the inferior mesenteric artery. This may represent early mesenteric injury, and close clinical and CT follow is recommended. This finding was discussed with Dr. [**First Name (STitle) **] approximately 1 pm on [**2175-2-4**]. 2. No acute injuries detected in the chest. Bibasilar opacities in the lungs most likely represent atelectasis. CT Cspine [**2-4**] IMPRESSION: 1) No cervical spine fracture detected. 2) Left proximal humerus fracture. 3) Endotracheal tube cuff appears overinflated. CT head [**2-4**] IMPRESSION: Large right frontal scalp hematoma. Questionable possible density in the right frontal lobe adjacent to this area could represent artifact vs early contusion. No fractures. XR shoulder [**2-4**] IMPRESSION: No shoulder abnormalities. Although unlikely, a shoulder dislocation is not fully excluded due to the lack of an axillary or Y view. XR T/L spine [**2-4**] IMPRESSION: No fracture of the spine identified. XR L ankle [**2-4**] FINDINGS: Frontal and lateral views of the left ankle demonstrate a fracture through the medial malleolus that extends to the joint space. Oblique films would be needed for a full evaluation of the ankle. XR L humerus [**2-4**] FINDINGS: Lateral and oblique views of the left humerus demonstrate a slightly impacted humeral neck fracture. The alignment is near anatomic. An IV line is seen in the antecubital fossa. XR L knee [**2-4**] FINDINGS: Frontal and lateral views of the right knee demonstrate normal alignment without fracture or dislocation. CT abd/pelvis [**2-6**] CONCLUSION: Although root of mesentery stranding is again identified worrisome for bowel injury, the small amount of free pelvic fluid would not account for a hematocrit drop. The appearances are relatively stable over 48 hours suggesting non progression of injury. The cases were discussed with the team at the time of diagnosis. CT head [**2-8**] IMPRESSION: Focus of hemorrhage seen within the occipital [**Doctor Last Name 534**] of the right lateral ventricle, not significantly changed. No new areas of hemorrhage or infarct. XR left humerus [**2-9**] s/p fall from bed FINDINGS: Left humerus, AP and lateral [**2175-2-9**]; compared to the images of [**2175-2-6**], there is now a side plate with multiple screws along the lateral aspect of the proximal humeral epiphysis and diaphysis. Hardware is in place. The plate is transfixed to the comminuted fracture of the left humeral neck. There is slight medial rotation of the humeral head. skin staples are present. Soft tissue edema is present. Brief Hospital Course: Pt found on ED trauma evaluation to have a left proximal humerus surgical neck fracture, a left medial malleolar fracture, and a question of mesenteric stranding on CT abdomen. Due to patient's mental status and dependence on mechanical ventilation, transfered to the TSICU for further management. Opthalmology consulted and assessed pt to have sunconjunctival hemorrage not a hyphema and no evidence of globe rupture. Over two days, serial abdominal exams unchanged, Hct trending down slowly then stabilized, pt was extubated, and mental status remained cloudy A0x1. HD 3 pt went to OR with orthopedics for ORIF L ankle and L humerus which he tolerated well. HD 4 pt remained with mild abdominal pain, CT abd demonstrated no worsening in mesenteric stranding. HD 5 pt remained with cloudy mental status AOx2 only, CT head demonstrated a small focus of right lateral ventricle where previously read as artifact vs contusion. HD 6 neurobehavorial team assessed patient to have diffuse axonal injury vs postconcussive vs ischemic/hypoxic injury and made some medication and sleep wake cycle recomendations. On HD 7, pt continued to become more awake and alert, exhibiting better judgement, but with continued poor recall and confabulation; his mental status was sufficient to allow his C-spine to be clear on this day as well. On HD#8, he was considered stable for D/C after family lovenox teaching. Medications on Admission: none Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 4. Trazodone HCl 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) for 5 days. Disp:*5 Tablet(s)* Refills:*0* 5. Enoxaparin Sodium 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours) for 2 weeks. Disp:*qs 30* Refills:*0* 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1) Left medial malleolus ankle fracture 2) Left humerus arm fracture 3) Post concussive syndrome vs. diffuse axonal injury Discharge Condition: fair, improving Discharge Instructions: - you may not put any weight on your left arm until instructed to by Dr. [**Last Name (STitle) 1005**] from Orthopedic Surgery - you may only transfer weight with your left leg, no full weight, also until cleared. However, it is important that you get up and walk around as much as possible. - you may return to your regular diet as tolerated - you must take all medications as prescribed, including the injections of Lovenox (as instructed to do by the nursing staff before leaving) Followup Instructions: 1. Follow up with Orthopedic Surgery Dr [**Last Name (STitle) 1005**] at ([**Telephone/Fax (1) 11416**], call for an appointment in 2 weeks for further evaluation of your arm and leg injuries 2. Followup with Trauma clinic Dr [**Last Name (STitle) **] at [**Telephone/Fax (1) 12786**] for an appointment in 2 weeks, call for an appointment on a Tuesday afternoon 3. Followup with Neurobehavorial medicine Dr [**Last Name (STitle) **] in [**1-26**] weeks for followup of your thinking, call for an appointment at [**Telephone/Fax (1) 59537**].

[ "824.0", "920", "305.20", "812.01", "305.00", "372.72", "E816.1", "314.00", "305.70" ]

icd9cm

[ [ [] ] ]

[ "96.04", "79.36", "96.71", "79.31" ]

icd9pcs

[ [ [] ] ]

7473, 7479

5307, 6714

333, 442

7646, 7663

1414, 5284

8196, 8746

1051, 1056

6769, 7450

7500, 7625

6740, 6746

7687, 8173

1071, 1395

275, 295

470, 835

857, 873

889, 1035

31,009

166,163

52455

Discharge summary

report

Admission Date: [**2191-12-28**] Discharge Date: [**2192-1-6**] Date of Birth: [**2111-5-27**] Sex: F Service: CARDIOTHORACIC Allergies: Ultram / Neurontin / Amoxicillin Attending:[**First Name3 (LF) 1505**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: CABG x3(Lima-LAD, SVG-OM, SVG-pda) [**1-2**] History of Present Illness: 80 yo F with sudden onset of chest pain at home, improved with NTG, presented to ED. Past Medical History: CAD s/p MI, cardiac arrest at age 59 PVD s/p multiple bypass surgeries RAS s/p stent HTN Colon cancer s/p resection, chemotherapy Hypothyroidism CRI (baseline creat 1.0-1.2), Stage 3 chronic renal failure Diverticulitis Gastritis with h/o GIB DVT with chronic L leg swelling since GERD LBP Fibromyalgia Carotid stenosis Hypercholesterolemia COPD Social History: Widowed. Lives with son at home. Rare EtOH use. Prior tobacco use - quit 1 week ago Family History: NC Physical Exam: NAD HR 72 RR 18 BP 143/55 Lungs CTAB ant/lat Heart RRR no Murmur Abdomen soft/NT/ND, no masses, healed scar around umbilicus Extrem warm, no edema Multiple LE varicosities, L>R Pertinent Results: [**2192-1-5**] 09:05AM BLOOD WBC-10.8 RBC-3.19* Hgb-9.5* Hct-28.3* MCV-89 MCH-29.7 MCHC-33.5 RDW-18.1* Plt Ct-168# [**2191-12-28**] 09:55AM BLOOD WBC-4.5 RBC-4.27 Hgb-12.1 Hct-38.0 MCV-89 MCH-28.4 MCHC-31.9 RDW-18.2* Plt Ct-187 [**2191-12-29**] 09:30AM BLOOD WBC-5.2 RBC-3.61* Hgb-10.7* Hct-31.2* MCV-87 MCH-29.8 MCHC-34.4 RDW-16.4* Plt Ct-153 [**2191-12-28**] 09:55AM BLOOD Neuts-51.2 Bands-0 Lymphs-39.7 Monos-6.7 Eos-1.3 Baso-1.0 [**2192-1-5**] 09:05AM BLOOD Plt Ct-168# [**2192-1-2**] 11:35AM BLOOD PT-14.3* PTT-56.3* INR(PT)-1.2* [**2191-12-29**] 09:30AM BLOOD PT-12.4 PTT-27.1 INR(PT)-1.0 [**2191-12-28**] 09:55AM BLOOD Plt Ct-187 [**2192-1-2**] 10:55AM BLOOD Fibrino-147* [**2192-1-5**] 09:05AM BLOOD Glucose-97 UreaN-23* Creat-1.5* Na-135 K-3.7 Cl-98 HCO3-29 AnGap-12 [**2191-12-28**] 09:55AM BLOOD Glucose-102 UreaN-20 Creat-1.4* Na-142 K-3.6 Cl-105 HCO3-28 AnGap-13 [**2191-12-29**] 09:30AM BLOOD ALT-12 AST-25 AlkPhos-60 TotBili-0.2 [**2191-12-28**] 02:05PM BLOOD cTropnT-<0.01 [**2192-1-2**] 06:00AM BLOOD Calcium-9.4 Phos-3.4 Mg-2.2 [**2191-12-29**] 09:30AM BLOOD TotProt-6.1* Albumin-3.6 Globuln-2.5 [**2191-12-29**] 09:30AM BLOOD %HbA1c-5.7 [**2191-12-30**] 05:30AM BLOOD Triglyc-56 HDL-58 CHOL/HD-2.3 LDLcalc-65 RADIOLOGY Final Report CHEST (PA & LAT) [**2192-1-6**] 10:44 AM CHEST (PA & LAT) Reason: eval pneumo [**Hospital 93**] MEDICAL CONDITION: 80 year old woman s/p CABG REASON FOR THIS EXAMINATION: eval pneumo HISTORY: Status post CABG. FINDINGS: In comparison with the study of [**1-5**], there is a decrease in the fluid component of the hydropneumothorax on the left. Little change in the degree of pneumothorax. The right lung remains essentially clear. DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**] Approved: [**First Name9 (NamePattern2) **] [**2192-1-6**] 11:01 AM Cardiology Report ECG Study Date of [**2192-1-3**] 2:35:02 AM Sinus rhythm. Indeterminate axis. Intraventricular conduction delay of right bundle-branch block type. Generalized low limb lead voltage. Compared to the previous tracing the axis is more indeterminate - to some degree related to the low voltage. The QRS width has decreased. There is now ST segment elevation in lead V3 of uncertain significance. Clinical correlation is suggested. TRACING #2 Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A. Intervals Axes Rate PR QRS QT/QTc P QRS T 71 170 118 422/441 87 0 41 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 108368**] (Complete) Done [**2192-1-2**] at 9:06:43 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. Division of Cardiothoracic [**Doctor First Name **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2111-5-27**] Age (years): 80 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Aortic valve disease. Coronary artery disease. Left ventricular function. Mitral valve disease. Right ventricular function. Valvular heart disease. ICD-9 Codes: 440.0, 396.9 Test Information Date/Time: [**2192-1-2**] at 09:06 Interpret MD: [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW01-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 0.8 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.0 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 2.5 cm Left Ventricle - Fractional Shortening: 0.38 >= 0.29 Left Ventricle - Ejection Fraction: >= 55% >= 55% Aorta - Sinus Level: 2.0 cm <= 3.6 cm Aorta - Ascending: 3.0 cm <= 3.4 cm Findings LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No spontaneous echo contrast in the body of the RA or RAA. A catheter or pacing wire is seen in the RA. No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness and cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Simple atheroma in ascending aorta. Complex (>4mm) atheroma in the aortic arch. Normal descending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets. No AS. Trace AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild mitral annular calcification. Mild thickening of mitral valve chordae. No MS. Mild to moderate ([**12-21**]+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic 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 TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-BYPASS: The left atrium is moderately dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No spontaneous echo contrast is seen in the body of the right atrium or right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 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. Mild to moderate ([**12-21**]+) mitral regurgitation is seen. There is no pericardial effusion. POST CPB: Preserved [**Hospital1 **]-ventricular systolic function. No change in valve structure and function. Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2192-1-2**] 10:57 Brief Hospital Course: Cardiac catheterization showed 3VD, and she was seen by cardiac surgery. She was taken to the operating room on [**1-2**] where she underwent a CABG x 3. She was transferred to the ICU in stable condition. She was given 48 hours of vancomycin as perioperative prophylaxis as she was in the hospital preoperatively and is allergic to penicillin. She was extubated later that same day. She was transferred to the floor on POD #1. Physical therapy worked with her for strength and mobility. She continued to progress and was ready for discharge to rehab on POD 4. Medications on Admission: metoprolol 12.5", lisinopril 20', Norvasc 5', Lipitor 40', Prilosec, Ecotrin 325', Synthroid 150', Plavix 75', Alprazolam 0.75', omeprazole 40' Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. 6. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO once a day for 5 days. 7. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 8. Slow Fe 160 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: CAD now s/p CABG MI, cardiac arrest at age 59, PVD s/p multiple bypass surgeries: Fem-fem bypass with right femoral patch angioplasty; right common iliac stent, ??RAS: s/p stent, Carotid stenosis: Bilateral 60-69% ICA stenosis as of [**10-26**], ^lipidemia, HTN, COPD, Colon cancer s/p resection, chemotherapy, Hypothyroidism, CRI (baseline creat 1.0-1.2), Diverticulitis, GERD and Gastritis with h/o GIB, DVT, LBP, Fibromyalgia 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 or driving until follow up with surgeon. Followup Instructions: Dr. [**Last Name (STitle) 108369**] 2 weeks Dr.[**Name (NI) 3733**] 2 weeks Dr. [**Last Name (STitle) **] 4 weeks Already scheduled appointments: Provider: [**First Name11 (Name Pattern1) 2671**] [**Last Name (NamePattern4) 10485**], MD Phone:[**Telephone/Fax (1) 8645**] Date/Time:[**2192-2-16**] 1:30 Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB) Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2192-4-26**] 1:30 Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2192-4-26**] 2:15 Completed by:[**2192-1-6**]

[ "412", "410.21", "440.1", "729.1", "530.81", "414.01", "433.10", "403.90", "496", "V10.05", "585.3", "790.01", "443.9", "244.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

9889, 9959

8183, 8746

310, 357

10432, 10440

1176, 2512

10738, 11420

959, 963

8940, 9866

2549, 2576

9980, 10411

8772, 8917

10464, 10715

6831, 7880

978, 1157

260, 272

2605, 6782

385, 471

493, 841

857, 943

7891, 8160

55,966

171,141

36006

Discharge summary

report

Admission Date: [**2119-4-5**] Discharge Date: [**2119-4-14**] Date of Birth: [**2070-11-1**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6346**] Chief Complaint: Complicated incisional ventral hernia Major Surgical or Invasive Procedure: Exploratory laparotomy, lysis of adhesions, small bowel resection, ileal transverse colectomy, jejunojejunostomy, ileal colostomy, component separation, ventral hernia repair with biologic material and polypropylene mesh. History of Present Illness: Mr. [**Known lastname **] is a 48-year-old gentleman with a history of a strangulated hernia repair complicated by an open wound. which required skin grafting by plastic surgery. He is almost completely healed his skin graft site. He reports that there has been some increased bulging at the incision, and developed a large ventral hernia after surgery. He was offered repair and was admitted for surgery. Past Medical History: PMHx: pneumonia, Sepsis s/p ileocecetomy and incarcerated hernia repair . PSHx: ORIF L wrist and L knee after MVC at age 15. [**2118-1-25**] Exploratory laparotomy, incarcerated ventral hernia reduction, hernia sac removal and hernia repair with mesh. [**2118-1-25**] Ex lap washout, ileocolectomy, ileocolostomy [**Doctor Last Name 406**] drain placement and primary fascial closure with back drain placement Social History: Works in construction, 15-20 pack years tobacco, former alcoholic, no drugs Family History: Parents - alive and healthy Siblings - first alive and well, second passed via complications of drug abuse Children - one healthy son Physical Exam: At Discharge: AVSS/afebrile GEN: Obese male in NAD. HEENT: Sclerae anicteric. O-P clear. NECK: Supple. LUNGS: CTA(B) COR: RRR; no m/c/r ABD: Protuberant with large midline incision with staples extending from epigastric area to supra-pubic area. (R)LQ JP drain intact/patent with serisanginous output. BSx4. Appropriately tender to palpation along incision, otherwise soft/NT/ND. EXTREM: WWP; no c/c/e NEURO: A+Ox3. Non-focal/grossly intact. Pertinent Results: On Admission: [**2119-4-5**] 10:39PM LACTATE-2.1* [**2119-4-5**] 07:13PM LACTATE-2.0 [**2119-4-5**] 06:31PM POTASSIUM-5.8* [**2119-4-5**] 05:07PM TYPE-ART PO2-453* PCO2-50* PH-7.28* TOTAL CO2-24 BASE XS--3 [**2119-4-5**] 04:57PM GLUCOSE-121* UREA N-13 CREAT-1.2 SODIUM-139 POTASSIUM-6.1* CHLORIDE-109* TOTAL CO2-21* ANION GAP-15 [**2119-4-5**] 04:57PM ALBUMIN-3.4* CALCIUM-8.6 PHOSPHATE-4.9*# MAGNESIUM-1.3* IRON-122 [**2119-4-5**] 04:57PM FERRITIN-461* [**2119-4-5**] 04:57PM WBC-12.7* RBC-4.84 HGB-13.9* HCT-43.0 MCV-89 MCH-28.6 MCHC-32.2 RDW-13.2 [**2119-4-5**] 04:57PM PLT COUNT-248 [**2119-4-5**] 02:54PM TYPE-ART PO2-159* PCO2-49* PH-7.27* TOTAL CO2-23 BASE XS--4 [**2119-4-5**] 02:54PM GLUCOSE-118* LACTATE-3.1* NA+-138 K+-5.2 CL--109 TCO2-22 [**2119-4-5**] 02:54PM HGB-13.5* calcHCT-41 [**2119-4-5**] 02:54PM freeCa-1.21 [**2119-4-5**] 02:05PM HGB-14.3 calcHCT-43 [**2119-4-5**] 02:05PM freeCa-1.09* . IMAGING: [**2119-4-7**] CXR: Low lung volumes are again seen. Mild retrocardiac atelectasis at the base. Again, there is an area of increased opacification at the right base that could represent merely crowding of pulmonary markings related to relatively low lung volumes. If there is clinical concern for pneumonia, lateral view would be helpful. . MICROBIOLOGY: [**2119-4-5**] MRSA Screen: Negative. . PATHOLOGY: [**2119-4-5**] SPECIMEN SUBMITTED: small bowel, ABDOMINAL WALL SKIN, GREATER OMENTUM, TRANSVERSE COLON. DIAGNOSIS: I. Small bowel, segmental resection (A-C): Small intestine with fibrous adhesions. II. Abdominal wall skin, excision (D-F): Skin with scar and epidermal ulceration. III. Greater omentum, omentectomy (G-H): Unremarkable fibroadipose tissue. IV. Transverse colon, partial colectomy (I-V): 1. Large and small intestines with few inflammatory polyps and focal mucosal ulcerations. 2. Changes consistent with previous surgery. 3. One unremarkable lymph node. Clinical: Ventral hernia. Gross: The specimen is received fresh in four parts, all labeled with the patient's name, "[**Known firstname 2174**] [**Known lastname **]" and the medical record number. Part 1 is additionally labeled "small bowel." It consists of an unoriented segment of small bowel which measures 13.1 cm in and 3.1 cm in diameter. The portions of mesenteric fat is attached which measures 9.9 x 1.1 x 0.5 cm. There are stapled margins which measure 0.2 cm. On the antimesenteric side, the superficial aspect of the serosa was previously peeled. The specimen is opened along the antimesenteric side to reveal small mucosal with normal folds. The bowel wall is unremarkable and measures up to 0.7 cm in thickness. Representative sections are submitted as follows: A = margins, B = representative sections of mucosa, C = representative sections of mesenteric fat. Part 2 is additionally labeled "abdominal wall skin." It consists of multiple fragments of skin which measure 23 x 10.1 x 3.9 cm in aggregate. The epidermis is focally firm and with an area of possible ulcer. The ulcerated measures approximately 2.8 cm x 1.2 cm and 2.5 x 1.5 cm. Two ulcerated areas are separated by 1.5 cm of normal appearing skin. There are multiple areas of scar and thickened skin. The thickest skin measures 1.5 cm in thickness and appears to be composed of scar tissue. Representative sections are submitted as follows: D = ulcerated appearing areas, E = representative sections of thickened scar area, F = normal appearing skin. Part 3 is additionally labeled "greater omentum." It consists of a red/yellow fibroadipose which measures 14 x 12 x 9.5 cm. Sectioning reveals unremarkable fibrofatty tissue. Representative sections are submitted in cassettes G-H. Part 4 is additionally labeled "transverse colon." It consists of an unoriented segment of large bowel which measures 52 cm long and 5.1 cm in diameter. There are two stapled margins which measure each 12.3 cm. The specimen is opened to reveal multiple black/yellow polyps at one end which measure 2.5 x 0.4 x 0.4 cm and comes to within 0.5 cm of one end. The serosa adjacent to the polyp is inked in blue. Representative sections are submitted as follows; I = staple line margin closest to polyp, J = other staple line margin, K-N = polyps, O-P = representative sections of normal mucosa. Q = one possible lymph node, R-Z = fat for lymph nodes. The bowel wall measures up to 0.5 cm in thickness. Brief Hospital Course: The patient was admitted to the General Surgical Service for surgical management of a large, complicated ventral incisional hernia. On [**2119-4-5**], the patient underwent exploratory laparotomy, lysis of adhesions, small bowel resection, ileal transverse colectomy, jejunojejunostomy, ileal colostomy, component separation, ventral hernia repair with biologic material and polypropylene mesh, which went well without complication (reader referred to the Operative Note for details). Post-operatively, the patient was admitted to the TICU as anesthesia was unable to extubate him in the PACU due to respiratory failure secondary to respiratory acidosis. The patient arrived NPO with an NG tube, on IV fluids, with an abdominal binder, foley catheter and two JP drains in place, and initially Propofol drip and Dilaudid IV PRN for pain control. He was started on empiric IV Vancomycin, Ciprofloaxin, and Flagyl. He was also placed on an Ativan CIWA scale given his history of alcohol use. The patient was hemodynamically stable. . Post-operative pain was initially not well controlled. After multiple adjustments, the patient experienced significantly improved pain control on a Clonidine patch, Ultram, round-the-clock acetaminophen, Methadone 20mg IV Q12hours, and a Dilaudid PCA. He was transferred to the floor on this regimen. When tolerating clear liquids, he was transitioned to Methadone 20mg PO BID plus Dilaudid PO PRN with continued good effect. He was successfully extubated on POD#2, and placed on supplemental oxygen by nasal cannula, from which he was ultimately weaned. He expereinced confusion overnight into POD#6, which was attributed to the Ativan CIWA scale, which was discontinued. He received two doses of Haldol IV with symptomatic resolution, and clearing of his mental status later that day. He remained neurologically intact thereafter. . The patient first cut, the self-discontinued his NG tube overnight on POD#6 when he experienced the confusion. The NG tube was not replaced. He was started on sips of clears advanced to clears on POD#7 with good tolerability. Diet was progressively advanced as tolerated to a regular diet by POD#8. IV antibiotics were discontinued on POD#5. He was given a dose of Flomax, then the foley catheter was discontinued at midnight of POD#8. The patient subsequently voided without problem. The patient self-discontinued the left JP drain by accident overnight on POD#9. The patient was discharged home with the right JP drain; he received care instructions. The large midline incision remained clean and intact. He wore the abdominal binder at all times, and was advised to do so until he follow-up with Dr. [**First Name (STitle) 2819**] as an outpatient. . During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirrometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. The patient's blood sugar was monitored regularly throughout the stay; sliding scale insulin was administered when indicated. He did not require exogenous insulin at discharge. Labwork was routinely followed; electrolytes were repleted when indicated. . At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. He was discharged home with [**First Name (STitle) 269**] services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: 1. Dilaudid 2mg 1 tab PO Q3-4Hours PRN pain 2. Loratidine 10mg 1 tab PO daily PRN 3. Colace 100mg 1 cap PO BID PRN Discharge Medications: 1. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*14 Patch 24 hr(s)* Refills:*1* 2. Nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) patch Transdermal every twenty-four(24) hours: Start once you complete the Nicotine 14mg/24hr patches. . Disp:*14 patches* Refills:*1* 3. Tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*0* 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation: Over-the-counter. 7. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day as needed for allergy symptoms. 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID x 1 week, then 1 tab PO QHS x1 week, then discontinue.: Start this prescription on Saturday, [**2119-4-15**]. Current clonidine patch should be removed before starting Rx. Disp:*21 Tablet(s)* Refills:*0* 10. Methadone 10 mg Tablet Sig: One (1) Tablet PO BID x 1week, then 1 tab PO daily x 1week, then discontinue. as needed for pain: DX: POST-OPERATIVE PAIN. Disp:*21 Tablet(s)* Refills:*0* 11. Dilaudid 4 mg Tablet Sig: 1-2 Tablets PO Q3-4Hours: PRN. Disp:*70 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] [**Hospital3 269**] Discharge Diagnosis: 1. Complicated ventral incisional hernia with intraabdominal loss of domain secondary large defect. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than 5 lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. *WEAR YOUR BINDER AT ALL TIMES EXCEPT WHEN BATHING. . JP Drain Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *Maintain suction of the bulb. *Note color, consistency, and amount of fluid in the drain. Call the doctor, nurse practitioner, or [**Hospital3 269**] nurse if the amount increases significantly or changes in character. *Be sure to empty the drain frequently. Record the output, if instructed to do so. *You may shower; wash the area gently with warm, soapy water. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Followup Instructions: Please call ([**Telephone/Fax (1) 81719**] to arrange a follow-up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (PCP) in [**2-8**] weeks. . Please call ([**Telephone/Fax (1) 8105**] to schedule a follow-up appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2819**], MD (Surgery) in 2 weeks. Completed by:[**2119-4-14**]

[ "584.9", "E939.4", "211.3", "292.81", "V11.3", "305.1", "564.09", "997.5", "338.18", "V85.4", "518.5", "E878.8", "278.00", "568.0", "276.50", "276.4", "553.21" ]

icd9cm

[ [ [] ] ]

[ "53.61", "45.62", "46.21", "54.59", "45.74", "54.4", "45.91", "96.71", "45.93" ]

icd9pcs

[ [ [] ] ]

11899, 11966

6605, 10262

351, 575

12110, 12110

2167, 2167

14165, 14556

1554, 1690

10427, 11876

11987, 12089

10288, 10404

12261, 12835

12851, 14142

1705, 1705

1719, 2148

274, 313

603, 1011

2182, 6582

12125, 12237

1033, 1444

1460, 1538

48,554

128,119

35711

Discharge summary

report

Admission Date: [**2137-3-11**] Discharge Date: [**2137-3-23**] Date of Birth: [**2060-6-2**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3227**] Chief Complaint: Subdural hematoma Major Surgical or Invasive Procedure: none History of Present Illness: 76 M s/p fall in [**Country 7192**] Sunday AM presented to the ED complaining of some slurred speech. Denies LOC. Neurosurgery was consulted s/p CT head demonstrating subdural hematoma approximately 1 cm. Past Medical History: Hypertension Osteo Arthritis Stroke with residual left sided weakness Exploratory laparotomy for UK reasons Social History: Primary language: Spanish Lives in U.S. Alone. Son is nearby. Visits family who live in [**Country 7192**]. Strong family support system. HCP: [**Name (NI) **] [**Name (NI) 81238**] [**Telephone/Fax (1) 81239**] Family History: N/C Physical Exam: VSS: 99.2-138/82-93-18 Abd: Soft, nontender, mildly distended Neuro: Awake, alert, oriented x3 with Spanish interpretation Coughs with thin liquid Eyes open spontaneously Follows commands Pupils: R 3->2 mm, L eye opacified Tongue midline Motor: Delt Bicep Tricep Grip LUE [**3-14**] 4+/5 ------------ Quad Ham Gastro AT [**Last Name (un) 938**] LLE [**2-11**] 1/5 [**4-11**] [**4-11**] equiv RLE 4/5 strength with prompting for position. Pertinent Results: [**2137-3-14**] 05:40AM BLOOD WBC-9.5 RBC-4.47* Hgb-15.2 Hct-40.2 MCV-90 MCH-34.0* MCHC-37.9* RDW-13.5 Plt Ct-311 [**2137-3-12**] 04:58AM BLOOD PT-13.8* PTT-30.2 INR(PT)-1.2* [**2137-3-11**] 04:32AM BLOOD PT-13.7* PTT-31.2 INR(PT)-1.2* [**2137-3-14**] 05:40AM BLOOD Glucose-91 UreaN-23* Creat-1.1 Na-133 K-3.9 Cl-96 HCO3-27 AnGap-14 [**2137-3-12**] 04:58AM BLOOD Phenyto-12.6 [**2137-3-11**] NON-CONTRAST HEAD CT: Roughly isodense subdural hematoma, overlying the left cerebral convexity, measures approximately 1 cm in maximal thickness, largely unchanged from prior exam. There is no new hemorrhage. Mass effect related to subdural hematoma results in effacement of the subjacent gyri, compression of the ipsilateral lateral ventricle, and approximately 5 mm rightward shift of the normally-midline structures . There is generalized atrophy as evidenced by the prominent ventricle and sulci of the contralateral cerebral hemisphere. The [**Doctor Last Name 352**]-white matter differentiation is preserved. Hypodensity in the periventricular and subcortical white matter reflect chronic microvascular infarction, with punctate foci of low density in the bilateral basal ganglia and subinsular regions consistent with chronic lacunar infarcts. Left infraorbital soft tissue hematoma measures 2.6 x 2.0 cm. The paranasal sinuses and mastoid air cells are normally aerated. No fracture is identified. [**2137-3-12**] IMPRESSION: Mild increase in the size of the left-sided subdural hematoma along the convexity, with a maximum transverse dimension of 1.4 cm compared to the prior of 1 cm. Edema of the left cerebral hemisphere and mild shift of the midline structures to the right side is unchanged. Close followup as clinically indicated. [**2137-3-18**] Noncontrast head CT: IMPRESSION: Slightly improved left subdural hematoma with slightly decreased mass effect. No new hemorrhage. Brief Hospital Course: Pt was first seen and evaluated on [**2137-3-11**] after being brought to the [**Hospital1 18**] for medical attention after a fall on [**2137-3-10**]. His knees buckled under him, he felt weak, fell and struck the left side of his head. There was no reported loss of conscience. He also presented with L eye ecymosis. The pt flew via commercial aircraft from Gutamala to [**Location (un) 86**] where his son lives. Once with family they noted [**Known firstname 24039**] to have slurred speech for which they brought him to an OSH and was found to have a Lt Subdural Hematoma. Serial CT imaging has revealed pts SDH is resolving without neurosurgical intervention. The pt was seen and evaluated by Physical therapy daily. There was a family meeting held on [**2137-3-15**] to discuss pts diagnosis,d/c planning points of concern and insurance issues. He was found to be [**3-12**] assist OOB, the family was very involved they wanted to bring Mr [**Name13 (STitle) 81240**] home so they worked with PT and physical therapy felt the family was safe to handle his needs they ordered DME and a hospital bed. He remained neurologically intact during his hospital stay with left sided weakness. Medications on Admission: Atenolol ASA HCTZ Lisinopril Discharge Medications: 1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 5. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed. Disp:*30 Tablet(s)* Refills:*0* 6. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Subdural hematoma Discharge Condition: Neurologically stable Discharge Instructions: General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. Completed by:[**2137-4-3**]

[ "728.89", "719.46", "272.0", "921.2", "438.89", "458.9", "852.21", "715.90", "E888.1" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5305, 5311

3369, 4563

336, 343

5373, 5397

1452, 1861

6664, 7025

957, 962

4642, 5282

5332, 5352

4589, 4619

5421, 6641

977, 1433

279, 298

371, 579

3234, 3346

601, 711

727, 941

13,041

137,188

30373

Discharge summary

report

Admission Date: [**2138-3-20**] Discharge Date: [**2138-3-28**] Date of Birth: [**2076-2-3**] Sex: F Service: MEDICINE Allergies: Codeine / Motrin / Aleve Attending:[**First Name3 (LF) 1974**] Chief Complaint: hypercapneic respiratory failure Major Surgical or Invasive Procedure: Bronchoscopy Intubation History of Present Illness: 62 y/o female with PMHx of DM, obesity, HTN, angina, hypercholesteremia who took phenegren and some percocet prior to admission for episodes of vomiting (She ate dinner on Wed and started vomiting immediately after). Patient went to sleep and was then unarousable by family after a few hours so was brought [**Hospital1 15331**] ED. When she arrived her ABG was 7.17/78/124 on NRB which resulted in her getting intubated. She was also found to be hyperkalemic and in renal failure with K 7.24; BUN 29; Cre 4.0. She was given IVF and her BUN and Cre improved to 31/3.1. She was given glucose and insulin as well as kayexalate and her K decreased to 5.4. While she was being intubated she was found to have thick secreations in her airway. Her CXR at the OSH did not show any obvious infiltrate. Patient was afebrile but did have a WBC of 11 with 5 bands and was given a dose of ceftriaxone. Her renal failure resolved with hydration and she was extubated [**3-23**] without incident after bronch [**3-4**] revealed minimal secretions without plugging, although culture revealed S. aureus (vanco added). LENIs were negative, prompting discontinuation of IV heparin for possible PE. Labetalol drip was started for BP control (180s/100s). She was transferred to the floor [**3-26**] AM without incident. . Past Medical History: DM Obesity HTN Angina Hypercholesterolemia Hypothyroidism Remote DVT Social History: No tobacco, no etoh, no drug use by her history. Married, lives in [**Location (un) 72241**] with husband and daughter, unemployed, from [**Name (NI) 4754**]. However, husband continues to smoke. Family History: non contributory Physical Exam: VS 99.2 180/111 87 16 96% RA Pleasant A+Ox3 elderly female, severely obese, NAD. No carotid bruits Lungs CTA B without significant rales or wheezes RRR S1S2 I/VI benign SEM ULSB Abd severely obese, ND NT BS+, no rebound or guarding Extr no pitting edema with 2+ B DP pulses. Pertinent Results: [**2138-3-26**] SPEECH/SWALLOW: No s/s aspiration. [**Month (only) 116**] have reg diet with thin liquids. Pills whole with thin liquids. . [**2138-3-20**] CXR: Technically limited study with retrocardiac density which may represent atelectasis versus airspace consolidation. Engorged vasculature but no evidence of frank edema. . [**2138-3-21**] BILAT LE VEINS: No evidence of lower extremity DVT. . [**2138-3-21**] CXR: Layering left pleural effusion and left retrocardiac opacity, representing atelectasis and/or infectious consolidation. The right hemithorax is not completely imaged on this study, but is more completely evaluated on the subsequent and separately dictated chest radiograph. . [**2138-3-23**] CXR: Suboptimal image due to underinflation of the lungs and blurring artifact. Patchy opacities at both bases, particularly on the left side may represent airspace disease/atelectasis. Patchy density appearing in the left hilar area may also represent airspace disease. . [**2138-3-21**] SPUTUM: GRAM STAIN (Final [**2138-3-21**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. RESPIRATORY CULTURE (Final [**2138-3-24**]): SPARSE GROWTH OROPHARYNGEAL FLORA. STAPH AUREUS COAG +. SPARSE GROWTH. Oxacillin sensitive. . Brief Hospital Course: 1) RESPIRATORY FAILURE: Initially, concern for pneumonia vs PE. Pt was noted to have thick secretions and underwent bronchoscopy. She was started on broad spectrum abx (vanco, levo, azithro) for pneumonia. CXR was poor but did show infiltrate. Culture grew out MSSA so abx were narrowd to levaquin only and she will complete a 10d course. In ICU, pt was extubated successfully and upon transfer to floor her respiratory status was stable. She remained mildly hypoxic (mid 90s on RA) but this may be secondary to obesity. PE was concern and pt was initially on heparin empirically. A CTA could not be done given size but LENIs were negative b/l. Givenn this, her heparin was stopped and she continued to improved off heparin, PE was not likely. Pt was also wheezing so she may have underlying RAD that flared with pneumonia. She was started on bronchodilators and inhaled steroids. These can be stopped once her pneumonia is cleared given she has no h/o asthma or COPD. . 2) ACUTE RENAL FAILURE: On initialy presentation to [**Hospital3 51058**], pt's Cr was 4.0. This improved steadily with IVF hydration suggesting a prerenal etiology. By discharge, her creatinine was wnl (0.5). . 3) HTN URGENCY: After extubation, pt became very agitated and in this setting SBP went up to 190s with DBP over 100. She was initially started on labetalol gtt. Then PO meds were restarted. Lopressor and nifedipine were added to her regimen with improved though not ideal control. She may need further titration of her meds to maximize BP control over long term. . 4) TRANSAMINITIS/ELEV CK: This was likely due to mild rhabdo from being down. CKs improved steadily with supportive care to around 300 several days before discharge. Her lovastatin was held, however, and not restarted at this time. Her lovastatin can be restarted (or another statin) by her outpt provider. . 5) HYPOTHYROIDISM: Continued on home dose of levothyroxine. . 6) DIABETES MELLITUS, Type 2: Initially, placed on SSI in ICU. Once taking POs, glyburide was restarted. Her metformin was not restarted in the hospital because her BG were very well controlled. But this may need to be restarted down the road. . 6) LEG PAIN: AFter extubation, pt c/o b/l calf pain. LENIs were negative for clot. Exam did not show tndr, therefore, neuropathic pain from critical illness is possible. She was given neurontin which can be titrated up and oxycodone for pain control. Medications on Admission: Lisinopril 20mg daily Lovastatin 80mg daily Percocet prn Effexor XR 150mg qam and 75mg qhs Seroquel 100mg qid Seroquel 300mg qhs Synthroid 25mcg daily Lasix 40mg daily Diovan 160mg daily Ambien 12.5 gm qhs Glyburide Metformin Discharge Medications: 1. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. Venlafaxine 75 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 3. Venlafaxine 75 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 4. Quetiapine 100 mg Tablet Sig: Three (3) Tablet PO at bedtime. 5. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 6. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 8. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. 11. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 12. Nifedipine 30 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. 13. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day) for 1 weeks. 14. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Puff Inhalation every six (6) hours as needed for shortness of breath or wheezing for 1 weeks. 15. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 16. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO three times a day. Discharge Disposition: Extended Care Facility: [**Hospital1 15331**] TCC Discharge Diagnosis: PRIMARY: 1) Hypercarbic respiratory failure 2) Staph pnuemonia 3) Hypertensive urgency SECONDARY: 1) Diabetes mellitus, type 2 2) Hypothyroidism Discharge Condition: Good-afebrile, vital signs stable. Discharge Instructions: 1. Take medications as prescribed. 2. Follow up as below. Followup Instructions: You have an appointment scheduled with your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 33430**] [**Name (STitle) 29994**], on Thursday [**2138-4-3**] at 12:00. If you are still in rehab, please call your PCP and make an appointment to follow up after discharge from rehab.

[ "511.9", "250.00", "482.41", "278.00", "401.9", "272.0", "244.9", "518.81", "V12.51", "584.9" ]

icd9cm

[ [ [] ] ]

[ "96.71", "33.22", "38.93", "96.04" ]

icd9pcs

[ [ [] ] ]

7823, 7875

3732, 6176

317, 343

8065, 8102

2327, 3709

8210, 8505

1998, 2016

6453, 7800

7896, 8044

6202, 6430

8126, 8187

2031, 2308

245, 279

371, 1676

1698, 1769

1785, 1982

6,620

140,314

45415

Discharge summary

report

Admission Date: [**2134-2-27**] Discharge Date: [**2134-3-8**] Date of Birth: [**2057-10-8**] Sex: M Service: Neurology HISTORY OF PRESENT ILLNESS: This is a 76-year-old right-handed man, who is uncertain of his past medical history, but believes he has diabetes. He says that he was in is usual state of health until he woke up the morning prior to admission and thinks he may have been sleeping on his arm, but is not quite sure if he was sleeping heavily or not. He denied drinking the day before admission as well. When he woke up, he could not move the right arm. His description was "my arm was going all over the place." He says that it was worse in the fingers than in the arm and shoulder. They felt numb (when he put it under water which he was able to feel, but just numb). It was not tingling and there was no pain in his neck, chest, or shoulders. There was no disturbance in speech or language, and he noted no difficulty with his face or with his legs. This has never happened before. He denied recent trauma or infection. There is no history of fever, headache, visual changes, nausea, vomiting, chills, night sweats, weight loss, chest pain, cough, abdominal pain, or pain or burning during urination. PAST MEDICAL HISTORY: Diabetes. MEDICATIONS: 1. NPH. 2. Aspirin at home. ALLERGIES: No known drug allergies. FAMILY HISTORY: No family history of stroke. Brother had an event several years ago in which his right arm became weak and became stronger after a cortisone injection. SOCIAL HISTORY: He lives at home with his wife. Worked with a watch company in the past, but now retired. Heavy smoking history in the past. Denies alcohol history. VITAL SIGNS: Afebrile, blood pressure 170/70, heart rate 100, and O2 saturation is 96% on room air. PHYSICAL EXAM: General medical exam unremarkable without carotid bruits. Neurological exam: Mental status alert and attentive, oriented x3. Short and long-term memory intact, no aphasia, no apraxia, no right-left confusion, normal affect and mood. Cranial nerves: Visual fields full to confrontation. Occasionally extinguishes on the right. EOMs intact, but problems with saccades induction to the right. Pupils are equal, round, and reactive to light and accommodation. Fundi: Discs are sharp. Bilateral corneal reflex intact, slightly asymmetric facial movements with flattening of the right nasolabial fold. Facial sensation intact. No spontaneous or induced nystagmus. Hearing intact. Palate elevates symmetrically. Gag present. Tongue is midline without atrophy or vesiculations. Motor: Normal bulk, decreased tone on the right, and no asterixis. No unusual postures and no atrophy. In the right, the deltoids, triceps, and biceps are all [**3-12**], otherwise the upper extremities are 0/5. The right IP is 4+/5. Hip extensors [**4-12**] and abductors 4+/5. Otherwise, the patient has full strength throughout. Deep tendon reflexes upper extremities 2+ on the left and 1+ on the right. Lower extremities: 2+ and symmetric. Babinski positive on the right. Sensory: Decreased pin prick, light touch, and temperature in the right arm. Normal proprioception, mildly impaired vibration sense with distal gradient, no extinction to double simultaneous stimulation. Coordination: Normal finger-to-nose on the left, cannot retest it on the right due to weakness. Normal heel-to-shin on both sides. Rapid alternating movements and fine finger movements cannot be tested on the right. Stance and gait deferred for now. LABORATORIES AND STUDIES: White count 8.1, hematocrit 34.8, platelets of 259. INR 1.1. Reticulocyte count 4.4. Urinalysis negative. Chem-10: Normal. AST 18, LD 152, total bilirubin 0.3. CKs became somewhat elevated, however, ruled out for MI by enzymes with a peak CK of 307. MB negative and troponins negative. Iron 44. Total cholesterol 160. TIBC 268, ferritin 117, TRF 206. Homocysteine 11.3. Triglycerides 172, HDL 43, LDL 83. MRI/MRA of the head on admission showed areas of restricted diffusion in the left frontoparietal and occipital regions consistent with acute infarcts in the distribution of the left middle cerebral and posterior cerebral arteries. Flare images: Acute infarct involving the left middle and posterior cerebral arteries also visualized. Gadolinium: No evidence of abnormal enhancement seen. MRA showed narrowing involving the petrous horizontal portion of the left internal carotid artery. There was also irregularity in the cavernous portion of the right internal carotid artery. No significant stenosis in the carotid bulb region bilaterally suggestion of paucity in the left MCA branches. On [**2134-3-2**] revealed unsuccessful attempt at catheterization of the left common carotid artery for treatment of a left internal carotid artery petrous segment. Internal carotid artery stenosis. At the end of the procedure, no evidence of dissection or intimal irregularity at the origin of the left common carotid. Carotid ultrasound showed minimal plaque identified at carotids in the neck. An echocardiogram showed normal left ventricular systolic function with an EF of 55%, normal right ventricular systolic function, no aortic regurgitation and trivial mitral regurgitation. There was no cardiac source of embolus seen. HOSPITAL COURSE: The patient was admitted for evaluation of subacute stroke. He underwent a full workup including carotid ultrasound, MRIs, and lipids. The patient underwent transthoracic echocardiogram, carotid ultrasound, as well as MRA. The MRA revealed stenosis in the intracranial left internal carotid artery and thus, the patient was taken for angiogram to attempt to stent this artery as the patient's stroke appeared to be in the watershed region perhaps as a result of this stenosis in this artery. The first angiogram was unsuccessful as far as stenting, but the patient was stable after the angiogram, and two days later was taken back for a repeat angiogram at which time the stenting procedure was indeed successful. The patient did well throughout his hospital course. His right arm continued to improve in strength, and he was nearly full strength in the proximal right arm, and was able to very slightly move his fingers of his right hand upon discharge. His hospital course was complicated by hematocrits, which seem to be downtrending overall. His final hematocrit was 34.8, however, it had been in the high 30s and 40s on admission. His hematocrit was followed quite frequently, and was very stable at this level. His reticulocyte count was also normal and iron studies were normal, and there was negative stool guaiacs recorded. The patient will follow up with his primary care physician. In addition to this, the patient did have two episodes of traumatic Foley catheter removal in which he self discontinued his Foley catheter, which resulted in traumatic bleeding of the urethra. The second time he did this was the day prior to admission, and this required recatheterization as well as irrigation of the blood clot. However, on discharge, the patient was able to urinate freely. Urology was consulted, and the patient will follow up with Urology as an outpatient. Otherwise, the patient was doing well throughout admission and he is discharged. DISCHARGE MEDICATIONS: 1. Plavix 75 mg p.o. q.d. (The patient had been loaded on Plavix prior to the first angiogram. This was 300 mg of Plavix x1). 2. Protonix 40 mg p.o. q.d. 3. Aspirin 325 mg p.o. q.d. 4. Insulin NPH 40 units subq q.a.m. and 28 units subq q.p.m. 5. Zestril 10 mg p.o. q.d. 6. Lipitor 10 mg p.o. q.d. DISCHARGE INSTRUCTIONS: The patient will receive home PT per PT referral. FOLLOW-UP INSTRUCTIONS: With Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1132**] on Neurosurgery on [**2134-3-19**] at 12:30, with Dr. [**First Name (STitle) **] [**Name (STitle) **] in [**Hospital 878**] Clinic on [**2134-4-13**] at 2:30 p.m., with Dr. [**Last Name (STitle) **] in Neurology. He will call to make an appointment and with his PCP on [**2134-3-10**] at 11 a.m. [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**], M.D. [**MD Number(1) 4269**] Dictated By:[**Last Name (NamePattern1) 10034**] MEDQUIST36 D: [**2134-3-8**] 16:23 T: [**2134-3-11**] 03:22 JOB#: [**Job Number 96934**] (cclist)

[ "578.0", "E958.8", "599.7", "E878.1", "250.00", "867.0", "433.31", "342.90", "998.12" ]

icd9cm

[ [ [] ] ]

[ "39.50", "39.90" ]

icd9pcs

[ [ [] ] ]

1379, 1533

7346, 7645

5353, 7323

7670, 7721

1821, 1880

1900, 2058

166, 1248

2075, 5335

7746, 8385

1271, 1362

1550, 1805

65,007

172,981

42579

Discharge summary

report

Admission Date: [**2148-7-14**] Discharge Date: [**2148-7-17**] Date of Birth: [**2120-9-20**] Sex: F Service: MEDICINE Allergies: Penicillins / Stock Ragweed Pollen Mixture Attending:[**First Name3 (LF) 594**] Chief Complaint: Nausea/Vomiting Major Surgical or Invasive Procedure: None History of Present Illness: 27F DM1, HCV on ribavarin and pegasys x5 weeks, recently started on boceprevir p/w N/V since this AM. Increased nausea and poor PO intake since beginning boceprevir, especially as of [**3-10**] days PTA. Blood sugars have been in 400s over past several days. Denies hematemesis but reports dark brown emesis, with black streaks but no coffee grounds. 10 episodes vomiting since this AM. Has had 4 episodes of DKA in the past, 3 in the past 13 months. No abdominal cramps, no diarrhea or constipation, last normal bowel movement last night. Has had some recent weight loss attributable to poor PO intake. Mother and father very involved in management of medical problems, she admits she does not a good job managing them by herself. Triggered for HR 140s in ED. Was still nauseated and given zofran. Given 10 units insulin and started drip, K with fluids, IVF switched to D51/2NS when sugars in 250s, got 1 amp bicarb. Received 5L of fluids, access 2 peripherals 16 and 18. Last ED vitals 99.3, 106/55, 128 18, 100% on ra. guaiac negative. CXR negative, UA negative. On arrival to the MICU, patient stable, tachycardic, sleepy. Review of systems: (+) Per HPI . Sunburn on feet with subsequent rash (-) Denies fever, chills, night sweats, recent weight gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Past Medical History: Chronic HCV-diagnosed [**2148-2-7**] DMI-diagnosed [**2143**] ecxema Social History: Lives at home with parents. Lost job at call center last year and has been unemployed ever since. No tobacco/illicits. [**2-9**] beers/drinks per month. Family History: Non-contributory 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: Tachycardic rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, grossly normal sensation, gait deferre Discharge Exam: Same as above except normal rate for heart. Pertinent Results: Admission Labs: [**2148-7-14**] 09:43PM TYPE-[**Last Name (un) **] TEMP-37.4 O2-21 PO2-70* PCO2-30* PH-7.11* TOTAL CO2-10* BASE XS--19 INTUBATED-NOT INTUBA COMMENTS-ROOM AIR [**2148-7-14**] 09:30PM GLUCOSE-217* UREA N-7 CREAT-0.7 SODIUM-143 POTASSIUM-3.3 CHLORIDE-114* TOTAL CO2-9* ANION GAP-23* [**2148-7-14**] 07:49PM TYPE-[**Last Name (un) **] O2-21 PO2-60* PCO2-28* PH-6.98* TOTAL CO2-7* BASE XS--25 INTUBATED-NOT INTUBA COMMENTS-ROOM AIR [**2148-7-14**] 07:40PM URINE HOURS-RANDOM [**2148-7-14**] 07:40PM URINE UCG-NEGATIVE [**2148-7-14**] 07:40PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.009 [**2148-7-14**] 07:40PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2148-7-14**] 07:40PM URINE RBC-0 WBC-2 BACTERIA-FEW YEAST-NONE EPI-2 [**2148-7-14**] 07:40PM URINE GRANULAR-8* HYALINE-1* [**2148-7-14**] 07:40PM URINE MUCOUS-RARE [**2148-7-14**] 05:58PM GLUCOSE-447* LACTATE-2.6* [**2148-7-14**] 05:55PM GLUCOSE-444* UREA N-10 CREAT-1.1 SODIUM-142 POTASSIUM-4.8 CHLORIDE-107 TOTAL CO2-7* ANION GAP-33* [**2148-7-14**] 05:55PM estGFR-Using this [**2148-7-14**] 05:55PM ALT(SGPT)-29 AST(SGOT)-17 ALK PHOS-103 TOT BILI-0.5 [**2148-7-14**] 05:55PM ALBUMIN-5.1 [**2148-7-14**] 05:55PM WBC-10.4# RBC-4.86 HGB-14.7 HCT-45.3 MCV-93 MCH-30.2 MCHC-32.4 RDW-17.0* [**2148-7-14**] 05:55PM NEUTS-86.7* LYMPHS-9.5* MONOS-3.5 EOS-0.1 BASOS-0.2 [**2148-7-14**] 05:55PM PLT COUNT-208 Discharge Labs: [**2148-7-17**] 03:58AM BLOOD WBC-2.5* RBC-2.87* Hgb-8.9* Hct-25.8* MCV-90 MCH-31.1 MCHC-34.7 RDW-17.0* Plt Ct-101* [**2148-7-17**] 03:58AM BLOOD Glucose-179* UreaN-3* Creat-0.4 Na-142 K-2.8* Cl-107 HCO3-26 AnGap-12 [**2148-7-17**] 03:58AM BLOOD Calcium-7.8* Phos-3.0 Mg-2.0 [**2148-7-15**] 09:10AM BLOOD %HbA1c-9.5* eAG-226* [**2148-7-16**] 03:35AM BLOOD Type-[**Last Name (un) **] pH-7.41 Sinus tachycardia. Poor R wave progression which may be a normal variant. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 115 156 82 318/414 68 63 39 CXR: FINDINGS: Two staples project over the right shoulder. Presumably these lie outside of the patient or on the surface. The cardiac, mediastinal and hilar contours are unremarkable. The lungs appear clear. There are no pleural effusions or pneumothorax. IMPRESSION: No evidence of acute disease. Two staples projecting over the right shoulder, probably outside of the patient; correlation with direct inspection is suggested, however. Brief Hospital Course: [**First Name8 (NamePattern2) **] [**Known lastname 92130**] is a 27F w/ history of DM1, HCV on ribavarin and pegasys x5 weeks, recently started on boceprevir. She had nausea and vomiting on [**2148-7-15**] found to be in DKA treated with iv fluids, insulin infusion, and electrolyte repletion with the gap resolved during the first hospital day. A chest xray and urinalysis did not find any clear source of infection. The urine culture grew mixed flora. Her infusion of insulin was continued over 2 days because of several episodes of nausea and vomiting. Her nausea was controlled with a combination of zofran, ativan, and promethazine. When she was able to tolerate food by PO she was bridged with half of her home dose of lantus (12 units half the home dose of 25 [**Hospital1 **])during day 2 of her hospitalization. Her hepatits C medicine were held during the hospitalization and Dr. [**Last Name (STitle) **] was contact[**Name (NI) **] and agreed with this plan. She received an endocrine consult through [**Last Name (un) **],with there recommendations being appreciated and applied to her care. She was found to have an A1C of 9.5. She was also found to be anemic during the hospitalization this was originally attributed to attributed to her being aggressively resuscitated and being hypovolemic on admission, but this may also be a side effect of her hepatitis C medication regimen. Further outpatient followup of this is warranted. Her final potassium remained low at 2.8, but she was given PO supplementation, told not to take her hepatitis C medications, and returned to her home insulin regimen with a sliding scale from [**Last Name (un) **] and given a followup appointment at [**Last Name (un) **]. Transitional Issues: Appointments at [**Last Name (un) **], Liver Center and PCP [**Name9 (PRE) **] Anemia that needs to be followed Full Code Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Boceprevir 800 mg PO Q8H 2. Peginterferon Alfa-2a 180 mcg SC 1X/WEEK (SA) 3. Ribavirin 600 mg PO QAM 4. Ribavirin 400 mg PO QPM 5. Prochlorperazine 5 mg PO Q6H:PRN nausea 6. Glargine 25 Units Breakfast Glargine 25 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 7. Vitamin D [**2136**] UNIT PO DAILY 8. Multivitamins W/minerals 1 TAB PO DAILY Discharge Medications: 1. Multivitamins W/minerals 1 TAB PO DAILY 2. Vitamin D [**2136**] UNIT PO DAILY 3. Glargine 25 Units Breakfast Glargine 25 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 4. Prochlorperazine 5 mg PO Q6H:PRN nausea 5. Potassium Chloride 40 mEq PO DAILY RX *Klor-Con 20 mEq 2 packets by mouth daily Disp #*6 Packet Refills:*0 6. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Diabetic Ketoacidosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 92130**], You were admitted to the intensive care unit for diabetic ketoacidosis (DKA). This is an illness that can occur if you are not taking adequate insulin for a period of time. We think that your current episode of DKA occurred because of nausea and vomiting related to starting a new medication, Boceprevir. Your sugars improved with an insulin drip and you were restarted on subcutaneous insulin. Additionally, your potassium remained low and you needed supplements to replace this. Finally, you were anemic in the hospital and we think this may be a result of your boceprevir as well. Your blood counts should be checked again several weeks after your discharge from the hospital. We made the following changes to your home medications: STOP boceprevir, ritonavir and pegylated interferon START potassium supplements for the next several days until your [**Last Name (un) 387**] appointment, where your potassium should be rechecked. A plan can be made at that time as to whether you need continued supplements. START Zofran as needed for nausea. RESUME your home insulin dosing of 25 units lantus in the morning and evening, as well as a humalog sliding scale Followup Instructions: Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3640**], NP Specialty: Primary Care Location: [**Last Name (un) **] DIABETES CENTER Address: ONE [**Last Name (un) **] PLACE # 239, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2378**] When: Friday, [**7-19**] at 9:00am Name: [**Last Name (LF) **],[**First Name3 (LF) **] R. Location: [**Location (un) 61279**] FAMILY MEDICINE Address: [**Last Name (un) **], [**Hospital1 **],[**Numeric Identifier 9647**] Phone: [**Telephone/Fax (1) 56739**] When: Tuesday, [**7-23**] at 1:30pm Department: LIVER CENTER When: WEDNESDAY [**2148-7-31**] at 4:00 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

[ "272.4", "070.54", "285.9", "250.13", "787.01", "276.8", "V58.67", "300.02", "268.9", "E931.7" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8283, 8289

5423, 7143

319, 325

8355, 8355

2873, 2873

9736, 10646

2233, 2251

7790, 8260

8310, 8334

7313, 7767

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2266, 2793

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1507, 1955

263, 281

353, 1488

2889, 4354

8370, 8482

1977, 2047

2063, 2217

1,872

111,375

47813

Discharge summary

report

Admission Date: [**2135-4-1**] Discharge Date: [**2135-4-11**] Date of Birth: [**2054-2-16**] Sex: F Service: MEDICINE Allergies: Penicillins / Darvocet-N 50 / Phenothiazines / Percocet Attending:[**First Name3 (LF) 800**] Chief Complaint: Fall Major Surgical or Invasive Procedure: [**2135-4-1**]: s/p Open reduction internal fixation, right femur. History of Present Illness: 81 year old female who fell on [**2135-4-1**] resulting in a right distal femur periprosthetic fracture requiring surgical management. 81 year old female with past medical history of dementia, epilepsy, cerebellar ataxia (wheelchair bound), and s/p remote right TKR who presented yesterday from nursing home after fall and femur fracture. Pt now POD # 1 s/p right TKR with acute mental status change. Patient was interactive, verbal, and responsive, althought not A and O x 3, prior to surgery. Post-operatively has been easily arousable but disoriented and non-verbal. Intra-op course uncomplicated, received 2 units PRBCs in OR. . Currently, patient opens eyes to name, but is not able to provide history. Per family, patient was interactive prior to ORIF. They did endorse a steady decline in mental status over the past 1-2 months, with increasing perseveration and some short term memory deficits. Son also notes intermittent episodes of confusion over many decades. . ROS: unable to obtain [**1-18**] altered mental status. Past Medical History: 1. Dementia. 2. Depression with a history of suicide attempts (last hospitalized on the Psychiatric Unit at [**Hospital1 18**] in 11/[**2132**]). 3. Multiple falls with subdural hematoma [**2128**]. 4. Seizure disorder. 5. Paroxysmal atrial fibrillation, not on any anticoagulation due to history of falls. 6. Hypothyroidism. 7. Hypertension. 8. Prior STH. PAST SURGICAL HISTORY: 1. currently POD #1 s/p right distal femur ORIF 2. Right cataract surgery [**2132**]. 3. s/p right TKR 9. Tardive dyskinesia. 10. Cerebellar degeneration with chronic ataxia. 11. History of alcohol abuse. 12. Hepatitis B. 13. Iron deficiency anemia. Social History: The patient is widowed; has 2 children (son and daughter). Went to [**University/College **]where she majored in English with a minor in history and worked a number of different jobs after graduating but primarily worked in editing for a publishing firm and at one point as a medical researcher. She ultimately had to quit work when she became psychiatrically ill in her 30s (also reports this is when her seizures started), and it appears this was all after she found her mother hanging after a suicide attempt, and her son says she has "PTSD" from this event). She has not worked since the early [**2104**], and was divorced from her husband around this time as well. She had been living independently in her own apartment until about 4 years ago but had been failing for about the last five years of that stretch with multiple falls which went undiscovered for days at a time. She has been wheelchair bound for falls and cerebellar ataxia (possibly related to extended phenytoin use) for the last 6 years or so. Her first placement was at [**Hospital1 **], where she stayed for a year and did not like, and she has been at [**Last Name (un) **] for the last three years. Substance Abuse History: Per son history of alcoholism, now has occasional weekly drinks at [**Last Name (un) **] with other residents and son. [**Name (NI) **] is unable to specify amount. Distant history of tobacco use, none in past 40 years. Denied knowledge of illicits. Possible distant history of valium abuse in 70s. Family History: [**Name (NI) **] mother with completed suicide, son unsure of etiology half sister who has been depressed and frequently hospitalized Physical Exam: PHYSICAL EXAMINATION Temp:97.0 HR:66 BP:112/95 Resp:20 O(2)Sat:98 Constitutional: Uncomfortable HEENT: Normocephalic, atraumatic, Pupils equal, round and reactive to light, Extraocular muscles intact Neck NT, Oropharynx within normal limits Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nontender, Nondistended GU/Flank: No costovertebral angle tenderness Extr/Back: Tender at R knee with deform; NV intact Skin: No rash, Warm and dry Neuro: Speech fluent Psych: Normal mood, Normal mentation Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae Exam on transfer to medicine: Vitals - T: 99 T max 100.6 BP: 122/76 HR: 82 RR: 16 02 sat: 98% RA GENERAL: alert, easily arousable to name, non-verbal, tracking HEENT: atraumatic, normocephalic, no scleral icterus CARDIAC: RRR s1, s2, II/VI SEM at USB, apex LUNG: rales at left base ABDOMEN: soft, ? tender suprapubic region (grimace), active BS, non-distended EXT: 2+ radial and DP pulses bilat, no LE edema; right knee dressed in splint NEURO: CNs intact, DTRs 2+ UEs, unable to complete remainder of exam [**1-18**] mental status Pertinent Results: [**2135-4-1**] 04:45AM URINE AMORPH-OCC [**2135-4-1**] 04:45AM URINE RBC-0 WBC-0-2 BACTERIA-MANY YEAST-NONE EPI-0 [**2135-4-1**] 04:45AM URINE BLOOD-NEG NITRITE-POS PROTEIN-25 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-9.0* LEUK-SM [**2135-4-1**] 04:45AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.023 [**2135-4-1**] 04:45AM PT-12.7 PTT-29.4 INR(PT)-1.1 [**2135-4-1**] 04:45AM PLT COUNT-363 [**2135-4-1**] 04:45AM NEUTS-81.2* LYMPHS-13.7* MONOS-4.2 EOS-0.5 BASOS-0.4 [**2135-4-1**] 04:45AM WBC-9.5# RBC-3.50* HGB-10.4* HCT-32.7* MCV-93 MCH-29.6 MCHC-31.7 RDW-13.5 [**2135-4-1**] 04:45AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2135-4-1**] 04:45AM URINE HOURS-RANDOM [**2135-4-1**] 04:45AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2135-4-1**] 04:45AM FREE T4-1.4 [**2135-4-1**] 04:45AM TSH-1.4 [**2135-4-1**] 04:45AM estGFR-Using this [**2135-4-1**] 04:45AM GLUCOSE-106* UREA N-34* CREAT-0.8 SODIUM-140 POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-24 ANION GAP-14 [**2135-4-1**] 03:22PM PLT COUNT-270 [**2135-4-1**] 03:22PM WBC-14.6*# RBC-2.51*# HGB-7.8* HCT-24.0*# MCV-96 MCH-31.1 MCHC-32.6 RDW-13.8 [**2135-4-1**] 03:22PM GLUCOSE-153* UREA N-25* CREAT-0.7 SODIUM-143 POTASSIUM-4.1 CHLORIDE-111* TOTAL CO2-23 ANION GAP-13 IMAGING/STUDIES: CT head- No acute intracranial abnormality Right knee- Displaced and angulated fracture of the distal femur CT C spine- No evidence of acute injury to the cervical spine. In case of clinical concern for cord-ligamentous injury, an MRI can be obtained. [**2135-4-3**] Chest PA lateral- IMPRESSION: PA and lateral chest compared to [**4-2**]: Multifocal pulmonary consolidation and generalized interstitial abnormality continued to improve in all areas except the perihilar right mid lung. Heart size is normal and the mediastinal vasculature is no longer engorged. Overall the findings are most likely due to resolving atypical edema. Continued surveillance of a possible pneumonia in the right mid lung; however, is appropriate. No pneumothorax. Pleural effusion if any is minimal. [**2135-4-4**] ECG: Sinus rhythm with atrial premature beats. Consider left atrial abnormality. Low limb lead QRS voltage. Modest ST-T wave changes. Findings are non-specific and baseline artifact makes assessment difficult. Since the previous tracing of [**2135-4-2**] there is probably no significant change. [**2135-4-4**] portable CXR: IMPRESSION: AP chest compared to [**4-3**]: Detail is severely obscured by respiratory motion. The caring physician declined [**Name Initial (PRE) **] repeat examination when offered at 11 a.m. on [**4-4**]. Cardiac silhouette has enlarged, and it is difficult to exclude interstitial edema but right perihilar consolidation has not cleared and remains a concern for pneumonia. Similarly pleural effusion is hard to exclude. There is no large pneumothorax but a small volume of pleural air would be missed. [**2135-4-4**] CTA chest: CTA OF CHEST WITH AND WITHOUT CONTRAST: There is marked atherosclerotic disease of the thoracic arch and arch vessels. Coronary artery calcification is also seen. The main pulmonary artery measures 3.9 cm, consistent with pulmonary artery hypertension. There is a moderate hiatal hernia containing both stomach and colon. There is no axillary, mediastinal, or hilar lymphadenopathy. There is patchy bilateral ground-glass opacification throughout both lungs consistent with pulmonary edema. There is a very small left pleural effusion. There is no pulmonary embolism within the main, lobar, or segmental pulmonary arteries. Within segment VII of the liver, there are three small enhancing lesions, the largest measuring 1.6 cm. These are nonspecific, but appearance is suggestive of peripheral shunts or vascular anomalies. BONES: There is degenerative disc disease throughout the thoracic spine. No osteolytic or osteoblastic lesion is seen. IMPRESSION: 1. There is no pulmonary embolism. 2. Bilateral patchy ground-glass opacifications consistent with pulmonary edema. 3. Pulmonary artery hypertension. 4. Three small peripheral segment VII liver lesions, nonspecific, but may represent small peripheral AVMs. If desired MRI may provide further assessment. 5. Hiatal hernia containing stomach and colon. [**2135-4-5**] TTE: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. Right ventricular chamber size is difficult to assess but free wall motion is normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. The pulmonic valve leaflets are thickened. The main pulmonary artery is dilated. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild aortic and mitral regurgitation. Mild ascending aortic dilation. Moderate tricuspid regurgitation. At least moderate pulmonary hypertension. Compared with the report of the prior study (images unavailable for review) of [**2130-2-8**], pulmonary hypertension has progressed. There is more tricuspid regurgitation. [**2135-4-5**] Portable CXR: FINDINGS: As compared to the previous radiograph, no motion artifacts are present. The lung volumes have slightly decreased. There is unchanged cardiomegaly. Indications of mild pulmonary edema are present and similar to the image from [**4-3**]. In addition, a pre-existing right basal parenchymal stone shows increased opacity that has slightly progressed as compared to the radiographs from [**4-3**] and [**4-4**]. Blunting of the left costophrenic sinus, potentially suggestive of small left pleural effusion. No other focal parenchymal opacities are present. [**2135-4-6**] Portable CXR: FINDINGS: In comparison with study of [**4-5**], there is little change. Cardiac silhouette is at the upper limits of normal in size and there is mild tortuosity of the aorta. Again, there is diffuse prominence of interstitial markings consistent with pulmonary edema as shown on the CT of [**4-4**]. The possibility of an underlying substrate of chronic interstitial lung disease must certainly be considered. Some atelectatic changes are seen at the left base. Of incidental note is diffuse osteopenia of the visualized bony elements. Micro data: [**2135-4-1**] 4:45 am URINE Site: CATHETER **FINAL REPORT [**2135-4-3**]** URINE CULTURE (Final [**2135-4-3**]): PROTEUS MIRABILIS. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS MIRABILIS | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R [**2135-4-2**] 8:55 pm BLOOD CULTURE Blood Culture, Routine (Pending) [**2135-4-3**] Legionella urinary antigen - negative [**2135-4-3**] MRSA screen - negative [**2135-4-4**] Stool for C. difficile toxin - negative ABG on 5 liters n/c and shovel mask- 7.54/31/44 with O2 sats near 80% ABG on NRB- 7.49/35/65 with O2 sats in mid 90s% Brief Hospital Course: Ms. [**Known lastname 100930**] was admitted to the Orthopedic service on [**2135-4-1**] for a right distal femur periprosthetic fracture after being evaluated and treated with closed reduction in the emergency room. She underwent open reduction internal fixation of the right femur without complication on [**2135-4-1**]. She was extubated without difficulty and transferred to the recovery room in stable condition. In the early post-operative course Ms. [**Name14 (STitle) 100936**] was transfused 2 units of packed red blood cells in the recovery room for post operative blood loss anemia and subsequently transferred to the floor in stable condition. She was then transferred to Medicine for evaluation and management of acute mental status changes. . 81 year old female with h/o dementia, epilepsy, cerebellar ataxia (wheelchair bound), and s/p remote right TKR who p/w fall and right distal femur fracture, now POD # 2 s/p right femur ORIF with acute mental status change. Triggered for hypoxia overnight. . # Hypoxemia- difficult to record accurate pleth given Tardive dyskinesia. Pt likely hypoxemic from V/Q mismatch/intra-pulmonary shunt, as overt e/o pulm edema on most recent Chest AP portable. Patient still (+) 2 liters for LOS, despite lasix 20 mg x 2. No e/o hypoventilation. Aspiration pneumonia and PE were on differential, but patient not meeting SIRS criteria (only white count), and on post-op anticoagulation. During the course of the day on [**2135-4-3**], the patient had difficulty tolerating the shovel mask and n/c to maintain oxygen saturation in the setting of tardive dyskinesia. She triggered again for hypoxia and required a non-rebreather to maintain oxygenation. Her A-a gradient was greater than 600, see above blood gases. V/Q mismatch with shunt physiology was suspected as etiololgy, as patient had no evidence of infection. A third dose of lasix 20 mg was given, and antibiotics were changed to vanc/cefepime for empiric coverage of HCAP. Repeat AP portable chest films showed improving atypical pulm edema with possible infiltrate in RML. Given worsening hypoxia, patient was transfered to the MICU on [**2135-4-3**]. She was initially on NRB but weaned to face mask and then to nasal cannula over 2-3 days in the setting of diuresis with IV furosemide. She was not treated for pneumonia, as it was felt that other etiologies could explain the patient's leukocytosis (recent surgery, UTI) and hypoxia (volume overload). She did not have cough and was unable to make a sputum sample for analysis. Urine legionella antigen was negative. An echocardiogram was obtained to assess for CHF (results as above). Once the patient was stable on O2 by nasal canula, she was transferred back to the medicine floor on [**2135-4-6**]. Following transfer, patient was given one more dose of lasix. Her renal function worsened in the setting of diuresis. There was a concern for aspiration, and the decision was made by the patient's family to defer speech and swallow eval and to allow her to eat despite risk of aspiration; she was maintained on aspiration precautions. Hypoxia persisted, and the patient was treated for aspiration pneumonia. Oxygen requirement did improve over the next few days, with oxygen weaned from shovel mask and 6 liters nasal cannula to 2 liters nasal cannula. Aspiration coverage was converted from IV to PO cefpodoxime and metronidazole. It is unclear what patient's baseline O2 requirements are, but even with aggressive diuresis, she has been requiring 2L and may need to be continued on that . # Leukocytosis- No evidence of infection aside from Proteus UTI. Proteus species was found to be resistant to ciprofloxacin. Blood cultures show no growth to date however, blood cultures were drawn after receiving peri-op clindamycin. C. diff toxin returned negative. Leukocytosis trended down without any other intervention. Patient will complete 5 more days of cefpodoxime and metronidazole on discharge. . # Altered Mental Status- Highest on differential was infection, given >[**Numeric Identifier 4856**] Proteus bacteriuria. Aspiration pneumonia, bacteremia also on differential. Hct stable, no signs of hemorrhage, with normal vascular exam. Patient on extensive psychotropic regimen, but do not expect acute withdrawal at this time. Peri-op anesthesia also may be contributing. The patient was kept NPO. Hypoxemia also likely contributing to AMS, see above for management. During her stay in the MICU, the patient became progressively more alert. She was oriented to person and place as "[**Hospital **] Hospital," but although she could name month as [**Month (only) 547**] she repeatedly stated the year as [**2116**]. . # Right distal femur fracture - patient underwent ORIF on [**2135-4-1**] and will need to complete 4 weeks of lovenox. She is scheduled to follow up with orthopedic as an outpatient for further management. . # Guaiac positive stool- The patient was noted to have guaiac positive stool while in the MICU, and anticoagulation with Lovenox was held for 2 days, but then resumed in the setting of stable Hct. . # h/o depression/dementia/cerebellar ataxia- Initially PO meds were held, but subsequently restarted on her oral medications while in the MICU after improvement of her mental status . # h/o hypothyroidism - patient was continued on levothyroxine . # h/o HTN- patient was continued on amlodipine . # CODE: DNR, but intubation is permitted . # CONTACT: daughter [**Name (NI) **], designated HCP, [**Telephone/Fax (1) 100937**] son [**Name (NI) **], [**Telephone/Fax (1) 100933**] home, or [**Telephone/Fax (1) 100938**] Medications on Admission: 1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets PO DAILY (Daily). 2. Quetiapine 200 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 3. Rivastigmine 3 mg Capsule Sig: One (1) Capsule PO daily (). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Levothyroxine 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Amlodipine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 11. Lamotrigine 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 13. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Medications: 1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets PO DAILY (Daily). 2. Quetiapine 200 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 3. Rivastigmine 3 mg Capsule Sig: One (1) Capsule PO daily (). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Levothyroxine 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Amlodipine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 11. Lamotrigine 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 13. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) syringe Subcutaneous DAILY (Daily) for 4 weeks. 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 17. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 5 days: last day is [**2135-4-15**]. 18. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days: last day [**2135-4-15**]. 19. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 537**]- [**Location (un) 538**] Discharge Diagnosis: 1. Right distal femur periprosthetic fracture. 2. post operative blood loss anemia. Discharge Condition: Mental Status: alert and oriented x 3. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Improved condition at discharge. Discharge Instructions: You were admitted to the hospital after falling. You suffered a broken right leg. Your leg was repaired in the operating room. After the operation, you were confused, which was thought to be due to a urinary tract infection. You were given antibiotics. You also developed the need for extra oxygen, which was thought to be due to excess fluid in your lungs. You received medication to help remove the fluid. You were also given antibiotics to treat a possible pneumonia. You became less confused, and your oxygen requirement improved. You were discharged back to [**Hospital3 537**] on [**2135-4-11**] in improved condition. Please see below for your follow up appointments. Wound Care: -Keep Incision dry. -Do not soak the incision in a bath or pool. Activity: -Continue to be touch weight bearing on your right leg. -Elevate right leg to reduce swelling and pain. -Do not remove brace. Keep brace dry. Other Instructions - Resume your regular diet. - Avoid nicotine products to optimize healing. - Resume your home medications. Take all medications as instructed. - Continue taking the Lovenox to prevent blood clots. -You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2. We are not allowed to call in narcotic (oxycontin, oxycodone, percocet) prescriptions to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. - Narcotic pain medication may cause drowsiness. Do not drink alcohol while taking narcotic medications. Do not operate any motor vehicle or machinery while taking narcotic pain medications. Taking more than recommended may cause serious breathing problems. If you have questions, concerns or experience any of the below danger signs then please call your doctor at [**Telephone/Fax (1) 1228**] or go to your local emergency room. Followup Instructions: Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**MD Number(3) 7967**] orthopedic clinic on [**2135-4-26**] at 10 AM. The number for the orthopedic clinic is [**Telephone/Fax (1) 1228**] Department: COGNITIVE NEUROLOGY UNIT When: THURSDAY [**2135-4-14**] at 2:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 20751**], M.D. [**Telephone/Fax (1) 1690**] Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]

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icd9cm

[ [ [] ] ]

[ "79.35" ]

icd9pcs

[ [ [] ] ]

21427, 21498

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21626, 21626

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22,337

125,014

15003

Discharge summary

report

Admission Date: [**2164-10-30**] Discharge Date: [**2164-11-2**] Service: MEDICINE Allergies: IV Dye, Iodine Containing Attending:[**First Name3 (LF) 2290**] Chief Complaint: GI Bleed Major Surgical or Invasive Procedure: blood transfusion History of Present Illness: History of Present Illness: Mr. [**Known lastname **] is an 86M with a history of A.fib on coumadin, systolic CHF with an EF of 35%, AS with an AV area of 1.2-1.9, s/p pacemaker who presented initially to [**Hospital1 **]-[**Location (un) 620**] on [**10-27**] with BRBPR in the setting of an elevated INR of 4. Upon presentation to [**Hospital1 **]-[**Location (un) 620**], he reported BRBPR and large clots on the day prior to admission (last [**Location (un) 2974**]). He was treated in the [**Hospital1 **]-[**Location (un) 620**] ICU with IVF, FFP (10 units FFP) & Vitamin K, and 13 units of PRBCs, no plts, and transferred to [**Hospital1 18**]. He had an EGD & c-scope at [**Hospital1 **]-[**Location (un) 620**]. The EGD showed a small hiatal hernia, 2.5 x 0.5 cm polyp within his stomach with yellow nodule. His duodenum was normal to second portion; no biopsies were obtained. His colonoscopy to cecum was consistent with poor preparation. He had lots of fresh clots, and procedure was terminated. The patient underwent a repeat colonoscopy on [**2164-10-30**], which showed severe diverticulosis with blood throughout, though without any evidence of active bleed. The patient was transferred to [**Hospital1 18**] on [**2164-10-30**] for further evaluation by IR. . Prior to his bloody stool on [**Name (NI) 2974**], Pt states that he was feeling tired for several days before his bleed. He also had a retinal hemorrhage one day prior, for which he received injections w/ ophthalmology. Pt denied any fevers, chills, chest pain, shortness of breath, nausea, vomiting, or pain of any sort prior to or during his bloody stool. Pt states that he has never had a GI bleed previously. . In the ICU here, he has remained hemodynamically stable without further rebleeding. He received 1 unit PRBC's this am with appropriate increase in Hct. His diet was advanced to regular high fiber diet. Most recent VS prior to transfer afebrile 80s 131/71 94% RA. . On the floors, he denies any fever, chills, nausea, vomiting, abdominal pain or any more bleeding. He denies chest pain or SOB. He says his left shoulder is a bit sore from a blood pressure cuff on the left for several days. Otherwise, he says he had a good lunch and dinner and is feeling well. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - Moderate to severe mitral regurgitation. - Pacemaker. - Atrial fibrillation. - Systolic CHF, EF of 35% on echo in [**2163**]. - Aortic stenosis with area of 1.2 to 1.9 cm. - History of MRSA in his bile in [**2159**]. - TIA. - Hypertension. - Diabetes mellitus. - CAD, status post MI [**2151**]. - peripheral neuropathy. - Hypothyroidism. - Chronic renal insufficiency. - Eye injection for macular degeneration. Social History: Social History: (per [**Hospital1 **]-[**Location (un) 620**] records) Pt lives in [**Location 13588**] w/ his wife. [**Name (NI) **] 1 daughter who lives in [**Name (NI) **], MA. No significant smoking history. He drinks 1 shot of scotch and a [**Doctor Last Name 6654**] nightly. No recreational drugs. Walks with a cane, occasional walker at night, but fully functional with ADLs. Is a veteran submariner, whose sub was sunk in the south Pacific during WWII. Pt spent several years in a Japanese war camp. Traveled extensively, worked in banking. Family History: Family History: no family history of bleeds. No history of cancer. Physical Exam: Physical Exam on transfer: Vitals: T: 97.4F, 128-147/64-81, HR 78-88, RR 18, 96% RA. General: well appearing elderly man in bed in no acute distress HEENT: PERRL at ~3mm, EOMI, no evidence of kyphema, no erythema, normal conjunctiva, no discharge, dry mucous membranes, no LAD Neck: supple, JVP not elevated Lungs: clear to auscultation bilaterally CV: irregularly irregular rhythm, [**3-18**] early systolic crescendo decrescendo murmur heard best at R 2nd ICS, no rubs or gallops Abdomen: normal bowel sounds, soft, non-tender, non-distended, no masses Ext: no edema bilaterally, 2+ pulses Neuro: A&Ox3, CN II-XII grossly intact, 5/5 strength in upper extremities, 4/5 strength bilaterally in lower extremities. Physical Exam on discharge: Vitals: T: 95.8F, 124-125/70-79, HR 86-98, RR 20, 96% RA. General: well appearing elderly man in bed in no acute distress HEENT: PERRL at ~3mm, EOMI, no evidence of kyphema, no erythema, normal conjunctiva, no discharge, dry mucous membranes, no LAD Neck: supple, JVP not elevated Lungs: clear to auscultation bilaterally CV: irregularly irregular rhythm, [**3-18**] early systolic crescendo decrescendo murmur heard best at R 2nd ICS, no rubs or gallops Abdomen: normal bowel sounds, soft, non-tender, non-distended, no masses Ext: no edema bilaterally, 2+ pulses Neuro: A&Ox3, CN II-XII grossly intact, 5/5 strength in upper extremities, 4/5 strength bilaterally in lower extremities. Pertinent Results: [**2164-10-30**] 09:28PM BLOOD WBC-8.9 RBC-3.13* Hgb-9.8* Hct-27.8* MCV-89 MCH-31.4 MCHC-35.2* RDW-16.1* Plt Ct-150 [**2164-10-30**] 09:28PM BLOOD Neuts-94.9* Lymphs-3.1* Monos-2.0 Eos-0 Baso-0.1 [**2164-10-30**] 09:28PM BLOOD PT-14.4* PTT-29.9 INR(PT)-1.2* [**2164-10-30**] 09:28PM BLOOD Glucose-100 UreaN-29* Creat-1.2 Na-145 K-4.5 Cl-106 HCO3-22 AnGap-22* [**2164-10-30**] 09:28PM BLOOD Calcium-8.2* Phos-3.6 Mg-2.3 [**2164-11-1**] 04:00PM BLOOD WBC-8.5 RBC-3.47* Hgb-10.6* Hct-31.3* MCV-90 MCH-30.5 MCHC-33.8 RDW-16.0* Plt Ct-221 [**2164-11-1**] 06:35AM BLOOD PT-13.2 PTT-28.2 INR(PT)-1.1 [**2164-11-1**] 06:35AM BLOOD Glucose-93 UreaN-37* Creat-1.4* Na-144 K-4.6 Cl-108 HCO3-29 AnGap-12 [**2164-11-1**] 06:35AM BLOOD Calcium-8.5 Phos-2.2*# Mg-2.2 Brief Hospital Course: Mr. [**Known lastname **] is an 86M with a history of atrial fibrillation on warfarin, systolic CHF with EF 35%, AS with an AV area of 1.2-1.9cm2, s/p pacemaker who presented to OSH on [**10-27**] with BRBPR in the setting of an elevated INR of 4 requiring massive transfusion, believed to be due to diverticular bleed. Pt has remained stable in the ICU with no further bleeding and is now transferred to medical floor for further monitoring. . Active issues: . #. GI Bleed: Based on negative EGD and colonoscopy demonstrating extensive diverticulosis plus total absence of any nausea, vomiting, or abdominal pain. Pt received 10 units FFP, vitamin K, plus 13 units of pRBCs prior to transfer to MICU here, and 1 additional unit of PRBC's in [**Hospital1 18**] MICU on [**10-31**]. Neither GI nor IR were consulted because the patient was hemodynamically stable and did not have any further bleeding after transfer. Pt has tolerated regular high-fiber diet on [**10-31**] and continues to tolerate this diet with no symptoms. Pt was monitored on telemetry with no significant events. He was initially treated with pantoprazole 40mg iv bid but this was transitioned to his home omeprazole 20 mg daily given lack of evidence for upper GI bleed. His HCT has remained stable at ~30. Pt was advised to continue high fiber diet for diverticulosis. Pt will need repeat Hct check on [**2164-11-5**]. . #. Atrial fibrillation: Rate controlled. His carvedilol was initially held but was increased back to his home dose by the time of discharge. His warfarin was initially held due to recent GI bleed. Pt has a CHADS2 score of 6. However, after extensive discussions with Dr. [**Last Name (STitle) **], the Pt's PCP, [**Name10 (NameIs) **] the Pt and the PCP wanted to hold warfarin for now. Dr. [**Last Name (STitle) **] felt that the risks of repeat diverticular bleed far outweighed the benefit of stroke prevention in this setting despite Pt's [**6-18**] CHADS2 score (which was explicitly discussed with both the primary care physician and the patient). . #. Systolic CHF: Based on ECHO in [**2163**] - Moderate regional LV systolic dysfunction with an EF 35-40% secondary to akinesis of the basal inferior and inferoseptal segments and dyskinesis of the basal inferolateral wall. Moderate to severe mitral regurgitation. Pt's carvedilol and lisinopril were restarted, given clinical stability. However, his furosemide was held and his lisinopril was only given at 10mg po daily (half of his regular dose) due to his blood pressure. #. Hypertension: Currently normotensive. Lisinopril at 10mg po daily (home dose 20mg po daily). . #. DM: A1C 5.8% in [**2164-7-13**]. Per VA and home pharmacy, Pt is not currently taking any anti-diabetic meds. He was on a diabetic diet and insulin sliding scale with no issues. . #. Chronic Renal Insufficiency: His baseline creatinine is between 1.4 and 2 per [**Hospital1 18**] [**Location (un) 620**] records. On day of transfer, his creatinine was 1.4 at OSH. Cr [**10-30**] 1.2 -> [**10-31**] 1.3 -> [**11-1**] 1.4. Pt's foley has been discontinued with no issues. Pt has no urinary complaints, but he should have a repeat Cr in 3 days. . #. Gout: Pt had an episode of gout at [**Hospital1 18**] in his knees. He was treated briefly with colchicine there, but reported intermittent knee pain. During this hospitalization, Pt was continued on his home allopurinol, but had intermittent knee pain, although none on palpation. Pt had some weakness in his lower extremities and inpatient physical therapists recommended rehabilitation. . #. Left eye s/p injection for macular degeneration: Increased discharge and erythema at OSH. Started on Tobramex at OSH, which was continued qid until discharge due to absence of symptoms. Pt was suggested to have outpatient follow-up with his ophthalmologist. . #. Constipation: Pt reports intermittent severe constipation. Pt has been written for milk of mag PRN and will need an aggressive bowel regimen. . Chronic problems: . #. CAD, status post MI. Pt never had any cardiac symptoms during his stay. He was monitored on telemetry without issue. Continued simvastatin 20mg daily. Per [**Name (NI) 1094**] PCP, [**Name10 (NameIs) **] is not on aspirin. . #. Hypothyroidism: continued home levothyroxine with no issue . #. BPH: continued tamsulosin with no issue . TRANSITIONAL ISSUES: -Pt's warfarin was held on the strong suggestion of his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. The decision of when to restart his warfarin is deferred to his primary care provider. [**Last Name (NamePattern4) 30412**]'s lisinopril dosage currently at half home dose (10mg), to be increased as BP necessitates and renal function allows. -Restart lasix when volume status dictates Medications on Admission: Home meds (confirmed w/ [**Company 4916**] [**Location (un) 620**]): -tamsulosin 0.4mg po bid -allopurinol 100mg po daily -warfarin 2.5 mg 1-2 tabs daily as directed -fluorouricil 5% cream - precancer skin cream [**Hospital1 **] 4 wks . Home meds (confirmed w/ [**Location 1268**] VA): -Ferrous sulfate 325 mg p.o. daily. -Simvastatin 40 mg p.o. [**1-15**] pill daily. -Carvedilol 25 mg p.o. b.i.d. -Levothyroxine 50 mcg p.o. daily. -Omeprazole 20 mg p.o. daily. -Calcitriol 0.25 mg p.o. daily. -Magnesium oxide 420 mg p.o. daily -Folic acid 1 mg p.o. daily. -Lisinopril 20 mg p.o. daily. -Furosemide 40 mg p.o. daily. Discharge Medications: 1. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO twice a day. 2. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. ferrous sulfate 325 mg (65 mg iron) Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO once a day. 4. simvastatin 40 mg Tablet Sig: 0.5 Tablet PO once a day. 5. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. magnesium oxide 420 mg Tablet Sig: One (1) Tablet PO once a day. 9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day: hold for SBP < 90. 11. Outpatient Lab Work Please check hematocrit and creatinine on [**2164-11-5**]. 12. Milk of Magnesia 400 mg/5 mL Suspension Sig: One (1) PO once a day as needed for constipation. 13. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day: hold for sbp < 90, HR < 55. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Doctor Last Name 5749**] [**Doctor Last Name **] Village - [**Location (un) **] Discharge Diagnosis: Primary: -lower gastrointestinal bleed, likely diverticular 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: Mr. [**Known lastname **], You initially came to the hospital because you had many bloody stool. At [**Hospital1 18**] [**Location (un) 620**], you were given multiple blood products due to acute blood loss. You had studies which suggested that your bleeding likely resulted from small outpouchings of your bowel call diverticula, but they did not identify an exact site of active bleeding. Due to the massive amounts of blood products that you required, you were transferred to [**Hospital1 18**] [**Location (un) 86**] for further care. Upon arrival, you were stable and our intensive care specialists did not feel that you needed further treatment by our interventional radiologists or our gastroenterologists. You only required one more unit of red blood cells during your admission here. You had a regular high fiber diet with no problems or pain, and you had no further bloody stools. Because of your prior major bleeding, your warfarin (Coumadin) was stopped. This medication is very important to prevent strokes. After a discussion with Dr. [**Last Name (STitle) **], you wished to follow his recommendation, which was to stop the warfarin (Coumadin) altogether for at least the next month. You were also evaluated by our physical therapists, who felt that you should have inpatient-level physical therapy at a skilled nursing facility prior to going to home. The following changes have been made to your medications: -temporarily stop taking warfarin (Coumadin) -temporarily stop taking furosmide (Lasix) -temporarily reduce your lisinopril to 10mg, 1 tab by mouth daily You should further discuss your medications when you follow-up with Dr. [**Last Name (STitle) **]. Please continue to take your other medications as previously prescribed. You should also have a repeat blood hematocrit and creatinine check in 3 days at your facility. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) 20**] B. Address: [**Apartment Address(1) 23478**], [**Location (un) **],[**Numeric Identifier 14512**] Phone: [**Telephone/Fax (1) 3259**] Appointment: [**Telephone/Fax (1) **] [**11-9**] AT 4:45PM Completed by:[**2164-11-2**]

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Discharge summary

report

Admission Date: [**2119-3-18**] Discharge Date: [**2119-3-23**] Date of Birth: [**2057-4-28**] Sex: M Service: MEDICINE Allergies: aspirin / ibuprofen Attending:[**First Name3 (LF) 3276**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: LP Central line placement History of Present Illness: The patient is a 61-year-old man with NSCLC stage IV with metastasis invading into the skull and sinus. The patient is on cycle 2, day 9 of pemetrexed following disease progression on carboplatin and paclitaxel. The patient has evidently been confused of late. Given the number of etiologies altered mental status could represent in this patient, he was referred to the Emergency Department. According to the patient's wife, he has been been spaking nonsense on and off for the past three days. Last night the patient was awake all of the night, but was not coherent. He had also been complaining of excruciating pain under the left chest, as well as groin pain on the left. The patient could point to an area on left chest that was site of pain--no radiation. He denies dyspnea, nausea, vomiting, sore neck, constipation or diarrhea, dysuria. In the ED, initial vital signs were 97.7 124 121/89 18 100% RA. In the ED the patient also complained of left "chest" pain, which seemed to be more LUQ in nature. An EKG showed diffuse ST elevations. Cardiology consult was called: likely pericarditis. MI unlikely. Flat troponins made them even more so. The patient had a bandemia and tachycardia on presentation, so there was concern for infection. Lactate arrived at 5.8 The patient recived vancomycin and Zosyn. The patient was then bolused between 2-3L of normal saline. CXR negative. CT abdomen negative. The ED placed a right IJ, but declined to do an LP because the patient had no meningeal signs. . On arrival to the MICU, the patient was hallucinating that he saw rats in his room. He also seemed to be ocnfused as to whether he wanted to make a call or had an incoming telephone call. He denies any specific areas of pain at this time. Past Medical History: Past Oncologic History: NSCLC stage IV KRAS, EGFR wild type - [**9-/2118**] Developed cough after trip to [**Country 3594**] - [**2118-11-16**] CXR showed spiculated R hilar mass - [**2118-11-25**] Bronch Bx showed adenocarcinoma - [**2118-11-28**] Presented with seizure. MRI head revealed a large lobulated heterogeneously enhancing mass in the frontal sinuses with destruction of the inner and outer tables and bilateral cribriform plates with intracranial extension and invasion of the anterior portion of the superior sagittal sinus with associated vasogenic edema and mild mass effect on the frontal [**Doctor Last Name 534**] of the left lateral ventricle and osseous destruction. - [**2118-11-29**] CT torso revealed a 6.3 x 5.7 cm spiculated right upper lobe lung mass abutting the mediastinum and complete obliteration of the right upper lobe bronchus with post-obstructive collapse, a 3.6 x 3.1 cm paratracheal lymph node, a 4.0 x 2.8 cm left adrenal mass, a 1.4 x 1.6 cm right adrenal mass, an indeterminate 1.9 x 1.9 cm right kidney lesion, and a 1.6 x 1.1 cm lying posterior to the left psoas muscle. - [**2118-12-7**] to [**2118-12-21**] WBRT with 3000 cGy - [**2118-12-20**] PET CT showed an FDG avid right upper lobe mass compressing the RUL bronchus, with surrounding non FDG avid post-obstructive consolidation. FDG avid right paratracheal adenopathy. FDG avid bilateral adrenal masses, left para-aortic node and psoas nodules are consistent with metastatic disease. FDG avid lytic left anterior 4th rib lesion. Known left frontal bone lesion is FDG avid. - [**2118-1-5**] C1D1 Carboplatin AUC 6 paclitaxel 200 mg/m2 - [**2119-1-26**] Cycle 3 Carboplatin paclitaxel Other Past Medical History: - Hypertension - Hyperlipidemia Social History: Lives with wife in [**Name (NI) 669**], MA. Originally from [**Country 3594**]. On disability due to back pain from Merchant Marines. Former 15 pack year smoking, stopped [**2091**]. No alcohol. Family History: The patient's father died from prostate cancer. Mother died from stroke. There is no other history of cancer in the family. Physical Exam: General: Alert, oriented to name, hallucinating but in no distress HEENT: Sclera anicteric, MMM, oropharynx clear and without erythema, EOMI, PERRL Neck: Supple, no LAD palpated, full rnage of motion and without any stiffness or meningeal signs CV: Regular rate and rhythm, S1, S2, no murmurs auscultated Lungs: Clear to auscultation bilaterally Abdomen: Soft, non-tender, non-distended, bowel sounds present GU: No foley Ext: Warm, well perfused, 2+ pulses, no edema Neuro: CNIII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally PHYSICAL EXAM: Vitals - 99.5 (tmax 100.8) 126/76 110 20 94%RA GENERAL: NAD, AOx3 SKIN: warm and well perfused, no excoriations or lesions, no rashes HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva, patent nares, MMM, good dentition, nontender supple neck, no LAD, no JVD CARDIAC: Regular tachycardia, S1/S2, no mrg LUNG: Clear to auscultation ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly M/S: moving all extremities well, no cyanosis, clubbing or edema, no obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, strength 5/5 all 4 ext, downgoing toes b/l Pertinent Results: [**2119-3-17**] 07:30PM BLOOD WBC-31.9*# RBC-4.62 Hgb-13.2* Hct-44.9 MCV-97 MCH-28.6 MCHC-29.4* RDW-18.0* Plt Ct-111*# [**2119-3-18**] 04:35AM BLOOD WBC-30.6* RBC-3.70* Hgb-10.7* Hct-36.2* MCV-98 MCH-29.1 MCHC-29.7* RDW-18.3* Plt Ct-105* [**2119-3-19**] 03:56AM BLOOD WBC-30.0* RBC-3.50* Hgb-10.2* Hct-33.6* MCV-96 MCH-29.2 MCHC-30.4* RDW-18.7* Plt Ct-102* [**2119-3-20**] 06:53AM BLOOD WBC-35.3* RBC-3.55* Hgb-10.1* Hct-34.4* MCV-97 MCH-28.5 MCHC-29.5* RDW-18.6* Plt Ct-129* [**2119-3-21**] 05:07AM BLOOD WBC-42.7* RBC-3.29* Hgb-9.8* Hct-31.4* MCV-95 MCH-29.9 MCHC-31.3 RDW-19.1* Plt Ct-120* [**2119-3-22**] 06:00AM BLOOD WBC-40.1* RBC-3.23* Hgb-9.5* Hct-30.5* MCV-94 MCH-29.5 MCHC-31.3 RDW-19.2* Plt Ct-155 [**2119-3-23**] 05:55AM BLOOD WBC-44.3* RBC-3.25* Hgb-9.9* Hct-31.4* MCV-96 MCH-30.5 MCHC-31.6 RDW-19.0* Plt Ct-203 [**2119-3-23**] 05:55AM BLOOD Neuts-93.0* Lymphs-5.0* Monos-1.5* Eos-0.4 Baso-0.1 [**2119-3-17**] 07:30PM BLOOD Glucose-740* UreaN-36* Creat-0.9 Na-133 K-4.5 Cl-96 HCO3-20* AnGap-22* [**2119-3-18**] 04:35AM BLOOD Glucose-241* UreaN-23* Creat-0.6 Na-142 K-3.3 Cl-109* HCO3-23 AnGap-13 [**2119-3-18**] 01:45PM BLOOD Glucose-400* UreaN-20 Creat-0.5 Na-137 K-4.5 Cl-108 HCO3-20* AnGap-14 [**2119-3-19**] 03:56AM BLOOD Glucose-202* UreaN-14 Creat-0.5 Na-136 K-3.7 Cl-106 HCO3-22 AnGap-12 [**2119-3-21**] 05:07AM BLOOD Glucose-62* UreaN-9 Creat-0.6 Na-141 K-3.9 Cl-103 HCO3-27 AnGap-15 [**2119-3-22**] 06:00AM BLOOD Glucose-68* UreaN-8 Creat-0.6 Na-140 K-3.4 Cl-102 HCO3-26 AnGap-15 [**2119-3-23**] 05:55AM BLOOD Glucose-49* UreaN-7 Creat-0.6 Na-140 K-3.8 Cl-104 HCO3-22 AnGap-18 [**2119-3-17**] 07:30PM BLOOD ALT-34 AST-14 AlkPhos-322* TotBili-0.4 [**2119-3-18**] 04:35AM BLOOD CK(CPK)-10* [**2119-3-21**] 05:07AM BLOOD LD(LDH)-559* [**2119-3-23**] 05:55AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.2 [**2119-3-19**] 11:31AM BLOOD %HbA1c-8.3* eAG-192* [**2119-3-18**] 04:35AM BLOOD Phenyto-1.8* [**2119-3-19**] 03:56AM BLOOD Phenyto-16.1 [**2119-3-20**] 06:53AM BLOOD Phenyto-18.7 [**2119-3-21**] 05:07AM BLOOD Phenyto-14.3 [**2119-3-17**] 07:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2119-3-17**] 07:41PM BLOOD Lactate-5.8* [**2119-3-17**] 10:15PM BLOOD Lactate-6.0* [**2119-3-18**] 04:55AM BLOOD Lactate-3.3* [**2119-3-18**] 03:42PM BLOOD Lactate-2.5* Na-135 K-4.4 [**2119-3-18**] 10:01PM BLOOD Lactate-3.4* Na-137 K-3.8 [**2119-3-19**] 11:56AM BLOOD Lactate-3.3* [**2119-3-20**] 01:16PM BLOOD Lactate-2.6* [**2119-3-21**] 06:35AM BLOOD Lactate-1.6 CT Thorax: IMPRESSION: 1. No evidence of infection. 2. Metastatic disease is slightly increased from [**2119-2-7**] as described above. There is loss of the fat plane between the mass and SVC, concerning for SVC invasion. Right upper lobe partial collapse and radiation change are similar. No new lesion is identified. 3. New pleural effusions, right larger than left. 4. Bland clot adjacent to the right internal jugular vein catheter. MRI Head: FINDINGS: Again noted, there is an enhancing lesion centered in the bilateral frontal sinuses with intracranial extension into the bilateral frontal region with nodular intraparenchymal enhancement as well as meningeal enhancement. There is mild increased T2, FLAIR signal in the right superior frontal gyrus and extensive increased T2, FLAIR signal in the left frontal lobe, unchanged since the prior exam and likely representing vasogenic edema. There is stable extension into the frontal-ethmoid recess as well as the cribriform plate. There is no evidence of acute infarct or hemorrhage. No evidence of new lesions. The flow voids of the major vessels are preserved. There is fluid in the bilateral mastoid air cells, worse on the right. The orbits are unremarkable. IMPRESSION: Overall stable mass involving the bilateral frontal sinuses with stable intracranial extension. No evidence of new parenchymal metastatic lesion. Brief Hospital Course: ASSESSMENT/PLAN: 61M hx NSCLC C2D12 of pemetrexed following disease progression on carboplatin and paclitaxel with mets to the frontal sinus/skull with local invasion who presents from home with altered mental status. #Altered mental status: Likely secondary to hyperglycemia as correction of blood sugars resulted in slow resolution of his altered mental status. MRI without change in mets or worsening vasogenic edema, LP without signs of infection (although HSV PCR pending). Urine and blood cultures negative. CT thorax without evidence of intrapulmonary or intraabdominal infection. Seizure is possible although unlikely with clinical presentation (predominantly hallucinations) in spite of low dilantin level on admission. He was dilantin loaded and at discharge was therapeutic for days. He was maintained on keppra as well without any evidence of seizure activity. Mental status cleared by time of discharge to baseline (mild slurring of words/stutter, AOx3 with good attention span). Blood sugars should be controlled in the future to avoid further worsening of his mental status. #Fever: Not septic appearing. CT thorax neg for infection. UA repeat neg x2. Likely cancer fever as his non-small cell lung cancer has demonstrated progression in spite of chemotherapy. His fever was treated symptomatically with tylenol. If he continues to spike high fevers >101.5 the nursing facility should contact his outpatient oncologist Dr [**Name (NI) **] for direction. #Non-small cell lung cancer/Goals of Care: metastatic to frontal sinus. C2D16 pemetrexed. CT thorax with worsening metastatic disease and interval loss of fat plane between primary tumor and SVC suggestive of SVC invasion. Due to these CT findings, his primary oncologist and the palliative care team determined that he was no longer a candidate for chemotherapy and that he should pursue inpatient hospice. He was made DNR/DNI without escalation of care after discussion with the patient and family, with goal to focus on comfort oriented care. #Hyperglycemia: Likely secondary to the patient's substantial steroid therapy although unclear why presented with glucose >700 now, ?stress reaction from unknown cause, ?occult infection that improved with antibiotics received in ED/MICU. Has been on chronic steroids at home without blood sugar support. Was covered with insulin sliding scale over the duration of the hospitalization, with tapering of the coverage over the course as his insulin requirements decreased. Of note, he has had morning hypoglycemia from unclear etiology over the past few days prior to discharge that has not resulted in clinical relevance. He was not on insulin or any other blood sugar medications at home prior to admission. He is being discharged on an insulin sliding scale in instruction to monitor blood sugars QACHS with understanding that the insulin coverage might not be needed eventually and can be discontinued. #Left chest pain/LUQ pain/L rib pain: Pericarditis highly unlikely in spite of initial concern in ED. Cardiac enzymes flat. Mild EKG changes resolved. Has complained of chronic left sided rib/chest/upper abdomen pain over the past 6+ months, secondary to metastatic lesion in this area that has grown in size despite chemotherapy. Treated with increasing doses of oxycodone as needed. #Elevated Lactate: unclear etiology. In [**Month (only) 956**] was 4.0 and not repeated, on admission >6. Downtrended to normal over the course of hospitalization. ?cancer related etiology. #Thrombocytopenia: new onset, unclear etiology. Possible marrow suppression from premetrexed. Resolving at time of discharge. #Leukocytosis: chronic, unclear etiology presumed secondary to steroids and leukemoid cancer reaction since [**12-5**]. Initially presented with WBC count of 80,000 and has since downtrended to approximately 40,000. #Anemia: stable at baseline. #Sinus tachycardia: baseline 100-110, unclear etiology for tachycardia, rising to ~120 while in house. Transitional Issues: GOALS OF CARE -> if the patient has any concerning symptoms (altered mental status, high fever, low blood pressures) please call the patient's primary oncologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 29078**] or Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 45322**] ([**Telephone/Fax (1) 14703**] for direction and goals of care discussion prior to initiating therapy or hospital transfer. Medications on Admission: - Dexamethasone 4mg [**Hospital1 **] - Famotidine 40mg [**Hospital1 **] - Folic acid 1mg - Ibuprofen 400mg Q6h prn pain - Levetiracetam 1,000mg [**Hospital1 **] - Lorazepam 0.5mg QHS prn insomnia - Ondansetron 8mg Q8h prn nausea - Oxycodone 5mg Q4h prn pain - Phenytoin ER 100mg; 2 tabs [**Hospital1 **] - Prochlorperazine 10mg Q6h prn nausea - Acetaminophen 325mg; 1-2 tabs Q4h prn headache Discharge Medications: 1. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 2. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*180 Tablet(s)* Refills:*0* 5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for fever>101.5. 6. insulin lispro 100 unit/mL Solution Sig: Subcutaneous ASDIR (AS DIRECTED). 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 9. famotidine 20 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). 10. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 11. ondansetron HCl 4 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed for nausea. 12. phenytoin sodium extended 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 13. Combivent 18-103 mcg/actuation Aerosol Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**] Discharge Diagnosis: Toxic metabolic encephalopathy Hyper osmolar non-ketotic syndrome Non-small cell lung cancer, stage 4 Discharge Condition: Mental Status: Clear and mildly coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted for altered mental status, found to be due to high blood sugars. We corrected the blood sugar and you became less confused. We did a CT scan which showed that your cancer has not improved, but instead has gotten worse. Note the following changes to your medications: STOP Folic acid Ibuprofen Lorazepam START Oxycodone 5-10mg by mouth every 4 hours as needed for pain Olanzapine 5mg by mouth at night for insomnia Otherwise take all medications as prescribed. Followup Instructions: Please call ahead to confirm appointments if requiring follow-up: Department: RADIOLOGY When: MONDAY [**2119-5-15**] at 9:50 AM With: RADIOLOGY MRI [**Telephone/Fax (1) 327**] Building: [**Hospital6 29**] [**Location (un) 861**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: NEUROLOGY When: MONDAY [**2119-5-15**] at 11:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12567**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1844**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]

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icd9cm

[ [ [] ] ]

[ "03.31", "38.97" ]

icd9pcs

[ [ [] ] ]

15561, 15683

9401, 9629

303, 331

15829, 15829

5494, 9378

16528, 17274

4103, 4228

14329, 15538

15704, 15808

13912, 14306

16019, 16278

4841, 5475

13420, 13886

16308, 16505

241, 265

359, 2102

15844, 15995

3840, 3874

3890, 4087

49,261

183,714

40401

Discharge summary

report

Admission Date: [**2167-7-9**] Discharge Date: [**2167-7-16**] Date of Birth: [**2130-6-2**] Sex: M Service: SURGERY Allergies: cefazolin Attending:[**First Name3 (LF) 4691**] Chief Complaint: s/p 40 fall Major Surgical or Invasive Procedure: [**2167-7-10**] Irrigation and debridement, ORIF OPEN HUMERUS FRACTURE LEFT,Irrigation and debridement AND ORIF OPEN ELBOW FRACTURE LEFT [**Location (un) **] [**2167-7-13**] 1. ORIF SACRAL AND PELVIC FRACTURE.2. APPLICATION OF PELVIS EX-FIX. 3. REVISION OF LEFT ELBOW ORIF History of Present Illness: 37 year old male who presents by ambulance after suffering 40 foot fall off cherry picker. Positive LOC. Pt perseverating asking repeat questions. Pt has gross deformity to left arm with open wound. Pt also complains of pain to head, back, tingling in left leg, pain with deep breathing and abdominal pain. Past Medical History: Denies Social History: SH: Denies smoking, alcohol or drugs. Family History: Noncontributory Physical Exam: Upon presentation to [**Hospital1 18**]: Constitutional: pt on backboard in obvious pain HEENT: abrasion to left forehead with mild crepitus collar in place Chest: decreased breath sounds due to pain with inspiration. abrasions to left chest Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, mild diffuse tenderness to abdomen. No rebound Pelvic: pain to sacrum Rectal: normal tone with no gross blood Extr/Back: left arm deformity with skin open wound. decreased sensation to left foot. DP palp bilaterally Skin: multiple abrasions including head, left arm and lateral chest Neuro: Speech fluent Psych: Normal Pertinent Results: [**2167-7-15**] 06:00AM BLOOD WBC-7.2 RBC-3.11* Hgb-9.3* Hct-26.7* MCV-86 MCH-29.9 MCHC-34.8 RDW-14.5 Plt Ct-196 [**2167-7-15**] 02:36AM BLOOD Hct-26.7*# [**2167-7-14**] 04:00PM BLOOD Hct-21.0* [**2167-7-14**] 06:00AM BLOOD WBC-6.6 RBC-2.84* Hgb-8.4* Hct-23.8* MCV-84 MCH-29.6 MCHC-35.2* RDW-14.5 Plt Ct-147* [**2167-7-10**] 02:38AM BLOOD WBC-16.2* RBC-4.27* Hgb-12.8* Hct-36.6* MCV-86 MCH-29.9 MCHC-34.9 RDW-14.2 Plt Ct-174 [**2167-7-9**] 09:39PM BLOOD WBC-20.4* RBC-4.10* Hgb-11.7* Hct-35.6* MCV-87 MCH-28.6 MCHC-33.0 RDW-14.0 Plt Ct-210 [**2167-7-9**] 06:40PM BLOOD WBC-16.7* RBC-4.62 Hgb-13.9* Hct-39.4* MCV-85 MCH-30.0 MCHC-35.2* RDW-14.0 Plt Ct-277 [**2167-7-15**] 06:00AM BLOOD Plt Ct-196 [**2167-7-15**] 06:00AM BLOOD PT-12.2 INR(PT)-1.0 [**2167-7-14**] 06:00AM BLOOD Plt Ct-147* [**2167-7-14**] 06:00AM BLOOD Glucose-113* UreaN-11 Creat-0.5 Na-143 K-3.6 Cl-104 HCO3-32 AnGap-11 [**2167-7-13**] 01:00PM BLOOD Glucose-102* UreaN-10 Creat-0.6 Na-141 K-3.8 Cl-104 HCO3-28 AnGap-13 [**2167-7-13**] 01:50AM BLOOD Glucose-107* UreaN-8 Creat-0.7 Na-142 K-3.6 Cl-103 HCO3-32 AnGap-11 [**2167-7-14**] 06:00AM BLOOD Calcium-7.6* Phos-2.2* Mg-2.1 [**2167-7-13**] 01:00PM BLOOD Calcium-7.5* Phos-3.3 Mg-1.8 [**2167-7-13**] 01:50AM BLOOD Calcium-8.3* Phos-2.2* Mg-2.1 [**2167-7-11**] 02:30AM BLOOD Lactate-1.1 [**2167-7-9**]: chest x-ray: FINDINGS: Single supine AP portable view of the chest was obtained. Underlying trauma board partially obscures the view. There are relatively low lung volumes. Left lateral pulmonary contusions seen on subsequent chest CT are better appreciated on that study, as are multiple left-sided rib fractures. The right lung is clear. No pleural effusion is seen. Small loculated left pneumothorax is also not appreciated on the current study, but seen on subsequent CT, due to differences in modality. The superior mediastinum is slightly prominent. The cardiac silhouette is not enlarged. [**2167-7-9**]: c-spine: IMPRESSION: No acute fracture or malalignment. [**2167-7-9**]: cat scan of the head: IMPRESSION: 1. Small left frontal scalp hematoma. However, no acute skull fracture. 2. No intracranial hemorrhage. [**2167-7-9**]: cat scan of abdomen and pelvis: IMPRESSION: 1. Comminuted fracture of the left superior and inferior pubic rami with mild pubic symphysis diastasis. 2. Vertical fracture through the left sacrum involving multiple sacral neural foramina. 3. Surrounding pelvic hematoma. 4. No evidence of bladder injury on CT cystogram. 5. Small anterior mediastinal hematoma may be venous in origin. No traumatic aortic injury or sternal fracture. 6. Multiple left-sided pulmonary contusions and possible laceration. 7. Nondisplaced rib fractures involving bilateral 1st and left 3rd, 4th, 5th, and 12th ribs, as above. Mildly displaced fractures of the left L1 through L5 tranverse processes 8. Small amount of air in the pleural space. 9. Spiral fracture of left humerus identified on scout image. [**2167-7-9**]: CTA chest: IMPRESSION: 1. Comminuted fracture of the left superior and inferior pubic rami with mild pubic symphysis diastasis. 2. Vertical fracture through the left sacrum involving multiple sacral neural foramina. 3. Surrounding pelvic hematoma. 4. No evidence of bladder injury on CT cystogram. 5. Small anterior mediastinal hematoma may be venous in origin. No traumatic aortic injury or sternal fracture. 6. Multiple left-sided pulmonary contusions and possible laceration. 7. Nondisplaced rib fractures involving bilateral 1st and left 3rd, 4th, 5th, and 12th ribs, as above. Mildly displaced fractures of the left L1 through L5 tranverse processes 8. Small amount of air in the pleural space. 9. Spiral fracture of left humerus identified on scout image. [**2167-7-10**]: IR: IMPRESSION: Initial pelvic angiography demonstrated a focus of hemorrhage in the territory of the internal iliac artery which was not seen onsubselective angiography and repeat angiography of the internal iliac. Resolution of bleeding corresponded to improvement in patient's hemodynamics suggesting resolution of bleeding without intervention. [**2167-7-10**]: cat scan of upper extremity: IMPRESSION: 1. Comminuted fracture of the humeral midshaft, with medial angulation of the major distal fracture fragment and shortening of the limb with overriding of the fracture fragments. 2. Highly comminuted fracture of the elbow, with comminuted fractures involving the lateral epicondyle extending to the capitellar articular surface, comminuted fracture of the olecranon, fracture of the trochlea, and radial head fracture. Large joint effusion. See discussion above. [**2167-7-10**]: left foot x-ray: No acute fracture or dislocation is detected on these views. If clinical suspicion for foot fracture remains high, then further assessment on an oblique view would be recommended. [**2167-7-10**]: left ankle x-ray: LEFT ANKLE No fracture or dislocation is detected about the left ankle. The mortise is grossly congruent. LEFT FOOT, TWO VIEWS. No acute fracture or dislocation is detected on these views. If clinical suspicion for foot fracture remains high, then further assessment on an oblique view would be recommended. [**2167-7-10**]: left elbow x-ray: IMPRESSION: 1. Comminuted mid shaft humeral fracture with large butterfly fragments and overriding of the fracture fragments. 2. Moderate medial angulation of the major distal fracture fragment. 3. Additional fracture of the lateral epicondyle of the humerus extending to the articular surface. 4. Suspected additional fractures of capitellum, trochlea, radial head, and ulna. See additional CT study for more complete evaluation. [**2167-7-10**]: x-ray of the pelvis: Comminuted fractures of left superior and inferior pubic rami, pubic symphysis diastasis and vertical fracture throughout the left sacrum are again noted, probably unchanged when compared to prior study, CT, though comparison is difficult due to difference in technique. Surgical clips project in the right lower quadrant [**2167-7-11**]: chest x-ray: Cardiomediastinal contours are unchanged with cardiomegaly and widened mediastinum due to increased mediastinal fat. There are low lung volumes. There is no pneumothorax or large pleural effusions. There is mild vascular congestion. Multiple left rib fractures with adjacent pleural and parenchymal abnormalities are unchanged from prior CT from [**7-9**]. [**2167-7-13**]: cat scan of upper extremity: IMPRESSION: Status post ORIF of the left mid humerus, distal humerus, and olecranon, as above without definite hardware complication. [**2167-7-13**]: lower extremity fluro: 277 fluoroscopic spot radiographs demonstrate ORIF complex pelvic fracture. [**2167-7-13**]: x-ray of left arm: Final Report HISTORY: Revision left elbow fracture. Fluoroscopic assistance provided to surgeon in the OR without the radiologist present. 17 spot views obtained. These demonstrate hardware in relation to the distal humerus and proximal ulna. Fluoro time not recorded on the electronic requisition. Correlation with real-time findings and when appropriate, conventional radiographs is recommended for full assessment. [**2167-7-9**] 9:30 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2167-7-12**]** MRSA SCREEN (Final [**2167-7-12**]): No MRSA isolated. Brief Hospital Course: 37 year old gentleman admitted to the acute care service after a 40 foot fall with loss of consciousness. Upon admission, he was made NPO, given intravenous fluids and underwent radiographic imaging. He was hypotensive and tachycardic requiring packed red blood cells. His imaging showed a pelvic fracture, rib fractures, and a left humerus/elbow fracture. Because of his injuries, he was evaluated by the orthopedic service. He was admitted to the Trauma intensive care unit due to his hemodynamic instability. During his stay in the intensive care unit, he required additional blood cell products and pressor support to maintain his blood pressure. The source of his bleeding was not identified and he was taken to IR for angiography. Initial pelvic angiography demonstrated a focus of hemorrhage in the territory of the internal iliac artery. The bleeding did resolve without intervention and the hematocrit stabilized. Once his hemodynamic status stabilized, he was taken to the operating room on HOD #2 for an I+D/ORIF of left humerus and olecranon fracture. During his operative course, he had a 500cc blood loss and required pressor support. He was monitored in the intensive care unit after the procedure and was extubated within 24 hours. He returned to the operating room on HOD #5 for ORIF left pelvis and external fixator. At the same time he also underwent an I+D of his left elbow and revision of implant. During this procedure, he had a 900cc blood loss. He was extubated in the operating room and monitored in the recovery room. He was transferred to the surgical floor on [**7-13**] where he continued to progress. His IV narcotics were switched to oral with adequate response. His weight bearing status was upgraded to WBAT on both right upper and right lower extremities while remaining NWB on the left upper and lower extremities. On HD #6 he was noted with a drop in his hematocrit to 20 without hemodynamic instability. He was transfused with 2 u PRBC and his current hematocrit is 26.7. Because of this acute drop, his anticoagulants were held. Serial hematocrits were followed thereafter and once stable he was started on Lovenox 40 mg daily as prophylaxis. He was evaluated by physical and occupational therapy and recommendations were made for his discharge to a rehabilitation facility because of his decreased mobility and physical limitations. Medications on Admission: none Discharge Medications: 1. famotidine 20 mg Tablet Sig: One (1) Tablet 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. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for loose stool. 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. ferrous gluconate 325 mg (37.5 mg iron) Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 8. hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3 hours) as needed for pain: hold for increased sedation, resp. rate <12. Disp:*30 Tablet(s)* Refills:*0* 9. enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) MG Subcutaneous DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Location (un) 931**] House Nursing & Rehabilitation Center - [**Location (un) 932**] Discharge Diagnosis: s/p Fall Injuires: Left open humeral shaft fracture Left open elbow fracture Left sacral fracture thru foramen/pubic diastasis Left sup/inf pubic rami fracture Mediastinal hematoma Left 1st-3rd rib fracture Right 1st rib fracture Small pulmonary contussion Acute blood loss anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hosptial after a 40 foot fall. You sustained a pelvic fracture, rib fractures, and a left arm fracture. You were taken to the operating room where you had your left arm and elbow repaired with plates and screws. You also had your pelvis repaired. You are now medically stable enough to be discharged to a rehabilitation facility wher3 you will have more intensive physical therapy to help re-build strength and endurance. You are prescribed a blood thinning injection called Lovenox to prevent you from developing blood clots. Once you are able to fully walk and put weight on your legs this medication can be stopped. This will be determined by the Orthopedic [**Location (un) 21334**] and the [**Name5 (PTitle) 21334**] at the rehab facility. Followup Instructions: Please follow up with the acute care service in 2 weeks. You can schedule your appointment by calling # [**Telephone/Fax (1) 600**]. Please let them know that you will need a chest x-ray prior to your visit. You will also need to follow up with Orthopedics, Dr. [**Last Name (STitle) **]/NP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 2 weeks. The telephone number is # [**Telephone/Fax (1) 1228**]. Please tell them you would like your appointment on a Thursday so Dr. [**Last Name (STitle) 1005**] will also be available. Completed by:[**2167-7-16**]

[ "E884.9", "807.04", "861.21", "860.0", "285.1", "805.6", "808.2", "812.50", "867.8", "E849.9", "812.31", "813.11" ]

icd9cm

[ [ [] ] ]

[ "79.62", "79.39", "79.31", "88.48", "84.72", "79.32", "78.53", "78.19", "79.61", "93.44", "38.91" ]

icd9pcs

[ [ [] ] ]

12441, 12555

9111, 11501

279, 555

12880, 12880

1704, 9088

13856, 14440

994, 1011

11556, 12418

12576, 12859

11527, 11533

13056, 13833

1026, 1685

228, 241

583, 892

12895, 13032

914, 922

938, 978

7,798

140,344

6845

Discharge summary

report

Admission Date: [**2161-2-13**] Discharge Date: [**2161-2-24**] Date of Birth: [**2111-8-2**] Sex: M Service: MEDICINE Allergies: Bactrim Ds / Ferrous Sulfate Attending:[**First Name3 (LF) 2074**] Chief Complaint: Chest pain, STEMI Major Surgical or Invasive Procedure: Right and left heart cardiac catheterization with bare metal stent placement to the left anterior descending artery [**2161-2-13**]. History of Present Illness: 49 yo Haitian male with hx of HIV (CD4 324, VL < 50 [**12-24**]), who presented to the [**Hospital1 18**] ED with chest pain. He states that it started after a BM in the AM. He describes it as substernal [**10-28**] radiates to throat and forearms bilaterally and worse with inspiration. He had dizziness, but no SOB. Pt developed anterioseptal ST elevations on EKG. He was rushed to cath lab where he had 100% ostial LAD occlusion and 2 BMS were placed. He was CP free upon arrival to the CCU, but hypoxic to the 70s (sat) and 90s. Past Medical History: 1. HIV-last CD4 324, VL < 50 [**12-24**]- dx [**2156**], acquired from sexual contact on [**Name (NI) 2775**] 2. Hep A and Hep B both cleared 3. Hypereosinophilia 4. internal hemorrhoids Social History: He denies any alcohol, tobacco or drugs. He is separated from his wife and living with a new girldfriend. He has two children ages 6 and 10, who are well. He works in banquets. He has lived in [**Location 86**] for approximately six to seven years and he arrived in the U.S. in his 30's from [**Country 2045**]. He is the son of [**Initials (NamePattern4) **] [**Hospital1 25873**] father and a Haitian mother. Family History: Both parents with hypertension and Type II diabetes. Physical Exam: T 97.2 HR 109 BP 116/72 RR 32 O2Sat on 87% NRB Gen: middle aged black man in moderate respiratory distress, shivering HEENT - MMM, PERRL Hrt- tachycardic, Lungs- coarse BS throughout Abd- +BS, soft, NTND Extrem- 2+ pulses, groin Neuro- Nonfocal Pertinent Results: [**2161-2-13**] 10:40AM CK-MB-2 cTropnT-<0.01 [**2161-2-13**] 07:15PM CK-MB-100* MB INDX-10.8* cTropnT-0.95* [**2161-2-14**] 05:07AM BLOOD CK-MB-329* MB Indx-11.3* cTropnT-6.58* [**2161-2-14**] 09:47AM BLOOD CK-MB-258* MB Indx-9.4* cTropnT-6.19* . DIRECT INFLUENZA A ANTIGEN TEST (Final [**2161-2-19**]): Positive for Influenza A viral antigen. . ECGs: In ED: 10:30 AM equivical STE in V1, V2, V3, reciprical STD in II, III, V5, V6 In ED: 11:22 AM evolving STE with tombstoning in v2, v3, Loss of R waves in precordial leads, same reciprical changes as 10:30 In ED: 19:12 AIVR, wide complex tachycardia with a-v dissociation Post PCI: STE in V1-V4 with loss of r-waves in precordium . Cardiac cath ([**2161-2-13**]): Selective coronary angiography of this right dominant system revealed 100% stump occluded LAD. LMCA, LCx and RCA don't have obstructive coronary artery disease. Resting hemodynamics was performed. The mean right atrial pressure was 8mmHg, RV pressure was 45/9mmHg, mean PCWP was 23mmHg with a wave of 23mmHg and V wave of 33mmHg. The cardiac output was 4.32 l/min and cardiac index was 2.39 l/min/m2. Successful PCI of the LAD with overlapping bare metal stents as detailed in this report. . Echo ([**2161-2-14**]): EF 35-40% Left ventricular wall thicknesses and cavity size are normal. There is mild to moderate regional left ventricular systolic dysfunction with severe hypokinesis to akinesis of the anterior septum, anterior wall, and apex. No masses or thrombi are seen in the left ventricle. Trace aortic regurgitation is seen. trivial mitral regurgitation. trivial/physiologic pericardial effusion. . R LENI ([**2161-2-19**]): Acute thrombus extending along the length of the right common femoral vein down inferiorly as far as the popliteal vein. Brief Hospital Course: Pt was admitted with an anterior STEMI, found to have 100% occlusion of the LAD, with placment of a bare metal stent to the LAD and transferred to the CCU post-cath for further management. CK's peaked at 2900 and he had a question of early pericarditis 3 days post-cath which resolved. His EF was 35-40% with anterior akinesis for which he was started on anti-coagulation for mural wall thrombus prophylaxis. Pt was also started on ASA, Plavix, Statin, Lisinopril and metoprolol during hospitalization. . Post-cath, his course was complicated by persistent right groin pain. Radiology noted a pseudoaneurysm at the R groin area which was revisualized with US and noted to be stable. Additionally was noted R common femoral->popliteal DVT, likely related to cardiac cath. Anti-coagulation was continued for DVT and mural wall thromubus prohylaxis. . Post-cath course was further complicated by persistent fevers, with some hypoxia. He had a positive DFA for influenza A but blood, stool and sputum cultures were all negative. An ID consult was called to assist with the management of his fevers. Fever was thought to be secondary to influenza or to the large thrombus burden, there was an eventual improvement in the fever curve. All other issues including his HIV were stable (CD4 > 300, VL undetectable) during this admission and pt. was discharged to home for further follow-up with his PCP and cardiac rehab. Medications on Admission: ANUSOL-HC 2.5% tid COLACE 100MG [**Hospital1 **] COMBIVIR 300-150MG [**Hospital1 **] SUSTIVA 600MG qhs Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Liquid Sig: Five (5) ML PO Q6H (every 6 hours) as needed. Disp:*QS ML(s)* Refills:*0* 8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Warfarin 2 mg Tablet Sig: 2 1/2 Tablets PO at bedtime. Disp:*90 Tablet(s)* Refills:*2* 10. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 11. Enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) mg Subcutaneous Q12H (every 12 hours) for 6 days. Disp:*QS mg* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Acute Myocardial Infarction, Influenza, pneumonia, deep vein thrombosis. Discharge Condition: Good. Discharge Instructions: Please take all medications as prescribed. Please keep all follow-up appointments. Please call your primary care doctor, Dr. [**First Name8 (NamePattern2) 3403**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 1300**], or return to the Emergency Department if you experience fevers, chills, worsening cough, chest pain, chest pressure shortness of [**Last Name (LF) 1440**], [**First Name3 (LF) 691**] bleeding, blood in your urine, blood in your stool, worsening leg pain or any symptoms that concern you. Followup Instructions: You are scheduled to see Dr. [**First Name8 (NamePattern2) 3403**] [**Last Name (NamePattern1) **] on Monday [**2161-3-2**] at 11:30am. Please call ([**Telephone/Fax (1) 1300**] if questions regarding this appointment. At this visit you should discuss with Dr. [**Last Name (STitle) **] an evaluation for hypercoagulability after your recent deep vein thrombosis (DVT), and follow-up for a spot on your liver noted on CT scan. . You are scheduled to have your INR checked at [**Hospital **] on Thursday [**2161-2-26**]. This will be monitored by the [**Hospital3 **] and they will contact you regarding the results and how you should change your coumadin dose. . Please call ([**Telephone/Fax (1) 2037**] to schedule follow-up with a cardiologist within 1-2 weeks of discharge. Completed by:[**2161-2-27**]

[ "V08", "453.41", "410.11", "442.3", "414.01", "487.0", "997.2", "E879.0" ]

icd9cm

[ [ [] ] ]

[ "37.22", "88.52", "99.20", "36.06", "00.40", "00.66", "88.55", "00.46" ]

icd9pcs

[ [ [] ] ]

6645, 6702

3802, 5217

306, 441

6819, 6827

1996, 3779

7389, 8198

1660, 1715

5371, 6622

6723, 6798

5243, 5348

6851, 7366

1730, 1977

249, 268

469, 1003

1025, 1214

1230, 1644

48,475

127,884

40937

Discharge summary

report

Admission Date: [**2121-3-31**] Discharge Date: [**2121-4-16**] Date of Birth: [**2065-10-7**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Oxycodone / Hydrocodone / morphine Attending:[**Attending Info 65513**] Chief Complaint: Ovarian cancer Major Surgical or Invasive Procedure: Exploratory laparotomy Total abdominal hysterectomy Bilateral salpingoophorectomy Pelvic and paraaortic lymph node dissection Diaphragm nodule excision and vaporization Liver biopsy Rectosigmoid resection and re-anastamosis History of Present Illness: Mrs. [**Known lastname **] is a 55yo G5P4 who initially presented to an OSH with a nodule in her umbilicus. A CT was performed demonstrating extensive ascites, with omental and peritoneal implants. The patient underwent a biopsy which demonstrated a poorly differentiated adenocarcinoma. She was referred to Dr. [**Last Name (STitle) **] for evaluation and initiation of chemotherapy. He referred her to Dr. [**Last Name (STitle) 5797**] for possible surgery. Past Medical History: HCV with undetectable VL at [**Hospital 1263**] Hospital Ovarian Adenocarcinoma, recently diagnosed c-section x 2 Social History: Initially from [**Country 3992**]. Married, 4 children. No tobacco, alcohol or drug use. Family History: per notes, no family history of malignancy Physical Exam: On Discharge: VSS, Afebrile NAD RRR CTAB, mildly decreased BS at bases Abdomen soft, nontender, nondistended. + BS. Incision well-healed with steri-strips LE NT/NE Pertinent Results: Hematology [**2121-3-31**] 09:41AM BLOOD WBC-5.7 RBC-4.58 Hgb-12.6 Hct-37.9 MCV-83 MCH-27.5 MCHC-33.2 RDW-12.2 Plt Ct-398 [**2121-4-2**] 07:00PM BLOOD WBC-8.0# RBC-3.70* Hgb-10.5* Hct-31.3* MCV-85 MCH-28.3 MCHC-33.4 RDW-12.6 Plt Ct-282 [**2121-4-3**] 04:46AM BLOOD WBC-8.4 RBC-4.23 Hgb-12.3 Hct-34.6* MCV-82 MCH-29.1 MCHC-35.6* RDW-13.2 Plt Ct-253 [**2121-4-4**] 04:52AM BLOOD WBC-10.3 RBC-3.53* Hgb-10.2* Hct-29.7* MCV-84 MCH-29.0 MCHC-34.4 RDW-13.5 Plt Ct-278 [**2121-4-6**] 03:58AM BLOOD WBC-5.1 RBC-3.34* Hgb-9.5* Hct-28.5* MCV-85 MCH-28.5 MCHC-33.4 RDW-13.7 Plt Ct-322 [**2121-4-7**] 06:31AM BLOOD WBC-6.3 RBC-3.38* Hgb-9.7* Hct-28.5* MCV-85 MCH-28.7 MCHC-34.0 RDW-13.1 Plt Ct-395 [**2121-4-9**] 06:23AM BLOOD WBC-7.6 RBC-3.37* Hgb-9.5* Hct-28.6* MCV-85 MCH-28.1 MCHC-33.2 RDW-14.1 Plt Ct-524* [**2121-4-11**] 09:30AM BLOOD WBC-8.1 RBC-3.48* Hgb-9.8* Hct-29.9* MCV-86 MCH-28.0 MCHC-32.7 RDW-14.1 Plt Ct-679* [**2121-4-12**] 05:30AM BLOOD WBC-7.9 RBC-3.18*# Hgb-8.9*# Hct-27.1*# MCV-85 MCH-27.9 MCHC-32.7 RDW-13.4 Plt Ct-727* [**2121-4-14**] 04:04AM BLOOD WBC-9.6 RBC-3.40* Hgb-9.5* Hct-28.5* MCV-84 MCH-27.8 MCHC-33.3 RDW-14.3 Plt Ct-795* [**2121-4-16**] 05:07AM BLOOD WBC-7.3 RBC-3.30* Hgb-9.3* Hct-28.2* MCV-85 MCH-28.1 MCHC-32.9 RDW-13.9 Plt Ct-736* [**2121-3-31**] 09:41AM BLOOD Neuts-76.6* Lymphs-15.1* Monos-6.8 Eos-1.1 Baso-0.4 [**2121-4-3**] 04:46AM BLOOD Neuts-88* Bands-1 Lymphs-4* Monos-6 Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 [**2121-4-6**] 08:50PM BLOOD Neuts-79.0* Lymphs-12.0* Monos-7.1 Eos-1.8 Baso-0.2 [**2121-4-11**] 09:30AM BLOOD Neuts-82* Bands-1 Lymphs-8* Monos-5 Eos-0 Baso-1 Atyps-0 Metas-2* Myelos-1* [**2121-4-15**] 04:47AM BLOOD Neuts-77.9* Lymphs-12.7* Monos-5.9 Eos-2.9 Baso-0.6 [**2121-3-31**] 09:41AM BLOOD PT-12.9 PTT-32.9 INR(PT)-1.1 [**2121-4-2**] 05:50AM BLOOD PT-11.5 PTT-31.0 INR(PT)-1.0 [**2121-4-2**] 07:00PM BLOOD PT-14.7* PTT-28.8 INR(PT)-1.3* [**2121-4-2**] 10:51PM BLOOD PT-14.0* PTT-31.0 INR(PT)-1.2* [**2121-4-3**] 04:46AM BLOOD PT-13.7* PTT-31.7 INR(PT)-1.2* [**2121-4-4**] 04:52AM BLOOD PT-12.9 PTT-35.7* INR(PT)-1.1 [**2121-4-5**] 06:00AM BLOOD PT-11.8 PTT-31.5 INR(PT)-1.0 [**2121-4-2**] 07:00PM BLOOD Fibrino-164 [**2121-4-2**] 10:51PM BLOOD Fibrino-220 [**2121-4-3**] 04:46AM BLOOD Fibrino-320 Chemistry: [**2121-3-31**] 09:41AM BLOOD Glucose-85 UreaN-12 Creat-0.6 Na-136 K-8.4* Cl-101 HCO3-26 AnGap-17 [**2121-4-2**] 05:50AM BLOOD Glucose-112* UreaN-7 Creat-0.6 Na-138 K-4.4 Cl-106 HCO3-24 AnGap-12 [**2121-4-2**] 10:51PM BLOOD Glucose-148* UreaN-7 Creat-0.5 Na-143 K-3.8 Cl-112* HCO3-24 AnGap-11 [**2121-4-3**] 04:20PM BLOOD Glucose-131* UreaN-9 Creat-0.6 Na-140 K-3.9 Cl-105 HCO3-28 AnGap-11 [**2121-4-5**] 06:00AM BLOOD Glucose-142* UreaN-14 Creat-0.3* Na-141 K-3.4 Cl-107 HCO3-29 AnGap-8 [**2121-4-7**] 06:31AM BLOOD Glucose-128* UreaN-10 Creat-0.3* Na-139 K-3.9 Cl-103 HCO3-31 AnGap-9 [**2121-4-9**] 06:23AM BLOOD Glucose-127* UreaN-12 Creat-0.4 Na-133 K-4.4 Cl-99 HCO3-28 AnGap-10 [**2121-4-10**] 05:05AM BLOOD Glucose-129* UreaN-14 Creat-0.4 Na-136 K-4.3 Cl-100 HCO3-28 AnGap-12 [**2121-4-12**] 05:30AM BLOOD Glucose-126* UreaN-16 Creat-0.4 Na-134 K-4.3 Cl-99 HCO3-27 AnGap-12 [**2121-4-16**] 05:07AM BLOOD Glucose-102* UreaN-23* Creat-0.5 Na-138 K-4.2 Cl-103 HCO3-25 AnGap-14 [**2121-3-31**] 09:41AM BLOOD ALT-22 AST-98* AlkPhos-52 TotBili-0.5 [**2121-4-5**] 06:00AM BLOOD ALT-35 AST-64* TotBili-0.3 [**2121-4-12**] 05:30AM BLOOD ALT-20 AST-20 LD(LDH)-218 AlkPhos-105 Amylase-211* TotBili-0.2 [**2121-3-31**] 09:41AM BLOOD Lipase-38 [**2121-3-31**] 11:40AM BLOOD Lipase-33 [**2121-4-12**] 05:30AM BLOOD Lipase-215* [**2121-3-31**] 09:41AM BLOOD Albumin-3.6 Calcium-8.7 Phos-4.1 Mg-2.4 Cholest-179 [**2121-4-2**] 05:50AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.2 [**2121-4-4**] 04:52AM BLOOD Calcium-7.4* Phos-2.6* Mg-2.1 [**2121-4-7**] 06:31AM BLOOD Calcium-7.5* Phos-3.7 Mg-2.0 [**2121-4-11**] 09:30AM BLOOD Calcium-8.6 Phos-3.9 Mg-2.3 [**2121-4-16**] 05:07AM BLOOD Calcium-8.8 Phos-5.2* Mg-2.1 HIV: [**2121-4-13**] 05:50PM BLOOD HIV Ab-NEGATIVE Urine: [**2121-4-3**] 04:55AM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2121-4-5**] 01:45PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-6.5 Leuks-NEG [**2121-4-9**] 08:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [**2121-4-14**] 08:43AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG [**2121-4-5**] 01:45PM URINE RBC-2 WBC-2 Bacteri-FEW Yeast-NONE Epi-0-2 [**2121-4-14**] 08:43AM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 Pleural fluid: [**2121-4-7**] 05:42PM PLEURAL WBC-500* RBC-[**Numeric Identifier **]* Polys-67* Lymphs-9* Monos-3* Eos-1* Meso-11* Macro-9* [**2121-4-7**] 05:42PM PLEURAL TotProt-2.6 Glucose-141 LD(LDH)-662 Cultures: [**2121-4-3**] 4:54 am BLOOD CULTURE Source: Line-a-line. **FINAL REPORT [**2121-4-9**]** Blood Culture, Routine (Final [**2121-4-9**]): NO GROWTH. [**2121-4-3**] 4:55 am URINE Source: Catheter. **FINAL REPORT [**2121-4-4**]** URINE CULTURE (Final [**2121-4-4**]): NO GROWTH. [**2121-4-5**] 1:11 pm URINE Source: Catheter. **FINAL REPORT [**2121-4-6**]** URINE CULTURE (Final [**2121-4-6**]): NO GROWTH. [**2121-4-6**] 8:20 pm BLOOD CULTURE Source: Line-PICC. **FINAL REPORT [**2121-4-12**]** Blood Culture, Routine (Final [**2121-4-12**]): NO GROWTH. [**2121-4-6**] 8:15 pm URINE Source: Catheter. **FINAL REPORT [**2121-4-9**]** URINE CULTURE (Final [**2121-4-9**]): 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. Piperacillin/Tazobactam sensitivity testing confirmed 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-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R [**2121-4-6**] 9:20 pm BLOOD CULTURE Site: ARM **FINAL REPORT [**2121-4-12**]** Blood Culture, Routine (Final [**2121-4-12**]): NO GROWTH. [**2121-4-7**] 5:42 pm PLEURAL FLUID **FINAL REPORT [**2121-4-13**]** GRAM STAIN (Final [**2121-4-7**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [**2121-4-10**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2121-4-13**]): NO GROWTH. [**2121-4-9**] 8:10 pm URINE Site: NOT SPECIFIED **FINAL REPORT [**2121-4-10**]** URINE CULTURE (Final [**2121-4-10**]): NO GROWTH. [**2121-4-11**] 10:10 pm BLOOD CULTURE Site: ARM **FINAL REPORT [**2121-4-17**]** Blood Culture, Routine (Final [**2121-4-17**]): NO GROWTH. [**2121-4-12**] 4:09 am BLOOD CULTURE Source: Line-picc. **FINAL REPORT [**2121-4-18**]** Blood Culture, Routine (Final [**2121-4-18**]): NO GROWTH. [**2121-4-14**] 8:43 am URINE Source: Catheter. **FINAL REPORT [**2121-4-15**]** URINE CULTURE (Final [**2121-4-15**]): NO GROWTH. EKG: [**2121-4-1**]: Sinus rhythm. Normal tracing. No previous tracing available for comparison. Radiology: [**2121-3-31**] CXR Pre-op: IMPRESSION: Right middle lobe linear atelectases/scarring with lesser involvement of the right lower lobe. [**4-2**] CXR: SUPINE BEDSIDE CHEST RADIOGRAPH: An endotracheal tube terminates at the level of the carina and could be retracted by 2-3 cm. Cardiac, mediastinal and hilar contours are normal. The lungs are clear. There are minimal bilateral pleural effusions. There is no pneumothorax. Linear right middle lobe opacity persists though is less prominent, likely atelectasis or scar. [**4-4**] CXR IMPRESSION: 1. New bilateral moderately large pleural effusions and pulmonary edema. 2. Satisfactory position of right upper extremity peripherally inserted central venous catheter. [**4-6**]: AP CHEST COMPARED TO [**4-4**]: Moderate to large bilateral pleural effusion, has increased substantially since [**4-2**], but may not have changed significantly since [**4-4**], allowing for differences in patient positioning. Currently, the substantial pleural effusions obscure the lung bases, but the left is more radiopaque than the right either atelectasis or pneumonia. The heart is not enlarged, but the upper mediastinum is widened, due at least in part to distention of the mediastinal veins, but it also raises concern, given the appropriate clinical history of dilatation of the aorta. Close clinical evaluation is advised. Nasogastric tube passes into the stomach and out of view. A right PIC line ends in the mid to low SVC. [**4-7**] CXR: Moderate-to-large bilateral pleural effusion has improved slightly. There is no pneumothorax. On the left, rounded contour projecting to the left of the hilus is probably a fissural component of pleural fluid. On the right, a new oblique contour projecting over the right hilus is probably the right major fissure indicating nearly complete collapse of the right lung extending to the superior segment of the lower lobe. Heart size is normal. Azygous distension has improved suggesting either decreasing volume overload or central venous hypertension. Right PIC line ends in the low SVC. [**4-7**] CXR: FINDINGS: As compared to the previous radiograph, the patient has received a right thoracocentesis. The extent of the pleural effusion has markedly decreased. There is no safe evidence of pneumothorax. On the left, the appearance of the lung is unchanged. Borderline size of the cardiac silhouette. Unchanged opacities at the right lung base. Unchanged course and position of the right PICC line. [**4-10**] CXR: FINDINGS: As compared to the previous radiograph, the very extensive left pleural effusion, better visible on the lateral than on the frontal radiograph, appears unchanged. On the right, a small effusion obliterates the costophrenic sinus on today's examination. There are areas of both right and left atelectasis that are slightly more extensive than on the previous image. Unchanged size of the cardiac silhouette. Unchanged position of the right PICC line. The remaining lung parenchyma is unremarkable. [**4-11**] CXR: FINDINGS: As compared to the previous radiograph, there is no relevant change. The bilateral pleural effusions, left more than right and subsequent areas of atelectatic consolidations are unchanged. No newly appeared focal parenchymal opacities. No increase of pleural effusion. Unchanged size of the cardiac silhouette. [**4-11**] CT Torso: IMPRESSION: 1. No evidence of rectosigmoid anastomotic dehiscence. 2. Postoperative findings in the abdomen and pelvis as above. A moderate volume of ascites persists. 3. Bilateral pleural effusions with overlying atelectasis. Brief Hospital Course: Ms. [**Known lastname **] is a 55yo F Vietmanese-speaking woman w/hx of HCV (previously undetectable VL) and ovarian adenocarcinoma was electivley admitted for pre-op optimization and pain control prior to planned hysterectomy and salpingo-oopherectomy and tumor debulking. On [**2121-4-2**], she underwent hysterectomy, salpingo-oopherectomy, tumor debulking, rectosigmoid resection with reanastomosis, omentectomy, resection of 2 diaphragmatic nodules, ablation of tumor implants and liver biopsy. Please see OMR for further details. She received 3 units blood, 5 units FFP and 3 grams of albumin. Approximately 5L of ascites fluid was drained and she had 1L EBL. Intraop findings significant for extensive disease, optimally debulked. A hepatobiliary consult was requested intra-op for resection of diaphragmatic nodules and liver biopsy. She was transferred to the [**Hospital Unit Name 153**] for post-op monitoring. She remained stable and was able to be extubated on [**4-3**]. Chest Xrays were significant for bilateral pleural effusions. She did have significant pain issues w/nausea and vomiting, relieved somewhat by zofran and ativan. She was started on a dilaudid PCA with small doses of toradol. An acute pain consult was requested and they recommended continuation of IV meds rather than placement of regional anesthesia. Ancef and Keflex were given as prophylaxis. TPN was ordered but pt had low grade fever which initially delayed PICC; PICC placed on [**2121-4-4**]. Pt was stable and able to be transferred to the floor on [**4-4**]. On the floor, she did well. She was continued on the Dilaudid PCA. She did have some R flank pain and was given a lidocaine patch with good relief. The TPN was continued and daily electrolytes were followed. She was continued on prophylactic heparin, which was changed to lovenox on POD#10. The TPN was weaned and then stopped on POD#12. The NGT was removed on POD#5. She was tolerating a regular diet with return of normal bowel function on discharge. She was also tolerating PO pain medication at this time. She was discharged home with a foley catheter as she failed two voiding trials. She had been noted to have minimal pleural effusions on CXR from POD#0. On POD#4 she had a desaturation to 90% on RA; she was given 1L O2 by NC with O2 sat of 96%. An AP CXR was done with a final read of moderate to large bilateral pleural effusions. A repeat was done on [**4-7**] with PA and lateral views demonstrating near collapse of the bilateral bases. Interventional pulmonology was consulted and performed a thoracentesis on POD#5. 800cc was drained, and this fluid was positive for malignant cells. She received two doses of lasix following this procedure for a desaturation which resolved. An attempt was made to drain the left collection on [**4-11**] but was unsuccessful. Further attempts were not pursued as the patient was saturating well on room air throughout the remainder of her hospitalization. Ms. [**Known lastname **] had persistent intermittent fevers during her post-op course. Blood cultures were negative on multiple occasions. A urine culture on POD#4 was positive for E. Coli that was ESBL-resistant but sensitive to Macrobid. She was started on this and continued for 7 days. A repeat culture on POD#7 was negative. A CT of the torso was performed on POD#9; no anastamotic leak was identified and no abscesses were seen. Infectious diseases was consulted on [**4-12**]; they initially recommended empiric coverage with tigecycline given the previous urine culture data, but after further discussion the decision was made to continue observation. HIV was tested for and she was negative. The fevers ultimately resolved and were attributed to drug fevers, and by discharge she was afebrile for over 48 hours. Medications on Admission: Ibuprofen Prilosec 20mg PO daily Discharge Medications: 1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 2. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 5. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*1* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Ovarian Cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted and underwent a large surgery to remove your ovarian cancer. In this surgery we had to take a piece of your bowel and we also had to biopsy your liver. You have overall recovered very well, but were unable to void on your own. We had to replace your catheter. You will need to be seen in Dr. [**Name (NI) 89357**] office for a repeat trial of voiding. Your catheter should be removed by the visiting nurse on the morning of this appointment, and you will be seen that afternoon to make sure that you have voided and that the bladder is not too full. If you have any problems in the meantime, please call Dr.[**Name (NI) 89358**] office at [**Telephone/Fax (1) 5777**]. Your steri-strips will fall off on their own; it is ok to shower with them on. Do not place anything in your vagina for at least 6 weeks. No lifting anything heavier than 10 pounds. If you need to take narcotics, you may not drive. Please continue to take stool softeners. Try to avoid taking Ginseng when taking the narcotic pain medication (Dilaudid) as it may potentiate the effects of this drug (make it last too long or more strongly than desired) Followup Instructions: [**First Name8 (NamePattern2) 1446**] [**Last Name (NamePattern1) **] will see you next Thursday [**4-24**] at 2 pm for the trial of void. Your routine post-op appointment with Dr. [**Last Name (STitle) 5797**] will be scheduled at this time. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 33326**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 5777**] Date/Time:[**2121-4-24**] 2:00 You will also have an appointment next Thursday with Dr. [**Name (NI) 35352**] office at 4:30 pm. Please call [**Telephone/Fax (1) 18574**] with any questions. Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2121-5-1**] 3:30 Provider: [**Name10 (NameIs) 5145**] [**Name11 (NameIs) 5146**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 22**] Date/Time:[**2121-5-1**] 3:30 [**Name6 (MD) 35354**] [**Name8 (MD) **] MD [**MD Number(2) 65515**] Completed by:[**2121-4-22**]

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icd9cm

[ [ [] ] ]

[ "38.93", "99.15", "59.02", "54.4", "48.69", "50.23", "65.61", "34.91", "68.49", "34.81", "54.3", "50.12" ]

icd9pcs

[ [ [] ] ]

18044, 18101

13533, 17320

322, 548

18160, 18160

1540, 13510

19476, 20467

1297, 1341

17404, 18021

18122, 18139

17346, 17381

18311, 19453

1356, 1356

1370, 1521

268, 284

576, 1037

18175, 18287

1059, 1175

1191, 1281

4,588

188,320

43982

Discharge summary

report

Admission Date: [**2116-3-13**] Discharge Date: [**2116-3-18**] Date of Birth: [**2073-1-19**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 20146**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 43 yo M with A1A def considering future lung transplant, COPD on continuous 5L O2, IDDM, chronic pain on methadone, and recent L distal fib fx, presenting with 2 weeks of low grade fevers, increased dyspnea, and productive cough with green sputum, being admitted for likely COPD exacerbation. . Prior to EMS arrival he reports experiencing some abdominal pain and nausea, as well as mild dizziness. Vitals were found to be 97.8, 80, 83/54, 14, 100% on ?. He was given IV Zofran 4 and an IVF bolus, with improvement in BPs up to 90s and resolution of nausea. . On presentation to the ED VS were 98 123 121/75 34 100% ? 10L. He appeared dyspneic and was wheezing so treated with IV solumedrol and combivent nebs with subsequent improvement. CXR revealed a new 8 mm pulmonary nodule. D-dimer was 735. He went for CTA, which showed bronchiectasis and atelectasis, no PNA or PE. Nodule was not described in CTA prelim report. Vitals prior to transfer were 97.1 95 115/67 16 100% 4L. . On transfer to the floor he reports continued dyspnea, which is mildly improved. He feels very dry and thirsty, and is reporting decreased hearing in his R ear [**2-5**] clogged wax. He denies chest pain, abdominal pain, fevers or chills. . Review of systems: (+) Per HPI, + weight loss , night sweats (-) Denies headache, sinus tenderness, rhinorrhea. Denied chest pain or tightness, palpitations. Denied vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: - Alpha-1 antitrypsin deficiency on [**Month/Day (2) **] for 8 years (followed by Dr [**Last Name (STitle) 6174**] at [**Hospital1 112**]); portocath for [**Hospital1 **] infusions - Type 1 diabetes - COPD on home O2 (3L at rest, 4L with activity) - Hep C (Dr [**Last Name (STitle) **] at [**Hospital1 112**]), A1A def, h/o ETOH (he reports cirrhosis on liver bx in past at [**Hospital1 112**] although recent RUQ u/s reports normal liver echotexture and spleen 12cm) - Chronic back pain secondary to compression fractures - Hypogonadism - Osteoporosis - Chronic methadone therapy for his chronic pain - History of polysubstance abuse, currently not using any illicits - Anxiety/depression - Distal fibula fracture Social History: (per OMR, confirmed) Currently on disability; formally employed as a furniture mover.nLives with mother and her boyfriend. Admits to h/o EtOH abuse and IVDU, and has ~ 25-pack-year smoking history. Currently not using ETOH, tobacco, or drugs. Family History: (per OMR, confirmed) Father (died at 46 y/o of throat/mouth cancer) Grandfather (CA) Paternal Uncle (brain CA) Physical Exam: Physical Exam: VS: 97.5, 114/84, 97, 16, 98% on 4L GA: AOx3, NAD, cachetic male, poor eye contact [**Name (NI) 4459**]: [**Name (NI) 2994**]. MMM. no LAD. no JVD. neck supple. Cards: RRR S1/S2 heard. no murmurs/gallops/rubs. Pulm: diffuse fine crackles and expiratory wheezes Abd: soft, +BS, mild tender hepatomegaly, no g/rt. Extremities: wwp, no edema. DPs, PTs strong and symmetric. Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities. normal gait. . DISCHARGE EXAM: Pulm: diffuse insp fine crackles (worse at R base), no wheeze Pertinent Results: ADMISSION LABS: [**2116-3-13**] WBC-8.3 RBC-4.56* Hgb-14.6 Hct-42.0 MCV-92 MCH-31.9 MCHC-34.7 RDW-12.7 Plt Ct-190 Neuts-63.8 Lymphs-30.9 Monos-2.7 Eos-1.3 Baso-1.2 Glucose-434* UreaN-16 Creat-0.8 Na-131* K-4.6 Cl-89* HCO3-33* AnGap-14 Calcium-10.0 Phos-3.6 Mg-1.9 ALT-46* AST-54* AlkPhos-119 TotBili-0.3 D-Dimer-735* cTropnT-0.04* CK-MB-6 . [**2116-3-14**] CK-MB-6 cTropnT-0.03* . DISCHARGE LABS: [**2116-3-18**] -WBC-4.8 RBC-3.85* Hgb-12.1* Hct-35.4* MCV-92 MCH-31.5 MCHC-34.3 RDW-13.2 Plt Ct-117* -Glucose-339* UreaN-15 Creat-0.7 Na-136 K-4.5 Cl-96 HCO3-35* AnGap-10 . MICROBIOLOGY: -Urine culture final negative -Blood cultures pending, no growth to date . -[**2116-3-15**] Sputum: GRAM STAIN: <10 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. RESPIRATORY CULTURE (Preliminary): SPARSE GROWTH Commensal Respiratory Flora. STREPTOCOCCUS PNEUMONIAE. HEAVY GROWTH. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. . IMAGING: [**2116-3-13**] CXR: 1. Right upper lobe pulmonary nodule, recommend further evaluation with CT. 2. No acute cardiopulmonary process on a background of marked panlobular emphysema related alpha-1 antitrypsin deficiency. 3. Stable-appearing MediPort with its tip projecting over the cavoatrial junction. . [**2116-3-13**] CTA: 1. No evidence of pulmonary embolus. 2. No concerning pulmonary nodule seen. 3. Bilateral bronchial wall thickening with distal plugging in the right lower lobe in the region of similar disease on prior studies. This may suggest chronic infection/aspiration, but without gross consolidation. 4. Severe emphysema, with appearances both typical centrilobular emphysema and some accentuation at the bases consistent with alpha-1 antitrypsin deficiency related emphysema. Bibasilar atelectasis. Bibasilar mild bronchiectasis. 5. Few slightly prominent right hilar lymph nodes; however, nonspecific, could be reactive. 6. T7 and T9 compression fractures. Brief Hospital Course: 43 yo Man with Alpha-1 Antitrypsin deficiency, subsequent severe emphysema on home O2, IDDM, Osteoporosis, and chronic pain on methadone presenting with 2 weeks of increasing dyspnea and productive sputum consistent with COPD exacerbation. His course was complicated by a short MICU stay for better control of hyperglycemia in the setting of starting oral steroids. He improved and was discharged with close follow up. . # COPD EXACERBATION: Given initial presentation of dyspnea, worsening hypoxia, increased sputum production and underlying Alpha-1 Antitrypsin deficiency, the patient was started on Azithromycin, Prednisone, B2 agonists and anticholinergic nebulizers for suspected COPD exacerbation. He was provided Guaifenesin for cough and supplemental oxygen to maintain O2 sats above 90%. CXR was negative for focal opacity. CT chest with angio was obtained in the ED and was negative for pulmonary embolism or focal consolidation; however, there was bilateral bronchial wall thickening with distal plugging in the RLL suggesting chronic infection vs. aspiration. His sputum sample had heavy growth of Streptococcus Pneumoniae and his antibiotic regimen was switched to Levaquin. His outpatient [**Month/Day/Year **] (Dr. [**Last Name (STitle) 6174**] at [**Hospital1 112**]) was contact[**Name (NI) **] and agreed with our management plan. The patient improved symptomatically and returned to his baseline oxygen requirement of 3L via NC. He was able to ambulate with only mild dyspnea (baseline) and O2 saturations of 92%. He was discharged with prescriptions for 3 days of Levaquin 750 mg daily (to complete a 5 day course) and 3 days of Prednisone 10 mg daily (to complete a 10 day taper). He will follow up with both his Primary Care Physician and [**Name (NI) **] after discharge. . # HYPERGLYCEMIA: The patient has a history of Type 1 Diabetes Mellitus for which he follows with [**Last Name (un) **]. His last Hgb A1c was 12. He reported a recent history of weight loss, likely secondary to chronic disease and hypercatabolic state in the setting of poorly-controlled blood glucose levels. Once started on steroids for his COPD exacerbation his blood glucose levels became increasingly difficult to control. He required large amounts of Humalog and very frequent Nursing attention, so was transferred to the MICU for potential insulin gtt and close monitoring. He never developed an anion-gap acidosis or symptoms of DKA. His basal and sliding scale insulin regimen were adjusted and he was transferred back to the floor. [**Last Name (un) **] was consulted and provided recommendations regarding his insulin regimen. On discharge he was sent on Lantus 20 qhs and an aggressive sliding scale. He will have early follow up with [**Last Name (un) **] after discharge, including follow up with the [**Last Name (un) **] Psychiatrist to address his fears of over-insulinizing. . # PANCYTOPENIA: Unclear etiology. Cell lines appear to drop on the 3rd day of admission, possibly in response to volume resuscitation. Additionally, it is difficult to really pinpoint a baseline for all three of his cell lines based on the values in our OMR. He has many reasons to have a pancytopenia, including cirrhosis and an acute illness. Reticulocyte count and RPI revealed an inadequate bone marrow response. There was no evidence of hemolysis or active bleeding. This can be monitored in the outpatient setting by his Primary Care Physician. . # HYPONATREMIA: Hyponatremia initially thought to be secondary to hypovolemia, given that he clinically appeared dehydrated. He received about 3L of NS over his hospitalization. When taking into account his elevated blood glucose levels, his serum sodium was normal, supporting pseudohyponatremia. . # CHRONIC PAIN: Continued on outpatient regimen of Amitriptyline 50 mg PO/NG HS, Gabapentin 600 mg PO/NG Q8H, Methadone 20 mg PO/NG TID and 40 mg PO/NG QHS and Oxycodone 15 mg PO/NG Q6H:PRN breakthrough pain. . # ANXIETY/DEPRESSION: Continued on outpatient regimen of Mirtazapine 60 mg qhs, Zyprexa 5 mg qhs, and Clonazepam 0.5 mg PO/NG TID:PRN. . # OSTEOPOROSIS: T7 & T9 compression fractures seen on CTA. Received IV Reclast 5 mg on [**2115-6-6**]. Continued on Calcium carbonate 500 [**Hospital1 **] and Vitamin D 400 daily. Ergocalciferal was re-started on discharge. . # HYPOGONADISM: Was provided Testosterone 5 mg TD daily. Re-started on androgel on discharge. . # HYPOTHYROIDISM: Continued on outpatient Levothyroxine Sodium 150 mcg daily. . # LEFT DISTAL FIBULAR FRACTURE: Continued air cast and walking boot. Will follow up as needed with Orthopedics as outpatient. . # HLD: Continued Pravastatin 20 mg PO daily. . # GERD: Continued Omeprazole 20 mg PO BID. . # Social Work and [**Hospital1 **] were consulted during this admission. Patient felt that he had adequate support system and resources. . # Code Status: Full Code . To Do: -Follow up pending blood cultures and finalization of sputum culture -Assess current blood glucose control Medications on Admission: 1. Ketoconazole 2 % Topical Cream AAA face twice daily 2. mirtazapine 30 mg Tab 2 Tablet(s) by mouth at bedtime 3. Zyprexa 5 mg Tab 1 Tablet(s) by mouth at bedtime 4. calcium carbonate-vitamin D3 500 mg-125 unit Tab 1 Tablet(s) [**Hospital1 **] 5. Glucerna Oral Liquid 1 bottle by mouth three times a day 6. Lantus 7 units [**Hospital1 **] 7. Humalog sliding scale QID 8. Advair Diskus 500 mcg-50 mcg/Dose for Inhalation [**Hospital1 **] 9. Senna 8.6 mg Tab 1 Tablet(s) [**Hospital1 **] 10. Ergocalciferol (Vitamin D2) 50,000 unit weekly 11. Methadone 10 mg Tab [**2-7**] Tablet(s) by mouth once a day FOR PAIN Take 2 with meals and 4 in the evening prior to sleep.(10 per day) 12. Nystatin 100,000 unit/mL Oral Susp 1 teaspoon(s) TID 13. Pravastatin 20 mg Tab 1 Tablet(s) by mouth DAILY (Daily) 14. clonazepam 0.5 mg Tab 1-2 tabs daily 15. Albuterol Sulfate HFA 90 mcg/Actuation Aerosol Inhaler [**1-5**] HFA(s) inhaled every 4-6 hours as needed for shortness of breath or wheezing 16. Omeprazole 20 mg Cap, Delayed Release 1 Capsule(s) by mouth [**Hospital1 **] 17. AndroGel 1.25 g/Actuation (1%) Transdermal Gel Pump 4 pumps topically every morning after showering To replace Androderm patch 18. Desonide 0.05 % Topical Cream AAA face twice a day use for up to 2 weeks; then as needed 19. Amitriptyline 50 mg Tab 1 (one) Tablet(s) by mouth HS 20. Ciclopirox 0.77 % Topical Cream Apply to affected areas of soles of both feet twice a day as directed. 21. Colace 100 mg Cap 1 Capsule(s) by mouth once a day 22. Synthroid 150 mcg Tab 1 Tablet(s) by mouth each morning 23. Oxycodone 15 mg Tab [**1-5**] Tablet(s) by mouth up to four times a day as needed for as needed for break through pain 24. Gabapentin 600 mg Tab 1 (one) Tablet(s) by mouth three times a day 25. Terbinafine 1 % Topical Cream twice a day to feet/toes 26. Multivitamin Cap 27. [**Month/Day (2) **] 500 mg IV Susp 28. Ascensia Autodisc Test Strips Chck your sugars at least 7 times a day Discharge Medications: 1. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 days. Disp:*3 Tablet(s)* Refills:*0* 2. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. Disp:*3 Tablet(s)* Refills:*0* 3. ketoconazole 2 % Cream Sig: One (1) application Topical twice a day as needed for as needed for rash. 4. mirtazapine 30 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 5. olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. calcium carbonate-vitamin D3 500-125 mg-unit Tablet Sig: One (1) Tablet PO twice a day. 7. Glucerna Liquid Sig: One (1) bottle PO three times a day. 8. Advair Diskus 500-50 mcg/dose Disk with Device Sig: One (1) inhalation Inhalation twice a day. 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 11. methadone 10 mg Tablet Sig: 2-4 Tablets PO four times a day as needed for pain: Take 2 with meals and 4 in the evening prior to sleep (10 per day)]. 12. nystatin 100,000 unit/mL Suspension Sig: One (1) teaspoon PO three times a day as needed for [**Month/Day (2) 11395**]: swish and swallow. 13. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day as needed for anxiety: may take additional 1 tab PO daily PRN anxiety . 15. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**1-5**] inhaled Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 16. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 17. AndroGel 1.25 g/Actuation Gel in Metered-dose Pump Sig: One (1) application Transdermal once a day: 4 pumps topically every morning after showering To replace Androderm patch. 18. desonide 0.05 % Cream Sig: One (1) application Topical twice a day: AAA to face twice a day use for up to 2 weeks; then as needed. 19. amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): Call with any worsening of symptoms . 20. ciclopirox 0.77 % Cream Sig: One (1) application Topical twice a day: Apply to affected areas of soles of both feet twice a day as directed. 21. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once a day. 22. levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a day: Take in the morning on an empty stomach before eating.. 23. oxycodone 15 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for breakthrough pain. 24. gabapentin 600 mg Tablet Sig: One (1) Tablet PO three times a day. 25. terbinafine 1 % Cream Sig: One (1) application Topical twice a day: twice a day to feet/toes. 26. multivitamin Capsule Sig: One (1) Capsule PO once a day. 27. [**Name8 (MD) **] NP 500 mg Suspension for Reconstitution Sig: One (1) infusion Intravenous once a week. 28. insulin glargine 100 unit/mL Cartridge Sig: Twenty (20) units Subcutaneous at bedtime. 29. insulin aspart 100 unit/mL Solution Sig: as directed Subcutaneous four times a day: please follow sliding scale provided at discharge. This may change after you follow up with [**Last Name (un) **] on [**2116-3-24**]. Discharge Disposition: Home With Service Facility: [**Last Name (un) **] at Home VNA Discharge Diagnosis: Primary Diagnoses: chronic obstructive pulmonary disease exacerbation hyperglycemia dehydration pancytopenia . Secondary Diagnoses: insulin dependent diabetes mellitus anxiety depression chronic pain hypothyroidism hypogonadism osteoporosis left distal fibular fracture hyperlipidemia gastro-esophageal reflux disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 12226**], You were recently admitted to [**Hospital1 18**] Medicine Service for evaluation of your shortness of breath. We believe this is secondary to an acute inflammation of your chronic lung disease. We treated you with medications and you improved. While you were here your blood sugars were elevated, [**First Name8 (NamePattern2) **] [**Last Name (un) **] (the Diabetes specialists) came and provided recommendations regarding your insulin dosing. Please follow the scale we are providing you at discharge. You will need to follow up with your Primary Care Physician, [**Name10 (NameIs) **], and [**Last Name (un) **]. Please call your Primary Care Physician with any questions you have regarding your health. . We are making the following changes to your outpatient regimen: -Please START Levaquin 750 mg daily for 3 days (stop after [**2116-3-21**]) -Please START Prednisone 10 mg daily for 3 days (stop after [**2116-3-21**]) -Please INCREASE Lantus to 20 mg at night -Please follow the sliding scale provided for Humalog dosing . It was a pleasure taking care of you during this hospitalization Followup Instructions: Department: [**Hospital3 249**] When: [**Hospital3 **] [**2116-3-23**] at 9:20 AM With: Dr. [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**] Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Central [**Hospital **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor in follow up. . Department: PSYCHIATRY When: [**Name10 (NameIs) **] [**2116-3-23**] at 10:30 AM With: [**First Name8 (NamePattern2) 8081**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1387**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 551**] Campus: EAST Best Parking: Main Garage . Department: [**Hospital3 249**] When: [**Hospital3 **] [**2116-3-23**] at 12:00 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 36070**], [**Last Name (NamePattern1) 1046**] [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7280**] Location: [**Last Name (un) **] Diabetes Center Address: [**Last Name (un) 3911**], [**Location (un) 86**] [**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2378**] Appointment: Tuesday [**2116-3-24**] 3:30 . Name: [**Last Name (LF) **],[**Name8 (MD) **] M.D. Location: [**Hospital6 **] Address: [**Doctor First Name **], [**Location (un) **],[**Numeric Identifier 6425**] Phone: [**Telephone/Fax (1) 94453**] Appointment: [**Telephone/Fax (1) 766**] [**2116-4-6**] 11:30am

[ "733.16", "491.21", "V13.51", "250.03", "272.4", "380.4", "530.81", "276.1", "338.4", "284.1", "244.9", "300.4", "257.2", "273.4", "824.8", "733.00", "070.54" ]

icd9cm

[ [ [] ] ]

[ "96.52" ]

icd9pcs

[ [ [] ] ]

15810, 15874

5595, 10590

326, 332

16236, 16236

3596, 3596

17545, 19495

2904, 3016

12596, 15787

15895, 16006

10616, 12573

16387, 17522

3993, 4408

3046, 3497

16027, 16215

3513, 3577

4443, 5572

1600, 1889

266, 288

360, 1581

3612, 3977

16251, 16363

1911, 2627

2643, 2888

3,395

134,416

54318

Discharge summary

report

Admission Date: [**2116-8-10**] Discharge Date: [**2116-8-17**] Date of Birth: [**2058-4-18**] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is s a 58 year old priest who presented with multiple risk factors for coronary artery disease, hypertension, diabetes mellitus, high cholesterol, positive smoking, positive family history, who had two episodes of chest pain at rest and was admitted to the hospital. Cardiac catheterization showed multiple stenoses and he was taken to the operating room. PHYSICAL EXAMINATION: His heart rate was 75 beats per minute, normal sinus rhythm, blood pressure 124/82, afebrile. He is markedly obese. His lungs were clear. His heart was regular rate and rhythm, no murmurs, rubs or gallops. The abdomen was soft, nontender, nondistended with no hepatosplenomegaly. Extremities were warm and well perfused with good pulses. PAST MEDICAL HISTORY: 1. Mild emphysema. 2. Gastroesophageal reflux disease. 3. Mild depression. 4. Hypertension. 5. Diabetes mellitus. 6. Status post appendectomy. ALLERGIES: He had no known drug allergies. MEDICATIONS ON ADMISSION: 1. Aspirin 81 mg p.o. once daily. 2. Nifedipine 90 mg p.o. once daily. 3. Prinivil 10 mg p.o. once daily. 4. Zocor 40 mg p.o. once daily. 5. Prilosec 20 mg p.o. once daily. 6. Celexa 40 mg p.o. once daily. LABORATORY DATA: White blood cell count 14.5, hematocrit 47.2, platelet count 415,000. Potassium 3.7, blood urea nitrogen 19, creatinine 0.7. INR 1.1. HOSPITAL COURSE: The patient was taken to the operating room where he had a coronary artery bypass graft performed times three using left internal mammary artery and saphenous vein grafting. The patient did well postoperatively and he was taken to the Intensive Care Unit. He continued along with protocol and did well. His chest tube was removed, and his wires were removed. He was put on Levofloxacin for possible infection. Culture were negative. The patient was extubated and transferred to the floor. Foley was taken out. The patient did well on the floor. Physical therapy evaluation consultation was obtained and he did well. Physical therapy took him through stairs and he continued to do well. His oxygen saturation was slightly low, and he was given supporting oxygen, however, he was found to be relatively stable at 90 to 91% in room air. The patient was discharged home after clearance from physical therapy in stable condition and instructed to follow-up in one to two weeks with his primary care physician. [**Name10 (NameIs) **] patient was discharged home in stable condition. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern4) **] MEDQUIST36 D: [**2116-8-17**] 10:05 T: [**2116-8-22**] 14:19 JOB#: [**Job Number 111267**]

[ "272.4", "401.9", "E878.2", "278.00", "414.01", "250.00", "V15.82", "411.1", "998.12" ]

icd9cm

[ [ [] ] ]

[ "39.61", "36.15", "88.53", "88.56", "37.22", "36.12" ]

icd9pcs

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1128, 1496

1514, 2865

542, 885

156, 519

907, 1102

69,537

122,775

38354

Discharge summary

report

Admission Date: [**2147-4-8**] Discharge Date: [**2147-4-16**] Date of Birth: [**2069-5-24**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: Episodes of Speech difficulty (dysarthria and non-fluency) and left arm numbness Major Surgical or Invasive Procedure: -[**2147-4-11**] Cerebral Angiogram -[**2147-4-14**] NeuroIntervnetional Embolization of Right Parietal AVM History of Present Illness: The pt is a 77yo RH male with PMHx of HTN, HL and NIDDM who presents because of 2 episodes of L arm numbness with L facial droop and 1 episode of slurred speech. The patient was at his baseline until Wednesday [**4-5**], when at noon her was at his grandson's lacrosse game when he noticed the onset of L hand numbness over seconds. He felt that the numbness was mostly in his 4th and 5th digit, and that it didn't feel like tingling, but rather "it was dead". He rubbed his hand and the sensation didn't go away. Within 30 seconds he noticed that his L face was drooping also and he also had a numbness sensation around his mouth on the left side "that felt like novocaine". He felt that his speech was normal and that he could produce and comprehend speech without difficulty and without slurring of his words. His wife drove him to [**Hospital3 **] where he was admitted and had an EKG notable for afib with RBBB, an unremarkable NCHCT but a CTA that showed a likely pial AV fistula in the R parietal [**Hospital3 3630**] measuring ~ 4.5cm. He was discharged home on [**4-7**] with plans to be seen as an outpatient in their neurology clinic. However, pt went home, ate pancakes, had coffee, but at around 6:30pm (~1hr after arriving home) he again noted numbness in his L hand, mostly the 4th and 5gh digits. He again had almost immediate L facial drooping with L facial numbness most notable around his mouth in addition to some mildly slurred speech. He reports that he had no difficulty with speech production or comprehension and was answering questions appropriately, but his speech was just "slurred". No associated weakness/tingling/HA/visual sx. He was then taken back to [**Hospital1 **], where they immediately sent him to [**Hospital1 18**] as they felt he needed to see neurosurgery. While here in the [**Name (NI) **] pt reported that while the slurred speech improved over the course of 45 mins since onset (but hasn't entirely gone away), the hand and face numbness has not gone away and only very mildly improved. He was initially evaluated by neurosurgery in the ED who felt that his presentation could be c/w TIAs rather than the AV fistula in his R parietal [**Last Name (LF) 3630**], [**First Name3 (LF) **] neurology was called to evaluate the patient further. On neuro ROS, the pt reports L hand and L face numbness. Denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: - HTN (average BP 160's) - HL - NIDDM - ? silent MI (pt had a cardiac stress test "many years ago" for chronic chest pain and palpitation, that was suggestive of a prior MI) - glaucoma - cataracts s/p surgery bilaterally Social History: Lives with wife, has 2 kids, smoked a ppd x40 yrs in addition to cigars and pipes, quit 20 years ago, denies EtOH or illicits. Is a part time hairdresser, was last full time 15 years ago. Family History: Mother died of CHF at age 64, dad died from stomach ca at 80, sister died of lung ca (smoker) at 70, no hx of strokes, blood clots or AVMs Physical Exam: ********** Physical Exam On Admission Vitals: T: 97.7 P: 70 R: 18 BP: 166/90 SaO2: 98% on RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to 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 [**1-20**] 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: pupils post-surgical bilaterally. VFF to confrontation. Funduscopic exam chronic changes c/w known glaucoma. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch and PP on R side, but decreased to LT and PP on the L forehead, cheek and chin in a V1, V2 and V3 distribution. 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. 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: Decreased PP in the L face, L arm and L leg, but not L torso. Decreased cold sensation to the knees bilaterally. Otherwise, no deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 1 0 R 2 2 2 1 0 Plantar response was flexor on the R and extensor on the L. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. Narrow-based, normal stride and arm swing, but unsteady on feet and stumbled when turning. Unable to walk in tandem without significant difficulty. Romberg positive for sway. . ***** On Discharge: Mental Status: Alert, Oritented, fluent speech, no paraphasic errors, able to name several objects without any anomia Cranial Nerves; VFFTC, face symmetric, no dysarthria Strength: full throughout Sensation: - pinprick sensation 100% on RUE and decreased by 50% in lateral aspect of left forearm (otherwise intact), decreased pinrpick (75%) in left face V2-V3 distribtuion (otherwise intact in face bilaterally); intact in lower extremities bilaterally - temperature sensation 100% on right upper extremity and decreased by 50% in the lateral aspect of the left forearm (otherwise intact); intact in the lower extremities and face - vibration sense intact bilaterally at the great toes and index finger - propriception intact bilaterally at the great toes and index finger Pertinent Results: LABS ON ADMISSION: [**2147-4-8**] 09:00AM BLOOD WBC-8.3 RBC-5.13 Hgb-15.7 Hct-47.9 MCV-93 MCH-30.5 MCHC-32.7 RDW-13.6 Plt Ct-257 [**2147-4-8**] 09:00AM BLOOD PT-10.7 PTT-28.7 INR(PT)-1.0 [**2147-4-8**] 09:00AM BLOOD Glucose-167* UreaN-10 Creat-0.9 Na-146* K-3.9 Cl-105 HCO3-31 AnGap-14 [**2147-4-8**] 09:00AM BLOOD ALT-21 AST-23 LD(LDH)-211 CK(CPK)-83 AlkPhos-84 TotBili-0.6 [**2147-4-8**] 09:00AM BLOOD Albumin-4.5 Calcium-9.7 Phos-4.0 Mg-2.0 Cholest-152 . STROKE RISK FACTOR ASSESSMENT: [**2147-4-8**] 09:00AM BLOOD Triglyc-129 HDL-52 CHOL/HD-2.9 LDLcalc-74 [**2147-4-8**] 09:00AM BLOOD %HbA1c-7.2* eAG-160* [**2147-4-8**] 09:00AM BLOOD TSH-2.3 . CARDIAC ENZYMES: [**2147-4-8**] 09:00AM BLOOD CK-MB-1 cTropnT-<0.01 . [**2147-4-8**] EEG: FINDINGS: ROUTINE SAMPLING: The background activity showed a symmetric 10 Hz alpha rhythm which attenuated with eye opening. SPIKE DETECTION PROGRAMS: There were 91 automated spike detections predominantly for electrode and movement artifact. There were no epileptiform discharges. SEIZURE DETECTION PROGRAMS: There was one automated seizure detection for electrode artifact. There were no electrographic seizures. PUSHBUTTON ACTIVATIONS: There were no pushbutton activations. SLEEP: The patient progressed from wakefulness to stage II, then slow wave sleep at appropriate times with no additional findings. CARDIAC MONITOR: Showed an irregularly irregular rhythm with an average rate of 85-90 bpm. IMPRESSION: This is a normal video EEG monitoring session with no pushbutton activations. Background activity was normal. There were no epileptiform discharges or electrographic seizures. A note was made of an irregularly irregular heart rhythm. . [**2147-4-8**] MRI HEAD: FINDINGS: There is no focus of slow diffusion in the brain parenchyma to suggest an acute infarct. Subtle increased signal intensity along the cortex in the parietal lobes on both sides is likely artifactual related to the interface between the brain and the bone. . There are several FLAIR hyperintense foci, in the periventricular and subcortical locations in the frontal and the parietal lobes, likely related to small vessel ischemic changes. There is moderate dilation of the lateral and the third ventricles along with a prominent cerebral aqueduct. This may relate to central parenchymal volume loss with or without a component of communicating hydrocephalus such as NPH. The bifrontal diameter at the level of the foramen of [**Last Name (un) 2044**], measures 3.5 cm. Bowing of the corpus callosum upward is noted. . The cerebral aqueduct is better seen on the prior CT angiogram sagittal reformations with ? minimal narrowing inferiorly. Foci of negative susceptibility are noted in the bilateral basal ganglia, left more than right, which may relate to mineralization. Left vertebral artery is dominant and indents the left side of the cervicomedullary junction. The right is diminutive in size. The major intracranial arteries and the known AV fistula/AVM, in the right parietal [**Last Name (un) 3630**] are better assessed on the prior CT angiogram study. . The ocular lenses are not seen. There is mild mucosal thickening in the ethmoid air cells on both sides. . IMPRESSION: 1. No focus of slow diffusion to suggest an acute infarct. 2. Mild to moderately dilated lateral ventricles and prominent third ventricle and cerebral aqueduct, which may relate to central parenchymal volume loss, with or without a component of normal pressure hydrocephalus/ minimal aqueductal narrowing. Correlate clinically. 3. Please see the prior CT angiogram study for evaluation of the major intracranial arteries and the known right parietal [**Last Name (un) 3630**] AVM/AV fistula. . [**2147-4-9**] EEG: ROUTINE SAMPLING: The background activity showed a symmetric 9.5-10 Hz alpha rhythm which attenuated with eye opening. SPIKE DETECTION PROGRAMS: There were no automated spike detections. SEIZURE DETECTION PROGRAMS: There was one automated seizure detection for movement artifact. There were no electrographic seizures. PUSHBUTTON ACTIVATIONS: There were no pushbutton activations. SLEEP: The patient progressed from wakefulness to stage II, then slow wave sleep at appropriate times with no additional findings. CARDIAC MONITOR: Showed an irregularly irregular rhythm with an average rate of 70 bpm. IMPRESSION: This is a normal video EEG monitoring session with no pushbutton activation. Background activity was normal. There were no epileptiform discharges or electrographic seizures. A note was made of an irregularly irregular cardiac rhythm. . [**2147-4-10**] TTE: The left atrium is mildly dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. The estimated right atrial pressure is 5-10 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 root is mildly dilated at the sinus level. The descending thoracic aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild to moderate ([**12-19**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . IMPRESSION: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Mild-moderate mitral regurgitation. Mild pulmonary artery hypertension. Dilated aorta.. . [**2147-4-11**] CEREBRAL ANGIOGRAM: PROCEDURE PERFORMED: Left vertebral artery arteriogram, left external carotid artery arteriogram, left internal carotid artery arteriogram, right external carotid artery arteriogram, right internal carotid artery arteriogram, right common femoral artery arteriogram. . Anesthesia was moderate. Sedation was provided by administering divided doses of fentanyl and Versed throughout the total intraservice time of 54 minutes during which the patient's hemodynamic parameters were continuously monitored. . INDICATION: The patient had presented with a dural AV fistula and I had performed this procedure in order to diagnose and possibly treat this. . DETAILS OF PROCEDURE: The patient was brought to the angiography suite. IV sedation was given. Following this, both groins were prepped and draped in a sterile fashion. Access was gained to the right common femoral artery using a Seldinger technique and a 5 French vascular sheath was placed in the right common femoral artery. We now catheterized the above-mentioned vessels and AP, lateral filming was done. This revealed that an arteriovenous fistula fed by both middle meningeal arteries with draining veins primarily in the right sensory motor area and draining down into the sylvian fissure. . Right common femoral artery arteriogram was done and manual compression applied for closure of the right common femoral artery puncture site. . FINDINGS: Left internal carotid artery arteriogram shows filling of the left internal carotid artery along the cervical, petrous, cavernous and supraclinoid portion. Both anterior and middle cerebral arteries are seen well. There is no evidence of supply to the fistula. . Left external carotid artery arteriogram shows supply to the dural AV fistula from the left middle meningeal artery and drainage into the right cortical veins. . Right external carotid artery arteriogram shows filling of the right middle meningeal artery which is predominantly supplied to fistula with drainage into the cortical vein which eventually drains through a single vein down into the sensory motor area. Right external carotid artery arteriogram also demonstrates minimal filling from the right occipital artery. . The right internal carotid artery arteriogram shows no evidence of supply to the AV fistula. . Left vertebral artery arteriogram shows filling of the left vertebral artery with a prominent PCA on the left side. The PCA on the right is hypoplastic. . Right vertebral artery arteriogram again demonstrates right vertebral artery arteriogram again demonstrates filling of the basilar artery and the PCAs with no evidence of supply to the AV fistula. . [**First Name8 (NamePattern2) **] [**Known lastname **] underwent cerebral angiography which revealed a dural AV fistula in the midline frontoparietal area primarily fed by the middle meningeal arteries with some supply from the left occipital artery. The d raining vein is predominantly cortical draining into the sensory motor area. . LABS AT TIME OF DISCHARGE: Brief Hospital Course: Mr. [**Known lastname **] 77 y.o. RH male with PMHx of HTN, HL and NIDDM who presented because of 2 episodes of L arm numbness with L facial droop and 1 episode of slurred speech. #Right Parietal Arterio-Venous Malformation: Patient initially had a neurological exam which revealed fluctating L sided numbness and mild dysarthria concerning for an ongoing process in the R hemisphere. Seizure (secondary to an AVM previously noted on imaging) was on the differential as the patient had 2 episodes while in the hospital with left hemisensory loss, transient dysarthria and word-finding difficulties. These episodes only lasted about 5 minutes in duration. The patient was monitored with a continuous EEG for 48 hours but no epiliptiform activity was recorded (of note he did not have any of these presenting episodes while on monitoring). He initially was started on Keppra 1000mg [**Hospital1 **] but had increased drowsiness with this and was brought down to 750 [**Hospital1 **]. He tolerated this well and did not have any other episodes while in the hospital. . Other imaging obtained included an MRI (see full report above) which did not show any signs of acute infart. The patient had his stroke risk factors evaluated and was noted that his Hba1c 7.2% , LDL 74. We continued him on his home dose statin, and have recommended uptitration of his metformin with PCP on [**Name9 (PRE) 85433**] basis for better control of blood sugars. The patient had a TTE performed without evidence of PFO/ASD and normal EF (see full report above). . Of note the patient on a previous CTA from OSH had a R parietal AVM. The Neurosurgical team performed a cerebral angiogram on [**2147-4-11**] with demonstrated a right parietal AV fistula with middle meningeal artery with pial drainage, which was noted to put the patient at an increased risk for intracranial bleed. The patient was taken by Neurosurgery for an AVM embolization on [**2147-4-14**], and he tolerated the procedure well. The patient's symptoms (dysarthria, word-finding difficulties, left-sided numbness) were though to to be secondary to his AVM and significant associated venous congestion (rather than seizure). We therefore decided to stop his Keppra. The patient will have a f/u MRI/MRA in 4 weeks and will have a follow-up appointment with Dr. [**First Name (STitle) **] of NSurg and Dr. [**First Name (STitle) **] of Neurology. . #Atrial Fibrillation: Patient has new onset atrial fibrillation (never had previous episodes documented before). His CHADS2 score is 3, so patient was deemed a good candidate for anticoagulation. Unfortunately as he has a known right parietal AVM that it is at increased risk of bleed, so his anticoagulation was deferred initially. He was continued on a baby aspirin prior to his Neurosurgical intervention. The patient was monitored on continuous telemetry without any significant adverse events. Patient also had his cardiac enzymes evaluated which were negative. The patient went for embolization of his dural AVM on [**2147-4-14**]. Afterwards he was started on ASA 325 and coumadin (his last INR was 1.1 on day of discharge). He will take the ASA 325 until he is therapeutic on his coumadin (goal INR [**1-20**]) for at least 24 hours. The antiocoagulation is to be monitored by his PCP. . #Hypertension: Patient had his home BP meds held initally for the first day of being in the hospital as there was concern for an ischemic event. He was restarted on his home amlodipine, and atenolol and tolerated this well with good control of his blood pressure. . #Hyperlipidemia: Patient had LDL of 74, he was continued on his home dose of statin. . #Diabetes Mellitus Type II: Hba1c 7.2%, patient on metformin 500BID at home. This was held during the hospital stay, and he was placed on a RISS with good control He will likely need uptitration of his metformin on an outpatient basis. . TRANSITIONAL ISSUES: 1) Follow-up with PCP (scheudled day after discharge) re: coumaadin and diabetes management 2) Patient started on Coumadin prior to discharge, INR was subtherapeutic. Will take ASA 325 until he is thereapeutic (INR [**1-20**]) on his coumadin. 3) Follow-up with Dr. [**First Name (STitle) **] of Neurology 4) Follow-up with Dr. [**First Name (STitle) **] of Neurosurgery in about 4 weeks after having MRI/MRA perforemd at 4 weeks Medications on Admission: - amlodipine 10mg QD - ASA 81mg QD - atenolol 25mg QD - lovastatin 20mg QHS - metformin 500mg [**Hospital1 **] - niacin 500mg [**Hospital1 **] - fish oil 1,000mg QD - travatan eye drops 1gtt QHS both eyes Discharge Medications: 1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 3. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. lovastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 5. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 6. travoprost 0.004 % Drops Sig: One (1) drop Ophthalmic QHS (once a day (at bedtime)): 1 drop in each eye at bedtime. 7. niacin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a day. 9. warfarin 1 mg Tablet Sig: Five (5) Tablet PO once a day: to be taken at 4pm daily. Do not drink alcohol while taking. dosage will be changed by your primary care provider. [**Name Initial (NameIs) **]:*70 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Dural Arterio-Venous Malformation (Right parietal area), Atrial Fibrillation Secondary Diagnosis: Diabetes Mellitus Type II, Hypertension, Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. . Neuro Exam at time of Discharge: Mental Status: Alert, Oritented, fluent speech, no paraphasic errors, able to name several objects without any anomia Cranial Nerves; VFFTC, face symmetric, no dysarthria Strength: full throughout Sensation: - pinprick sensation 100% on RUE and decreased by 50% in lateral aspect of left forearm (otherwise intact), decreased pinrpick (75%) in left face V2-V3 distribtuion (otherwise intact in face bilaterally); intact in lower extremities bilaterally - temperature sensation 100% on right upper extremity and decreased by 50% in the lateral aspect of the left forearm (otherwise intact); intact in the lower extremities and face - vibration sense intact bilaterally at the great toes and index finger - propriception intact bilaterally at the great toes and index finger Discharge Instructions: Dear Mr. [**Known lastname **], . It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted with recurrent episodes of speech difficulties and numbness on the left arm. We performed some imaging of your head and did not see any signs of a stroke. In addition we performed electrical studies of the brain, which showed no clear signs of seizure activity(although you did not have episodes of symptoms while you were connected to the EEG monitoring). Importantly, your previous imaging from the outside hospital had identified a malformation in the blood vessels in your brain known as an AVM (Arterio-Venous Malformation). This is likely to have caused some congestion and back pressure in the veins draining the right side of the brain. We think the secondary effects of this "back pressure" phenomenon most likely account for the symptoms that brought you to the hospital. . Neurosurgery performed a procedure to treat your arterio-venous malformation (known as an embolization), and you tolerated this procedure well. You subsequently shared that your speech has returned to baseline and you have had no more epiosdes of sensory disturbance. . Due to your underlying heart rhthym abnormarlity, you are at an increased risk for stroke. Your irregular heart beat is known as Atrial Fibrillation. Due to your increase risked of having a clot form in the heart and go to the brain, we are recommending that you take a blood thinning medication known as Coumadin (warfarin). This medication causes your blood to be thin which can be measured by a simple blood test known as an INR. The INR gives us a good idea of how thin the blood is, and your blood will be need to be tested frequently to make sure it is within range (your goal INR will be between [**1-20**]). Before you reach that range, it will be important for you to take Aspirin 325mg one tablet daily. The aspirin can be discontinued after the INR has been in the 2-3 range for at least 24 hours. . The blood thinning medication known as Coumadin interacts with several other mediations and can be affected by your diet. For example, green vegetables such as spinach with a lot of Vitamin K can make the coumadin less effective. Also, there are certain medications such as antibiotics that can also affect the blood thinning compenent and change your INR. Therefore it is imperative that you talk with your primary care provider before starting any new medications while on the coumadin. In addition to this, alcohol also affects the coumadin, so you should be particularly careful to avoid alcohol while taking coumadin. . We will work to contact your primary care provider [**Name Initial (PRE) 503**] ([**4-17**]) in order to setup the next time for you to get your blood drawn and your INR checked. . We assessed your stroke risk factors, and found that your cholesterol in a good range, but your blood sugars have not been well controlled. Your hemoglobin A1c (a marker of your average blood sugars over the past 3 months was eleavetd at 7.2%). Therefore, we are recommending that you talk to your primary care provider about increasing your metformin medication, or considering other treatments to help control your blood sugars. . Also, Neurosurgery would like for you to have a repeat scan of your head and its vessels(MRI/A). We have put in an order for this, but you will need to call to setup your appointment tomorrow. The number is: [**Telephone/Fax (1) 590**]. Both the neurosurgeon, Dr. [**First Name (STitle) **], and the neurologist, Dr. [**First Name (STitle) **], would like to meet with you over the next few months. We have been able to schedule some follow-up appointments for you, please see below. . We made the following changes to your medications: -CHANGE Aspirin to 325mg tablet, take one tablet by mouth daily until your blood is thin enough on the coumadin (goal INR [**1-20**]) -START Coumadin (warfarin) take 5mg (five 1mg tablets) by mouth daily at 4pm (your blood levels will need to be checked with a lab known as INR and your goal INR is [**1-20**]) Followup Instructions: Please call [**Telephone/Fax (1) 590**] tomorrow to schedule the MRI/A of the head with and without contrast for a time in four weeks from now. . Also, please call to setup an appointment with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] (Neurosurgery). You can schedule the appointment for a date that is after your MRI scan. The number for his office is: ([**Telephone/Fax (1) 85434**] . --Please discuss with your primary care provider better blood sugar control with your metformin as well as your blood thinning medication-- Department: [**Hospital1 18**] [**Location (un) 2352**] When: MONDAY [**2147-4-17**] at 8:10 AM With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1144**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site . Please meet with Dr. [**First Name (STitle) **]: Department: NEUROLOGY When: TUESDAY [**2147-5-30**] at 10:30 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**] Building: [**Hospital6 29**] [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "88.41", "39.72" ]

icd9pcs

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Discharge summary

report+addendum

Admission Date: [**2135-6-30**] Discharge Date: [**2135-7-7**] Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamides) / Calcitonin Attending:[**First Name3 (LF) 2704**] Chief Complaint: CC: Chest pain Major Surgical or Invasive Procedure: Cardiac Catheterization with stent placement in the RCA [**2135-6-30**] History of Present Illness: HPI: The patient is an 85 year old caucasian female with a history of angina, CHF and hypertension who who awoke at approximately 4 AM ([**2135-6-30**]) with intense chest pain with radiation to bilateral arms, associated with nausea and presyncope. She had one episode of heaving and emesis of saliva. Patient took [**1-20**] SL nitroglycerins and 2 baby Aspirins, pain persisted and she called EMS. Vitals at that time were HR 81 BP 150/90 RR 22 O2 sat 94%.En route to Joradan she was given an additional 1 SL nitroglycerine tab. She was transferred to [**Hospital3 **] where she was given 2 Aspirins and 4mg morphine with relief of pain. An EKG was done that showed 2mm inferior ST elevation in 2,3, AVF, (trop I 0.827.) She was given a bolus of aggrastat (14 mL) and heparin (2800 bolus then 900 drip) and transferred to [**Hospital1 **] for urgent catheterization. She had a cardiac catheterization at [**Hospital1 **] which showed: A right dominant system LMCA: mild diffuse disease LAD: minimal disease Lcx: minimal disease RCA: 70 % mid followed by total occlusion with LCA collaterals The RCA was crossed and dilated and stented with cypher stents; very distal cutoff of small pda and pl branches was noted. A cardiac output of 4.59 and cardiac index of 3.06 was also noted. . Immediately post reperfusion she had marked bradycardia and hypotension responding to atropine and dopamine. At the end of the catheterization she was in stable sinus rhythm with SBP about 100 on 2.5 dopamine. She was brought up to the floor with a dopamine drip. Pressures were stable. Dopamine was weaned to off. Pt then had an episode of hematemsis of ~[**12-19**] liter bright red blood. Aggrastat and heparin was stopped. She was transfused 2 units PRBCs and blood pressures remained stable. She reports a history of hemoptysis with a "bleeding ulcer" in past. Past Medical History: PMH: s/p hysterectomy, HTN, CHF Chronic stable angina History of "stomach ulcers Social History: SH: Patient lives alone in Ducksbury. Recent PCP change, notes has not seen assigned PCP at [**Hospital6 **]. From notes, appears she smoked [**12-19**] ppd and quit 1 mo ago Family History: FH: Noncontributory Physical Exam: PE: VS: T93, BP 117/52, P77r. SpO2 100% on 2LNC Gen: Alert, overweight female in no distress. Patient somewhat upset and refuses to provide additional medical details. CV: reg rate, nl S1 S2, no S3 / S4 on auscultation, no murmurs, no JVP noted Lungs: Crackles in lungs bilaterally Abd: NT/ND/hypoactive BS Ext: No C/C/E Pertinent Results: [**2135-6-30**] 12:19PM BLOOD WBC-11.5* RBC-4.05* Hgb-8.0* Hct-28.9* MCV-71* MCH-19.7* MCHC-27.6* RDW-15.5 Plt Ct-454* [**2135-7-1**] 04:02AM BLOOD WBC-9.1 RBC-3.69* Hgb-8.9* Hct-28.6* MCV-78* MCH-24.0* MCHC-30.9* RDW-17.7* Plt Ct-278 [**2135-7-3**] 06:40AM BLOOD WBC-8.8 RBC-4.43 Hgb-10.4* Hct-34.9* MCV-79* MCH-23.4* MCHC-29.7* RDW-18.7* Plt Ct-263 [**2135-7-5**]: wbc 8.4 hgb 10.5* hct 35.3 plt ct 321 [**2135-6-30**] 02:59PM BLOOD Neuts-86* Bands-0 Lymphs-8* Monos-6 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2135-7-3**] 06:40AM BLOOD Plt Ct-263 [**2135-7-2**] 06:30AM BLOOD PT-11.8 PTT-22.6 INR(PT)-0.9 [**2135-6-30**] 12:19PM BLOOD PT-13.0 PTT-73.4* INR(PT)-1.1 [**2135-6-30**] 12:19PM BLOOD Glucose-136* UreaN-18 Creat-0.9 Na-140 K-4.4 Cl-105 HCO3-28 AnGap-11 [**2135-7-1**] 04:02AM BLOOD Glucose-136* UreaN-19 Creat-0.7 Na-140 K-3.9 Cl-106 HCO3-29 AnGap-9 [**2135-7-3**] 06:40AM BLOOD Glucose-77 UreaN-8 Creat-0.7 Na-141 K-3.8 Cl-101 HCO3-29 AnGap-15 [**2135-7-1**] 04:02AM BLOOD ALT-16 AST-51* LD(LDH)-300* CK(CPK)-341* AlkPhos-84 TotBili-0.3 [**2135-6-30**] 07:39PM BLOOD CK(CPK)-647* [**2135-6-30**] 12:19PM BLOOD CK(CPK)-437* [**2135-7-1**] 04:02AM BLOOD CK-MB-47* MB Indx-13.8* cTropnT-1.25* [**2135-6-30**] 07:39PM BLOOD CK-MB-103* MB Indx-15.9* [**2135-6-30**] 12:19PM BLOOD CK-MB-77* MB Indx-17.6* cTropnT-1.39* [**2135-6-30**] 12:43PM BLOOD Type-ART pO2-84* pCO2-61* pH-7.28* calHCO3-30 Base XS-0 [**2135-6-30**] 11:04AM BLOOD Type-ART O2 Flow-2 pO2-123* pCO2-65* pH-7.28* calHCO3-32* Base XS-2 Intubat-NOT INTUBA . [**2135-7-6**]: Femoral artery u/s for bruit: No pseudoaneurysm or AV fistula was seen. Atherosclerotic calcifications were noted in the right femoral artery. . [**2135-7-4**] chest CT: 1. Severe emphysema. 2. Extensive asbestos-related pleural plaque and thickening. No evidence of pulmonary fibrosis or interstitial lung disease. 3. Bronchiectasis in both lower lobes and the right middle lobe. 4. Mild mediastinal lymphadenopathy. In the absence of known malignancy, this is likely of no clinical significance. 5. Air fluid level in the esophagus suggests dysmotility or a distal stricture. 6. Non-obstructing 5 mm stone in the upper pole of right kidney. . [**2135-7-3**] Chest x-ray: IMPRESSION: No acute infiltrates or congestive heart failure. Numerous calcified pleural plaques. . [**2135-7-1**] echo: Conclusions: 1. The left atrium is normal in size. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Resting regional wall motion abnormalities include basal and mid inferior hypokinesis. 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. 5.The mitral valve leaflets are structurally normal. Moderate (2+) mitral regurgitation is seen. 6. There is mild pulmonary artery systolic hypertension. 7.There is no pericardial effusion. . Cardiac Cath ([**2135-6-30**]): 1. Coronary angiography of this right dominant system revealed one (1) vessel coronary artery disease. The Left main showed mild diffuse disease. The LAD and the LCX demonstrated minimal disease throughout the vessels. The RCA demonstrated an 70% mid vessel lesion followed by a hazy complete occlusion with LCA collaterals. 2. Successful placement of a 3.0 x 33 mm Cypher drug-eluting stent in the mid-RCA with an overlapping and more distal 2.5 x 28 mm Cypher drug-eluting stent for treatment of an acute ST elevation myocardial infarction. Final angiography demonstrated no residual stenosis, no angiographically apparent dissection, and normal flow (See PTCA Comments). FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Successful placement of drug-eluting stents in RCA. 3. Transient bradycardia and hypotension with reperfusion treated with atropine and dopamine. . CXR [**2135-6-30**]: IMPRESSION: Bilateral pleural calcifications. No evidence for CHF. Can follow up with standard PA and lateral films when condition permits for better evaluation. Brief Hospital Course: 85 year old female with CAD, HTN, and likely fresh total occlusion of RCA on [**2135-6-30**], taken for urgent stenting. Procedure was complicated by hypotension and bradycardia, resolving after atropine in catheterization laboratory. No instability on floor during length of stay. Several hours post-catheterization, patient had an episode of bloody emesis x1. Summary of stay: . CAD: Patient had ST segment elevation MI with occlusion and stenting of the RCA. Medical management with Aspirin and Plavix. GP2b/3a inhibitor was discontinued secondary to GI bleeding. Started metoprolol, captopril, and continued atorvastatin at high dose (80 mg qd). LFTs were not significantly elevated. . Pump: Patient has a history of CHF per patient report, though it was not known whether she has systolic or diastolic dysfunction. No prior echo reports were available. Lungs had some coarse crackles but no JVP or peripheral edema. She had an echo which revealed preserved EF of 50-55%. She was put on PO lasix during her stay but this made her hypotensive. It was decided that the crackles were likely not secondary to congestive heart failure, and the patient was no longer diuresed. . Rhythm: Patient remained in normal sinus rhythm during CCU / SDU stay. . Hypotension and bradycardia post cardiac catheterization: Was possibly secondary to Beezel-Jarisch phenomenon, characterized by hypotension and bradycardia after reperfusion with a right sided infarction. It is also possible that the patient began to have a GI bleed in lab but did not have hematemesis until she reached the CCU. Patient remained stable throughout her stay and was transferred to SDU for observation until discharge. . Hypertension: Patient was on diltiazem at admission. Although she was no longer hypotensive on arrival to the CCU, diltiazem was held given the recent bradycardia. . Hypoxemia: Ms. [**Known lastname 3640**] had initial acidemia consistent with hypoventilation on arrival. She was on pulmicort, presumably for her COPD, prior to admission, and this was switched to fluticasone at admission. She was also started on combivent MDIs. She had an O2 requirement in the hospital and was placed on 2L NC O2. When taken off the oxygen her oxygen sats would fall into the mid 80s. The patient was well diuresed and it was not thought the O2 requirement was secondary to CHF. Pleural plaques were noted on a chest x-ray and a chest CT was done to obtain further information. Significant pleural plaques and calcifications were noted on CT and were consistent with asbestos exposure. Significant emphysema was noted and bronchiectasis was seen in both lungs. Her regimen was changed to include Advair, and fluticasone was stopped. She was advised that she should go home with home O2. She remained stable on 2 L NC oxygen. . Acidemia: Patient's pH was 7.28 with CO2 in 60s and bicarb 32 at admission. Could have been secondary to COPD and CO2 retention, but would expect patient to have been more compenstated. Likely initial acidemia was from sedation from fentanyl given during catheterization and hypoventilation. . GI Bleed: Patient had one episode of 300-500 cc of hematemesis of bright red blood after coming to the CCU from her cardiac cath. She had a history of 'stomach ulcers' in the past and was maintained on protonix at home. She was on heparin and aggrastat during her cardiac catheterization, but they were discontinued after the hematemesis began. She was evaluated by the GI service, but since she was stable and was considered high risk in the peri-MI period, it was decided that she would have an EGD as an outpatient. She received 2 units of PRBCs after the hematemesis without incident, with no further episodes of hematemesis. She was advanced to full diet without difficulty. She was scheduled to follow-up with her GI doctor as an outpatient. . Dysmotility disorder?: Patient had one episode of emesis on [**2135-7-7**] that was non-bloody. She was on dicyclomine and reglan prior to admission, likely due to a motility disorder, but these were held because it was not clear why they had been started. Reglan was re-started on [**2135-7-7**] because of the emesis and a recent chest CT that showed an air fluid level in the esophagus suggestive of a motility disorder. . Right femoral bruit: Hear for first time on [**2135-7-5**]. Femoral arterial u/s was done that showed no evidence of pseudoaneurysm or AV fistula. Some atherosclerotic calcification was seen in the femoral artery. . Depression: Patient was upset during her stay. She noted that she did not want to live and wanted to "just die of natural causes." She was occasionally tearful and was started on Celexa 20 mg. She was to follow-up with her PCP for further management. . Glaucoma - She was maintained on outpatient eye medications. . Prophylaxis: She was kept on a Proton pump inhibitor. . On [**2135-7-7**] patient was discharged to Silver [**Doctor Last Name **] [**Hospital 42905**] rehab in Ducksburry. She will obtain followup with her primary care physician within one week. Medications on Admission: Meds: Miacalcin 3.7 ml, dicyclomine 20 mg, reglan 10 mg, protonix 40 mg qd, Cartia XT 300 mg qd, Klnopin 0.5 mg , travatan (optho), Pulmicort 200 mg, IC nitrotab 4 mg Discharge Disposition: Home with Service Discharge Diagnosis: 1. Inferior MI 2. Hematemesis 3. Emphysema 4. Depression Discharge Condition: stable on 2L NC O2 Discharge Instructions: Your medications have been changed. Please take your new medications as prescribed. Please call your doctor or return to the ER if you have difficulty breathing, chest pain, dizziness, fevers of chills or if you vomit blood or see blood in your stools. Please follow-up with your primary care doctor within one to two weeks. Please use your oxygen at all times. Followup Instructions: Please follow-up with your gastroenterologist Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 2520**]. You have an appointment scheduled on [**2135-7-19**] at 2:45 pm. Please call ([**Telephone/Fax (1) 32401**] if you need to re-schedule your appointment. . Please follow-up with your primary care doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. You have an appointment scheduled for [**2135-7-11**] at 10 Am at the [**Location (un) 8072**] Office. Please call [**Telephone/Fax (1) 36012**] to re-schedule. Please let your primary care physician know that your pulmonary function tests are pending at this time. Name: [**Known lastname 8451**],[**Known firstname 2138**] Unit No: [**Numeric Identifier 11343**] Admission Date: [**2135-6-30**] Discharge Date: [**2135-7-7**] Date of Birth: [**2050-2-4**] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamides) / Calcitonin Attending:[**First Name3 (LF) 2129**] Addendum: pulmonary function tests: SPIROMETRY 12:37P Pre drug Post drug Actual Pred %Pred Actual %Pred %chg FVC 0.84 1.90 44 1.43 75 +70 FEV1 0.40 1.19 34 0.47 40 +19 MMF 0.19 1.54 12 0.19 12 0 FEV1/FVC 48 63 76 33 53 -30 Discharge Disposition: Home with Service [**First Name11 (Name Pattern1) 448**] [**Last Name (NamePattern4) 2130**] MD [**MD Number(1) 2131**] Completed by:[**2135-7-7**]

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28627

Discharge summary

report

Admission Date: [**2150-2-11**] Discharge Date: [**2150-2-19**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4760**] Chief Complaint: dark stool Major Surgical or Invasive Procedure: None History of Present Illness: 84 y/o woman with a history of diabetes, biventricular congestive heart failure, right sided more than left, right sided systolic and left sided diastolic, presumed though not documented coronary artery disease, atrial fibriallation on coumadin, and chronic kidney disease is admitted to the [**Hospital Unit Name 153**] with a drop in hematocrit and dark stools. . She notes that she has been feeling weak for some time. She in fact correlates her weakness with a recent increase in her hydralazine dose from 10mg po TID to 25mg po TID three weeks ago. She had dark "greenish" stool on monday, and had her routine labs checked on tuesday which include INR and CBC. Her INR was noted to be 5 and Hct had droppped form 33 to 24. Her PCP was [**Name (NI) 653**] and she was brought to the [**Name (NI) **] by her family. . On evaluation in the ED, her BP was 110/60, HR 66, INR 7.7, Hct 19.7. She was given 2 units of FFP, 2 units of PRBCs, 10mg po vitamin K, and admitted to the [**Hospital Unit Name 153**]. She had an 18G and 20g PIV in place. Of note, asymptomatic ST depressions were noted on precordial leads V2-V4. . Further review of systmes is notable for the absence of abdominal pain, though she does remark on an increase in bloating and indegestion in recent weeks. She denies diarrhea but does not constipation. She has never had bleeding before and reports a normal colonoscopy @ [**Hospital1 2025**] a number of years ago. Of note, her family took note of a recent increase in her blood sugars, with values in the last several days consistenyl > 300. The patient has a history of UTIs and hyperglycemia associated with this, but denies fevers, dysuria, or polyuria currently. She denies shortness of breath, no chest pain. Past Medical History: -HTN -DM2 -CAD -CHF: echo [**10-11**] showing lvef 40-45%, E/e' > 15, 2+ MR [**First Name (Titles) **] [**Last Name (Titles) **], mod pul htn -Afib -PVD -Pulmonary HTN -CRI: Baseline Cr 1.8 -Renal artery stenosis -Gout PSH: -TAH -CCY -Appendectomy . Social History: Lives with her daughter and son-in-law, never smoked or used etoh. Family History: Father had DM and died of this in the era before insulin. Mother had CAD and died at 84. Sister died of breast cancer at 36. Brother had CAD in 40's. Physical Exam: afebrile 120/53 HR: 80, irregular sating 100%RA GEN: well appearing, not in any distress HEENT: JVP noted pulsating at earlobe CV: irregular, s1, s2, no murmurs moted RESP: quite clear to ascultation bilaterally ABD: soft, obese, not tender to palpation RECTAL: black, guiac posative stool Pertinent Results: [**2150-2-11**] 09:57PM URINE RBC-3* WBC-20* BACTERIA-MOD YEAST-NONE EPI-<1 [**2150-2-11**] 01:05PM GLUCOSE-266* UREA N-146* CREAT-2.0* SODIUM-129* POTASSIUM-3.3 CHLORIDE-91* TOTAL CO2-25 ANION GAP-16 [**2150-2-11**] 01:05PM ALT(SGPT)-8 AST(SGOT)-20 CK(CPK)-40 ALK PHOS-118* TOT BILI-0.5 [**2150-2-11**] 01:05PM TRIGLYCER-141 HDL CHOL-31 CHOL/HDL-5.0 LDL(CALC)-96 [**2150-2-11**] 01:05PM WBC-12.4* RBC-2.28*# HGB-6.5*# HCT-19.7*# MCV-86 MCH-28.4 MCHC-33.0 RDW-20.1* [**2150-2-11**] 01:05PM NEUTS-86.4* LYMPHS-9.8* MONOS-2.4 EOS-1.0 BASOS-0.3 [**2150-2-11**] 12:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD [**2150-2-12**] 04:44AM BLOOD WBC-12.4* RBC-3.56*# Hgb-10.5*# Hct-29.7* MCV-83 MCH-29.5 MCHC-35.3* RDW-17.9* Plt Ct-148* . CXR [**2150-2-11**]: The heart is enlarged. There is linear atelectasis in the right lower lobe. There is prominence of the pulmonary vasculature. There is no acute pulmonary consolidation. CONCLUSION: Overall, findings are suggestive of mild-to-moderate CHF. Please ensure followup to clearance. . [**2150-2-11**] 9:57 pm URINE Site: CATHETER **FINAL REPORT [**2150-2-15**]** URINE CULTURE (Final [**2150-2-15**]): PROTEUS VULGARIS. >100,000 ORGANISMS/ML.. ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS VULGARIS | ESCHERICHIA COLI | | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- 2 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S LEVOFLOXACIN----------<=0.25 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- 256 R <=16 S PIPERACILLIN---------- <=4 S <=4 S PIPERACILLIN/TAZO----- 16 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S Brief Hospital Course: 84 y/o woman with diabetes, atrial fibrialltion on coumadin, biventricular heart failure, presenting with weakness, a drop in hemaotcrit and guaiac positive stools. Hospital course also complicated by afib with RVR # Gastrointestinal bleed/Acute blood loss anemia: Patient was found to have grossly melanotic stools in the ED and a hematocrit drop to 20 in the setting of an INR of 7. She was given Vitamin K 10mg po and two units of FFP and transfused with a total of 4 units of blood within the first 18 hours of her presentation. The source of her bleeding was unclear but thought to be upper GI given the rise in her BUN and melena. However, after discussion with GI, the decision was made to not pursue endoscopy. Her hematocrit stabilized as her INR normalized. Her antihypertensives and betablockers were held initially, then restarted. Of note, H Pylori was positive, but favor not treating as she has no symptoms of gastritis and bleed was in setting of elevated INR. Hct was stable at 29 at discharge. . # Acute on Chronic biventricular diastolic heart failure: Torsemide was restarted once patient was stable. Also restarted BB, imdur 20 mg three times daily, hydralazine 25 mg three times daily once hct stabilized. Pt is not on ACE given h/o RAS. During her admission on the floor, pt developed afib with RVR (see below), requiring increased dosing of her lopressor. Her hydralazine and imdur were held in the setting of uptitrating her lopressor and SBP only in the 100s-110. Pts cardiologist, Dr. [**Last Name (STitle) 171**], was consulted while pt was here given her tenuous volume status at home and the need for many medications changes (ie increasing her lopressor, holding her imdur/hydralazine), and noted her weight was up 10 lbs from her dry weight. Her torsemide was continued at 40 mg three times a day, and she received metolazone 2.5 mg intermittently. Her hydralazine was restarted at 10 mg TID, her imdur was re-titrated in at 10 mg tid, and it was felt by Dr. [**Last Name (STitle) 171**] that if her BP runs in 90s-100s systolic, this is ok. Given her intake and output were essentially even on her home diuretic regimen, she was started on lasix 80 mg IV with metolazone 5 mg prior to each dose. Her weight dropped from 187 lbs down to 185 lbs prior to discharge. Her home dose of torsemide 40 mg tid and metolazone 2.5 mg as needed was restarted at discharge as this seems to keep her just euvolemic. . # Leukocytosis/UTI: Pt had GNR in urine from [**2-11**]. CXR [**2-11**] c/w CHF, no PNA. Started bactrim on [**2-13**] and urine noted to be growing pansensitive E Coli and Proteus. She completed a 3 day course of bactrim. Daughter requested we start prophylactic antibiotics, however it was felt that bactrim would interfere with pts coumadin, and macrobid could be neurotoxic in the setting of chronic kidney failure. . # Diabetes: Reports elevated and difficult to control blood sugars of late. Current UTI also likely contributing. On NPH [**Hospital1 **] plus RISS. Increased NPH here. . # Hypertension: Initially many BP meds were held due to hemodynamic instability. All were resumed when hct was stabilized. As per below, pt developed a fib with RVR, requiring her hydralazine and imdur to be held while increasing her lopressor. Hydral was titrated back in at 10 mg tid and imdur was titrated back in at 10 mg tid. . #A.Fib with RVR: Given massive recent bleed, the source of which has not been treated (or identified), coumadin was stopped. ASA was started. Upon discussion with pts daughter and pts cardiologist Dr. [**Last Name (STitle) 171**], it was felt her GI bleed was in the setting of supratherapeutic INR and she has a high risk for stroke off of coumadin. We agreed on restarting coumadin, and if pt is on antibiotics at any given time for her frequent urinary tract infections she will need her INR monitored twice weekly (daughter aware). Pt did have an episode of Afib/RVR the AM of [**2-14**] with rate up to 140s. This was in the setting of her lopressor having been held. Lopressor was resumed at her home dose of Toprol 100 mg daily. Rate was stlll noted to be in the low 100s, so lopressor was increased to 75 mg tid (225 mg daily) for rate control. Her rate was in the 70s-80s on this regimen. . # Social: Of note, pts daughter is very involved in her care. However her daughter would often attempt to dictate care, which would at times interfere with the patient's care. Many attempts needed to be made to explain why certain medication changes were being made. The pts daughter often felt medication changes were not appropriate and questioned care, when the changes indeed ended up being beneficial (ie daughter was initially upset about metoprolol being titrated up, but pts HR was in the 120s. With increase in metoprolol, her HR was much better controlled). In addition, it was noted that the daughter made very derogatory and inappropriate comments about the hospitalist caring for the pt to the pts nurse. . #Dementia: Pt is oriented to place "hospital", but not year. She was not sure why she is here. Per family, pt does have some dementia and this is baseline for pt. Apparently did not tolerate aricept in the past. . #CAD-had troponin leak around the time of admission, felt to be consistent with demand ischemia. . # Chronic Kidney Failure, stage 3: Cr remained at baseline of approx 2.2-2.6. . # CODE: DNR/DNI Medications on Admission: hydralazine 25mg po tid isordil 20mg po tid synthroid 50mcg po Qday metolazone 2.5mg po Qday as needed for weight > 177 pounds Torsemide 40mg po TID allopurinol 100mg po QOD NPH 16units Qam, 10Units Qpm Humalog TID-4 times daily per sliding scale Aspirin 325mg po qday potassium 10meq protonix 40mg po Qday Discharge Medications: 1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain, fever. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO every twenty-four(24) hours. 6. Insulin Lispro 100 unit/mL Solution Sig: One (1) unit Subcutaneous as directed: Resume your usual sliding scale insulin prior to meals. 7. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO as directed: for weight >177 lbs. 8. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): This is a stool softener and can be purchased over the counter. 10. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 11. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 12. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day: with a 25 mg tablet for a total of 225 mg a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 13. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day: with a 200 mg tablet for a total of 225 mg daily. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 14. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. Disp:*60 Tablet(s)* Refills:*2* 15. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: One (1) unit Subcutaneous as directed: take 30 units in the morning and 10 units in the evening. Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: GI bleed Anemia Demand ischemia Diabetes mellitus II, uncontrolled, no complications Atrial fibrillation with rapid rate Urinary tract infection Acute on chronic diastolic heart failure Discharge Condition: stable, hct 29 Discharge Instructions: You were admitted with a GI bleed in the setting of your INR being too high on coumadin. You were transfused 4 units of blood with your red blood cell level stabilizing at approximately 30. Your coumadin was initially held and then restarted at 4 mg a night. Your INR was 2.3 before leaving. If you are on antibiotics in the future, you need to have your INR drawn twice a week. Please have your INR redrawn by next Monday. Your goal INR is 1.8-2.5. . Please complete your course of antibiotics for your urinary tract infection. . Your fingersticks were noted to be high. We increased your NPH to 30 units in the morning and 10 units at night. . The following other medication changes were made to your medications: Your aspirin was stopped. Your imdur restarted at 10 mg three times a day. Your hydralazine was maintained at a dose of 10 mg three times a day. Your Toprol was increased to 225 mg a day. You can resumed your torsemide at 40 mg three times a day, and metolazone as needed. . Call your doctor or return to the ER for any recurrent rectal bleeding, weakness, fainting, chest pain, shortness of breath, abdominal pain, bleeding, or any other concerning symptoms. . Please weigh yourself everyday and call Dr. [**Last Name (STitle) 171**] for weight gain greater than 3 lbs. Do not drink more than 1.2 liters of fluid a day, and consume no more than 2 grams of sodium in your diet a day. Followup Instructions: 1. Please follow up with Nurse [**First Name8 (NamePattern2) **] [**Last Name (Titles) 717**] on Tuesday [**2-24**] at 9:30 AM. You need to have your hematocrit, INR, and electrolytes checked at that visit. (fax: [**Telephone/Fax (1) 69267**]) . 2. Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2150-3-4**] 9:30 . 3. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2150-5-18**] 10:20

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

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5230, 10637

273, 279

13146, 13163

2900, 5206

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27778

Discharge summary

report

Admission Date: [**2192-8-30**] Discharge Date: [**2192-9-7**] Date of Birth: [**2138-7-23**] Sex: F Service: MEDICINE Allergies: Iodine / Shellfish Derived Attending:[**First Name3 (LF) 14689**] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: EGD paracentesis pleurx catheter placement into peritoneum History of Present Illness: The patient is a 54 yoF w/ a h/o metastatic breast cancer (to liver, hips spine, skull- on taxol weekly) who presented with large hemetemesis x 3 today and melana. Patient also noted to have to bouts of hemetemesis two times yesterday. She has had intermittent nausea and vomiting for the past week that she attributes to her ascites and chemotherapy. Today she felt mildy dizzy, and her husband was concerned which led her to come to the ED. Patient has a history of PE secondary to BCA. She was treated with lovenox and completed treatment in [**1-2**]. She denies taking any blood thinning medication, like aspirin or NSAIDS. Of note, in her past admission in [**Month (only) 462**], she had an episode of hemetemesis. She received 2 units of PRBCs, and no further intervention was done. . Vital signs prior to transfer were 119 106/61 97% on RA. In the ED, she was guaiac positive. Her hct was found to be 19.8. She received 2 units prbc's. After the first unit, her hct increased to 22. They were unable to get an NG tube as patient refused (distraught) at wits end with disease process. GI was consulted and a pantoprazole and octreotide gtt was started. There was concern that her liver mets and ascites and increased portal hypertension could lead to varices that may be causing the bleed. . In the unit, GI scoped patient and found Diffuse ulcerations in the distal esophagus and scattered ulcers in the mid esophagus in the esophagus compatible with severe esophagitis Granularity and erythema in the fundus, stomach body, antrum and pylorus compatible with portal hypertensive gastropathy. Nodularity of the distal duodenal bulb was noted suggestive of external compression. Otherwise normal EGD to second part of the duodenum No active bleeding. Patient also received one more unit of prbcs. Past Medical History: Oncologic History: Patient presented in [**2188**] with back pain, and underwent an MRI which showed spinal mets with cord compression. Physical exam then revealed a previously undetected breast mass. Pt was then diagnosed with Stage IV breast cancer (ER+ PR+ Her2/neu- ductal invasive carcinoma) s/p XRT and spinal fusion T9-L4 on [**2189-5-9**] and treated with Arimedex and lupron. Shortly after the patient was diagnosed with a PE. In [**9-29**], Arimdex was switched to Tamulosin/Lupron until [**6-30**] when the patient was found to progressive disease in her spine and her regimen was switched to Xeloda/Zometa. At that time the patient also recieved additional treatments with XRT, and the patient then underwent a posterior laminectomy and fusion T1-T9 in [**8-30**]. While on Zometa, the patient continued to have progressive disease, and due to this, she is currently recieving adriamycin/cytoxan. Other Past Medical History: 1. tubal ligation and uterine fibroid removal 2. severed right 5th digit 3. tonsilectomy 4. HTN 5. paroxysmal AFib 6. PE/DVT - on Lovenox 7. Portal Vein Thrombosis Social History: The pt any tobacco, EtOH, or IVDU. She lives with her husband and does not work, she has 2 children (in college). Family History: Denies family history of breast CA or other malignancy Physical Exam: Vitals: T: 99 BP: 113/67 P: 115 R: 19 O2: 99% RA General: Thin, Cachectic, Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP at clavicle Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, moderate distension, BS+, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pitting pedal edema, R>L Pertinent Results: [**2192-8-30**] 01:50PM BLOOD WBC-4.8 RBC-1.95*# Hgb-6.5*# Hct-19.8*# MCV-101* MCH-33.1* MCHC-32.7 RDW-20.1* Plt Ct-233# [**2192-9-1**] 11:53PM BLOOD WBC-4.2 RBC-2.95* Hgb-9.8* Hct-28.6* MCV-97 MCH-33.3* MCHC-34.3 RDW-20.1* Plt Ct-144* [**2192-8-30**] 01:50PM BLOOD Neuts-78.9* Lymphs-14.4* Monos-5.2 Eos-1.2 Baso-0.2 [**2192-8-30**] 01:50PM BLOOD PT-14.1* PTT-31.4 INR(PT)-1.2* [**2192-9-1**] 11:53PM BLOOD Plt Ct-144* [**2192-9-1**] 11:53PM BLOOD PT-14.4* PTT-30.8 INR(PT)-1.3* [**2192-8-30**] 01:50PM BLOOD Glucose-108* UreaN-30* Creat-0.8 Na-139 K-2.8* Cl-102 HCO3-26 AnGap-14 [**2192-9-1**] 11:53PM BLOOD Glucose-146* UreaN-20 Creat-0.9 Na-139 K-3.2* Cl-110* HCO3-24 AnGap-8 [**2192-8-30**] 01:50PM BLOOD ALT-19 AST-57* AlkPhos-132* TotBili-1.4 [**2192-9-1**] 11:53PM BLOOD ALT-20 AST-54* AlkPhos-122* TotBili-1.2 [**2192-8-30**] 01:50PM BLOOD Albumin-2.4* Calcium-7.7* Phos-2.4* Mg-1.8 [**2192-9-1**] 11:53PM BLOOD Calcium-7.6* Phos-2.7 Mg-1.7 [**2192-8-30**] 01:54PM BLOOD Hgb-7.3* calcHCT-22 Labs at discharge: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 6.3 3.23* 10.5* 32.7* 101* 32.6* 32.3 18.8* 163 Glucose UreaN Creat Na K Cl HCO3 AnGap 130* 19 0.9 133 4.4 105 21* 11 Albumin Calcium Phos Mg 2.4* 7.6* 3.8 2.2 ECG: Sinus tachycardia. Diffuse low voltage. The tracing is of improved technical quality. As compared with previous tracing of [**2192-7-31**] the rate has slowed. Otherwise, no diagnostic interim change. CXR: No acute cardiopulmonary abnormality Paracentesis: Successful therapeutic ultrasound-guided paracentesis yielding 6.2 liters of yellow ascitic fluid without immediate post-procedure complications. Pleurx catheter placement: Successful placement of a tunneled abdominal Pleurx catheter. The catheter is ready to be used Brief Hospital Course: Ms. [**Known lastname **] is a 54 year old woman with a history of metastatic breast cancer, hx of DVT, PE, and Portal Vein Thrombosis, who was admitted to the ICU after upper endoscopy for upper GI Bleed. . # UGIB: Upper endoscopy showed esophagitis and portal hypertensive gastropathy with no active bleeding. Her hematocrit bumped appropriately after three units of pRBC transfusion, and she remained hemodynamically stable. Possible causes of her esophagitis and gastropathy include radiation, drugs, CMV or HSV as she is immunocompromised. She was continued on pantoprazole and an octreotide drip overnight, per GI recommendations. Following transfer to the floor, octreotide was discontinued, and proton pump inhibition was transitioned from intravenous to oral upon discharge. The patient had no recurrence of the upper GI bleed following initial presentation. She was also discharged on sucrulfate, with GI follow up in the coming weeks. . # Ascites: Her ascites was initially thought to be related to history of portal vein thrombosis. No Portal Vein Thrombosis was seen on on abdominal ultrasound, but liver metastases were found. Her ascites is most likely secondary to her malignancy. Following significant relief from a therapeutic paracentesis, during which over 6 liters of fluid was removed, it was decided to place an indwelling pleurx catheter in the peritomeum for symptomatic drainage. The patient tolerated the procedure well. . # End Stage Metastatic Breast CA Her primary oncologist was notified of her hospitalization. The Palliative Care team recommended giving patient an outpatient prescription for Ritalin to increase her mood and energy level. Social work was also involved because of patient's poor prognosis and was helpful in getting the patient the resources she needed. The patient declined methylphenidate at time of discharge, and will follow up with her primary oncologist in the coming weeks. Medications on Admission: calcium 500mg po bid metoprolol 50mg po tid multivitamin zofran q8hrs prn ativan 1mg po qhs compazine Discharge Medications: 1. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 4. Calcium 500 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 6. Ondansetron HCl 8 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 7. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 8. Compazine 10 mg Tablet Sig: One (1) Tablet PO twice a day as needed for nausea. 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO three times a day. Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Primary Diagnosis: metastatic breast cancer Secondary Diagnoses: 1. tubal ligation and uterine fibroid removal 2. severed right 5th digit 3. tonsilectomy 4. HTN 5. paroxysmal AFib 6. PE/DVT - on lovenox in past 7. Portal Vein Thrombosis Discharge Condition: stable and improved Discharge Instructions: You were admitted to the hospital after having an episode of vomiting blood. You had a low blood pressure and fast heart rate in the ED, and for this reason you were initially admitted to the ICU. An endoscopic procedure showed that you had changes in your stomach from high blood pressure that may have led to your bleeding episode- there was no active bleeding during the procedure, and no intervention was done. You were then given intravenous medications and monitored in the ICU. You did well, your blood count improved after three blood transfusions, and you were transferred to the floor. You had abdominal distention that caused you discomfort, and had drainage procedures to relieve the distention. You then had a catheter placed to facilitate drainage after you leave the hospital. You were discharged home on [**2192-9-7**] in improved and stable condition. Please see below for follow up appointments. The following changes were made to your medications: please start taking sucrulfate and pantoprazole please restart taking your metoprolol Please call your physician if you develop fevers/chills, abdominal pain, shortness of breath, problems with your catheter, nausea/vomiting/vomiting blood, bloody stools or black stools, lightheadedness, or any other concerning medical symptoms. Followup Instructions: Dr.[**Name (NI) 67735**] office will contact you to set up your next appointment. [**Name6 (MD) 81**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2192-10-3**] 2:00 [**Name6 (MD) **] [**Name8 (MD) 10341**] MD [**MD Number(2) 14690**]

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icd9cm

[ [ [] ] ]

[ "45.13", "54.91" ]

icd9pcs

[ [ [] ] ]

8790, 8861

5850, 7793

299, 360

9143, 9165

4024, 5025

10521, 10812

3471, 3527

7945, 8767

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17,236

157,478

19041

Discharge summary

report

Admission Date: [**2149-8-9**] Discharge Date: [**2149-9-2**] Date of Birth: [**2072-12-29**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1973**] Chief Complaint: sepsis Major Surgical or Invasive Procedure: Percutaneous drainage of liver abscesses PICC line placement Transesophageal Echo Video swallow evaluation Paracentesis History of Present Illness: This is a 76 y/o male with a h/o pancreatic CA s/p modified Whipple [**2146**], e.coli bacteremia complicated by recurrent liver abcesses in [**3-3**] and [**5-31**] treated with drainage and Cefepime/Vanco x5 weeks, who initially presented to an outside hospital on [**8-8**] with fever, dysuria, fatigue and difficulty ambulating. Found to have a drop in Hct to 25, WBC of 20.9, was transferred to [**Hospital1 18**] for further work up. Found to have e.coli bacteremia originally treated with Levaquin, although strain was resistant and this was switched to CTX 1g QD on [**8-11**]; later increased to CTX 2g qD on [**8-13**]. A RUQ U/S obtained on [**8-12**] showed multiple liver nodules concerning for abscesses vs malignant nodules, with MRI not more helpful in delineating the two. . In regards to his hct drop on admission, he was transfused 3u pRBC and GI was consulted who felt it was related to chronic anemia as well as in the setting of sepsis and marrow suppression with recommendations only to tx to hct >28, and obtain OSH records regarding previous colonoscopies. Pt remained stable until [**8-14**] at 7pm when he had a large volume bloody BM on the floor. He was otherwise asx, denying any N/V/hematemesis, abd pain, f/chills, melena. He otherwise denied any CP, SOB, LH/dizziness. He was given IVF x1L NS and had an NG lavage performed that was negative. His VS were: T96.7, HR 90, BP 122/58, RR20, 98%RA. He was admitted to the MICU for monitoring Of note, he had been started on a heparin gtt 2 days prior due to an upper extremity DVT; however, his heparin gtt had been turned off for the 24 hours prior due to a ? liver biopsy of the above lesions. Past Medical History: 1. Pancreatic adenocarcinoma- s/p Whipple [**9-28**] and chemo/XRT 2. Liver abscess ([**3-3**]) in [**Country 32814**]; treated with ? Amphotericin/Vanco and possibly drainage. Recurred in [**5-31**]- Abscess composed of E. coli, Morganella morganii, and enterococcus-Rx w/ IR drainage, and 5 weeks of cefipime, vancomycin, Fungizone - treatment halted due to ARF 3. Acute Renal Failure at OSH in DC [**5-/2149**] 4. Anemia secondary to bleeding duodenal ulcers ([**5-/2149**]) 5. E. coli bacteremia ([**5-31**]) 6. Chronic diarrhea-secondary to pancreatic insufficiency 7. Hypertension-no longer on Rx 8. GERD 9. Sigmoid diverticulosis ([**2146**]) 10. Abdominal aortic aneurysm 3cm ([**2146**]) 11. Pancreatitis 12. Ascites-3L removed ([**5-/2149**]) 13. DM- well controlled w/ Prandin Social History: SH: Lives with wife in [**Hospital3 4298**]. Of Argentinian decent, travelled to [**Country 32814**] earlier this year, where his liver abcess was diagnosed. Used tobacco for >10 yrs as youth. Denies EtOH, drugs. Family History: non-contributory Physical Exam: VS: T97.2 HR92 BP139/73 RR20 o2: 98%RA GEN: Elderly male in NAD, comfortably talking at rest HEENT: Anicteric sclera. PERRL. EOMi. MM moist NECK: No elev JVP CV: Regular, nml s1,s2. RESP: CTAB anteriorly. No c/w/r ABD: Soft, NTND. No TTP. No rebound/guarding EXT: Mild pedal edema. Pulses symmetric NEURO: AAOx3. Moves all ext spont. Pertinent Results: MICRO: - Urine Cx from OSH grew klebsiella pneumoniae, sensitive to ceftriaxone and levofloxacin. - Bcx [**8-9**]: [**4-29**] bottle from [**8-9**] grew E. coli (different strains isolated). Sensitive to ceftriaxone, resistant to levofloxacin. - Bcx [**8-10**] E. coli - Ucx [**8-9**] and [**8-11**]: negative - Bcx [**8-11**]: E. coli - Bcx [**8-12**]: 2/4 bottles E.coli, Klebsiella - Bcx [**8-13**] negative - Bcx [**8-15**]: E. coli, Klebsiella - Bcx [**8-17**]: E.coli, enterococcus - Abscess [**8-15**]: E. coli, strep viridans, [**Female First Name (un) **] [**Female First Name (un) 17939**], GPR - Abscess [**8-19**]: E. coli, enterococcus, bacteroides - peritoneal fluid ([**8-27**]): [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 17939**] IMAGING: -([**8-9**])Port AP CXR: Opacity at the right base which likely represents a combination of atelectasis and pleural fluid, view. Focal opacities in the left mid zone. In particular, there is a 2-cm opacity abutting the left chest. -([**8-9**])CT head w/o contrast: No intracranial mass effect or hemorrhage is identified. -([**8-11**])PA/lat CXR: There are persistent bilateral pleural effusions, moderate on the right and small on the left. The right effusion likely has a subpulmonic component. There are 2 poorly defined areas of opacity in the left midlung region without change from prior a portable chest radiograph of [**8-9**], [**2149**]. -([**8-11**])U/S LE b/l: No left or right lower extremity DVT study. -([**8-11**])R UE U/S: Thrombus within the right axillary vein extending into the right brachial veins. - ([**8-12**]) Abdominal U/S: 1. Two predominantly cystic heterogeneous lesions within the right lobe of the liver showing characteristics more concerning for metastatic disease. Gvien history of bactermia and prior liver abscess, an abscess is difficult to exclude. Strongly recommend MR for further characterization. 2. Bilateral pleural effusions. 3. Moderate ascites. - ([**8-13**]) Abdominal MRI: 1. Multiple rim enhancing necrotic lesions within the liver parenchyma with overlapping characteristics of abscesses (hyperemia) and necrotic metastases (rounded hypervascular mass in segment V). Thus this study is nondiagnostic for histologic differentiation between these two entities and tissue diagnosis is recommended. - ([**8-15**]) TTE: The LA is mildly dilated. There is mild symmetric LV hypertrophy with normal cavity size and hyperdynamic systolic function (LVEF 60-70%). RV chamber size and free wall motion are normal. The aortic root is moderately dilated. The aortic valve leaflets are mildly thickened. No masses or vegetations are seen on the aortic valve or mitral valve. -([**8-18**]): Redemonstration of liver abscess in right inferior lobe of liver. Catheter placement unable to be performed due to NPO status. - -([**2149-8-23**]) Abnormal MRI: : Several areas of slow diffusion with enhancement in the brain as described above are suspicious for septic emboli. The post-gadolinium images are limited by motion. Repeat study would help for further assessment if clinically indicated. No mass effect or hydrocephalus. -([**8-25**]) MRCP abd: 1. Mild interval decrease in size of liver abscesses. There is no intra- or extra-hepatic biliary dilatation to suggest obstruction of the biliary system as an etiology for the patient's liver abscesses. Of note, the MRCP images are markedly limited due to patient's inability to hold his breath and a small stone in that region cannot be excluded on this study. 2. Large loculated collections of ascites within the abdomen which appear to have thick enhancing rims, although assessment for enhancement is limited on this study. This raises the concern for peritonitis and a cytological tap is recommended to further evaluate. -([**8-28**]) TEE: No mass/thrombus is seen in the left atrium or left atrial appendage. No spontaneous echo contrast is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis. No 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 a small pericardial effusion. No vegetation or abscess seen. Brief Hospital Course: In brief, Mr. [**Known lastname 52006**] presented to a [**Hospital6 **] with what was thought to be an acute hct drop to 25 and e. coli bacteremia and was transferred to [**Hospital1 18**] for treatment and further workup. He was initially treated with levaquin, then ceftriaxone when sensitivities returned quinolone-resistant. RUQ U/S on [**8-12**] showed multiple liver nodules concerning for abcesses vs. metastases. He received a CT guided drainage of one liver abscess and drain placement on [**8-15**] -> growing klebsiella resistant to cetriaxone, enterococcus and yeast. No malignant cells were found on abscess biopsy. He also received a paracentesis and peritoneal fluid grew out [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 17939**] and fluid analysis showed elevated WBCs c/w SBP. Meropenem and vanco were started on [**8-17**] due to ceftriaxone and methacillin resistance profiles. Caspofungin started [**8-19**] for [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 17939**] coverage. He had two other liver nodules also drained by IR, last on [**8-19**]. Attempted to replace percutaneous drains on [**8-27**] after drainage slowed but abscesses were not amenable to drainage by IR. Secondary to this ,antibiotics will need to be continued for 6 weeks with serial imaging to monitor for resolution of absecesses. Pt had heme + guaiac and was initially transfused 3u PRBCs upon admission and GI was consulted who felt anemia was likely chronic, especially in the setting of sepsis and marrow suppression. Per patients reports, has had recent colonoscopies without evidence of bleed. Pt maintained hematocrit until [**8-14**] at 7pm when he had a large volume bloody BM on the floor. NG lavage performed at that time was negative, and he refused colonoscopy. He was sent to the ICU and was stabilized with PRBCs and aggressive IVF rehydration. Gastroenterology saw again and thought that the bleeding was most likely due to an upper GI bleed from known gastric and duodenal ulcers. Mr. [**Known lastname 52006**] had low urine output during his ICU stay, and was bolused with IVFs to keep urine output>30cc/hr. As a result, he had been positive ~10L and developed anasarca, likely secondary to poor nutritional status with an initial albumin of 2.2 which decreased to 1.2 by the time he was transferred back to the floor. Tube feeds were started with minimal increase in albumin to 1.3 after 1 week. He continued to maintain marginal urine output despite fluid repletion and blood transfusions. He remained in positive fluid status throughout his admission. He received 1 paracentesis for fluid culture and at the time had 6 L of peritoneal fluid removed which reaccumulated rapidly. SAG was < 1.1, not suggestive of portal hypertension involvement. Again attributed to low albumin. He had waxing and [**Doctor Last Name 688**] mental status with persistent word finding difficulties throughout admission. Head MRI showed possible septic emboli on [**8-23**], however, a TEE on [**8-28**] was negative for vegetations. It was thought that his mental status changes were most likely delerium secondary to metabolic/infectious encephalopathy. A lumbar puncture was considered but refused by the patient. It was not repersued as it was thought to be low yield with improved mental status by the time of discharge. At discharge patient's mental status had improved, he was tolerating tube feeds well, urine output was stable, he had been afebrile for 2 weeks, hematocrit had been stable, and he denied colonoscopy as an inpatient. He received a PICC placement by IR, was given 2 units of blood to increase his hematocrit prophylactically, and he was discharged to an acute rehab facility for prolonged IV antibiotic therapy for 6 weeks with close monitoring by infectious disease. Medications on Admission: Prandin 0.5mg [**Hospital1 **] Immodium Prilosec 20mg qd Percocet 325 prn Zofran prn oxycontin 5 Lupram 4500 pancrealipase Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Prandin 0.5 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 3. Simethicone 80 mg Tablet, Chewable Sig: [**1-27**] Tablet, Chewables PO QID (4 times a day) as needed. Disp:*200 Tablet, Chewable(s)* Refills:*2* 4. Loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed. Disp:*90 Capsule(s)* Refills:*2* 5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Zofran 24 mg Tablet Sig: One (1) Tablet PO once a day as needed for nausea. Disp:*10 Tablet(s)* Refills:*2* 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*100 Tablet(s)* Refills:*0* 8. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. Disp:*60 Tablet(s)* Refills:*2* 9. Amylase-Lipase-Protease 468 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Vancomycin in Normal Saline 1 g/250 mL Solution Sig: One (1) gram Intravenous Q48 hours for 6 weeks: Goal vanco trough [**11-14**]. 12. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 15. Outpatient Lab Work Please check: CBC, Na, K, Cl, CO2, BUN, Cr, AST, ALT, Alk Phos, Tbili, vancomycin trough (hr prior to next scheduled dose) QFriday for the duration of IV antibiotic therapy 16. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg Intravenous every eight (8) hours for 6 weeks. 17. Caspofungin 50 mg Recon Soln Sig: Fifty (50) mg Intravenous Q24 hours for 6 weeks. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Hospital1 **] Discharge Diagnosis: Primary: 1. sepsis 2. liver abscess 3. GI bleed 4. Ascites 5. malnutrition secondary: 1. pancreatic cancer 2. hypertension 3. chronic diarrhea 4. acute renal failure 5. Diabetes Discharge Condition: stable Discharge Instructions: You are being treated for infections in your blood and in your liver. You will need to remain on antibiotics for at least 6 weeks. You will follow up with an infectious disease doctor who will help monitor your therapy. Please continue to take all medications as prescribed. Please note that your Prilosec has been changed to Protonix. Please take your Protonix twice a day for 1 month and then decrease to once daily. Metoprolol has been added to your medication list to help control your heart rate and blood pressure. Calcium carbonate, thiamine, and a multivitamin have been added to help with your nutrition. You will need to continue taking IV vancomycin, meropenem, and caspofungin for at least 6 weeks or until instructed to stop by another physician. You will need to continue your tube feeds until you are tolerating a regular diet. You will need to have weekly labs checked to ensure tolerance of your antibiotics as well as appropriate antibiotic levels in your blood. Please call your doctor or return to the hospital for fevers, chills, nausea, vomiting, lightheadedness, dizziness, confusion, chest pain, abdominal pain, shortness of breath, change in your urination or stools, or any other concerns. Followup Instructions: Please follow up with infectious disease: Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name 9406**] Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2149-10-7**] 9:00 Please have an [**Month/Day/Year 950**] performed prior to above visit: Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2149-10-6**] 10:30 Please call your primary care provider to set up a follow up appointment in the next 1-2 weeks. Please let your primary care doctor know that at the time of your discharge from [**Hospital1 18**], an H. Pylori serology test was pending. Please call your gastroenterologist in [**Hospital1 1562**], MA to set up a follow up appointment in 1 month. Please let your gastroenterologist know that at the time of your discharge from [**Hospital1 18**], an H. Pylori serology test was pending.

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icd9cm

[ [ [] ] ]

[ "54.91", "50.91", "96.6", "38.93" ]

icd9pcs

[ [ [] ] ]

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8274, 12104

321, 443

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3594, 8251

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12278, 14287

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12130, 12255

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30114

Discharge summary

report

Admission Date: [**2200-5-21**] Discharge Date: [**2200-5-26**] Date of Birth: [**2131-4-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1148**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: endoscopy History of Present Illness: This is a 69 year old man with PMH of colostomy 20 years ago who presents with bleeding per rectum. He reports being in his normal state of health until 4 days ago, when he noticed slight stomach ache, then had maroon bowel movements, [**4-13**] daily. He reports that this continued until the morning of presentation, when he had a syncopal episode and went to the ER on [**Location (un) 7453**] by EMS. He was found to have a HCT of 19, and was given 3 units prbc. An abdominal CT was performed with showed possible gastric mass but was limited by lack of contrast. He was transferred to [**Hospital1 18**] by [**Location (un) **]. . At [**Hospital1 18**], his initial hct was 26. He was tachycardic to 117 but blood pressure was 137/56. He had a bowel movement reported to be "maroon" with some black parts, but denies black bowel movments otherwise. He was admitted to the ICU for further management and endoscopy. . ROS: He denies abdominal pain, nausea, vomiting, hematemesis, fever, chills, lightheadedness, chest pain, shortness of breath, or other concerns. Past Medical History: diverting colostomy [**2182**] for 12 months, then reversed, for "stomach leak" Social History: Lives at home. Drinks 2-3 drinks per night. Smokes 1 ppd. Family History: no bowel problems Physical Exam: V: Tc 97.6 P108 BP 109/59 R20 100% RA Gen: slightly disheveled, no distress HEENT: right pupil with cataract, left none. Reactive to light. OP clear. MM dry Resp: CTA bilaterally CV: tachycardic, nl s1s2 no mGR Abd: soft NTND +BS Ext: no edema Pertinent Results: EKG: sinus tachy at 118 no Q waves no ST/t wave changes. . Imaging: CXR: AP bedside chest shows normal heart and aorta without vascular congestion, consolidations, or effusions. Lungs are well inflated with relative prominence central pulmonary vessels suggesting possible emphysema/cor pulmonale. No comparison exams on PACS. . CT Chest: 1. No duodenal or pancreatic mass identified. Inflammatory changes between the pancreatic head and duodenum as well as enhancement and dilatation of the common bile duct are likely secondary inflammatory changes related to recently seen duodenal bulb ulcer (see Careweb for EGD findings from [**2200-5-22**]). 2. Four-mm nodule in the right upper lobe abutting the major fissure. Conservative followup in one year is recommended to ensure stability. 3. Multiple bilateral renal hypodensities are too small to characterize, but likely cysts. 4. Tiny bilateral pleural effusions with adjacent atelectasis. . [**2200-5-21**] 03:00PM PT-13.8* PTT-23.4 INR(PT)-1.2* [**2200-5-21**] 03:00PM GLUCOSE-133* UREA N-57* CREAT-1.3* SODIUM-135 POTASSIUM-4.8 CHLORIDE-107 TOTAL CO2-19* ANION GAP-14 [**2200-5-21**] 04:35PM PLT COUNT-188 [**2200-5-21**] 04:35PM WBC-13.3* RBC-2.79* HGB-9.1* HCT-26.3* MCV-95 MCH-32.6* MCHC-34.5 RDW-14.6 [**2200-5-21**] 04:35PM NEUTS-76.3* LYMPHS-18.3 MONOS-5.1 EOS-0.1 BASOS-0.3 [**2200-5-21**] 06:50PM ALBUMIN-2.5* CALCIUM-7.5* PHOSPHATE-2.9 MAGNESIUM-1.3* [**2200-5-21**] 06:50PM LIPASE-35 [**2200-5-21**] 06:50PM ALT(SGPT)-27 AST(SGOT)-25 ALK PHOS-46 AMYLASE-54 TOT BILI-1.1 Brief Hospital Course: 69M with remote history of colectomy, reversed, presented with syncope and GI bleed . 1) GI bleed - Still unclear whether upper or lower. although suspect upper source. Intially, he was NPO with serial HCTs. He also received a PPI [**Hospital1 **]. Endoscopy revealed small hiatal hernia, erosion in the antrum compatible with non-steroidal induced gastritis, ulcer in the posterior bulb (given thermal therapy). Otherwise normal EGD to second part of the duodenum. He was transfused 3 units PRBCs and remained hemodynamically stable. H pylori sent and pending at time of discharge; patient started on empiric therapy that can be discontinued if serology returns negative. Counseled to stop alcohol as well. . 2) Syncope - most likley syncope in setting of GI bleed. 1 set CE's negative. EKG - sinus tach. Tele x 24 hours showed no events. . 3) Smoking - Given nicotine patch while in hospital. Counseled on need to stop smoking. Lung nodule incidentally seen on CT scan chest; should get repeat CT scan in next 6 months-year to follow for stability. Medications on Admission: ibuprofen 2 tabs 3-4 times weekly for "cold prevention" Discharge Medications: 1. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day for 14 days. Disp:*28 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 2. Tetracycline 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours). Disp:*240 Capsule(s)* Refills:*2* 3. Bismuth Subsalicylate 262 mg Tablet, Chewable Sig: Two (2) Tablet PO QID (4 times a day) for 14 days. Disp:*112 Tablet(s)* Refills:*0* 4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 14 days. Disp:*42 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Acute Blood Loss Anemia Gastric Hemorage Duodenitis with hemorage Duodenal Ulcer Discharge Condition: Good Discharge Instructions: Please note: you have a 4 mm nodule that was noted on your chest CT. This needs to be followed up in 6 months to 1 year. Please discuss with your primary care doctor, as this could represent cancer. You need to stop smoking completely. . Your stool will likely turn black on the anti-biotics you will be on. This is normal, however, if it becomes truly black or tarry, or have blood in the stool, you should immediately go to the hospital. You are recommended to get a repeat endoscopy in a month. Followup Instructions: Please make a follow up appointment with a primary care doctor in the next week to get follow up blood counts and overall care. . CT chest in 6 months to 1 year . You will need to follow up with our gastroenterology service for a repeat endoscopy in [**5-16**] weeks, as well as follow up on your biopsies.

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icd9cm

[ [ [] ] ]

[ "44.43", "99.04" ]

icd9pcs

[ [ [] ] ]

5236, 5242

3505, 4561

324, 335

5367, 5374

1927, 3482

5921, 6231

1627, 1647

4667, 5213

5263, 5346

4587, 4644

5398, 5898

1662, 1908

276, 286

363, 1432

1454, 1535

1551, 1610

64,992

195,367

55029

Discharge summary

report

Admission Date: [**2132-4-22**] Discharge Date: [**2132-5-11**] Date of Birth: [**2081-4-21**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 10593**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: trans-thoracic lung biopsy bronchoscopy aborted History of Present Illness: Patient is an extremely poor historian and much of the history was obtained from signout. Per report Ms. [**Known lastname 112340**] is a 51 yo F with LUL and RUL FDG avid lesions who presented to [**Location (un) 1459**]/[**Hospital3 **] in [**Month (only) 958**] with unintentional weight loss and severe left sided chest and arm pain. Per Atrius records, a chest x-ray was taken on [**2132-3-5**] at [**Location (un) 1459**] [**Location (un) **]. The radiologist described an irregular left upper lobe parenchymal opacity and recommended a chest CT. She returned on [**2132-3-6**] where CT chest revealed a 2.5 x 4 cm thin walled air containing cyst, which contains a mural nodule laterally on the left. The radiologist raised concerns for possible pulmonary aspergilloma or fungus ball. There was also an irregular density at the right lung apex, a right hilar lymph node, 2 left hilar lymph nodes and upper lobe emphysema. There were no effusions. The radiologist raised concerns for a fungal infection such as mycetoma and/or malignancy. The above imaging was followed up with PET here on [**2132-4-17**] which revealed FDG avid RUL, LUL, left axillary, left lung base and pleural thickening. Blood tests from previous workup show negative Quantiferon TB gold, aspergillus fumigatus 2 bands positive, concerning for possible fungus ball, elevated esr with +[**Doctor First Name **] and DS-DNA+. She was referred to IP for consideration of bronchoscopy for diagnosis and staging. However, in clinic, pt was noted to be in extreme pain, and was referred to ED for admission with IP following. . In the ED, initial vitals 98.6 79 97/78 20 95% RA. Labs notable for WBC 11 (WBC 10), Hct 32.3 (most recent Hct 29), plts 536, lytes wnl. ECG showed SR 76, no ST changes, no priors for comparison. She received morphine x2. Vitals prior to transfer: 98.4 115/73 71 16 96%RA. . On the floor, patient is in no acute distress, but c/o chest wall pain and some LUE pain. Cannot describe the pain, saying "I don't know" and "It's weird". By report from nursing, Pt had highly abnormal behavior, but patient able to follow commands. [**Name (NI) 1094**] mother was able to provide further history. States that Pt had a dry cough since [**2131-11-8**]. Denied any hemoptysis, no significant phlegm. No fevers, no chills, no nightsweats. Reports that Pt had greatly reduced appetite and has lost about 10 lbs unintentionally over the last 3-4 months. States that Pt's mental status has changed only in the last 10-14 days, and attributes it to excess pain medications, which she says Pt takes (either oxycodone or hydrocodone) 2 pills every 4 hours everyday, although Pt started taking her pills 4 weeks prior. Also says Pt complained about R arm and leg numbness and weakness. No incontinence. Pt has apparently had L scapular pain starting in [**Month (only) 956**]. Mother reports Pt had forgetfulness, personality changes, and confusion since [**2132-2-7**]. Last week, Pt apparently forgot how to answer her mobile phone. Pt also was so weak that she could not sit up in bed. Pt had severe L sided rib and chest pain. Past Medical History: LUL mass (Per Atrius Records) Elevated sed rate positive [**Doctor First Name **] abnormal CT with LUL mass, hilar lymphadenopathy Social History: Lives with husband, mother is in from [**Name (NI) **] to help with her care. Was previously working as a medical assistant in [**Hospital 246**] rehab hospital. Smoking history 35 pack year history Alcohol denies. PER PATIENT--DO NOT DISCUSS DETAILS WITH PT'S HUSBAND - PT WILL NEED SW CONSULT in house. [**Name (NI) 1094**] husband extremely agitated in [**Name (NI) **]. Family History: No history of lung disease or cancers. Physical Exam: PHYSICAL EXAM on admission: VS - Temp 98.2F, BP 110/70 , HR73 , R 18 , 98O2-sat % RA GENERAL - middle-aged woman, crying, complaining of severe L sided chest pain. HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - coarse breath sounds throughout, worse on left. HEART - RRR, no MRG, nl S1-S2 CHEST/BACK - severe tenderness to palpation of left chest and back. ABDOMEN - tender to palpation in left abdomen, but not right. No masses. Normal bowel sounds. EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - A&O x name, unable to state location (city or country, but knows it's not [**Location (un) **]), does not know date. Seems very distracted by pain, tearful. Exam limited by lack of Pt participation, but Pt denied any numbness of bilateral upper extremities. Pertinent Results: Admission labs: [**2132-4-22**] 04:30PM BLOOD WBC-11.1* RBC-3.40* Hgb-10.9* Hct-32.3* MCV-95 MCH-32.0 MCHC-33.7 RDW-12.7 Plt Ct-536* [**2132-4-22**] 04:30PM BLOOD Neuts-76.3* Lymphs-17.8* Monos-3.5 Eos-2.0 Baso-0.4 [**2132-4-22**] 04:30PM BLOOD PT-12.4 PTT-30.3 INR(PT)-1.1 [**2132-4-24**] 10:45AM BLOOD ESR-118* [**2132-4-22**] 04:30PM BLOOD Glucose-97 UreaN-21* Creat-0.7 Na-136 K-4.2 Cl-101 HCO3-24 AnGap-15 [**2132-4-23**] 03:10AM BLOOD ALT-33 AST-27 LD(LDH)-188 AlkPhos-252* TotBili-0.2 [**2132-4-23**] 03:10AM BLOOD Albumin-3.6 Calcium-9.4 Phos-4.0 Mg-1.8 [**2132-4-23**] 03:10AM BLOOD Hapto-425* [**2132-4-24**] 09:02PM BLOOD Osmolal-300 [**2132-4-24**] 06:20AM BLOOD CRP-37.8* [**2132-4-23**] 03:10AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2132-4-24**] 12:36AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.049* [**2132-4-24**] 12:36AM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2132-4-24**] 12:36AM URINE RBC-4* WBC-1 Bacteri-NONE Yeast-NONE Epi-2 Micro: [**2132-4-24**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2132-4-24**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) [**2132-4-24**] BLOOD CULTURE [**2132-4-24**] SEROLOGY/BLOOD [**2132-4-24**] MRSA SCREEN Imaging: LABS/STUDIES: Please see below, of note: FDG tumor imaging [**2132-4-17**]: IMPRESSION: 1. FDG avid right apical (SUVmax 6.02) and left lung (SUVmax 5.63) lesions concerning for malignancy. Large left upper lung cavitary mass abutting the left chest wall with extension to the left axilla (SUVmax 12.3). 2. Left hilar lymphadenopathy (SUVmax 11.55) with adjacent compressive effect on the distal left main bronchus. Left paratracheal and AP window FDG avid nodes. Findings were emailed to Dr. [**Last Name (STitle) **] at 5:21pm on [**2132-4-17**]. . [**2132-4-23**] Radiology CT HEAD W/ & W/O CONTRAST FINDINGS: There is no evidence of intracranial hemorrhage on the pre-contrast acquisition. There is extensive left hemispheric edema within the temporoparietal and occipital lobes. To a lesser degree, there is right temporo-occipital edema adjacent to the occipital [**Doctor Last Name 534**] of the right lateral ventricle. These surround a number of intracranial masses, better evaluated on postcontrast images. There are four total subcortical masses, the largest of which, located in the left parietal lobe, measures 3.5 x 3.0 cm (3:14). This lesion, along with all of the others, demonstrates a conspicuously very thin rim of peripheral contrast enhancement. This lesion along with the associated edema exerts mass effect on surrounding structures, including minimal rightward deviation of midline structures, and effacement of the left lateral ventricle. Superior to this, there is a 1.7 x 1.2-cm lesion in the subcortical white matter of the left parietal lobe, with similar characteristics (3:21). In the right parieto-occipital region, just inferior to the occipital [**Doctor Last Name 534**] of the right lateral ventricle, lies a more irregularly-contoured lesion measuring 2.7 x 2.5 cm (3:13). A distinguishing feature of this lesion is possible subependymal enhancement (3:9). Finally, a posterior fossa lesion in the right cerebellar hemisphere measures 1.6 x 1.4 cm (3:6). Upon retrospective review of the prior CT (from PET study), although the masses cannot be visualized due to incomplete imaging through the head, unenhanced nature of the scan, and low-dose acquisition technique, there is some evidence of cerebral edema, suggesting that the masses were present at that time. The major intracerebral vessels including the principal vessels of the circle of [**Location (un) 431**] and the dural venous sinuses are all patent. There is no fracture. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbital and extracranial soft tissues are unremarkable. IMPRESSION: Several intracerebral white matter lesions with very thin rim-enhancement and extensive vasogenic edema; the differential diagnosis includes metastatic disease, or less likely, based on imaging characteristics, an infectious processes, such a pyogenic abscess. The pending tissue diagnosis of the lung lesion should aid in refining the diagnosis. [**2132-4-23**] Radiology MR HEAD W & W/O CONTRAS - read pending. Prelim examinations shows extensive lesions and edema consistent w/ prior CT head. prelim PATH: poorly differentiated lung cancer Neurophysiology Report EEG Study Date of [**2132-4-24**] IMPRESSION: This is an abnormal continuous ICU monitoring study because of excessive drowsiness. Given the time of day that this study started, it still may be within normal limits. There were no significant focal abnormalities to go along with the clinical examination and history. No seizures were recorded and no interictal epileptic activity was identified. CT HEAD W/O CONTRAST Study Date of [**2132-4-24**] 11:40 AM IMPRESSION: Overall stable mass effect from the multiple intracranial lesions causing significant distortion of the midbrain, which continues to raise concern for impending downward transtentorial herniation. However, the basal cisterns at this stage remain preserved MRI: Rim enhancing lesions in the right cerebellum, left frontal corona radiata and left post-central region and right parieto-temporal lobes with surrounding edema and mass effect as described above; abnormal enhancement surrounding the right lateral ventricle likely representing subependymal extension. Differential diagnosis includes metastatic disease versus infective etiology such as fungal, other etiology etc. Possible leptomeningeal involvement given the subependymal enhancement. Correlate clinically and labs and rec. NS consult/close f/u if no surgical intervention is contemplated Brief Hospital Course: Ms. [**Known lastname 112340**] is a 51 yo F with LUL and RUL FDG avid lesions who presented to [**Location (un) 1459**]/[**Hospital3 **] in [**Month (only) 958**] with unintentional weight loss and severe left sided chest and arm pain admitted for expedited workup of lung lesions, now found to have altered mental status and brain masses. #Non-small cell lung cancer with brain metastasis complicated by cerebral edema with encephalopathy and motor weakness. Pt was initially very confused and noncompliant with pieces of exam with repetition of phrases such as "it's weird" and "i don't know". Electrolytes were all normal. Pt's alterness and interactiveness improved by mid-day [**2132-4-23**], but CT head w/ contrast showed extensive rim enhancing brain lesions and edema as described above, concerning for brain mets versus less likely infection. Neuro-oncology was consulted and felt that imaging was consistent with metastatic disease, but could not rule out infection. Given the extent of edema and pt's worsening mental status, Pt was started on dexamethasone 12mg iv x 1, followed by dexamethasone 4mg iv q6h. Pt reportedly had seizure like activity on [**2132-4-23**] evening, and Pt was started on levetiracetam 1000mg iv x 1 and 750mg iv q12h. Pt had MRI on [**2132-4-23**] evening, showing multiple masses consistent w/ CT. On [**2132-4-26**] morning, Pt was found to be anisocoric w/ L pupil 5mm and R pupil 2mm, intermittently responsive to light and only responsive to pain. Given changes in mental status and marked concern from neurosurgery consult service, discussed with Neuro-onc attending, who transferred pt to neuro-icu for dexamethasone (4mg IV Q6H and mannitol 25g Q4H). The patient's pupil asymmetry improved with mannitol. However on [**4-27**] and [**4-28**] she again had pupil asymmetry that was again mannitol responsive. Patient was extubated on [**2132-4-26**] and [**2132-4-27**] a family meeting was held at the bedside with palliative care, neurosurgery, SICU team, Dr. [**Last Name (STitle) 6570**] and patient's mother/sister. It was explained that patient will likely not survive and she is too unstable to receive any treatment at this time, including whole brain radiation. They agreed to a plan that includes continuing basic supportive care hoping patient will stabilize so she can receive whole brain radiation; if patient deteriorates do not allow suffering, treat any symptoms of distress; if she is actively dying make her comfortable and she is DNR/DNI. Per Dr. [**Name (NI) 86075**] recommendations, mannitol was weaned off on [**4-28**]. She was transferred to the medical service with Dr. [**Last Name (STitle) 6570**] and palliative care following. At that point the family understands that the primary issues are to control her symptoms including pain, discomfort, agitation, anxiety. Over the following 3 days she did not have any substantial improvement in her confusional state and her exam waxed/wanned between acute agitation with yelling, pulling at clothes/hair, and sedation. Given the lack of clinical improvement, Dr. [**Last Name (STitle) 6570**] and the medical team agreed that radiation therapy is not safe and should not be pursued and that the patient be made comfort care only. Her likely disposition which the family understands will be to hospice. Guardianship paperwork was completed as patient cannot make her own decisions and she has no healthcare proxy appointed. #Comfort: She was started on haldol, ativan and dilaudid which helped with her agitation. Palliative Care followed the patient and made recommendations on adjustments to medications to maximize comfort. #LUL mass: Lung biopsy during this admission returned showing poorly differentiated cancer with squamous features. The patient's mannitol was stopped on [**4-28**] and she was transferred to the Medical Oncology team. # Chest pain: patient c/o chest pain on admission, likely related to her lung mass abutting the pleura. DDx included fungal infection, infiltrating malingancy, bony mets, pulmonary embolism and ACS. However, pt was not tachycardic, and had no hypoxia so we felt PE was less likely. ACS was unlikely given ECG with no changes and ongoing nature of chest pain with reproducibility on palpation and position changes. # RUE, RLE numbness and weakness: Atrius records suggest RLE/LUE sensorimotor neuropathies, but unable to discern on exam due to lack of Pt participation. [**Name (NI) 1094**] mother describes that Pt has R upper extremity and R lower extremity numbness and weakness for at least 2 weeks. Very likely due to multiple brain masses. # Normocytic chronic anemia: Hct on admission 32, most recent baseline high 20s to low 30s. Atrius records not c/w anemia of chronic disease or [**Doctor First Name **]. Bilirubin, haptoglobin, and LDH are all normal. Possibly due to anemia of chronic disease. Continue folate supplementation (low on Atrius records) # Social issues: Per pt's stated preferences, she does not want her husband to make health care decisions on her behalf. Social work also helping with [**Name (NI) 1094**] mother's coping with new diagnosis of brain masses with poor prognosis. At this time there is no signed HCP, and guardianship paperwork was filled out by Dr. [**Last Name (STitle) **]. . The patient expired on [**2132-5-11**] at 9:06am. Family members were [**Name (NI) 653**] by phone, and they arrived later in the day (mother, sister, and brother-in-law). They declined an autopsy. The family said they would notify the patient's husband, who was incarcerated on the day of the patient's death. Medications on Admission: Patient says "none" but per recent Atrius notes, Folic acid, gabapentin, Vicodin p.r.n., Aleve. Gabapentin was started a few weeks ago to try and help with her numbness. Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: lung cancer, metastatic brain metastasis cerebral edema encephalopathy catheter associated uti Discharge Condition: expired Discharge Instructions: none Followup Instructions: none

[ "790.7", "782.0", "162.3", "348.30", "305.1", "E879.6", "276.2", "338.3", "799.02", "041.49", "198.3", "599.0", "V66.7", "V49.86", "379.41", "285.22", "996.64", "287.5", "348.5" ]

icd9cm

[ [ [] ] ]

[ "96.04", "38.97", "96.71", "33.26", "40.11" ]

icd9pcs

[ [ [] ] ]

16813, 16822

10933, 16563

317, 367

16961, 16970

5099, 5099

17023, 17030

4084, 4125

16784, 16790

16843, 16940

16589, 16761

16994, 17000

4140, 4154

266, 279

395, 3520

5116, 10910

4168, 5080

3542, 3675

3691, 4068

23,633

159,089

24824

Discharge summary

report

Admission Date: [**2184-10-12**] Discharge Date: [**2184-10-27**] Date of Birth: [**2106-6-14**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Shortness of breath, syncope Major Surgical or Invasive Procedure: [**2184-10-13**] Aortic valve replacement with 25 millimeter CE Pericardial Tissue Valve History of Present Illness: This is a 78 year old male with known aortic stenosis since [**2173**]. He has been followed by serial echocardiograms and has been asymptomatic until this past year when he began to experience progressive fatigue, shortness of breath and dyspnea on exertion. He also experienced a syncopal episode. Cardiac catheterization in [**2184-2-17**] confirmed moderate to severe aortic stenosis with a valve area of 0.9 cm2. Angiography showed no significant coronary artery disease with only a 20% lesion in the first diagonal artery. His most recent ECHO from [**2184-7-19**] revealed an aortic valve area of 0.7cm2 with peak and mean gradients of 91 and 48 mmHg. There was mild to moderte aortic insufficiency and only trace mitral regurgitation. Past Medical History: Aortic Stenosis; Hypertension; Chronic Renal Insufficiency; COPD; Anemia; GERD; BPH; Depression; Asthma; Diverticular Disease; Hiatal Hernia; Hemorrhoids; Appendectomy; Bilateral Cataract Surgery; Skin Cancer; s/p appendectomy Social History: Married, retired, lives in [**Hospital1 1562**]. At least a 65 pack year history of tobacco - quit 2 years ago. Family History: No prematue coronary disease. Father died at age 39 of rheumatic heart disease. Physical Exam: VITALS: BP 120/70, HR 84 GENERAL: elderly male in no acute distress HEENT: oropharynx benign NECK: supple, no JVD HEART: regular rate, normal s1s2, 2/6 systolic murmur LUNGS: decreased right base o/w clear. delayed expiration, no wheeze ABDOMEN: soft, nontender, normoactive bowel sounds EXT: warm, trace edema PULSES: 2+ distally NEURO: alert and oriented; normal gait but slow, upper extremity tremors noted, no focal deficits noted Pertinent Results: [**2184-10-12**] 04:15PM BLOOD WBC-5.3 RBC-3.32* Hgb-11.3* Hct-32.5* MCV-98 MCH-34.1* MCHC-34.9 RDW-13.5 Plt Ct-166 [**2184-10-17**] 04:37AM BLOOD WBC-8.2 RBC-2.69* Hgb-8.6* Hct-25.7* MCV-96 MCH-32.1* MCHC-33.5 RDW-15.7* Plt Ct-63* [**2184-10-24**] 06:00AM BLOOD WBC-10.9 RBC-3.44* Hgb-10.6* Hct-32.6* MCV-95 MCH-30.8 MCHC-32.5 RDW-14.7 Plt Ct-174 [**2184-10-12**] 04:15PM BLOOD PT-12.5 PTT-24.3 INR(PT)-1.0 [**2184-10-25**] 06:10AM BLOOD PT-13.0 PTT-23.9 INR(PT)-1.1 [**2184-10-12**] 04:15PM BLOOD Glucose-101 UreaN-39* Creat-1.5* Na-141 K-4.6 Cl-105 HCO3-27 AnGap-14 [**2184-10-17**] 01:40PM BLOOD Glucose-93 UreaN-59* Creat-3.0* Na-137 K-5.2* Cl-102 HCO3-24 AnGap-16 [**2184-10-25**] 06:10AM BLOOD Glucose-98 UreaN-28* Creat-1.6* Na-143 K-4.4 Cl-103 HCO3-30 AnGap-14 [**2184-10-19**] 09:18PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019 [**2184-10-19**] 09:18PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2184-10-27**] 07:40AM BLOOD WBC-11.9* RBC-2.90* Hgb-9.3* Hct-28.0* MCV-96 MCH-32.1* MCHC-33.3 RDW-14.8 Plt Ct-215 [**2184-10-27**] 07:40AM BLOOD Plt Ct-215 [**2184-10-27**] 07:40AM BLOOD Glucose-93 UreaN-36* Creat-1.9* Na-144 K-4.7 Cl-105 HCO3-29 AnGap-15 [**2184-10-27**] CXR Comparison made to prior study of [**2184-10-24**]. There are small bilateral pleural effusions. The lungs are otherwise clear. Mild cardiac enlargement is present and is unchanged from the prior study. [**2184-10-22**] MRI/MRA Head Diffusion images demonstrate no evidence of acute infarct. There is no evidence of midline shift, mass effect, or hydrocephalus seen. Mild changes of small-vessel disease are noted in the white matter. There is mild-to-moderate brain atrophy seen. IMPRESSION: No evidence of acute infarct. MRA OF THE HEAD: The head MRA is somewhat limited by motion. The MRA demonstrates no evidence of vascular occlusion or high-grade stenosis in the arteries of anterior or posterior circulation. IMPRESSION: Slightly motion-limited normal MRA of the head. Brief Hospital Course: Mr. [**Known lastname 18134**] was admitted on [**2184-10-12**]. The following day, he underwent an aortic valve replacement with a 25 millimeter pericardial tissue valve. Surgery was uneventful and he transferred to the CSRU for invasive monitoring. Within 24 hours, he was extubated and awoke neurologically intact. He was successfully weaned from inotropic support and transferred to the SDU on postoperative day one. He remained somewhat hypotensive with a low hematocrit, dropping as low as 24%. He was concomitantly noted to have an acute decline in renal function with creatinine peaking to 3.0 on postoperative day five. Over several days, he received several units of packed red blood cells with an appropriate response in blood pressure and hematocrit. His renal function slowly improved. Due to worsening tremulousness of his upper extremities(which was noted preop), along with gait disturbance and hallucinations, the neurology service was consulted. A brain MRI/MRA was essentially normal. A full work-up as an outpatient was recommended and follow-up appointments were scheduled. He was also noted to have thrombocytopenia. An HIT assay was checked which was negative. By time of discharge, his platelet count had normalized. He also continued to have bilateral expiratory wheezes post-operatively and required nebulizer treatments. Mr. [**Known lastname 18134**] had a run of Atrial fibrillation on POD #9 and Amiodarone and Lopressor were started with conversion to normal sinus rhythm. Despite him being rather stable, he was not able to achieve a level 5 status at POD #12. On post-op Day # 13, his Foley was re-inserted for a post-void residual of roughly 1 liter. Flomax and proscar were started, and he should attempt another voiding trial at rehab. Bactrim was started for prophylactic foley coverage and follow-up should be made with a urologist if retention continues. The occupational therapy and physical therapy service worked with Mr. [**Known lastname 18134**] daily. He continued to make steady progress and was discharged to [**Hospital3 **] on postoperative day fourteen. He will follow-up with Dr. [**Last Name (Prefixes) **], his cardiologist, his primary care physician, [**Name10 (NameIs) **] neurology service and the urology service as an outpatient. Medications on Admission: 1. Depakote 500 [**Hospital1 **] 2. Zyprexa 7.5 qam 3. Aricept 10 qam 4. Remeron 45 qpm 5. Flomax 0.4 qd 6. Effexor 150 [**Hospital1 **] 7. Proscar 5 qd Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Divalproex Sodium 500 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a day). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 4. Olanzapine 7.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 5. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). Disp:*30 Tablet(s)* Refills:*0* 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*1* 7. Mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). Disp:*90 Tablet(s)* Refills:*0* 8. Venlafaxine 37.5 mg Tablet Sig: Four (4) Tablet PO BID (2 times a day). Disp:*240 Tablet(s)* Refills:*0* 9. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 10. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 13. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Take 400mg 2x/day for until [**2184-10-28**]. Than 200mg 2x/day for 1week. Than 200mg 1x/day thereafter. Disp:*120 Tablet(s)* Refills:*1* 14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 15. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily) for 7 days. Disp:*14 Capsule, Sustained Release(s)* Refills:*0* 16. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 17. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation every four (4) hours as needed for shortness of breath or wheezing. 18. Combivent 103-18 mcg/Actuation Aerosol Sig: Two (2) Inhalation four times a day. 19. Sulfamethazine Powder Sig: One (1) Tablet Miscell. DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**] Discharge Diagnosis: Aortic Stenosis s/p Aortic Valve Replacement (tissue valve ) on [**2184-10-13**] Post-operative Atrial Fibrillation Hypertension Chronic Renal Insufficiency Chronic Obstructive Pulmonary Disease Anemia Gastroesophageal Refulx Disease Benign Prostatic Hypertophy Depression Asthma Diverticular Disease Tremor Hiatal Hernia Discharge Condition: Good Discharge Instructions: 1) Can take shower, wash incision with soap and water and gently pat dry. Do not apply any lotions, creams, ointments or powders until wound has healed. 2) Do not take baths or swim until wound has healed. 3) Call office if you notice any redness or drainage from incision, fever>101, or weight gain more than 2 pounds in one day or five in one week. 4) No lifting more then 10 pounds for 10 weeks or driving for 1 month. 5) Bactrim for foley coverage. Void trial at rehab. If fails void trial, please schedule appointment with urologist. Discontinue bactrim when foley out. 6) Amiodarone 400 [**Hospital1 **] until [**2184-10-28**], then 200mg twice daily for 1 week then 200mg once daily thereafter until seen by cardiologist. 7) Lasix and potassium should be taken as directed for 1 week then stopped unless otherwise directed by a physician. [**Name10 (NameIs) 357**] monitor electrolytes while on lasix and replete as needed. 8) Call with any questions or concerns. Followup Instructions: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1290**] in 4 weeks Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) **](cardiologist) in [**1-22**] weeks Dr. [**Last Name (STitle) **](PCP) in [**12-21**] weeks Please call providers for appointmnets. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 658**], M.D. Phone:[**Telephone/Fax (1) 1690**] Date/Time:[**2184-11-19**] 1:00 [**Hospital Ward Name 860**] 253 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8384**], MD Phone:[**Telephone/Fax (1) 1690**] Date/Time:[**2184-12-27**] 10:00 Completed by:[**2184-10-27**]

[ "427.31", "285.9", "997.1", "781.0", "V10.83", "585.9", "493.20", "V45.61", "E878.1", "V15.82", "997.5", "530.81", "401.9", "788.21", "428.0", "600.00", "424.1" ]

icd9cm

[ [ [] ] ]

[ "89.64", "35.21", "88.72", "38.91", "34.04", "39.61", "99.04", "39.64" ]

icd9pcs

[ [ [] ] ]

9042, 9154

4229, 6520

352, 443

9520, 9526

2161, 3951

10545, 11196

1610, 1691

6723, 9019

9175, 9499

6546, 6700

9550, 10522

1706, 2142

284, 314

471, 1215

3968, 4206

1237, 1465

1481, 1594

52,566

182,654

50468

Discharge summary

report

Admission Date: [**2153-10-24**] Discharge Date: [**2153-10-26**] Date of Birth: [**2081-10-10**] Sex: M Service: MEDICINE Allergies: Generic Ativan Attending:[**First Name3 (LF) 7333**] Chief Complaint: pericardial effusion Major Surgical or Invasive Procedure: Pericardiocentesis with balloon pericardiotomy History of Present Illness: 72 yo male patient of Dr. [**Last Name (STitle) **] with history of recently diagnosed stage IV NSCLC followed by Onc at [**Hospital1 2025**], COPD, and Afib admitted to CCU following pericardial drain and window. He was recently admitted here from [**Date range (1) 20188**] for drainage of pericardial effusion which was found to have malignant cells on cytology along with high suspicion for lung CA on CT from [**Hospital1 2025**]. Since then, he has followed up at [**Hospital1 2025**] (where he was admitted previously) for oncological treatment and chemo with his first dose on [**10-18**] and next dose scheduled for [**11-8**]. Since chemo, he has felt more fatigued, has had decreased appetite and nausea but denies any new shortness of breath. During an office visit with Dr. [**Last Name (STitle) **] this past Monday, he was noted to have an ECG with very low voltages concerning for re-accumulation. He was arranged for outpatient pericardiocentesis with balloon pericardiotomy and window. . In the cath lab, pericardiocentesis performed with 220cc (fluid sent for culture) drained. He tolerated the procedure well without any complications. On the floor he is comfortable with what he calls tolerable pain in his chest. . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain other than that associated with his procedure, 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: Atrial fibrillation - CABG: - PERCUTANEOUS CORONARY INTERVENTIONS: - PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: HTN Atrial fibrilation not on coumadin because of prior SDH dCHF COPD GERD Anxiety Back surgery after MVA Social History: - Tobacco history: Previous 60 pack year smoker, quit 12 years ago - ETOH: one glass of wine per night, prior heavier use - Illicit drugs: Denies No family live in US, friend [**Name (NI) **] is HCP Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION EXAM: GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 7 cm above the sternal angle. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. No rubs appreciated. LUNGS: Diminished breath sounds bilaterally, mostly at bases, no crackles or wheezes ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ . DISCHARGE EXAM: GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP not appreciated. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. No rubs appreciated. LUNGS: Diminished breath sounds bilaterally, mostly at bases, no crackles or wheezes ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: ADMISSION LABS: [**2153-10-24**] 06:01PM GLUCOSE-117* UREA N-18 CREAT-0.8 SODIUM-141 POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-29 ANION GAP-13 [**2153-10-24**] 06:01PM CALCIUM-8.8 PHOSPHATE-2.9 MAGNESIUM-2.2 [**2153-10-24**] 06:01PM WBC-6.3 RBC-4.85 HGB-15.0 HCT-45.8 MCV-94 MCH-30.9 MCHC-32.8 RDW-13.3 [**2153-10-24**] 06:01PM NEUTS-82.0* LYMPHS-11.4* MONOS-0.9* EOS-5.5* BASOS-0.2 [**2153-10-24**] 06:01PM PLT COUNT-114* [**2153-10-24**] 06:01PM PT-12.9 PTT-24.1 INR(PT)-1.1 . PERICARDIAL FULID: [**2153-10-24**] 11:50AM OTHER BODY FLUID WBC-800* RBC-[**Numeric Identifier **]* POLYS-43* LYMPHS-50* MONOS-7* [**2153-10-24**] 11:50AM OTHER BODY FLUID TOT PROT-3.2 GLUCOSE-101 LD(LDH)-947 AMYLASE-20 ALBUMIN-2.2 . PERICARDIOTOMY COMMENTS: 1. Pericardiocentesis was performed with needle entry from the subxiphoid position. Opening pericardial pressure was 5mmHg. 2. Pericardiotomy was performed using balloon. 3. Subsequent to 220mL of sanguinous fluid was drained from the pericardium and confirmation of minimal residual pericardial effusion a pericardial drain was placed. FINAL DIAGNOSIS: 1. Mild pericardial tamponade status post balloon pericardiotomy. . PRE PROCEDURE ECHO [**2153-10-24**] There is a small to moderate sized pericardial effusion. The effusion appears circumferential. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. . Compared with the prior study (images reviewed) of [**10-5**]/201, the pericardial effusion has increased in size. . POST-PROCEDURE ECHO [**2153-10-25**] Limited views. There is a small pericardial effusio similar to prior effusion seen after the pericardiocentesis [**2153-10-24**] which appears loculated and not circumferential. No diastolic collapse of RA as seen on echocardiogram prior to the pericardiocentesis on [**2153-10-24**]. . ECHO [**2153-10-26**] There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. Brief Hospital Course: 72 yo male patient of Dr. [**Last Name (STitle) **] with history of recently diagnosed Stage IV NSCLC s/p one cycle of chemo at [**Hospital1 2025**], COPD, afib, dCHF admitted to CCU for monitoring s/p pericardial drain and balloon pericardotomy. . #Malignant Pericardial Effusion: Mr [**Known lastname 105142**] [**Last Name (Titles) 1834**] pericardial drainage with 220 cc immediate drainage and the drain was left in place. He also [**Last Name (Titles) 1834**] balloon pericardiotomy. The the drain output was less than 80ccs and the drain was pulled the next day. Post procedure echos showed resolution of the effusion. . CHRONIC ISSUES: #Stage IV NSCLC: Followed at [**Hospital1 2025**] and undergoing chemo. . #COPD: Stable. Continued Advair. . #Atrial fibrillation: Rate controlled with home diltiazem while admitted. Not on warfarin for prior SDH. Continued aspirin. . #GERD: Continued home pepcid 20 mg daily . #HTN: Continued home diltiazem. . #Anxiety: Cont ativan [**Hospital1 **] PRN . TRANSITIONAL ISSUES: #Pericardial effusion: He should undergo repeat echo to ensure the effusion has not recurred prior to follow up with Dr. [**Last Name (STitle) **] in [**3-7**] weeks. Medications on Admission: Diltiazem 120 mg daily Advair inh [**Hospital1 **] ASA 81 mg daily Ativan 0.5 mg daily Pepcid 10 mg daily Discharge Medications: 1. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO BID (2 times a day). 2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 5. pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. famotidine 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. Home oxygen O2 at 2 L per minute per nasal cannula continuously pulse dose portability to keep O2 Sat above 92%. Patient desatted to <88% on ambulation. Discharge Disposition: Home Discharge Diagnosis: Primary: Pericardial effusion Secondary diagnosis: Cancer, most likely lung COPD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 105142**], It was a pleasure taking care of you during your stay here at [**Hospital1 18**]. You were admitted to the hospital with a fluid collection around your heart. You [**Hospital1 1834**] a procedure which resolved this collection and improved your symptoms. You were monitored closely in the CCU and did very well. You are being discharged home with plans to follow-up with Dr. [**Last Name (STitle) **] in 1 month. No changes were made to your medications. Please continue to use your home oxygen. Followup Instructions: Department: CARDIAC SERVICES When: WEDNESDAY [**2153-11-21**] at 4:20 PM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "198.89", "162.9", "496", "423.3", "300.00", "428.0", "427.31", "428.32", "530.81", "V46.2", "423.8" ]

icd9cm

[ [ [] ] ]

[ "37.0", "37.12" ]

icd9pcs

[ [ [] ] ]

8522, 8528

6444, 7073

299, 348

8655, 8655

4399, 4399

9366, 9686

2753, 2870

7791, 8499

8549, 8581

7661, 7768

5502, 6421

8806, 9343

2885, 3641

2299, 2380

3657, 4380

7467, 7635

239, 261

376, 2194

8602, 8634

4415, 5485

8670, 8782

2411, 2518

7089, 7446

2216, 2278

2534, 2737

56,149

100,350

38183

Discharge summary

report

Admission Date: [**2197-6-7**] Discharge Date: [**2197-6-12**] Date of Birth: [**2112-10-10**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 3531**] Chief Complaint: Seizure/sepsis Major Surgical or Invasive Procedure: CVL, intubation History of Present Illness: Ms. [**Known lastname **] is an 84 yo female with PMH of DM, resident of a nursing home, who presented to [**Hospital3 4107**] after being found at her nursing home with periods of unresponsiveness of facial twitching. Per her daughter, she was talking and in her normal state of health at her evening meal on [**6-6**]. She had a repeat of these periods at [**Hospital1 **]. Per report, there was no generalized tonic-clonic component but possibly some tonic head turning and upper extremity shaking. There, she was also noted to be hypotensive with systolic BP in the 80s and as low as 50/p and hypothermic to 95. She was intubated for airway protection in the setting of possible status and also for hypotension. She had a negative head CT as well as a CT thorax which was unremarkable. She was given phosphenytoin, vancomycin 1g, possibly levo, ativan, cerebryx and sent to [**Hospital1 18**] because there was no neurologist there. . She has had a big decline over the past year cognitively. She suffered a fall last year and has since been in a nursing facility. She has had dementia diagnosed. She also has had two heel ulcers in the last year, the latest over the past four months last requiring antibiotics 2 months ago. She has also lost 15lb in the last 2 months with decreased appetite. . Initial vitals in the ED: T 95 HR 73 110/60 RR18 intubated, sedated with fentanyl/versed, on dopamin (10-15mcg). Her pupils were reactive and her neck supple. She was noted to have pyuria > 50, + nitrite, WBC 20 with 90% neutrophils, and a heel ulcer that looked infected. Cefepime was added to the vanc she already had. An IJ was attempted for access, but was not successful, so a right femoral line was placed. She was given 2L IVF rapidly, but her SBP remained in the 80s if the dopa was taken off. They did however get her dopa down to 5mcg with the fluid and reduction of her sedation. Neurology was consulted who recommended keppra 1g IV. Her lactate was 1.5, down to 0.7 on repeat. ABG showed pH 7.40/34/312. . Upon arrival, she is on 7.5mcg of dopa. . Past Medical History: DM neuropathy gout PVD cervical CA age 49 s/p hysterectomy chronic heel ulcers Social History: [**11-3**] yr smoking history, quit in her late 30s. No alcohol. Retired bookkeeper. Lives in a nursing home. Husband died in his late 60s. Family History: no history of seizure disorder Physical Exam: vitals: 110/56 86 100% 50% FiO2. AC 500/12 gen: intubated sedated. Not responding to voice or painful stimuli. heent: ncat, mmm. pupils pinpoint 2 to 1 mm reactive to light. neck: JVD 10-12 CM pulm: CTA anteriorly. no w/r/r cv: HRRR, 1/6 SEM throughout. quiet S1/S2. abd: NT/ND. hypoactive BS neuro: intubated, sedated, not responding to voice or painful stimuli. Not following commands. Extremities: dressing on right heal ulcer. No C/C/E. Non dopplerable LE peripheral pulses, 2+ in UEs. Pertinent Results: [**2197-6-7**] 05:49PM CEREBROSPINAL FLUID (CSF) PROTEIN-50* GLUCOSE-96 [**2197-6-7**] 05:49PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-27* POLYS-3 LYMPHS-46 MONOS-50 ATYPS-1 [**2197-6-7**] 04:20PM TYPE-ART PO2-236* PCO2-41 PH-7.38 TOTAL CO2-25 BASE XS-0 [**2197-6-7**] 04:20PM LACTATE-1.5 [**2197-6-7**] 04:10PM WBC-14.2* RBC-3.47* HGB-9.1* HCT-28.7* MCV-83 MCH-26.3* MCHC-31.7 RDW-18.0* [**2197-6-7**] 04:10PM PLT COUNT-483* [**2197-6-7**] 04:10PM PT-12.6 PTT-24.1 INR(PT)-1.1 [**2197-6-7**] 04:10PM FIBRINOGE-596* [**2197-6-7**] 05:09AM GLUCOSE-141* LACTATE-0.7 [**2197-6-7**] 05:06AM GLUCOSE-177* UREA N-18 CREAT-0.9 SODIUM-141 POTASSIUM-3.5 CHLORIDE-108 TOTAL CO2-21* ANION GAP-16 [**2197-6-7**] 05:06AM ALT(SGPT)-9 AST(SGOT)-20 ALK PHOS-207* TOT BILI-0.5 [**2197-6-7**] 05:06AM CALCIUM-7.5* PHOSPHATE-3.8 MAGNESIUM-1.9 [**2197-6-7**] 05:06AM WBC-17.2* RBC-3.39* HGB-9.1* HCT-28.3* MCV-83 MCH-26.9* MCHC-32.3 RDW-17.6* [**2197-6-7**] 05:06AM NEUTS-89.8* LYMPHS-6.5* MONOS-3.5 EOS-0.1 BASOS-0.1 [**2197-6-7**] 05:06AM PLT COUNT-349 [**2197-6-7**] 01:18AM TYPE-ART RATES-[**12-26**] TIDAL VOL-500 PEEP-5 PO2-312* PCO2-34* PH-7.40 TOTAL CO2-22 BASE XS--2 -ASSIST/CON INTUBATED-INTUBATED [**2197-6-7**] 12:59AM GLUCOSE-185* LACTATE-1.5 K+-4.0 [**2197-6-7**] 12:50AM UREA N-22* CREAT-1.2* [**2197-6-7**] 12:50AM LIPASE-35 [**2197-6-7**] 12:50AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2197-6-7**] 12:50AM URINE HOURS-RANDOM [**2197-6-7**] 12:50AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2197-6-7**] 12:50AM WBC-20.0* RBC-4.08* HGB-10.5* HCT-34.1* MCV-84 MCH-25.7* MCHC-30.8* RDW-17.6* [**2197-6-7**] 12:50AM NEUTS-90.9* LYMPHS-5.0* MONOS-3.7 EOS-0.1 BASOS-0.3 [**2197-6-7**] 12:50AM PLT COUNT-415 [**2197-6-7**] 12:50AM PT-12.3 PTT-23.6 INR(PT)-1.0 [**2197-6-7**] 12:50AM FIBRINOGE-666* [**2197-6-7**] 12:50AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.020 [**2197-6-7**] 12:50AM URINE BLOOD-LG NITRITE-POS PROTEIN-300 GLUCOSE-100 KETONE-15 BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-LG [**2197-6-7**] 12:50AM URINE RBC-21-50* WBC->50 BACTERIA-MANY YEAST-NONE EPI-[**6-29**] [**2197-6-7**] 12:50AM URINE AMORPH-MOD CT head from [**Hospital1 **]: There is no evidence for midline shift. There is no CT evidence for an acute infarct or intracranial hemorrhage or for hydrocephalus. Moderate white matter disease and volume loss are identified. The sinuses, mastoids and orbits appear normal. There is no evidence for an acute fracture or malalignment. Impression: There are no acute concerning abnormalities. . CT chest/abd/pelvis from [**Hospital1 **]: There is no evidence for aortic dissection or for a pericardial effusion on these noncontrast images. It is not possilbe to assess for pulmonary embolus on these noncontrast images. The tip of the endotracheal tube is approximately 3.5cm above the carina. There is no signficant adenopathy. There is probable atelectasis/scar in the lungs. There is a small right pleural effusion. Tehre is no pneumothorax. Degenerative change i identified in the spine. There is no evidence for acute fracture or malalignment. There has been a cholecystecomy. there is no evidence for pancreatitis. There is no evidence for renal calcifications or for hydronephrosis. The urteters appear normal in caliber where visualized. Hypodenisities in the kidney are too small to definitiely characterize although statistically they most likely represent benign cysts. there is a large amount of stool in the rectosigmoid colon suggesive of constipation. there is no significant bowel dilation. Bowel evaluation is limited on these noncontrast images. No bowel mass is seen. Degenerative change is identified in the spoine. There is no evidence for acute fracture or malalignment. there is no evidence for abdominal or pelvic adneopathy by CT size criteria. Impression: There is a large amount of stool in the rectosigmoid colon suggestive of constipation. There is a small right pleural effusion. There is no pneurmothorax. . CXR [**2197-6-6**]: endotracheal 2.7 cmabove advanced OG tube gastric distension streaky opacity likely atelectasis no consolidation. . EEG: IMPRESSION: Abnormal portable EEG due to the disorganized and slow background and bursts of generalized slowing, a few with triphasic or sharp appearances. These findings indicate a widespread encephalopathy affecting both cortical and subcortical structures. There were no areas of prominent focal slowing, but encephalopathies may obscure focal findings. Sharp features appear to be more likely part of the encephalopathy. There were no simple spike or sharp and slow wave discharges. An abnormal cardiac rhythm was noted, but this would be assessed better through routine ECG tracings. . MRI HEAD: IMPRESSION: 1. No evidence of acute infarct, mass or hemorrhage. 2. Diffuse enlargement of the ventricles, including the temporal horns indicating brain and medial temporal atrophy. Brief Hospital Course: # Sepsis: Originally she met SIRS criteria with WBC 17-20 and temp 95F, and most likely sources urinary +/- skin (right heel). She also has septic shock with low UOP and seizures possibly related to her sepsis. Pulmonary source less likely with negative CXR. CNS source had to be considered since she had seizures. A femoral line was placed because of collaps of her IJ during insertion, suggesting still significant volume depletion. Lactate wnl and Cr wnl. Intubation did not appear to be for respiratory failure, but for airway protection and sepsis. She was weaned off pressors after agressive IVF resuscitation. She was initially started on broad spectrum abx to cover meningitis, urinary sources, and heel ulcers as these were thought most likely causes of her septic shock. Eventually urine culture grew out Ecoli sensitive to Ceftriaxone (resistant to Cipro), LP was negatve, and blood cultures were no growth so patient's antibiotics were weaned to just Ceftriaxone for a planned 14-day course. Her femoral line was replaced with a midline prior to discharge to the floor. On transfer to the floor, she was changed to oral antibiotics (Cefpodoxime) with plan to take 8 days as outpatient to complete 14 day course. On discharge, she was afebrile and hemodynamically stable. Midline IV was pulled prior to discharge. # Seizures: No known seizure history. Differential includes primary CNS vs related to septic process. She does have a remote history of cervical CA at age 49. CT head from OSH not suggesting primary CNS source. Seen by neuro in the ED and started on keppra. MRI of the head was unrevealing with only age-related changes. LP was performed and was negative. Abx were tailored to treat UTI only from meningitis coverage (originally with vancomycin and ceftriaxone at 2gm to ceftriazone only). Neurology continued to follow. Keppra was discontineud and eeg off keppra showed no seizure activity. Neurology recommended she follow-up with a neurolgist as an outpatient. Should Mrs. [**Known lastname **] decide to follow-up at [**Hospital1 18**], the number has been provided. Ultram was not continued on discharge due to potential to lower seizure threshold. # Right Heel Pressure Ulcer - Present on admission and originally concerned for possible source of infection. Wound consult was obtained and pressure ulcer was cared for per wound care recommendations. # DM: Controlled with humalog insulin sliding scale. Discharged on sliding scale without restarting standing Novolin N. Nursing home facility can restart Novolin N pending evaluation of PO intake and blood sugars. # Dementia: Restarted dementia medications after CNS infeciton ruled-out. Medications on Admission: per Nursing Home Allopurinol 100 mg daily Lidoderm patch daily R cervical spine MVI with minerals Prilosec 40 mg daily KCl 20 mEq daily Lopid 600mg [**Hospital1 **] Namenda 10 mg [**Hospital1 **] Ultram 25 mg [**Hospital1 **] Zyprexa 2.5 mg po BID ES Tylenol 1000mg Q8H Aricept 10 mg QHS Melatonin 1mg QHS Glucerna health Novolin N 12U SC QAM before breakfast FS 6:30AM, 4:30pm ISS with regular insulin 70-130 0 180 2 240 4 300 6 350 8 400 10 >400 12 PRN Glucagon Discharge Medications: 1. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 8 days: LAST DAY [**2197-6-20**]. 2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): To right cervical spine. Apply for 12 hours then remove for 12 hours prior to placing next patch. 4. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for sedation. 9. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 10. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 11. Melatonin 1 mg Tablet Sig: One (1) Tablet PO at bedtime. 12. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 13. Humalog 100 unit/mL Solution Sig: 0-10 Subcutaneous three times a day: Per sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital3 13990**] Discharge Diagnosis: Primary Diagnosis: - Sepsis - Respiratory Failure - Urinary Tract Infection - Hypotension - Seizure - Right Heel Pressure Ulcer (present on admission) Secondary Diagnosis: - Diabetes Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital with a very serious infection that affected many organs. You required antibiotics, medicaiton to raise your blood pressure and a machine to temporarily breath for you. The source of the infection was felt to be from an untreated urinary tract infection. You also had a seizure at the emergency room prior to transfer to [**Hospital1 **] Hospital. You were temporarily placed on medication to help prevent seizures while the neurologists evaluated you and felt you did not need to continue the medication, but should be evaluated by neurologist after discharge. CHANGES IN MEDICATIONS: START - Cefpodoxime 200 mg by mouth twice a day for 8 days STOP - Ultram STOP - Novolin N (may restart once PO intake improved) STOP - Potassium Chloride HOLD - Glucerna (may restart once evaluated in nursing home) Please take all other medication as previously prescribed. Followup Instructions: Please follow-up with a Nuerologist as an outpatient. An appointment should be arranged at your earliest convenience. If you choose to see a Neurologist at [**Hospital1 1170**], please call [**Telephone/Fax (1) **]

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icd9cm

[ [ [] ] ]

[ "03.31", "96.71", "38.91", "96.04" ]

icd9pcs

[ [ [] ] ]

12762, 12810

8342, 11035

287, 304

13038, 13038

3267, 8319

14139, 14359

2698, 2730

11550, 12739

12831, 12831

11061, 11527

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332, 2418

13004, 13017

12850, 12983

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2440, 2520

2536, 2681

23,036

149,907

23706

Discharge summary

report

Admission Date: [**2132-5-29**] Discharge Date: [**2132-7-1**] Date of Birth: [**2063-8-24**] Sex: F Service: MEDICINE Allergies: Amoxicillin / Sulfa (Sulfonamides) / Codeine / Iodine; Iodine Containing Attending:[**First Name3 (LF) 943**] Chief Complaint: E. Coli bacteremia Major Surgical or Invasive Procedure: colonoscopy History of Present Illness: 68 year old female with history of cirrhosis from AIH on transplant list, and celiac dx, who presented to OSH 1 week ago with abrupt onset of rigors, F/C, diarrhea which awoke her from sleep. On admission her temp was 104 but was and remained hemodynamically stable. Blood cxs drawn on admission grew [**1-2**] pan sensitive E. Coli and Urine cx grew MSSA. Her creatinine was slightly elevated on admission at 1.2 but trended down with IVFs. She was initially treated with IV Cipro and gent and later switched to PO Cipro. She defervesced and subsequent cultures were negative. Stool cultures were also negative. W/U for the source of bacteremia included an Abd CT w/o contrast which showed a moderately distended GB, ascites, ? inflammatory changes involving R colon and mid small gut, and decreased density of renal pyramids suggestive of chronic UPJ obstruction; RUQ U/S wich showed sludge with moderately distended GB, MRCP which showed very large BF showing areas of decreased signal in region of GB neck/prox cystic duct but no definite ductal dilatation and no stones in hepatic or CBD. Her Azathioprine was held since admission. Her WBC dropped to 1.5 but returned to 3.5 the following day and has remained stable. She was transferred to [**Hospital1 18**] for surgical evaluation regarding possible cholecystectomy and unknown source of bacteremia. Upon admission, pt denies abd pain, biliary colic, dysuria, urinary frequency, SOB, or cough. She reports having had mild chills several days earlier but it went away and she had been feeling well. She denies any sick contacts or eating anything unusual. Currently she feels well without complaints. She ate a [**Country 1073**] [**Location (un) 6002**] without any resulting abdominal pain. Past Medical History: PMH: -AIH dx 5y ago, on azathioprine -cirrhosis s/p recent liver bx, on transplant list, h/o ascites but no varicies on recent EGD, no h/o SBP, no h/o encephalopathy -celiac sprue on gluten free diet -osteoporosis -asthma, bronchitis, COPD(PFT [**4-3**] with FEV1 1.68 (87%), FEV1/FVC 89%, TLC 98%) -eczema -recent urinary tract infection -s/p hysterectomy 32 years ago for fibroids -s/p laryngeal tumor removed (benign) in [**2112**] -allergies -1+ MR (on TTE [**5-4**]) -h/o Etoh abuse Social History: Ex smoker. Quit 5 years ago. Used to drink heavily, worked as a bartender, also quit 5 years ago. Has 4 children. She is divorced and subsequently widowed female. She works 4 days per week as a hostess in a restaurant. Family History: Father died of cirrhosis. Mother had hepatitis and some form of cancer. Brother has CABG. Physical Exam: Vit: 99.1 96/58 78 18 95%RA thin woman in NAD sclera anicteric, MMM supple, no LAD RRR, no MGR, nl S1, S2 bibasilar crackles, otherwise CTA soft, +BS, NT, ND, no HM, neg [**Doctor Last Name **], no fluid wave no CVAT no edema [**Location (un) **] erythema, few spiders A&O x 3, no asterixis Pertinent Results: [**2132-5-30**] Albumin-1.8* Calcium-7.3* Phos-3.4 Mg-1.4* ALT-44* AST-83* AlkPhos-79 TotBili-2.1* Glucose-82 UreaN-16 Creat-0.9 Na-132* K-4.3 Cl-105 HCO3-24 PT-17.3* PTT-38.5* INR(PT)-2.0 WBC-5.0 RBC-2.44* Hgb-9.6* Hct-27.7* MCV-114* (Neuts-68 Bands-0 Lymphs-22 Monos-7 Eos-1 Baso-2 Atyps-0 Metas-0 Myelos-0) Blood cx [**5-31**] and [**6-1**] grew B frag and clostridium (not perfringens or septicum) in anaerobic bottles. Blood cx [**6-2**] no growth Blood cx [**6-7**] VRE Blood cx mycolytic and AFB [**6-9**] no growth Blood cx [**6-10**], [**6-11**], [**6-12**] No growth to date [**5-30**] Abd U/S: distended GB, small-mod ascites, no stones, cirrhotic liver. attempted diagnostic tap but not enough ascites by U/S [**6-4**] CT: B pleural effusions, small ascites, normal anatomic variant in portal vein, sigmoid diverticulosis, calcification in mesenteric arteries. [**6-4**] Echo: no vegetations, trivial MR, trace AR. EF>55% [**6-9**] colonoscopy: many sigmoid diverticuli, limited study due to anatomy, unable to visualize rest of colon. [**6-9**] virtual colonoscopy: many sigmoid diverticuli, microperforations in sigmoid colon. Brief Hospital Course: 1. Recurrent Anaerobic Bacteremia: Over her total hospitalization, Ms. [**Known lastname 60582**] failed a course of Cipro and a course of Zosyn. Her cultures showed intermittently E.coli, B frag and clostridium, and VRE. She was continued on Zosyn throughout to cover for Gram Negatives and was also placed on daptomycin 300mg IV daily. After many studies, a GI source was finally identified as her sigmoid diverticuli with microperforation. Surveillance daily blood cultures were drawn and have been negative since [**2132-6-9**]. As the pt is not a surgical candidate given her very poor liver function, she will be discharged on antibiotics indefinitely to treat for what will likely be continued recurrent seeding of her blood with GI bacteria. She also tested positive for Strongyloides antibodies and was treated with two days of ivermectin. On [**6-14**] the pt spiked a fever to 101 and fluconazole was added to regimen. She never grew fungals in any of her blood cultures, and after about one week of fluconazole her AST began to rise, so fluconazole was changed to ambisome. On day 3 of ambisome the pt developed a drug rash and antifungal therapy was discontinued. [**6-26**] Fluconazole was restarted. [**6-28**] Zosyn was d/c'ed and replaced w/ Levaquin and Flagyl, for concern of drug rash as well as possible bone marrow suppression. A PICC line was placed and the pt was d/c'ed on Daptomycin IV, and Levaquin, Flagyl, and Fluconazole po. She will follow up with infectious diseases, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**], as an outpatient. 2. Diarrhea: The pt had diarrhea at the beginning of her hospital stay, which eventually resolved, and then recurred. Stool cultures x 3 were negative for C. diff toxin. The most likely etiology for recurrent diarrhea was simple antibiotic-associated diarrhea, and cipro, zosyn, and daptomycin could all be implicated. After three weeks in the hospital, the pt's diarrhea was improved, with infrequent formed stools only. 3. Fever: The pt intermittently had fever and chills during her hospitalization likely associated with new bacterial seeding of the blood. 4. Rash: On [**6-11**] the pt developed an itchy, pink maculopapular spotty rash over her entire back and a small amount periumbilically. This was felt to be a drug rash and dermatology was consulted. Most likely etiology is allergy to daptomycin (rash on day 4) or Zosyn (rash on day 12). Temporally either was possible. Although it started after initiating daptomycin, this drug is also less likely to give rash. As the patient was thrombocytopenic, the ID team did not wish to change her datomycin to linezolid, which has a high risk of pancytopenia. We decided to treat through her drug rash, as it did not seem severe and decreased over her 3 days in the hospital and appeared to resolve on [**6-14**]. The pt was written for Atarax qhs. After one week without the rash, the atarax was discontinued. After three days, when ambisome had been started and atarax had been discontinued, the pt developed another drug rash, this time over her back, abdomen, and bilateral arms and legs. The pt was restarted on Atarax qhs, given hydrocortisone cream, and antifungal therapy was stopped, although fluconazole was eventually restarted. 5. Autoimmune hepatitis/cirrhosis: the pt was follwed by the liver team at [**Hospital1 18**]. Her azathioprine and aldactone were held during her entire admission. She is on the transplant list at this time. She will follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**]. 6. Anemia: pt remained at her stable baseline anemia with iron studies consistent with anemia of chronic disease. Per liver service, pt was transfused 2U PRBC [**2132-7-1**]. 7. FEN: the patient initially followed a gluten free diet with boost for nutrition supplement. She was then placed on bowel rest, during which time she ate a clear liquid diet and had TPN through her PICC. She was given the name of [**First Name8 (NamePattern2) 781**] [**Last Name (NamePattern1) **] to discuss celiac diet. Electrolytes, especially magnesium, were frequently repleted. She refused TPN after [**6-27**], and stated that she would eat enough po. She is discharged on a gluten free regular diet. 8. PPx: the pt remained ambulatory throughout her stay. 9. Full code. Medications on Admission: Cipro 500 mg [**Hospital1 **] Ibuprofen 800 mg QID prn Spironolactone 25 mg daily Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Bacteremia Diverticulosis Autoimmune hepatitis with cirrhosis Discharge Condition: Fair Discharge Instructions: If you have fever, chills, abdominal pain, Chest pain or shortness of breath, call Dr. [**Last Name (STitle) 497**] or go to the emergency room. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD Where: LM [**Hospital Unit Name 3126**] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2132-7-9**] 1:00 Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 5628**] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2132-7-10**] 10:40 You will also be called with an appointment with our celiac nutrition specialist.

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icd9cm

[ [ [] ] ]

[ "45.25", "38.93", "99.07", "99.15", "99.04", "45.23" ]

icd9pcs

[ [ [] ] ]

9042, 9094

4529, 8910

350, 364

9200, 9206

3353, 4506

9399, 9835

2928, 3021

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8936, 9019

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3036, 3334

292, 312

392, 2160

2182, 2671

2687, 2912

69,472

189,088

33277

Discharge summary

report

Admission Date: [**2144-2-4**] Discharge Date: [**2144-2-13**] Date of Birth: [**2086-9-15**] Sex: F Service: CARDIOTHORACIC Allergies: IV Dye, Iodine Containing Attending:[**First Name3 (LF) 165**] Chief Complaint: Syncope Major Surgical or Invasive Procedure: [**2144-2-4**] 1. Aortic valve replacement with size 23 St. [**Male First Name (un) 923**] Regent mechanical valve. 2. Mitral valve repair with size 26 [**Doctor Last Name 405**] annuloplasty band. History of Present Illness: 57 yo female w h/o known bicuspid aortic valve (x2yrs) presented to outside hospital following syncopal episode while walking to work. Echo revealed critical aortic stenosis with AVA0.7cm2. Cardiac cath confirmed critical AS and ruled out significant coronary disease. Cardiac surgery evaluation was requested for AVR. The patient states she has been more fatigued recently. She denies shortness of breath- but admittedly does not partake in a lot of physical activity. Past Medical History: Bicuspid aortic valve with aortic stenosis s/p TAH [**2142**] s/p Left nephrectomy age 24 s/p Cholecystectomy Social History: Race: Hispanic Last Dental Exam: years Lives with: two children (17 & 22), divorced Occupation: Spanish teacher- 7th & 8th grades Tobacco: denies ETOH: denies Family History: Mother alive at 87. Father passed away age [**Age over 90 **] with Alzheimers. 20 siblings and 2 children A&W. Physical Exam: Pulse: 80 Resp: 18 O2 sat: 95%RA B/P Right: Left: 107/73 Height: Weight: 273lb General: NAD, WGWN, obese female, pleasant Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur 3/6 SEM Abdomen: obese, Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema- trace Varicosities: None [x] Neuro: Grossly intact x Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: NP Left: NP Radial Right: 1+ Left: 1+ Carotid Bruit Right: Left: no bruits Pertinent Results: [**2-4**] Echo: Prebypass: A left-to-right shunt across the interatrial septum is seen at rest. A small secundum atrial septal defect is present. There is mild symmetric left ventricular hypertrophy. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve is bicuspid. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2144-2-4**] at 900am. Post bypass: Patient is AV paced and receiving an infusion of phenylephrine. Biventricular systolic function is unchanged. Mechanical valve seen in the aortic position. The leaflets move well and the valve appears well seated. The paeak gradient across the aortic valve is 20 mm Hg. The mitral regurgitation varies between 2 to 3 +. Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**] present to confirm the findings. Surgeon made aware of findings. Decided to go back on CPB to fix the mitral regurgitation. Post second bypass there is a jet seen extending from the aortic root to the left atrium. Dr [**Last Name (STitle) 3318**] present to confirm findings. Surgeon made aware. On CPB to fix it. Despite third bypass run the jet extending from the aortic root to the left atrium persists. Dr [**Last Name (STitle) **] made aware. Dr [**Last Name (STitle) **] consulted. To be left alone for now. Annuloplasty ring seen in the mitral position. It appears well seated. Trivial mitral regurgitation persists. Aorta is intact post decannulation. [**2144-2-12**] 03:40AM BLOOD WBC-13.0* RBC-3.52* Hgb-10.8* Hct-32.2* MCV-92 MCH-30.6 MCHC-33.4 RDW-14.6 Plt Ct-416 [**2144-2-12**] 03:40AM BLOOD Glucose-113* UreaN-35* Creat-1.1 Na-138 K-4.3 Cl-97 HCO3-33* AnGap-12 [**2144-2-12**] 03:40AM BLOOD Calcium-9.9 Phos-3.8 Mg-2.1 [**2144-2-11**] 04:18AM BLOOD PT-26.1* PTT-28.7 INR(PT)-2.5* [**2144-2-10**] 05:36AM BLOOD PT-25.1* INR(PT)-2.4* [**2144-2-9**] 05:32AM BLOOD PT-25.1* INR(PT)-2.4* [**2144-2-13**] 05:27AM BLOOD WBC-12.8* RBC-3.44* Hgb-10.4* Hct-31.4* MCV-91 MCH-30.1 MCHC-33.0 RDW-14.6 Plt Ct-395 [**2144-2-13**] 05:27AM BLOOD Glucose-113* UreaN-37* Creat-1.2* Na-137 K-3.8 Cl-92* HCO3-37* AnGap-12 [**2144-2-13**] 05:27AM BLOOD PT-26.5* PTT-28.1 INR(PT)-2.6* Brief Hospital Course: This 57-year-old patient with recent syncopal attacks was investigated and was found to have a critical aortic stenosis, moderate mitral regurgitation with preserved left ventricular function. The patient was brought to the operating room on [**2144-2-4**] where the patient underwent an aortic valve replacement with size 23 St. [**Male First Name (un) 923**] Regent mechanical valve and mitral valve repair with size 26 [**Doctor Last Name 405**] annuloplasty band. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. The patient was diuresed on post operative day 1 and ventilator was weaned. Early POD 2 found the patient extubated, alert and oriented and breathing comfortably. She was weaned off her vasoactive medications on post operative day 2, including epinephrine and Neosynephrine. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. She went into a rapid atrial fibrillation and was loaded with Amiodarone in the CVICU. The patient was transferred to the telemetry floor for further recovery. Beta blockers were increased and Diltiazem was added for better heart rate control. Coumadin was started for atrial fibrillation and mechanical AVR. She was therapeutic with her INR at the time of discharge with a goal INR 2.5-3.5. Chest tubes and pacing wires were discontinued without complication. Cipro was started for a Klebsiella UTI (sensitive to Cipro). She was completing a 3 day course at the time of discharge and had a repeat urine culture prior to discharge which was pending. An echocardiogram was done on [**2-13**] and results were pending at the time of this discharge summary. Upon discharge Zaroxyln was stopped and Lasix was changed to 40 mg po BID due to slight rise in BUN and creatinine. Her fluid status should be monitored closely and Lasix dosing is to be reevaluated in 2 weeks based on need for further diuresis. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 9 the patient was ambulating with assistance, she was tolerating a full oral diet, the wound was healing and pain was controlled with Ultram. The patient was discharged to [**Location (un) **] House Rehab in [**Location (un) **] in good condition with appropriate follow up appointment instructions and lab work instructions. Medications on Admission: Aspirin 81mg daily Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 7. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day: 400 mg [**Hospital1 **] x 1 week then 400 mg daily x 2 weeks then 200 mg daily x 1 month then as directed by cardiologist. 8. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 9. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): Hold for SBP<100 HR<60. 10. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day): Hold for SBP<100 HR<60. 11. warfarin 1 mg Tablet Sig: Four (4) Tablet PO ONCE (Once): Give 4 mg [**2-14**] then dose for INR goal 2.5-3.5 for mech AVR/A fib. 12. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 doses: last dose 2/18 AM. 13. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks: 40 mg [**Hospital1 **] x 1 week then 40 mg daily x 1 week. 14. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: Two (2) Tablet, ER Particles/Crystals PO Q12H (every 12 hours) for 2 weeks. Discharge Disposition: Extended Care Facility: [**Location (un) **] Nursing & Rehabilitation Center - [**Location (un) **] Discharge Diagnosis: Bicuspid aortic valve with aortic stenosis, mitral regurgitation s/p Aortic valve replacement and mitral valve repair Past medical history: s/p TAH [**2142**] s/p Left nephrectomy age 24 s/p Cholecystectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Ultram Incisions: Sternal - 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**] 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. [**First Name (STitle) **] on [**3-2**] at 2:15pm Cardiologist: Dr. [**Last Name (STitle) 11493**] on [**2-14**] at 3:45pm. Please call to schedule appointments with your Primary Care: [**Location (un) **] Family Practice (Her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 77265**] recently left practice) in [**3-31**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication A fib, Mech AVR Give Coumadin 4 mg on [**2144-2-13**] and check BUN/Crea/K/INR on [**2-14**] Goal INR 2.5-3.5 Long term Coumadin follow up to be arranged upon discharge from rehab [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2144-2-13**]

[ "285.9", "V45.73", "998.11", "746.4", "599.0", "518.5", "396.2", "287.5", "041.3", "416.8", "E878.1", "998.6", "E849.7", "787.01", "427.31", "998.0" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.12", "37.49", "35.22" ]

icd9pcs

[ [ [] ] ]

8934, 9036

4806, 7271

298, 497

9286, 9451

2150, 4783

10374, 11287

1325, 1437

7340, 8911

9057, 9175

7297, 7317

9475, 10351

1452, 2131

251, 260

525, 1000

9197, 9265

1149, 1309

7,700

125,258

20288

Discharge summary

report

Admission Date: [**2124-12-30**] Discharge Date: [**2125-1-16**] Date of Birth: [**2086-9-9**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5790**] Chief Complaint: Transfered from OSH for Aspiration PNA and gastric outlet obstruction [**1-11**] migrated gastric band. Major Surgical or Invasive Procedure: -Laparoscopic surgery to remove gastric band -Insertion of right chest tube. -Right VATS repair of right upper lobe iatrogenic laceration, VATS right middle lobe diagnostic wedge resection, multiple intercostal rib blocks, flexible bronchoscopy and aspiration of purulent secretions, mechanical pleurodesis. History of Present Illness: The pt. is a 38 year-old mle with significant h/o Myoclonus Opsoclonus on chronic ACTH and h/o of Lap. gastric banding in [**2122**], who initially presented to OSH with long h/o N/V since [**Month (only) 1096**]. Per his mother, since [**11-13**], patient has had cough, weakness, lethargy and multiple episodes of vomitting "brownish liquid". He was initially treated a month ago for community acquired pneumonia from [**Date range (1) 43171**] with levo. He finished a course of abx, but symptoms did not resolve, and he presented to [**Hospital 1562**] Hosp. on [**12-28**]. At that time he was found to have miliary pattern of infiltrate on CXR. Given his chronic steroid use and risk of immunocompromise, the patient was started on broad spectrum abx, as well as antiPCP and CMV coverage. Was taken for bronch on [**12-29**], that noted friable Right bronch. c/w asiration. Post bronch, noted to be hypoxic; CXR noted right PTX with right chest tube insertion. Was started on broad spectrum abx including PCP coverage, [**Name9 (PRE) 54460**], [**Name9 (PRE) **] and CMV. On [**12-29**], on review of rads data, was noted to have large gastric/esoph. distension c/w gastric outlet obstruction [**1-11**] to migrated gastric band. Attepmts were made by surgery and IR at OSH to relieve gastric band without success. Was arrange to be transfered to [**Hospital1 18**] for further intervention. Was intubated for airway protection on [**12-30**] for transfer to [**Hospital1 18**]. Planned to go to OR [**12-31**]. Past Medical History: Myoclonus. Opsoclonus [**3-/2123**] Lap Gastric Banding Social History: SH: lives indep. no tob/etoh/drugs . FH: Mother with HTN breats CA, PE father with [**Name (NI) 54461**] HTN: All siblings healthy Physical Exam: Vitals: T:98.5 P:75 R:14 BP:101/64 SaO2: AC 650/14/5/ 60% 7.37/42/82 General: intubated and sedated; HEENT: no scleral icterus noted, MMdry , no lesions noted in OP Neck: no carotid bruits appreciated Pulmonary: Lungs CTA bilaterally anterior with basilar crackles. Right CT: CDI: At PEEP of 8 small air leak in pleural vac. Cardiac: RR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Pertinent Results: ADMISSION LABS: [**2124-12-30**] 08:55PM BLOOD WBC-16.2* RBC-4.06* Hgb-12.2* Hct-35.5* MCV-87 MCH-30.1 MCHC-34.4 RDW-13.2 Plt Ct-191 [**2124-12-30**] 08:55PM BLOOD Neuts-89.1* Bands-0 Lymphs-7.6* Monos-2.4 Eos-0.1 Baso-0.8 [**2124-12-30**] 08:55PM BLOOD PT-14.2* PTT-25.0 INR(PT)-1.4 [**2124-12-30**] 08:55PM BLOOD Plt Smr-NORMAL Plt Ct-191 [**2124-12-30**] 08:55PM BLOOD Glucose-85 UreaN-9 Creat-0.9 Na-143 K-4.5 Cl-111* HCO3-26 AnGap-11 [**2124-12-30**] 08:55PM BLOOD Calcium-7.2* Phos-2.4* Mg-1.9 [**2125-1-2**] 02:10AM BLOOD Cortsol-20.5* [**2125-1-3**] 04:33AM BLOOD Cortsol-49.4* [**2125-1-5**] 07:38AM BLOOD Cortsol-15.4 [**2125-1-3**] 04:45AM BLOOD Lactate-0.8 K-3.2* MICRO: Intra-Op BAL: Intra-Op Path: bronchopneumonia and foreign body reaction c/w aspiration/food particles All other data NGTD. IMAGING: Admission CXR: FINDINGS: Comparison is made to the barium study from [**2124-9-13**], and chest radiograph from [**2123-10-27**]. There is a central venous catheter on the right side with the distal tip in the proximal right atrium. There is a feeding tube identified with the distal tip in the proximal gastric remnant. Contrast material pools within this remnant just above the gastric band. No contrast is seen distally. There is some radiopaque density, possibly contrast, projecting over the left heart, which is possibly external to the patient. Correlation on followup studies is recommended to this area. The cardiac silhouette is within normal limits. There is minimal density at the left base, which may be secondary to atelectasis or early infiltrate. There is some mild prominence of the interstitial markings without evidence for overt pulmonary edema. There is a right-sided chest tube identified with the distal tip in the right upper chest. No definite pneumothorax is identified. LENI: IMPRESSION: No evidence of DVT. Chest CT [**1-4**]: IMPRESSION: 1. Large right-sided pneumothorax with chest tube within the right major fissure. These findings were communicated to Dr. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 8360**]. 2. Peripheral consolidation/atelectasis in the right upper lobe and left apex. 3. Interstitial pulmonary edema. 4. Diffuse micronodules along the interlobular septa and bronchovascular bundles may represent oppurtunistic infections such as miliary tuberculosis, fungal infection.Alternatively miliary sarcoid and miliary metastasis are less likely possiblities. 5. Left lower lobe pneumonia/aspiration. 6. Subacute emphysema anterior and along the right side. CXR [**1-11**] IMPRESSION: AP chest compared to [**1-8**] and 31 and [**1-10**]: Small right pneumothorax has decreased in size with only a basal residual. Two right pleural drains are still in place. Lungs are low in volume and clear of substantial consolidation. A region of postoperative atelectasis or hemorrhage in the right lower lung is clearing. The heart is normal size and mediastinum is midline. Both subcutaneous emphysema and pneumomediastinum are resolving. CXR [**1-13**] Portable erect AP radiograph of the chest is reviewed and compared with the previous study of yesterday. Two right chest tubes remain in place. There is continued extensive subcutaneous emphysema in the right chest wall. CXR [**1-15**] after chest tube removal: There has been interval removal of a right-sided chest tube, and resolution of a small right pneumothorax. Subcutaneous emphysema remains in the right chest wall. There is otherwise no significant change from the earlier study. Brief Hospital Course: 38 yo male with chronic ACTH dependence, aspiration events [**1-11**] to funtional gastric outlet obstruction, bronchonscopy c/b right PTX. PTX - pt had chest tube in place with air leak. Went to OR [**1-5**] for VATS. Found to have an area in RUL with air leak (likely [**1-11**] bronch). This was resected and oversewn to prevent further leak. Pt remained intubated after OR due to a desat in the OR to 80's despite FiO2 of 70. The patient was eventually extubated and weaned to 2L O2 via nasal cannula but and became stable for floor transfer on [**2125-1-9**], however, the chest tube continued to leak air. CXR on the [**2125-1-9**] showed pneumomediastinum and worsening subcutaneous emphysema. The patient desatted on the first night on the floor requiring a nonrebreather mask. A stat CXR showed stable pneumomediastinum and after suctioning and nebs, was weaned to nasal cannula. Plan was to check serial CXR. Thoracic surgery performed pleurodesis for airleak with doxycycline on [**1-10**] and the patient was transferred to Thoracic surgery service. Gastric Outlet Obstruction - patient went to OR on [**12-30**] and band removed laparoscopically. The patient tolerated it well and was gradually advanced bariatric diet stage IV. . HTN - Was started on metoprolol and was titrated up to 37.5 TID. Maintain proper pain control and ativan/prn was given for anxiety. LLL retrocardiac PNA: Zosyn course was finished ([**2124-1-5**]) and vancomycin was given for a short period of time. RLE asymmetric edema. DVT has been r/o'd by LENI. Per patient RLE has always been more edematous since R knee surgery and cellulitis. Mycoclonus: Per endocrine, methylpred was d/c'd on [**1-6**] and continued with home dose of cosyntropin depot. [**1-1**] CXR on water seal, no PTX in a.m.; ~25% PTX in p.m. [**1-2**] CT back on wall sxn, CXR post tube repositioning - lung back up In brief, on [**1-5**] patient was taken to the operating room for a R VATS wedge/resection. Pathology demonstrated bronchopneumonia and foriegn body reaction c/w aspiration/food particles. On [**1-8**] the patient's PTX had worsened when placed on water seal and he was placed back on back on wall sxn. On [**1-10**] he underwent pharmacologic pleurodesis with doxycycline. On [**1-14**] his basilar CT drain was dc'd. On [**1-15**] both chest tube's were out, and the patient was comfortable and ambulating with physical therapist. Medications on Admission: Medications at OSH: Cosyntropin 0.2mg po qd hydrocortisone 50mg q12 Lovenox 40mg qd PPI Fluconazole 200mg po qd Levo 500mg qd Ganclyclovir 380mg q12 Bactrim q8 Cefepine 2gm iv q8 RISS/klonopin/baclofen/lasix/triamterene Discharge Medications: Metoprolol 50 mg PO TID Oxycodone-Acetaminophen [**4-18**] ml PO Q4-6H:PRN Pantoprazole 40 mg PO Q24H Acthar H.P. *NF* 0.25 mL sc daily Acthar HP Gel (repository corticotropin injection) 80 units/mL **Patient taking own medication*** Dolasetron Mesylate 12.5 mg IV Q8H:PRN nausea Heparin 5000 UNIT SC TID Ipratropium Bromide Neb 1 NEB IH Q6H:PRN Discharge Disposition: Home with Service Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: R pneuomothorax s/p bronch @OSH for pneumonia s/p R VATS w/ wedge resection of hole in lung parenchyma Myoclonus [**3-/2123**] Laparoscopic Gastric Banding pneumonia gastric outlet obstruction (due to band migration) s/p band removal Discharge Condition: stable Discharge Instructions: [**Name8 (MD) **] M.D. for shortness of breath, redness or drainage at skin incision site, fever, chills, increase in severity of symptoms. Keep chest tube dressing dry for 48 hours. After that time may shower and change dressing daily until follow-up appointment. Followup Instructions: Follow up with Dr [**Last Name (STitle) **] in 2 weeks. Please call clinic to schedule [**Telephone/Fax (1) 46193**]. Follow-up with Thoracic surgery clinic in [**9-22**] days with Dr. [**Last Name (STitle) **]. Please call cliic to schedule [**Telephone/Fax (1) 170**]. Completed by:[**2125-1-16**]

[ "512.1", "997.4", "333.2", "401.9", "537.89", "E849.8", "E878.8", "507.0", "518.0", "276.0", "537.0", "E879.8", "E849.7", "733.00", "996.59", "518.81" ]

icd9cm

[ [ [] ] ]

[ "32.29", "96.72", "34.21", "44.97", "34.92", "34.04", "99.21", "33.24", "38.91" ]

icd9pcs

[ [ [] ] ]

9680, 9754

6610, 9039

425, 735

10032, 10040

3061, 3061

10354, 10657

9310, 9657

9775, 10011

9065, 9287

10064, 10331

2527, 3042

282, 387

763, 2283

3078, 6587

2305, 2363

2379, 2512

11,520

157,511

26655

Discharge summary

report

Admission Date: [**2126-3-21**] Discharge Date: [**2126-4-9**] Date of Birth: [**2074-3-9**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: struck on head by large beam Major Surgical or Invasive Procedure: anterior cervical fusion [**3-21**] posterior cervical fusion [**3-24**] Open trach, PEG [**3-29**] History of Present Illness: 52 year-old male who had a large metal [**Doctor Last Name 9808**] fall 8 inches onto his head. No LOC but on arrival of EMS had no sensation or motor function beloow nipples. In field SBP was in 90s started on levophed. On arrival there was no sensation/motor function below nipple line. The patient was intubated for agitation and started on salumedrol drip. Past Medical History: healthy Social History: married Family History: non-contributory Physical Exam: Awake and alert on arrival. 10 cm head laceration stapled in the trauma bay. Pupils are equal and reactive. Lungs are clear bilaterally. Heart is regular. Abdomen is soft, nontender, and nondistended. Extremities are warm, perfused, but sensation to pin-prick is absent over all extremities. there is no motor function over any extremity. Pertinent Results: [**2126-3-21**] 09:30AM URINE RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2126-3-21**] 09:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-6.5 LEUK-NEG [**2126-3-21**] 09:30AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.026 [**2126-3-21**] 09:30AM FIBRINOGE-251 [**2126-3-21**] 09:30AM PT-12.7 PTT-21.4* INR(PT)-1.1 [**2126-3-21**] 09:30AM PLT COUNT-187 [**2126-3-21**] 09:30AM WBC-6.7 RBC-4.33* HGB-14.1 HCT-39.1* MCV-90 MCH-32.7* MCHC-36.1* RDW-13.3 [**2126-3-21**] 09:30AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2126-3-21**] 09:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2126-3-21**] 09:38AM GLUCOSE-167* LACTATE-1.4 NA+-140 K+-4.3 CL--106 TCO2-23 [**2126-3-21**] 12:51PM TYPE-ART PO2-225* PCO2-43 PH-7.29* TOTAL CO2-22 BASE XS--5 [**2126-3-21**] 01:11PM HCT-42.1 [**2126-3-21**] 01:11PM CALCIUM-8.6 PHOSPHATE-2.8 MAGNESIUM-1.9 [**2126-3-21**] 01:11PM GLUCOSE-214* UREA N-21* CREAT-0.9 SODIUM-137 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-21* ANION GAP-15 Brief Hospital Course: Mr. [**Known lastname 7518**] was evaluated in the Trauma Bay and a spine consult was obtained immediately. His injuries included: C4-6,[**2-1**] fractures, nonenhancing vertebral artery R C3-6, R 1st rib, R clavicle, scalp lac, cervical epidural hematoma no motor/senstn UEs or [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]/CTA Hd: no acute bleed CT/CTA Csp: as above CT Torso: as above The steroid protocol was initiated and continued for a total of 24 hours. He was brought to the operating room for an anterior cervical fusion ([**3-21**]). The patient was stabilized and returned to the OR for a posterior fusion ([**3-24**]). An IVC filter was placed by the Vascular surgery service. After the spine surgery team cleared the patient, an open tracheostomy and percutaneous endoscopic gastrostomy tube were performed ([**3-29**]). His postoperative course has been complicated by a postoperative pneumonia. He was treated with a 7 day course of levofloxacin for a pan sensitive enterobacter pneumonia ([**3-27**]). At present he has MRSA ([**4-1**], [**4-2**]) growing from sputum and has been treated now with 8 days of vancomycin. He also has been started on pipercillin-tazobactam ([**4-8**]) for gram negative rods in his sputum ([**4-2**]). Medications on Admission: none Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation Q4H (every 4 hours) as needed. 2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for fever. 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 9. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO Q 24H (Every 24 Hours). 10. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily). 11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML Miscell. Q2H (every 2 hours) as needed. 13. Lansoprazole 15 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 14. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3-4H (Every 3 to 4 Hours) as needed. 15. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for mucous production. 16. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed. 17. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 18. Metoclopramide 5 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours). 19. Lorazepam 2 mg/mL Syringe Sig: [**12-31**] Injection Q2H PRN () as needed for anxiety. 20. Vancomycin 500 mg Recon Soln Sig: Three (3) Recon Soln Intravenous Q 8H (Every 8 Hours). 21. Ampicillin-Sulbactam [**1-30**] g Recon Soln Sig: Three (3) Recon Soln Injection Q8H (every 8 hours). 22. Acetazolamide Sodium 500 mg Recon Soln Sig: One (1) Recon Soln Injection Q6H (every 6 hours). Discharge Disposition: Extended Care Facility: [**Company **] Discharge Diagnosis: C4-6, T2-3 fractures with quadraplegia Discharge Condition: stable Discharge Instructions: tracheostomy care gastrostomy care

[ "806.20", "860.0", "482.41", "518.5", "852.41", "852.01", "433.20", "807.01", "482.83", "E916", "806.05", "873.1", "810.03", "530.10", "806.00" ]

icd9cm

[ [ [] ] ]

[ "43.11", "81.63", "81.02", "96.6", "31.1", "81.03", "33.24", "38.7", "81.62", "03.53", "86.59", "96.72", "03.59", "99.04", "84.51" ]

icd9pcs

[ [ [] ] ]

5749, 5790

2455, 3728

341, 442

5873, 5882

1300, 2432

905, 923

3783, 5726

5811, 5852

3754, 3760

5906, 5944

938, 1281

273, 303

470, 833

855, 864

880, 889

26,501

168,750

46273

Discharge summary

report

Admission Date: [**2186-3-17**] Discharge Date: [**2186-3-23**] Date of Birth: [**2126-1-17**] Sex: F Service: MICU, ONC CHIEF COMPLAINT: Transferred to Intensive Care Unit for hypoxia. HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 38357**] is a 60-year-old woman diagnosed with metastatic adenocarcinoma of unknown primary in 02/[**2186**]. She presented to the [**Hospital **] clinic on [**2186-3-17**] for outpatient evaluation. She appeared very debilitated and so was admitted to the hospital for further workup. On admission she was noted to have acute renal failure with creatinine of 2. She also was noted to be tachypneic and, indeed, she reported a one two-week history of increasing tachypnea. After she was admitted her urine output remained very minimal despite aggressive fluid boluses. She also suffered from hyperkalemia with potassium as high as 6.0 on admission, requiring Kayexalate. She was transferred to the Intensive Care Unit on [**2186-3-20**] because she was noted to be hypoxic to the mid-80s on nasal cannula oxygen. Oxygenation improved to 94% on 100% face mask. On transfer to the Intensive Care Unit she was a chronically ill appearing, elderly woman with a right eyelid droop, reported as new in the past week. She was markedly tachypneic. The lungs were dull two-thirds of the way up bilaterally. The heart was regular rate and rhythm without any murmurs. She had 3+ extremity edema. LABORATORY DATA: Her laboratory tests on admission to the Intensive Care Unit were significant for WBC of 43.6, hematocrit to 32.1, and a platelet count of 327. The INR on admission to the ICU was 1.6 and it was 2.0 on [**2186-3-22**]. The lab values were also significant for a creatinine of 2.0 on [**2186-3-20**] when admitted to the Intensive Care Unit. This had risen to 2.7 on [**2186-3-22**]. The liver function tests also worsened daily while she was in the Intensive Care Unit. On [**2186-3-22**] the ALT was 125, AST was 478, alkaline phosphatase was 4695, and total bilirubin was 4.1. A chest x-ray was performed which showed very low lung volumes and elevation of the right hemidiaphragm. Review of the CT scan of the chest and abdomen from [**2-/2186**] showed a massively enlarged liver which was compressing the right atrium, the diaphragms, and also the stomach. She had a cardiac echo performed on [**2186-3-20**] which demonstrated an ejection fraction of greater that 6% and demonstrated right atrial compression by an external mass. While patient was in the Intensive Care Unit she remained on face mask oxygen and continued to feel tachypneic at rest. Her urine output was very minimal. Given her extremely poor prognosis and lack of treatment options, she elected to go home to Hospice on [**2186-3-23**]. DISCHARGE MEDICATIONS: 1. Ativan elixir 0.5 to 2 mg q. 4 hours sublingual p.r.n. 2. Levsin elixir 0.125 to 0.25 mg q. 4 to six 6 sublingual p.r.n. 3. Morphine elixir 5 to 20 mg q. 1 to 2 hours sublingual p.r.n. 4. Colace 100 mg p.o. b.i.d. 5. Senna one tablet p.o. b.i.d. 6. Compazine, one tablet, p.o. q. 6 hours. 7. Ambien 5 mg q. h.s. p.r.n. insomnia. DISCHARGE DIAGNOSES: 1. Hypoxia. 2. Respiratory failure. 3. Acute renal failure. 4. Metastatic adenocarcinoma of unknown primary. DISCHARGE CONDITION: Poor. DISPOSITION: Discharged to home with Hospice services. Family was aware and in agreement with the plan. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**] Dictated By:[**Name8 (MD) 4123**] MEDQUIST36 D: [**2186-3-23**] 12:59 T: [**2186-3-25**] 10:49 JOB#: [**Job Number 98377**] cc:[**Last Name (NamePattern1) 48222**]

[ "518.81", "276.6", "276.4", "197.7", "599.0", "584.9", "276.7", "198.5", "276.5" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

3314, 3725

3178, 3292

2817, 3157

156, 205

234, 2794

23,613

141,660

2885

Discharge summary

report

Admission Date: [**2140-7-5**] Discharge Date: [**2140-7-7**] Service: MICU GREEN HISTORY OF THE PRESENT ILLNESS: This is a 79-year-old white male with a history of bilateral carotid stenosis, hypothyroidism, low-grade lymphoma who presents with upper GI bleed. The patient was in his normal state of health until two days ago when he noticed a tarry black stool and lightheadedness. The patient denied any nausea, vomiting, no weight loss, no fever, chills, no abdominal pain. He does report symptoms of gastroesophageal reflux. The patient had a vocal cord polyp removed approximately seven days ago. In addition, the patient restarted Plavix four days ago for his carotid stenosis. The patient denied any other NSAID use, no alcohol use or any tobacco use. The patient denied melena, bright red blood per rectum but does have a history of external hemorrhoids. The patient received 2 liters of normal saline in the Emergency Room as well as 1 unit of packed red blood cells and IV Protonix. The patient denied any chest pain, shortness of breath, lower extremity edema, but does report lightheadedness without dizziness or syncope. PAST MEDICAL HISTORY: 1. DJD. 2. Carotid stenosis with 70% occlusion of the left carotid and 100% occlusion of the right internal carotid artery. The patient is asymptomatic with good collateral flow. 3. Questionable coronary artery disease. 4. Low-grade lymphoma with retroperitoneal lymphadenopathy incidentally found on CT of the abdomen. 5. Status post bilateral hip replacement. 6. Status post polyp removal and colonoscopy in [**2139-3-2**]. 7. Hypothyroidism. 8. Squamous cell carcinoma of the left mandibular region requiring surgery and radiation therapy in [**2135**]. OUTPATIENT MEDICATIONS: 1. Aspirin 81 mg q.d. 2. Plavix 75 mg q.d. 3. Lipitor 20 mg q.d. 4. Synthroid 0.1 mg q.d. ALLERGIES: The patient has no known drug allergies. FAMILY HISTORY: His father died at age 59 of an MI. His mother died at 88 of Alzheimer's disease. SOCIAL HISTORY: He is a retired business executive. He is married with seven children. He smoked cigars for five years greater than 25 years ago. He has no alcohol use. His neurologist is Dr. [**Last Name (STitle) **]. His oncologist is Dr. [**Last Name (STitle) **]. His internist is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 96.1, blood pressure 105/62, 02 saturation 98% on room air, heart rate 110, breathing at 16 respirations per minute. General: He was confused but in no acute distress. The pupils were equal, round, and reactive to light. The extraocular muscles were intact. He had moist mucous membranes. The oropharynx was clear without exudate, erythema, and no epistaxis visible. Neck: Supple with a left carotid bruit. Cardiovascular: Regular rate and rhythm without a murmur. Pulmonary: Clear to auscultation bilaterally. Abdomen: Soft, nontender, nondistended with positive bowel sounds. Rectal: Guaiac positive per ED with black stool in the commode. Extremities: Without edema, clubbing, or cyanosis. He had palpable distal pulses, 2+. Neurologic: Cranial nerves II through XII were intact. He had 5/5 strength in the upper and lower extremities bilaterally. LABORATORY/RADIOLOGIC DATA: At 2:00 p.m., his hematocrit was 39.1, white blood cell count 13.4, platelet count 294,000. At 7:00 p.m., his hematocrit dropped from 39.1 to 28.9. His baseline hematocrit is 43. Chem-7 on admission was 138 sodium, potassium 4.3, chloride 99, bicarbonate 27, BUN 51, creatinine 1.3 with glucose of 109. His INR was 1.1, PTT 23.8. His differential was 74 neutrophils, 18 lymphocytes, 5 monos, 2.3 eosinophils. His EKG in the ED showed a normal sinus rhythm at 100 beats per minute with Q waves in III and aVF with left axis deviation. The patient had an EGD performed upon admission to the Intensive Care Unit for evaluation of his upper GI bleed given his acute drop in hematocrit. The patient's EGD showed erosions in the stomach body as well as the stomach antrum with an actively bleeding vessel that was injected and successfully treated with BICAP electrocautery therapy. HOSPITAL COURSE: 1. UPPER GASTROINTESTINAL BLEED: The patient's likely cause for upper GI bleed is gastritis with an acute exacerbation upon restarting aspirin and Plavix. The patient's EGD displayed an actively bleeding vessel which was successfully treated with epinephrine injection as well as electrocautery therapy. During endoscopy, the patient became transiently hypotensive with conscious sedation and required invasive blood pressure monitoring with an arterial line as well as transiently requiring pressor support. Postprocedure, the patient's blood pressure returned to baseline at 100/50s. The patient was monitored in the Intensive Care Unit for two additional days with hematocrit checks and IV Protonix therapy. The patient's hematocrit remained stable while in the Intensive Care Unit ranging between 29 and 30. The patient received a total of 2 units of packed red blood cells and 4 liters of normal saline over the initial 24 hour period. The patient showed no additional signs of bleeding with stable hematocrit and asymptomatic with stable blood pressure and heart rate. The patient was given follow-up with a GI fellow, Dr. [**Last Name (STitle) **], for repeat EGD in three to four weeks as well as follow-up on his H. pylori antibody test. 2. CAROTID ARTERY STENOSIS: The patient had 100% occlusion of his right and 70-90% occlusion of his left internal carotid artery by recent MRA. Given his significant carotid artery disease, the patient was placed as an outpatient on aspirin and Plavix. The patient was discharged from the hospital off his Plavix and aspirin given his recent presentation with gastric erosions and GI bleeding. The patient was told to follow-up with his primary care physician and his neurologist concerning his carotid disease and the benefits and risks of restarting his antiplatelet medications. The patient was fully informed of the need for follow-up and the risks and benefits of his antiplatelet therapy. The patient was told to follow-up with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], in the next seven to ten days to further discuss his options for his carotid disease treatment. The patient also had a follow-up appointment with Dr. [**Last Name (STitle) **], his neurologist, in approximately two months. 3. HYPOTHYROIDISM: The patient was continued on his Synthroid at his outpatient dose of 0.1 mg per day. 4. HYPERCHOLESTEROLEMIA: The patient was restarted on his statin medication when he was able to take adequate p.o. He was discharged on his same outpatient dose. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSIS: 1. Upper GI bleed. 2. Gastritis with bleeding erosions. 3. Acute blood loss. 4. Carotid stenosis. 5. Hypothyroidism. 6. Lymphoma. 7. Hypercholesterolemia. DISCHARGE MEDICATIONS: 1. Atorvostatin 20 mg q.h.s. 2. Pantoprazole 40 mg q. 12 hours. 3. Levothyroxine 100 micrograms q.d. FOLLOW-UP: The patient is to make an appointment with Dr. [**Last Name (STitle) **], his primary care physician, [**Name10 (NameIs) **] the next seven to ten days and an appointment with Dr. [**Last Name (STitle) **], the GI fellow, on [**2140-7-13**] at 2:00 p.m. The patient had a follow-up appointment with Dr. [**Last Name (STitle) **] concerning his lymphoma on [**2140-8-25**] at 1:30 p.m. The patient had a follow-up appointment with Dr. [**Last Name (STitle) **], his neurologist, at some point in [**Month (only) **]. [**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**] Dictated By:[**Last Name (NamePattern4) 13967**] MEDQUIST36 D: [**2140-7-29**] 03:38 T: [**2140-7-30**] 10:20 JOB#: [**Job Number 13968**]

[ "280.0", "272.0", "535.01", "426.11", "E935.3", "433.10", "202.83", "458.9", "244.9" ]

icd9cm

[ [ [] ] ]

[ "43.41" ]

icd9pcs

[ [ [] ] ]

1936, 2020

7102, 7999

6916, 7079

4250, 6834

1769, 1918

2420, 4232

1178, 1745

2037, 2405

6859, 6895

15,737

113,968

44766+58753

Discharge summary

report+addendum

Admission Date: [**2163-5-10**] Discharge Date: [**2163-6-6**] Date of Birth: [**2098-2-11**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1781**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: exploratory laparotomy placement of 16mm dacron aortic tube graft placement of PA catheter percutaneous tracheostomy bronchoscopy endoscopy History of Present Illness: 65F with known infrarenal AAA who presents with 4 days of worsening left lower quadrant abdominal pain, radiating to her back & down legs. She denied any fevers, chills, nausea, vomiting, prior episodes, urinary or bowel symptoms. No prior episodes. Past Medical History: CAD s/p CABG [**2155**] A fib HTN DM2 s/p C section x3 ventral hernia Social History: +cigs, smokes 1 ppd lives with husband, [**Name (NI) **], in [**Location (un) 11333**], MA daughter [**Name (NI) **] is health care proxy ([**Telephone/Fax (1) 95768**]) Family History: noncontrib Physical Exam: Afeb, VSS AOx3, NAD RRR, no bruits CTA bilat Soft obese LLQ>RLQ TTP (no rebound), no CVAT, guaiac neg Pulses: palp throughout Pertinent Results: See carevue for specific results. * * * --RADIOLOGY-- CT ABD W&W/O C [**2163-5-10**] 9:47 PM CT ABD W&W/O C; CT PELVIS W&W/O C Reason: please eval AAA size, rupture; please also evaluate for kidn Field of view: 42 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 65 year old woman with abdominal pain radiating to back, says she has a known AAA (?size); I suspect renal stone REASON FOR THIS EXAMINATION: please eval AAA size, rupture; please also evaluate for kidney stones CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 65-year-old woman with abdominal pain radiating to back. No abdominal aortic aneurysm. TECHNIQUE: Contiguous axial CT images of the abdomen and pelvis were obtained with and without the administration of IV contrast [**Doctor Last Name 360**], with CTA technique. No comparison. FINDINGS: Note is made of 5.3-cm infrarenal abdominal aortic aneurysm with mural thrombus, surrounded by hyperdense fat stranding and soft tissue measuring up to 46 [**Doctor Last Name **], most likely representing abdominal aortic aneurysm with impending rupture. No definite abscess is identified, however, the possibility of infection cannot be totally excluded. Celiac, SMA, and iliac vessels are patent. No evidence of active extravasation is noted. Left kidney is atrophic, with very small left renal artery. Right kidney is unremarkable. Note is made of fatty liver. No focal liver lesion. The bladder, spleen, pancreas, adrenal glands, and the visualized portions of large and small intestines are within normal limits. No lymphadenopathy. PELVIS: Note is made of sigmoid diverticulosis. Otherwise, the visualized portions of the small intestines are within normal limits. No ascites. No lymphadenopathy. In the visualized portion of the chest, note is made of coronary artery calcification in this patient who is status post CABG. Note is made of 5-mm noncalcified pulmonary nodule in the left lower lobe, which needs to be followed in three months. Note is made of atherosclerotic disease of the thoracoabdominal aorta. There is no suspicious lytic or blastic lesion in skeletal structures. IMPRESSION: 1. 5.3-cm infrarenal abdominal aortic aneurysm with mural thrombus, surrounded by hyperdense soft tissue and fat stranding suggestive of impending rupture with hematoma. No definite abscess is identified, however, superimposed infection cannot be totally excluded. No evidence of active extravasation. 2. Sigmoid diverticulosis. 3. Fatty liver. 4. 5-mm noncalcified pulmonary nodule in left lower lobe. Please follow in three months. The information was discussed with the ED physicians and surgery resident, including Dr. [**Last Name (STitle) **] in person at the time of examination, and it was also flagged to ED dashboard. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 7210**] [**Name (STitle) 7211**] [**Doctor Last Name 7205**] DR. [**First Name (STitle) 7204**] [**Name (STitle) 7205**] Approved: WED [**2163-5-11**] 7:51 AM POST-PYLORIC FEEDING TUBE PLACEMENT UNDER FLUOROSCOPIC GUIDANCE: A 120 cm 8 French [**Location (un) 2174**]-[**Doctor First Name 1557**] feeding tube was inserted into the fourth portion of the duodenum under fluoroscopic guidance. The position was confirmed by injection of approximately 10 cc of Gastrografin. No immediate complications were seen. IMPRESSION: Successful post-pyloric feeding tube placement. THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST. DR. [**First Name (STitle) 46933**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**] Approved: SAT [**2163-5-28**] 6:29 PM Procedure Date:[**2163-5-27**] * * * --MICROBIOLOGY-- [**2163-5-23**] 11:17 am SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2163-5-23**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Final [**2163-5-26**]): OROPHARYNGEAL FLORA ABSENT. Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. YEAST. SPARSE GROWTH. SERRATIA MARCESCENS. SPARSE GROWTH. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. GRAM NEGATIVE ROD(S). SPARSE GROWTH. GRAM NEGATIVE ROD #3. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ SERRATIA MARCESCENS | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- 1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S FUNGAL CULTURE (Preliminary): YEAST. [**2163-5-23**] 10:56 am MRSA SCREEN Site: RECTAL Source: Rectal swab. **FINAL REPORT [**2163-5-25**]** MRSA SCREEN (Final [**2163-5-25**]): NO STAPHYLOCOCCUS AUREUS ISOLATED. [**2163-5-23**] 10:56 am SWAB Source: Rectal swab. **FINAL REPORT [**2163-5-26**]** R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2163-5-26**]): ENTEROCOCCUS SP.. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S PENICILLIN------------ =>64 R VANCOMYCIN------------ =>32 R * * * EKG [**Known lastname 95769**],[**Known firstname **] S.: [**Hospital1 18**] ECG Detail - CCC Record #[**Numeric Identifier 95770**] ELECTROCARDIOGRAM PERFORMED ON: [**2163-5-24**] 18:12:04 The rhythm is likely sinus with A-V conduction delay. P-R interval 0.22. There is much baseline artifact. Right bundle-branch block. Low precordial lead voltage. Compared to the previous tracing of [**2163-5-17**] no diagnostic interim change. Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**] Intervals Axes Rate PR QRS QT/QTc P QRS T 49 0 138 446/426 0 23 132 Brief Hospital Course: After being diagnosed in the ER with a rupturing AAA, Ms [**Known lastname **] was rapidly consented for ex lap & brought emergently to the OR by the vascular team. Please refer to the previosuly dictated op note from [**5-10**] by Dr. [**Last Name (STitle) **] for procedure details. She was then transferred to the Surgical ICU, where she remained for 23 days. This extended ICU course can be summarized in an organ systems based approach. NEURO: Her pain was controlled with fentanyl drips & she was sedated with propofol during her intubation. She moved all extremities soon after surgery & was interactive, although nonverbal bc of her tracheostomy, at the time of discharge. Her pain/sedation regimen currently consists of a fentanyl patch & intermittent roxicet & ativan as needed. CV: She remained hemodynamically stable before being taken to the OR on [**5-10**]. Postop, she did develop rapid atrial fibrillation, which was controlled with amiodarone and beta blockade. Later postop, she had signficant hypertension & with the assistance of cardiology, was placed [**Female First Name (un) **] regimen of prazosin, clonidine, norvasc & intermittent hydralazine. RESP: She developed a postoperative vent-associated pneumonia (serratia), which was successfully treated with 21 days of levaquin. This impaired her ability to vean from the ventilator & on [**5-26**], she was taken to the OR by thoracic surgery for a percutaneous tracheostomy. She has developed significant coughing episodes when suctioned via her tracheostomy. FEN: She was maredly fluid requiring postop, ultimately reaching about 15kg above her baseline weight (92kg). After treating her penumonia, she was successfully diuresed back to 95kg at the time of discharge. Her creatinine only developed a small rise to 2.0 from postoperative ATN, but normalized to 1.2 at the time of DC. GI: She had a prolonged postoperative ileus & required TPN to sustain her during this time. She was transitioned over to novasource tube feeds once her GI tract was functional. She is currently tolerating tube feedings at a goal rate of 45cc/hr. HEME: She is prophylaxed against DVTs with TID SQ heparin. Her current hematocrit is 28. She required multiple transfusions for her blood loss anemia. ID: pneumonia as above. She also was noted to be VRE by rectal swab on [**5-23**]. ENDO: Her perioperative blood glucose was tightly controlled via insulin gtt & then sliding scale. Prior to DC, an attempt to restart her oral hypoglycemics resulted in hypoglycemia. She is controlled currently on just sliding scale. Medications on Admission: coumadin 5/7.5 (A fib) aspirin lopressor norvasc enalapril glyburide glucophage lipitor Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 4. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 5. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). Disp:*qs container* Refills:*2* 6. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-13**] Drops Ophthalmic PRN (as needed). Disp:*qs container* Refills:*2* 7. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). Disp:*5 Patch Weekly(s)* Refills:*2* 8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Prazosin 5 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 11. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). Disp:*10 Patch 72HR(s)* Refills:*2* 12. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) dose PO DAILY (Daily): 30mg PGT qD. Disp:*30 dose* Refills:*2* 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection TID (3 times a day). Disp:*90 ML* Refills:*2* 14. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheeze. Disp:*1 inhaler* Refills:*5* 15. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day) as needed. Disp:*qs containter* Refills:*0* 16. Docusate Sodium 150 mg/15 mL Liquid Sig: Two (2) teaspoons PO BID (2 times a day). Disp:*120 teaspoons* Refills:*2* 17. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [**Hospital1 **] (2 times a day) as needed for constipation. Disp:*30 Suppository(s)* Refills:*0* 18. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Liquid Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. Disp:*250 ML(s)* Refills:*0* 19. Insulin Regular Human 100 unit/mL Solution Sig: One (1) dose Injection every six (6) hours: follow attached sliding scale. Disp:*qs ml* Refills:*2* 20. Hydralazine 20 mg/mL Solution Sig: One (1) ML Injection Q4-6H (every 4 to 6 hours) as needed for breakthrough SBP > 160. Disp:*50 ML* Refills:*0* 21. Ativan 1 mg Tablet Sig: 1-2 Tablets PO three times a day as needed for anxiety. Disp:*30 Tablet(s)* Refills:*0* 22. Roxicet 5-325 mg/5 mL Solution Sig: [**12-13**] teaspoons PO every six (6) hours as needed for pain. Disp:*250 ML* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Hospital1 **] Discharge Diagnosis: hypertension CAD s/p CABG atrial fibrillation type 2 diabetes, controlled ruptured AAA hyperalimentation/TPN vent associated pneumonia postoperative ileus blood loss anemia acute renal failure acute tubular necrosis Discharge Condition: improved Discharge Instructions: Tube feeds via dobhoff as tolerated. Contact your MD if you develop fevers>101, redness or drainage about your wound, or if you have any questions or concerns. Followup Instructions: Contact Dr.[**Name (NI) 7257**] office at [**Telephone/Fax (1) 2395**] to arrange a follow up appointment in about 1 month. Completed by:[**2163-6-2**] Name: [**Known lastname 15185**],[**Known firstname 2**] S. Unit No: [**Numeric Identifier 15186**] Admission Date: [**2163-5-10**] Discharge Date: [**2163-6-6**] Date of Birth: [**2098-2-11**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3717**] Addendum: Patient developed a fib again requiring electrical cardioversion. Electro physiology consult obtained, atrial fibrilation felt to be secondary to respiratory distress. Patient is requiering succioning every 20-30 min. EP sign off, no pacemaker necessary. Discharge Disposition: Extended Care Facility: [**Hospital3 14**] & Rehab Center - [**Hospital1 15**] [**First Name11 (Name Pattern1) 798**] [**Last Name (NamePattern4) 3683**] MD [**MD Number(1) 3724**] Completed by:[**2163-6-6**]

[ "V09.80", "305.1", "482.83", "250.00", "441.3", "440.0", "518.5", "285.1", "427.31", "401.9", "584.5", "560.1", "V45.81", "428.0" ]

icd9cm

[ [ [] ] ]

[ "99.00", "89.38", "99.04", "96.6", "31.1", "99.07", "44.13", "38.93", "99.62", "96.05", "38.14", "38.44", "00.40" ]

icd9pcs

[ [ [] ] ]

15006, 15246

8106, 10706

328, 470

13966, 13977

1221, 1458

14186, 14983

1048, 1060

10844, 13609

1495, 1608

13728, 13945

10732, 10821

14001, 14163

1075, 1202

6675, 8083

274, 290

1637, 6639

498, 751

773, 845

861, 1032

73,540

175,839

34092

Discharge summary

report

Admission Date: [**2111-3-2**] Discharge Date: [**2111-3-11**] Date of Birth: [**2039-2-13**] Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 78**] Chief Complaint: Altered mental status / Bifrontal Contusions Major Surgical or Invasive Procedure: None History of Present Illness: 72 yo M significant PMH on Coumadin, Fondaparinaux and ASA 81 mg who per his family has not been acting like himself for 2 days, since Saturday [**2-28**]. Saturday he c/o not feeling well and went to bed early. He stayed in bed all day Sunday, not eating, only getting up to use the bathroom. Today his family contact[**Name (NI) **] his PCP who sent him for [**Name (NI) **] evaluation. CT head from OSH shows bifrontal ICH. PT himself does not recall trauma. C/O headache. Denies nausea, vomiting, dizziness, blurred vision, double vision. He has baseline right hand weakness. Denies numbness, tingling, neck pain. ROS: Denies CP, SOB, palpitations Pt is somewhat of a poor historian and he states that he is in the hospital now for drainage of his lung. Past Medical History: PMHx: AICD defib implant [**2103**], CAD including ischemic cardiomyopathy, lung CA, s/p right middle lung lobectomy, right pleural effusion, metastatic adenocarcinoma, HTN, anemia, PE, COPD, asbestosis, chronic Afib, high cholesterol, PVD s/p left femoral endarterectomy [**2106**] at [**Hospital1 18**] Social History: hx ETOH use 12 beers daily Family History: NC Physical Exam: On Admission: Gen: WD/WN, comfortable, NAD. HEENT: old left occipital laceration Neck: Supple. No tenderness Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date but unable to clearly state why he is at the hospital. 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, 3 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 [**5-2**] throughout except right Grip [**3-2**] and finger intrinsics [**4-2**] (baseline). No pronator drift Sensation: Intact to light touch bilaterally. Coordination: normal on finger-nose-finger Upon discharge: Awake, alert, oriented x3, follows commands, MAE [**5-2**], L nasolabial flattening. Pertinent Results: Head CT [**2111-3-2**]: Significant bifrontal contusions, left occipital skull fx. Head CT [**2111-3-3**]: IMPRESSION: 1. Overall similar appearance to extensive inferior bifrontal parenchymal hemorrhages, inferior bitemporal parenchymal hemorrhages, and right frontal subdural hematoma. 2. Minimal layering hyperdense material in bilateral occipital horns likely represents acute blood. ECHO [**2111-3-3**]: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. Overall left ventricular systolic function is moderately depressed with inferior/inferolateral akinesis/hypokinesis and hypokinesis elsewhere (LVEF= 30%). Right ventricular chamber size and free wall motion are normal. The right ventricular cavity is dilated with normal free wall contractility. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. LENIS [**2111-3-3**]: IMPRESSION: No evidence of deep vein thrombosis in either leg. Carotid Ultrasound [**2111-3-3**]: IMPRESSION: 1. 60-69% stenosis in the left internal carotid artery with no significant stenosis in the right internal carotid artery. 2. Diffuse moderate heterogeneous calcified plaque in the bilateral common carotid and internal carotid artery, left more than the right. EEG [**2111-3-5**]: IMPRESSION: This is an abnormal continuous telemetry because of mild to moderate diffuse background slowing. These findings are indicative of mild to moderate diffuse encephalopathy which is etiologically non- specific. In addition, there is right more than left centrotemporal slowing indicative of a more severe cerebral dysfunction in the right centrotemporal region. There are no epileptiform features. CT Head [**2111-3-5**]: IMPRESSION: 1. No significant interval change in the extensive hemorrhagic contusions and surrounding edema in the inferior frontal lobes bilaterally. Stable bilateral temporal lobe hemorrhagic contusions. Stable small parafalcine frontal subdural hematoma. 2. No evidence of herniation or significant interval change. EEG [**2111-3-6**]: IMPRESSION: This EEG is evidence for diffuse slowing of background frequencies into the theta and delta bandwidth. There is some focality over the central regions with a slight rightsided preference. No epileptiform activity was identified. No seizures were recorded. LENIS [**2111-3-11**]: Negative for DVT Brief Hospital Course: Mr. [**Known lastname **] was admitted to the ICU on the Neurosurgery service for frequent neuro checks and systolic blood pressure control less than 140. He was loaded with Dilantin for seizure prophylaxis and started on 100mg TID. He was given 2 units of FFP to reverse an INR of 2.4 and started on Vitamin K daily x 3 days. Given his history of heavy EtOH use he was placed on a CIWA protocol and observed for signs and symptoms of alcohol withdrawal. Syncope work up was performed as the patient had no recollection of falling. An EKG was done that revealed sinus rhythm with some ectopy. A TTE was done that revealed mild left atrium dilation and an LVEF of 30%. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. An EEG was done that revealed no seizures. Carotid ultrasounds were performed that revealed: 1. 60-69% stenosis in the left internal carotid artery with no significant stenosis in the right internal carotid artery. 2. Diffuse moderate heterogeneous calcified plaque in the bilateral common carotid and internal carotid artery, left more than the right. Lower extremity ultrasound was performed to assess for lower extremity DVT: No evidence of deep vein thrombosis in either leg. EP was also consulted to interrogate his pacemaker/defibrillator for any discharges. No arrhythmias were found during pacemaker interrogation. On [**3-5**]: patient continued to be disoriented and at 12:30, while working with PT, patient had a sudden onset episode of speech arrest and confusion that self resolved. It was thought that patient may have had a seizure and underwent an EEG that revealed no seizure activity on final read. On [**3-6**]- A UTI was noted and Cipro was started. EEG continued to be negative. [**Date range (1) 25583**], patient remained stable and was awaiting dispo planning. Physical therapy felt Acute Rehab was needed. Screening began and patient was approved. On [**3-9**], he had a short episode of speech arrest that self resolved. Keppra was added. Patient remained stable. On [**3-10**] his right pleurex catheter was drained. On [**3-11**]- we began tapering down Dilantin as there was no EEG confirmation of seizure. Keppra 1000 mg [**Hospital1 **] was continued. Bilateral lower extremity doppler ultrasound was performed for extended bedrest and was negative for DVT. Patient was discharged to [**Location (un) 16493**]Rehab in [**Location 9583**]. At the time of discharge the patient was tolerating a regular diet, ambulating with assistance, afebrile with stable vital signs. Medications on Admission: Patanol 0.1% to each eye twice weekly, Methadone 5mg Q am and 20mg QPM, Meclizine 12.5mg [**Hospital1 **], Carvedilol 6.25mg [**Hospital1 **], ASA 81mg Daily, Amiodarone 100mg Daily, MVI daily, Magnesium 40mg Daily, Simvastatin 10mg QHS, lisinopril 5mg daily, MOM PRN, [**Name (NI) **] daily, Folic acid 1mg daily, Coumadin 2mg Daily, Furosemide 40mg Daily, Potassium 20 MEQ daily, Omeprazole 40mg [**Hospital1 **], Percocet PRN, Isosorbide 30mg Daily, Fondaparinaux pen 500mg 4 xdaily Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, HA. 2. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for HA. 3. phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO twice a day for 7 days. 4. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days: started [**3-6**], d/c [**3-13**]. 12. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 17. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Location (un) 39857**] - [**Location 9583**] Discharge Diagnosis: Bifrontal contusions Occipital skull fx Subdural hematoma Traumatic Subarachnoid hemorrhage Alcoholism Delirium confusion Seizures Urinary Tract infection Slurred speech 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: General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate ([**Location **]) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin prior to your injury, you may safely resume taking this once cleared by your Neurosurgeon. We will discuss this in clinic at your follow-up. ?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, but we started you on Keppra and would like to taper your Dilantin off. Continue Dilantin 100mg [**Hospital1 **] x 7 days then discontinue. You have been discharged on Keppra (Levetiracetam) as well, you will not require blood work monitoring. Please continue until follow-up. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 2102**] to schedule an appointment with Dr. [**Known firstname **], to be seen in 1 week. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. ??????We recommend you see Dr [**First Name (STitle) **] in the Traumatic Brain Injury (TBI) clinic the phone number is [**Telephone/Fax (1) 6335**]. If you have any problems booking this appointment please ask for [**First Name8 (NamePattern2) 16367**] [**Last Name (NamePattern1) 16368**]. Completed by:[**2111-3-11**]

[ "427.31", "285.9", "784.59", "E928.8", "780.39", "599.0", "272.0", "801.21", "V12.55", "V49.87", "511.81", "197.2", "V58.61", "V10.11", "414.8", "790.92", "V45.02", "041.7", "496", "041.49", "501", "801.11" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10086, 10160

5599, 8171

350, 357

10374, 10374

2894, 5576

12126, 12777

1547, 1552

8708, 10063

10181, 10353

8197, 8685

10550, 12103

1567, 1567

266, 312

2788, 2875

385, 1156

2021, 2772

1581, 1715

10389, 10526

1178, 1486

1502, 1531

58,100

158,178

5305

Discharge summary

report

Admission Date: [**2157-8-24**] Discharge Date: [**2157-9-9**] Date of Birth: [**2104-5-14**] Sex: M Service: SURGERY Allergies: Pollen Extracts Attending:[**First Name3 (LF) 6088**] Chief Complaint: abdominal pain / left testicular pain Major Surgical or Invasive Procedure: [**2157-8-24**] - exploration of retroperitoneum through previous midline incision with washout and component separation and abdominal wall closure with polypropylene mesh overlay. Percutaneus drain placement History of Present Illness: 53M with lumbar spondylosis who recently underwent anterior lumbar interbody fusion ([**2157-8-18**]) and posterior placement of percutaneous pedical screws ([**2157-8-19**]) returns to the ED one day after being discharged to home with abdominal pain and left testicular pain. The patient reports he was feeling somewhat distended after surgery but had attributed this to constipation; he had a bowel movement yesterday and was discharged to home in good condition. Today, however, he found that the abdominal pain and distention was increasing, and he began to experience pain and tenderness in the left testicle. He complained of left-sided abdominal tenderness as well. ROS is negative for fevers, chills, nausea/vomiting, chest pain. He does endorse some shortness of breath, which he attributes to his asthma. Notably during the posterior pedical screw placement on [**8-19**] he vomited and aspirated some gastric contents; subsequent chest x-rays demonstrated some evidence of aspiration however the patient did not clinically have pneumonia and was discharged to home. A CXR and KUB in the ED were essentially unremarkable. A CT scan of the abdomen and pelvis demonstrates a large retroperitoneal hematoma. Vascular surgery consult is requested due to this finding. Past Medical History: PMH: - asthma - GERD - low back pain PSH: - anterior lumbar interbody fusion [**8-18**] - posterior lumbar pedicle screw placement [**8-19**] - tonsillectomy - uvulectomy - resection of right thumb cyst Social History: Nonsmoker, no EtOH, lives with wife, occasional marijuana use for facial pain relief Family History: noncontributory Physical Exam: 97.8 84 110/77 12 100RA Gen NAD CV RRR Chest CTAB Abd distended, diffusely tender, most tender in LLQ/LUQ; no rebound or guarding; no skin changes or ecchymoses GU no scrotal edema; left testicle moderately tender to palpation, slightly higher riding than right testicle Ext WWP, 2+ distal pulses b/l Pertinent Results: [**2157-9-8**] 07:30AM BLOOD WBC-6.4 RBC-3.22* Hgb-9.5* Hct-27.9* MCV-87 MCH-29.4 MCHC-33.9 RDW-13.8 Plt Ct-391 [**2157-9-9**] 06:20AM BLOOD PT-16.6* PTT-30.0 INR(PT)-1.5* [**2157-9-8**] 07:30AM BLOOD Glucose-104* UreaN-13 Creat-0.9 Na-142 K-4.1 Cl-105 HCO3-31 AnGap-10 [**2157-9-8**] 07:30AM BLOOD Calcium-8.4 Phos-3.8 Mg-2.2 [**2157-9-4**] 10:32PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016 URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2157-9-6**] 4:05 pm FLUID,OTHER GRAM STAIN (Final [**2157-9-6**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. CT SCAN IMPRESSION: 1. Slight decrease in the size of the left-sided, retroperitoneal abdominal/pelvic hematoma. 2. Bilateral pulmonary emboli. 3. Partial left-sided obstruction of the collecting system with dilation of the renal pelvis secondary to compression of the ureter by the retroperitoneal hematoma. XRAY: FINDINGS: As compared to the previous radiograph, the patient has been extubated. There are no focal parenchymal opacities suggesting pneumonia. Unchanged mild retrocardiac atelectasis, unchanged mild widening of the mediastinum, notably on the right, without evidence of abnormal contours. This finding requires radiological followup. Overall left ventricular systolic function is normal (LVEF>55%). with severe global free wall hypokinesis. There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. 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 pericardial effusion. Brief Hospital Course: He was admitted to the floor on [**2157-8-23**]. He was taken to the operating room on [**8-24**] for washout and evacuation of his hematoma and had an additional component separation with polypropylene mesh overlay for appropriate closure of his abdominal wall. This proceeded without complication and he was returned to the floor in stable condition. [**8-24**] - [**8-29**] His postoperative course was complicated by pain control issues and abdominal distention and illeus. KUB showed dilation of large bowel, especially cecum and dilated small bowel loops. Narcotics were minimized. He was made NPO and serial KUBs showed passage of gas through colon. Patient reported flatus throughout. NG tube was inserted. pt [**Name (NI) **] [**Name (NI) 1788**]. Illeus resolved, with decreased distention on physical exam he was advanced to a clear liquid diet which he tolerated well and JP drains were dc'd by gen surgery. Also on exam patient was found to have [**1-8**]+ edema in b/l lower extremities but left slightly greater than right. A duplex study was obtained to r/o DVT which was negative. Lasix diuresis was started with 20 mg IV to which he responded well. He was advanced to a regular diet. Hct was found to be trending down, his SQ heparin was stopped. He was transfused PRBC. responded well. Also his creatinine was 1.9, Baseline 0.9 Maintained good urine output. LR started foe increase creatinine. After 1 unit, HCT increased to 29.9. ARF resolved with IV fluids, Through out the hospital course. On DC, normalized to 0.9. [**8-30**] - [**9-1**] Pt was seen in morning rounds, complaining of SOB he was diaphoritic, Code red was called. Pt was intubated on the floor and transferred to the CVICU. CTA was performed. Found to have PE. IV heparin was started. Pt had TEE showing right heart strain. He also had a troponin leak. This has normalized. He was extubated without sequele. [**9-2**] - [**9-6**] Transfered back to the VICU. He was delined. diet readvanced. Pt did have fevers to 102. IV antibiotics started emperically. The recollection of fluid was thought to be a possible source. Pt went for percutaneous drainage and placement of drain. All cx are negative from flui. CXR and Blood cx are also negative. IV antibiotics stopped, put on PO augmentin prophylactically. [**9-6**] - [**9-9**] IV heparin swithched to Lovenox. Now on lovenox / coumadin bridge. PT, case management. Stable for rehab HCT / CREAT stable Medications on Admission: oxycodone 5-10mg q4h prn, quetiapine 25' qHS, albuterol nebs, gabapentin 800 q6h, fluoxetine 20', colace 100'', tylenol prn Discharge Medications: 1. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: INR goal is 2-2.5. Stop Lovenox when your INR is 2. Disp:*30 Tablet(s)* Refills:*6* 2. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 14 days. Disp:*28 Tablet(s)* Refills:*0* 3. Enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours): Please stop when INR is 2. Waste 10 mg. Disp:*8 Enoxaparin (Subcutaneous) 100 mg/mL Syringe* Refills:*1* 4. Fluoxetine 10 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 5. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours). 6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain for 20 days: 6x day prn. Disp:*40 Tablet(s)* Refills:*0* 7. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 8. Home 02 HOME OXYGEN @ [**2-10**] ltrs pER mINUTE CONTINUOUS VIA NASAL CANNULA, CONDERVING DEVISE FOR PORTABILITY 9. Ventolin HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**1-8**] Inhalation four times a day: prn. 10. Oxcarbazepine 150 mg Tablet Sig: One (1) Tablet PO once a day. 11. Melatonin 5 mg Tablet Sig: Three (3) Tablet PO at bedtime. 12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 13. Centrum Silver Tablet Sig: One (1) Tablet PO once a day. 14. Tramadol 50 mg Tablet Sig: One (1) Tablet PO four times a day: prn. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Last Name (un) 2646**] VNA Discharge Diagnosis: Retroperitoneal Hematoma B/L Saddle Pulmonary Embolism ARF secondary to post o amnemia Anemia secondary to Retroperoneal bleed Troponin leak secondary to right heart strain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Catheter Security: check the patency of tube and that the tube and drainage bag are secured to the patient. Troubleshooting: If catheter stops draining suddenly: 1) Check that the stopcock is open. 2) Remove dressing carefully and inspect to make sure that there is no kink in the catheter. 3) inspect to be sure that there is no debris blocking the catheter. If there is, then firmly flush 5 cc of sterile saline into the catheter. Change the dressing daily. Cleanse skin with 1/2 strength hydrogen peroxide. Rinse with saline moistened q-tip. Apply a DSD. Catheter Flushing: Flush and aspirate. Flush with 10cc sterile saline and spirate back. Repeat this until aspirate is clear. Do not continue to flush if the volume out is significantly less than the volume in. If there is pain with flushing this may mean that the abscess cavity has collapsed. Notify the Radiologist [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 21635**] [**Telephone/Fax (1) 5546**] Pulmonary Embolism DC instructions Home Care Take your medications exactly as directed. [**Male First Name (un) **]??????t skip doses. Avoid sitting, standing, or lying down for long periods without moving your legs and feet. When traveling by car, stop to get out and move around at least once every three hours. On long airplane, train, or bus rides, get up and move around when possible. If you can??????t get up, wiggle your toes and tighten your calves to keep your blood moving. Ask your doctor about daily aspirin therapy. Drink [**6-14**] glasses of water a day, unless directed otherwise. Wear support stockings as directed by your doctor. Learn to take your own pulse. Keep a record of your results. Ask your doctor [**First Name (Titles) 6643**] [**Last Name (Titles) 21636**] mean that you need medical attention. Lifestyle Changes Begin an exercise program. Ask your doctor how to get started. You can benefit from simple activities such as walking or gardening. If you are a smoker, break the smoking habit. Enroll in a stop-smoking program to improve your chances of success. Maintain a healthy weight. Get help to lose any extra pounds. Cut back on salt. Here are some tips: Limit canned, dried, packaged, and fast foods. These tend to be high in salt. [**Male First Name (un) **]??????t add salt to your food at the table. Season foods with herbs instead of salt when you cook. When to Seek Medical Attention Call 911 right away if you have any of the following: Chest pain Trouble breathing Otherwise, call your doctor if you have any of the following: Cough with blood or bloody sputum Rapid or pounding heartbeat Sweating more than usual Fainting Dizziness Swelling in your leg Followup Instructions: Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2157-9-14**] 10:00 You are set up for the coumadin clinic at Dr [**Last Name (STitle) 21637**] office. Go to the lab, they will draw your blood. [**9-13**] at 1030 hrs. You should also make an appoinment to see your PCP below Name: [**Last Name (LF) **],[**First Name3 (LF) **] F. Location: [**Hospital **] MEDICAL ASSOCIATES Address: [**Location (un) 21638**], [**Location (un) **],[**Numeric Identifier 21639**] Phone: [**Telephone/Fax (1) 21640**] Fax: [**Telephone/Fax (1) 21641**] Completed by:[**2157-9-9**]

[ "415.11", "285.9", "530.81", "E878.8", "518.81", "493.90", "584.9", "560.1", "327.23", "429.9", "568.81", "998.12" ]

icd9cm

[ [ [] ] ]

[ "96.04", "38.91", "54.72", "96.71", "88.72", "99.77", "54.12", "54.91" ]

icd9pcs

[ [ [] ] ]

8553, 8613

4422, 6881

313, 525

8829, 8829

2552, 3213

11712, 12355

2194, 2211

7057, 8530

8634, 8808

6907, 7034

8979, 11689

2226, 2533

235, 275

553, 1839

3293, 4399

8844, 8955

1861, 2075

2091, 2178

3245, 3257

18,353

134,705

52584

Discharge summary

report

Admission Date: [**2167-3-20**] Discharge Date: [**2167-4-14**] Date of Birth: [**2101-6-19**] Sex: M Service: MEDICINE Allergies: Benadryl / Morphine / Ativan / Compazine / Lisinopril Attending:[**First Name3 (LF) 1828**] Chief Complaint: Neck pain. Major Surgical or Invasive Procedure: Anterior and posterior revision of instrumented fusions. History of Present Illness: [**Known firstname **] [**Known lastname 91245**] is a 65-year-old male with a long history of end-stage renal disease on hemodialysis who originally presented to Dr. [**Last Name (STitle) 548**] in [**2166-12-4**] with a cervical spine collapse into kyphosis who was subsequently treated with a discectomy and then later a staged anterior and posterior cervical spine reconstruction. He was discharged from the hospital, but represented approximately 5 weeks later after having fallen on the ice and found to have failure of his construct with migration of his anterior and posterior hardware, as well as dislodgement of his anterior fibular graft. The structure was reassessed with imaging and planned to undergo a revision anterior and posterior cervical spine reconstruction with deformity correction in a surgical setting. Past Medical History: 1. Coronary artery disease: MI in [**2155**], NSTEMI in [**2160**], s/p RCA and LCx stenting ([**10-8**]) 2. CHF: EF 20% 3. Diabetes Mellitus II: > 20 years, c/b nephropathy 4. Hypertension 5. ESRD on HD: MWF schedule, R AV fistula 6. PVD: S/p R PFA to BK [**Doctor Last Name **] bypass graft with vein, s/p L 1-5th toe and 1-3rd toe amputation, s/p left CFA to AK [**Doctor Last Name **] with PTFE 7. Hypothyroidism 8. Atrial fibrillation 9. COPD- by report, last PFTs here in [**2160**] w/ nl FEV1 and FEV1/FVC 10. Hepatitis C- last VL 623,000 in [**2160**] 11. Chronic pancreatitis 12. Peptic ulcer disease 13. Right perinephric hematoma; status post embolization 14. Obstructive sleep apnea on CPAP 15. Ruptured right groin abscess; recurrent right groin abscess [**12-7**] 16. Status post L inguinal hernia repair 17. Status post umbilical hernia repair 18. Status post cervical discectomy and corpectomy Social History: Lives in [**Location 686**] with wife. [**Name (NI) 1139**]: 1 ppd x 60 yrs. He is still smoking, unclear how much. EtOH: denies Illicits: h/o narcotic abuse. Should avoid IV pain medications, especially dilaudid, morphine. Family History: Non contributory Physical Exam: PHYSICAL EXAM: Gen: WD/WN, comfortable, NAD. Neck: in hard collar though apparent kyphosis Lungs: bibasilar decreased BS 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. [**Name (NI) **]: D B T FE FF IP Q AT [**Last Name (un) 938**] G Sensation: Intact to light touch bilaterally. Pertinent Results: CT c-spine 2/15/08:1. Since [**2167-3-12**], progression of focal kyphotic angulation with the apex of the curve at the C4 level causing at least moderate canal stenosis. New fracture of the C6 spinous process and further distraction of the left C5/6 facet joint. Further destructive changes of the C3 and C6 vertebral bodies and the lateral masses of C6. 2. Ventral epidural soft tissue extending from C4/5 to the C6/7 level which may represent hematoma or phlegmon. 3. Anterior displacement of the anterior fixation plate and screws as well as fracture, angulation, and displacement of the bone graft. There has been further inferior displacement of the fixation plate and bone graft since [**2167-3-12**]. . [**2167-3-20**] 11:30AM PT-12.7 PTT-32.8 INR(PT)-1.1 [**2167-3-20**] 11:30AM WBC-7.0 RBC-3.74* HGB-11.7* HCT-38.6* MCV-103* MCH-31.3 MCHC-30.3* RDW-15.4 [**2167-3-20**] 11:30AM PLT COUNT-448* [**2167-3-20**] 11:30AM UREA N-34* CREAT-6.0*# SODIUM-137 POTASSIUM-4.7 CHLORIDE-97 TOTAL CO2-26 ANION GAP-19 [**2167-3-20**] 11:30AM [**Month/Day/Year **]-10.0 PHOSPHATE-5.4* MAGNESIUM-2.4 . [**2167-3-28**] ECHO: LVEF 23%, No evidence of endocarditis. Dilated left ventricle with severe regional/global systolic dysfunction. Mild right ventricuilar systolic dysfunction. At least mild aortic stenosis. Mild pulmonary hypertension. . [**2167-3-30**] CT scan: No hardware malalignment or fracture. Expected postoperative findings include air in the soft tissues as well as soft tissue swelling with loss of fat planes. . [**2167-4-7**] PICC placement: Uncomplicated ultrasound and fluoroscopically guided single-lumen PICC line placement via the left basilic venous approach. Final internal length is 42 cm, with the tip positioned in SVC. The line is ready to use. . Labs on discharge: [**2167-4-12**] 05:00AM BLOOD WBC-11.9* RBC-2.93* Hgb-9.1* Hct-29.6* MCV-101* MCH-31.1 MCHC-30.9* RDW-18.4* Plt Ct-515* [**2167-4-12**] 05:00AM BLOOD Plt Ct-515* [**2167-4-12**] 05:00AM BLOOD Glucose-140* UreaN-23* Creat-5.0* Na-137 K-4.1 Cl-97 HCO3-27 AnGap-17 [**2167-4-12**] 05:00AM BLOOD [**Year/Month/Day 9409**]-8.2* Phos-3.1 Mg-2.1 Brief Hospital Course: Mr. [**Known lastname 91245**] is a 65 y.o. M with ESRD on HD, CAD, CHF, renal cervical spondyloarthropathy s/p anterior cervical discectomy in [**12-11**] admitted to the Neurosurgery service with increasing shoulder pain found to have cervical hardware failure treated with surgical revision of anterior/posterior cervical fusion (C3-C6). His course has been complicated by respiratory failure, VAP and hypotension requiring several transfers to the MICU. . 1. Renal cervical spondyloarthropaty s/p surgical revision of anterior posterior fusion: He was admitted due to hardware failure of prior anterior/posterior cervical fusion. He was readied for the OR and brought there on [**2167-3-24**] where under general anesthesia he [**Date Range 1834**] revision anterior and posterior cervical spine reconstruction with deformity correction, removal of anterior plate, removal of posterior lateral mass screws, removal of anterior intervertebral graft, revision corpectomy C3, C4,C5, C6, revision anterior interbody allograft strut, arthrodesis anterior C2-C7, interior plate instrumentation C2-C7, posterior wound culture, posterior revision arthrodesisC2-T1, hardware removal posterior cervical spine, revision instrumentation C2-T1, revision posterior arthrodesis with local autograft, allograft chips and In Fuse bone morphogenic protein supplementation. He tolerated this well and remained intubated and was transferred to the ICU for close monitoring. He had drains placed intraop - posterior and anterior - output was monitored. He was moving all 4 extremities well post-op. Incisions were CDI. On [**Date Range **]#3 he tolerated extubation and drains were removed. He was transferred to the floor, seen in consultation by PT/OT. On [**Date Range **]# 5 he had respiratory distress requiring intubation and transfer back to ICU. Following intubation a CT of the c-spine was obtained showing good hardware alignment. He was treated for pain with standing tylenol and low dose oxycodone 2.5 - 5mg as needed. He was advised to continue wearing the cervical collar at all times for at least the next three months. He will be advised by Dr.[**Last Name (STitle) 548**] when he can remove the cervical collar. His posterior staples were removed during his inpatient stay and he was scheduled for follow up with Dr. [**Last Name (STitle) 548**] prior to discharge. . 2. Respiratory Failure: He was transferred to the MICU on two separate occasions, the first for hypercarbic respiratory failure requiring intubation thought due to VAP/aspiration pneumonia and, obstructive sleep apnea, and hypercarbic from narcotics. He may have also had a component of edema in soft tissues surrounding airway from c-spine surgery. His second MICU transfer was for difficulty clearing secretions and macroglossia, he did not require intubation the second time. He was treated with vanocmycin and zosyn to complete a 14 day course of treatment for VAP/aspiration pneumonia. Since transfer out of the MICU on [**2167-4-6**] he has been breathing comfortably on room air, and doing well on CPAP overnight. On [**2167-4-8**] he was cleared by speech and swallow video study for thin liquids, soft solids, drink by cup only, no straws, crushed meds with purees, no mixed consistency foods. He tolerated this diet well without any evidece of aspiration. . 3. ESRD: No acute issues during this admission, he was continued on hemodialysis MWF. He was continued on nephrocaps, cinacalcet, and lanthanum. He was given vancomycin with dialysis to complete a 14 day course for pneumonia as above. . 4. Hypertension: Normotensive during admission with dialysis MWF. The patient was continued on his current dose of metoprolol 12.5mg [**Hospital1 **], which was held on dialysis days. Prior to discharge he was changed back to metoprolol xl 25mg daily. . 5. CAD: Chronic systolic heart failure with EF 23%. Significant cardiac history. No active issues during his admission. The patient was continued on low dose aspirin 81mg daily, atorvastatin, and metoprolol. Lisinopril was stopped due to history of recent angioedema. . 6. Atrial fibrillation: Throughout his admission he remained in normal sinus rhythm and rate controlled. He was continued on aspirin, amiodarone, and metoprolol. He is not on coumadin due to prior bleeding episodes. . 7. Type 2 diabetes: Diet-controlled. No acute issues. He was continued on humalog insulin sliding scale and diabetic diet. . 8. COPD: No active issues. He was continued on albuterol, atrovent and mucomyst nebs as needed. . 9. Hypothyrodisim: No active issues. He was continued on levothyroxine. . 10. Smoking History: No active issues. He was given a nicotine patch while in hospital. . 11. FEN: Cleared by speech and swallow video study for thin liquids/soft solids, replete lytes prn. Cardiac/diabetic diet. . 12. Code Status: Full Medications on Admission: Albuterol 0.083% Neb Amiodarone 100 mg PO DAILY Citalopram Hydrobromide 20 mg PO DAILY Atorvastatin 10 mg PO DAILY Levothyroxine Sodium 50 mcg PO DAILY Pantoprazole 40 mg PO Q24H Cinacalcet HCl 60 mg PO DAILY Sevelamer 1600 mg PO TID W/MEALS Gabapentin 200 mg PO Q48H Tizanidine HCl 2 mg PO BID Metoprolol XL 25mg daily Discharge Medications: 1. Heparin Flush PICC (100 units/ml) 2 mL IV DAILY:PRN 10 ml NS followed by 2 mL of 100 Units/mL heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 2. Sodium Chloride 0.9% Flush 3 mL IV DAILY:PRN Peripheral IV - Inspect site every shift 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO once a day. 8. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 9. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. Aspirin 81 mg Tablet Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for indigestion. 13. Amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day. 14. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 16. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 17. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 18. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 19. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 20. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed. 21. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO DAILY (Daily). 22. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 23. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 24. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift 25. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: 2.25 g Intravenous Q8H (every 8 hours): last day [**2167-4-19**]. 26. Insulin Lispro 100 unit/mL Solution Sig: inject as directed according to sliding scale Subcutaneous ASDIR (AS DIRECTED). 27. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for neck pain. 28. Vancomycin 1,000 mg Recon Soln Sig: per HD Intravenous qHD: last day [**2167-4-19**]. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 38**] Discharge Diagnosis: Primary: 1. Cervial spine hardware failure 2. Hypercarbic respiratory failure 3. Aspiration pneumonia . Secondary: 1. Coronary artery disease 2. Systolic heart failure 3. Diabetes mellitus type 2 4. Hypertension 5. End-stage renal disease on hemodialysis: MWF schedule, R AV fistula 6. Peripheral [**Location (un) 1106**] disease 7. Hypothyroidism 8. Atrial fibrillation 9. Chronic obstructive pulmonary disease 10. Hepatitis C 11. Chronic pancreatitis 12. Peptic ulcer disease 13. Right perinephric hematoma 14. Obstructive sleep apnea on CPAP 15. Ruptured right groin abscess 16. Status post left inguinal hernia repair 17. Status post umbilical hernia repair 18. Status post cervical discectomy and corpectomy Discharge Condition: Stable. Discharge Instructions: You were admitted to the hospital because you were having worsening shoulder pain and had surgery to revise a prior anterior/posterior cervical fusion. Your hospitalization was complicated by respiratory failure and very low blood pressure requiring intubation and transfer to the ICU. You were also thought to have a pneumonia likely from aspiration, which is when food/stomach contents get into your airway. . You are undergoing treatment for aspiration pneumonia. You should continue vancomycin at hemodialysis and zosyn every 8 hours to complete a 14-day course. You will complete your courses of vancomycin and zosyn [**2167-4-19**]. . DISCHARGE INSTRUCTIONS FOR SPINE CASES ?????? Do not smoke ?????? Keep wound clean / No tub baths or pools until seen in follow up/ take daily showers ?????? You have steri-strips in place on the front of your neck. Do not pull them off. They will fall off on their own or be taken off in the office ?????? No pulling up, lifting> 10 lbs., excessive bending or twisting for two weeks. ?????? Limit your use of stairs to 2-3 times per day ?????? Have a family member check your incision daily for signs of infection ?????? You are required to wear cervical collar at all times ?????? Take pain medication as instructed; you may find it best if taken in the a.m. when you wake for morning stiffness and before bed for sleeping discomfort ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, aspirin, Ibuprofen etc. for 3 months ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine ?????? Any weakness, numbness, tingling in your extremities ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F ?????? Any change in your bowel or bladder habits Followup Instructions: You have an appointment scheduled to follow up with your neurosurgeon, Dr. [**Last Name (STitle) 548**], on [**2167-5-22**]. Please arrive at 10:00am and have an xray prior to your appointment. The xray will be taken in the clinical center building at [**Hospital1 7768**]. Your appointment with Dr. [**Last Name (STitle) 548**] will be at 10:45am. PLEASE CALL [**Telephone/Fax (1) **] if you need to reschedule. . Please call [**Telephone/Fax (1) 250**] and schedule an appointment to follow up with your primary care doctor within one to two weeks of discharge from rehab. . You have a previously scheduled appointment: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2167-4-14**] 11:20

[ "041.19", "996.63", "305.1", "533.90", "E878.2", "E878.1", "414.01", "070.70", "E849.7", "518.81", "440.20", "496", "403.91", "583.81", "327.23", "428.0", "428.22", "585.6", "577.1", "250.40", "E849.8", "427.31", "737.19", "507.0", "996.49", "244.9" ]

icd9cm

[ [ [] ] ]

[ "93.90", "99.04", "96.71", "38.93", "81.02", "78.69", "96.04", "84.52", "39.95", "80.99", "81.62", "81.33", "96.07" ]

icd9pcs

[ [ [] ] ]

13163, 13244

5134, 10013

325, 384

14001, 14011

2970, 4752

16156, 16961

2436, 2454

10383, 13140

13265, 13980

10039, 10360

14035, 16133

2484, 2683

275, 287

4771, 5111

412, 1241

2698, 2951

1263, 2178

2194, 2420

83,079

116,856

5978

Discharge summary

report

Admission Date: [**2122-2-21**] Discharge Date: [**2122-2-25**] Date of Birth: [**2052-4-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 12**] Chief Complaint: Right Lower Quadrant Pain, Hypotension Major Surgical or Invasive Procedure: Embolization of the left hepatic artery. History of Present Illness: Mr. [**Known lastname 1968**] is a 69 year old male with a history of HIV (CD4 238), hepatitis C and multifocal hepatocellular carcinoma with admission in [**9-/2121**] for hemoperitoneum from bleeding cancer focus who presents from home with right lower quadrant abdominal pain which began approximately thirty minutes after he bent down to pick up a crate at the supermarket. The pain continued to worsen and became more diffuse with enlargement of his abdomen. The pain is now severe and [**8-29**]. It was associated with nausea, vomiting. It was not associated with diarrhea, constipation, dysuria or hematuria. It was not associated with lightheadedness or dizziness. He presented to the emergency room. . In the emergency room his initial vitals were T: 99.2 HR: 94 BP: 66/36 RR: 16 O2: 100% on RA. He received a total of 4L normal saline and 2 unit PRBCs with stabilization of his blood pressure to the 120s systolic. He transiently required levophed but this was quickly turned off. He received vancomycin 1 gram IV and zosyn 4.5 mg IV as well as fentanyl 50 mcg x 1 and dilaudid 1 mg x 1. He underwent a diagnostic paracentesis which showed a calculated hematocrit of 18.5 with 2278 WBCs. He underwent a CT scan with IV contrast which showed a large amount of new perihepatic hemorrhage with evidence for active extravasation at site of previous liver capsular rupture. Moderate amount of abdominal pelvic hemorrhage. New segment VIII low attenuation concerning for metastasis. Increased metstatic disease burden in left lobe. No distant metastasis. He was seen by the surgical consult service who recommended that he undergo emergent IR embolization of bleeding region. . On arrival to the floor his blood pressure is in the 130s sytolic and his heart rate was in the 110s. He continued to note pain in his abdomen. He endorses pain with deep inspiration and mild dyspnea. He denies nausea, vomiting, dysuria, hematuria, lightheadedness, dizziness, melena, hematochezia, leg pain or swelling. All other review of systems negative in detail. . Pateint's HCT was stable for 24 hours in the unit in 30s. It bumped appropiately after 2 RBC units. Antibiotics were stopped. Patient has been afebrile. Now he is transfered to the OMED service to further management of his bleeding and to discuss treatment options. Past Medical History: Past Medical History: -HIV on HAART - last CD4 238, viral load 334 on [**2122-2-15**] -Hepatitis C (genotype 1), last viral load 693,000 on [**2120-12-3**] -Hepatocellular Carcinoma with multifocal disease, not a ressection candidate complicated by hemoperitoneum in [**9-27**] requiring IR embolization Social History: Patient is single and rents a room from an elderly woman and acts as her caretaker. [**Name (NI) **] was born in Bermuda. Has 3 daughters and 1 son. Smokes [**Name2 (NI) **] 1 pack every 3-4 days for the past 15 years. No ETOH in 8 years. Prior heavy use in past. No IVDU in 15 years. Prior to this used IV heroin and cocaine. Family History: Diabetes. No known history of malignancy. Physical Exam: Vitals: T: 100.3 HR: 103 BP: 148/95 RR: 18 O2: 98% on 2L . General: Awake, alert, speaking in full sentences, wheezes HEENT: Sclera anicteric, MM moist, oropharynx clear, no lymphadenopathy, parotid gland enlargement Neck: JVP not elevated Cardiac: Tachycardic, regular rhythm, s1 + s2, SEM RUSB [**2-23**], rubs, gallops Lungs: expiratory wheezes, no rales or ronchi. Pt has ginecomastia. GI: firm, distended, tender diffusely, present bowel sounds, no rebound tenderness, + guarding GU: foley draining red urine, small testes Ext: Warm and well perfused, 1+ pulses, no clubbing, cyanosis or edema Neurologic: No asterixis, grossly intact, A&Ox3, cerebelar exam intact, adequate strenght. Pertinent Results: On Admission: [**2122-2-21**] 06:40PM WBC-13.5*# RBC-3.47* HGB-10.6* HCT-33.1* MCV-96 MCH-30.7 MCHC-32.1 RDW-18.4* [**2122-2-21**] 06:40PM NEUTS-79.9* LYMPHS-15.6* MONOS-3.9 EOS-0.3 BASOS-0.3 [**2122-2-21**] 06:40PM PLT COUNT-436 [**2122-2-21**] 06:40PM PT-13.2 PTT-26.9 INR(PT)-1.1 [**2122-2-21**] 06:40PM GLUCOSE-238* UREA N-13 CREAT-1.5* SODIUM-132* POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-20* ANION GAP-18 [**2122-2-21**] 06:40PM ALT(SGPT)-65* AST(SGOT)-55* ALK PHOS-108 TOT BILI-0.5 [**2122-2-21**] 06:40PM ALBUMIN-3.0* [**2122-2-21**] 06:55PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019 [**2122-2-21**] 06:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2122-2-21**] 06:55PM URINE RBC-0-2 WBC-[**4-29**]* BACTERIA-FEW YEAST-NONE EPI-0-2 TRANS EPI-0-2 [**2122-2-21**] 11:57PM LACTATE-1.6 [**2122-2-21**] 11:57PM TYPE-ART TEMP-36.6 PO2-73* PCO2-39 PH-7.34* TOTAL CO2-22 BASE XS--4 INTUBATED-NOT INTUBA [**2122-2-21**] 11:44PM HCT-26.8* [**2122-2-21**] 11:44PM PT-14.0* PTT-28.4 INR(PT)-1.2* . EKG: sinus tachycardia at 101, left axis deviation, left anterior fascicular block, no acute ST segment changes. . Imaging: CXR: Lung volumes are mildly diminished. No consolidation or edema is noted. The mediastinum is unremarkable. The cardiac silhouette is within normal limits for size. A small hiatal hernia is incidentally noted. No effusion or pneumothorax or free intraperitoneal air identified. The osseous structures are grossly unremarkable. . CT Abdomen with contrast: 1. Increase in the extent of metastatic disease, likely hepatocellular carcinoma, involving the left lobe of the liver and evidence of capsular rupture and large volume of hemoperitoneum. A new 8 mm hypoattenuating focus within the right lobe of the liver is now seen. An area of increased attenuation within the center of the hemoperitoneum adjacent to the liver is concerning for active extravasation. Overall, the amount of hemoperitoneum has increased in size when compared back to the initial presentation of this condition on the CT of [**2121-10-4**]. Surgical consultation advised. 2. Moderate hiatal hernia. 3. Left renal cyst. . Upon Discharge: [**2122-2-25**] 05:35AM BLOOD WBC-11.8* RBC-3.56* Hgb-10.7* Hct-32.1* MCV-90 MCH-30.1 MCHC-33.4 RDW-17.6* Plt Ct-266 [**2122-2-25**] 05:35AM BLOOD Plt Ct-266 [**2122-2-25**] 05:35AM BLOOD Glucose-79 UreaN-12 Creat-0.6 Na-133 K-3.1* Cl-101 HCO3-25 AnGap-10 [**2122-2-25**] 05:35AM BLOOD ALT-413* AST-141* LD(LDH)-836* AlkPhos-280* TotBili-3.0* DirBili-1.8* IndBili-1.2 [**2122-2-25**] 05:35AM BLOOD Albumin-2.8* Brief Hospital Course: Impression: 69 year old male with history of HIV (CD4 238), hepatitis C and multifocal hepatocellular carcinoma who presents with abdominal pain found to have hemoperitoneum with associated shock likely from bleeding liver malignancy. . Hemoperitoneum: Patient with evidence of active extravasation of contrast on abdominal CT scan and calculated peritoneal fluid hematocrit of 18. Hemodynamically stable s/p 4L normal saline and two units PRBCs in ED. He underwent IR embolization of the left hepatic artery. He was monitored 24 hours in the ICU with frequent HCT that were stable. He did not require further transfusions. His pain was controlled with IV dilaudid and then switched to an oral regimen. . Hypotension/Hemorrhagic Shock: Related to acute blood loss in the setting of hemoperitoneum. . Acute Renal Failure: Patient's creatinine upon presentation was 1.5 and improved up to 0.6 upon discharge after IVF and stopping hemorrhage. It was thought to be pre-renal renal failure since patient improved rapidly and there were no cast suggesting ATN. He had good UOP. . Hyperglycemia: No documented history of hyperglycemia but blood glucose on chemistry panel is 238. He was started on ISS. He had minimal requirements during hospitalization. . HIV: CD4 count 238 with viral load of 334 on [**2122-2-11**]. HAART was continued. . Hepatocellular Carcinoma: Patient is not good candidate for resection and has already failed hepatic artery embolization in the past. He now bleed into the abdomen and most likely has metastatic disease (not proven). Extensive discussions took place between Dr. [**Last Name (STitle) **] and him and decided to give a 2-week break and then meet to evaluate for either continuing hospice care or oral chemotherapy regimen with sorafenib. . FEN: Regular diet. . Access: 2 16 g peripheral IVs. . Prophylaxis: pneumoboots, home PPI. . Code: DNR/DNI. . Contact: Proxy name: [**Name (NI) 23548**] [**Name (NI) **] (sister) Phone: [**Telephone/Fax (1) 23549**]. . Disposition: Home with hospice. Medications on Admission: Senna 8.6 mg [**Hospital1 **]:PRN Combivir 150 mg-300 mg [**Hospital1 **] Kaletra 200 mg-50 mg 2 Tablets [**Hospital1 **] Methadone 5 mg TID:PRN Tylenol 325 mg TID:PRN Omeprazole 20 mg daily Ibuprofen 400 mg TID:PRN Lactulose 30 mls TID:PRN for constipation Oxycodone 5 mg Tab Q4:PRN Discharge Medications: 1. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 2. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Lopinavir-Ritonavir 200-50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Methadone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain: Then continue your regular oxycodone, once the pain improves. Do not drive or do high risk activities. This medication has sedative effects. Disp:*15 Tablet(s)* Refills:*0* 8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO once a day as needed for constipation. 9. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain. 10. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Primary Diagnosis: Abdominal Hemhorrage secondary to hepatocelular carcinoma. . Secondary Diagnosis: Hepatocellular Carcinoma Hepatitis C Cirrhosis HIV Discharge Condition: Stable, tolerating PO, pain controlled, ambulating. Discharge Instructions: You were seen at the [**Hospital1 18**] for abdominal pain. You had a CT scan of your abdomen that showed signs of bleeding. Some fluid from your abdomen was obtained and it showed blood corroborating the prior clinical impression. You bleed from your liver massess, therefore you underwent ebolization of one of the arteries of your liver to stop the bleeding. You required multiple blood transfusions to replete the loss. We followed closely your blood level and it was stable and you did not further require any transfusions. You had exacerbation of your abdominal pain that was controlled with dilaudid. You will meet with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 4613**] (see below) to discuss further oral chemotherapy and other ways we can help you. . If you have chest pain, shortness of [**Last Name (LF) 1440**], [**First Name3 (LF) 691**] changes in the abdominal pain, [**Last Name (un) 23550**] stools, blood in your stools, or anything else that concerns you please come back to our ER. . We started you on a nicotine patch. You can use if if you want to stop smoking. Do not use the patch and smoke at the same time. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2122-3-13**] 10:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 23551**], MD Phone:[**Telephone/Fax (1) 447**] Date/Time:[**2122-3-13**] 10:00 . Please follow with oyour PCP within [**Name Initial (PRE) **] month of discharge.

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Discharge summary

report

Admission Date: [**2159-10-22**] Discharge Date: [**2159-10-29**] Date of Birth: [**2081-7-13**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1936**] Chief Complaint: fever, chills, transferred from outside hospital for ERCP to evaluate pneumobilia Major Surgical or Invasive Procedure: Endoscopic Retrograde Cholangiopancreatography History of Present Illness: HPI on transfer to Gen Med floor on [**10-24**] Patient is a 78 year old male with a h/o htn, dementia and hypercholesterolemia who presented to [**Hospital **] Hosp on [**10-22**] with two days of fever and diarrhea. Per wife, he was at his USOH until [**10-21**] night, but had temps to 102. Next am, was fine until afternoon, developed rigors. Has been having gas/intermittent diarrhea on/off for weeks. No abdominal pain/vomiting. On arrival to OSH his temp was 103 and he was initially normotensive. No leukocytosis, creat 2.4, LFTs wnl, lipase okay, flu negative. Had episode of NBNB emesis. Underwent CT scan of his abdomen which showed air in the biliary tree so he was transferred to [**Hospital1 18**] Surgical ICU for further management. Got flagyl and levo at OSH, 1L IVfs. En Route to [**Hospital1 18**], reported hypotension/brady, thus on arrival to [**Hospital1 18**], got 2L IVFs, BP better since. . Since his transfer blood cultures from the outside hospital became positive with 4/4 bottles growing [**Last Name (LF) **], [**First Name3 (LF) **] report. He has been on Unasyn, he was also found to have [**1-21**] blood cx positive from the ER for Gram+ cocci in clusters, Vanc started (stopped [**10-24**] since CONS). He has been evaluated by surgery and ERCP service [**10-22**]. Had a right upper quadrant ultrasound that showed concern for possible air vs. stone in the gall bladder, and possible air in the left lobe of the liver. These findings were most concerning for biliary enteric fistula vs. emphysematous cholecystitis, with emphysematous cholecystitis being less likely base on imaging. Was still having fevers on [**10-23**]. Cipro was added for double coverage. After ERCP consult, it was recommended that he undergo ERCP for further evaluation, so he was transfered to [**Hospital Ward Name **] MICU to facilitate his procedure and for further monitoring on [**10-24**]. Underwent ERCP on [**10-24**] with sphincterotomy, stone fragment extraction, no pus, no fistula. last temp was 103 on am of [**10-24**] (0500) a/w rigors (before ERCP). . [**Hospital Unit Name 153**] course also remarkable for acute hypoxia, resp distress on [**10-24**] am. Got lasix and nebs with some improvement. IVF stopped. Echo with mod-severe MR, nl EF. . Was transfered to Gen Med evening [**10-24**] after ERCP. He currently has no complaints, saying that he feels well. Is npo given ERCP. his diarrhea is improving. Denies any fever/chills, chest pain, shortness of breath, nausea/vomiting. . . . Past Medical History: HTN Hypercholesterolemia chronic diastolic heart failure since [**2155**] Valvular heart disease-MR [**Name13 (STitle) 84516**] Endocarditis (p/w FTT/fevers) of mitral valve [**3-25**] s/p 4weeks Vanc (staph epidermis)- f/u culture neg/ESR neg. Cath reported normal in [**2155**] h/o acute cholecystitis in past year-defered ccy in past h/o PNAs-last [**1-26**] Hypothyroid Chronic thrombocytopenia-100s Dementia, alzhiemers since [**2156**] Diabetes, on insulin lantus/humalog, last A1c 7.1 CKD IV, baseline 2.0-2.2 since [**8-26**]-sees a nephrologist, Dr. [**First Name (STitle) **] [**Name (STitle) 84517**] CPAP or BiPAP at home Lyme disease '[**57**] (IgM pos, fevers/chills) s/p Doxy X1 month, last month IgG positive, got treated again with doxy X3weeks (not active disease) [**9-26**] s/p appy s/p tonsillectomy Social History: married. lives at home. 2 grown children. no active smoker, rare ETOH, or illicits. Family History: no GI malignancy Physical Exam: on discharge Vitals: 98.3 138/70 60 18 97%RA I/Os not accurately recorded, making good UOP Pain: denies Access: RUE PICC Gen: lying in bed HEENT: o/p clear, mmm CV: RRR, [**2-23**] SM LSB Resp: CTAB +bilateral crackles improved, not cleared with coughing Abd; soft, nontender, +BS Ext; trace edema Neuro: unchanged, A&OX2-3 (doesnt know exact date or name of hospital), otw nonfocal Skin: no changes psych: appropriate . Pertinent Results: no leukocytosis wbc [**4-23**] Hgb [**10-28**] stable, MCV 90s INR 1.3 BUN/creat 42/2.2-->28/1.8-->32/2.0-->35/2.5-->37/2.8-->40/2.6-->34/1.9 K 3.4, Mag 1.7, phos 2.0 AST 59, ALT 36, alkphos and Tbili wnl BNP [**Numeric Identifier 56578**], trops neg X2 ESR 30 CRP 60 . UA [**10-27**] neg FeNa 2%, [**Month/Year (2) 84518**] 55% Urine eos neg . UA [**10-24**] with 4wbc, few bacteria UCx negative . blood cx [**10-22**] 1 of 2 with CONS blood cx [**10-24**] X2 NTD . OSH: blood cx [**10-22**]: 4 of 4 Klebsiella pneumonia Sensitive to all except ampicillin . flu neg BUN/creat 48/2.4 UA negative, UCx negative . . Imaging/results: . Renal US [**10-27**]: essentially normal. small 8mm AML upper pole L kidney . CXR [**10-27**]: Two views of the chest demonstrate the lungs to be clear. The cardiomediastinal silhouette is unremarkable. . . CXR [**10-24**]: The lung volumes are lower on the current study. There is extensive bilateral perihilar new interstitial prominence as well as newly developed left retrocardiac opacity that might be a progression of pre-demonstrated abnormality on [**2159-10-22**] radiograph suggesting worsening of infection in combination with pulmonary edema. Followup of the patient after diuresis is recommended to evaluate the relationship between suspected infection and pulmonary edema changes. There is no pneumothorax. The cardiomediastinal silhouette is stable . CXR [**10-22**] IMPRESSION: Left basilar atelectasis. No focal consolidation identified. . Echo: IMPRESSION: Mild symmetric LVH with normal LV cavity size and normal systolic function. There is moderate to severe mitral regurgitation - there is mild bileaflet prolapse. There may be a partial flail of the posterior leaflet (images # 1 and 2). The RV is mildly dilated/hypokinetic. Moderate pulmonary artery systolic hypertension. . RUQ U/S ([**10-22**]): wet read: gb collapsed with possible air (linear hyperechoic foci with dirty shadowing) although stone could have similar appearance- less likely given no stone on recent outside CT images. possible air within left lobe of liver. no bil dil. DDx includes recent procedure or possible biliary enteric fistula. emphysematous cholecystitis could also present with gb air, however there is no inflammatory changes/wall edema or gb distention. . . ERCP [**10-24**]: Impression: Normal major papilla. No evidence of a biliary enteric fistula An air pneumogram was seen on the scout image. Cannulation of the biliary duct was successful and deep with a sphincterotome after a guidewire was placed. Contrast medium was injected resulting in complete opacification A distal CBD filling defect consistent with a small stone was seen at the biliary tree. There was no post-obstructive dilation A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. Multiple stone fragments were extracted successfully using a 12 mm balloon. The bile duct was clear at the end of the procedure (sphincterotomy, stone extraction) Otherwise normal ercp to third part of the duodenum Note that there was no pus in the bile duct - it is not clear that biliary sepsis is the cause of his recurrent fevers - consider other causes . . Brief Hospital Course: 78 year old male with h/o hypertension, DM on insulin, CKD IV, chronic dCHF who presented to OSH [**10-22**] with one day of fevers, CT scan concerning for pneumobilia so transfered to [**Hospital1 18**]. ERCP done on [**10-24**] with CBD stone/sludge which was removed, but no pus or fistula as suggested on CT/US. Found to have klebsiella bacteremia with unclear source but most likey biliary as the admission UA/CXR at OSH and here were unremarkable. Had daily fevers until [**10-24**] am but has been afebrile since ERCP. Subsequent blood cultures at [**Hospital1 18**] negative except 1 of 4 bottles on [**10-22**] in ER had CONS, deemed to be contaminant (esp given we had other bacteria isolated from OSH). Since transfer to Gen Med on [**10-24**], has been doing well, no more fevers, BP improved. His home medications reintroduced. His diet advanced. His MS much improved. Got some PT. Given his bacteremia, plan for IV unasyn X14days total (until [**11-4**]) and RUE PICC was placed. Of note, surgery did reccommend outpt cholecystectomy, esp since this appears to be his 2nd complication. Pt has defered this in the past but can be discussed once again. One other issue complicating hospital stay was that he initially recieved fluids given transient hypotension en route to [**Hospital1 18**] and ongoing fevers and concern for sepsis. Then on [**10-24**] am, was wheezing and CXR/BNP c/w acute worsening CHF (Echo normal EF, mod-severe MR). Was given IV lasix [**10-24**] and [**10-25**] with improvement in breathing, O2 sats. Creat did remain stable with this (2.4 on admission, 1.8 after fluids, 2.0 after diuresis (baseline)). However, on [**10-26**], he had a bump in his creat, which peaked at 2.8 on [**10-27**]. Renal was consulted given unclear etiology ([**Name (NI) 84518**] 55%, US neg, urine eos neg, I/Os positive balance, no contrast, no documented hypotension, no nephrotoxins). They felt it may have been due to relative hypotension/hypoperfusion in setting of sepsis and restarting lisinopril and lasix (got his home PO dose lisinopril 5mg and lasix 80mg PO on [**10-26**] am before labs were drawn). We held his lasix and lisinopril and allowed his BP to be a bit higher to maintain perfusion. His creat improved on his own. Given that his O2 sats were good, we did not resume his lasix on discharge and this can be done over the next few days per Dr. [**Last Name (STitle) 1159**] if his creat remains stable. We also did not resume his lisinopril and this can be resumed after a week or so if BP and creat are good after resuming lasix. He does tend to have hypoK/Mag, even when he was not getting lasix and this can be monitored. His family/wife updated on daily basis. PCP updated as well and [**Hospital 33857**] transfer to [**Hospital6 **] for IV Abx and short rehab stay. Of note, after being seen by PT, there was some concern about the safety of patient being able to drive a car as outpt and this concern was related to pt's wife and she is asked to further discuss this with his PCP. [**Name10 (NameIs) **] has an outpt cardiologist and nephrologist and he can f/u with them in the next two weeks. .. . Below is the daily progress note from the day of discharge for further details according to problem list: . ARF on CKD IV: per OSH records, creat since [**8-26**] has been around 2.0-2.2. Was 2.4 at OSH, got fluids, improved to 1.8, then developed heart failure, got lasix 80mg IV [**10-24**] and [**10-25**], creat stabilized around 2.0-2.2. Resumed on lasix 80mg PO on [**10-26**], dose held [**10-27**]. Also got his lisinopril 5mg dose resumed on [**10-26**] (one dose). -on [**10-26**] afternoon, creat 2.0->2.5-->2.8 on [**10-27**]. By I/Os pt has been positive. -[**Month/Year (2) **] 55% and not orthostatic and clinically not dry. renal US unremarkable, urine eos neg. no contrast recently. no documented hypotension. -Holding lasix/lisinopril per renal as they think relative hypotension in setting of sepsis -creat improved 2.8-->1.9 with holding lasix and lisinopril, will continue to hold and can resume as outpt -renally dose meds, avoid nephrotoxins . . Allergy to Midline: developed streaking along LUE midline so removed and PIV placed. On [**10-29**], a new PICC placed RUE . . Klebsiella bacteremia/fevers: Given CT and US findings, initially concern for biliary source. however, LFTs wnl, GB otw normal, and ERCP w/o evidence of pus or fistula. OSH UA/UCx negative. CXR also negative on admission. ERCP doesnt think biliary source, but may have been transient bactermia->though unusual why recurrent fevers X3days, it is still most likely the case. will treat for 14days for bacteremia -will continue unasyn per sensitivites. Day [**8-31**]. d/c'd cipro [**10-25**]. -f/u blood cx, NTD here (except CONS) -note, repeated CXR after diuresis, no infiltrate -CIS, last temp [**10-24**] am . . CONS bacteremia: only 1/4 bottles. has h/o CONS endocarditis BUT since 1/4 bottles and we already have other source, this is likely a contaminant. Vanc stopped [**10-24**] . . Acute on chronic diastolic HF: [**2-19**] IVfs. s/p lasix 80IV [**10-24**] and [**10-25**] with some improvement. Off O2. I/Os suggest pt drinks a lot of fluids. Echo with EF >55% and valvular dz (mod-severe MR) -got lasix 80mg PO home dose on [**10-26**]. Has been held since [**10-27**] given ARF and per renal, cont to hold for a couple days. need close monitoring of creat if resumes (also hypoK) -cont BB, ACE-i held -repeat CXR much improved -I/Os, daily weights, BP, creat -inhalers prn . . Choledocholithiasis: again as above, ERCP wtih small distal CBD stone, s/p sphincterotomy and sweep. No pus or fistula seen. per PCP, [**Name10 (NameIs) **] has h/o cholecystitis but has deferred CCY in past. -outpt elective outpt ccy per surgery . . HTN: resumed BB (on higher dose at home). Holding ACE-I, BPs ar acceptable and per renal, avoid hypotension in setting of recent bacteremia/sepsis. Can start as outpt in next couple weeks and monitor creat. . . DM, type II, controlled with complications: sugars here around 150-200 and is on SSI. -cont home lantus 14U qam, humalog SSI, accuchecks, diabetic diet . . Anemia: baseline hgb around 13. Here has been around [**10-28**] but stable. likely due to acute illness and dilutional. Also CKD component -follow trend . . Dementia: baseline oriented and independent. Here is nearly oriented. high risk delirium -nonpharm measures -foley d/c'd -no narcotics/sedatives -PT following -reorient frequently -resumed home aricept and namenda . . Hypothyroid: continue home dose synthroid 50mg PO . . Code/dispo: Full Code. Wife is [**Name (NI) **]: 1-[**Telephone/Fax (1) 84519**]. PCP. [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1159**] [**Telephone/Fax (1) 20587**]. Cardiology: Dr. [**Last Name (STitle) **], [**Telephone/Fax (1) 16827**]. Plan is for [**Hospital6 **], was defered over weekend given ARF, however, can go today. . Medications on Admission: ASA 81 mg qday Levothyroxine 50 mcg qday Lisinopril 5 mg qday Carvedilol 12.5 mg-1.5 tabs qd Lasix 80 mg qday Donepezil 10 mg qday Memantine 5 mg [**Hospital1 **] lantus 14U qam humalog TID Mag ox 400mg qd MVI Vit C 500mg qd folic B6 100mg qd Vit B1 100mg qd Vit D 1000U qd Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): this is lower than previous dose. 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Lantus 100 unit/mL Cartridge Sig: Fourteen (14) Subcutaneous once a day: in morning. 7. Humalog 100 unit/mL Cartridge Sig: One (1) Subcutaneous three times a day: use per your previous sliding scale. 8. Memantine 5 mg Tablet Sig: One (1) Tablet PO bid (). 9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): NOTE, we have been holding this medicine in lite of ARF. Please ask your doctor when it is safe to resume. . 10. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): We have been holding this medication since [**10-26**]. Please discuss with Dr. [**Last Name (STitle) 1159**] BEFORE starting and will need to closely follow creat. . 11. Ampicillin-Sulbactam 3 gram Recon Soln Sig: One (1) Recon Soln Injection Q12H (every 12 hours) for 6 days: continue until [**11-4**]. 12. MagOx 400 mg Tablet Sig: One (1) Tablet PO once a day. 13. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a day: take when taking lasix. 14. Multi-Vitamin W/Minerals Capsule Sig: One (1) Capsule PO once a day. 15. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day. 16. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 17. Vitamin B-1 100 mg Tablet Sig: One (1) Tablet PO once a day. 18. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 25759**] & Rehab Center - [**Location (un) **] Discharge Diagnosis: Klebsiella bacteremia, likely biliary source Choledocholithiasis s/p ERCP ARF on CKD Acute on chronic diastolic CHF Mild delirium with baseline mild dementia CONS bacteremia 1/4 bottles, likely contaminant Discharge Condition: STABLE Discharge Instructions: You were admitted with fevers and were found to have bacteria (klebsiella) in your blood. the source of this bacteria is likely from your gallbladder since your urine and ChestXray were okay on presentation. You will be treated with IV antibiotics (unasyn) for 2weeks total. You have a PICC line (IV ) on your right arm that will be removed at [**Hospital6 **] after your antibiotics are completed. . You also had some kidney problems while here. Your lasix and lisinopril were held and this improved back to your baseline. Your doctor will decide to reintroduce these meds in the next few days, but will need to closely monitor your kidney function. Followup Instructions: You will be followed by Dr. [**Last Name (STitle) 1159**] at [**Hospital6 **]. Please make an appointment to see Dr. [**First Name (STitle) **] (nephrologist) and Hack (cardiologist) in next 1-2weeks. Surgeons have reccommended that you undergo gallbladder surgery since this is your second complication with gallstones.

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icd9cm

[ [ [] ] ]

[ "38.93", "51.85", "51.88" ]

icd9pcs

[ [ [] ] ]

16675, 16761

7681, 10925

399, 447

17010, 17018

4442, 7658

17718, 18041

3964, 3982

14941, 16652

16782, 16989

14642, 14918

17042, 17695

3997, 4423

278, 361

475, 3003

10939, 14616

3025, 3847

3863, 3948

5,142

118,845

1077

Discharge summary

report

Admission Date: [**2126-10-28**] Discharge Date: [**2126-11-3**] Date of Birth: [**2060-2-3**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 7046**] is a 66-year-old male known to Dr. [**Last Name (STitle) **] and our service. He had been inpatient at the end of [**Month (only) **] with cardiac catheterization showing VVD and he was referred for coronary artery bypass graft at that time. Carotid ultrasound showed 80 to 99 percent right sided plaque and 60 to 69 percent left sided plaque. He underwent stenting of the right carotid on [**2126-9-27**], he experienced HAS post intervention with question of SAH and was unclear as to why his surgery was delayed at that time. It was considered that he would wait 4 to 6 weeks for coronary artery bypass graft after his carotid stenting. He is also experiencing worsening of his right lower extremity and claudication and on [**2126-10-12**] he had a thrombectomy at the right aorta bifemoral graft. At this time prior to admission on [**2126-10-23**] he reported one episode of nonspecific gas verses chest pain on [**10-21**], it was unrelieved by sublingual nitroglycerin which sent him to the emergency room. He was negative for myocardial infarction by enzymes and electrocardiogram. Denied any shortness of breath, nausea, vomiting, diaphoresis, dizziness, syncope or edema. Aortobifemoral bypass grafting with peripheral vascular disease and chronic renal insufficiency. He had no chest pain since his admit. When he was seen on the 28th his meds at home were as follows: 1. Atenolol 12 mg once daily 2. Ticlid 250 mg p.o. twice a day 3. Lipitor 80 mg p.o. daily. 4. Lisinopril 20 mg p.o. twice a day. 5. Tricor 160 mg p.o. once daily 6. Aspirin 81 mg daily. ALLERGIES: Iodine, Plavix and Norvasc. When he was seen on the 20th his pressure was 117/61 with a heart rate of 65, respiratory rate 24, sating 99 percent on room air. He was alert and oriented neurologically and appropriate, had expiratory wheezes on the right side. His lungs were clear otherwise. His heart was regular rate and rhythm with an S1 and S2 and no murmur, rub or gallop heard. His abdomen was soft, nontender, with positive bowel sounds. His extremities were warm, well perfused with no edema or varicosities. His right groin incision site was well healed. He had bilateral dorsalis pedis and posterior tibial 1 plus pulses and bilateral 2 plus radial pulses. He was also seen by Dr. [**Last Name (STitle) 7047**] and Dr. [**Last Name (STitle) **] on the 21st prior to admission. Preoperative labs were hematocrit of 35.1, PT 14.2, PTT 68.1, INR 1.3, BUN 38, creatinine 2.2, and a K of 4.6. Discussion was held as to whether or not a neuro consultation will be held at that time prior to the patient coming back at some point for his surgery. Dr. [**Last Name (STitle) **] also advised the patient to stop smoking for a week to ten days prior to him coming back and have a repeat creatinine and platelet counts prior to his discharge. He also recommended to repeat creatinine and platelets before surgery and tentatively scheduled the patient for [**2126-10-3**]. The patient was actually re-admitted on [**2126-10-28**] and was seen by Cardiology at that time. On [**2126-10-28**] the patient underwent coronary artery bypass graft times three by Dr. [**Last Name (STitle) **] with a left internal mammary artery to the left anterior descending coronary artery, a vein graft to the posterior descending coronary artery, and a vein graft to the OM. He was transferred stable to the Cardiothoracic Intensive care unit on a Propofol titrated drip. The patient was also seen and evaluated by Case Management and on postop day one he was transfused one unit of packed red blood cells for low hematocrit which then rose to 30. He was not able to tolerate CPAP because of some agitation. He was hemodynamically stable in sinus rhythm at 80, he had a blood pressure of 108/61, his index was 2.99. He remained intubated. At that time his heart was regular rate and rhythm, his lungs were clear bilaterally, his examination was otherwise unremarkable and his creatinine rose to 3.0. His Swann was discontinued, he started intravenous Lasix with plan to try and extubate him. The patient was also on insulin drip at two units an hour and Neo-Synephrine drip at 1.2 mcg per kg per minute. Dopamine drip was also started. The patient remained in the Intensive care unit. Later that evening the patient was cardioverted for rapid atrial fibrillation in 180's to with blood pressure 80's despite Neo- Synephrine at 6 mcg per kg per minute. The patient converted to normal sinus rhythm after a single cardioversion at 100 Joules. He remained n a Procainamide drip as an anti- arrhythmic at that time. At 7:30 in the morning the patient went into atrial flutter, atrial fibrillation, at 8 o'clock he converted to normal sinus rhythm with frequent Premature atrial contractions. He remained on Procainamide drip at 2 mg a minute, he was transfused two units of packed red blood cells for a hematocrit of 24, repeat crit was 28.4. He was also given several doses of intravenous Lasix between units of blood. The patient remained in sinus rhythm at that time. On postop day two, his examination was unremarkable other than decreased breath sounds bilaterally. His chest tubes were discontinued. On postop day three he received 3 mg of Coumadin the night prior for his history of atrial fibrillation. His incisions were clean, dry and intact grossly with decreased breath sounds bilaterally. He had 1 plus peripheral edema, his hematocrit stayed at 28.2 with a creatinine that dropped slightly from 2.9 to 2.5. A HIP panel was sent off, the pacing wires were discontinued. He was seen and evaluated by physical therapy. After his extubation the patient was stable, he complained of some itching and he had a little bit of a rash on his abdomen and back with raised areas that were hive like, non-bleached sheets were ordered and applied. The patient was also given 25 mg Benadryl dose for his itching and rash and Percocet for pain. He was transferred out to the floor on the 28th. Foley was discontinued. On postop day four the patient had another episode of atrial fibrillation the evening prior which converted to normal sinus rhythm with intravenous Lopressor. He remained on Procainamide orally, had been restarted on his Ticlid for his carotid stent and continued beta-blockade with Lopressor 50 mg p.o. twice a day. Procaine NAP levels were pending. Creatinine dropped from 2.5 to 2.3. Hematocrit was stable at 33.8, INR was 3.2, HIP panel was pending. The patient had coarse rhonchorus breath sounds at the lower basis bilaterally. He had trace peripheral edema. Incision was clean, dry and intact. Coumadin was held that evening for his INR already at 3.2. He continued to work with physical therapy, following that had no complaints. On postop day five he remained in sinus rhythm with a pressure of 140/64, he had decreased breath sounds at the basis, he was alert with a nonfocal examination. Procainamide was discontinued. He remained hemodynamically stable. His INR dropped to 2.9 the following day, hematocrit remained stable at 30.7, creatinine dropped to 2.1. The patient was encouraged to take more p.o.'s, he worked with an incentive spirometer, he continued to ambulate with the nurses and physical therapy. He was seen by the EP service on [**2126-11-3**], the day of discharge and they recommended discontinuing his Procainamide, increasing his Lopressor, continue his Coumadin and to follow-up with his primary cardiologist and EP in the future. The patient was discharged on [**2126-11-3**] with the following diagnosis: 1. Status post coronary artery bypass graft times three. 2. Peripheral vascular disease, status post right carotid stenting and bilateral carotid stenosis. 3. Myocardial infarction with percutaneous transluminal coronary angioplasty 10 years ago. 4. Hypertension. 5. Hypercholesterolemia. 6. Positive smoking history. 7. Status post aortobifemoral bypass graft. 8. Meniere's disease. 9. Left kidney atrophy. DISCHARGE MEDICATIONS: 1. Lasix 40 mg p.o. daily times seven day. 2. Potassium chloride 20 mEq p.o. twice a day times seven days. 3. Colace 100 mg p.o. twice a day. 4. Percocet 5/325 mg one tab p.o. q 4 hours p.r.n. for pain. 5. Protonix 40 mg Entericoated one tablet p.o. every 24 hours. 6. Ticlid 250 mg p.o. twice a day. 7. Lopressor 75 mg p.o. twice a day. 8. Coumadin 2.5 mg p.o. just on the day of discharge [**2126-11-3**] with instructions to follow-up for an INR check on [**11-4**] and to call the results to Dr. [**Last Name (STitle) 656**] the primary care physician for further dosing. The patient was also instructed to follow-up with Dr. [**Last Name (STitle) 656**] in one to two weeks in the office as he would be responsible for his Coumadin INR management. The patient was also instructed to follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] his Cardiologist in one to two weeks and make an appointment with Dr. [**Last Name (STitle) **] his surgeon for postop surgical check in the office at four weeks. The patient was discharged on [**2126-11-2**]. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2126-11-29**] 15:10:24 T: [**2126-11-29**] 16:42:02 Job#: [**Job Number 7048**]

[ "401.9", "272.0", "593.9", "V15.82", "411.1", "427.31", "412", "443.9", "414.01", "997.1", "V45.82" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

8205, 9548

165, 8182

30,383

106,358

34505

Discharge summary

report

Admission Date: [**2146-8-14**] Discharge Date: [**2146-8-17**] Date of Birth: [**2064-12-9**] Sex: M Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 1257**] Chief Complaint: abd pain Major Surgical or Invasive Procedure: percutaneous nephrostomy tube placement, [**2146-8-13**] History of Present Illness: 81 yo male with presumed COPD and recently diagnosed metastatic bladder CA with known left hydronephrosis presents from OSH ED after complaining of abd pain. The pt reports that he was in his usual state of health until mid-day on the day PTA. At that point, he noted the onset of RLQ abd pain that was non-radiating and intermittently sharp and dull. He presented to the ED at [**Hospital1 **]-[**Location (un) 620**] where he was afebrile but noted to appear unwell and have an SBP in the 90s with associcated sinus tachycardia. A CT scan there demonstrated left hydronephrosis and a question of gallbladder distention. In the [**Hospital1 18**] ED, initial vitals were 97.2, 103, 24, 98/68 and 90% RA. An abd ultrasound was obtained in the ED. This study did not show gall bladder abdnormalities but did demonstrate extensive hepatic mets. He was given emperic doses of Zosyn and vancomycin as well as 5L NS. A urology consultation was obtained given the pt's hydronephrosis and a positive UA. There was a concern for left sided upper urinary tract infection and urgent percutaneous nephrostomy tube placement was advised; this was performed by IR immediately after the pt's arrival to the MICU. A VQ scan was also obtained given the pt's tachycardia and relative hypoxia; the results of this study are pending. ROS was otherwise essentially negative. The pt endorsed intermittent hemature but denied recent unintended weight loss, fevers, night sweats, chills, headaches, dizziness or vertigo. No changes in hearing or vision, neck stiffness, lymphadenopathy, hematemesis, coffee-ground emesis, dysphagia, odynophagia, heartburn, nausea, vomiting, diarrhea, constipation, steatorrhea, melena, hematochezia, cough, hemoptysis, wheezing, shortness of breath, chest pain, palpitations, dyspnea on exertion, increasing lower extremity swelling, orthpnea, paroxysmal nocturnal dyspnea, leg pain while walking, joint pain. Past Medical History: multiple papillary bladder tumors --first dx in [**4-18**] --s/p BCG therapy --concern for mets to mid left femur, known extensive liver mets renal stones many years ago s/p left inguinal hernia repair lung nodule concerning for possible malignancy noted on CT scan Social History: Retired clerical worker. Smoked multiple PPD from age 14 to 61. Denies EtOH. Family History: No FH of malignancy or other heritable disease. Both parents lived to advanced age. Physical Exam: General: Awake and alert though mildly sleepy. NAD, pleasant, appropriate, cooperative. HEENT: NCAT, PERRL, EOMI, no scleral icterus, MMM, no lesions noted in OP. Neck: Supple, no significant JVD or carotid bruits appreciated. Pulmonary: Few crackles at bases bilaterally, no wheezes or rhochi. Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated Abdomen: Soft, NT, ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: Trace edema, 2+ radial and DP pulses b/l Skin: No rashes or lesions noted. Neurologic: Alert, oriented x 3. Able to relate history without difficulty. Cranial nerves II-XII intact. Normal bulk, strength and tone throughout. No abnormal movements noted. No deficits to light touch throughout. No nystagmus, dysarthria, intention or action tremor. 2+ biceps, triceps, brachioradialis, patellar reflexes and 2+ ankle jerks bilaterally. Plantar response was flexor bilaterally. Pertinent Results: [**2146-8-14**] 01:05AM WBC-16.3* RBC-4.49* HGB-14.2 HCT-41.5 MCV-92 MCH-31.6 MCHC-34.2 RDW-14.0 [**2146-8-14**] 01:05AM NEUTS-91.8* LYMPHS-4.4* MONOS-3.3 EOS-0.3 BASOS-0.1 [**2146-8-14**] 01:05AM GLUCOSE-100 UREA N-68* CREAT-2.4* SODIUM-140 POTASSIUM-5.6* CHLORIDE-103 TOTAL CO2-18* ANION GAP-25* . CXR: The cardiomediastinal contour is normal. The heart is not enlarged. There is linear platelike atelectasis at the left lung base. The lungs are otherwise clear. Osseous structures are unremarkable. IMPRESSION: No evidence of focal consolidation on this single view. . Abd US 1. Innumerable hepatic metastases from bladder cancer. 2. Cholelithiasis without evidence of cholecystitis. 3. No evidence of intrahepatic biliary ductal dilatation; normal size of CBD. Brief Hospital Course: 81 yo male presenting with bladder cancer, found to have abd pain, tachycardia and borderline blood pressure, s/p perc nephrostomy tube drainage of left hydronephrosis, became persistently hypotensive and subjectively dyspneic with a refractory metabolic acidosis. It was decided to place the patient via care measures and he was placed on a morphine drip -- the patient subsequently expired. #UTI: Treating with Cipro. Await culture results. WBC slightly decreased. Does not meet SIRS criteria. Pt was agressively volume repleted. . #ARF: Pt's baseline somewhat unclear, however SCr was 1.7 at OSH approximately one week ago, further elevated on admission, still further increasing today. Some baseline renal dysfunction expected given pt's obstruction; suspect that acuity of further obstruction resulting in additional failure. Pt s/p perc drainage placement and volume repletion. Developed a refractory metabolic acidosis with resultant tachypnea. . #SOB/question COPD: Pt with extensive smoking history and a question of COPD based on prior imaging. No has crackles on exam after 5L volume resuscitation in MICU. Patient became subjectively dyspneic and tachypneic during exams which was summarily relieved by morphine after CMO status. . #Abnormal LFTs/coagulopathy: Likely secondary to extensive hepatic mets. . #Abd pain: Has resolved. Likely secondary to worsening hydronephrosis/UTI, although numerous other etiologies were certainly possible. Medications on Admission: oxycontin PRN colace Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: N/A Discharge Condition: N/A Discharge Instructions: N/A Followup Instructions: N/A Completed by:[**2146-8-21**]

[ "599.0", "198.5", "591", "458.9", "198.0", "584.5", "799.02", "188.9", "496", "403.90", "570", "995.92", "286.7", "197.7", "574.20", "585.3", "038.9", "305.1", "V66.7", "197.0", "276.4" ]

icd9cm

[ [ [] ] ]

[ "55.03" ]

icd9pcs

[ [ [] ] ]

6089, 6098

4530, 5990

277, 335

6145, 6150

3735, 4507

6202, 6236

2687, 2772

6061, 6066

6119, 6124

6016, 6038

6174, 6179

2787, 3716

229, 239

363, 2287

2309, 2576

2592, 2671

2,921

142,029

50979

Discharge summary

report

Admission Date: [**2143-10-1**] Discharge Date: [**2143-10-6**] Date of Birth: [**2098-9-22**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2160**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Arteriovenous fistula placement History of Present Illness: This is a 45 y/o female with poorly controlled HTN, h/o frequent admssions for hypertensive urgency/emergency (negative w/u for secondary causes), ESRD on HD, presented with dyspnea and was found to have elevated blood pressure 200s/130s. She reports compliance with medications, but she is not able to clearly state names and dosages. She also complained of L chest pain, frontal HA, pain under the anterior ribs bilaterally, and N/V, all of which have now resolved. She denies visual changes, weakness, slurred speech, dysarthria, confusion, or hematuria. . In ED, she was treated with 5 gm IV lopressor x 2, labetolol 20 mg IV, labetolol 40 mg IV x2, then Hydralazine 10 mg IV, Hydralazine 20 mg IV x1, with improvement in BP. She recieved 80 mg IV lasix with mild response in urine output. She was then transferred to the MICU for further care. . In the MICU, her blood pressure has now been well controlled on her home PO medications, with the exception that her labetalol was changed to metoprolol. She had hemodialysis yesterday and again today (usual days T/Th/Sat). She also ruled out for MI. She is currently asymptomatic and feels back at her baseline. . ROS negative. Past Medical History: 1. HTN- poorly controlled with recurrent admissions for HTN urgency/emergency. Secondary w/u negative including normal TSH, cortisol, and [**Male First Name (un) 2083**] levels, MRI/A abd negative for adrenal masses/no evidence of RAS. 2. CRI/ESRD- in [**2141**] Cr 0.9, since [**12/2142**] Cr elevated, more acutely from baseline 2.7-3.5 to [**7-11**] in [**2143-5-2**]. 3. Anemia- baseline Hct 23-30 4. Schizophrenia - Diagnosed approximately 4-5 years ago. Followed at [**Hospital **] Hospital, where she receives risperidone IM injections every 2 weeks. 5. h/o Hyperprolactinemia?????? Found to have elevated prolactin level to 229 in [**Month (only) 359**], in context of missed menses in and galactorrhea. Pituitary MRI was negative. Resolved with adjustment of risperidone dose. Social History: Patient has been working at Old Navy for the past 4-5 years, and she just completed a certificate program to work as a medical office assistant. She lives alone in [**Location (un) **], but she occasionally spends the night with her mother in the [**Location (un) 4398**] when she works nights. She has been in a monogamous, heterosexual relationship for the past 10 months. She stopped taking her OCP??????s in [**Month (only) **], but she reports condom use most of the time. She smoked approximately [**4-6**] cigarettes/day for one year and quit 1 1/2 months ago. She denies alcohol or drug use. Family History: Mother, 65, has refractory hypertension and glaucoma. Maternal relatives also have hypertension. No known family history of psychiatric illness (depression, bipolar, schizophrenia). No reported family history of diabetes, renal disease, rheumatologic disease, stroke, or sudden cardiac death. Physical Exam: Upon arrival to ICU: VS: T 96.1, BP 143/99, HR 72, RR 18, 99% on RA GEN: NAD HEENT: PERRL, EOMI, anicteric sclera Neck: supple, no thyromegaly Heart: RRR, nl S1/S2, no murmur Chest: Few bibasilar crackles ABD: +BS, soft, ND/NT EXT: Warm, trace edema, 2+DP pulses B/L NEURO: A&OX3, no focal weakness. Pertinent Results: [**2143-9-30**] 11:30PM WBC-9.2 RBC-2.99* HGB-9.0* HCT-25.5* MCV-85 MCH-30.1 MCHC-35.3* RDW-15.0 [**2143-9-30**] 11:30PM PLT COUNT-197 [**2143-9-30**] 11:30PM GLUCOSE-86 UREA N-75* CREAT-10.1*# SODIUM-133 POTASSIUM-4.2 CHLORIDE-96 TOTAL CO2-19* ANION GAP-22* [**2143-9-30**] 11:30PM TOT PROT-5.8* CALCIUM-9.0 PHOSPHATE-5.3*# MAGNESIUM-2.0 [**2143-9-30**] 11:30PM CK(CPK)-169* [**2143-9-30**] 11:30PM cTropnT-0.03* [**2143-9-30**] 11:30PM CK-MB-4 . [**2143-10-31**]: Chest Xray - Findings consistent with mild CHF . [**2143-10-31**]: EKG Sinus tachycardia, RV conduction delay Lateral ST-T changes are nonspecific Since previous tracing of [**2143-9-4**], rate is increased Brief Hospital Course: In brief, the patient is a 45 year old woman with poorly controlled hypertension, end-stage renal disease on hemodialysis who presented with shortness of breath found to be in hypertensive urgency. . 1. Hypertensive Urgency: There was no evidence of end organ damage (no neurologic deficits and ruled out for MI). Her blood pressure was initially controlled with iv medications. The likely trigger to this hypertensive episode was irregular medication adherence. Her prior evaluation for causes of secondary hypertension did not reveal evidence consistent with either endocrine or renovascular causes. During her [**2143-1-30**] evaluation she had an isolated aldosterone level of 37, however, 3 days later the an aldosterone and renin levels were measured (7 and 9.2, respectively) and were not consistent with a primary hyperaldosterone state. Prior imaging of her adrenals by MRI revealed normal size and signal to the glands. Repeat aldosterone and renin levels were drawn to confirm the prior findings. These labs were pending at time of discharge. Her blood pressure was ultimately stabilized on combination of minoxidil and lisinopril with volume control by ultra-filtration at hemodialysis. . 2. Shortness of Breath: The presenting shortness of breath was likely due to flash pulm edema in the setting of uncontrolled hypertension. As above, she ruled out for MI. Her breathing improved with continued hemodialysis. . 3. End-stage renal disease: The patient has been dialysis dependent secondary to her end-stage renal disease on a T/Th/Sat schedule. She had been scheduled to undergo an AV fistula placementUsual schedule T/Th/Sat. Says has not missed HD appointments. Followed by Dr. [**First Name (STitle) 805**] of Nephrology and Dr. [**Last Name (STitle) 816**] of transplant. She underwent an AV fistula placement in the left arm without complications. Please the operative report from [**2143-10-4**] for details. She continued on phosphate binders while in the hospital. . 4. Anemia: Multifactorial - ACD and contribution from renal disease. Baseline HCT 23-30. No signs of active bleeding. Stable hct. She received IV iron at HD. Erythopoetin adiministration will be per nephrology team. . 5. Low Serum Bicarbonate with AG of 18: This was thoughtly ikely due to renal failure/uremia. The lab value improved with dialysis. . 6. Elevated CK, Trop: The patient presented with hypertensive urgency and had a small elevation in her troponins and CK consistent with demand ischemia in setting of hypertension and pulmonary edema. An EKG revealed no acute ischemic changes. . 7. Schizophrenia: Reports that she is followed at [**Hospital **] Hospital, where she is treated with risperdone 25mg IM injections every two weeks. There was no evidence of acute psychosis during this admission. The patient will follow-up with her regular providers as previously scheduled. . 8.) PPX: PPI, SC heparin . 9.) Code: Full. . 10.) Dispo: the patient was discharged in good condition with stable vital signs to follow-up with 3x/week dialysis sessions. Medications on Admission: Labetalol 600 mg [**Hospital1 **] Amlodipine 10 mg QD Terazosin 5 mg [**Hospital1 **] Lisinopril 20 mg [**Hospital1 **] B Complex-Vitamin C-Folic Acid Tab QD Lanthanum 500 mg TID (phos binder-Fosrenol Discharge Medications: 1. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 5. Minoxidil 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for 3 days. Disp:*36 Tablet(s)* Refills:*0* 7. Risperdal Consta 25 mg/2 mL Syringe Sig: Two (2) mL Intramuscular every 2 weeks. Discharge Disposition: Home Discharge Diagnosis: Primary: Hypertensive Urgency . Secondary: End-stage renal disease Anemia Schizophrenia Discharge Condition: good. stable vital signs. ambulating unassisted. tolerating oral medications and nutrition. blood pressure controlled on oral medications. Discharge Instructions: You have been evaluated and treated for extremely high blood pressure. You pressure was controlled with a combination of IV and oral medications. There was no evidence of damage to your organs because of this episode of high blood pressure. . It is essential that you take your blood pressure medications as prescribed. Managing your blood pressure properly is an essential goal to maintain your health and to prevent bad events such as strokes and heart attacks. . Your next dialysis session will be on Tuesday [**2143-10-8**] on [**Hospital Ward Name 121**] 7. . Please attend the recommended appointments described below. . If you develop any new concerning symptoms particularly chest pain, shortness of breath, persistant nausea or vomiting please seek medical attention. . Please call [**First Name4 (NamePattern1) 1743**] [**Last Name (NamePattern1) 174**] at the [**Hospital **] Clinic at [**Numeric Identifier 105926**] to schedule your next injection of risperidone. Followup Instructions: You have the following appointments scheduled for you: 1) Internal Medicine: Dr. [**First Name4 (NamePattern1) 1356**] [**Last Name (NamePattern1) **] on [**2143-10-31**] at 1:30pm ([**Telephone/Fax (1) 250**]) 2) Dialysis: on [**Hospital Ward Name 121**] 7 on Tuesday [**2143-10-8**]

[ "295.90", "428.0", "285.21", "585.6", "403.01" ]

icd9cm

[ [ [] ] ]

[ "39.95", "39.27" ]

icd9pcs

[ [ [] ] ]

8385, 8391

4370, 7441

335, 369

8523, 8666

3658, 4347

9694, 9982

3025, 3322

7693, 8362

8412, 8502

7467, 7670

8690, 9671

3337, 3639

276, 297

397, 1579

1601, 2389

2405, 3009

19,119

198,243

50381+59250

Discharge summary

report+addendum

Admission Date: [**2145-9-29**] Discharge Date: [**2145-10-8**] Date of Birth: [**2088-4-5**] Sex: F Service: CARDIOTHORACIC Allergies: Zestril / Codeine / Ibuprofen Attending:[**First Name3 (LF) 4679**] Chief Complaint: Left vocal fold immobility. Non-small cell lung cancer. Major Surgical or Invasive Procedure: [**2145-9-29**]: Left thoracotomy. Left upper lobectomy. Mediastinal lymph node dissection [**2145-10-1**]: OROPHARYNGEAL VIDEOFLUOROSCOPIC SWALLOWING History of Present Illness: The patient is a 57-year-old woman with a biopsy-proven cancer arising from the left upper lobe. The cancer was 4 cm in size and given the size of the tumor we recommended an open approach. The patient had limited pulmonary function and we consented the patient for lobectomy, but also were hopeful that the lesion could be resected by an upper division segmentectomy. Past Medical History: Diabetes [**First Name9 (NamePattern2) **] [**Last Name (un) **] patient DKA-hypertension Diastolic CHF, preserved EF mitral stenosis,w mild to moderate AR, TR Pulmonary hypertension worsening vision, to be eval'd by optho soon for "legal blindness," leg braces for bilateral drop foot and neuropathy Depression/anxiety, migraine PSHx: bioprosthetic valve [**2138**] complicated by wound infections, dehiscence Social History: Patient lives alone, smoke 1 pack/day, no alcohol or recreational drug use. Family History: Father died from MI at age 45 Physical Exam: 99.2 98.7 68 120/62 18 97-RA GEN: NAD HEENT: OP clear, edentulous, raspy voice NECK: supple, full ROM, no LAD CV: RRR, s1/s2 LUNGS: breath sounds bilaterally, diffuse wheezes ABD: s/nt/nd EXT: warm/dry INCISION: well-approximating without evidence of infection Pertinent Results: Chest CT [**2145-10-3**]: Postoperative changes status post left upper lobectomy with leftward mediastinal shift. There is a large left hydropneumothorax with a left chest tube terminate within the apical aspect of the hydropneumothorax. Near complete atelectasis of the left lung with opacification of the left bronchus and its visualized branches, suggesting mucous plug or blood. Patchy ground-glass opacity throughout the right lung concerning for developing pnemonia vs. edema. Mildly enlarged main pulmonary artery measuring 3.7 cm. CXR: [**2145-10-7**]: The fluid component of the moderate left hydropneumothorax is slightly increased. Subcutaneous gas in the left chest wall is unchanged. Multifocal opacities in the right upper and lower lung and left lower lobe are improved, possibly due to improving pneumonia. Cardiomediastinal silhouette is stable. [**2145-10-5**]: left-sided hydropneumothorax is slightly decreased. More focal parenchymal opacities, greatest in the right upper lobe could represent aspiration. The heart size is mildly enlarged, however, unchanged. There is mild tortuosity of the aorta. An aortic valve replacement is unchanged in position. Deformity of the left posterior rib is unchanged. [**2145-10-2**]: the left apical lateral pneumothorax. However, in the interval, a large pleural effusion has also developed, the effusion occupies approximately two-thirds of the volume of the left hemithorax. There is thus, now, a large fluidopneumothorax. The left lateral air collection in the soft tissues is unchanged. Also unchanged are the post-operative rib defects. Brief Hospital Course: 57 year-old female admitted [**2145-9-29**] for Left thoracotomy, Left upper lobectomy. Mediastinal lymph node dissection and Direct laryngoscopy with operating telescope. Local fold injection with Radiesse Voice gel. She was extubated in the operating room, transfer to the PACU with a right chest, Foley and Bupivacaine Epidural managed by the acute pain service. She transfer to the floor in stable condition. Events: Chest CT [**2145-10-3**] negative for PE. Possible aspiration Pneumonia on Right Flexible bronchoscopy [**2145-10-4**] with BAL and large mucus plug removal. ID: spike temp 101, BAL with GNR, Ucx with E.coli, started on Ceftriaxone. Outpatient antibiotics switched to PO cipro, with fluconazole/clotrimazole for thrush seen on bronchoscopy. Respiratory: aggressive nebs, ambulation, incentive spirometer; her oxygen requirements improved with saturations of 95% @rest, 91-97% 1L activity Chest-tube: left with moderate serousanguious discharge, removed [**2145-10-5**]. Serial chest films showed left-sided hydropneumothorax is slightly decreased, with slightly increased fluid component. Focal parenchymal opacities showed improvement by the day of discharge. Cardiac: history of diastolic heart failure. Her home medications were titrated as her HR and blood pressure tolerated. She remained in sinus rhythm 70's blood pressure 110-140's. GI: PPI and bowel regime. Speech/Swallow: seen by speech for soft signs and possible symptoms of aspiration of thin liquids during today's bedside evaluation. Given her recent surgery and history, she is felt to be at high risk for silent aspiration. pureed solids and nectar thick liquids were started. Video-swallow [**2145-10-1**] no aspiration safe for a PO diet of thin liquids and regular consistency solids. Laryngology followed for left vocal cord immobility. Voice should improve over 1-2 weeks. Mild hoarsness while hospitalized Endocrine: blood sugars initially 200-300's, insulin sliding scale adjusted lantus 10 [**Hospital1 **] continued. AM BS low 48-99. [**Hospital1 **] consulted recommended d/c PM lantus and start humalog sliding scale at 180. Her blood sugars improved, lantus PM dose was slowly restarted prior discharge. Renal: IV fluids were maintained until taking PO's. Urine output improved. Gentle diureses was restarted on POD2. Electrolytes replete as needed Pain: Bupivacaine/fentanyl Epidural managed by the acute pain service. The epidural was split on [**2145-10-1**] with Bupivacaine and home MS Contin dose with good control. Anxiety: very anxious following surgery requiring Ativan 1-2 mg every 4-6 hours. Once she restarted her home dose opioids her anxiety improved. Disposition: she was seen by physical therapy. She was discharged on [**2145-10-8**]. She will follow-up with Dr. [**First Name (STitle) **] as an outpatient. Medications on Admission: 1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 2. carbamazepine 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. trazodone 100 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime). 7. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q 12H (Every 12 Hours). 8. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day. 10. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 12. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-24**] Puffs Inhalation PRN (as needed) as needed for wheezing. 13. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 14. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q8H (every 8 hours) as needed for chronic pain. 15. morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for breakthrough pain. 16. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 17. carvedilol 25 mg Tablet Sig: Two (2) Tablet PO twice a day. 18. valsartan 320 mg Tablet Sig: 1-2 Tablets PO at bedtime. 19. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day. 20. insulin detemir 100 unit/mL Solution Sig: Ten (10) units Subcutaneous twice a day. 21. Humalog insulin sliding scale 0-70 mg/dL Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol 71-100 mg/dL 0 Units 0 Units 0 Units 101-150 mg/dL 2 Units 2 Units 2 Units 151-200 mg/dL 4 Units 4 Units 4 Units 201-250 mg/dL 6 Units 6 Units 6 Units 251-300 mg/dL 8 Units 8 Units 8 Units 301-350 mg/dL 10 Units 10 Units 10 Units 351-400 mg/dL 12 Units 12 Units 12 Units 22. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) mL Inhalation every 4-6 hours as needed for SOB/wheezes. 23. ipratropium bromide 0.02 % Solution Sig: Two (2) mL Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 24. lactulose 10 gram/15 mL Solution Sig: One (1) dose PO once a day as needed. Discharge Medications: 1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 2. carbamazepine 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. trazodone 100 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime). 7. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q 12H (Every 12 Hours). 8. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day. 10. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 12. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-24**] Puffs Inhalation PRN (as needed) as needed for wheezing. 13. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 14. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q8H (every 8 hours) as needed for chronic pain. Disp:*21 Tablet Extended Release(s)* Refills:*0* 15. morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for breakthrough pain. Disp:*28 Tablet(s)* Refills:*0* 16. carvedilol 25 mg Tablet Sig: Two (2) Tablet PO twice a day. 17. valsartan 320 mg Tablet Sig: 1-2 Tablets PO at bedtime. 18. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day. 19. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) mL Inhalation every 4-6 hours as needed for SOB/wheezes. 20. ipratropium bromide 0.02 % Solution Sig: Two (2) mL Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 21. lactulose 10 gram/15 mL Solution Sig: One (1) dose PO once a day as needed. 22. ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 14 days. 23. fluconazole 100 mg Tablet Sig: One (1) Tablet PO once a day for 6 days. 24. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety. 25. clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day) for 7 days. 26. insulin glargine 100 unit/mL Solution Sig: Ten (10) Units Subcutaneous QAM. 27. insulin glargine 100 unit/mL Solution Sig: Five (5) Units Subcutaneous at bedtime. 28. Humalog 100 unit/mL Solution Sig: sliding scale Subcutaneous four times a day: Per insulin flowsheet. Disp:*qs * Refills:*2* 29. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. Discharge Disposition: Extended Care Facility: [**Hospital **] LivingCenter - Elmhurst - [**Location (un) **] Discharge Diagnosis: non-small cell lung cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid bilateral prothetes Discharge Instructions: Please follow the attached insulin flowsheet for insulin dosing. Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience: -Fevers > 101 or chills -Increased shortness of breath, cough (it is normal to cough up blood tinge sputum for a few days) or chest pain -Incision develops drainage or increased redness -Chest cover site with a bandaid until healed. Pain -Acetaminophen 650 every 6 hours as needed for pain -Morphine 30 mg [**Hospital1 **], 15 mg prn as needed -Take stool softners with narcotics Activity -Shower daily. Wash incision with mild soap & water, rinse, pat dry -No tub bathing, swimming or hot tubs until incision healed -No lotions, creams or ointment applied to incision site Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**] Date/Time:[**2145-10-12**] 10:00 on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**] Chest X-Ray [**Location (un) 861**] [**Location (un) **] 30 minutes before your appointment Completed by:[**2145-10-8**] Name: [**Known lastname 17067**],[**Known firstname **] Unit No: [**Numeric Identifier 17068**] Admission Date: [**2145-9-29**] Discharge Date: [**2145-10-8**] Date of Birth: [**2088-4-5**] Sex: F Service: CARDIOTHORACIC Allergies: Zestril / Codeine / Ibuprofen Attending:[**First Name3 (LF) 1999**] Addendum: During this hospitalization, Ms. [**Known lastname **] developed a bacterial pneumonia, not present on admission, which was treated with ceftriaxone as an inpatient and then later ciprofloxacin as an outpatient. Discharge Disposition: Extended Care Facility: [**Hospital **] LivingCenter - Elmhurst - [**Location (un) 8597**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2000**] MD [**MD Number(2) 2001**] Completed by:[**2145-11-22**]

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icd9cm

[ [ [] ] ]

[ "31.0", "33.24", "32.49", "99.29", "40.3", "31.42" ]

icd9pcs

[ [ [] ] ]

13525, 13776

3411, 6263

352, 505

11621, 11621

1784, 3388

12558, 13502

1451, 1482

8761, 11439

11572, 11600

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11806, 12535

1497, 1765

256, 314

533, 905

11636, 11782

927, 1341

1357, 1435

9,736

160,259

6125

Discharge summary

report

Admission Date: [**2184-5-19**] Discharge Date: [**2184-5-30**] Date of Birth: [**2115-6-2**] Sex: M Service: CT Surgery CHIEF COMPLAINT: The patient presents with known aortic regurgitation and worsening shortness of breath. HISTORY OF PRESENT ILLNESS: The patient is a 68 year old male who has been known to have aortic regurgitation. The patient was followed by his personal cardiologist and was complaining of worsening shortness of breath at this time. The patient was diagnosed with worsening aortic dilation and was subsequently referred for cardiothoracic surgical intervention. PAST MEDICAL HISTORY: 1. Hypertension. 2. Placement of DDD pacemaker secondary to AV block approximately three years ago. 3. Patient denies neurologic, gastrointestinal or pulmonary problems. MEDICATIONS ON ADMISSION: Cozaar 100 mg p.o.q.d., atenolol 25 mg p.o.q.d., Norvasc 10 mg p.o.q.d. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: The patient quit smoking 35 years ago. PHYSICAL EXAMINATION: On physical examination, the patient presented with a pulse of 78 and blood pressure 157/66. General: Well appearing 68 year old male in no acute distress. Skin: Intact, without lesions or abrasions. Head, eyes, ears, nose and throat: Normocephalic, atraumatic, unremarkable. Neck: Supple, nontender, without jugular venous distention or lymphadenopathy. Chest: Clear to auscultation bilaterally without wheezes or rhonchi appreciated. Cardiovascular: Normal S1 and S2, regular rate and rhythm, IV/VI systolic ejection murmur appreciated. Abdomen: Soft, nontender, nondistended, positive bowel sounds. Extremities: Warm and well perfused. Neurologic: Grossly intact. HOSPITAL COURSE: The patient was taken to the Operating Room on [**2184-5-19**] and underwent a Bentall procedure by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**]. The patient tolerated the procedure very well and was transferred to the Cardiothoracic Intensive Care Unit in stable condition. On the first postoperative day, the patient had quite labile blood pressures, requiring the use of a Nipride drip in order to manage. The patient was extubated on postoperative day one without difficulty. His vital signs all appeared to be stable at this time. The patient was alert, oriented, following commands and attended to the examination. His lungs were clear to auscultation bilaterally with a regular heart rate. The patient's pacemaker seemed to be slightly misreading the patient's intrinsic rhythm, as noted on the telemetry monitor. The cardiology service was consulted and interrogated the patient's pacemaker. They reprogrammed the pacemaker to have a better sensing of the patient's heart beats. On postoperative day number two, the patient began expressing worsening changes in mental status. The patient became increasingly disoriented and confused. The patient required multiple doses of Haldol in order to calm him. The patient also required four-point restraints at time to prevent the pulling out of lines. An infectious workup was negative at this time, with a maximum temperature of 98.5. A chest x-ray showed a large right sided pleural effusion, which required the placement of a #28 French chest tube to approximately 13 cm within the chest cavity. The patient tolerated the procedure well and spontaneously drained 450+ cc from the right chest cavity. The patient also had the onset of worsening respiratory secretions during this time, requiring aggressive pulmonary therapy and frequent suctioning. The patient underwent a bronchoscopy on [**2184-5-23**], which showed minimal secretions deep within the bronchial system, but narrowing of the left main bronchus. Washings were taken from the bronchi at this time. The patient required reintubation secondary to agitation and respiratory secretions. His pulmonary status was much easier to care for once put back onto the ventilator. The patient did, however, require large amounts of Haldol, morphine and Ativan for sedation during the next few days. Multiple attempts were made to wean the patient off sedation, but his agitation would not allow this. Gram stain from the patient's bronchial washings showed 1+ gram negative rods and 1+ gram positive cocci, and 4+ polymorphonuclear neutrophils. These organisms were not speciated as they were felt to be representative of commensurate respiratory pathogens. The patient was, however, started on intravenous levofloxacin in consultation with infectious disease, for prophylaxis of possible infected pleural effusion. It was, however, found on later cultures that the patient's urine/blood/sputum/bronchial washings were all culture negative. The patient was noted to have intermittent fevers over the following few days, with a maximum temperature of 101.2. The patient's mental status continued to wax and wane, with episodes of increasing alertness mixed with episodes of worsening disorientation. The patient's medications which were thought to be contributing to his mental status changes were discontinued. Given the negative cultures, it was felt that the patient's mental status changes were most likely representative of Intensive Care Unit psychosis. Care continued until postoperative day number seven, when the patient's mental status began to show marked improvement. The patient was more awake, following commands and appeared to be much less agitated. It seemed that the combination of morphine and Versed helped the patient improve more so than Haldol had. The patient was transferred to the floor in stable condition on postoperative day number eight, having shown great improvement in his mental status, indicated by the ability to extubate. Over his three days on the floor, the patient continued to show great improvement and was fully awake, alert and oriented times three. The patient was ambulating very well with physical therapy, taking a regular diet and voiding on his own. The patient was afebrile throughout this time, with a normal sinus rhythm of 80s to 90s and a blood pressure of 120s/70s. The patient was begun on Coumadin anticoagulation and his INR achieved a level of 2.5 prior to discharge. On his last two admission days, the patient showed some sun-downing, in which he became more disoriented during the overnight hours, with difficulty in sleeping. The patient's Lopressor was also increased to 75 mg twice a day for a mildly increased heart rate. It was felt at this point that the patient was stable from a medical and surgical standpoint to be discharged home. In addition, it was felt that he would do much better in his home environment. DISPOSITION: To home. CONDITION ON DISCHARGE: Stable. DISCHARGE MEDICATIONS: In addition to preoperative medications, the patient is to take: Aspirin 81 mg p.o.q.d. Lopressor 75 mg p.o.b.i.d. Coumadin 5 mg p.o.q.d. Combivent. Lasix 40 mg p.o.b.i.d. and potassium chloride 20 mEq p.o.b.i.d. until patient reaches his preoperative weight. Colace 100 mg p.o.b.i.d. Captopril 25 mg p.o.q.d. Amiodarone 400 mg p.o.q.d. Levofloxacin 400 mg p.o.q.d., to be discontinued on [**2184-6-2**]. Norvasc 10 mg p.o.q.d. Percocet one to two tablets p.o.q.i.d. Ativan p.r.n. DISCHARGE INSTRUCTIONS: The patient is to take his medications as outlined above. The patient is to follow-up with his primary care physician for the management of his Coumadin, to achieve an INR level of 2.5 to 3 for prophylaxis of his mechanical valve. The patient is to follow up with Dr. [**Last Name (STitle) 1537**] of the cardiothoracic surgery service and is to call the office to establish a follow-up appointment in approximately two to three weeks. The patient is to have his staples removed at that time. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern1) 13463**] MEDQUIST36 D: [**2184-5-30**] 13:51 T: [**2184-5-30**] 15:14 JOB#: [**Job Number 23955**]

[ "424.1", "997.3", "441.2", "V45.01", "511.9", "401.9" ]

icd9cm

[ [ [] ] ]

[ "96.04", "33.24", "35.22", "34.04", "96.72", "39.61", "38.45" ]

icd9pcs

[ [ [] ] ]

6788, 7270

839, 966

1746, 6731

7295, 8075

1046, 1728

160, 249

278, 613

636, 812

983, 1023

6756, 6765

42,694

180,323

54555+59618

Discharge summary

report+addendum

Admission Date: [**2111-4-8**] Discharge Date: [**2111-4-11**] Date of Birth: [**2062-1-2**] Sex: F Service: NEUROSURGERY Allergies: Tetracycline / Penicillins / Sulfa (Sulfonamide Antibiotics) / Clindamycin / Cephalosporins / Macrolide Antibiotics / Lactulose / cefuroxime / ciprofloxacin / Levaquin / Erythromycin Base Attending:[**First Name3 (LF) 1835**] Chief Complaint: skull defect Major Surgical or Invasive Procedure: [**2111-4-8**]: Right Cranioplasty History of Present Illness: 49 yo woman with a hx brain abscess s/p craniectomy. Her bone flap was lost from her empyema surgery. She has been doing rather well. No fevers, chills or sweats. No systemic malaise. She continues on IV Vancomycin due to her many allergies to antibiotics. She now presents electively for cranioplasty. Past Medical History: Brain aneurysm s/p coiling (vs. surgery?) at [**Hospital1 112**], 1st surgery [**2103-4-30**] followed by a 2nd surgery [**2103-9-3**]. Tubal Ligation DMII- (patient states that she does not have diabetes but this is listed in her chart in multiple places)/Polycystic ovarian syndrome. admission for meningitis [**2108**] Social History: She does smoke 1ppd. She drinks alcoholic beverages occasionally. No IVDU. Family History: Non contributory Physical Exam: On discharge: PERRL, oriented x3, MAE full motor, no drift Pertinent Results: Head CT [**2111-4-8**]: FINDINGS: Study is compared with the most recent NECTs of [**3-17**] and [**3-10**], as well as enhanced MR examination of [**2111-1-20**]. The patient is now status post right frontovertex cranioplasty with expected subcutaneous emphysema in the overlying scalp soft tissues. However, there is no significant subgaleal fluid collection. There is expected small pneumocephalus within a thin subdural collection measuring up to 6-7 mm in maximal thickness overlying the right frontotemporal convexity. No other acute intra- or extra-axial hemorrhage is seen, and there is no significant mass effect or evidence of cerebral edema. Again demonstrated are aneurysm clips involving the tip of the basilar artery and the right MCA at its bifurcation, with associated metallic artifact, limiting the evaluation of the immediately adjacent parenchyma. IMPRESSION: Status post right frontal cranioplasty, with expected post-surgical changes but only a thin subdural collection overlying the right frontotemporal convexity. Brief Hospital Course: On [**4-8**] the patient electively presented and underwent cranioplasty. Surgery was without complication and she tolerated it well. Post operative head CT was stable. She was kept in the PACU until a ICU bed was available. ID was consulted for antibiotic desensitization. She was admitted to the SICU for desensitization x 24hrs. She was then transferred to the floor in stable condition late [**4-9**]. She remained stable but c/o pain especially to her R jaw. Pt has chronic R facial/jaw pain but post-surgical swelling has intensified the pain. Patient is tolerating PO intake and ambulating safely. Med changes were made and she was discharged home with her family on [**4-11**] with 2 weeks of narcotic supply. Medications on Admission: ALPRAZOLAM - 0.5 mg Tablet - 1 Tablet(s) by mouth once take 1hr before MRI. MRx1 15min before MRI if necessary DULOXETINE [CYMBALTA] - (Prescribed by Other Provider) - 30 mg Capsule, Delayed Release(E.C.) - 4 Capsule(s) by mouth DAILY (Daily) as taken at home please see your PCP for continued scripts GABAPENTIN - (Prescribed by Other Provider) - 400 mg Capsule - 4 Capsule(s) by mouth three times a day home medication - please see your PCP for continued scripts for this medication TRAZODONE - (Prescribed by Other Provider) - 50 mg Tablet - 1.5 Tablet(s) by mouth HS (at bedtime) as taken at home- please see your PCP for continued scripts Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**Month/Year (2) **]:*60 Capsule(s)* Refills:*2* 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [**Month/Year (2) **]:*60 Tablet(s)* Refills:*2* 3. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Four (4) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. cephalexin 250 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours): Please f/u with ID regarding this med. [**Month/Year (2) **]:*60 Capsule(s)* Refills:*0* 5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 6. gabapentin 300 mg Capsule Sig: Four (4) Capsule PO TID (3 times a day). 7. trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 8. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q12H (every 12 hours) for 14 days: F/u with pain MD. [**Last Name (Titles) **]:*28 Tablet Extended Release(s)* Refills:*0* 9. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO q 3-4 hrs as needed for pain for 14 days. [**Last Name (Titles) **]:*100 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: skull defect Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed, we provided 2 week supply until you see your [**Name8 (MD) 1194**] MD. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Your wound was closed with non-dissolvable sutures, you must wait until after they are removed to wash your hair. You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin, prior to your injury, do not resume these until cleared by your surgeon. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [**11-1**] days(from your date of surgery/ the office will clarify) for removal of your sutures. This appointment can be made by calling [**Telephone/Fax (1) 3231**]. ??????Please call ([**Telephone/Fax (1) 9403**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in [**4-24**] weeks. ??????You will need a CT scan of the brain without contrast Completed by:[**2111-4-11**] Name: [**Known lastname 18345**],[**Known firstname **] Unit No: [**Numeric Identifier 18346**] Admission Date: [**2111-4-8**] Discharge Date: [**2111-4-11**] Date of Birth: [**2062-1-2**] Sex: F Service: NEUROSURGERY Allergies: Tetracycline / Penicillins / Sulfa (Sulfonamide Antibiotics) / Clindamycin / Cephalosporins / Macrolide Antibiotics / Lactulose / cefuroxime / ciprofloxacin / Levaquin / Erythromycin Base Attending:[**First Name3 (LF) 599**] Addendum: ID follow-up Discharge Disposition: Home Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [**11-1**] days(from your date of surgery/ the office will clarify) for removal of your sutures. This appointment can be made by calling [**Telephone/Fax (1) 4958**]. ??????Please call ([**Telephone/Fax (1) 18347**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in [**4-24**] weeks. ??????You will need a CT scan of the brain without contrast *** ID follow-up *** Please follow-up with ID as scheduled on [**2111-4-17**] at 9AM. All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 3791**] or to on [**Name8 (MD) 233**] MD in when clinic is closed. [**Name6 (MD) **] [**Last Name (NamePattern4) 603**] MD [**MD Number(2) 604**] Completed by:[**2111-4-11**]

[ "738.19", "V12.42", "784.92", "V07.1" ]

icd9cm

[ [ [] ] ]

[ "02.06", "01.23", "99.12" ]

icd9pcs

[ [ [] ] ]

7535, 7541

2469, 3189

463, 500

5064, 5064

1404, 2446

7564, 8424

1291, 1309

3887, 4978

5028, 5043

3215, 3864

5215, 6479

1324, 1324

1339, 1385

411, 425

528, 835

5079, 5191

857, 1182

1198, 1275

1,182

117,380

29804

Discharge summary

report

Admission Date: [**2107-1-23**] Discharge Date: [**2107-2-1**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 759**] Chief Complaint: MS change . Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 88 M w/ presented to OSH after having fallen while carrying groceries from his car. Wife thinks it was a mechanical fall. No head trauma. No LOC. He was noted to have an acute MS change within 30 minutes. T=101.8 upon arriving to OSH ED. Electively intubated for airway protection and transferred to [**Hospital1 18**]. . ED COURSE: -- U/A - 11-20 WBCs, occasional bacteria -- WBCs - 28.9 w/ 91% lymphs -- UCx and BCx sent -- ceftriaxone and vancomycin started -- CXR - Abnormal opacity involving both lungs. The finding represents both airspace and interstitial disease. Diagnostic considerations include pulmonary edema in the setting of chronic interstitial changes. Bilateral pleural effusions are present as well. -- CT CHEST - Severe emphysema and moderate pulmonary edema. Left lower lobe consolidation could represent pneumonia, aspiration or atelectasis. Mild stranding in left upper quadrant around the splenic flexure of uncertain etiology. -- CT HEAD - negative -- EKG - sinus tachycardia, PVCs, nl axis, nl intervals, no significant ST interval or T wave changes. . Past Medical History: PMH: -- PAF -- htn -- dyslipidemia -- Transitional Cell bladder CA -- BCG tx -- Lung mass (seen on staging CT [**7-/2106**]) -- left lower lobe 4x4x3cm, concerning for malignancy. pt has to present refused intervention. -- TTE ([**7-18**]) - NL LV size and function, EF=60-65%. -- glaucoma -- osteoporosis . Social History: lives with wife. . Family History: non-contributory . Physical Exam: VENT: Vt=550, Pressure=10, PEEP=5, FiO2=50, RR=20 T=100.2 BP=120/70 HR=90 RR=20 O2sat=97% GEN: lying in bed intubated, sedated HEENT: no lad CV: rrr PULMO: ctab anteriorly ABD: bs+, nt, nd EXT: warm, no c/c/e NEURO: pinpoint pupils, reactive, b/l. reactive to painful stimuli. moving all extremities, but not to command. toes are neither upgoing or downgoing. . Pertinent Results: MRI [**2107-1-24**]:IMPRESSION: 1. Multiple punctate foci of increased diffusion signal are suggestive of multiple watershed infarcts in the cortex between the MCA/ACA distribution and MCA/PCA distribution. This could be secondary to an episode of global hypotension and/or hypoxia. 2. No evidence of intracranial mass. 3. Left choroid plexus xanthogranuloma. 4. Fluid layering in the nasopharynx, possibly secondary to patient unresponsive state or intubation. . [**2107-1-23**] 07:45PM URINE BLOOD-SM NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2107-1-23**] 07:45PM URINE RBC-[**2-14**]* WBC-[**11-1**]* BACTERIA-OCC YEAST-NONE EPI-<1 [**2107-1-23**] 07:38PM LACTATE-2.2* [**2107-1-23**] 07:28PM TYPE-ART PO2-303* PCO2-48* PH-7.38 TOTAL CO2-29 BASE XS-2 [**2107-1-23**] 06:24PM URINE BLOOD-SM NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2107-1-23**] 06:10PM GLUCOSE-141* UREA N-16 CREAT-0.8 SODIUM-137 POTASSIUM-3.3 CHLORIDE-99 TOTAL CO2-27 ANION GAP-14 [**2107-1-23**] 06:10PM CK(CPK)-170 [**2107-1-23**] 06:10PM CK-MB-18* MB INDX-10.6* cTropnT-.78* [**2107-1-23**] 06:10PM CALCIUM-9.9 PHOSPHATE-2.9 MAGNESIUM-2.0 [**2107-1-23**] 06:10PM WBC-28.9* RBC-5.27 HGB-16.0 HCT-49.2 MCV-93 MCH-30.3 MCHC-32.5 RDW-14.9 [**2107-1-23**] 06:10PM NEUTS-91.1* BANDS-0 LYMPHS-3.9* MONOS-4.4 EOS-0.1 BASOS-0.6 [**2107-1-23**] 06:10PM PT-27.9* PTT-29.8 INR(PT)-2.9* Brief Hospital Course: A/P: 88 M w/ presented from OSH intubated after having fallen. . The patient was admitted from an OSH intubated to the MICU. He was noted to have had a fall complicated by altered mental status. Non-contrast head CT was negative for intracranial bleed. There was high concern for an infectious process due to a leukocytosis. CT torso revealed no focal inectious etiology. The patient was noted to have a positive UA and a question of a pneumonia. The patient was initiated on ceftriaxone and vanco at meningeal dosing. LP was not done due to elevated INR and minimal clinical indications. MRI/A of the head on the day of admission revealed numerous watershed infarcts. These were felt to be consistent with either an episode of hypotension (which the patient was not known to have had) or embolic phenomena. The patient was known to have A. Fib but TTE did not reveal any intra-cardiac thrombi. The patient was already fully anticoagulated on admission and heparin gtt was initaited at the time of infarct discovery. It is possible that the patient is hypercoaguable secondary to malignancy. Repeat MRI/A on hospital day 4 revealed progression of the patient's infarcted area. He was successfully weaned from the ventilator. After discussion with the family regarding the patient's poor prognosis, he was advanced to comfort measures only and transferred to the medicine floor service. On the medicine service he received ativan, morphine and scopolamine as needed for comfort. The patient expired at 09:55AM on [**2107-2-1**] when he was found to have no pulse, no spontaneous breaths and no pupillary reflex. The patient's family was contact[**Name (NI) **]. They declined an autopsy. Medications on Admission: MEDS: --aspirin 81 mg daily --terazosin 2 mg [**Hospital1 **] --oxybutynin 5 mg HS --tylenol prn --atenolol 50 mg daily --coumadin 5 mg M, W, F --coumadin 2.5 mg T, Th, Sat, Sun --alendronate 40 mg every Mon --simvastatin 5 mg HS --brimonidine 0.2 1 drop in each eye daily --travoprost 0.004% 1 drop each eye daily --calcium, mvi Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Cerebrovascular accident Discharge Condition: None Discharge Instructions: None Followup Instructions: None

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icd9cm

[ [ [] ] ]

[ "96.72" ]

icd9pcs

[ [ [] ] ]

5819, 5828

3720, 5410

273, 279

5897, 5904

2217, 3697

5957, 5965

1788, 1809

5790, 5796

5849, 5876

5436, 5767

5928, 5934

1824, 2198

221, 235

307, 1401

1423, 1734

1750, 1771

2,719

173,993

22234

Discharge summary

report

Admission Date: [**2149-8-26**] Discharge Date: [**2149-8-29**] Date of Birth: [**2086-12-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: Syncope Major Surgical or Invasive Procedure: EGD [**8-29**] History of Present Illness: 62 y/o male with PMH sig for Mult CVAs, (B) ICA stenosis s/p LCEA in [**6-2**], HTN, hyperhol, Type 2 DM. Of note, pt AC since [**5-4**] for R ICA occlusion. Today wife found patient slumped over in the bathroom on the toilet after having a bm. Pt does not recall the event, no cp/sob but does note intermittent dizziness over past few days. Also notes some left hand numbess/leg weakness--seen by Neuro in ED (see plan). In short, came to [**Hospital1 18**] ED where had INR of 37 and HCT of 22. Melena on exam but no active GI bleeding appreciated. Pt reports having INR checked in early [**Month (only) **] and it being at goal. No new meds/abx/dietary changes/change in coumdain dose. IN ED, initial VS 89/42 P 103, given 2 L NS, 2 U PRBC, 4U FFP. 10 mg SQ K. Past Medical History: peripheral [**Month (only) 1106**] disease anxiety htn DM inc lipids left CEA stroke [**7-3**] Social History: -works as a car salesman -sedentary lifestyle -2ppd x 30 smoking history, quit after stroke [**7-3**], on wellbutrin -h/o heavy etoh in the past -no illicit drug use -lives with wife Family History: -mother had pna -father died at 58 secondary to strokes over a 2 year period -brother with CAD and AICD Physical Exam: Gen: 98.5 100/60 87 94RA, supine 108/78 92 standing 110/76 111 CV: s1 s2 no mrg chest: exp wheezes throughout, no crackles Abd: normoactive bs, nt/nd ext: no c/c/e neuro cnII-Cnxii intact Pertinent Results: [**2149-8-29**] EGD Erosions in the antrum and fundus. Likely sources of bleeding in the setting of INR of 37.4 Erythema in the fundus compatible with gastritis 9//29/05 Echo The left atrium is elongated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF 70%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. [**2149-8-26**] 07:04PM CK(CPK)-367* [**2149-8-26**] 07:04PM CK-MB-14* MB INDX-3.8 cTropnT-0.11* [**2149-8-26**] 07:04PM HCT-21.3* [**2149-8-26**] 07:04PM PT-17.9* PTT-32.8 INR(PT)-2.2 [**2149-8-26**] 03:30PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.015 [**2149-8-26**] 03:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2149-8-26**] 03:30PM URINE RBC-21-50* WBC-[**2-1**] BACTERIA-NONE YEAST-NONE EPI-[**2-1**] [**2149-8-26**] 12:15PM WBC-9.7 RBC-2.67* HGB-7.1* HCT-22.2* MCV-83 MCH-26.6* MCHC-32.1 RDW-14.2 [**2149-8-26**] 12:15PM NEUTS-81* BANDS-0 LYMPHS-16* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2149-8-26**] 12:15PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+ [**2149-8-26**] 12:15PM PLT COUNT-300 [**2149-8-26**] 12:15PM PT-66.8* PTT-70.3* INR(PT)-37.4 [**2149-8-26**] 10:30AM GLUCOSE-235* UREA N-76* CREAT-1.9* SODIUM-135 POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-25 ANION GAP-14 [**2149-8-26**] 10:30AM ALT(SGPT)-11 AST(SGOT)-11 CK(CPK)-113 ALK PHOS-61 AMYLASE-25 TOT BILI-0.2 [**2149-8-26**] 10:30AM LIPASE-17 [**2149-8-26**] 10:30AM cTropnT-<0.01 [**2149-8-26**] 10:30AM CK-MB-3 [**2149-8-26**] 10:30AM ALBUMIN-3.9 CALCIUM-8.3* PHOSPHATE-3.7 MAGNESIUM-1.9 [**2149-8-26**] 10:30AM WBC-10.0 RBC-2.91*# HGB-7.9*# HCT-23.9*# MCV-82 MCH-27.3 MCHC-33.3 RDW-14.2 [**2149-8-26**] 10:30AM NEUTS-77.0* LYMPHS-17.8* MONOS-4.6 EOS-0.5 BASOS-0.1 [**2149-8-26**] 10:30AM MICROCYT-1+ [**2149-8-26**] 10:30AM PLT COUNT-338 [**2149-8-26**] 10:30AM PT-66.7* PTT-52.4* INR(PT)-37.2 Brief Hospital Course: CC:[**CC Contact Info 57993**]. 62 y/o male with PMH sig for Mult CVAs, (B) ICA stenosis s/p LCEA in [**6-2**], HTN, hyperhol, Type 2 DM presented with INR of 37, and anemia. . 1. UGIB. The patient required admission to the MICU for management of his anemia and elevated INR> He was given 10mg IV Vitamin K, his coumadin was held and required 10 U PRBCs for management of his anemia. He had melanotic stools on admission, but did not have active bleeding and did not require emergent EGD. He was made NPO, started on a PPI and monitored. He was stabilized and transferred to the floors. Because he had leak of his cardiac enzymes, likely secondary to ischemic demand, cardiology was consulted to determine if EGD would be tolerated. Cardiology determined that he was low risk for the EGD procedure and he underwent an EGD which showed erosions in the antrum and fundus. Likely sources of bleeding in the setting of INR of 37.4. Erythema in the fundus compatible with gastritis. Gastroenterology felt it was not contraindicated to start aggrenox. . 2. Indigestion: There was a mild CK bump (150--300) with positive troponin as high as 1.51. He remained chest pain free, and the etiology was likely secondary to demand ischemia. Cardiology was consulted and although he has peripheral [**Date Range 1106**] disease, and history of CVAs and likely cardiac disease did not feel this was ACS and he was to follow up with outpatient stress test and possible catherization. . 3. DM: SSI . 4. Neuro sx: Essentially, felt to be to low perfusion state from anemia. Head CT without new stroke or bleed. His neuro exam was monitored without any change or worsening from baseline . 5. PPx: Holding anticoagulation given supertherapeutic INR . 6. Code: FULL . 7. Comm with pt. Medications on Admission: Wellubtrin Avandia ASA Coumadin Zocor Aggenox Altace Labetolol advair prn Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Ramipril 5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 5. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 HR Sig: One (1) Cap PO BID (2 times a day). Disp:*60 caps* Refills:*2* 6. Tylenol Extra Strength 500 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 7. Avandia Oral 8. Advair Diskus Inhalation 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:*0* Discharge Disposition: Home Discharge Diagnosis: GI bleed coagulopathy Myocardial damage [**1-1**] demand ischemia anemia hx CVA's Discharge Condition: afebrile, hemodynamically stable, with stable HCT Discharge Instructions: Please take all medications as prescribed. Please discontinue coumadin now. Please contact your primary care physician for an appointment this week. Please contact your physician or return to the emergency department if you have chest pain, shortness of breath, bleeding, lightheadedness, weakness or any other worrisome symptoms Followup Instructions: Please contact your primary physician for an appointment this week to discuss your hospital stay. You must discuss with your physician the option of having a stress test done to evaluate for coronary artery disease. Please have your blood count (hematocrit) assessed within the next week to ensure that is remains stable. Please discuss with him your ongoing use of aggrenox. If you continue to have foot pain, contact your PCP for possible prednisone or colchicine treatment for gout. Please keep the following appointments arranged for you by Dr. [**Name (NI) 19759**] office: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3627**] [**Name12 (NameIs) 3628**] [**Name12 (NameIs) **] [**Name12 (NameIs) 3628**] (NHB) Date/Time:[**2149-9-4**] 9:30 Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3627**] [**Name12 (NameIs) 3628**] [**Name12 (NameIs) **] [**Name12 (NameIs) 3628**] (NHB) Date/Time:[**2149-9-4**] 10:30 Provider: [**Name10 (NameIs) 1111**],[**First Name7 (NamePattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB) Date/Time:[**2149-9-4**] 1:00

[ "433.10", "493.90", "E879.8", "578.1", "V58.61", "250.00", "V12.59", "790.92", "410.71", "443.9", "401.9", "780.2", "285.1", "V17.1", "272.0", "999.8" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

7046, 7052

4297, 6076

323, 340

7178, 7230

1808, 4274

7609, 8726

1478, 1584

6200, 7023

7073, 7157

6102, 6177

7254, 7586

1599, 1789

276, 285

368, 1142

1164, 1261

1277, 1462

28,999

128,539

16343

Discharge summary

report

Admission Date: [**2179-2-28**] Discharge Date: [**2179-3-3**] Date of Birth: [**2116-7-30**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3556**] Chief Complaint: Tachycardia Major Surgical or Invasive Procedure: IR-guided PICC line insertion History of Present Illness: Mr. [**Known lastname **] is a 62M with a PMH significant for renal cell carcinoma with mets to the brain and lungs s/p V-P shunt and on chronic steroids. He was admitted on [**2179-2-28**] from his nursing home with tachycardia to the 130s. In the ED his blood pressure was low-normal at 98/71. He spent one night in the [**Hospital Unit Name 153**] where he was managed with fluids and antibiotics. CXR showed a retrocardiac opacity. Per ID consult, he is being treated for a hospital- acquired pneumonia with vancomycin, cefepime, and azithromycin. His heart rate responded well to this regimen and is currently in the 100 range. He will be transferred to the floor for further management. Past Medical History: 1. Metastatic Clear Cell Renal Cancer with metastases to brain and lung - right radical nephrectomy and right lower lung wedge resection in [**11-9**] - completed Tarceva/Avastin trial [**7-/2175**] --> [**2177-5-7**] --> started Avastin alone. - [**12-14**] increased lung nodules --> s/p 1 cycle IL-2 - [**12-14**] found to have brain metastases - s/p: 1. Cyberknife SRS [**Date range (1) 46548**] to 2750 cGy brainstem 2. Cyberknife SRS [**2178-5-5**] to 1800 cGy left cerebellar met 3. WBXRT [**Date range (1) 46549**]/07 to 3600 cGy 4. Sutent started [**2178-7-7**] - VP shunt placed on [**10-15**] for hydrocephalus seen secondary to met in tectum. 2. Hypertension 3. Hyperlipidemia 4. History of aspiration pneumonia 5. Steroid induced hyperglycemia Social History: He graduated from high school. He is retired. He is married. He quit smoking 15 years ago and has 20-pack-year history of smoking. He formerly drank alcohol socially only. He has not used any recreational drug use. he is currently at a rehab. Family History: Mother is alive at 81 and has some heart problems and coronary artery disease. His father died at 49 of an MI. He has three sisters in good health and two brothers in good health. He has one daughter 25 in good health and one son 22 in good health. Physical Exam: T 97.3 / HR 95 / BP 114/86 / RR 18 / 100% RA Gen: lying in bed, cachectic, able to answer questions an follow commands. HEENT: Clear OP, dry mucous membranes NECK: Supple, No LAD, No JVD CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops LUNGS: CTAB ABD: Soft, NT, ND. NL BS. No HSM. G tube site without erythema, drainage, or discharge. EXT: L>R foot edema, 2+, no calf edema. DP and PT pulses 2+, all four extremities warm and well-perfused. SKIN: No lesions NEURO: A+O x3,able to move all four extremities, although diffusely weak 3-4/5 strength. CN 2-12 intact. PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: CXR: 1. Retrocardiac opacity may correspond to the clinically suspected pneumonia. 2. Increased right infrahilar opacity, which could reflect worsening adenopathy. 3. Stable appearance of left hilar mass and multiple left lung nodules. . CT head: Unchanged appearance of hyperdense right midbrain mass lesion. The hyperdense appearance may represent internal hemorrhage or progressive dystrophic calcification as described before. No additional intracranial hemorrhage is seen. Brief Hospital Course: Mr. [**Known lastname **] is a 62M with a past medical history of metastatic renal cell carcinoma to the brain and lungs, who was admitted with tachycardia, and found to have a hospital acquired pneumonia. . #. Pneumonia: Confirmed on CXR showing a retrocardiac opacity. Clinically with rhonchorous breath sounds in the setting of sinus tachycardia. Likely hospital acquired given residence in a nursing home. Per ID consult will continue to manage this as such with a seven day course of vancomycin, cefepime, and azithromycin. . #. Tachycardia: The patient had sinus tachycardia to the 130s on admission, which has improved with fluids and antibiotics. Likely secondary to infection vs. hypovolemia. . #. Metastatic Renal Cell Carcinoma: Dr. [**Last Name (STitle) 4253**] was consulted and recommended a slow decadron taper which is detailed in the discharge plan. We otherwise continued bactrim prophylaxis, and keppra. Medications on Admission: 1. Decadron 4mg [**Hospital1 **] - 6am, 6pm 2. Decadron 2mg q daily - 12pm 3. Keppra 1000mg via G-tube [**Hospital1 **] 4. Dulcolax 10mg PR daily prn 5. Milk of Magnesia prn 6. Tylenol prn 7. Atrovent nebs q4h prn 8. Heparin 5000 units SC tid 9. Guiafenesin prn Discharge Medications: 1. Dexamethasone 2 mg Tablet Sig: As directed Tablet PO As directed for 4 weeks: Pleas take 4 mg at 6AM, 2 mg at 6PM, and 2mg at 12AM for one week, then decrease the AM dose to 2mg for one week, then 2mg [**Hospital1 **] (6AM and 6PM) for one week, then 2mg daily for one week, then 1mg daily for one week. Disp:*73 Tablet(s)* Refills:*0* 2. Levetiracetam 100 mg/mL Solution Sig: Ten (10) mL 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. 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulized solution Inhalation Q6H (every 6 hours) as needed for cough or shortness of breath. 6. heparin Sig: 5000 (5000) units Subcutaneous three times a day. 7. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 8. PICC line care per protocol 9. Cefepime 2 gram Recon Soln Sig: Two (2) grams Intravenous every twelve (12) hours for 5 days. 10. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous every twelve (12) hours for 5 days. 11. Azithromycin 500 mg Recon Soln Sig: Five Hundred (500) mg Intravenous once a day for 5 days. Discharge Disposition: Extended Care Facility: Glenridge -[**Location (un) 1468**] Discharge Diagnosis: Pneumonia Discharge Condition: Stable, minimally verbal, mildly tachycardic (90's). Discharge Instructions: You were admitted with pneumonia. We are treating you with antibiotics through your PICC line intravenously. . We made the following changes in your medications: 1. You will complete a seven day course of three antibiotics called vancomycin, cefepime, and azithromycin 2. We will be gradually tapering your decadron dose . Please follow up as indicated below, take all of your medications as directed, and return to the emergency room if you have any concerning symptoms. Followup Instructions: Provider: [**Name10 (NameIs) 5005**] [**Last Name (NamePattern4) 5342**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2179-4-12**] 11:30 Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2179-4-12**] 10:35 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]

[ "401.9", "V15.82", "486", "V10.52", "272.4", "198.3", "V85.1" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.6" ]

icd9pcs

[ [ [] ] ]

6121, 6183

3588, 4516

326, 358

6237, 6292

3080, 3321

6813, 7193

2151, 2405

4829, 6098

6204, 6216

4542, 4806

6316, 6790

2420, 3061

275, 288

386, 1088

3331, 3565

1110, 1869

1885, 2135

40,995

189,082

46523

Discharge summary

report

Admission Date: [**2118-6-6**] Discharge Date: [**2118-6-9**] Date of Birth: [**2058-4-22**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5018**] Chief Complaint: L thalamic hemorrhage Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a 60 yo RHW with morbid obesity, HTN, DM and asthma transferred her from [**Hospital3 **] after presenting with syncope and found to have L thalamic hemorrhage with <3mm midline shift. History is difficult to obtain from the patient given dysarthria and frustration likely from fatigue causing less than optimal cooperation. Grand-daughter is at bedside but she was not present at the time of injury/event hence unable to give details other than that she was told, her grandmother fell while in church at 2:30 pm and was found to be slurring her speech hence taken to the hospital. Per patient, she fell forward and hit her head because she fainted. She denies any chest pain, palpitations or headache. She endorses that she had trouble speaking but she is unable to clarify whether she had trouble thinking up the words, if wrong words came out or if speech was just slurred. She also reports that she had double vision but cannot clarify whether it was monocular/binocular or it was lateral, vertical or skewed. She has trouble walking at baseline due to chronic arthritis. Per grand-daughter, she has been compliant to her meds including her anti-hypertensives and she quit smoking just this past year after smoking for > 30 years. ROS negative including fever, cough, N/V/D, unintended weight loss or sick contact. There has been no recent medication changes. Of note, patient SBP was in 200's while at [**Hospital3 **] for which she received nicardipine gtt while there but currently under control without intervention. Past Medical History: 1. HTN 2. DM 3. Arthritis 4. Asthma 5. Morbid obesity Social History: Lives at home with grand-daughter ([**Name (NI) 651**] [**Last Name (NamePattern1) **]) who is her next of [**Doctor First Name **] and also her PCA. Her son is currently incarcerated. Heavy smoker until [**11-15**] and no EtOH hx. Full code. Family History: Non-contributory Physical Exam: T BP 134/75 HR 60 RR 18 O2Sat 100% 2L NC Gen: Lying in bed, appears sleepy - extremely obese. HEENT: NC/AT, moist oral mucosa CV: RRR, no murmurs/gallops/rubs Abd: +BS, soft, nontender Ext: 2+ edema bilaterally upto malleoli Neurologic examination: Mental status: Awake and alert, minimally cooperative with exam, normal affect. Oriented to person, hospital and current president but thinks its [**2110**]. Inattentive - needs multiple prompting for questions and exam. Speech is fluent with normal comprehension and repetition; dysnomia with low freq words. Moderate dysarthria. Cranial Nerves: II: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Blinks to visual threats bilaterally. III, IV & VI: Extraocular movements intact bilaterally, no nystagmus. V: Reports different sensation between L and R for both PP and LT - unable to clarify more than that. VII: Mild R facial droop. X: Palate elevation symmetrical. XII: Tongue midline, movements intact Motor: Normal bulk and tone bilaterally. No observed myoclonus or tremor. Unable to lift both arms up likely due to body habitus hence difficult to ascertain drift or asterixis. Unable to do individual muscle group testing - does move R side less than L and appear to be weaker on R than L - more prximally than distally. Sensation: Reports discrepancy between R and L for both LT and PP and appears to report decreased sensation on R but unable to clarify further. Reflexes: 2+ for upper extremities but none for patellar or Achilles. Coordination and Gait: Deferred. Pertinent Results: [**2118-6-6**] 02:00AM BLOOD WBC-6.5 RBC-4.63 Hgb-13.2 Hct-38.9 MCV-84 MCH-28.6 MCHC-34.0 RDW-13.9 Plt Ct-423 [**2118-6-6**] 05:04AM BLOOD PT-14.0* PTT-34.8 INR(PT)-1.2* [**2118-6-6**] 02:00AM BLOOD Glucose-120* UreaN-15 Creat-0.8 Na-140 K-3.7 Cl-101 HCO3-28 AnGap-15 [**2118-6-6**] 02:00AM BLOOD Calcium-9.9 Phos-4.0 Mg-1.7 [**6-6**] Head CT repeated and shows no significant changes to L thalamic hemorrhage measuring 1.2 X 2.1cm with some edema but minimal midline shift. [**6-6**] Heat CT repeated for somnolence - unchanged Brief Hospital Course: In summary, patient is a 60yo RHW with hx of DM, HTN, morbid obesity and significant although not currently smoking hx who presented to [**Hospital3 **] after syncope/fall and found to have L thalamic hemorrhage plus SBP in 200's. Neuro: Pt admitted to the neuro ICU for monitoring. In the AM of [**6-6**] she was noted to be more somnolent with increased bradycardia to 40s. Repeat CT head was stable. Her exam continued to was and wane. In the AM [**6-7**] she was more alert w/ orientation varying from 1 to 3, following commands with mild dysarthria and mild anomia with right sided weakness. All antiplatelet and anticoagulants were held w/ plan to start subQ heparin [**6-8**]. She was also started on a statin and her home BP medications were restarted on 7.1 CVR: SBP goal 120-160 was easily controlled without home meds or many prn boluses. FEN/GI: Pt failed speech and swallow eval [**6-6**] however on repeat eval she was able to tolerate a diet Medications on Admission: 1. Flonase 2 puffs daily 2. Duoneb PRN 3. Endocet PRN for pain 4. Singulair 10 daily 5. Lisinopril 40 daily 6. Advair 500/50 [**Hospital1 **] 7. Metformin 850 [**Hospital1 **] 8. HCTZ 25mg daily 9. Loratadine 10 daily PRN 10. Proair HFA PRN 11. Colace 100mg [**Hospital1 **] 12. Ca2+/Vit D [**Hospital1 **] Discharge Medications: 1. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 2. Ipratropium Bromide 0.02 % Solution Sig: [**12-10**] Inhalation Q8H (every 8 hours) as needed for wheezing. 3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: [**12-10**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for wheezing. 7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Loratadine 10 mg Tablet Sig: One (1) Tablet PO Qday (). 10. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). 11. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 12. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily): To start on [**2118-6-9**]. 14. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Hypertensive left thalamic hemorrhage Secondary: hypertension DM Arthritis Asthma Morbid obesity Discharge Condition: Stable, no significant deficits aside from mild inattention and dysarthria Discharge Instructions: You were admitted to the hospital with bleeding in the left side of your brain in a region called the thalamus due to uncontrolled hypertension. This caused weakness of the right side of your body and some trouble with speech. . Please take all medications as prescribed. If you have concerns about the medications, please call your PCP before changing the doses. Your home dose of metformin was 850mg Twice a day, this was decreased to 500mg twice a day as your blood sugar here was less than 200. Your dose may therefore need to be increased. . Please call your PCP or return to the emergency room if you experience any worsening in your symptoms or have other concerns. Followup Instructions: 1) Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**] Date/Time:[**2118-7-19**] 2:30 2) Follow up evaluation in the sleep disorders center at [**Hospital1 18**] is recommended and may be arranged at ([**Telephone/Fax (1) 98809**]. [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]

[ "401.9", "250.00", "784.5", "716.90", "780.2", "431", "493.90", "427.89", "V15.82" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7050, 7120

4436, 5402

337, 343

7262, 7339

3881, 4413

8063, 8493

2274, 2292

5760, 7027

7141, 7241

5428, 5737

7363, 8040

2307, 2534

275, 299

371, 1918

2909, 3862

2573, 2893

2558, 2558

1940, 1995

2011, 2258

16,148

180,201

961

Discharge summary

report

Admission Date: [**2105-1-19**] Discharge Date: [**2105-1-30**] Service: SURGERY Allergies: Ciprofloxacin Attending:[**First Name3 (LF) 1**] Chief Complaint: Presents for surgery Major Surgical or Invasive Procedure: [**1-19**] Right colectomy History of Present Illness: Ms. [**Known lastname 6377**] is an 85 year old female who presented to [**Hospital1 18**] on [**1-19**] for scheduled surgery with Dr. [**Last Name (STitle) **]. She This had previously undergone a proctectomy with end colostomy for rectal cancer and presented with a cecal carcinoma. Past Medical History: Rectal cancer, s/p chemotherapy and radiation Past Surgical History: [**9-29**] Lower anterior resection with end colostomy Lysis of adhesions x 2 (15 yrs. ago) Hx. of volvulus 15 yrs. prior with surgical treatment Multiple C-sections Social History: Lives at home alone with dog. health care aid from AM to 6 PM. One of 7 children stays with mother from night until sun up. Remote hx of smoking as per report, patient denies. Family History: Mother expired brain anuerysm at age 65 Son with diabetes Physical Exam: Upon admission: 98.6 112/42 57 16 99% room air Gen: Non-toxic Chest: Clear to auscultation bilaterally CV: Regular rate and rhythm Abd: Soft, non-tender, left lower quadrant stoma present Pertinent Results: Operative note: Cecal carcinoma. OPERATION: 1. Lysis of adhesions (extensive). 2. Right hemicolectomy. Cardiology Report ECG Study Date of [**2105-1-19**] 12:31:40 PM Ventricular bigeminy. Native beats are with slight right axis deviation. Right bundle-branch block. ST segment elevations in leads V4-V6 of uncertain significance. Compared to the previous tracing of [**2104-12-31**] right axis deviation and ventricualr ectopy have newly appeared. TRACING #1 Intervals Axes Rate PR QRS QT/QTc P QRS T 91 140 108 400/448.71 85 96 61 Echo [**1-21**]: Conclusions: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. LV systolic function appears depressed with inferior/inferolateral/apical akinesis/hypokinesis. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) 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. The interatrial septum is bowed to the right. Chest X-Ray [**2105-1-22**]: IMPRESSION: Moderate-sized left-sided pleural effusion with retrocardiac opacification likely due to atelectasis. Lungs otherwise clear. Admission labs: [**2105-1-19**] 11:18AM BLOOD Hct-30.2* [**2105-1-20**] 07:40AM BLOOD Plt Ct-389 [**2105-1-20**] 07:40AM BLOOD Glucose-114* UreaN-19 Creat-0.7 Na-136 K-5.0 Cl-101 HCO3-26 AnGap-14 [**2105-1-20**] 07:40AM BLOOD Calcium-8.4 Phos-4.4 Mg-2.3 Cardiac enzymes: [**2105-1-21**] 04:13PM BLOOD CK-MB-36* MB Indx-18.6* cTropnT-0.91* [**2105-1-21**] 10:28PM BLOOD CK-MB-21* MB Indx-15.1* cTropnT-1.02* [**2105-1-22**] 05:43AM BLOOD CK-MB-24* MB Indx-13.3* cTropnT-1.05* [**2105-1-24**] 01:51AM BLOOD CK-MB-NotDone cTropnT-1.23* [**2105-1-24**] 01:51AM BLOOD CK(CPK)-36 Discharge labs: [**2105-1-29**] 10:20AM BLOOD WBC-10.9 RBC-4.08* Hgb-12.0 Hct-36.0 MCV-88 MCH-29.4 MCHC-33.3 RDW-14.6 Plt Ct-373 [**2105-1-30**] 07:20AM BLOOD PT-27.3* INR(PT)-2.8* [**2105-1-29**] 10:20AM BLOOD Plt Ct-373 [**2105-1-28**] 07:52PM BLOOD Glucose-78 UreaN-16 Creat-0.5 Na-138 K-3.8 Cl-106 HCO3-23 AnGap-13 [**2105-1-28**] 07:52PM BLOOD Calcium-7.6* Phos-2.6* Mg-1.9 [**2105-1-21**] 07:45AM BLOOD Triglyc-113 HDL-27 CHOL/HD-4.6 LDLcalc-74 Brief Hospital Course: Ms. [**Known lastname 6377**] had no intra-operative complications, post-operatively she was noted to have PVC's with bigeminy, without anginal symptoms; cardiac enzymes were cycled and elevated. A cardiology consult was placed for further management of the NSTEMI. She was transferred to the intensive care unit for close monitoring. Neuro: NAD, A&Ox3 throughout her hospital stay, including through her NSTEMI. Immediately post-op patient was given a morphine PCA. On POD2 the PCA was d/c'd and pain was well-controlled with Tylenol. On discharge she had been pain free for several days. CV: Echo demonstrated depressed LV systolic function with inferior apical hypokinesis. She was started on beta-blockade, and transfused PRBC's to maintain her hematocrit > 30. She was also started on an oral statin and when she became normotensive it was recommended to also at low dose ace inhibitor. POD 7, she developed atrial fibrillation with hypotension which responded to an Amiodarone drip, she was then transitioned to oral Amiodarone. Cardiology determined that she would benefit from anticoagulation therapy, she received one dose of Coumadin, her INR increased to 4.8. She was given 1u FFP with f/u INR of 3.5. Coumadin was then held and her INR trended down slowly over the remainder of her hospital stay. She was discharged on 0.5mg coumadin qhs with strict instructions to see her PCP on [**Name9 (PRE) 766**]. At discharge she was given prescriptions for ASA 81, amiodarone taper, toprol XL, sivastatin, and instructions to discuss starting an ACE-inhibitor with her PCP. GI/GU: NPO until POD2 when she was advanced to clears. Passed flatus on POD4 but was kept on sips due to NSTEMI/ICU stay. POD7 diet advanced to regular and supplemented with Ensure. At discharge, colostomy was working well. Skin: POD11 a 4cm diameter pressure ulcer was found at midline upper back. This was sharply debrided at the bedside and ulcer was seen by surgery team as well as wound care nurse. Patient discharged with wound care regimen: Change dressing Every 3 days, start [**2-2**]. Clean wound bed with commercial wound cleanser. Apply Duoderm wound gel to wound bed. Apply no sting barrier wipes to peri-wound skin. Place Allevyn foam dressing to site MSK: PT evaluated patient and recomomended home PT, which we arranged. Medications on Admission: Toprol Ritalin Vitamin B 12 Senna Benadryl Discharge Medications: 1. Toprol XL 25 mg Tablet Sustained Release 24 hr [**Month/Year (2) **]: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0* 2. Amiodarone 200 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 3. Amiodarone 200 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day for 2 weeks: Start after finishing 7 days of amiodarone 200mg twice daily. Disp:*14 Tablet(s)* Refills:*0* 4. Coumadin 1 mg Tablet [**Month/Year (2) **]: 0.5 Tablet PO at bedtime: ** Clarify dose with primary care physician **. Disp:*14 Tablet(s)* Refills:*0* 5. Simvastatin 40 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*0* 7. Blood test [**Last Name (STitle) **]: One (1) every other day: Start [**1-31**] PT, INR Fax results to Dr.[**Last Name (STitle) 838**], [**Telephone/Fax (1) 4776**]. Disp:*30 * Refills:*2* 8. Aspirin 81 mg Tablet, Delayed Release (E.C.) [**Telephone/Fax (1) **]: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 9. Acetaminophen 500 mg Tablet [**Telephone/Fax (1) **]: Two (2) Tablet PO TID (3 times a day). Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Rectal cancer NSTEMI with atrial fibrillation Post-operative ileus Post-operative anemia Stage II pressure ulcer Discharge Condition: Stable Discharge Instructions: Notify MD or return to the emergency department if you experience: *Increased or persistent pain *Fever > 101.5 *Nausea, vomiting, or abdominal distention *If ostomy outpus increase or decrease over 24 hours *If incision or upper back wound develop redness or drainage *Bleeding or bruising from any part of the body *Shortness of breath or chest pain *Any other symptoms concerning to you You may shower and wash incision with soap and water, be sure back wound is covered with occlusive dressing Please take all medications as directed You will need to speak with Dr. [**Last Name (STitle) 838**] regarding your Coumadin and when to start taking it, please be sure to call his office on Monday, [**2-2**], call [**Telephone/Fax (1) 4775**] for an appointment Be sure to eat small frequent meals, drink fluids and Ensure throughout the day You may take Tylenol every 4 to 6 hours as needed for pain Followup Instructions: Follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 838**] on Monday, [**2-2**] via the telephone, call [**Telephone/Fax (1) 4775**]. Follow-up with Dr. [**Last Name (STitle) **] in [**11-25**] weeks, call [**Telephone/Fax (1) 9**] for an appointment. Completed by:[**2105-1-30**]

[ "427.31", "E878.6", "998.2", "518.0", "V10.06", "568.0", "458.9", "997.1", "707.02", "V44.3", "285.1", "560.1", "410.71", "196.2", "153.6" ]

icd9cm

[ [ [] ] ]

[ "86.22", "46.73", "45.73", "54.59" ]

icd9pcs

[ [ [] ] ]

7814, 7872

3912, 6245

238, 266

8029, 8038

1341, 2861

8992, 9304

1052, 1111

6338, 7791

7893, 8008

6271, 6315

8062, 8969

3453, 3889

675, 842

1126, 1128

3133, 3437

178, 200

294, 582

2877, 3116

1143, 1322

604, 651

858, 1036

67,711

179,373

7375

Discharge summary

report

Admission Date: [**2131-4-1**] Discharge Date: [**2131-4-12**] Service: MEDICINE Allergies: All allergies / adverse drug reactions previously recorded have been deleted Attending:[**First Name3 (LF) 2901**] Chief Complaint: Malaise, weakness, bilateral arm pain and nausea Major Surgical or Invasive Procedure: Valvuloplasty History of Present Illness: Briefly, [**Known firstname **] [**Known lastname **] is an [**Age over 90 **] year old woman with history of CAD s/p CABG, ischemic and valvular cardiomyopathy (EF 20-25%), severe aortic stenosis ([**Location (un) 109**] 0.8cm2), recent admission for chest pain s/p cath which showed 3 vessel native coronary artery disease, patent SVG-OM, SVG-RCA, LIMA-LAD, severe aortic stenosis, and severely elevated LV diastolic and systolic pressures. Her EKG at the time showed small ST elevations in V1 and aVR, CE were negative. She returned to the hospital complaining malaise and weakness, bilateral arm pain and nausea. The patient developed chest pain again while in the ED, her EKG showed concerning ST depression in the inferior lateral leads. The cardiology fellow was called and she was started on heparin drip with bolus and given a dose of morphine, now chest pain free. Her troponins were negative. She was given a dose of potassium for hypokalemia. She was admitted for further management of Afib with RVR and hypotension. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: - Coronary artery disease - Severe aortic stenosis with [**Location (un) 109**] of 0.8 cm2 (Symptomatic as of [**2127**]) - Moderate mitral regurgitation - Ischemic and valvular cardiomyopathy with an EF 20-25% -CABG: 3V CABG in [**Location (un) 5622**] per patient report [**2107**] -PERCUTANEOUS CORONARY INTERVENTIONS: 3. OTHER PAST MEDICAL HISTORY: - Breast cancer, grade 3 s/p mastectomy - Right rotator cuff tendinopathy. - Right biceps tendinitis - Polymyalgia rheumatica - Osteoporosis - Right fourth trigger finger release - Squamous cell carcinoma (left dorsal hand) s/p excision - Hysterectomy Social History: Housing: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Hospital3 400**] Facility. Has a daughter nearby who is her emergency contact. Occupation: Was a homemaker. Functional Status: Very active, exercises 3x week, does treadmill, aerobics and yoga. Tobacco/EtOH/Illicit Drugs: Denies. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: GENERAL: WDWN elderly woman 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 8cm. No bruits. CARDIAC: normal S1, S2. 3/6 systolic crescendo-descrescendo murmur at RUSB with radiation to the neck. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities. Khyphotic. Resp were unlabored, no accessory muscle use. Bilateral crackles up to the apices. ABDOMEN: +BS, soft, NT, ND. No HSM. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: wwp, trace bilateral LE edema. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: Labs on admission: [**2131-4-1**] 12:10PM PLT SMR-NORMAL PLT COUNT-156 [**2131-4-1**] 12:10PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL [**2131-4-1**] 12:10PM NEUTS-86* BANDS-0 LYMPHS-13* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2131-4-1**] 12:10PM WBC-4.0 RBC-3.94* HGB-10.7* HCT-31.6* MCV-80* MCH-27.1 MCHC-33.7 RDW-17.8* [**2131-4-1**] 12:10PM cTropnT-<0.01 [**2131-4-1**] 12:10PM estGFR-Using this [**2131-4-1**] 12:10PM GLUCOSE-125* UREA N-25* CREAT-0.8 SODIUM-142 POTASSIUM-3.2* CHLORIDE-102 TOTAL CO2-27 ANION GAP-16 [**2131-4-1**] 01:18PM PT-11.7 PTT-21.7* INR(PT)-1.0 [**2131-4-1**] 03:00PM URINE MUCOUS-RARE [**2131-4-1**] 03:00PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE EPI-1 [**2131-4-1**] 03:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-TR [**2131-4-1**] 03:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2131-4-1**] 04:20PM cTropnT-0.02* . Labs at discharge: [**2131-4-12**] 06:10AM BLOOD WBC-5.1 RBC-2.87* Hgb-7.7* Hct-24.0* MCV-84 MCH-26.9* MCHC-32.1 RDW-17.3* Plt Ct-335 [**2131-4-12**] 06:10AM BLOOD Plt Ct-335 [**2131-4-12**] 06:10AM BLOOD PT-25.4* PTT-71.4* INR(PT)-2.4* [**2131-4-12**] 06:10AM BLOOD Glucose-119* UreaN-10 Creat-0.8 Na-138 K-4.3 Cl-103 HCO3-31 AnGap-8 [**2131-4-12**] 06:10AM BLOOD Calcium-8.7 Phos-3.6 Mg-1.8 . Imaging: - Portable TTE (Complete) ([**2131-4-2**] at 3:45:43 PM) The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is moderately depressed (LVEF= 30 %) with global hypokinesis and regioanl akinesis of the distal LV/apex and lateral walls. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. An eccentric jet of moderate to severe (3+) 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 prior study (images reviewed) of [**2131-3-8**], the LVEF and RVEF hasve decreased. If indicated, a dobutamine echo may better assess true critical AS from a low-output state. . - Portable TEE (Complete) ([**2131-4-5**] at 10:30:00 AM) IMPRESSION: Significant calcific aortic stenosis. Mild aortic regurgitation. Moderate to severe mitral regurgitation. Complex aortic atheroma. Depressed [**Hospital1 **]-ventricular function. . Portable TTE (Complete) ([**2131-4-11**] at 11:43:26 AM) RESULT: Compared with the prior study (images reviewed) of [**2131-4-2**], velocities across the aortic valve have decreased. LV function is substantially better - ejection fraction appears normal on the current study. Therefore, the degree of reduction of aortic stenosis is probably greater than that suggested by reduced velocities. The degree of mitral regurgitation has also decreased and is now mild to moderate. Mild to moderate aortic regurgitation is now seen. . Cardiac Catheterization ([**2131-3-9**]) FINAL DIAGNOSIS: 1. Three vessel native coronary artery disease. 2. Patent SVG-OM, SVG-RCA, LIMA-LAD. 3. Severe aortic stenosis. 4. Severely elevated left ventricular diastolic and systolic pressures. . ECG ([**2131-4-1**] 12:21:12 PM) Sinus rhythm. Left atrial abnormality. Left ventricular hypertrophy with ST-T wave abnormalities. Intra-ventricular conduction delay with left axis deviation is probably left anterior fascicular block and additional intraventricular conduction delay/possible right ventricular conduction delay. Cannot exclude ischemia. Clinical correlation is suggested. Since the previous tracing of [**2131-3-9**] there may be no significant change but unstable baseline on previous tracing makes comparison difficult. . ECG ([**2131-4-10**] 9:08:54 AM) Sinus bradycardia. Left axis deviation. Non-specific intraventricular conduction delay. Left ventricular hypertrophy. Non-specific ST-T wave changes. Compared to the previous tracing of [**2131-4-3**] the rate is slower and sinus rhythm is now clearly present. TRACING #1 . ECG ([**2131-4-11**] 9:35:38 AM) Sinus rhythm. Left axis deviation. Non-specific intraventricular conduction delay. Left ventricular hypertrophy. Non-specific ST-T wave changes. Compared to the previous tracing of [**2131-4-10**] there is no significant change. TRACING #2 . CHEST (PA & LAT) ([**2131-4-1**] 2:04 PM) Stable mild cardiomegaly. Tortuous aorta with calcifications. Diffuse bilateral ground-glass opacities, minimally improved since [**2131-3-7**] consistent with pulmonary edema. No evidence of pleural effusion or pneumothorax. Retrocardiac opacification likely represents atelectasis. . CT CHEST W/O CONTRAST ([**2131-4-4**] 5:42 PM) IMPRESSION: 1. Multifocal mosaic attenuation with more focal consolidation in the right upper lobe consistent with severe pulmonary edema, given similar distribution of asymmetric edema previously. 2. Mild atherosclerotic calcification of the aortic root and descending thoracic aorta without evidence of porcelain aorta in this portion, calcification of the aortic arch, its branches and descending thoracic aorta and coronary arteries is moderately severe. 4. Severe calcification of the aortic valve consistent with aortic stenosis. 5. Bilateral small pleural effusions. 6. Right upper pole exophytic renal lesion, probably represents cyst but merits ultrasound evaluation, if this has not been already performed at another institution. . CT BRAIN PERFUSION / CTA HEAD W&W/O C & RECO / CTA NECK W&W/OC & RECON([**2131-4-10**] 12:28 PM) IMPRESSION: 1. Short-segment, approximately 5 mm occlusion of a sylvian left MCA branch, with robust distal reconstitution. The occluded segment is hyperdense on precontrast images, consistent with a thrombus or embolus. There is associated increased mean transit time in the superior left MCA distribution without a matched decrease in regional cerebral blood volume, suggesting ischemia without evidence of a completed infarction. MRI would be more sensitive for an acute infarction. 2. Chronic left superior parietal infarction in the left MCA territory. 3. Mild cervical carotid atherosclerosis without a hemodynamically significant stenosis. 4. The left vertebral artery arises directly from the aortic arch. Calcified plaque at its origin results in mild stenosis. 5. Marked interval improvement, though not complete resolution of opacities at the imaged lung apices, compared to the [**2131-4-4**] chest CT. Brief Hospital Course: 89-year-old woman with severe AS, CAD s/p CABG, HTN, HL, and DM Type 2 who presented with malaise, weakness, bilateral arm pain and nausea with progressively worsening aortic stenosis. . # Severe Aortic Stenosis with Angina: Initial concern that patient's presenting symptoms were secondary to worsening AS ([**Location (un) 109**]: 0.9, gradient of 42, velocity of 3.2). She refused AVR during previous admission. Extensive conversation regarding potential therapeutic interventions for AS: AVR vs Corevalve vs ballon valvuloplasty. Patient considered high risk from a surgical standpoint. Patient and family highly interested in CoreValve, however patient excluded from trial due to moderate to severe mitral regurgitation. Decision made to proceed with valvuloplasty. Valvuloplasty successfully improved aortic gradient as well as valve area however it was complicated by CVA of left MCA territory, likely embolic in nature. Fortunately, the next day, there were no neurologic deficits, and initial dysarthria resolved without intervention. . # CORONARIES: History of CAD s/p CABG [**39**] years ago. Cardic risk factors include known CAD, HTN, HL, type 2 DM, advanced age, and postmenopausal state. Recent cath in [**2131-2-23**] demonstrated right-dominant system with 3 vessel native coronary artery disease. (LMCA had 40% stenosis, LAD 80% stenosis before the 1st diagonal. The LCx was diffusely diseased. The RCA was totally occluded). Venous conduit angiography demonstrated a patent SVG-OM. The SVG-RCA had diffuse disease but supplied the proximal RCA. On this admission patient presented with chest pain and elevated biomarkers. She was medically treated for NSTEMI. . # PUMP: History of ischemic cardiomyopathy. TTE on [**2131-4-2**] moderately depressed left ventricular systolic function (LVEF= 30 %) with global hypokinesis and regioanl akinesis of the distal LV/apex and lateral walls; no ventricular septal defect. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. Her most recent TTE revealed new diastolic dysfunction in addition to systolic dysfunction. Patient was actively diuresis with IV lasix bolus with good effect. . # RHYTHM: On admission patient in NSR. Interventricular conduction delay present and at baseline. During hospitalization noted to transition to atrial fibrillation, likely paroxysmal atrial fibrillation. Episode of atrial fibrillation with rapid ventricular rate prompted transfer to CCU as patient hypotensive with worsening heart failure when reverted to Afib with RVR. Patient was amiodarone loaded and maintained on amiodorane 400mg PO BID for total of 10gm prior to transition to daily dosing. Patient reverted to NSR with amio with rates well controlled on beta-blocker. Patient was CHADS 3 and anti-coagulated with argatrobran (in setting of ? HIT) initially. When serotonin release assay returned negative, patient switched to coumadin. Patient switched from metoprolol tartrate to carvedilol for rate control given her congestive heart failure. . # Thrombocytopenia/HIT. Initially suspected due to heparin so heparin was off. Thrombocytopenia resolved thereafter. Although PF4 Ab was positive, serotonin assay returned negative. Therefore, she is HIT negative. Argatroban was stopped. Her platelet count normalized at the time of discharge. . # Group B Strep Bacteremia. A PICC was placed. ID recs noted that in light of complex aortic atheroma seen on TEE and heavy calcifications a prolonged course may be warranted in the instance that the patient developed an endovascular infection. She received ceftriaxone daily for a four week course starting from day of valvuloplasty. Last day is [**2131-5-9**]. . # Left MCA ischemia The patient experienced dysathria after valvuloplasty where balloon burst mid-procedure. This was believed to be a stroke secondary to a possible air embolism. CT/CTA performed (see under results). She was put on 4-hourly neurological checks and her SBP was held at goal of 120s-160s. Dysarthria resolved the next day and she returned to baseline. . # Iron Deficiency Anemia: Pt was anemic on admission, iron studies reveal iron deficiency anemia and due to her history of colonic adenoma four years ago. In house she was maintained on iron supplementations, stools were guaiac positive, however no frank melena or BRBPR. Patient transfused to achieve HCT>23. She was also started on PPI. OUTPATIENT ISSUE: -- Utility/Need for outpatient evaluation and repeat colonoscopy. . # Diabetes: Her metformin was held during this admission and she maintained on an insulin sliding scale. Metformin restarted on discharge. . # HTN: Metoprolol was switched to coreg. Lisinopril was restarted. Amlodipine was held at discharge as there is no cardiac benefit, but can be restarted if she remains hypertensive in the outpatient setting. . # Code Status: Full Code # Emergency contact: [**Name (NI) 1439**] [**Name (NI) 27145**] (Health care proxy). Home: [**Telephone/Fax (1) 27146**]; Cell: [**Telephone/Fax (1) 27147**] Medications on Admission: 1. alendronate 70 mg Tablet PO once a week. 2. amlodipine 5 mg Tablet PO DAILY (Daily). 3. furosemide 40 mg Tablet PO once a day. 4. lisinopril 10 mg Tablet PO DAILY (Daily). 5. metformin 850 mg Tablet PO twice a day. 6. metoprolol tartrate 25 mg Tablet Tablet PO DAILY 7. metoprolol tartrate 50 mg Tablet Two (2) Tablet PO at bedtime. 8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY 9. trazodone 50 mg Tablet (1) Tablet PO HS (at bedtime) as needed for insomnia. 10. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO three times a day as needed for pain. 11. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 12. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 13. Centrum Silver 500-250 mcg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 14. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID . Discharge Medications: 1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: start [**2131-4-12**]. Disp:*30 Tablet(s)* Refills:*2* 2. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 3. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 6. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO twice a day. 7. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 8. multivitamin with iron-mineral Tablet Sig: One (1) Tablet PO once a day. 9. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 10. metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day. 11. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. 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* 13. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig: One (1) gram Intravenous Q24H (every 24 hours) for 25 days: Day 1 of 4 week course of antibiotics was [**4-10**]. Disp:*25 gram* Refills:*0* 14. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:*30 Tablet(s)* Refills:*2* 15. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 16. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Location (un) 1036**] - [**Location (un) 620**] Discharge Diagnosis: Primary: NSTEMI Atrial Fibrillation Aortic Stenosis Transient Ischemic Attack Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms [**Known lastname **] it was pleasure taking care of you. . You were admitted to [**Hospital1 18**] due to treatment of chest pain. You were found to have a heart attack and you were medically managed. While hospitalized you [**Doctor Last Name **] seen to enter an abnormal rhythm known as atrial fibrillation. Unfortunately when you entered this rhythm it was difficult for your heart to pump blood forward and instead it pooled in your lungs. You were transferred to the cardiac intensive care unit for close monitoring and diuresis. . While hospitalized there was ample discussion surrounding the management of your aortic stenosis. After careful deliberation it was decided to proceed with valvuloplasty. The valvuloplasty was successful in dilating your aortic stenosis however it was complicated by mild stroke. The Neurology team saw you and recommended close monitoring. Your symptoms, predominantly slurred speech, resolved without intervention. . While hospitalized you were also found to have an infection in your blood stream. You were started on IV antibiotics. A PICC line was placed to facilitate further treatment as an outpatient. . CHANGES TO YOUR MEDICATIONS: - START Ceftriaxone 2gm daily through [**5-9**] - STOP taking your amlodipine until you follow up with your primary care doctor - START taking pantoprazole to prevent bleeding from your stomach - START taking amiodarone for your atrial fibrillation - START taking warfarin for your atrial fibrillation. Your goal INR is [**12-28**] and will be checked at rehab. - STOP taking metoprolol - START taking carvedilol . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Please follow up at the appointments below: Department: GERONTOLOGY When: TUESDAY [**2131-4-17**] at 11:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RNC [**Telephone/Fax (1) 719**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: INFECTIOUS DISEASE When: MONDAY [**2131-4-30**] at 9:50 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: CARDIAC SERVICES When: WEDNESDAY [**2131-5-9**] at 1 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: INFECTIOUS DISEASE When: TUESDAY [**2131-5-29**] at 2:30 PM With: [**Name6 (MD) 2323**] [**Name8 (MD) 2324**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**] Completed by:[**2131-4-13**]

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Discharge summary

report

Admission Date: [**2174-10-14**] Discharge Date: [**2174-10-17**] Date of Birth: [**2129-10-19**] Sex: M Service: MEDICINE Allergies: Latex / Methotrexate Attending:[**First Name3 (LF) 69390**] Chief Complaint: DOE Major Surgical or Invasive Procedure: none History of Present Illness: 44yo M PMHx significant for Lupus, ESRD on HD (Tues/Thurs/Saturday) awaiting renal transplant, CHF w severe mitral regurgitation and pHTN, HTN, GERD who initially presented to [**Hospital 1474**] Hospital with 1 week of SOB and chest pain, workup significant for flat cardiac enzymes, unremarkable CXR, BNP of 773; patient reports that over the last year, he has had recurrent episodes of these symptoms that have been attributed to his mitral valve disease. Review of his [**Location (un) 2274**] notes confirm this (stays on [**11-2**]), and describe chronic worsening of his dyspnea on exertion. Workup in the past has included TTE (EF 55-60%, moderate-severe AI, severe posteriorly-directed MR, and severe pulmonary HTN), Chest CT (c/w interstitial lung disease). On his admission to OSH, there was concern for need for MVR workup. Patient now transfered to [**Hospital1 18**] for further management. . On arrival, he reported some stable shortness of breath. He described his symptoms as the sensation that he was not getting enough air. He reported that his symptoms would often improve with morphine. He denied any associated chest pain, productive cough, headache, dizziness. Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: - Severe mitral regurgitation, pulmonary hyptertension (no reports available) 3. OTHER PAST MEDICAL HISTORY: - Lupus - ESRD on HD (Tues/Thurs/Saturday) - GERD Social History: Lives with 6 year old son in [**Name (NI) 1474**]. Has good relationship with ex-wife. Retired. [**Name2 (NI) **] smoker with 30pk-yr smoking history. Denies etoh, illicits. Mother recently died of bonce cancer. Family History: Several family members w autoimmune disorders. Physical Exam: ON admission: VS: 84 79/53 100% with taking NRB on and off throughout conversation GENERAL: NAD, comfortable HEENT: PERRL, EOMI, OP clear NECK: Supple, no JVD CARDIAC: RRR, III/VI holosystolic murmur, loudest at apex, w loss of S2 LUNGS: Resp unlabored, no accessory muscle use, CTA b/l, no wheezes/rales/rhonchi ABDOMEN: Soft, NT/ND. EXTREMITIES: No c/c/e. SKIN: dry skin PULSES: DP 2+ PT 2+ bilaterally . On discharge: VS: 98.1/97.6, HR 73-74 SR, RR 18-20, BP 111-117/68-72 O2 sat: 100% RA. GENERAL: NAD, comfortable HEENT: PERRL, EOMI, OP clear NECK: Supple, no JVD CARDIAC: RRR, III/VI holosystolic murmur, loudest at apex, LUNGS: Resp unlabored, no accessory muscle use, Dry crackles b/l bases ABDOMEN: Soft, NT/ND. EXTREMITIES: No c/c/e. SKIN: dry skin PULSES: DP 2+ PT 2+ bilater Pertinent Results: On admission: [**2174-10-14**] 09:25PM BLOOD WBC-5.6 RBC-3.50*# Hgb-9.9* Hct-31.4*# MCV-90 MCH-28.2 MCHC-31.4 RDW-18.3* Plt Ct-203 [**2174-10-14**] 09:25PM BLOOD PT-17.4* PTT-28.2 INR(PT)-1.5* [**2174-10-14**] 09:25PM BLOOD Glucose-131* UreaN-22* Creat-4.7*# Na-137 K-4.6 Cl-97 HCO3-26 AnGap-19 [**2174-10-14**] 09:25PM BLOOD Calcium-8.7 Phos-3.5 Mg-2.0 On discharge: [**2174-10-17**] 07:00AM BLOOD WBC-8.0 RBC-3.40* Hgb-9.3* Hct-30.1* MCV-89 MCH-27.4 MCHC-30.9* RDW-18.0* Plt Ct-243 [**2174-10-17**] 07:00AM BLOOD Glucose-76 UreaN-72* Creat-10.2*# Na-139 K-3.9 Cl-98 HCO3-25 AnGap-20 [**2174-10-15**] 05:19AM BLOOD CK(CPK)-44* [**2174-10-14**] 09:25PM BLOOD CK(CPK)-51 [**2174-10-15**] 05:19AM BLOOD CK-MB-1 cTropnT-0.02* [**2174-10-17**] 07:00AM BLOOD Calcium-8.8 Phos-4.9* Mg-2.1 . ECHO [**10-15**]: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). There is mild regional left ventricular systolic dysfunction with probable thinning and hypokinesis of the basal inferior segment. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. Mild to moderate ([**11-28**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: the basal inferior wall is probably hypokinetic. There is moderate to severe mitral regurgitation. Mild to moderate aortic regurgitation. Moderate pulmonary artery systolic hypertension. . CXR [**10-15**]: FINDINGS: The lung volumes are low. There is moderate cardiomegaly with mildpulmonary edema. In addition, relatively extensive bilateral areas of opacities are seen that could be atelectatic, but could also represent pneumonia. These opacities are more severe on the right than on the left. Nopleural effusions. A double-lumen left-sided central venous access line. Brief Hospital Course: # Shortness of Breath - Patient w chronic worsening of shortness of breath, thought to be [**12-29**] mitral regurgitation; patient denying any chest pain. R/O'd at [**Hospital 1474**] hospital. EKG not consistent with ischemic origin; no signs to suggest infection on history, imaging, labs; does not appear to be acute worsening of MR, but more slow progression. Ground glass appearance on chest CT and bilat pleural effusions may be suggestive of interstitial lung disease and may be somewhat responsible for DOE. Also, pt has hx of OSA and not currently using CPAP which may be causing moderate pulmonary hypertension seen on ECHO. Cardiac surgery saw pt today and recommeneded further testing via cardiac catheterization and TEE to better evaluate valve. PCP also [**Name (NI) 653**] by [**Name (NI) 2274**] cardiologist [**First Name8 (NamePattern2) **] [**Name (NI) 2920**] to arrange pulmonary f/u appt to assess above pulmonary issues. Pt was walked on day of discharge and displayed no DOE with O2 sats in high 90's. . #H/O graft thrombus: pt was not being followed by PCP or [**Hospital3 **] since moving from [**Hospital1 1474**] to [**Hospital1 392**]. He states he has been taking warfarin 5 mg regularly (a dose that he was therapeutic on previously). Dr. [**First Name (STitle) 2920**] has [**First Name (STitle) 653**] PCP to [**Name9 (PRE) 107265**] [**Name Initial (PRE) **]/u with [**Hospital 2274**] [**Hospital3 **] after discharge. INR 1.6 on discharge, 5 mg dose was continued. . # GERD: no issues, will cont PPI [**Hospital1 **]. . # Lupus: pt states he is in a flare but able to ambulate with a cane and no increase in pain medicines needed. He has a rheumatologist in [**Hospital1 1474**] where he previously lives who told him to increase prednisone to 20 mg with a taper down to 5 mg over one week. Apparently, pt has a soft diagnosis of lupus per [**Location (un) 2274**] notes. No changes were make in his medicines (including oxycodone) and Dr. [**First Name (STitle) **] will arrange rheumatology through [**Location (un) 2274**]. . # ESRD on HD: Scheduled Tues/Thurs/Sat. Rec'd HD today without incident and removed 2L total. Appears euvolemic on exam. Unclear if more aggressive fluid removal in HD has helped his SOB. . # HTN: BP well controlled at present on atenolol. No ACE on admission. . # Insomnia / Anxiety; Trazadone and lorazepam were continued at home doses. . Transitional issues: 1. Pt was counseled to continue care at [**Location (un) 2274**] and seek referrals for rheumatology and pulmonology within that system. AS he is a young complicated pt, he would benefit from an integrated health care system. 2. PCP will arrange [**Name Initial (PRE) **]/u in [**Hospital3 **] for INR monitoring. 3. PCP will arrange [**Name Initial (PRE) **]/u with pulmonology to evaluate sleep apnea and pulmonary hypertension 4. Cardiac surgery will arrange cardiac catheterization and TEE as an outpt in preparation for MVR. Medications on Admission: - Chloroquine 250mg daily - Albuterol / ipratropium inhaler - ASA 81mg daily - B complex / Folic Acid - Atenolol 50mg daily - Nexium 40mg [**Hospital1 **] - Fluticasone INH 2 spray - Coumadin 5mg daily - Oxycodone 15mg q4hrs prn pain - Ativan 2mg [**Hospital1 **] prn anxiety - Trazodone 50mg qhs prn insomnia - Prednisone 5mg daily Discharge Medications: 1. chloroquine phosphate 250 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation four times a day. 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 5. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 7. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 8. oxycodone 5 mg Tablet Sig: Three (3) Tablet PO Q4H (every 4 hours) as needed for pain: no more than 6 doses per day. 9. lorazepam 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for insomnia, anxiety. 10. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 11. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 13. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for pain: do not take more than 2 tablets 5 minutes apart. . Discharge Disposition: Home Discharge Diagnosis: Mitral Valve Disease Lupus Chronic Diastolic Congestive heart failure Hypertension End stage renal disease. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were having trouble breathing and was transferred from [**Hospital 1474**] Hospital to [**Hospital1 18**] to be evaluated by cardiac surgery for a potential valve replacement or repair. We have continued your dialysis treatments and home medicines. You will need to see a lung doctor (pulmonologist) before surgery to see if your breathing difficulties may be because of lung issues in addition to your heart valves. We have [**Hospital1 653**] Dr. [**First Name (STitle) **] to set up coumadin monitoring through [**Hospital1 **] and she will also refer you to a pulmonary doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) 392**]. The cardiology surgery team will contact you at home to schedule the two tests, cardiac catheterization and echocardiogram via the esophagus. We did not make any changes to your medicines, please continue to take coumadin 5 mg every day Followup Instructions: [**10-24**] at 11:20AM at [**Hospital1 392**] [**Location (un) 2274**] with Dr. [**Last Name (STitle) 88768**] [**Name (STitle) 10102**]. She will refer you to a lung specialist at [**Location (un) 2274**]. . [**Hospital3 **] at [**Location (un) 2274**]: they will contact you tomorrow and will tell you how much coumadin to take every day. . The cardiac surgery department will call you at home to schedule a cardiac catheterization and esophageal echocardiogram in the near future. . Department: TRANSPLANT SOCIAL WORK When: FRIDAY [**2174-10-28**] at 10:30 AM [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: TRANSPLANT CENTER When: FRIDAY [**2174-10-28**] at 9:00 AM With: [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**First Name8 (NamePattern2) 20**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 69391**]

[ "530.81", "300.00", "V45.11", "V49.83", "416.0", "585.6", "337.20", "403.91", "428.32", "424.0", "710.0", "780.52", "428.0", "285.9", "327.23" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

9713, 9719

5136, 7543

289, 296

9871, 9871

2894, 2894

10932, 12054

2024, 2072

8478, 9690

9740, 9850

8121, 8455

10022, 10909

2087, 2087

1619, 1697

3265, 5113

7564, 8095

246, 251

324, 1509

2909, 3250

9886, 9998

1728, 1779

1531, 1599

1795, 2008

25,996

106,525

5683

Discharge summary

report

Admission Date: [**2200-4-21**] Discharge Date: [**2200-4-25**] Service: NEUROSURGERY HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 22705**] is an 89 year-old lady seen on [**3-18**] with increased difficulty ambulating, incontinence, headache, falls and left sided weakness. She was found to have right sided subdural hematoma on the [**3-20**]. secondary to increased lethargy and mild showed increased volume of subdural hematoma on the left side with compression of the lateral ventricles and subfalcine herniation. She also had elevated blood pressures at this time. This had been drained and she was discharged to rehab. She was brought back to the hospital on the [**3-22**] by her son, because of increasing lethargy and weakness. Repeat head CT showed an enlarged subdural hematoma, which required PAST MEDICAL HISTORY: Significant for coronary artery disease status post coronary artery bypass graft, congestive heart failure with an ejection fraction of 30%, atrial fibrillation, hypertension, has a pacemaker and diabetes mellitus. MEDICATIONS: She is on Synthroid 25 micrograms q day, atenolol 25 mg q day, Glipizide 5 mg q.d., Lisinopril 10 mg q.d., Lipitor 10 mg q.d., Zantac 150 mg b.i.d. and sliding scale insulin. SOCIAL HISTORY: She is a nonsmoker and she does not drink alcohol. PHYSICAL EXAMINATION ON ADMISSION: Her temperature was 98.6. Blood pressure 139/64. Heart rate was 73 and in atrial fibrillation. Respiratory rate was 18 and a saturations were 98% on room air. She was elderly and reasonably nourished. She was alert and oriented times two and she was incorrect of the year and month. She is status post right craniotomy, which had healed well. She has also had a recent left crani with a bur hole and sutures, which had healed well. The pupils are post surgical. Extraocular movements intact. the neck was supple. There was full range of motion bilaterally. Neurological she was attentive to examination, follows only single, but she was progressively getting drowsy. Strength was 5 out of 5 to gross examination on all extremities. She had an increased tone in the right upper extremity. The Babinski was down going and the deep tendon reflexes were diminished or absent throughout. There was no clonus. Tongue was midline. The head CT done on the [**3-22**] showed a large residual left sided subdural hematoma with minimum midline shift. HOSPITAL COURSE: She was admitted in the Neurosurgical Floor for observation. Eye opening was a bit slow. She had some drift in the right arm. The plan was to rule out a metabolic encephalopathy and also to do an electroencephalogram. Repeat head scan was performed, because the patient was found to be more lethargic on the [**3-24**] and the drift was worse. Therefore repeat head CT was performed and this showed an increase in the subdural hematoma with an acute compliment to it, which was drained on the [**3-24**]. In the immediate postoperative period she opened her eyes to voice. She was more alert and awake then in the preoperative period and moved all extremities. She was oriented to time and place, but not the year and month. There was no facial asymmetry and tongue was midline. Ms. [**Known lastname 22705**] was transferred to the neurosurgical floor on the 23 and she has remained stable in the neurosurgical floor. CONDITION ON DISCHARGE: She is stable. She is awake, alert, follows single commands. She shows her tongue, moves all extremities. Can grip hands, can show one or two fingers on request. She is not oriented to the month and year. MEDICATIONS ON DISCHARGE: Levothyroxine 25 micrograms po q day, atenolol 75 mg po q day, Glipizide 5 mg po q day, Lisinopril 10 mg po q day, Ranitidine [**Age over 90 **] m po q day. Insulin sliding scale as per the flow sheet, Metoprolol 5 mg intravenous q 3 to 4 hours prn if the heart rate is continuously more then 130 beats per minute. She is on Ciprofloxacin 500 mg po for a urinary tract infection for the duration of five days, which was started on the [**3-25**]. Dilantin 300 mg po q.d. She is also receiving normal saline 70 cc per hour. Nutrition, she receives house diet with full liquids and soft consistency. She has been seen by the physical therapist and the occupational therapist during her stay here. She has urinary retention, therefore she had a Foley placed with a residual of 800 cc therefore the Foley catheter is draining the bladder at present. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**] Dictated By:[**Doctor Last Name 22706**] MEDQUIST36 D: [**2200-4-25**] 09:03 T: [**2200-4-25**] 09:40 JOB#: [**Job Number 22708**]

[ "V45.81", "401.9", "250.00", "V45.01", "428.0", "432.1" ]

icd9cm

[ [ [] ] ]

[ "01.31" ]

icd9pcs

[ [ [] ] ]

3626, 4753

2436, 3364

126, 829

1363, 2418

852, 1258

1275, 1348

3389, 3599

15,002

125,654

1331

Discharge summary

report

Admission Date: [**2132-3-27**] Discharge Date: [**2132-3-30**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1711**] Chief Complaint: STEMI Major Surgical or Invasive Procedure: cardiac catheterization bare metal stent placement History of Present Illness: 87 y/o M with HTN developed acute onset severe substernal chest pain after dinner on DOA. He had mild HA associated with it. He did not have any n/v, SOB, palpitations or dizziness. He came to ED where he was found to have STE in precordial leads with CEs showing flat CK & Trop of 0.07. He also had 30 beat run of VTach & was hemodynamically stable. However he was given bolus of Amiodarone 150 mg. He was taken emergently to the cath lab where his cath showed the following: -- LMCA 20% -- LAD: TO after 1st septal with bridging collaterals -- LCX: 95% ulcerated stenosis before large brainching OM1, lower pole has a 70% stenosis -- RCA: Moderate diffuse disease HEMODYNAMICS: CO: 3.48 CI: 1.77 RA Mean: 12 PCW Mean: 15 PA Mean: 27 He was transferred to the CCU after his cath. He briefly had AIVR rhythm. He got boluses of Integrillin in the cath lab but was not continued on it due to his renal function. He was also not started on beta blockers given his low normal BP of around 110-120 and HR between 55-60. Past Medical History: -- Hypertension -- Gout -- Hypothyroid . PAST SURGICAL HISTORY: 1. Right adrenalectomy, reasons uncertain. 2. Appendectomy. Social History: Does not smoke or drink Family History: 5 brother died from CAD in their 40s No h/o SCD in family . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Physical Exam: VS: 95.4, 58, 126/62, 18, 97%/2L NC HEENT: PERLA, EOMI, Dry MM Neck: JVD not elevated Heart: S1/S2, RRR, no mumurs Lungs: CTAB Abdomen: soft/NT, no hepatosplenomegaly, normoactive BS Ext: varicose vein from mid-thigh to lower foot, predominant on right side with venous stasis changes on the right . Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Pertinent Results: C. Cath: 1. Selective coronary angiography of this right dominant system revealed two vessel disease. The LMCA had a 20% distal lesion. The LAD was totally occluded after the first septal branch and filled distally via bridging collaterals. The LCx had a 95% ulcerated stenosis just proximal to a large bifurcating OM1 branch, which had a 70% stenosis in its lower pole. The RCA had moderate diffuse disease. 2. Resting hemodynamics revealed moderately elevated left and right sided filling pressures with a mean RA of 13mmHg and mean PCWP of 21mmHg. The cardiac index was depressed at 1.8l/min/m2. 3. Left ventriculography was deferred. 4. Successful PTCA and stenting of OM1 with a 3.5 Vision BMS. The final angiogram demonstrated no residual stenosis with no angiographic evidence of dissection, embolization or perforation with TIMI III flow in the distal vessel. (See PTCA comments) . . ECHO: EF: 40% The left atrium is elongated. 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 mildly depressed with infero-lateral akenisis. The apex is not well seen but appears hypokinetic. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is an anterior space which most likely represents a fat pad. Brief Hospital Course: 87 M with HTN p/w STEMI, now s/p BM stent to LCX and remained well post-cath. His active issues during this hospital admission includes: . # MI: STEMI s/p cath with 2VD and bare metal stents in LCx. In the cath lab, he was noted to have AIVR rhythm. In addition, he received boluses of integrillin in the cath lab but was not continued on it due to his renal function. Initially, he was not started on beta blockers given his low normal BP of around 110-120 and HR between 55-60. However, all appropriate medications were titrated up and on discharge, he was discharged on ASA, Plavix, lipitor 80 QD, lisinopril 5 QD, metoprolol 25 [**Hospital1 **]. He and his family were instructed to call and set up outpatient cardiac follow-up appointments. . # Pump: He appeared euvolemic on exam. ECHO demonstrated EF 40%. Overall left ventricular systolic function was mildly depressed with infero-lateral akenisis. The apex is not well seen but appears hypokinetic. He was discharged on ACE inhibitor and B-Blocker as above. . # Hypertension: His home regimen was bisoprolol/hctz. His medications were adjusted as above. . # AAA: This was observed during cath, but CTA was deferred given poor renal function. Patient was instructed to follow-up with his PCP for abdominal/aortic [**Hospital1 950**] to further evaluate aorta. He remained hemodynamically stable during hospital course and this was felt to be an outpatient issue. . # UTI: Pt noted to have . # Gout: He continued allopurinol . # Hypothyroid: He continued levothyroxine . # CKD: baseline Creatinine of 1.9. His creatinine remained better than baseline. . # FEN: low sodium/heart healthy . # PPX: protonix, full activity . # FULL CODE . # Contact: wife [**Name (NI) 382**] Medications on Admission: Allopurinol 300 mg QD Levothyroxine 100 mcg Bisoprolol/HCTZ 2.5/6.25 Clobetasol cream Protonix 40 mg QD Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 months: For at least 3 months. Disp:*30 Tablet(s)* Refills:*2* 2. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. 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* 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: STEMI Hypertension AAA . Secondary: Chronic kidney disease Gout Hypothyroid Discharge Condition: Stable. Tolerating PO. Afebrile. Discharge Instructions: You were admitted to the hospital because you experienced a heart attack. You should call your doctor or return to the ER if you experience any of the following symptoms: fever > 101.4, recurrent chest pain, intractable nausea or vomiting or any other concerning symptoms. . Please take all medications as prescribed. . Please follow up with all appointments as instructed. . You may have an enlarged aorta and you will need an [**Name (NI) 950**] of your aorta for further evaluation. Your primary care physician should arrange this. . Please carry the stent information cards with you at all times. Followup Instructions: Please call your primary care physician, [**Last Name (NamePattern4) **].[**Name (NI) 8156**], office on Monday to schedule an appointment in the next week to follow-up on your recent heart attack, your aorta enlargement, and your urinary and diarrhea symptoms. . Please attend to following appointments: Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2132-3-31**] 11:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8157**], M.D. Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2132-5-21**] 2:30

[ "414.01", "585.9", "244.9", "427.1", "441.4", "403.90", "599.0", "274.9", "410.31" ]

icd9cm

[ [ [] ] ]

[ "00.45", "88.56", "88.52", "36.06", "00.40", "37.23", "00.66", "99.20" ]

icd9pcs

[ [ [] ] ]

6812, 6818

4040, 5772

268, 321

6947, 6982

2252, 4017

7631, 8194

1575, 1801

5927, 6789

6839, 6926

5798, 5904

7006, 7608

1456, 1518

1816, 2233

223, 230

349, 1370

1392, 1433

1534, 1559

27,574

140,207

10409

Discharge summary

report

Admission Date: [**2128-3-12**] Discharge Date: [**2128-3-17**] Date of Birth: [**2080-5-8**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2745**] Chief Complaint: DKA, ?narcotic OD Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 34476**] is a 47M with a PMH s/f IDDM, ?CAD, recent MRSA/aspiration PNA with discharge from rehab 4 days ago (completed recent courses of vancomycin, cefepime, zosyn, and flagyl), and recent c. diff infection [**1-/2128**] s/p 14 days of flagyl. By report, his HCP found him somnolent at his home today with 100/200 oxycodone tabs missing from his pill bottle. She took him to [**Hospital3 **], where he had a blood glucose of 1209, and a WBC count of 32. He was given a total of 6L NS, 1g vancomycin and an insulin drip, and transferred to [**Hospital1 18**]. . In our ED, he was somnolent on admission, but arousable and able to answer simple questions, though he could not give a detailed history. His initial vital signs were: T 96.6, HR 101, BP 143/56, 100%RA, RR 17. FSBS= 500s. He was given 1.5L NS, and started on an insulin gtt at 10u/hr. A 400mcg fentanyl patch was removed. No narcan given as the patient was arousable with good RR. Exam was notable for a left great toe ulcer, which did not appear infected, bilateral foot drop, and chronic neck pain. UA was negative for any signs of infection, and showed positive glucose and ketones. CBC was notable for leukocytosis to 35,000. CXR is clear. Blood and urine cultures sent. Lactate is mildly elevated to 2.3 Urine tox is negative. Serum tox was negative. Electrolytes showed K+ of 4.7 and a bicarb of 11 with an anion gap of 23. Patient is altered, but states that he has not been having any fevers or chills, no abdominal pain, no chest pain, palpitations, dizziness, no diarrhea or nausea/vomiting. He also states that he did not take any of his home oxycodone the day of admission. Per OSH records, the patient reports two days of decreased PO intake, with two episodes of vomiting overnight. Past Medical History: - Narcotic abuse - IDDM c/b peripheral neuropathy, gastroparesis, chronic kidney disease - Mild regional LV systolic dysfunction on [**1-/2128**] echo, consistent with CAD? (EF 50%). Has required 20mg of lasix to manage fluids. - Impaired speech and swallow, with history of aspiration. Requires thin liquids/pureed diet. - History of hospital acquired MRSA pneumonia ([**2128-12-21**]) completed a courses of vanc/zosyn, and vanc/cefepime/flagyl - History of C. diff s/p 14 days of flagyl [**1-/2128**] - CKD: baseline Cr runs anywhere from [**2-26**] - Medullary sponge kidney - Nephrolithiasis - chronic pain: with narcotic abuse currently based on conversations with HCP - gastritis - depression/anxiety - HTN Social History: Divorced though still in contact with ex-wife. Lived with his father in [**Name (NI) **], MA, prior to hospitalization in [**Month (only) 1096**]. Smoked [**1-23**] ppd x 20 yrs but no longer smokes. ?history of substance abuse based on prior OMR notes. Family History: Mother: Leukemia, currently undergoing chemotherapy Father: CAD, HTN Physical Exam: T=98.2 BP=120/70 HR=97 RR=11 O2=100% on RA . . PHYSICAL EXAM GENERAL: Thin appearing gentleman, somnolent, NAD HEENT: Normocephalic, atraumatic. No scleral icterus. Pupils equal round, reactive but slightly sluggish. EOMI with no nystagmus. MMM. OP clear. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: CTAB, good air movement biaterally. ABDOMEN: Soft, nondistended, mild-moderate tenderness in the epigastrium, no guarding, no rebound, decreased bowel sounds EXTREMITIES: Warm, No edema or calf pain, 2+ dorsalis pedis; well demarcated ulcers on the left great toe, and right heel; right heel ulcer with erythematous border NEURO: Somnolent, oriented to person, but not to place and time. Follows simple commands Pertinent Results: CBC : 35>32<365 Diff N 88 L 8 Na 138 K 4.5 Cl 103 HCO3 11 BUN 46 Cre 1.5 Glu 712 Anion Gap: 24 Ca: 8.2 Mg: 2.1 P: 5.5 Lactate: 2.3 Urine Tox: negative Serum Tox: negative U/A:Leuk neg, Nitr neg, Prot neg, Glu 1000, Ketones 150 STUDIES: CXR: no acute cardiopulmonary process Brief Hospital Course: 47 yo male with IDDM, h/o MRSA PNA, C. diff, presenting with DKA, c. difficile infection and altered mental status in setting of narcotic abuse and acute medical illness. Of note, the patient's most important medical issue at this point is his severe opiate abuse and dependence. An extensive family discussion was held with reports of many instances where the patient would try to fool caregivers in increasing the patient's opiate dosages. These included fashioning fake kidney stones out of paint. The family brought documentation that the patient was filling several different opiate scripts at different pharmacies and using far in excess of the prescribed dosages. The patient was on a whopping dose of narcotics on his discharge from [**Hospital **] rehab including 400 mcg of fentanyl patches and very large ocycodone prn doses. The patient does not have severe organic pain that necessitates high opiate usage. His pain will be managed through adjunctive pain meds. His fentanyl patch will be weaned completely off over the next few weeks. Note, the patient is not to receive prn opiates. 1. DKA - Presenting BG 1200, HCO3 11, and AG 24. Required insulin gtt overnight in the ICU, and then transitioned to home subcutaneous dose. Likely initiated by C. difficile infection. Patient was initially covered broadly with vanc/ceftaz/flagyl. Cdiff toxin assay, blood and urine cultures were sent. C. diff toxin + (though did have recent infection). All other culture data remained negative and foot ulcers did not appear infected. Foot ulcers were debrided by podiatry with wound care recs. There was no evidence of osteomyelitis or deep tissue infection per podiatry and no antibiotics were recommended for the patient's foot ulcers, Vanc/ceftaz were d/cd and flagyl was continued. His insulin regimen was titrated [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations. 2. Altered mental status - per report of health care proxy, patient complained of "not feeling well" 2 days prior to admission, and gradually developed an altered mental status. He was then found altered with 100/200 of his monthly prescription of oxycodone gone, though his prescription was for 20mg every 2 hours, though his tox screen in our ED was negative but does not detect all forms of opiates. In the emergency [**Apartment Address(1) **] 100mcg patches of fentanyl were removed, which was the dose he was on at the time he was discharged from rehab. His mental status improved in the ICU, but prior to transfer to the floor, patient was noted to be agitated and complain of nausea, which was thought to be secondary to potential narcotic withdrawal. He was reintiated on 200mcg of fentanyl and the next day his mental status had improved. 3. Leukocytosis - Patient had elevated WBC to 32K upon admit, not febrile. He had hx of recent hospital aquired MRSA pneumonia, treated with vancomycin, cefepime, zosyn. CXR upon admit was negative for new or developing infiltrate. He also had recent history of CDiff, was treated with 14 day course of IV flagyl. Also had a history of foot ulcers, which appeared infected upon admission, which prompted coverage for polymicrobial etiology of diabetic ulcers; vanco for MRSA coverage, Ceftaz/Flagyl for gram negatives, anaerobes, and C. diff. Cultures were pending at time of transfer to floor. Cultures noteable for +C. diff and he was continued on flagyl. Vanc and ceftaz were d/cd. See section above regarding podiatry evaluation and recommendations. 3. Chronic Kidney Disease - creatinine was at baseline upon admission. 4. Chronic pain - Patient was on huge home doses of narcotics. The patient was taken off all PRN opiate pain meds and he was weabed down on his fentanyl patch. The patient's fentanyl patch should be weaned off at 25 mcg/hr every several days. The patient was seen by the pain service and addictions service. The plan is for strict weaning off of fentanyl. If at time of discharge from [**Hospital1 1501**] the patient is completly off fentanyl, then he will be admitted to the [**Hospital **] Hospital for substance abuse treatment. If the fentanyl has not been completly weaned off at discharge, then the patient should go to [**Hospital1 **] for substance abuse treatment. The pain service saw the patient and agreed with the above plan. The patient was started on clonidine patch as an adjuncive pain med along with tylenol. If there is concern for diabetic neuropathic pain, then the patient could also be started on cymbalta. the patient agreed with the above plan on several occasions 5. Depression/anxiety - Patient's clonazepam was discontinued given his history of substance abuse. 6. Anemia - has baseline low hct, thought [**2-23**] CKD, at baseline upon admission and remained stable. 7. Benign HTN: All BP meds initially held at admission. His toprol was reinitiated. 8. Systolic CHF: Did not appear volume overloaded. Beta-blocker was reinitiated. 9. Nausea: Upon transfer to the floor, patient complained of nausea and noted to have biliary emesis. KUB negative for obstruction. Unclear if related to DKA, narcotic withdrawal, ileus, or gastroparesis. With conservative treatment and aggressive PUD/GERD treatment, the patient was able to advance his diet with improvement in his nausea. 10. Depression: Escitalopram held at admission, but restarted. Clonazepam discontinued given significant substance abuse history. 11. Multiple foot ulcers: Podiatry consulted. Radiographs negative for osteo and recommended wound care. Full Code Medications on Admission: 1. Escitalopram 10 mg daily 2. Hydrochlorothiazide 25 mg daily 3. Lasix 20 mg daily. 4. Fentanyl 400mcg/hr Patch 72 hr 5. Clonazepam 0.25mg tid 6. Oxycodone 30mg Q2hrs PRN 7. Lantus 18 units subcutaneous qhs 8. Humalog 100 unit/mL sliding scale. 9. Neurontin 800 mg tid 10. Toprol 75mg qd 11. Omeprazole 20 mg qd 12. ASA 81mg qd 13. Darbepoetin Alfa In Polysorbat 100 mcg/0.5 mL One Hundred (100) mcg Subcutaneous every Friday. 14. Sucralfate 1 gram qid 15. Docusate Sodium 100 mg [**Hospital1 **] 16. Senna 8.6 mg [**Hospital1 **] 17. Lidocaine 5 %(700 mg/patch)as needed for low back pain: on for 12 hours, remove for 12 hours. Discharge Medications: 1. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal every seventy-two (72) hours: Total 175 mcg with strcit plan to wean completely off. 2. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal every seventy-two (72) hours: Total 175 mcg with strict plan to wean off completly. 3. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTUES (every Tuesday): Can slowly uptitrate as patient tolerates. Has sedating effect. 4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY, 12 HOURS ON, 12 HOURS OFF (). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 12 days. 7. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Neurontin 800 mg Tablet Sig: One (1) Tablet PO three times a day. 9. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. 10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO Q 12H (Every 12 Hours). 11. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for heartburn. 12. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg Injection Q8H (every 8 hours) as needed for nausea. 13. Prochlorperazine Edisylate 5 mg/mL Solution Sig: Ten (10) mg Injection every six (6) hours as needed for nausea. 14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 16. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day): Hold for diarrhea. 17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 19. Hydroxyzine HCl 25 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for nausea. 20. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for heartburn. 21. Lantus 100 unit/mL Solution Sig: Twenty Two (22) units Subcutaneous at bedtime. 22. Humalog 100 unit/mL Solution Sig: One (1) units Subcutaneous QACHS: Administer per sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital6 25759**] & Rehab Center - [**Location (un) **] Discharge Diagnosis: Diabetic Ketoacidosis Opiate Overdose/abuse/dependence Clostridium Difficile Infection Depression Chronic Kidney Disease Discharge Condition: Vital Signs Stable, Patient off all PRN opiate meds, only opiate is fentanyl patch with strict plan to completely wean off. Discharge Instructions: Patient to return to ED if having high fevers, confusion, diabetic ketoacidosis, acutely distended abdomen, vomiting blood, red blood in his stool. The patient is to be eventually weaned off of all narcotics. Do not give the patient any narcotics other than his fentanyl patch which is being weaned off gradually. The patient's clonazepam has been discontinued. Followup Instructions: Provider: [**Name10 (NameIs) 2841**] LABORATORY Phone:[**Telephone/Fax (1) 2846**] Date/Time:[**2128-3-25**] 2:30 PCP: [**Name10 (NameIs) 28955**] [**Name11 (NameIs) **],[**Name12 (NameIs) **] [**Telephone/Fax (1) **]

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icd9cm

[ [ [] ] ]

[ "86.22" ]

icd9pcs

[ [ [] ] ]

13068, 13154

4381, 9948

332, 338

13318, 13444

4076, 4358

13857, 14077

3195, 3265

10630, 13045

13175, 13297

9974, 10607

13468, 13834

3280, 4057

275, 294

366, 2168

2190, 2907

2923, 3179

57,935

135,223

51256

Discharge summary

report

Admission Date: [**2147-12-1**] Discharge Date: [**2147-12-16**] Date of Birth: [**2083-10-7**] Sex: M Service: CARDIOTHORACIC Allergies: Heparin Analogues Attending:[**First Name3 (LF) 31264**] Chief Complaint: Weakness Major Surgical or Invasive Procedure: None. History of Present Illness: 64M history of alcohol abuse, hypothyroidism presenting from home with a 5 day history of weakness. Patient reports he had a mechanical fall about 3 days ago. He states he was in the bathroom and lost his balance hitting his right side. He denies head strike or loss of consciousness. He also denies preceding dizziness or chest pain. He denies sz activity, loss of bowel or bladder control. Since the fall he has noticed pain in his R knee and hip. He however denies any cough, chest pain, abdominal pain, loose stools or bloody stools. He does note "losing his breath with ambulation" and occasional LE edema over the past week. He additionally reports a poor appetite in addition to an unintentional 50 lb wt loss over the past year. He denies travel of recent medication changes. Given on going weakness and difficulty with ambulation EMS was called. He was found on the porch cold with a blood pressure of 70/palp. In the ED, initial VS were: 97 78 73/49 16 100% RA. Exam was notable for dry skin. There was no evidence of trauma. Rectal exam notable for guaiac negative stool. Xrays were done as patient noted knee and hip pain and were negative for fracture. Labs were notable for a lactate of 5.6, HCT of 25.3 (from 34 in [**12-17**] though consistent with prior), WBC 4.5, Cr of 1.8 (1.3 in [**12-17**]), ALT/AST 31/75. Serum tox was negative. CXR demonstrated no acute process. UA was unremarkable. EKG was notable for diffuse low voltage. The patient was given in total 3L NS. Pressures remained low and he was started on levophed which was titrated up to 0.15. He was additionally given a multivitamin, thiamine and folate. Vitals on transfer were 68 103/64 16 100% On arrival to the MICU, patient is alert and oriented x 3. He notes pain in R knee and hip but it otherwise symptom free. Past Medical History: # ETOH abuse - denies history of blackout, withdrawal seizure, DTs - history of DUI, attended mandatory AA - currently reports drinking [**2-6**] to 1 pint of gin 2 times per week # M-W tear with UGIB [**8-/2146**] # hypothyroidism # h/o acute pancreatitis requiring hospitalization [**9-/2145**] # fatty liver # peripheral neuropathy # macrocytic anemia # gout # HTN # impaired vision secondary to a battery acid splash in his eyes # Cyst removal from the back about 40 years ago. Social History: Prior notes from [**2145**] indicate heavy drinking, up to half a gallon of gin every couple of days. Currently lives with wife and daughter. [**Name (NI) 1139**] use consists of about 14-15 cigarettes per day. Family History: The patient has a sister who has diabetes. The patient's father died at 94. The patient's mother died at 84. She had diabetes and hypertension. The patient's maternal grandmother died at age [**Age over 90 **]. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: BP: 92/56 P:66 R: 18 O2:100% RA CVP 6 General: Alert, oriented, no acute distress, thin/ cachetic male HEENT: Sclera anicteric, dry moucous membranes, 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 Abdomen: soft, non-tender, non-distended, bowel sounds present GU: no foley Ext: cool, dry skin over bilateral feet, 1+ pulses, no clubbing, cyanosis or edema, R knee with effusion, no eryhtema no warmth Neuro: CNII-XII intact, 4/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, finger-to-nose intact DISCHARGE PHYSICAL EXAM: Pertinent Results: ADMISSION LABS: [**2147-12-1**] 04:12PM PT-13.4* PTT-44.9* INR(PT)-1.2* [**2147-12-1**] 04:12PM PLT SMR-LOW PLT COUNT-131* [**2147-12-1**] 04:12PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL TARGET-1+ BURR-OCCASIONAL ELLIPTOCY-1+ [**2147-12-1**] 04:12PM NEUTS-66 BANDS-0 LYMPHS-19 MONOS-4 EOS-11* BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1* [**2147-12-1**] 04:12PM WBC-4.5 RBC-2.13*# HGB-8.0*# HCT-25.3*# MCV-119*# MCH-37.7*# MCHC-31.7 RDW-14.9 [**2147-12-1**] 04:12PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2147-12-1**] 04:12PM FREE T4-0.84* [**2147-12-1**] 04:12PM TSH-11* [**2147-12-1**] 04:12PM VIT B12-GREATER TH FOLATE-17.6 [**2147-12-1**] 04:12PM ALBUMIN-2.3* CALCIUM-8.2* PHOSPHATE-4.9* MAGNESIUM-1.5* [**2147-12-1**] 04:12PM cTropnT-0.08* [**2147-12-1**] 04:12PM LIPASE-10 [**2147-12-1**] 04:12PM ALT(SGPT)-31 AST(SGOT)-75* CK(CPK)-118 ALK PHOS-242* TOT BILI-0.9 [**2147-12-1**] 04:12PM estGFR-Using this [**2147-12-1**] 04:12PM GLUCOSE-100 UREA N-16 CREAT-1.8* SODIUM-140 POTASSIUM-4.7 CHLORIDE-98 TOTAL CO2-26 ANION GAP-21* [**2147-12-1**] 04:17PM LACTATE-5.6* [**2147-12-12**] CT abdomen and pelvis with contrast IMPRESSION: 1. Increased size of pleural effusions, ascites and diffuse anasarca. 2. New dilation of the distal pancreatic duct in the tail (new since [**2146**]), with stable atrophy involving the distal pancreas. Small amount of fluid adjacent to the body of the pancreas, which was seen in [**2147-11-6**]. Findings may be related to acute on chronic pancreatitis, however exclusion of an underlying neoplasm is recommended. An EUS can be performed for further characterization as at this time MRCP seems impractical. 3. Enhancing nodular area within the head of the pancreas measuring 8 mm is unchanged from [**2146-9-5**], could be a neuroendocrine tumor. This can be assessed at the time of EUS. 4. Slightly thickened and edematous duodenum and jejunum may be from duodenitis/jejunitis versus third spacing. 5. Gallstones. 6. Heterogeneous enhancement of the kidneys suggest underlying medical renal disease. [**2147-12-12**] EGD Ulcers with overlying eschar in the first, second, and third part of the duodenum Normal mucosa in the antrum (biopsy) Erythema in the gastroesophageal junction and lower third of the esophagus compatible with esophagitis Otherwise normal EGD to third part of the duodenum [**2147-12-13**] Video/barium swallow 1. Unchanged mild narrowing of the distal esophagus. Otherwise, normal caliber esophagus. 2. Ineffective primary peristaltic contraction followed by tertiary contractions. [**2147-12-14**] CXR (portable) FINDINGS: As compared to the previous radiograph, the bilateral pleural effusion have substantially increased in extent and severity. Effusions are now more extensive on the left than on the right. Mild pulmonary edema is present. Areas of atelectasis are seen at both lung bases. Normal size of the cardiac silhouette. Unchanged appearance of the right PICC line Brief Hospital Course: 64 yo male with hx of ETOH, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tears and fatty liver p/w weakness at home with associated poor PO intake initially admitted to the MICU with hypotension requiring pressor support. He improved and was transferred to the floor for sometime before decompensating again immediately post-thoracentesis. He returned to the MICU and was reintubated. He was dependent on three pressors and persistently hypoxemic and acidemic despite ventilatory support, showing signs of multi-organ system failure. Care was withdrawn per the family's wishes and patient expired on [**12-16**]. # Hypotension/Shock- Patient noted to have hypotension of unclear etiology which has failed to improve with the administration of IVF and initially requiring pressor support on admission. There is clearly a component of volume depletion as the patient is visibly dry on exam. No clear infectious source to suggest a septic picture (normal WBC, nml CXR, nml UA, effusion on exam but exam not c/w a septic joint). The patient does have a history of hypothyroidism but reports compliance with levothyroxine therapy. No hx of bleeding and HCT is stable from previously documented baseline. EKG findings is concerning for cardiac etiology namely effusion with possible tamponade however reassuringly there is no evidence of JVD or cardiomegaly on CXR. PE is on ddx given history of dyspnea but this is less likely. Bedside echo was without significant effusion. The patient was aggressively fluid resuscitated during his ICU course, with a total net positive of almost 18L, and weaned off of pressors but despite this he continued to have low SBPs in the 80-90 range with low measured CVPs. Adrenal insufficiency was entertained as a diagnosis, however his cortisol was wnl and there was no mention of atrophic adrenal glands on his CT scan, and on a trial of hydrocortisone his BPs were minimally responsive, if at all. Hypothyroid contributing to his picture is a possibility, however his TSH is minimally elevated and he has been stable on his dose of thyroid replacement for quite some time. The leading diagnoses for this patient at the time of transfer to the floor are autonomic dysfunction vs possible adrenal insuffiency. He was empirically started on antibiotics on admission, were continued for a total 8 days course. On [**2147-12-14**], patient found to have T <[**Age over 90 **]F, short of breath and hypotension in the low 100s. CXR revealed worsening bilateral pleural effusions. Blood and urine cultures were sent and patient emperically started on vanc/zosyn. Despite bearhugger and IVF, patient continued to be hypotensive (in the 80s/50s) and short of breath. A left thoracentesis was attempted, but patient blood pressure dropped to the 70s. Procedure was aborted and he was sent to the ICU. Patient's blood pressures remained low despite support with levophed, phenylephrine, and vasopressin. He was persistently acidemic despite maximal ventilatory setting. He was given stress dose steroids, broadened to ESBL and anti-fungal coverage and still continued to remain pressor dependent. He was showing signs of multisystem organ failure including worsening hypoxemia and kidney failure. Further diagnostic procedures were deferred due to patient instability. After discussion with the family about his poor prognosis, patient was terminally extubated and pressor support was withdrawn and he expired shortly thereafter. Family was present at the bedside and agreed to an autopsy. # Weakness/Malnutrition - Likely related to poor PO intake and generalized deconditioning. Wt loss is certainly concerning for possible malignancy, immunsuppression or TB given findings on CT chest. HIV negative. A nutrition consult was placed for input into the best method/route of providing nutrition in this patient. Patient refused NGT and he was started on TPN on [**2147-12-9**] and patient tolerated it well. GI was also consulted given his diarrhea, with recommendations for a hemochromatosis workup including DNA testing, MRI liver, AFP, vitamin K levels. A PPD was placed and read negative on [**2147-12-8**], quantiferon levels were sent and were indeterminate (patient did not mount a response to positive control), and sputum cultures were sent for AFB x3 which were all negative. Concern for possible immunosupression: HIV negative, HIV viral load and T cell subsets were sent which were negative. #) Duodenal ulcers: EGD showed significant ulcers in the duodenum which may explain his difficulty with po intake. He was started on high dose IV pantoprazole. H. Pylori was negative. CT abdomen showed a hypoattenuating mass at the head of the pancreas, which was suspcious for possible gastrinoma. However, gastrin level was sent and returned normal. Unclear if mass is malignancy (pancreatic or lymphoma) vs. CMV infection vs. pseudocyst secondary to alcohol use. #) Hypothyroidism: diagnosed in [**2146**], but etiology is unclear as his antibodies were negative and a CT chest revealed a normal thyroid. Elevated TSH and free T4 of 0.84 on [**12-1**] suggests noncompliance or need for higher dose of levothyroxine. Switched to IV for concern for low intestinal absorption due to diarrhea and thickened colonic mucosa per CT. Hypothyroidism likely contributing to the weakness. Endocrine was consulted and adjusted levothyroxine dose as needed based on thyroid function tests. #) RASH: The patient exhibited a scaly, peeling rash over most of his extremities and trunk. Per derm consult unlikely to be specific vitamin deficiency syndrome, most likely xerosis and age-related changes. No corkscrew hairs which herald scurvy. Zinc level low, vitamin C pending. He receieved repletion with vitamin C, MVI and thiamine during his ICU course, as well as Aquaphor lotion for his xerosis. Throughout his hospitalization, rash significantly improved. #) THROMBOCYTOPENIA: Allergic to heparin products, not receiving them here, but central line was coated in heparin. Also possibly secondary to bone marrow suppression from inflammation vs TTP. Seems disproportionate from other cell lines. H/O was consulted who recommended BM biopsy, however patient declined the bone marrow biopsy. Thrombocytopenia likely a result of alcohol induced bone marrow suppression with contribution from malnutrition. Also possible cirrhosis given presence of ascites. #) Macrocytic anemia: Downtrended throughout his hospital course, suspect significant hemodilution. Did receieve intermittent transfusions. No evidence of active bleeding, although meets criteria for transfusion with hemoglobin of 7.0. B12 and folate were supplemented. Likely secondary to alcohol. No evidence of active bleeding and folate and vitB12 are normal. Elevated ferritin with high transferrin saturations concerning for hemochromatosis. In addition, macrocytic anemia with thrombocytopenia can be a result of MDS/Myeloma/POEMS syndrome. Peripheral smear only shows many target cells, possibly from underlying alcoholic liver disease. Patient has refused bone marrow biopsy. UPEP/SPEP are negative. Normal kappa/lambda ratio, negative hemochromatosis mutation analysis. # ETOH abuse- Pt still actively drinking. No hx of withdrawal szs or DTs. Tox screen negative on admission. He was monitored on a CIWA without any administration of BZDs. Repletion with thiamine, folate, MVI as above. Unclear if patient has cirrhosis. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ferrous Sulfate 325 mg PO DAILY 2. FoLIC Acid 1 mg PO DAILY 3. Thiamine 100 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Levothyroxine Sodium 50 mcg PO DAILY Discharge Medications: Patient expired Discharge Disposition: Expired Discharge Diagnosis: Patient expired Discharge Condition: Patient expired Discharge Instructions: Patient expired Followup Instructions: Patient expired

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icd9cm

[ [ [] ] ]

[ "96.04", "38.93", "94.62", "96.71", "99.15", "45.16", "34.91", "38.91" ]

icd9pcs

[ [ [] ] ]

14738, 14747

6989, 14425

295, 302

14806, 14823

3883, 3883

14887, 14905

2896, 3109

14698, 14715

14768, 14785

14451, 14675

14847, 14864

3149, 3837

247, 257

330, 2144

3899, 6966

2166, 2650

2666, 2880

3864, 3864

27,517

112,658

45178

Discharge summary

report

Admission Date: [**2107-8-28**] Discharge Date: [**2107-9-10**] Service: MEDICINE Allergies: Lipitor / Lovastatin / Vancomycin Attending:[**First Name3 (LF) 106**] Chief Complaint: Suprapubic pain on Initial Presentation. Admitted to the ICU because of Dyspnea. Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] y/o female with history of CAD s/p CABG, HTN, Hypercholesterolemia, and atrial fibrillation who was in her USOH until 1 wk before presentation when she developed intermittent epigastric tenderness she believes began after an episode of vomiting (perhaps associated with taking a medication). Since then, she has experienced mild epigastric pressure. No N/V/hematemesis. No diarrhea, melena. She denies any chest pressure, CP, SOB, dyspnea, cough, fever/chills. She was brought into the ED today. In the ED, VSS AF. Received 1L NS and admitted to medical floor. On arrival to the floor, she states that her epigastric pressure has spontaneously resolved. No other c/o. ROS otherwise normal. Past Medical History: Hypertension Hypercholesterolemia CAD s/p CABG at [**Hospital1 112**] [**2092**] CHF (EF 30%) Carotid stenosis AFib Cholecystitis Left cataract surgery Vaginal cyst removal Seasonal allergies hx of MRSA Social History: She works as a volunteer at the [**Hospital1 18**]. Denies tobacco, alcohol, IVDU. She lives by her self [**Last Name (NamePattern1) 18764**] at baseline but has been at [**Hospital3 2558**] in [**Location (un) **] since recent d/c. Has a daughter who lives in [**Name (NI) 4628**]. Family History: Non Contributory. Physical Exam: GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM RESP: CTA b/l with good air movement throughout. No rales throughout both lung fields CV: Regular rate, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: 1+ edema to mid-shins bilaterally; appears chronic SKIN: no rashes NEURO: AAOx3. Pertinent Results: ADMISSION LABS: [**2107-8-28**] 02:30PM BLOOD WBC-12.4*# RBC-3.52* Hgb-10.5* Hct-31.5* MCV-89 MCH-29.9 MCHC-33.5 RDW-16.6* Plt Ct-313 [**2107-8-28**] 02:30PM BLOOD PT-24.2* PTT-26.3 INR(PT)-2.4* [**2107-8-28**] 02:30PM BLOOD Glucose-118* UreaN-25* Creat-1.1 Na-142 K-4.0 Cl-102 HCO3-26 AnGap-18 [**2107-8-28**] 02:30PM BLOOD CK-MB-7 cTropnT-0.05* proBNP-[**Numeric Identifier **]* . U/A - negative leuk est, nitrite. 0-2 WBC, occ bact . CXR [**8-28**]: Relative to the prior examination, there is mild engorgement of the vascular structures with mild cephalization. No overt failure is evident. There has, however, been interval increase in the bilateral pleural effusions previously noted. There is a tortuous atherosclerotic aorta. The cardiac silhouette again is enlarged but stable. The bones are diffusely osteopenic with a severely exaggerated kyphosis of the thoracic spine again seen. . Cardiology Report ECG Study Date of [**2107-8-28**] 2:41:48 PM Baseline artifact Sinus rhythm Atrial premature complexes Left ventricular hypertrophy with ST-T abnormalities Delayed R wave progression - could be due in part to left ventricular hypertrophy or prior septal myocardial infarction Since previous tracing of [**2107-7-20**], probably no significant change . Cardiology Report ECHO Study Date of [**2107-8-31**] The left atrium is elongated. The estimated right atrial pressure is 11-15mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. No masses or thrombi are seen in the left ventricle. LV systolic function appears moderately-to-severely depressed (ejection fraction 30 percent) secondary to hypokinesis of the anterior septum, anterior free wall, and apex. There is no ventricular septal defect. The right ventricular cavity is mildly dilated. There is focal hypokinesis of the apical free wall of the right ventricle. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2). Mild to moderate ([**1-11**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior report (images unavailable for review) of [**2089-12-16**], the mitral regurgitation is increased; mild aortic stenosis is now present. . RENAL US [**2107-9-6**] No appropriate demonstration of diastolic arterial flow in either kidney, suggestive of increased resistive indices which can be seen in the setting of renal artery stenosis. . DISCHARGE LABS: [**2107-9-9**] 06:30AM BLOOD WBC-6.5 RBC-3.74* Hgb-10.5* Hct-34.5* MCV-92 MCH-28.2 MCHC-30.6* RDW-15.4 Plt Ct-432 [**2107-9-7**] 07:15AM BLOOD PT-14.3* PTT-25.3 INR(PT)-1.3* [**2107-9-9**] 06:30AM BLOOD Glucose-103 UreaN-28* Creat-PND Na-139 K-3.9 Cl-99 HCO3-32 AnGap-12 [**2107-9-8**] 06:20AM BLOOD Glucose-90 UreaN-30* Creat-1.1 Na-141 K-3.9 Cl-101 HCO3-34* AnGap-10 [**2107-9-7**] 07:15AM BLOOD ALT-19 AST-20 LD(LDH)-227 AlkPhos-72 TotBili-0.3 [**2107-9-9**] 06:30AM BLOOD Mg-2.6 [**2107-8-31**] 05:26AM BLOOD Triglyc-54 HDL-78 CHOL/HD-2.1 LDLcalc-74 Brief Hospital Course: [**Age over 90 **] y/o Female with PMHx of CAD s/p CABG, CHF (EF 35%), HTN, Hypercholesterolemia, and atrial fibrillation who presented with suprapubic pain, with a negative urine culture spontaneous resolution. She then developed respiratory distress requiring tranfer to ICU without intubation (she is DNR/DNI). She was transfered from the MICU to the CCU for treatment of heart failure and possible need for catheterization, which was untimately not required. 1. Abdominal Pain NOS: Unclear etiology, may potentially be related to episode of vomiting vs mild gastritis. Spontaneously resolved. U/A negative for cystitis. No further traetment needed. 2. Respiratory Distress: Likely systolic heart failure and may have had some component of flash pulmonary edema. Off oxygen with good O2 saturations. 3. Pneumonia: Completed a seven day course for community acquired PNA with antibiotics (Ceftriaxone). 3. Systolic Heart Failure: Baseline EF 35%, elevated BNP to 35K (prior baseline 5-7K), and evidence of CHF. Repeat Echo showed EF 30% with hypokinesis of the anterior septum, anterior free wall, and apex. Continued on low dose beta blocker. Ace inhibitor was held due to renal insufficiency and possible renal artery stenosis on renal ultrasound. Please consider restarting once creatinine comes down for afterload reduction. Patient has shown labile blood pressure, and per Dr. [**Last Name (STitle) **] will revisit staring ACE as an outpatient. 4. CAD s/p CABG: Concern for prior ischemic espisode given anterior wall motion abnormality. Continue ASA, low dose metoprolol. ACE held for likely RAS, which can be restarted if Cr is returning to normal. 5. HTN - Stopped ACE because of concermn for renal artery stenosis. Beta blocker continued at 2 mg [**Hospital1 **]. 6. Afib - Currently in NSR with occassional ATach. Decision was made to stop anticoagulation because of fall risk based on PT evaluation. 7. Transaminitis: Resolved despite being on amiodarone. Will need to be followed while on amiodarone. Code - DNR/DNI Medications on Admission: 1. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 3. Propafenone 150 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 4. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 7. Metoprolol Tartrate 25 mg Tablet Sig: 2mg elixir PO BID (2 times a day). Disp:*qs mg/ml* Refills:*2* 8. Citalopram 20 mg Tablet Sig: 0.25 Tablet PO DAILY (Daily). Discharge Medications: 1. Metoprolol Tartrate (Bulk) 100 % Powder Sig: Two (2) mg Miscellaneous [**Hospital1 **] (2 times a day). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Amiodarone 100 mg Tablet Sig: One (1) Tablet PO twice a day. 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 5. Multivitamins Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Systolic Congestive Heart Failure Pneumonia Atrial Taachycardia Discharge Condition: Improved breathing, comfortable on room air with oxygen saturations in the upper 90's. Fall risk with need for physical therapy. Discharge Instructions: You were treated for heart failure and pneumonia. Sone changes in your medications were made. Your proprafenone, lisinopril, and your coumadin were stopped, and you were started on amiodarone. Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 1730**] [**Name12 (NameIs) **] appointment should be in 2 weeks Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 904**] Appointment should be in [**7-19**] days Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2107-10-6**] 11:20

[ "584.9", "486", "428.20", "427.89", "427.31", "428.0", "414.00", "V45.81" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8460, 8539

5351, 7397

321, 328

8647, 8778

2013, 2013

9127, 9556

1620, 1639

8036, 8437

8560, 8626

7423, 8013

8802, 9104

4773, 5328

1654, 1994

201, 283

356, 1074

2029, 4757

1096, 1300

1316, 1604

60,749

176,750

42034

Discharge summary

report

Admission Date: [**2177-9-26**] Discharge Date: [**2177-10-7**] Date of Birth: [**2119-1-26**] Sex: M Service: CARDIOTHORACIC Allergies: metformin Attending:[**First Name3 (LF) 1406**] Chief Complaint: Exertional angina Major Surgical or Invasive Procedure: Cardiac cath [**2177-9-29**] Aortic valve replacement(221mm St. [**Male First Name (un) 923**] mechanical), Coronary artery bypass graft x 3 (Left internal mammary artery to left anterior descending, Saphenous vein graft to obtuse marginal, saphenous vein graft to posterior descending artery) [**2177-9-30**] History of Present Illness: Mr. [**Known lastname **] is a 58 year old gentleman with a past history of insulin-dependent diabetes, hyperlipidemia, minimal aortic stenosis (valve area 1.7) and aortic insufficiency, who has been experiencing intermittent chest pain for several weeks and was admitted after a positive stress echocardiogram. The patient has been experiencing an "ache" in the center of his chest with exertion during his work as a landscaper since [**Month (only) 547**] [**2177**]. It is [**5-25**] in intensity. This pain resolves within one minute of resting (standing or sitting); lying down exacerbates the pain. He has also felt increasingly short of breath, especially with the pain. Episodes of pain occurred zero to multiple times per day, based on level of exertion. He has had no associated diaphoresis, nausea, vomiting, abdominal pain, radiation to arm or jaw. He has no history of acid-reflux. After evaluation by his PCP [**Last Name (NamePattern4) **] [**2177-9-16**], he was instructed to take nitroglycerin for chest pain. On [**2177-9-26**], the patient saw his cardiologist for a stress/Echo, during which he walked for 3:05 and achieved 82% maximum predicted heart rate. He experienced moderate chest pain during the test. EKG showed [**Street Address(2) 2051**] depressions (downsloping), with many PVCs and ventricular bigeminy. He had a "borderline drop in blood pressure" during the test Chest pain lasted 30 minutes into recovery. Echo showed mild anteroseptal hypokinesis and global LV dysfunction with predominantly inferolateral, lateral and anterior ischemia. Patient's cardiologist urged him to go to the [**Hospital1 18**] ED for a diagnostic catheterization. Past Medical History: Aortic regurgitation Insulin dependent diabetes mellitus Hyperlipidemia Diverticulosis Colonic polyps h/o testicular cancer(remote) Social History: Married (wife is [**Name2 (NI) **], with two daughters ([**Name (NI) 636**] 18 at [**University/College 23925**] for Architecture and [**Doctor Last Name **] 15). Owns a landscaping company. -Tobacco history: Never smoker -ETOH: 4 beers per week -Illicit drugs: none ever Family History: Father with hypertension, [**Doctor Last Name 2320**] and Hodgkin's disease, deceased at 66 years old. Mother and sister with [**Name (NI) 2320**]. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Pulse:78 SR Resp:16 O2 sat: 96% 2LNP B/P Right: 100/75 Left: Height: 5'8" Weight: 74.8Kg 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 [x] grade _2/6SEM Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x] Extremities: Warm [x], well-perfused [x] Edema-none Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 1+ Left: 1+ Radial Right: cath Left: 2+ Carotid Bruit -none Pertinent Results: INTRAOP TEE:[**9-30**] PRE-BYPASS: No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Mild to moderate ([**2-16**]+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results at the time of surgery POST-BYPASS: There is a well-seated, well-functioning mechanical prosthetic valve in the aortic position. No aortic regurgitation is seen aside from the small washing jets typical for this type of mechanical valve. No aortic stenosis is seen. Biventricular function is unchanged. Mitral regurgitation is unchanged. The ascending aorta, aortic arch, and descending aorta are intact. . Cath [**2177-9-29**]: 1. Selective coronary angiography of this right dominant system demonstrated one vessel coronary artery disease. The LMCA had a 95%ostial stenosis. The LAD had a mid 30% and 30% ostial D1 stenosis. The LCX had a proximal 50% stenosis. The RCA had a proximal 70% stenosis. 2. Limited resting hemodynamics revealed low systemic arterial pressure at the aortic level at the begining of the case. 3. Patient had a vaso-vagal episode at the begining of case with mild nausea, diaphoresis and hypotension with systolic blood pressure dipping into the SBP 60mmHg. This was reversed with administraation of IV fluids and atropine. After left coronary angiography patient developed anginal chest pain which resolved after administration of IV nitroglycerine and metoprolol. [**2177-9-26**] 03:30PM BLOOD WBC-8.9 RBC-4.82 Hgb-14.2 Hct-40.8 MCV-85 MCH-29.5 MCHC-34.8 RDW-14.0 Plt Ct-181 [**2177-10-1**] 02:10AM BLOOD WBC-8.7 RBC-3.37* Hgb-10.0* Hct-29.1* MCV-86 MCH-29.7 MCHC-34.4 RDW-14.0 Plt Ct-109* [**2177-10-7**] 06:50AM BLOOD WBC-8.1 RBC-3.07* Hgb-9.0* Hct-25.6* MCV-84 MCH-29.4 MCHC-35.2* RDW-13.6 Plt Ct-366 [**2177-9-26**] 06:15PM BLOOD PT-12.9 PTT-25.1 INR(PT)-1.1 [**2177-10-2**] 12:10PM BLOOD PT-15.6* PTT-31.4 INR(PT)-1.4* [**2177-10-7**] 06:50AM BLOOD PT-26.7* INR(PT)-2.6* [**2177-9-26**] 03:30PM BLOOD Glucose-68* UreaN-22* Creat-1.3* Na-144 K-4.6 Cl-108 HCO3-28 AnGap-13 [**2177-10-3**] 09:29AM BLOOD Glucose-181* UreaN-28* Creat-1.1 Na-136 K-3.9 Cl-97 HCO3-30 AnGap-13 [**2177-10-7**] 06:50AM BLOOD Glucose-71 UreaN-28* Creat-1.2 Na-137 K-3.9 Cl-93* HCO3-38* AnGap-10 [**2177-9-27**] 06:23AM BLOOD Calcium-9.4 Phos-3.8 Mg-2.4 [**2177-10-6**] 05:58PM BLOOD Calcium-9.3 Phos-4.8* Mg-2.3 Brief Hospital Course: After admission Mr. [**Known lastname **] [**Last Name (Titles) 1834**] a cardiac catheterization which revealed 95%left main disease as well as 70% proximal right and 50% circumflex disease. He was referred for surgical evaluation given his echo findings of aortic stenosis/regurgitation and a positive stress echocardiogram with significant coronary disease at catheterization. Following cath he was admitted to the CVICU for medical management prior to surgery. He [**Last Name (Titles) 1834**] the usual preoperative workup and on [**9-30**] [**Month/Year (2) 1834**] coronary artery bypass graft x 3 and aortic valve replacement (see operative note for details). Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Later this day he was weaned from sedation, awoke neurologically intact and extubated. The pressor was weaned off on post-op day one and Coumadin was started for his mechanical valve. Pacing wires were discontinued on post-op day two, however, chest tubes remained in place due to high output. On post-op day three his chest tubes were removed and he was transferred to the step-down floor for further care. Physical Therapy was consulted for mobility and strength assistance. [**Last Name (un) **] service was also consulted for improved diabetes management. On post-op day seven he was doing well and discharged home with VNA services with the appropriate medications and follow-up appointments. His Coumadin for his mechanical valve with be managed by his PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 2411**] [**Last Name (NamePattern1) 12997**]. Medications on Admission: 1.) Simvastatin (unknown dose); was prescribed Rosuvastatin 5 mg PO daily for one week then 10 mg PO daily, but has not taken yet 2.) Nitroglycercin 0.3 mg SL [**Last Name (NamePattern1) **], PRN chest pain 3.) Glyburide 5 mg PO BID 4.) Pioglitazone 30 mg PO daily 5.) Insulin glargine 25 units SC qHS 6.) Aspirin 81 mg PO daily 7.) was prescribed Metoprolol tartrate 12.5 mg PO BID (started today after stress test) Discharge Medications: 1. aspirin 81 mg [**Last Name (NamePattern1) 8426**], Delayed Release (E.C.) Sig: One (1) [**Last Name (NamePattern1) 8426**], Delayed Release (E.C.) PO DAILY (Daily). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. ranitidine HCl 150 mg [**Last Name (NamePattern1) 8426**] Sig: One (1) [**Last Name (NamePattern1) 8426**] PO BID (2 times a day). Disp:*60 [**Last Name (NamePattern1) 8426**](s)* Refills:*2* 4. warfarin 1 mg [**Last Name (NamePattern1) 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] DAILY (Daily) as needed for mechanical valve. Disp:*100 [**Last Name (Titles) 8426**](s)* Refills:*0* 5. glyburide 5 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO BID (2 times a day). Disp:*60 [**Last Name (Titles) 8426**](s)* Refills:*2* 6. pioglitazone 15 mg [**Last Name (Titles) 8426**] Sig: Two (2) [**Last Name (Titles) 8426**] PO DAILY (Daily). Disp:*60 [**Last Name (Titles) 8426**](s)* Refills:*2* 7. tramadol 50 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO Q4H (every 4 hours) as needed for pain. Disp:*50 [**Last Name (Titles) 8426**](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:*60 Capsule, Ext Release 24 hr(s)* Refills:*2* 9. metoprolol tartrate 50 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO three times a day. Disp:*90 [**Last Name (Titles) 8426**](s)* Refills:*2* 10. potassium chloride 20 mEq [**Last Name (Titles) 8426**], ER Particles/Crystals Sig: Two (2) [**Last Name (Titles) 8426**], ER Particles/Crystals PO once a day for 2 weeks. Disp:*28 [**Last Name (Titles) 8426**], ER Particles/Crystals(s)* Refills:*0* 11. warfarin 2.5 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO ONCE (Once) for 1 doses: Take on day of discharge, [**10-7**]. Disp:*1 [**Month/Year (2) 8426**](s)* Refills:*0* 12. Lasix 40 mg [**Month/Year (2) 8426**] Sig: One (1) [**Month/Year (2) 8426**] PO once a day for 2 weeks. Disp:*14 [**Month/Year (2) 8426**](s)* Refills:*0* 13. rosuvastatin 10 mg [**Month/Year (2) 8426**] Sig: One (1) [**Month/Year (2) 8426**] PO once a day. Disp:*30 [**Month/Year (2) 8426**](s)* Refills:*2* 14. insulin glargine 100 unit/mL Solution Sig: Forty (40) units Subcutaneous once a day. Disp:*qs units* Refills:*2* 15. Humalog 100 unit/mL Solution Sig: sliding scale Subcutaneous once a day as needed for hyperglycemia: per sliding scale (see attached). Disp:*qs * Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Aortic insufficiency and Coronary artery disease s/p aortic valve replacement and coronary artery bypass graft x 3 Past medical history: Hyperlipidemia Insulin dependent diabetes mellitus h/o testicular cancer Colonic polyps Diverticulosis Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with oral analgesia Incisions: Sternal - healing well, no erythema or drainage Edema: 1+ (L)LE Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]on [**10-30**] at 1:30pm [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **], [**Hospital Unit Name **] Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2177-11-19**] at 9:20am Please call to schedule appointments with: Primary Care: Dr.[**First Name11 (Name Pattern1) 2411**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 12997**] ([**Telephone/Fax (1) 86132**]) in [**5-20**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication: mechanical heart valve Goal INR 2.5-3.0 First draw [**2177-10-8**] Results to: PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 86132**] Completed by:[**2177-10-7**]

[ "564.00", "458.29", "511.9", "411.1", "250.02", "414.01", "272.0", "V10.47", "V58.67", "401.9", "285.9", "562.10", "584.9", "V15.82", "746.4", "V12.72", "276.69" ]

icd9cm

[ [ [] ] ]

[ "36.15", "88.56", "37.22", "35.22", "38.91", "39.61", "36.12" ]

icd9pcs

[ [ [] ] ]

11660, 11718

6898, 8535

294, 605

12001, 12181

3693, 6875

13023, 14021

2776, 3041

9002, 11637

11739, 11854

8561, 8979

12205, 12998

3056, 3674

237, 256

633, 2315

11876, 11980

2486, 2760

27,598

176,518

48526

Discharge summary

report

Admission Date: [**2161-8-2**] Discharge Date: [**2161-8-4**] Service: MEDICINE Allergies: Epinephrine Attending:[**First Name3 (LF) 443**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: NONE History of Present Illness: The patient is a [**Age over 90 **] year old man with a past medical history of CAD s/p MI , CHF, A-FIB and CVA who had an episode of chest pressure this morning after breakfast. He was in his usual state of health prior to this event. The pressure radiated up his sternum but did not feel like his normal heartburn. Durring that episode the also became very fatigued. He went to the ED as the pressure did not relieve with rest. He was found to be in a wide complex tach with HR of 180 and BP of 80/50 per the OSH ED report. He was given a bolus of Amiodarone 150 and recieved two shocks (50 jouls). He then went back into sinus rhythm followed by slow A-FIB. He was then transffered to [**Hospital1 18**]. ROS + Lightheadedness, fatigue. . Cardiac review of systems is notable for absence, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope. Past Medical History: CHF Cardiomyopathy Atrial Fibrillation CAD s/p MI [**2129**] CVA [**2159**] Goiter (Dr. [**Last Name (STitle) 6467**] Anemia (Iron Deficiency) S/P Herpes Zoster w/ post herpetic neuralgia Diverticulosis Paget's disease of the Bone Chronic Sinusitis GIB [**2148**] + H. Pylori --> treated. . Cardiac Risk Factors: No DM, No HTN, No Hyperlipidemia. . Social History: Pt lives with his wife who is very ill. They have 24 hour nursing assistance. Quit smoking at age 60. Family History: Non-contributory. Physical Exam: VS: T: 96.8, BP: 102/41, HR: 53, RR: 20, O2 98% on RA Gen: Elderly male in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of cm. CV: S1, S2. No S4, no S3. Irregularly irregular. 3/6 SEM at the apex suggestive of MR. Chest: No crackles, wheeze, rhonchi. Abd: soft, NT/ND +BS. Ext: No c/c/e. Pertinent Results: [**2161-8-2**] 01:14PM WBC-7.3 RBC-3.73* HGB-10.8* HCT-32.4* MCV-87 MCH-28.9 MCHC-33.2 RDW-14.4 NEUTS-81.1* LYMPHS-14.6* MONOS-3.8 EOS-0.3 BASOS-0.2 PT-13.7* PTT-25.6 INR(PT)-1.2* TSH-<0.02* FREE T4-1.3 CALCIUM-10.1 PHOSPHATE-2.7 MAGNESIUM-2.0 CK-MB-23* MB INDX-21.7* cTropnT-0.32* CK(CPK)-106 GLUCOSE-147* UREA N-23* CREAT-1.0 SODIUM-136 POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-21* ANION GAP-16 . [**2161-8-2**] 08:35PM CK-MB-22* MB INDX-21.2* cTropnT-0.73* [**2161-8-2**] 08:35PM CK(CPK)-104 [**2161-8-3**] 05:39AM cTropnT-0.51* . CHEST (PORTABLE AP) Study Date of [**2161-8-2**] 4:48 PM IMPRESSION: Mild vascular engorgement. No frank edema. Small pleural effusion most likely bilateral. Questionable nodular opacity in the right lower hemithorax may be a pulmonary nodule or nipple, repeated examination with nipple marking is recommended. Extensive mediastinal widening with right tracheal deviation due to known goiter containing areas of calcification. The study and the report were reviewed by the staff radiologist. . Portable TTE (Complete) Done [**2161-8-3**] at 10:34:45 AM FINAL IMPRESSION: Left ventrivcular cavity enlargement with regional and global systolic dysfunction c/w multivessel CAD. At least moderate mitral regurgitation. Pulmonary artery systolic hypertension. Brief Hospital Course: The patient is a [**Age over 90 **] yo man who presented to OSH for with chest pain, SOB and fatigue who was found to be in V-tach with hypotension and was shocked twice, then transferred to [**Hospital1 18**]. . # Rhythm: It was felt that the patient's initial wide complex rhythm was ventricular tachycardia. On arrival to [**Hospital1 18**], the patient was sable with a LBBB. He was maintained on his home medications with the exception of digoxin. While the etiology his initial tachycardia was unclear, scar related [**Name (NI) 102121**] was considered the most probable given his history of MI. During his hospital course, the patient was mostly in sinus rhythm but did have one episode of asymptomatic V-tach 24 hours after admission. This lasted for approximately 16 beats and was self resolving. The patient was seen by the electrophysiology service who recommended permanently discontinuing digoxin in order to avoid it's proarrhythmic properties. The patient's dig level at the time of discharge was 0.6. He should follow-up with his outpatient cardiologist, Dr. [**First Name (STitle) **] [**Name (STitle) **], the in next 2 weeks. . #A-FIB: The patient had a history of slow A-FIB with a history of paroxysmal A-FIB. The patient was intermittently in A-FIB during his hospital course. He was not on Coumadin given his history on GIB. He was continued on Plavix. . # CAD/Ischemia: The patient had a history of MI in [**2129**] which was medically managed. Troponins were elevated on admission (peak 0.71) and this was felt to be due to his cardioversion at the OSH. The patient was started on aspirin while hospitalized but this was discontinued upon discharge given the patient's previously documented GI bleed/?Adverse reaction to aspirin. . # Pump/valves: The patient had a history of heart failure. Echocardiogram was performed which demonstrated at least moderate mitral regurgitation and an ejection fraction of ~30%. Chest x-ray was without evidence of volume overload. The patient was scheduled for a follow up appointment with his primary cardiologist. . # HTN/Hypotension: The patient has a history of hypotension but his blood pressures were low throughout most of his hospitalizations (SBP's in the 80's-100). The patient denied feeling symptomatic despite some orthostatic component to his hypotension. The patient was continued on his home BP medications and follow up was recommended. . # Neuralgia: The patient was on Neurontin for pain control. The patient denied pain during his hospital course. . # Home Safety: The patient was seen by Physical therapy who recommended home PT as well as a home safety evaluation. Medications on Admission: Digoxin 125 mcg daily Neurontin 200 mg QHS Carvedilol 12.5 mg daily Plavix 75 mg daily furosemide 20 mg daily protonix 40 mg daily potassium chloride 20 mEq daily quinapril 5 mg daily ferrous sulfate 325 mg daily Discharge Medications: 1. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. Quinapril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 8. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO once a day. Discharge Disposition: Home With Service Facility: Caregroup home care Discharge Diagnosis: Primary Diagnosis: Ventricular Tachycardia Low EF Moderate/Severe Mitral Valve regurgitation Discharge Condition: The patient was hemodynamically stable, afebrile and without pain at the time of discharge. Discharge Instructions: You were admitted for evlauation of shortness of breath and fatigue. It was felt that your symptoms were due to an irregular heart beat which resolved with an electric shock to your heart. Beacause of this heart rhythm, you are at high risk for fainting and we recommend, for your safety as well as the safety of others, that you do not drive. . We have have stopped your use of digoxin and you should not take this medication at home. You should continue to take all of your other medications as previously directed. . Please follow up with your cardiologist, Dr. [**Last Name (STitle) **]. We have scheduled an appointment for [**8-18**] at 2:30pm. . During your admission, you were seen by physical therapy and they have recommended home physical therapy follow-up. This will be arranged for you. . Please call your doctor or seek medical attention if you develop a return of your symptoms (fatigue. chest discomfort) or if you develop new symptoms of chest pain, nausea, vomiting, lightheadedness, changes in vision, muscle weakness or any other symptom of concern. Followup Instructions: Please follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] Date: [**8-18**] Time: 2:30 pm Phone #: ([**Telephone/Fax (1) 97348**] Completed by:[**2161-8-4**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7048, 7098

3463, 6122

236, 242

7235, 7329

2139, 3440

8452, 8627

1636, 1655

6385, 7025

7119, 7119

6148, 6362

7353, 8429

1670, 2120

177, 198

270, 1127

7138, 7214

1149, 1500

1516, 1620

6,884

128,932

1851

Discharge summary

report

Admission Date: [**2122-3-18**] Discharge Date: [**2122-4-2**] Date of Birth: [**2075-4-14**] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfamethoxazole/Trimethoprim Attending:[**First Name3 (LF) 5893**] Chief Complaint: respiratory failure Major Surgical or Invasive Procedure: intubation History of Present Illness: Ms. [**Known lastname 10336**] is a 46 year old lady with a history malignant thymoma (full onc history below), myasthenia [**Last Name (un) 2902**], and severe restrictive/obstructive lung disease (FVC of 25% of predicted, FEV1 27%) who presents with SOB. Her SOB started acutely last night and worsened overnight. Per the husband, he increased her O2 from 2 L by NC to 3.5 L with some relief. She was also given nebulizer treatments that helped for about 1 hour. She did not have a cough, chest pain, fever, chills, abdominal pain, nausea/vomiting, diarrhea. She was complaining of thirst, drinking lots of water, and dizziness. . Her family brought her to [**Hospital6 10353**]. Her ABG there was 7.36/79/273 on 100% NRB. Labs were sig. for Na 126, Cl 84, Trop T of 0.193, BNP 521. She had a CT scan that showed plueral mets/nodular thickening and mets to pericardium. No definite infiltrate or fluid. She received solumedrol 125 mg IV and Lasix 80 mg IV there. . At [**Hospital1 18**], initial VS were: 97.0 103 107/68 20 100. Labs are sig. for WBC 18.1 (89% neutrophils), Na 123, Cl 78, bicarb 37, ALT 364, AST 382, TB 25.7. Lactate is 3.2. She received Vanc, Meropenam, and levofloxacin. She was intubated, is on AC 300 x 16, PEEP 5, FiO2 40%, with ABG of 7.45/55/343. AFter intubation, her blood pressure fell from systolics of 90s-100s to 70s. She got bolused 4 L of NS and started on levophed. RIJ CVL was placed, RIJ. She also had an episode of desaturation, which resolved with suctioning. She was noted to have pink secretions. . She was recently admitted from [**2122-2-13**] to [**2122-3-9**] with SOB. She was found to have listeria bacteremia, treated with IV Bactrim -> Meropenam x3 weeks. She was also treated with a 5 day course of levofloxacin for CAP/bronchitis. She also was noted to ahve hyperbilirubinemia. A liver MRI showed diffuse hepatitis. A liver biopsy demonstrated zone 3 nerosis c/w toxic hepatitis. She had been taking herbal medications. Past Medical History: --Malignant thymoma: Initially presented in [**2115**] with diplopia and lid droop. She was diagnosed with Myasthenia [**Last Name (un) **]. Subsequently, found to have a thymoma with evidence of metastases to the pleura. Treatment History: 1. Neoadjuvant Cytoxan/Adriamycin/Cisplatin--small response 2. Resection of mass and pleural stripping 3. External Beam Radiation 4. 1 cycle of Carboplatin/Paclitaxel with carboplatin infusion reaction 5. 8 weeks of weekly Taxol completed in [**1-16**]. Developed pulmonary nodules 6. Tarceva [**Date range (1) 10344**] 7. Prednisone [**Date range (1) 10335**] 8. Plasmapheresis for Myasthenia Flare [**11-18**] 9. Alimta [**Date range (1) 10345**] 10. Xeloda [**Date range (1) 10346**] 11. Doxil [**Date range (1) 10347**], then observation . Other Past Medical History: # Myasthenia [**Last Name (un) 2902**] - treated with Cellcept since [**6-/2119**] # Chronic bell's palsy # Allergies # Combined restrictive/obstructive lung disease # Malignant thymoma: Initially presented in [**2115**] with diplopia and lid droop. She was diagnosed with Myasthenia [**Last Name (un) **]. Subsequently, found to have a thymoma with evidence of metastases to the pleura. Treatment History: 1. Neoadjuvant Cytoxan/Adriamycin/Cisplatin--small response 2. Resection of mass and pleural stripping 3. External Beam Radiation 4. 1 cycle of Carboplatin/Paclitaxel with carboplatin infusion reaction 5. 8 weeks of weekly Taxol completed in [**1-16**]. Developed pulmonary nodules 6. Tarceva [**Date range (1) 10344**] 7. Prednisone [**Date range (1) 10335**] 8. Plasmapheresis for Myasthenia Flare [**11-18**] 9. Alimta [**Date range (1) 10345**] 10. Xeloda [**Date range (1) 10346**] 11. Doxil [**Date range (1) 10347**], then observation . Other Past Medical History: --Myasthenia [**Last Name (un) 2902**] --Treated with Cellcept since [**6-/2119**] --Chronic bell's palsy --Allergies --Combined restrictive/obstructive lung disease --Mild pulmonary hypertension Social History: Married and has two young children. Originally from southern [**Country 651**]. Ms. [**Known lastname 10336**] used to work overnight at a bank, but is currently unemployed. Her husband works in a restaurant. She denies use of tobacco, ethanol, or other drugs. Family History: No history of cancer, myasthenia [**Last Name (un) 2902**], diabetes, MS, SLE, or other autoimmune diseases. Physical Exam: GENERAL: Jaundiced, intubated HEENT: Sclera are jaundiced and edematous, pupils were equal, sluggish to reaction, No LAD CARDIAC: Holosystolic murmur best heard at left sternal border; normal S2, sinus tachycardia LUNGS: Coarse bibasilar crackles ABDOMEN: +BS, soft, non-tender, non-distended, no obvious organomegally EXTREMITIES: 2+ edema bilaterally; +pedal pulses SKIN: hyperpigemented rash throughout torso and extremities, some desquamation/flakiness at the abdomen NEURO: decreased tone, downgoing Babinskis Brief Hospital Course: 46 yo with end stage malignant thymoma and associated autoimmune phenomena affecting all organ systems including skin. She did not improve and was terminally extubated according to her wishes and passed away in the presence of her family, friends and loved ones. Discharge Disposition: Expired Discharge Diagnosis: respiratory failure Discharge Condition: death

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icd9cm

[ [ [] ] ]

[ "96.6", "33.24", "03.31", "96.72", "86.11", "96.04", "38.93" ]

icd9pcs

[ [ [] ] ]

5601, 5610

5314, 5578

323, 335

5673, 5681

4649, 4759

5631, 5652

4774, 5291

264, 285

363, 2339

4153, 4350

4366, 4633

10,490

104,810

25049

Discharge summary

report

Admission Date: [**2101-9-9**] Discharge Date: [**2101-10-7**] Date of Birth: [**2075-10-11**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5790**] Chief Complaint: Cervical esophageal perforation Major Surgical or Invasive Procedure: 1) Repair of cervical esophageal perforation with wide drainage of the neck 2) Right thoracotomy and exploration and wide drainage of the mediastinum 3) Placement of percutaneous endoscopic gastrostomy tube 4) Placement of left chest tube 5) Esophagogastroduodenoscopy 6) Flexible bronchoscopy 7) Left thoracoscopy with intrapleural pneumolysis and evacuation of loculated pleural effusion and empyema 8) Placement of intercostal rib locks-multiple History of Present Illness: Mr. [**Known lastname **] is a 25-year-old incarcerated gentleman who was beaten in a prison fight 4 days prior to presentation in the emergency room. He complained of diffuse pain but then this worsened to odynophagia and finally developed neck swelling and crepitus. On his preoperative studies, a chest CT noted the presence of pneumomediastinum and air around the cervical esophagus. There was pleural fluid which looked more complex than a simple effusion in both pleural spaces. A Gastrograffin swallow confirmed the location of the tear to be in the cervical esophagus. There did not appear to be any other esophageal pathology. Past Medical History: Depression Social History: Positive for Tobacco, alcohol and marijuana use. He denies IVDU. Physical Exam: On discharge, patient's physical exam is as follows: Vitals: AVSS Gen: NAD HEENT: PERRLA, EOMI, occipital decubitus CVS: RRR, no MRG PULM: CTA bilaterally ABD: soft, NT/ND, +BS EXT: no CCE Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2101-10-5**] 12:50PM 9.9 3.00* 7.9* 25.4* 85 26.4* 31.2 16.7* 489* DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos [**2101-9-19**] 07:33AM 81* 0 7* 9 1 0 0 2* 0 RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy Polychr [**2101-9-19**] 07:33AM 1+ NORMAL NORMAL NORMAL NORMAL NORMAL BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [**2101-10-5**] 12:50PM 489* RADIOLOGY Final Report CHEST (PA & LAT) [**2101-10-5**] 1:54 PM Reason: eval for interval change, s/p pleural drain d/c [**10-4**] [**Hospital 93**] MEDICAL CONDITION: 25 year old man with rupt esophagus, 1 pleural drain to bulb suction s/p loculated bilateral pleural effusions; now w/ some pain s/p drian pull [**10-4**]. REASON FOR THIS EXAMINATION: eval for interval change, s/p pleural drain d/c [**10-4**] CHEST, TWO VIEWS INDICATION: 25-year-old man with ruptured esophagus. COMMENTS: PA and lateral radiographs of the chest are reviewed, and compared with previous study of [**2101-10-2**]. The left chest tube remains in place. There is continued small left pleural effusion with atelectasis in the left lung base. Minimal patchy atelectasis is seen at the right lung base. The lungs are clear otherwise. The heart and mediastinum are within normal limits. The tip of the right-sided PICC line is identified in the distal portion of the right subclavian vein. No pneumothorax is noted. RADIOLOGY Final Report ESOPHAGUS [**2101-9-28**] 2:22 PM Reason: swallow study w/ WATER SOLUBLE CONTRAST ONLY.eval for esopha [**Hospital 93**] MEDICAL CONDITION: 25 year old man with esophgeal rupture and repair. REASON FOR THIS EXAMINATION: swallow study w/ WATER SOLUBLE CONTRAST ONLY.eval for esophageal leak. BARIUM ESOPHAGRAM INDICATION: 25-year-old man with esophageal rupture and repair. BARIUM ESOPHAGRAM: Orally administered Optiray contrast was observed under fluoroscopic guidance passing freely into the stomach with no evidence for extra luminal extravasation. Thin barium was then orally administered for better resolution of the esophagus. There is no aspiration into the airway and no significant retention in the vallecular or piriformis sinuses. No structural abnormalities are detected in the region of the pharynx, cervical esophagus, or mid and distal esophagus. Normal primary peristaltic contractions. There is no evidence for extra luminal extravasation of contrast. IMPRESSION: No evidence for extraluminal extravasation. RADIOLOGY Final Report TEETH (PANOREX FOR DENTAL) [**2101-9-28**] 1:59 PM Reason: abscess [**Hospital 93**] MEDICAL CONDITION: 25 year old man with poor dentition REASON FOR THIS EXAMINATION: abscess HISTORY: Abscess, ____. Panorex single view. The mandibular condyles and TM joints are excluded from this view. There is increased density over the mental portion of the mandible, obscuring fine bony detail. There is a broken tooth posteriorly on the right. RADIOLOGY Final Report ESOPHAGUS [**2101-9-8**] 8:23 PM Reason: need swallow study under fluoro to assess for esophageal [**Doctor First Name **] Contrast: [**Hospital 13288**] [**Hospital 93**] MEDICAL CONDITION: 25 year old man with REASON FOR THIS EXAMINATION: need swallow study under fluoro to assess for esophageal leak ESOPHAGEAL STUDY INDICATION FOR STUDY: Evaluate for esophageal leak following trauma to neck. A scout film of the upper thorax and neck reveals free air within the mediastinum. Thereafter, a water-soluble esophageal study was performed which demonstrates a leak in the upper esophagus on the right side at the level of the manubrium. Free extravasation of air and contrast is noted to the right side of the esophagus at this level with passage of leaked contents both superiorly and inferiorly tracking along the right side of the esophagus. The remaining mid and distal esophagus is entirely normal with no leakage present or mucosal irregularities. IMPRESSION: Rupture of esophagus on right side at level of manubrium with leaked contents traveling both superiorly and inferiorly along the right side of the esophagus. These findings were communicated immediately to the ordering surgeon Dr. [**Last Name (STitle) **]. Brief Hospital Course: Mr. [**Known lastname **] was admitted to Dr.[**Name (NI) 2347**] service at [**Hospital1 18**] via the ED on [**2101-9-8**]. On that day, he underwent a repair of his cervical esophageal perforation with wide drainage of the neck, right thoracotomy, exploration and wide drainage of the mediastinum, placement of percutaneous endoscopic gastrostomy tube, placement of left chest tube, esophagogastroduodenoscopy and flexible bronchoscopy. For details of the procedure, see operative dictation. He was taken to the SICU post-operatively intubated and sedated. He was placed on Vancomycin, Zosyn and Fluconazole as prophylaxis. Upon presentation, his diagnosis was made via an esophagram which showed his esophageal rupture was at the level of manubrium with leaked contents traveling both superiorly and inferiorly along the right side of the esophagus. A follow-up esophagram was done on POD 9 but showed a continued leak. He was therefore kept NPO. This exam was then repeated on POD 20 with resolution of the leak. He was transitioned to sips of clears on that day and then slowly advanced thereafter; all of which was well tolerated and without issue. Lastly, he had been on tube feeds throughout his hospital course and which were begun on POD 4. He was then cycled starting on POD 23. These were discontinued on POD 25 given his very good PO intake. From an infectious disease standpoint, a sputum culture on [**9-11**] returned positive for Klebsiella and he was additionally placed on Unasyn. Furthermore, a JP fluid culture from [**9-22**] was also positive for Klebsiella and he was then switched from Unasyn to Levofloxacin on [**2101-9-24**] for more narrowed, specific antibiotic coverage. He, however, continued to spike intermittent fevers during his initial hospital course despite broad and specific spectrum antibiotic coverage. He was then taken back to the OR on [**2101-9-26**] for a Left VATS after two large loculated pleural effusions were noted on imaging. For details of the procedure, see operative dictation. His vancomycin was stopped at that time and he was continued on zosyn, fluconazole and levofloxacin which will continue for about one month after discharge from the hospital. On POD 25, he was deemed fit to return to his Corrections Facility. He had been afebrile for approximately a week--beginning a day or two after his left VATS. He was ambulating without difficulty and was tolerating a regular diet. He was then discharged in good condition in the care of the State Corrections System. He is asked to return each week for follow-up so that his last remaining neck drain may be evaluated and slowly removed. Medications on Admission: Seroquel Discharge Medications: 1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*30 Tablet(s)* Refills:*0* 2. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 4. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*30 Tablet(s)* Refills:*0* 5. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). Disp:*10 Patch 72HR(s)* Refills:*2* 6. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. Disp:*qs ML(s)* Refills:*0* 7. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). Disp:*1 qs* Refills:*2* 8. Zosyn 4.5 g Recon Soln Sig: One (1) Intravenous every eight (8) hours for 4 weeks. Disp:*1 qs* Refills:*0* 9. Lansoprazole 30 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* 10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day) for 2 weeks. Disp:*1 qs* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital6 2222**] - [**Location (un) 538**] Discharge Diagnosis: Esophageal rupture Empyema Discharge Condition: Good Discharge Instructions: Please call Thoracic Surgery/Dr.[**Name (NI) 2347**] office (Thoracic Surgery) at [**Telephone/Fax (1) 170**] for any post surgical issues. Left pleural drain remains in place. Zosyn IV, fluconazole po, levofloxacin po UNTIL left pleural drain discontinued. Pleural drain to be evaluated by Dr.[**Last Name (STitle) **] on a weekly basis, until drain discontinued. Appointment with Dr. [**Last Name (STitle) **], [**2101-10-13**] at 11:00am for follow-up visit.See details below. No heavy lifting or exertion for 4- 6 weeks. Zosyn IV, fluconazole po, levofloxacin po UNTIL left pleural drain discontinued. You may take a brief shower(no baths) every 2-3 days. Dry area near drain well, change dressing daily and after each shower Followup Instructions: Patient to be seen by Dr. [**Last Name (STitle) **], [**2101-10-13**] at 11:00am for follow-up visit at [**Hospital1 69**], [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **], [**Location (un) 86**], MA, [**Location (un) 8939**], Thoracic Surgery Clinic. If this appointment cannot be kept call [**Telephone/Fax (1) 170**]. Completed by:[**2101-10-7**]

[ "519.2", "521.00", "305.1", "518.5", "958.7", "482.0", "707.09", "862.22", "285.9", "E960.0", "311", "510.9" ]

icd9cm

[ [ [] ] ]

[ "34.51", "04.81", "34.09", "96.72", "96.6", "38.93", "43.11", "42.82", "33.22", "99.04", "34.04" ]

icd9pcs

[ [ [] ] ]

10056, 10129

6113, 8787

353, 803

10200, 10207

1809, 2448

10986, 11356

8846, 10033

5051, 5072

10150, 10179

8813, 8823

10231, 10963

1600, 1790

282, 315

5101, 6090

831, 1468

1490, 1502

1518, 1585

25,661

159,589

29265

Discharge summary

report

Admission Date: [**2133-12-12**] Discharge Date: [**2133-12-26**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: right sided weakness and tremor Major Surgical or Invasive Procedure: Burr holes with evacuation of SDH bilaterally History of Present Illness: History of present illness: Pt is a [**Age over 90 **] year old man with dementia with three days of intermittent right sided weakness and tremor. By report, Pt's family reported right sided weakness at breakfast then again in the bathroom the afternoon of admission. Taken to an OSH for evaluation via EMS at ~2:45pm. Head CT revealed bilateral subdural hemorrhages. Pt was transferred to [**Hospital1 18**] for further evaluation. . Pt has had several falls recently due to the right sided weakness. No known head trauma or loss of consciousness. . Review of systems (from patient): Denies recent fever, chills, congestion, cough, chest pain, vomiting, diarrhea, rash. Denies weakness, numbness, loss of consciousness, involuntary movements. Past Medical History: Past medical history: Dementia s/p pacemaker placement for bradycardia Diabetes mellitus . Allergies: NKDA Social History: Retired, lives with son; had worked until 2 weeks prior to admission. Family History: noncontributory Physical Exam: PHYSICAL EXAM: T 98.2 HR 61 BP 138/63 RR 20 O2sat 95%RA Gen - WD/WN, comfortable, NAD. HEENT - neck supple Lungs - CTA bilaterally. Cardiac - RRR Abd - Soft, NT, BS+ Extremities - Warm and well-perfused. Neuro: Mental status - Awake and alert, cooperative with exam. Oriented to person, hospital (but not [**Hospital1 18**]), "[**Hospital1 1559**]", "[**2043-5-4**]". Registers [**3-6**] objects, 0/3 at one minute. Speech fluent without errors. Somewhat inattentive. Follows simple commands but has difficulty with more complex tasks. No dysarthria. Cranial Nerves: I - Not tested II - PERRL 2.5 to 2mm bilaterally. Blinks to threat bilaterally. III, IV, VI - Decreased upgaze, eye movements otherwise intact without nystagmus. V, VII - Slight left lower facial droop. Sensation intact to light touch. VIII - Hearing intact to snap (but not finger rub). IX, X - Palatal elevation symmetric. [**Doctor First Name 81**] - Sternocleidomastoid and trapezius normal bilaterally. XII - Tongue midline without fasciculations. Motor - Decreased bulk throughout, normal tone. Strength full power [**5-8**] throughout. No pronator drift. Sensation - Intact to light touch and pinprick; decreased vibration at the toes bilaterally (improved at the ankles). No extinction. Reflexes - 2+ brisk at biceps, triceps, brachioradialis, patella bilaterally. Unable to elicit at the ankles. Toes upgoing bilaterally. Coordination - mild intention tremor on finger to nose, rapid alternating movements are symmetric. Pertinent Results: OSH: CBC 7.4>32.6<285 60N 27L 11M Na 137 K 4.8 Cl 101 CO2 27 BUN 24 Cr 1.5 Glu 389 U/A glucose >1000 CXR negative OSH head CT - bilateral subdural hemorrhages, L>R, subacute component on the left, chronic on the right. [**Hospital1 18**]: CBC 7.2>32.9<284 Na 140 K 4.2 K 103 CO2 28 BUN 23 Cr 1.3 Glu 101 PT 12.4 PTT 26.2 INR 1.1 BIHead CT [**12-11**] - Large bilateral subdural hematomas, left larger than right, with shift of the septum pellucidum to the right by 9 mm Brief Hospital Course: Mr. [**Name13 (STitle) **] is a [**Age over 90 **]-year-old man with a history of dementia who presented with R sided weakness and falls. His brief hospital course is as follows: . 1. Falls, Subdural Hematoma. He was found to have bilateral subdural hematoma at the OSH and was transferred to [**Hospital1 18**] for monitoring. He was initially admitted to the ICU. His neurologic status declined and he was taken to the OR where under MAC anesthesia he underwent left and right bilateral burr hole evacuation for worsening mass effect from subdural hematomas. He tolerated this procedure well and was transferred to the PACU and then to neuro stepdown unit. He was followed with CT of head which showed slightly less blood and less mass effect. . His post-operative course was complicated by poor recovery. He showed some neurologic improvement 3 days post-op, opening his eyes to command. However, he deteriorated again from that point, becoming unresponsive on POD#5. He was transferred to medicine at that point as there was no further indication for neurosurgery: his Head CT was stable and he was no longer a surgical candidate. Many discussions were held with his family that culminated in the decision not to transfer him to the ICU and to avoid any invasive maneuvers but to continue managing him medically. His mental status waxed and waned slightly over the next three days, but his peak functioning was to open his eyes on command. Without evidence of significant progression and with a poor overall prognosis even with optimal medical care, the decision was made to change his status to comfort measures only (CMO). This decision was made by his son in consultation with the medical team; his son felt that he would not have wanted further intervention. At this point, his NG tube was removed, no further labs were checked, and the only medications administered were those aimed at improving his immediate comfort. He subsequently died comfortable. . 2. Hypervolemia. On transfer from the Neurosurgery service to the Medicine service, the primary assessment was a volume overload impairing his respiratory status. He was consequently diuresed with Lasix with good effect on his breathing, although minimal effect on his mental status. . 3. Hypernatremia. His sodium peaked at 150 after diuresis. This improved with a small return of free water. Labs were no longer followed after he was made CMO. . 4. Nutritional status. Albumin 2.7. An NG tube was placed for tube feeds. However, shortly after that, the family decided that they definitely did not want him to receive a PEG tube and instead would prefer to focus on comfort measures only. . 5. UTI. Although there was some concern for infection and sepsis at the time of transfer to Medicine, a urine culture positive for pseudomonas was the only sign of a localizing infection. His vitals were stable over the last several days. Therefore, empiric antibiotic coverage was no longer indicated, and since the pseudomonas in culture was sensitive to ciprofloxacin, he was switched to this. Once the CMO status was established, antibiotics were stopped. He received a total of three days of Vancomycin and Zosyn and one day of Cipro. . 6. Acute Renal Failure. This improved with diuresis and was likely the result of decreased ECV. His labs were no longer followed after CMO status was established. . 7. DM2. He had reasonably good control with NPH and HISS. Fingersticks were no longer checked after CMO status was established. . 8. HTN. His antihypertensive medications were held given concerns of hypotension and an uncertain intracranial pressure. . 9. Communication: His son [**Name (NI) **] [**Name (NI) **] ([**Telephone/Fax (1) 70358**]) was the primary contact and decision-maker. . 10. CODE: CMO. This was discussed many times at length. Ultimately, the family decided to have comfort measures only. . 11. Dispo: Transferred to a long-term care facility close to his home in [**Hospital1 1559**] for palliative end-of-life care. Medications on Admission: Medications prior to admission (doses unknown): Lisinopril Metformin Glyburide Discharge Medications: None Discharge Disposition: Extended Care Discharge Diagnosis: B/L SUBDURAL HEMATOMAS Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "852.21", "518.5", "432.1", "428.0", "585.9", "294.8", "E885.9", "599.0", "276.0", "V45.01", "276.2", "584.9", "041.7", "250.92", "V15.88" ]

icd9cm

[ [ [] ] ]

[ "96.6", "01.31" ]

icd9pcs

[ [ [] ] ]

7579, 7594

3418, 7420

295, 343

7661, 7670

2906, 3395

7723, 7851

1351, 1368

7550, 7556

7615, 7640

7446, 7527

7694, 7700

1398, 1938

224, 257

399, 1117

1954, 2887

1161, 1248

1264, 1335

29,063

190,020

32911

Discharge summary

report

Admission Date: [**2140-1-4**] Discharge Date: [**2140-1-21**] Date of Birth: [**2078-9-6**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 78**] Chief Complaint: found down Major Surgical or Invasive Procedure: Coil embolization of left middle cerebral artery aneurysm with vascular neck reconstruction device. Angiogram History of Present Illness: HPI: 61F had episode of vomiting this morning, remembers going to the bathroom, does not remember if she fell but says she hit her forehead. Her son heard a noise and found her on the floor outside of the bathroom and was unresponsive. He called EMS and she was taken to [**Hospital3 **]. She was found to have a SAH and was transferred to [**Hospital1 18**] ED for further management. She is currently complaining of neck pain and a headache. Past Medical History: PMHx: DM, HTN, sleep apnea Social History: Social Hx: lives with son Family History: nc Physical Exam: PHYSICAL EXAM: O: T: 99.5 BP: 177/81 HR: 88 R 18 O2Sats 99% 2L NC Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 1.5mm b/l min reactive EOMs intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, Extrem: Warm and well-perfused. Neuro: Mental status: Drowsy, had to keep asking patient to open her eyes, 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 minimally reactive to light, 1.5mm 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 [**4-11**] throughout. No pronator drift Sensation: Intact to light touch Coordination: normal on finger-nose-finger Pertinent Results: CT/CTA:Left MCA aneurysm [**2140-1-4**] 10:05AM WBC-8.8 RBC-3.98* HGB-12.5 HCT-36.6 MCV-92 MCH-31.3 MCHC-34.0 RDW-13.3 [**2140-1-4**] 10:05AM NEUTS-85.8* LYMPHS-10.8* MONOS-2.9 EOS-0.4 BASOS-0.1 [**2140-1-4**] 10:05AM PLT COUNT-245 [**2140-1-4**] 10:05AM PT-11.9 PTT-21.0* INR(PT)-1.0 [**2140-1-4**] 10:05AM GLUCOSE-198* UREA N-14 CREAT-0.9 SODIUM-140 POTASSIUM-3.4 CHLORIDE-101 TOTAL CO2-25 ANION GAP-17 [**2140-1-4**] 10:05AM CALCIUM-9.3 PHOSPHATE-2.1* MAGNESIUM-2.0 [**2140-1-4**] 10:08AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.030 [**2140-1-4**] 10:08AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2140-1-4**] 10:08AM URINE RBC-21-50* WBC-0-2 BACTERIA-RARE YEAST-NONE EPI-0 CT [**2140-1-19**]: FINDINGS: Comparison is made to [**2140-1-16**]. The previously seen right frontal ventricular shunt has been removed and the shunt tract is still visible. There may be minimal increase in size of the ventricles diffusely. Again seen are subarachnoid hemorrhage predominantly along the sulci of the left cerebrum. The previously seen hemorrhage involving the left temporal lobe is no longer visualized, although the hypodensity persists. There is a left-sided coil pack in the sylvian fissure and the streak artifact limits evaluation of the adjacent brain. The basal cisterns are patent. There are scattered small hypodensities of the deep and periventricular white matter which likely represent chronic microangiopathic changes. A right frontal burr hole is again seen. No suspicious bony abnormalities are noted. There is fluid/soft tissue change of the right mastoid air cells. IMPRESSION: 1. Since [**2140-1-16**], removal of right ventricular shunt with minimal increase in size of the ventricles diffusely. 2. Persistent predominantly left-sided subarachnoid hemorrhage and edema of the anterior left temporal lobe. CT [**2140-1-4**]: FINDINGS: The patient has undergone interval coiling of the previously demonstrated left MCA aneurysm. Streak artifact from the coils somewhat obscures visualization at this level. Redemonstrated is diffuse subarachnoid hemorrhage not appreciably changed compared to [**2140-1-4**] at 10:47 a.m. There has been interval placement of a ventriculostomy catheter via a right frontal craniotomy which enters the frontal [**Doctor Last Name 534**] of the right lateral ventricle and terminates near the third ventricle. The ventricular system is slightly smaller compared to the prior study, although it remains symmetric. Slight shift of the septum pellucidum to the right by approximately 4 mm has not appreciably changed. The paranasal sinuses and mastoid air cells remain clear. IMPRESSION: Interval coiling of left MCA aneurysm. Diffuse subarachnoid hemorrhage not appreciably changed. Interval placement of ventriculostomy catheter which enters frontal [**Doctor Last Name 534**] of right lateral ventricle to a termination near the third ventricle. Slight interval decrease in size of ventricular system. No change in slight rightward subfalcine herniation by about 4 mm. Brief Hospital Course: The patient was admitted to the ICU on [**2140-1-4**]. She had a non-traumatic SAH. She had a CTA which revealed a left MCA aneurysm. The patient had an angio with a coiling on the day of admission as well as an EVD placement. She was started on aspirin and plavix after the angio. On [**2140-1-5**] she was extubated. She had a CTA/CTP on [**1-6**] which showed no vasospam and she remained neurologically stable. The patient was more somnolent on [**2140-1-8**] and after a family meeting a CTA was obtained. It showed no vasospasm. On [**1-9**] CSF was sent because the patient spiked a fever to 103.4. She was started on antibiotics by the ICU team for a presumed pneumonia. She had LENIs which were negative on [**2140-1-10**]. On [**1-10**] the patient was neurologically stable and her drain was raised to 20 cm H2O. She had a repeat CTA/CTP on [**1-12**] which showed no change and she also had a PICC line placed for her antibiotics. On [**2140-1-15**] her CSF came back which showed no micro-organisms with 2+ polys. We tried clamping her drain but she failed with ICPs > 25. On [**2140-1-16**] her CT showed increased size of temporal horns. On [**2140-1-17**] one antibiotic was stopped. When her drain was clamped on [**2140-1-17**], she did well. Her ICPs were < 20. The drain was removed on [**2140-1-19**]. The patient was also transferred to the floor that day. On [**2140-1-20**] she passed her speech and swallow evaluation and her vanco was discontinued. Physical therapy and occupational therapy recommended rehab. The patient was neurologically stable and was deemed ready for discharge on [**2140-1-21**]. Her PICC line was removed prior to discharge. She was afebrile. Neurologically: she was oriented x 3 and full strength in all extremities; no pronator drift; face symmetric. Medications on Admission: All: NKDA Medications prior to admission: Lisinopril Discharge Medications: 1. Metoprolol Tartrate 5 mg/5 mL Solution Sig: One (1) Intravenous Q4-6H () as needed for HR > 110. 2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed. 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 5. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 7. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day): hold for SBP < 100 or HR < 60. 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 9. Levetiracetam 100 mg/mL Solution Sig: One (1) PO BID (2 times a day). 10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed). 11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Five (5) Subcutaneous once a day: please give prior to breakfast. 13. Insulin Lispro 100 unit/mL Cartridge Sig: One (1) Subcutaneous AS DIRECTED: Please follow sliding scale. 14. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4 hours) for 5 days: Today is day 17 of 21. Please stop on [**1-25**], [**2139**]. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Left MCA aneurysm rupture Discharge Condition: Neurologically Stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: PLEASE HAVE YOUR SUTURES REMOVED ON [**2140-1-24**]. PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR [**First Name (STitle) **] TO BE SEEN IN 4 WEEKS. YOU WILL NEED AN MRA OF THE BRAIN WITH/WITHOUT GADOLIDIUM Completed by:[**2140-1-21**]

[ "486", "327.23", "V45.89", "401.9", "430", "250.00" ]

icd9cm

[ [ [] ] ]

[ "38.91", "99.29", "96.6", "38.93", "03.31", "02.2" ]

icd9pcs

[ [ [] ] ]

8730, 8800

5451, 7257

326, 439

8870, 8894

2300, 5428

10264, 10530

1027, 1031

7361, 8707

8821, 8849

7283, 7294

8918, 10241

1061, 1319

7326, 7338

276, 288

467, 917

1607, 2281

1334, 1591

939, 967

983, 1011

4,473

117,913

19096

Discharge summary

report

Admission Date: [**2176-7-8**] Discharge Date: [**2176-7-30**] Date of Birth: [**2129-11-15**] Sex: M Service: HISTORY OF PRESENT ILLNESS: Patient is a 46-year-old male status post a motorcycle crash, positive loss of consciousness found down with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] coma score of 8, sats of 90%. He had a large amount of crepitus in the right chest, needed compressions x2 with rush of air and sats up to 100%. [**Location (un) 2611**] coma score of 12. Hemodynamically stable and brought to the Emergency Room. Airway was patent with right chest tube placed. Patient was later intubated. Pupils were 4 down to 2 mm and briskly reactive. EOMs full. Blood pressure was 100/palp. Respiratory rate was 15. Sats were 92%. He had left facial abrasion. His face is stable. Tympanic membranes are clear. Neck was crepitus bilaterally, right chest crepitus. Bilateral breath sounds were equal. Regular, rate, and rhythm. Abdomen negative. Rectal tone was normal. Back with no stepoffs or tenderness. No deformities in the extremities. Chest x-ray shows a large amount of subcutaneous emphysema with right clavicular fracture. Pelvis: No fractures. Head CT showed no bleed, some facial bone screws from an old fracture. CT of the C spine showed C7 left vertebral artery foramen fracture. Chest showed multiple rib fractures, right scapula fracture, no solid organ injury. The patient was monitored in the ICU with mainly respiratory issues. Had a bronchoscopy done in [**7-8**] that showed no injury, clot which was aspirated, an irregular distal airways without ............. On [**7-9**], the patient was awake and alert, although intubated, following commands, moving all extremities. EOMs full. He was neurologically stable, remained in hard collar. Patient had an arteriogram to rule out vertebral and carotid artery dissection which was ruled out. He remained neurologically stable. Patient was followed by the Ortho service for the right clavicular and scapula fractures and rib fractures. Ortho recommended a sling and swath for right scapular and clavicular fractures. They were nonoperative. He spiked a temperature. Sputum culture showed gram-negative rods. The patient was started on Levaquin and finished a 10 day course. He remained neurologically stable. Continued to have the C7 fracture. He was transferred to the Neurosurgery Service on [**2176-7-24**]. Patient was taken to the OR and underwent C6-T1 posterior fusion without intraoperative complications. Vital signs are stable. Postoperative, he was monitored in the ICU. Vital signs were stable. He was transferred to the regular floor on [**2176-7-28**], evaluated by Physical Therapy and Occupational Therapy, and found to be safe for discharge to home. PCA pump was discontinued on [**2176-7-29**]. His drain was removed and he was ready for discharge home on [**2176-7-30**]. DISCHARGE MEDICATIONS: 1. Oxycodone 40 mg p.o. q.12h. 2. Hydromorphone 2-6 mg p.o. q.3-4h. prn. 3. Trazodone 50 mg p.o. q.h.s. 4. Zantac 150 mg p.o. b.i.d. 5. Nicotine patch 21 mg topically q.d. 6. Peroxetine hydrochloride 20 mg p.o. q.d. 7. Bacitracin ointment application to abrasions b.i.d. CONDITION ON DISCHARGE: Stable. FOLLOW-UP INSTRUCTIONS: He will follow up with Dr. [**Last Name (STitle) 1327**] in one week for staple removal. [**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2176-7-29**] 08:36 T: [**2176-7-29**] 08:40 JOB#: [**Job Number 52123**]

[ "518.5", "E812.2", "958.7", "807.4", "861.21", "482.82", "305.00", "805.07", "860.0" ]

icd9cm

[ [ [] ] ]

[ "96.72", "88.41", "38.93", "34.04", "03.53", "96.6", "03.90", "81.03", "38.91", "96.04" ]

icd9pcs

[ [ [] ] ]

2982, 3254

160, 2959

3313, 3666

3279, 3288

28,815

194,861

45259

Discharge summary

report

Admission Date: [**2136-3-16**] Discharge Date: [**2136-4-7**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Intubation Mechanical Ventilation History of Present Illness: Please see original MICU Admit note dated [**2136-3-16**]. In brief, Mr. [**Known lastname 96706**] is a [**Age over 90 **] yo M with h/o a-fib on coumadin, CAD s/p CABG X 2, and recent hospitalizations at [**Hospital1 112**] for C. diff colitis who initially presented with hypotension and supratherapeutic INR. Per wife, pt had ongoing diarrhea prior to presentation. In [**Name (NI) **], pt's BP 60/30, given 2L IVFs without improvement in BPs and pt started on pressors with improvement of SBPs to 100s. RIJ placed, given vancomycin, levofloxacin, ceftriaxone, flagyl, and 10 units vit K for INR > 20. NCHCT and CT abd/pelvis without bleed. . In the MICU, given 2 units FFP. Due to continued hypotension, neo and vasopressin were added to levophed. [**Last Name (un) **] stim wnl. Had brief episode of SVT to 180s, resolved with carotid massage. Cardiac enzymes showed flat CKs, but elevated CK-MB (18), MBI (23.1), and troponin peak to 0.95 in setting of acute on chronic renal failure which was thought to be pre-renal in etiology. Intubated on [**3-20**] for worsening mental status and airway protection. Infectious w/u thus far negative beyond CXR with ? retrocardiac opacity, fluffy infiltrates, and pleural effusions. He was treated for HAP with IV vanc/cefepime, kept on IV cipro, and treated for c. diff with po vanc/flagyl. Pressors weaned off on [**3-21**], extubated without event on [**3-22**]. The patient was called out to the medical floor on [**3-24**]. Upon transfer to the floor, his vital signs were T: 97.0, BP: 126/65, HR: 93, RR: 20, O2 95% 3L NC. . On the floor, the patient had blood pressures in the 90s systolic, with HR in the 80s-110s, with SaO2 persistently in the high 90s. Initially, he was found to be more tachycardic, and his outpatient lopressor was re-started to control his atrial fibrillation. The patient had completed an 8 day course of cefepime and cipro for pneumonia, and these antibiotics were discontinued. The patient received 10 mg IV lasix in the AM on [**3-25**] to promote diuresis, given that the patient was felt to be intravascularly depleted with third spacing after fluid resuscitation. The patient's WBC had been followed, and over the past 3 days was 23-->31-->28.1. Differential on [**3-24**] showed 91 % neutrophils, 1% bands, 3% lymphs. All blood and urine cultures were no growth to date, including repeat C. diff. toxin. Pt received a 250 mL NS bolus for BP systolic 88. Nightfloat called again for BP 73/50s. 1 L NS hung wide open, with pressures transiently bumping to 90s systolic, but BP noted as low as 60s systolic. On exam, patient was noted to have upper respiratory noises, but SaO2 persistently high 90s on 3L. . On arrival to the MICU, cuff pressures 70s systolic originally. Patient still has CVL from prior MICU admit and was started on levophed. Arterial line placed which demonstrated BPs 140s systolic (on levophed) so levophed was turned off. BPs then 110s/50s (map > 60). Past Medical History: (all records at [**Hospital1 112**], PMH here per wife) atrial fibrillation on coumadin CAD s/p CABG X 2 ([**2111**], [**2118**]) CHF: EF 45% in [**2135-4-10**] hypertension recent renal insufficiency (baseline creatinine 1.6) anemia (on iron) Social History: Lives with wife. [**Name (NI) 6**] artist and writer. Family History: noncontributory Physical Exam: ON TRANSFER TO MICU: T: 96.3 Ax BP: 79/51 HR: 93 RR: 24 O2 91% RA 4 L NC Gen: elderly gentleman in mild distress, grunting occasionally while lying in bed HEENT: No conjunctival pallor. PERRL. No icterus. MM slightly dry. OP clear. NECK: supple, no LAD, no JVD appreciated, has Right IJ CVL in place CV: normal rate & irregular, no murmurs appreciated LUNGS: clear anteriorly, decreased breath sounds at bases ABD: somewhat distended, + bowel sounds, nontender to palpation EXT: feet & hands slightly cool but + DP & radial pulses, no peripheral edema SKIN: scattered ecchymoses NEURO: moaning, not following commands, but turns head to voice Brief Hospital Course: A/P: This is a [**Age over 90 **] y/o M with h/o recent C diff, CAD s/p CABG, atrial fibrillation who who presented initially with supratherapeutic INR and hypotension in setting of C. diff, and who now is re-admitted to the ICU with hypotension. . # Hypotension: Etiology most likely due to sepsis. Pt.'s initial presentation to ICU on [**3-16**] was septic shock. Differential sources at the time included C diff or pulmonary. Pt completed 8 day course of ciprofloxacin and cefepime, continued on flagyl, IV vancomycin and po vancomycin. Blood cultures no growth. Has R IJ placed at admission. Patient wa maintained on pressors and it was not possible to wean of due to hypotension. Repeat blood cultures, urine cultures, sputum cultures, c. Diff were send, however without identification of any pathogens. Started Zosyn for ? of aspiration event. C Diff was treated with Flagyl and po vancomycin for 14 days after [**3-24**], and also covered for hospital-acquired pneumonia with vancomycin. Patient had PEA arrest on [**2136-3-28**]. Goals of care discussed with family. Patient was continued to receive full care but no resuscitation if heart stops. Patient remained on Levophed, with difficulty with titration as patient dropped pressures with turning. Likely initial trigger was sepsis. ECHO [**3-29**] no right heart strain, largely unchanged from prior. CE trending downward, likely elevated in setting of CPR and renal failure. . #. Acute mental status change: Patient not waking up much since extubation. Had CT head on [**3-20**] which was negative for acute intracranial hemorrhage. Patient may had difficulty clearing sedatives, although has been off for several days. Likely due to sepsis or pre-septic. Continued on Flagyl, vanc IV and po. Added Zosyn for broader coverage. . # Respiratory failure: Pt initially intubated for respiratory failure, but extubated on [**3-22**]. Was reintubated [**2136-3-28**] during code. Patient with loud respiratory noises, secretions, coarse breath sounds on exam. Empirical treatment for hospital acquired pneumonia with Vancomycin and Zosyn. . # Renal insufficiency: Baseline Cr 1.6-2.0. Cr now stable at 2.1 FeNa supported prerenal etiology on prior MICU admit. He was not on maintenance IVFs, but bolus for UOP as needed. Dose meds per CrCl < 15. . # Volume status: pt overloaded during LOS and pitting edema on physical exam. Audible wheezing. Given IV Lasix on floor. During ICU course held Lasix, given hypotension. . # Supra therapeutic INR: On admission, likely related to recent poor nutrition and diarrhea plus medication changes with Coumadin. During the course corrected & therapeutic. . # CAD s/p CABG X 2: Not on aspirin at home per current medication record. Re-cycle cardiac enzymes in setting of hypotension as above. All of which negative. . # CHF: EF 15-20% on echo [**3-17**], down from reported prior of 45% EF. Representing cute decompensation in the setting of sepsis and possible fluid overload. Cardiac ischemia ruled out, and no new valvular disease During the course of MICU stay it was not possible to wean patient off pressors and ventilator. His mental status remained unchanged and he remained unresposive. On [**2136-4-7**] decission was made by patients family (with the support of the medical team) that patient should receive comfort messures only. Patient deceased on the same day due to cardiopulmonay arrest. Medications on Admission: MEDS at home (per wife's medication sheet): artificial tears every two hours digoxin 0.125 mg daily enalapril 2.5 mg daily ferrous sulfate 325 mg TID flonase nasal spray [**Hospital1 **] lasix 60 mg [**Hospital1 **] lactobacillus 2 tabs TID lopressor 25 mg [**Hospital1 **] prilosec 20 mg daily miralax 17 g every morning sarna lotion aldactone 25 mg daiy tamsulosin 0.4 mg daily MVI 1 tab daily coumadin 8 mg every night tylenol 650 mg q6h prn fever combivent 2 puff four times daily as needed . medications on transfer: 1. Ipratropium Bromide Neb 1 NEB IH Q6H 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN 3. Artificial Tears 1-2 DROP BOTH EYES PRN 4. Metronidazole 500 mg IV Q8H started [**3-17**] 5. docusate sodium (liquid) 100 po bid 6. Metoprolol 25 mg po bid hold for sbp <100, hr <60 7. Nystatin Cream 1 Appl TP [**Hospital1 **] 8. Pantoprazole 40 mg IV Q24H 9. Senna 1 TAB PO BID 10. Vancomycin Oral Liquid 250 mg PO Q6H started [**3-17**] 11. Vancomycin 1000 mg IV Q48H started [**3-17**] 12. Insulin Sliding Scale 13. sodium bicarbonate 650 mg po tid Discharge Disposition: Expired Discharge Diagnosis: Sepsis Discharge Condition: deseased

[ "785.51", "790.92", "427.5", "276.1", "008.45", "263.9", "V45.81", "995.92", "486", "038.9", "584.9", "427.31", "785.52", "414.00", "518.81" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.6", "96.72", "38.93", "99.60", "96.71" ]

icd9pcs

[ [ [] ] ]

8883, 8892

4356, 7768

273, 309

8942, 8953

3656, 3673

8913, 8921

7794, 8291

3688, 4333

222, 235

337, 3301

8316, 8860

3323, 3569

3585, 3640

23,748

174,943

52503

Discharge summary

report

Admission Date: [**2112-2-11**] Discharge Date: [**2112-3-15**] Date of Birth: [**2063-4-12**] Sex: Service: ADMISSION DIAGNOSES: 1. Abdominal pain of unknown origin. 2. Human immunodeficiency virus. 3. Hepatitis C. 4. Thrombocytopenia. 5. Anemia. 6. Renal insufficiency. DISCHARGE DIAGNOSES: 1. Methicillin-resistant Staphylococcus aureus and vancomycin- resistant enterococcus septicemia. 2. Anemia. 3. Thrombocytopenia. 4. Human immunodeficiency virus disease. 5. Hepatitis C. 6. Renal insufficiency. ADMITTING HISTORY AND PHYSICAL: Please note, this History and Physical is as per Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3315**] (pager #[**Numeric Identifier 108451**]). CHIEF COMPLAINT: Abdominal pain. HISTORY OF PRESENT ILLNESS: A 48-year-old male with HIV, a CD4 count of 600 in [**2111-10-19**], with a history of thrombocytopenia who complains of abdominal pain x 4 to 5 months which has worsened in the last several days. He had previously been worked up at an outside hospital but felt unsatisfied with his treatment. He does have associated nausea, and vomiting, and diarrhea. He admits to a weight loss of 10 to 15 pounds over the previous week. Also admits to fevers and chills and complains of a rash over his trunk and leg with positive pruritus, headaches, nose bleeds, and gingival bleeding that he has noticed. PAST MEDICAL HISTORY: Significant for HIV disease x 14 years (for which he has stopped antiretroviral therapy), thrombocytopenia, hepatitis C, question cirrhosis. MEDICATIONS AT HOME: Include Protonix, oxycodone, 3 antiretroviral's that he discontinued 2 months ago, and Ultram. ALLERGIES: The patient has no known drug allergies. FAMILY HISTORY: Significant for diabetes and CHF in his mother. His father died of unknown causes. SOCIAL HISTORY: He lives with his mother in [**Name (NI) 669**]. He denies any alcohol, smoking, or drug use. He has been clean for 2 years. Previously he has used cocaine and heroin IV, and he is currently sexually active with women. REVIEW OF SYSTEMS: As per HPI. PHYSICAL EXAMINATION: Temperature of 100.6, pulse of 103, blood pressure of 123/76, respiratory rate of 20, pulse oximetry of 97% on room air. Generally, a chronically ill male. Appears in no acute distress. HEENT with question of macroglossia. Mucous membranes are dry. Extraocular movements intact, and PERRLA intact. Neck is supple with no lymphadenopathy. Cardiovascular with a regular rate and rhythm, slightly tachy, [**12-24**] blowing murmur heard. Abdominal exam with generalized tenderness noted in the superior portion of the abdomen. Dull to percussion, but no shifting dullness, and no masses appreciated. Rectal exam is guaiac negative, as per the emergency department resident, no masses noted. Extremities with 1 to 2+ pitting edema to the knee. Neuro exam reveals alert and oriented x 3. A vague and poor historian. Ambulates well. Skin with diffuse raised white papules, pruritic, without drainage noted on the back of his legs bilaterally. LABORATORY DATA ON ADMISSION: Sodium of 135, potassium of 3.9, chloride of 104, bicarbonate of 25, BUN of 18, creatinine of 1.4, glucose of 97. ALT of 96, AST of 468, amylase of 41, alkaline phosphatase of 102, lipase of 33, total bilirubin of 3.0, albumin of 2.4. White blood cell of 7.7, hematocrit of 29.5, platelets of 48. UA showed some small blood and occasional bacteria. RADIOLOGIC STUDIES: Ultrasound of his abdomen showed no ductal dilatation, mild gallbladder wall edema which probably relates to hepatitic disease as per radiology resident. Chest x-ray showed low volumes with segmented atelectasis in the right middle lobe. HOSPITAL COURSE: The patient was admitted to the floor, at which time he spiked a temperature to 104.1 in the first couple hours. He was started on ceftriaxone. An ID consult was obtained as well as a hepatobiliary consult. His ceftriaxone was switched over to IV vancomycin as per ID. He was diagnosed as having had gram-positive cocci bacteremia. Aggressive fluid resuscitation was used to maintain his blood pressure, and the patient was transferred to the medical intensive care unit. The septicemia was identified as being staph aureus. On hospital day 4, Kaposi sarcoma was identified on his left foot by infectious disease. The previously mentioned leg culture revealed later that the staph aureus that grew out was MRSA. More history was gained from the ID consult as they had access to his records from his workup at an outside hospital. His stool had been negative for C. diff, he had a negative EGD; and a CT at that time had shown a large gallbladder, hardened wall, and a diffuse collection around the pancreas. Retroperitoneal density and retroperitoneal adenopathy were also noted. In light of the MRSA positive cultures his antibiotic coverage was expanded to include vancomycin, ceftriaxone, and Flagyl. The patient was transfused up to a hematocrit of 30, and an echo was ordered to assess for endocarditis. On [**2-15**], hospital day 4, the patient's CD4 count was identified as being 158; down significantly from the previous value of 602. The patient remained afebrile for hospital day 3 and hospital day 4. At the end of hospital day 4 the patient was transferred to the floor out of the intensive care unit while a tolerating a p.o. diet. The patient's central line was discontinued and a PICC line was placed for long-term antibiotic therapy. On the floor, the patient's antibiotic coverage was changed to Flagyl and vancomycin. The patient continued to remain afebrile. On [**2112-2-17**] the patient underwent a TEE to evaluate for possible SBE. No vegetations were found. On the night of [**2-17**] the patient became lethargic and was started on rifamycin for possible encephalopathy. The patient underwent a bone scan on [**2112-2-18**] which showed no evidence of osteomyelitis. Over the following couple of days the patient remained afebrile, although he developed severe anasarca; and on [**2112-2-22**] he tried to pull out his PICC line, which had to be replaced. Psychiatry saw the patient and determined that he was in delirium (mild) which was due to multifactorial's including AIDS, effects of opiates, resolving sepsis, and hepatic encephalopathy. One of the possibilities raise by psychiatry was surreptitious drug use within the hospital. For this, the patient's urine was tested and turned up positive only for opiates which he had been receiving for analgesia while in the hospital. On [**2112-2-26**] cultures came back from his PICC line that were positive not only for MRSA but also VRE. For this ID was consulted again, and they recommended discontinuing the current PICC line and adding dactinomycin to cover both VRE and MRSA. So, consistent with these recommendation, on [**2112-2-26**] vancomycin was discontinued and dactinomycin was initiated. On [**2112-2-27**] the patient complained of increased fluid in his lower extremities, scrotum, and abdomen. In order to control this edema, his furosemide dose was increased and the patient was continued on his dactinomycin. On the 12th, surgery was also consulted for possible lymph node biopsy to rule out lymphoma to explain his thrombocytopenia and his lower extremity edema. At that time, surgery felt that any biopsy would carry with it a significant risk of complications. Interventional radiology attempted a lymph node aspiration which showed MRSA but was an inadequate sample to rule out lymphoma. The patient remained stable and on current therapy until [**2112-3-2**] at which time he spiked to a temperature of 101.9. The white blood cell count of the patient dropped from 7 to 2.1, and his platelets dropped from 39 to 22. Hematocrit was 26.7. UA was sent which was positive for yeast. His Foley was discontinued, and the patient was started on Diflucan and levofloxacin empirically. Blood cultures subsequently found gram-negative rods in his blood, and he failed his trial of void for which a Foley was re-placed with a 22 French coude catheter, and ceftazidime was added to the antibiotic regimen. The patient had also been started on lactulose p.o. On [**3-3**], surgery was re-consulted for possible cellulitis in the lower extremity. At that time, surgery felt that he needed emergent I and D with possible hip disarticulation. Once again surgery noted that due to his thrombocytopenia, his immunocompromised status, and for other reasons he was an extremely high surgical risk. After discussion with the family, the family wished to proceed with the I and D of the lower extremity despite the high risk. In preparation for the surgery patient was transfused platelets, FFP, and cryoprecipitate infusions. This action was in response to a spike to 104 on the night of [**3-2**] and a blood pressure drop at that time to 90/30. The patient had received 3 liters of crystalloid boluses in order to maintain his blood pressure. His right lower extremity had developed 3+ pitting edema and erythema. PO Flagyl and ciprofloxacin IV were also added to his antibiotic regimen at that time. On the morning of [**3-3**] lactate was noted at 9.7. The patient was also relocated to the MICU, then to the SICU when surgery had agreed to take the patient to the OR for the I and D. At this point the patient's antibiotic regimen included clindamycin, dactinomycin, fluconazole, metronidazole, meropenem. Later on [**2112-3-3**] the patient was taken to surgery for his I and D; after which he was relocated to the SICU again. On the afternoon of [**2112-3-4**] the patient was taken back to the OR for more debridement of the right lower extremity with a diagnosis now of necrotizing fasciitis of the right leg and scrotum. The patient remained critically ill in the SICU over the remainder of [**3-4**] and [**3-5**] but without apparent expansion of the fasciitis. On the night of [**2112-3-5**] the patient received 2 units of platelets, 6 units of FFP, and 3 units of packed red blood cells; but his wounds continued to soak their bandages with blood. On the remainder of the 20th there was noted to be no further bleeding from his wounds. The patient was judged to be stable though critical and was followed closely. On [**3-7**] the results of previous blood cultures came back positive for Enterobacter which was consistent with the urine culture earlier as well as a candidal positive culture from a swab taken in the OR from the right thigh. The patient was then noted to have poly organism infection, as well as thrombocytopenia, and coagulopathy which were multifactorial. The patient's blood pressure had been maintained postoperatively on propofol, Levophed, Pitressin; and maintaining his blood pressure became more of a problem on postoperative day [**6-22**] (which was [**2112-3-10**]). Necrotic tissue was noted on the right lower extremity, and it was debrided at the bedside on both [**3-9**] and [**2112-3-10**]; debridement of necrotic muscle. Still necrotic tissue formed and patient had to be debrided again, with each debridement raising the problems of more bleeding in this severely thrombocytopenic patient. On [**2112-3-11**] the patient was again transfused 4 units of packed red blood cells, 2 units of platelets, 3 units of FFP, and cryoprecipitate in order to maintain hemodynamic and coagulation status. On [**3-12**], propofol and fentanyl were discontinued. The patient was being maintained solely on Levophed and Pitressin for blood pressure support; but once again platelets dropped precipitously down to 19 from 50. On [**3-14**], the patient's renal and hepatic failure continued to worsen as well as progressive necrosis noted in his lower extremity, and the team decided to discuss with the family the futility of ongoing aggressive measures in this patient and ongoing care which in their opinion would futile. During this time, on the morning of [**3-15**], the patient became hemodynamically unstable again. His FiO2 was increased to 100%. His ABG showed increasing metabolic acidosis. Later in the morning of [**2112-3-15**] the patient's lower extremity dressing was reinforced. Hematocrit was noted to be down to 17. The patient was transfused a total of 10 units of packed red blood cells that night, 3 units of platelets, and 7 units of FFP. The patient also required increasing doses of pressors in order to maintain blood pressure. Later in the morning, after long meeting with family, the patient was made a DNR. The patient continued to require increasing doses of pressors with less response. The patient expired on [**2112-3-15**] at 9:40 a.m. DISPOSITION: Patient expired. DISCHARGE INSTRUCTIONS: Not applicable. FOLLOWUP: Not applicable. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6633**], M.D. [**MD Number(2) 12418**] Dictated By:[**Last Name (NamePattern1) 5032**] MEDQUIST36 D: [**2112-6-26**] 16:56:52 T: [**2112-6-26**] 18:29:39 Job#: [**Job Number 108452**]

[ "042", "V09.81", "785.52", "608.4", "518.81", "070.44", "728.86", "070.22", "428.0", "682.6", "995.92", "707.15", "570", "038.8", "403.91", "996.62", "305.1", "284.8", "584.5", "785.4", "304.73", "112.2", "286.6", "558.9", "788.20" ]

icd9cm

[ [ [] ] ]

[ "99.04", "83.09", "40.11", "99.07", "83.45", "99.05", "39.95", "61.3", "38.95", "86.22", "48.23", "38.93", "88.72", "99.15" ]

icd9pcs

[ [ [] ] ]

1743, 1827

314, 729

3718, 12652

12677, 12998

1576, 1726

149, 293

2120, 3074

2084, 2097

747, 764

793, 1389

3089, 3700

1412, 1554

1844, 2064

75,586

181,228

19233

Discharge summary

report

Admission Date: [**2125-5-15**] Discharge Date: [**2125-5-25**] Date of Birth: [**2062-12-18**] Sex: F Service: CARDIOTHORACIC Allergies: Levaquin Attending:[**First Name3 (LF) 5790**] Chief Complaint: pericardial effusion with cardiac tamponade Major Surgical or Invasive Procedure: Emergent left thoracotomy and drainage of left pericardial clot and blood, creation of pericardial window History of Present Illness: Patient is a 62F well known to our service who recently underwent a mediastinoscopy with LN sampling for what we now know is stage IIIA lung CA who presents from an OSH with cardiac tamponade. Per family and OSH reports, pt presented to OSH ED with chest pain. Pain actually began in her lower neck and then migrated to her chest. She was receiving lovenox and coumadin for recently diagnosed PE. At OSH she underwent a CT chest which showed a significant pericardial effusion and was found to have an INR of 6. Shortly thereafter she apparently quickly decompensated with hypotension and tachycardia. She was emergently intubated, started on dopamine, given 20 vit K, 2uFFP, and total of 6L crystalloid. She was then transferred here emergently. In the ED, patient continued to demonstrate signs of tamponade including sinus tachycardia and hypotension with preload dependence. Cardiology and thoracics were immediately consulted. Bedside echo showed an approximately 2cm pericardial space, of which approximately 1-1.5cm was occuppied by what appeared to be clot. There was significant collapse of the RV. Cardiology felt an attempt at drainage via a pericardiocentesis with placement of a pigtail in the cath lab was futile and instead recommended an emergenent pericardial window. We agreed and the patient was emergently taken to the OR. Past Medical History: Parkinsons, stage IIIa (T1N2MO) right-sided lung CA s/p chemoradiation, PE on lovenox/coumadin, HLD, HTN Social History: ex-smoker:D/C'd on 20 years ago Pack-years: [**10-16**] Occupation: office worker Marital Status: Married Lives:With family ETOH: Denies Family History: Non-contributory Physical Exam: Vital Signs: 97.4 HR: 98 BP: 114/68 RR 20 General: NAD A+OX3 Cardiac: RRR S1S2 Lungs: decreased BS on the left ABD: Large soft nontender nondistended Extremities [**12-29**]+ edema bilaterally Pertinent Results: [**2125-5-24**] 04:40AM BLOOD WBC-7.1 RBC-3.02* Hgb-9.5* Hct-28.0* MCV-93 MCH-31.4 MCHC-33.9 RDW-17.0* Plt Ct-315 [**2125-5-23**] 02:21AM BLOOD WBC-6.3 RBC-2.92* Hgb-8.8* Hct-27.5* MCV-94 MCH-30.3 MCHC-32.2 RDW-16.9* Plt Ct-277 [**2125-5-22**] 02:11AM BLOOD WBC-6.4 RBC-2.73* Hgb-8.5* Hct-25.2* MCV-92 MCH-31.3 MCHC-33.9 RDW-17.4* Plt Ct-220 [**2125-5-24**] 04:40AM BLOOD Plt Ct-315 [**2125-5-24**] 04:40AM BLOOD PT-23.6* PTT-28.4 INR(PT)-2.3* [**2125-5-23**] 02:21AM BLOOD Plt Ct-277 [**2125-5-24**] 04:40AM BLOOD Glucose-96 UreaN-23* Creat-0.9 Na-131* K-4.1 Cl-93* HCO3-28 AnGap-14 [**2125-5-23**] 02:21AM BLOOD Glucose-92 UreaN-18 Creat-0.8 Na-132* K-4.2 Cl-95* HCO3-26 AnGap-15 [**2125-5-21**] 02:07AM BLOOD Glucose-111* UreaN-14 Creat-0.8 Na-141 K-3.9 Cl-106 HCO3-26 AnGap-13 [**2125-5-16**] 02:06AM BLOOD CK(CPK)-784* [**2125-5-15**] 06:14PM BLOOD CK(CPK)-726* [**2125-5-15**] 10:10AM BLOOD CK(CPK)-449* [**2125-5-14**] 09:32PM BLOOD Lipase-73* [**2125-5-16**] 02:06AM BLOOD CK-MB-5 cTropnT-0.08* [**2125-5-15**] 06:14PM BLOOD CK-MB-8 cTropnT-0.11* [**2125-5-15**] 10:10AM BLOOD CK-MB-12* MB Indx-2.7 cTropnT-0.17* [**2125-5-24**] 04:40AM BLOOD Albumin-3.4 Calcium-8.9 Phos-3.8 Mg-1.9 [**2125-5-23**] 02:21AM BLOOD Calcium-8.7 Phos-4.1 Mg-1.9 [**2125-5-22**] 02:25AM BLOOD Type-ART pO2-99 pCO2-40 pH-7.46* calTCO2-29 Base XS-4 [**2125-5-21**] 02:34AM BLOOD Type-ART pO2-109* pCO2-40 pH-7.48* calTCO2-31* Base XS-5 [**2125-5-19**] 05:12PM BLOOD Lactate-1.2 K-4.3 [**2125-5-15**] 01:12AM BLOOD Hgb-10.1* calcHCT-30 Brief Hospital Course: On [**2125-5-15**] 62F with stage IIIa adeno lung CA s/p med [**5-2**] and recently dx with PE on coumadin p/w pericardial bleed with tamponade INR 6 To OR for thoracotomy pericardial window. Admitted to ICU post-op intubated and hypotensive. [**5-15**] lasix, 2upRBCs, temp spike, TTE - no wall abnormalities, borderline pulmonary hypertension, EF>55% 5/20 20 mg lasix; extubated; LENIs negative [**2125-5-17**] 20 mg lasix; hep gtt started; ?pulmonary edema; bedside TTE - no effusion [**2125-5-19**] CT#1 pulled; coumadin started; tachypnic, tachy; ECHO - no RV strain; CTA neg PE [**2125-5-20**] amiodarone drip; R pleural thoracentesis - 600cc serosang; CT pulled diruresis with albumin [**2125-5-21**] albumin, 1 unit pRBC with lasix [**2125-5-22**] heparin gtt stopped; still on coumadin, diuresed [**2125-5-23**] transferred to floor, bactrim dc/'d [**2125-5-24**] Clinically stable rmains on 02 nc and BIPAP at night (her norm) informed Dr [**First Name (STitle) **] (Radiology Oncologist) Patient to follow up on [**6-5**] 9am shapario building [**Location (un) 442**] Medications on Admission: Coumadin sinemet mirapex quinapril lipitor Discharge Medications: Furosemide 40 mg PO BID Acetaminophen [**Telephone/Fax (1) 1999**] mg PO/PR Q6H:PRN fever, pain Do not exceed 4gm per day Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheeze Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing Metoprolol Tartrate 25 mg PO BID hold for SBP< 100 or HR < 60 Amiodarone 400 mg PO BID give with food Mirapex *NF* 0.5 mg Oral TID parkinsons Atorvastatin 10 mg PO DAILY Senna 1 TAB PO BID:PRN constipation Carbidopa-Levodopa (25-100) 1 TAB PO TID Docusate Sodium 100 mg PO BID Warfarin 2 mg PO DAILY Famotidine 20 mg PO Q12H Discharge Disposition: Extended Care Facility: The [**Hospital 1474**] Hospital Transitional Care Unit Discharge Diagnosis: Pericardial Effussion s/p thoracotomy with pericardial window Sage IIIa adeno lung CA PE on coumadin Sleep apnea -Bipap at night Discharge Condition: fair Discharge Instructions: Follow INR goal INR 2.0-2.5 Positive Airway Pressure for OSA: Indication Known OSA Consult Respiratory Therapy Nasal CPAP w/PSV (BIPAP) CPAP level: 10/5 cm/h2o Inspiratory pressure: 10 cm/h2o Expiratory pressure: 5 cm/h2o Supp O2: 7 L/min Please follow up with patients PCP and Dr. [**First Name (STitle) **] at Rad. ONC. Followup Instructions: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Radiation Oncology at the Treatment Planning Center, [**Hospital Ward Name 23**] 5 - Call for appointment, [**Telephone/Fax (1) 9710**] Appointment booked for 9am in the Shapario building floor 5 with Dr. [**First Name (STitle) **] for radiology oncology. Completed by:[**2125-5-30**]

[ "423.0", "162.8", "518.5", "V58.61", "V12.51", "263.9", "332.0", "423.3", "511.9", "272.4" ]

icd9cm

[ [ [] ] ]

[ "37.12", "34.91" ]

icd9pcs

[ [ [] ] ]

5648, 5730

3900, 4983

320, 427

5902, 5908

2357, 3877

6281, 6639

2111, 2129

5076, 5625

5751, 5881

5009, 5053

5932, 6258

2144, 2338

237, 282

455, 1811

1833, 1940

1956, 2095

76,930

151,074

34112

Discharge summary

report

Admission Date: [**2107-6-7**] Discharge Date: [**2107-6-17**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4748**] Chief Complaint: right foot ulceration Major Surgical or Invasive Procedure: angiogram, diagnostic via left fem access [**2107-6-7**] Right SFA-Dp bpg with svg [**2107-6-10**] angiogram diagnostic left lower extremity [**2107-6-16**] History of Present Illness: [**Age over 90 **] y/o with known PVD ,chroinc lower foot /heel ulcerations bilaterally R>L with right foot/leg rest painAdmitted for IV hydration prior to diagnositic angiogram for chronic renal disease with cr 1.5 Past Medical History: DM2,neuropathy coronary artery disease aortic valve disease,s/p [**Age over 90 1291**] St. [**Male First Name (un) 923**], anticoagulated systolic CHF, chronic Social History: widowed lives at home with 24hr [**Location (un) **] care aides, presently was in rehab prior to admission to [**Hospital1 8482**] [**6-7**] Daughter very active in patient's care-Shisa [**Telephone/Fax (1) 78656**] Denies tobacco or ETOH use Family History: father died @ 84yrs mother died @64 complications of DM and CAD Physical Exam: vital signs: 98.6-91-16 O2 98% room air Gen: AAOx3 HEENT: no carotid bruits, diminished hearing bilaterally Lungs: clear to ausculation Heart: RRR ABd: bengin Pulses: palpable femorals bilaterally, dopperable dp/pt's bilaterally Neuro:nonfocal Pertinent Results: [**2107-6-7**] 08:25PM GLUCOSE-143* UREA N-23* CREAT-1.5* SODIUM-136 POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-24 ANION GAP-15 [**2107-6-7**] 08:25PM CALCIUM-9.2 PHOSPHATE-3.0 MAGNESIUM-2.0 [**2107-6-7**] 09:25AM GLUCOSE-139* UREA N-27* CREAT-1.7* SODIUM-139 POTASSIUM-5.4* CHLORIDE-105 TOTAL CO2-26 ANION GAP-13 [**2107-6-7**] 09:25AM estGFR-Using this [**2107-6-7**] 09:25AM CALCIUM-8.8 PHOSPHATE-3.4 MAGNESIUM-2.3 [**2107-6-7**] 09:25AM WBC-8.7 RBC-3.61* HGB-10.4* HCT-31.5* MCV-87 MCH-29.0 MCHC-33.1 RDW-14.6 [**2107-6-7**] 09:25AM PLT COUNT-272 [**2107-6-7**] 09:25AM PT-14.7* PTT-32.6 INR(PT)-1.3* [**2107-6-17**] ptt 55.1 [**2107-6-17**] inr 2.1 [**2108-6-16**] Hct: 25.5 transfused 1 uPRBC's check Hct [**6-18**] [**2107-6-15**] CXR FINDINGS: In comparison with the study of [**6-13**], the cardiac silhouette remains at the upper limits of normal. The engorgement of pulmonary vessels seen previously is not appreciated and the pulmonary markings are essentially within normal limits. Mild atelectatic change is seen at the bases with some blunting of the costophrenic angles suggesting a small pleural effusion. Brief Hospital Course: [**2107-6-7**] angiogram, admitted [**Last Name (un) **] study. IV hydration and vascular monitering. small left groin hematoma nonexpanding. [**2107-6-8**] IV heparin gtt began for aortic valve. Hct. stable 30.0 bun/cr 20/1.5 [**2107-6-9**] onset of new AF, nonsustanted EKG without acute changes cardiac enzymes flat. [**2107-6-10**] Right fem-DP bpg wit SVG. post Hct 26 transfused transfered to VICU for continued postop care. [**2107-6-11**] POD#1 continued oozing rt. thigh wound-hematoma. transfused for hct 26.IV Hep Gtt held secondary to groin wound.. repeat hct 24.4- transfused . Swan converted to CVL. post transfusion hct 30.0 thigh hematoma stablized. Iv heparin restarted [**2107-6-13**] POD # 2 coumadin 2.5mgm started dopperable pedal pulses and plapable graft pulse. warm foot. ambulation to chair began. rt. IJ line placed without diffculty. cxr good placement no ptx.PT recommends rehab to increased mobility. [**2107-6-14**] POD#3coumadin 4mgm 7/16/08POD#4 coumadin 0mgm IV heparin continued, coumadin held for planned angio [**6-16**] [**2107-6-16**] POD#5 Angio, intervention not do-able transfused 1 units for hct 23 [**2107-6-17**] POD#6 post transfusion Hct 25 transfused another 1 unitPRBC's. ;hematoma stable no bleed ing from left fem access site. [**Month (only) 116**] partially secondary to hemadilution from Iv hydration for angio. Notified of pulses change in rt. foot and graft exam. duplex of graft-aoccluded graft. situation discussed with Dr. [**Last Name (STitle) 1391**], target vessel and conduit was dimunitive in caliber. no further intervention .Patient's family aware. Patient will require revascularization of left leg in the future. This will be decided on f/up visit with Dr. [**Last Name (STitle) 1391**] and discussion with family.Family made aware of graft failure and underlying causes.IV heparin continued for [**Last Name (STitle) 1291**] , INr 2.1 can d/c once inr >2.5 In meanwhile moniter PTT for goal 60-70 and inr goal 2.5-3.0. Will continue foley secondary to thigh wound to avoid contamination. patient discharged to rebab stable. check hct in am [**6-18**] Medications on Admission: persantin 50mg' cymbalta 30mg' glyburide 10mg' vivocan 5/500prn flomax 0.4mg' bactrium DC [**6-7**]-x 10 days for hell ulcers coumadin 2.5mg held since [**6-8**] Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Dipyridamole 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 11. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral Solution Sig: as directed Intravenous ASDIR (AS DIRECTED): 575 units/hr (DW 25000u hep/250ml goal 60-80 ptt. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: PVD history of DM2 histroy of coronary artery disease histroy of systolc congestive heart failure history of aortic valve disease s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1291**], [**First Name3 (LF) **]. [**Male First Name (un) 923**], anticoagulated chronic renal disease with cr 1.5 postoperative blood loss anemia,transfused postoperative right thigh hematoma-stable postoperative graft failure [**2107-6-17**] post angio oliguria, fluid resustated Discharge Condition: stable Discharge Instructions: elevate rt. leg when in chair ace [**Last Name (un) 78657**] foot to knee when ambulating c/w foley catheter to protect rt. thigh/knee wound hematoma site may shower continue stool softner while on narcotics call if develope fever >101.5 call if leg wounds develope erythema,drainage. right graft is occluded, rt. toes pale but not cool/cold. moniter INR daily while on IV heparin gtt. for aortic valve goal inr 2.5-3.0 goal PTT 60-70 PTT 55.5 heparin @ 575u/hr coumadin 5mgm tonight9 not given) Followup Instructions: 2 weeks Dr. [**Last Name (STitle) 1391**], call for an appointment [**Telephone/Fax (1) 1393**] Completed by:[**2107-6-17**]

[ "414.8", "998.12", "428.0", "788.5", "250.60", "280.0", "V43.3", "413.9", "707.14", "428.22", "276.2", "511.9", "E879.2", "996.1", "997.5", "585.9", "V58.61", "357.2", "427.31", "414.01", "440.23", "E878.2" ]

icd9cm

[ [ [] ] ]

[ "39.29", "99.04", "88.48", "38.91", "38.93" ]

icd9pcs

[ [ [] ] ]

6067, 6133

2651, 4773

282, 441

6650, 6659

1491, 2628

7203, 7330

1147, 1212

4985, 6044

6154, 6629

4799, 4962

6683, 7180

1227, 1472

221, 244

469, 687

709, 870

886, 1131

65,954

125,130

38118

Discharge summary

report

Admission Date: [**2149-3-14**] Discharge Date: [**2149-3-17**] Date of Birth: [**2104-6-13**] Sex: M Service: MEDICINE Allergies: trileptal Attending:[**First Name3 (LF) 1115**] Chief Complaint: Gabapentin and seroquel overdose Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname **] is a 44-year-old gentleman with a history of of alcohol abuse and depression with suicidal ideation characterized by multiple recent ED visits for the above who presents to the ED today with report of overdose. In the ED, he was rousable but too somnolent to provide clear history. He endorsed thoughts of suicide. He also brought with him bottles of prescription medication, including gabapentin (prescription date 3 days ago, # 90, 3 pills remaining), thorazine, seroquel, and clonidineIn the ED, he endorsed taking more gabapentin than prescribed, but was unable to provide clear medication intake history including timecourse. On the floor, he is somnolent but answers most questions. He reports he doesn't know exactly what he took, but took excess meds because he "felt suicidal." He says he took the gabapentin over 3 days spaced out, but cannot be more specific. Denies any recreational drug use or ingestions. States his last alcoholic drink was at 11:00 AM of about a pint of vodka (maybe a little less). When he drinks, he typically drinks vodka. . When asked about his ear, he states no trauma, "maybe a spider bite." He awoke with the ear inflamed 2 days ago, thinks it is maybe a little better now. No pain. . Upon arrival to the ED vitals were: T 97.5, HR 72, BP 136/79, RR 18, 100% RA. He received 2 g IV magnesium for level of 1.8, 2 L of IVF with NS, 10 mg PO valium for agitation/anxiety, 500 mg PO Keflex and 1 tab DS Bactrim for erythema on ear. Vitals prior to transfer to the MICU were: BP 91/55, HR 64, RR 14, O2 sat 97% on 2L NC. . On arrival to the ICU, he reports feeling thirsty, needing to urinate, and feeling anxious. Requesting valium and water. Noted to have hesitancy with urinating, though states he always has difficulty when not standing (attempting to use urinal at edge of bed). Past Medical History: - Alcohol dependence (denies history of seizures in setting of withdrawal). - Hypertension - Wisdom teeth removed (no other known surgeries). . Per OMR: - Therapist Onah Sharchar at [**Hospital1 1680**] [**Hospital1 **] ([**Telephone/Fax (1) 85060**]) sent the patient on section 12 but promptly terminated care with the patient. - Frequent hospitalizations for substance abuse/dual dx, including [**Hospital6 5016**] and Medical Centter [**2130-2-22**], [**2130-4-25**], [**2130-2-28**]), Caritas [**Hospital6 5016**] ([**2146-5-15**], [**2147-6-11**]), and [**Location (un) 1475**] for section 35 (date unknown), [**Location (un) 3786**] (date unknown), [**Hospital 1680**] Hospital (date unknown), [**Hospital 189**] [**Hospital 85061**] Hospital (date unknown), [**Location (un) 63735**] Hospital (date unknown). - History of SIB/SA by cutting his wrist. - Has at least 5 psych admission in the past 6 months, two following ICU admissions for ODs. Social History: Last drink was 11am on day of admission. . SOCIAL HISTORY : Pt reports not having completed high school. The pt has lived in his current sober house group home for the past 8 months has lived in various sober homes for the past 3 years. When asked about his schedule day-to-day the pt says he spends his days "taking walks." The pt reports feeling safe in the sober home and having friends there. When asked if his mother and father were still living the patient also says "I don't know". . FORENSIC HISTORY: Patient reports only one arrest for disorderly conduct while intoxicated; he denies any jail time. One [**Location (un) 1475**] admission for Section 35. Family History: Schizophrenia Alcoholism Physical Exam: ADMISSION EXAM GEN: Sleeping but rousable, opens eyes to voice, answering questions, following commands, smells strongly of alcohol HEENT: Left ear diffusely erythematous and enlarged; small superficial ulceration just behind left lobe. No tenderness with manipulation of the pinna. Mild erythema in ear canal but drum appears clear. Dry MM. Pustular acne on face. NECK: Suppe PULM: CTA bilaterally CARD: RRR, no M/R/G ABD: Soft, NT/ND, +NABS EXT: 2+ DP, radial pulses. No edema. NEURO: Oriented to person, place, knows month [**Month (only) 958**], season winter, unable to state date PSYCH: Agitated at times but then somnolent, refuses to answer some questions, reqesting valium . DISCHARGE EXAM: Mental Status: AOx3, paranoid/agitated at times Left Ear: No erythema Pertinent Results: I. Radiology A. CXR [**2149-3-14**]: 1. Ill-defined opacity at the left lung base could be atelectasis; however, cannot exclude aspiration or superinfection. 2. Opacification of left costophrenic angle cannot exclude small pleural effusion. If concern, consider lateral view. II. Microbiology [**2149-3-15**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT [**2149-3-14**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] III. Labs A. Admission [**2149-3-14**] 07:10PM BLOOD WBC-7.8 RBC-3.83* Hgb-12.9* Hct-36.2* MCV-94 MCH-33.7* MCHC-35.7* RDW-13.6 Plt Ct-270 [**2149-3-14**] 07:10PM BLOOD Neuts-58.7 Lymphs-34.5 Monos-5.2 Eos-0.8 Baso-0.8 [**2149-3-14**] 07:10PM BLOOD Glucose-86 UreaN-11 Creat-0.9 Na-134 K-3.8 Cl-97 HCO3-26 AnGap-15 [**2149-3-14**] 07:10PM BLOOD ALT-25 AST-41* LD(LDH)-197 AlkPhos-78 TotBili-0.2 [**2149-3-14**] 07:10PM BLOOD Lipase-19 [**2149-3-14**] 07:10PM BLOOD Albumin-4.4 Calcium-9.3 Phos-3.7 Mg-1.8 [**2149-3-14**] 07:10PM BLOOD ASA-NEG Ethanol-89* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-POS [**2149-3-14**] 07:45PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.004 [**2149-3-14**] 07:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [**2149-3-14**] 07:45PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG B. Discharge [**2149-3-15**] 04:16AM BLOOD WBC-5.7 RBC-3.57* Hgb-11.7* Hct-33.6* MCV-94 MCH-32.7* MCHC-34.7 RDW-13.7 Plt Ct-217 [**2149-3-15**] 04:16AM BLOOD Glucose-78 UreaN-9 Creat-0.8 Na-141 K-4.3 Cl-106 HCO3-28 AnGap-11 [**2149-3-15**] 04:16AM BLOOD ALT-21 AST-28 AlkPhos-63 TotBili-0.2 [**2149-3-15**] 04:16AM BLOOD Calcium-8.1* Phos-3.6 Mg-2.1 ## Pending studies: [**2149-3-14**] Blood culture pending [**2149-3-15**] MRSA screening pending Brief Hospital Course: 44-year-old gentleman with a history of alcoholism and suicidal ideation who presents with intentional overdose of ? gabapentin +/- other medications (seroquel, thorazine, clonidine also in bag). Toxidrome cleared with supportive measures. No evidence of active medical conditions which would require ongoing inpatient medical issues. Patient suitable for transfer to inpatient psychiatric facility for stabilization of his decompensated psychiatric disease. # Drug overdose secondary to suicide attempt Exact ingestion is uncertain but likely includes 87 tablets of Gabapentin (dose of tablets unknown). TCA level was also positive though unclear if he overdosed on this as well. Patient monitored closely, able to protect airway, and provided supportive measures with clearing of mental status. ECG monitored and did initially demonstrate QTc prolongation which has now stabilized. # Suicidal Ideation: Pt endorsed intermittent suicidal ideations without plan and was placed on suicide precautions with 1:1 security sitter given agitation. Psychiatry followed closely. # Depressive disorder NOS and Psychosis NOS Psychiatry assessed patient with depressive disorder NOS, psychosis NOS, and polysubstance abuse in addition to ineffective coping mechanisms. Recent TSH, UA, head CT not suggesting disorder secondary to generalized medical condition. He was re-started on chlorpromazine 100 mg PO BID, risperidone 3 mg PO HS. Psychiatry suggested restarting seroquel 300mg qHS this evening. He was started on diazepam 5mg [**Hospital1 **] due to high level of anxiety (This was in addition to Valium with CIWA scale). Suggest continuing to monitor a daily ECG, paying attention to QTc as you uptitrate his seroquel and thorazine. # ALCOHOL WITHDRAWAL: Ethanol level 89 mg/dL on admission. He was started on CIWA scale consisting with diazepam 5mg Q4PRN CIWA>10 which was decreased to 2.5mg Q4;PRN. CIWA on discharge was 15, and alcohol withdrawal should be continued to be treated. # EAR SWELLING: Patient has likely superficial cellulitis. He was started on bactrim and keflex for MRSA coverage that should be continued for 5-days total (last dose on [**2149-3-18**]). No visible erythema remaining at time of discharge. There is desquamation of ear which demonstrates resolving cellulitis. # Pustular acne Pt started on clindamycin topical. Acne treatment should be followed up by a PCP. # HYPERTENSION: Per old records, patient has a history of hypertension. Takes propranolol 20mg [**Hospital1 **] which we presume is for hypertension. This was initially held in setting of overdose but should be restarted. Please set up PCP appointment on discharge so patient can have BP check. #. HYPERLIPIDEMIA: Outpatient follow-up advised. CODE STATUS: Full EMERGENCY CONTACT: None (per patient he is homeless, no recent contact with family) TRANSFER OF CARE: --Psychiatry has advised that medications be administered by VNA rather than self-administered --CSU should coordinate with outpatient prescriber to be certain that she is aware of his tendency to abuse and/or sell medications, the extent of his drinking, and multiple admissions for psychiatric issues --It would be good to simplify his medication regimen including reduction of medications with anticholinergic effects including chlorpromazine and benztropine. --Blood pressure check by his PCP. Medications on Admission: Outpatient Meds, per [**Company 4916**] [**State 85064**],[**Location (un) 669**] ([**Location (un) 86**]), [**Numeric Identifier 18406**], ([**Telephone/Fax (1) 85065**]: Filled [**3-5**]: clonidine 0.1 mg 1 [**Hospital1 **] prn anxiety #60 benztropine 1 mg 1 [**Hospital1 **] prn #60 imipramine 50 mg 1 qhs #30 propranolol 20 mg 1 [**Hospital1 **] #60 risperidone 3 mg 1 qhs #30 chlorpromazine 200 mg #90 1 tid chlorpromazine 100 mg 1 qid prn #120 seroquel 300 mg #60 1 [**Hospital1 **] Discharge Medications: 1. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for fever or pain. 2. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): last dose [**2149-3-18**]. 3. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): last dose [**2149-3-18**]. 4. clindamycin phosphate 1 % Solution Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for acne. 5. chlorpromazine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 7. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q 12H (Every 12 Hours). 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 10. quetiapine 300 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO QHS (once a day (at bedtime)). 11. risperidone 2 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 12. diazepam 2 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for CIWA > 10. 13. propranolol 20 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital3 15986**]--[**Hospital1 **] Health System Discharge Diagnosis: Primary diagnosis: medication overdose, depression NOS with suicide attempt, psychosis NOS, left ear superficial cellulitis, prolonged QTc Secondary: hypertension, hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Intermittent suicidal ideations. Need suicide precautions. Some psychotic symptoms include 'people monitoring mind.' Alert and oriented to person, place, time usually Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for a drug overdose secondary to a suicide attempt. You were evaluated and provided supportive measures. Psychiatry also evaluated you and recommended a stay at a facility to optimize your psychiatric condition. You were also treated for a left ear cellulitis with an antibiotic. Medication changes: DECREASE chlorpromazine from 200mg three times per day TO 100mg three times per day STOP chlorpromazine 100 mg 1 four times per day, as needed STOP clonidine 0.1 STOP benztropine STOP imipramine START cephalexin (last dose [**2149-3-18**]) START Bactrim DS (last dose [**2149-3-18**]) START clindamycin 1 apply thin amount to entire face for acne twice daily START Diazepam 2.5 mg by mouth every 4 hours if CIWA scale > 10 START Nicoderm patch Followup Instructions: Please follow-up with your primary care physician after discharge from facility: SIRAKOV,DIMITRE T. [**Telephone/Fax (1) 24335**]

[ "303.90", "V60.0", "969.3", "706.1", "272.4", "682.8", "291.81", "E950.3", "E950.4", "311", "401.9", "966.3", "298.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11679, 11759

6516, 9880

303, 309

11982, 11982

4686, 6493

13104, 13238

3854, 3880

10420, 11656

11780, 11780

9906, 10397

12300, 12616

3895, 4579

4595, 4595

12636, 13081

231, 265

337, 2183

11799, 11961

11997, 12276

2205, 3158

3174, 3838

13,569

147,784

13548

Discharge summary

report

Admission Date: [**2112-3-7**] Discharge Date: [**2112-4-6**] Date of Birth: [**2060-2-12**] Sex: F Service: NOTE: First, we will summarize the Medical [**Year (4 digits) 15593**] Care Unit course followed by a summary of general [**Hospital **] hospital course. HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old woman with a history of hypertension and chronic obstructive pulmonary disease who was admitted to the [**First Name (Titles) **] [**Last Name (Titles) 15593**] Care Unit on [**2112-3-7**] as a transfer from [**Hospital3 417**] Hospital where she had presented one day prior with a history of acute onset epigastric abdominal pain without any associated nausea, vomiting or diarrhea. She had had no fevers. At the outside hospital, she had laboratory studies which showed an elevated white blood count to approximately 25 and an elevated amylase. An abdominal CT was consistent with pancreatitis. The patient was admitted overnight for fluid resuscitation and pain control. While at the outside hospital, her white count continued to rise, her urine output decreased and she had an episode of coffee ground emesis which cleared with nasogastric lavage. She was briefly guaiac positive. She was also noted to have a left purple index finger on presentation to the outside hospital. She was subsequently transferred to the [**Hospital3 **] on the 15th for more acute management of her progressively worsening pancreatitis. Her urine output had been decreasing. Her mental status was also decreasing, as was her ability to ventilate and oxygenate. Her fingerstick blood sugars were becoming increasingly difficult to control in the 400s. On admission to the [**Hospital6 256**], she had [**1-26**] Rinson's criteria. The patient was aggressively treated with intravenous fluids and empirically started on a two week course of imipenem on [**2112-3-8**]. Surgery was consulted and did not feel there was any role for direct surgical intervention in the patient's necrotizing pancreatitis. Abdominal CT scan performed following admission to the [**Hospital3 **] confirmed necrotizing pancreatitis as well as multiple abdominal infarcts in the spleen, liver, kidneys bilaterally. Follow up head CT reveals multiple embolic infarcts as well. The patient was noted to have a progressively more necrotic right index finger which was also thought to be secondary to an embolic event. Also noted on the abdominal CT of [**2112-3-8**] was an aortic thrombus which was thought to potentially be the origin of these embolic events, potentially the origin of the initial pancreatitis as well. On [**2112-3-9**], the patient was started on intravenous Neo-Synephrine for decreased arterial pressures. A right upper quadrant ultrasound was negative for evidence of cholecystitis for gallstones. On [**2112-3-9**], a Swan-Ganz catheter was placed for better hemodynamic monitoring. The patient's Swan-Ganz numbers were consistent with a vasodilatory sharp like picture which was consistent with her necrotizing pancreatitis. Given the patient's rising fingerstick blood sugars in the setting of pancreatic necrosis, the patient was maintained on an insulin drip. On [**2112-3-10**], the patient underwent a transesophageal echocardiogram which was negative for a valvular lesion. On that same date, the patient was able to come off of pressors. The patient was also noted to have a persistent left lower lobe with a question of a parapneumonic effusion. Following ultrasound guided thoracentesis, this was found to be consistent with an exudative effusion thought secondary to pancreatitis. As noted above, CT scan of the head revealed a right cerebellar, left occipital and left frontal lesions. Transesophageal echocardiogram was also notable for an aortic thrombus as had been noted on abdominal CT scan. There was no obvious lesion proximal to takeoff of the carotids and thus it was difficult to explain the brain lesions. While in the [**Date Range 15593**] Care Unit, anticoagulation with heparin was considered, but deferred secondary to high bleeding risk in the setting of necrotizing pancreatitis. An EEG was performed while in the [**Date Range 15593**] Care Unit which was consistent with frontal slowing, no seizure activity. On [**2112-3-16**], the patient began to develop large volume diarrhea up to 48 liters per day, thought secondary to secretory diarrhea. Her Clostridium difficile cultures were negative. On [**3-17**], the patient was extubated and treated empirically for Clostridium difficile with Flagyl. Her diarrhea subsequently improved somewhat. On [**3-18**], the patient was put back on an insulin drip for uncontrolled fingerstick blood sugars. On [**3-19**], a small bowel follow through was performed to evaluate question of secretory diarrhea which was thought to be secondary to inflammation secondary to pancreatitis versus ischemia. The patient was noted to have some persistent fevers while on antibiotics which were attributed to her multiple organ infarcts. Follow up MRA of the aortic arch revealed a distal aortic arch thrombus/atheroma with no proximal lesions to explain the brain emboli. At the time of her transfer to the floor, the patient remained persistently tachypneic and tachycardic. Her electrocardiogram did not reveal any evidence of right heart strain to suggest pulmonary embolism. Prior to her transfer to the floor, the patient had gradual improvement in her mental status. She did require reintubation on [**3-20**] for increased tachypnea. The patient was also noted to be somewhat hypernatremic prior to transfer to the floor and was treated with free water boluses. On [**2112-3-21**], the patient completed her two week course of imipenem. A postpyloric feeding tube was temporarily placed. On [**2112-3-24**], the patient was again weaned and extubated. She still had some marked confusion and disorientation at the time of her transfer to the floor. She received a three day course of vancomycin for concern for a line infection after spiking a fever and the presence of a central line. Please see below for events of additional hospital course. PAST MEDICAL HISTORY: 1. Hypertension 2. Chronic obstructive pulmonary disease 3. History of diverticulitis 4. History of cholecystectomy 5. History of mediastinal mass, later found to be likely secondary to a herniated lobe of liver. 6. History of vaginal hysterectomy. OUTPATIENT MEDICATIONS: 1. Univasc 5 mg po qd 2. Atenolol 50 mg po qd 3. Hydrochlorothiazide 25 mg po qd 4. Premarin 1.25 mg po qd 5. Tetracycline 250 mg qid since [**2-20**]. 6. Combivent 7. Flovent MEDICATIONS ON TRANSFER TO FLOOR FROM [**Month (only) **] CARE UNIT: [**Unit Number **]. Tylenol prn 2. Flovent [**Hospital1 **] 3. Albuterol and Atrovent nebulizers prn 4. Miconazole powder prn 5. Protonix 40 mg po qd 6. Nystatin ointment prn 7. Desitin prn 8. Enteric coated aspirin prn 9. Plavix 10. Risperidone 11. Regular insulin sliding scale 12. NPH ALLERGIES: Patient with no known drug allergies. SOCIAL HISTORY: The patient is married, worked as a switchboard operator and [**Hospital6 10353**]. She drinks alcohol occasionally and she smoked one to one and a half packs per day x30 years. FAMILY HISTORY: Noncontributory. HOSPITAL COURSE BY SYSTEM: 1. GASTROINTESTINAL: Patient with necrotizing pancreatitis of unclear etiology. One explanation is that the patient embolized to her pancreas from her arterial thrombi as she appeared to have done to her other abdominal organs, as well as to her head precipitating the initial necrotizing pancreatitis. It is also possible that the patient became hypercoagulable following her pancreatitis. While on the floor, the patient's abdominal pain resolved. Her diet was gradually advanced. Her amylase and lipase remained within normal limits. She will have outpatient follow up with gastrointestinal. Repeat MRI of the abdomen during the latter week of her hospital stay revealed persistent evidence of pancreatic necrosis. 2. DIARRHEA: Patient with a perfuse secretory diarrhea while in the [**Hospital6 15593**] Care Unit. Clostridium difficile cultures were consistently negative. Another possibility is that the patient has some malabsorption secondary to her pancreatitis. Should her diarrhea recur, this will need to be followed up further as an outpatient. 3. GASTROINTESTINAL: Patient with evidence of upper gastrointestinal bleed on her initial presentation in the setting of her pancreatitis. This may be secondary to acute gastritis. Her hematocrit remained stable throughout her hospital course after leaving the [**Hospital6 15593**] Care Unit. 4. CARDIOVASCULAR: Patient with evidence of distal aortic arch thrombus with unclear etiology. It was initially unclear whether this was thrombus versus atheroma. It may actually be a combination of two. At the time of discharge, it still remains unclear whether thrombus formed secondary to or prior to pancreatitis. In any case, the patient was maintained on anticoagulation which should be of indeterminate, perhaps even lifelong length awaiting follow up with hematology. 5. PULMONARY: Patient with a history of chronic obstructive pulmonary disease. She was maintained on albuterol and Atrovent nebulizers after coming to the floor. 6. RENAL: The patient has had a stable creatinine and is coming to the floor. 7. HEMATOLOGICAL: As noted above, it was unclear whether the patient had an underlying hypercoagulable state. Hypercoagulable work up for inherited thrombophilias was negative. Pending at the time of discharge was the result of the prothrombin mutation analysis and the beta 2 glycoprotein 1, latter of which can be a marker for antiphospholipid syndrome. In any case, the patient had a negative lupus anticoagulant and anticardiolipin antibody, as well as the other usual thrombophilia. Following her transfer to the floor, the patient was noted to have some upper extremity swelling, left greater than right. Ultrasound of the upper extremities revealed proximal deep venous thromboses, including right subclavian and axillary vein thrombosis, as well as left internal jugular and left subclavian vein thrombosis. These deep venous thromboses were thought to be secondary due to her hypercoagulable state secondary to pancreatitis. Given the presence of these lesions and previously noted arterial thrombus, the patient was started on heparin and given a therapeutic overlap of heparin and Coumadin. The patient will need one further day of heparin on [**2112-4-6**] prior to his discontinuation on [**2112-4-7**]. The patient should remain on Coumadin indefinitely with a goal INR of 2 to 3 with hematologic follow up and follow up with the [**Hospital3 **]. The patient was noted to have a necrotic finger on the right index finger. This was likely secondary to an embolic event. The patient has follow up scheduled with vascular surgery for amputation. 8. NEUROLOGIC: Patient with residual left sided weakness secondary to her brain lesions. Her mental status has mainly resolved and returned to baseline at the time of discharge. She is to receive outpatient physical therapy and occupational therapy, as well as training in self blood sugar monitoring which she was unable to do at the time of discharge secondary to lack of dexterity on the left side. 9. ENDOCRINE: The patient was an insulin requiring diabetic secondary to her pancreatitis. She was maintained on a regimen of NPH and a regular insulin sliding scale. She has a follow up appointment scheduled with the [**Last Name (un) **] Diabetes Center. DISCHARGE CONDITION: Stable DISCHARGE DIAGNOSES: 1. Necrotizing pancreatitis 2. Embolic infarcts to brain, liver, spleen, kidneys and skin 3. Left sided weakness secondary to brain infarcts 4. Gastrointestinal bleed 5. Chronic obstructive pulmonary disease 6. Secretory diarrhea 7. Diabetes, insulin requiring 8. Deep venous thromboses of bilateral upper extremities DISCHARGE MEDICATIONS: 1. Heparin drip with a goal PTT of 60 to 100 which should be discontinued on [**2112-4-7**]. Please see heparin protocol on discharge page 1. 2. Coumadin, goal to keep INR 2 to 3. Daily INR should be checked and Coumadin level adjusted. The patient had been requiring approximately 2 mg per night at the time of discharge. 3. NPH insulin 8 units subcutaneous q a.m., 20 units subcutaneous q p.m. 4. Regular insulin sliding scale. Please see attached sheet on page 1. 5. Protonix 40 mg po qd 6. Atenolol 50 mg po qd 7. Enteric coated aspirin 325 mg po qd 8. Nystatin ointment prn 9. Combivent 2 puffs qid 10. Flovent 2 puffs [**Hospital1 **] 11. Univasc 5 mg po qd OUTPATIENT REHABILITATION TREATMENT: 1. The patient should receive physical therapy and occupational therapy as noted in physical therapy consults. 2. The patient should receive training in self blood sugar monitoring, as she currently lacks dexterity. The patient has follow up appointments as scheduled. Please see page 1 for details. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-981 Dictated By:[**Last Name (NamePattern4) 4689**] MEDQUIST36 D: [**2112-4-6**] 07:38 T: [**2112-4-6**] 07:44 JOB#: [**Job Number **]

[ "453.8", "434.11", "444.89", "577.0", "250.02", "444.1", "787.91", "578.9", "518.82" ]

icd9cm

[ [ [] ] ]

[ "96.04", "34.91", "99.15", "96.6", "88.72", "38.93", "96.72" ]

icd9pcs

[ [ [] ] ]

11712, 11720

7304, 7322

11741, 12068

12091, 13340

7349, 11690

6488, 7090

314, 6186

6208, 6464

7107, 7287

80,833

177,027

41171

Discharge summary

report

Admission Date: [**2148-12-10**] Discharge Date: [**2148-12-16**] Date of Birth: [**2077-12-25**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 2080**] Chief Complaint: GI Bleed Major Surgical or Invasive Procedure: 1. Nasogastric tube placement 2. Colonoscopy 3. Esophagealgastroduodenoscopy 4. Angiogram with coiling History of Present Illness: This is a 70 year-old male with a history of gout and depression who presents with GI bleed and transferred to [**Hospital1 18**] for further management. The patient presented to [**Hospital3 3765**] on [**2148-12-2**] with complaints of [**2-1**] days of multiple large liquid maroon stool. He denied any recent NSAID use, but did report taking ibuprofen 3 weeks prior during a UTI. His Hct on admission was noted to be 18. He underwent EGD on [**12-2**] and was noted to have mild gastritis & esophagitis, but no source of GI bleed. He undewent colonscopy the following day that showed old and new blood in the colon with non-bleeding diverticula, but no clear source of bleeding. . The evening of [**2148-12-3**] the patient had an NSTEMI with the development of burning chest pain and ECG showing ST depression in v3-v4. CE were positive with a trop 2.90 (ULN: 0.78), but flat CK (89). ECHO showed EF 40-45% with wall motion abnormality consistent with apical infarct. The patient was started on low dose beta-blocker and ASA, plavix and heparin gtt were not started given his GI bleed. He undewent a tagged RBC scan on [**2148-12-9**] that did not show evidence of active bleeding. He also undewent a push enteroscopy on [**2148-12-9**] that also did not identify the source of the bleed. The patient has received a total of 17U pRBC since his admission requiring an average of 2U per day. He states that he felt orthostatic at times, but remained hemodynamically stable. He continues to have maroon stools with his last one being yesterday. He has been NPO for the last 2 days. The patients Hct this morning was 24.2. CE were wnl at 0.206. He was transfused en route. . On arrive the patient states he feels well without N/V or abdominal pain. . Of note, the patient also had 2 episodes of transient visual distubances and was evaluated by neuro. He had carotid U/S that did not showed no hemodynamically significant carotid stenosis. It was thought to be related to his migraines. Past Medical History: Gout Depression h/o of Gastric Ulcers in his 20's Social History: Married and lives with his wife. [**Name (NI) **] is a retired Language teacher. He smoked 1ppd x 10years but quit 40yrs prior to admission. He has been sober for the last 20 years. His daughter is a pediatrician. Family History: Patient was adopted. Physical Exam: On admission: VS: 94.3 127/44 73 100% BiPAP 50% GEN: somnelent, wearing BiPAP mask, able to nod yes/no to questions and opens eyes to voice, knows daughter by the bedside. HEENT: MM dry, no conjunctival icterus, pallor, or injection. Neck is supple without LAD or JVD RESP: Mild wheezes anterior throughout. CV: RRR. no m/r/g ABD: Soft, NT/ND, no HSM, no rebound tenderness or guarding EXT: cool distally, with symmetric palpable pulses bilaterally. No edema. SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. Generalized 4/5 weakness in upper and lower extremities, without focal deficits. Pertinent Results: Labs on admission: [**2148-12-10**] 05:23PM BLOOD WBC-6.7 RBC-3.17* Hgb-9.9* Hct-27.6* MCV-87 MCH-31.2 MCHC-35.8* RDW-16.4* Plt Ct-178 [**2148-12-10**] 05:23PM BLOOD Neuts-80* Bands-0 Lymphs-16* Monos-3 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2148-12-10**] 05:23PM BLOOD PT-13.5* PTT-27.1 INR(PT)-1.2* [**2148-12-10**] 05:23PM BLOOD Glucose-93 UreaN-20 Creat-0.9 Na-140 K-3.7 Cl-109* HCO3-28 AnGap-7* [**2148-12-10**] 05:23PM BLOOD ALT-7 AST-11 LD(LDH)-79* CK(CPK)-44* AlkPhos-36* TotBili-0.5 [**2148-12-10**] 05:23PM BLOOD Albumin-2.2* Calcium-8.1* Phos-2.6* Mg-1.8 Cardiac enzymes: [**2148-12-10**] 05:23PM BLOOD CK-MB-3 cTropnT-0.24* [**2148-12-11**] 02:35AM BLOOD CK-MB-2 cTropnT-0.18* [**2148-12-11**] 06:07AM BLOOD CK-MB-4 cTropnT-0.18* [**2148-12-11**] 04:07PM BLOOD CK-MB-9 cTropnT-0.20* [**2148-12-11**] 10:54PM BLOOD CK-MB-9 cTropnT-0.23* Imaging: [**12-10**] Echo: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and ejection fraction are normal (LVEF 70%). The apex is focally dyskinetic. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are myxomatous. There is borderline/mild posterior leaflet mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Impression: focal apical dyskinesis; consider Takotsubo cardiomyopathy vs apical infarct [**12-10**] CXR: roughly 3-cm wide opacity projecting over the intersection of the left fourth anterior and tenth posterior ribs could be superimposition of normal structures or early region of consolidation, particularly if patient has had aspiration episodes. Followup advised. Lungs are otherwise clear. Heart size normal. No pleural or mediastinal abnormalities. No free subdiaphragmatic gas and no pneumothorax. . Tagged RBC scan INTERPRETATION: Following intravenous injection of autologous red blood cells labeled with Tc-[**Age over 90 **]m, blood flow and dynamic images of the abdomen for 120 minutes were obtained. Blood flow images show normal abdominal blood flow. Dynamic blood pool images show intermittent brisk bleeding from the hepatic flexure of the colon. Bleeding was first noticed at about 40 minutes. IMPRESSION: Active bleeding from the hepatic flexure. EGD: Findings: Esophagus: Normal esophagus. Stomach: Normal stomach. Duodenum: Normal duodenum. Other findings: No blood or bleeding seen. Impression: No blood or bleeding seen. Otherwise normal EGD to third part of the duodenum COLONOSCOPY: Findings: Contents: Extensive red blood and large clots were seen throughout the colon. The clots could not be suctioned adequately despite multiple attempts. In addition, the magnitude of blood was too great to allow for evaluation of the mucosa. The procedure was aborted. Excavated Lesions A single non-bleeding diverticulum was identified in the sigmoid colon. Per report, there were additional diverticula throughout the sigmoid on the last procedure, so we presume that these were obscured by the massive amount of blood. Impression: Red blood and clots throughout the visualized portions of the colon. Diverticulum in the sigmoid colon Otherwise normal colonoscopy to splenic flexure DISCHARGE LABS: [**2148-12-16**] 04:09AM BLOOD WBC-4.6 RBC-3.47* Hgb-10.8* Hct-31.2* MCV-90 MCH-31.2 MCHC-34.7 RDW-16.0* Plt Ct-219 [**2148-12-15**] 04:56AM BLOOD Glucose-130* UreaN-11 Creat-0.9 Na-141 K-3.9 Cl-109* HCO3-29 AnGap-7* [**2148-12-14**] 04:20AM BLOOD CK-MB-3 cTropnT-0.31* [**2148-12-13**] 04:32AM BLOOD Triglyc-102 Brief Hospital Course: Mr [**Known lastname 7842**] is a 70 year-old male with a history of gout and depression who was transferred from [**Hospital3 3765**] for further evaluation of GI bleed. . #. Large volume GI Bleed: Thorough OSH work-up without clear source identified. Had received 17units of pRBCs at OSH. Transferred here for question capsule study. Continued to have BRBPR. HCT trended Q8hrs. Required additional 12units of pRBC in house (total of 28units). Fibrinogen, coags wnl in setting of massive transfusion requirement. GI bleed work-up in house: tagged RBC scan on [**12-12**] with dynamic blood pool images demonstrated intermittent brisk bleeding from the hepatic flexure of the colon. Subsequent angio on [**12-12**] revealed blushing in area of hepatic flexure, no intervention performed. Imaging reviewed and on [**12-13**] decision made to repeat IR guided angio. 3 coils successfully deployed in the vasculature supplying hepatic flexure. HCT stable post-procedure. Per GI will likely plan on outpatient colonoscopy. On day of transfer out of [**Hospital Unit Name 153**] transitioned from IV Q12hrs PPI -> PO PPI, maintained on clear diet wirh plan to advance as tolerated. Of note, due to large volume dye load patient received renal protective N-Ac and bicarbonate. TO DO: - will need follow up CBC - will need repeat colonoscopy at [**Hospital1 18**] in next 2-4 weeks to re-assess area - recommend surgical consultation at [**Hospital1 18**] to discuss semi-elective resection of area of bowel that was bleeding. . #. NSTEMI: Pt with NSTEMI in the setting of GI bleed and severe anemia at OSH. Likely secondary to demand in setting of blood loss. Patient with 2 episodes with chest pain in the ICU. EKG with dynamic changes in V2-4, flat CKs and trops peak at 0.3. Cards consulted initially for question of pre-operative risk if GI bleed necessitated. Bleed successfully controlled with coil. Per cards, NTEMI not an indication for catherization however will likely require stress as an outpatient. At time of transfer pt chest pain free with biomarkers downtrending. Low dose metoprolol 6.25mg [**Hospital1 **] discontinued on day of transfer due to asymptomatic hypotension in the 90s. Continued on simvastatin 40mg daily. Of note has not been given ASA, plavix or heparin given his continued GI bleed. Transfusion goal > 30. TO DO: - Needs to follow up with cardiology ASAP to consider stress testing, cath, and further medical management - ASA on HOLD given bleeding. Can re-consider after further GI/cardiology evaluation - Beta blocker held given HYPOTENSION with this medication in [**Hospital Unit Name 153**] with chest pain. Can consider on follow up - ON high dose statin . #. Gout. Continued home allopurinol . #. Depression. Continued home Venlafaxine XR 75mg daily, Klonopin qhs prn. Medications on Admission: Allopurinol Venlafaxine ASA 81mg daily Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 2. venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). 3. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Outpatient Lab Work Please check a CBC and EKG on next follow up Discharge Disposition: Home Discharge Diagnosis: Lower GI bleed Blood loss anemia NSTEMI (non-ST elevation myocardial infarction) Depression Gout Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for a large lower GI bleed, as well as a heart attach. The bleeding was caused by an area in your "hepatic flexure." After many blood transfusions, the bleeding was stopped via angiogram and coiling. Your heart attack was caused by a lack of blood supply to the heart. You will need to follow up with your PCP closely for repeat blood work and for coordination of care. You will need to see your cardiologist as soon as possible to further assess your recent heart attack and need for further testing and treatment. You will also need to schedule a colonoscopy in the next few weeks, and consider a surgery evaluation. This is because we are not definitively sure where or why you had your bleeding Please call your doctor and/or return to the nearest emergency department immediately if your bleeding resumes, OR you experience chest pain or shortness of breath. Your aspirin has been STOPPED for now given your severe bleeding, though you may have to go back on it after discussion with your PCP and cardiologist. Followup Instructions: You have an appointment with Dr. [**Last Name (STitle) 26929**] in Wednesday [**12-18**] at 1:30PM in [**Location (un) **] office Please call [**Telephone/Fax (1) 463**] to schedule a colonoscopy at [**Hospital1 18**] within the next 2-4 weeks. Please follow up with your cardiologist as soon as possible, Dr. [**Known firstname **] [**Last Name (NamePattern1) 89679**]. Please call [**Telephone/Fax (1) 85388**] to schedule an appointment, or speak with your PCP about [**Name Initial (PRE) **] referral. We recommend that you follow up with a surgeon here to discuss possible surgical options. Please call [**Telephone/Fax (1) 600**] to schedule an appointment

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icd9cm

[ [ [] ] ]

[ "46.95", "38.86", "88.47", "45.23", "45.13", "38.93", "99.29" ]

icd9pcs

[ [ [] ] ]

10945, 10951

7409, 10217

317, 421

11092, 11092

3433, 3438

12309, 12980

2762, 2784

10306, 10922

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269, 279

449, 2438

3452, 4002

11107, 11219

2460, 2511

2527, 2746

47,443

195,656

37293

Discharge summary

report

Admission Date: [**2135-7-25**] Discharge Date: [**2135-7-28**] Date of Birth: [**2078-5-5**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor First Name 2080**] Chief Complaint: acute renal failure, poor urine output Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a 57 yo male with hx of HTN, who presents with a [**3-2**] week hx of decreased urinary output and dysuria. Over the same time period patient is also endorsing difficulty swallowing, with a foreign body sensation in his throat. Given almost compleate decline in UOP over the past 2-3 days, he presented to ED for evaluation. In addition, he reports 15 Ib weight loss over the past 6 months. Of note he had a screening colonoscopy at the beginning of [**Month (only) **], and on inspection, there was a slightly small firm prominence in the anal canal it was strongly recommend that he see a colorectal surgeon for that. . His review of system is negative for fevers, chills, URI, ?cough (inconsistent report), no hemoptysis, no diarrhea, no dizziness. . In the ED, initial vs were: T97.7 P 88 BP 93/62 R 20 O2 sat99%RA. . . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies arthralgias or myalgias. Denies rashes or skin changes. . Past Medical History: HTN Chronic lower back pain Impotence Social History: Originally from [**Country 2045**]. Independent with all ADLs at baseline. Tobacco: 1 ppweek since teens Alcohol: rarely Illicits: never Family History: No known family history of any renal diseases. Otherwise non-contributory. Physical Exam: ADMISSION EXAM: Vitals: T: 99.4 BP: 104/58 P: 74 R: 12 O2: 99%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, tender in lower quadrants as well a, non-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: ADMISSION LABS: [**2135-7-25**] 02:10PM NEUTS-74.9* LYMPHS-13.8* MONOS-10.4 EOS-0.3 BASOS-0.6 [**2135-7-25**] 02:10PM WBC-9.1 RBC-4.99 HGB-14.2 HCT-40.0 MCV-80* MCH-28.4 MCHC-35.4* RDW-15.3 [**2135-7-25**] 02:10PM CALCIUM-9.8 PHOSPHATE-4.2 MAGNESIUM-2.0 [**2135-7-25**] 02:10PM CK(CPK)-23* [**2135-7-25**] 02:10PM estGFR-Using this [**2135-7-25**] 02:10PM GLUCOSE-105* UREA N-43* CREAT-2.9*# SODIUM-134 POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-19* ANION GAP-22* [**2135-7-25**] 02:40PM LACTATE-1.8 [**2135-7-25**] 09:16PM SED RATE-100* [**2135-7-25**] 09:16PM C3-162 C4-67* [**2135-7-25**] 09:16PM CRP-GREATER TH [**2135-7-25**] 09:16PM [**Doctor First Name **]-NEGATIVE [**2135-7-25**] 09:16PM ANCA-NEGATIVE B . URINE STUDIES: [**2135-7-25**] 02:10PM URINE BLOOD-LG NITRITE-POS PROTEIN->300 GLUCOSE-NEG KETONE-15 BILIRUBIN-MOD UROBILNGN-1 PH-5.0 LEUK-LG [**2135-7-25**] 02:10PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.025 [**2135-7-25**] 07:23PM URINE HOURS-RANDOM CREAT-489 SODIUM-35 POTASSIUM-32 CHLORIDE-28 . . MICRO DATA: [**2135-7-25**] 2:10 pm URINE Site: CLEAN CATCH **FINAL REPORT [**2135-7-27**]** URINE CULTURE (Final [**2135-7-27**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 16 I CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . ADDITIONAL STUDIES: . [**7-25**] RENAL ULTRASOUND: The right kidney measures 9.2 cm. The left kidney measures 9.3 cm. Both kidneys are normal in appearance without evidence of hydronephrosis or son[**Name (NI) 5326**] evidence renal mass. The urinary bladder is decompressed around a Foley catheter. IMPRESSION: No hydronephrosis. . CXR: IMPRESSION: 1. Cephalization of pulmonary vessels, suggesting mild pulmonary edema 2. Emphysema. 3. Crowding of vessels at the right cardiophrenic angle, most consistent with atelectasis, but an early infectious process cannot be ruled out. Brief Hospital Course: 57yo male who presented with nearly 2 weeks of poor PO intake, mild low abdominal / suprapubic discomfort, and very poor urine output. Patient found to have UTI but never became overtly uroseptic during this hospital stay. He also had ARF which was attributed to pre-renal causes as well starting ACE-inhibitor over prior week, as well as possible mild ATN in setting of low blood pressure. He had rapid improvement with antibiotics and antibiotics. Please see more detailed hospital course as outlined below per problem. . #UTI: Initial urinalysis in ED revealed WBCs, bacteria and positive nitrites concerning for urinary source. Patient was started on IV Ciprofloxacin in ICU and preliminary urine cultures grew out E.Coli. R/S Data showed sensitivity to Cipro and he was switched to PO cipro on [**7-27**], and should continue a 10 day course. . # Acute Renal Failure: Per recent records the patient's baseline Creatinine is betweeen 1.2 -1.3 range. He presented with Cr 2.9 in ED with several days of decreased urine output and decreased oral intake due to feeling intermittently nauseas. A foley was placed in the ED with no output of urine. A STAT renal ultrasound was done and was reassuring with no obstructions, abnormalities or hydronephrosis. It was felt that patient had no urine output secondary to severe dehydration. He was admitted to the ICU with ARF. He was given 3 L of IV fluid resulting in ~ 100-150 cc/hr of urine output and decline in creatinine by the next afternoon to 1.4 range from 2.9. His ARF was attributed to pre-renal azotemia with his limited PO intake , along with his recent start of lisinopril just days prior. Also, ATN may also have been a smaller element contributing to his ARF, although no classic granular casts noted. Calculated FeNa also indicated a pre-renal etiology. Moreover, his rapid improvement and excellent urine output following 4 L IVFs seemed to indicate clinically his ARF cause mostly from severe dehydration effects. As outlined above, he had a UA which was positive for nitrites, leukocytes and protein >300, an he was treated with Cipro for UTI. HCTZ restarted at D/C. ACE-I pending follow up. - Renal follow up is recommended. . #Mild nausea: Patient had some mild nausea which was attributed to both his UTI and ARF. This symptom resolved over 24 hours. He was given small doses of Zofran PRN for relief. . #Hypotension: Likely secondary to decreased po intake possibly complicated by early urosepsis. Resolved with fluid boluses over first few hours in ICU. Patient never required any pressors to control blood pressure. At time of his transfer to the medical floor his BPs had been in the 120s systolic ranges. . # Dysphagia: While patient in ICU he also complained of approximately 1 month of dysphagia. He mentioned noticing trouble swallowing items like meat and larger vegetables. He may have underlying Zenkers diverticula or other anomaly. For this issue, he had a speech and swallow consult which was normal. It is recommended that he undergo a video swallow non-urgently. . Medications on Admission: Home Medications ( reconciliation done with patient pharmacy*) . HCTZ 25 mg daily Cardizem 300 mg daily Lisinopril 5mg daily ( patient states started less than 1 wk ago) Vit B12 1000 mcg daily Viagra PRN Ultram 50mg TID PRN (ALSO:Previously filled - Percocet 5/325 [**1-29**] q4-6h prn, Megace) . Discharge Medications: 1. Diltiazem HCl 300 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. Disp:*10 Tablet(s)* Refills:*0* 3. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for Pain-: back pain. do not use with alcohol or driving. Disp:*10 Tablet(s)* Refills:*0* 5. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Discharge Disposition: Home Discharge Diagnosis: 1. Acute Renal Failure 2. Urinary Tract Infection with E. Coli 3. Hypotension 4. Hypertension, benign Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you here at [**Hospital1 771**]. You were admitted with trouble urinating and were found to have a urinary tract infection. You also had acute kidney failure which resolved after IV fluids, and by stopping your lisinopril. You were given antibiotics to treat your urinary tract infection and your symptoms resolved. . Please be sure to keep well hydrated. Medication changes: START ciprofoxacin 500mg twice daily through [**2135-8-2**] STOP lisinopril until follow up with your doctor . Please ask your doctors to arrange for a video swallowing study. Followup Instructions: Name: [**Name6 (MD) 83923**] [**Name8 (MD) 122**] NP Location: [**Hospital 3578**] COMMUNITY HEALTH CENTER Address: [**Hospital1 3579**], [**Location (un) **],[**Numeric Identifier 18406**] Phone: [**Telephone/Fax (1) 3581**] Appointment: Tuesday [**2135-8-2**] 3:30pm . Please follow up with a kidney doctor. Please call [**Telephone/Fax (1) 721**] for an appointment. . Please ask your doctor to help schedule a video swallowing study

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9106, 9112

5042, 8098

354, 360

9258, 9258

2509, 2509

10018, 10459

1836, 1912

8446, 9083

9133, 9237

8124, 8423

9409, 9798

1927, 2490

1238, 1604

9818, 9995

276, 316

388, 1219

2525, 5019

9273, 9385

1626, 1665

1681, 1820

62,927

109,943

36510

Discharge summary

report

Admission Date: [**2173-3-30**] Discharge Date: [**2173-4-6**] Date of Birth: [**2091-9-8**] Sex: F Service: MEDICINE Allergies: Demerol / Sulfa (Sulfonamide Antibiotics) / Promethazine Attending:[**First Name3 (LF) 458**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac Catheterization Dialysis History of Present Illness: 81 year old woman with ESRD from hypertensive glomerulonephritis s/p bilateral nephrectomy on dialysis, s/p recent admission for "multilobar pneumonia", admitted on [**2173-3-25**] after developing chest pain at rest. Patient was admitted to LGH two weeks prior to this admission with fevers, AMS, and CXR consistent with multifocal PNA. At that time she was also have chest pain that was thought [**1-18**] GI etiology. She had a barium swallow that showed marked dysmotility of the esophagus with tertiary contractions but no GERD or strictures. For the PNA she was started on levoquin and her fevers trended down. She was then transitioned to rocephin and sent back to [**Location (un) **] House. She was home for one day and then developed chest pain at rest. This responded to nitroglycerin at home. She was then taken to the ED at LGH. In the ED at LGH she had an EKG that showed ST depressions in the lateral and anterior leads which was unchanged from prior EKGs. Her troponin I was 4.15. CK was negative. She was admitted to LGH for NSTEMI. While admitted she remained painfree for several days. Cardiology was consulted the next day and recommended cardiac cath as in retrospect it seemed that the multifocal PNA may have been acute CHF exacerbation that could have been related to ischemia. Therefore the patient was started on heparin gtt, plavix, and aspirin and transferred to the LGH CCU to await catheterization. She received last dialysis Saturday [**2173-3-27**](removed 2.6 liters) via left arm fistula. She remained chest pain free for the next few days. On [**2173-3-30**] she underwent cath where she was found to have an 85% LAD stenosis and a 95% lesion in a small RCA. Meds in cath lab included 0.5mg versed80cc contrast, 50 cc NS. Sheaths were pulled as there were plans for her to have dialysis and then transfer to [**Hospital1 18**] tomorrow for PCI. However, following cath, pt developed 10/10 chest pain that was treated with 6mg morhine, zofran, ativan, SL nitro, IV nitro at 30mcg/min and was transferred to [**Hospital1 18**] for PCI (painfree). . Vitals on transfer: HR 60SR, BP 150/50, Satting 96% on 2L. . Patient underwent second cardiac cath at [**Hospital1 18**] during which she received 12mg fentanyl, 5mg IV hydralazine, and a nitro gtt for elevated BP. She had cypher stent placed in LAD distally and second cypher stent placed in LM into proximal LAD as well. . On admission to the CCU patient was somnolent but arousable. She was unable to answer complicated questions. She was not in pain. . As above patient was too somnolent to answer ROS questions. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes(-), Dyslipidemia(+), Hypertension (+) 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: Cath at LGH [**2173-3-30**]: LAD ostial 85% small RCA 90% LV s/d/e: 162/-[**2-18**] AO s/d/m: 119/22/51 . -PACING/ICD: None - ADmission for acute LV failure in [**2-22**]. Adenosine test reportedly negative for ischemia at that time with EF 56%. 3. OTHER PAST MEDICAL HISTORY: - Hypertension - ESRD on dialysis - Nephrectomy bilaterally for severe htn - PAF - Hx of GIB from diverticuli and hemorrhoids (off anticoagulation) - Rheumatoid arthritis - Multiple joint replacements - Anxiety/depression requiring ECT Social History: Widowed. Was at [**Location (un) **] House rehab center. Patient normally lives with her daughter [**Name (NI) **] [**Name (NI) **] who is the primary care giver. -Tobacco history: None -ETOH: None -Illicit drugs: None Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: T: 97.1 BP146/39 HR 76 RR 13 O@ 100% 2L GENERAL: Elderly female in NAD. HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 7 cm. CARDIAC: RR, Unable to hear clear S1. Soft S2 [**1-22**] SM at RUSB early peaking. radiating to carotids. LUNGS: CTAB, no crackles, wheezes or rhonchi anteriorly ABDOMEN: Soft, NTND. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. NEURO: lethargic but arousable. Pertinent Results: [**2173-3-30**] 09:40PM GLUCOSE-131* UREA N-70* CREAT-8.5* SODIUM-138 POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-23 ANION GAP-20 [**2173-3-30**] 09:40PM CK(CPK)-12* [**2173-3-30**] 09:40PM CK-MB-NotDone [**2173-3-30**] 09:40PM CALCIUM-10.4* PHOSPHATE-5.1* MAGNESIUM-2.9* [**2173-3-30**] 09:40PM WBC-21.0* RBC-3.38* HGB-9.7* HCT-30.4* MCV-90 MCH-28.6 MCHC-31.8 RDW-22.7* [**2173-3-30**] 09:40PM NEUTS-91.2* LYMPHS-4.4* MONOS-2.6 EOS-1.7 BASOS-0.2 [**2173-3-30**] 09:40PM PLT COUNT-366 [**2173-3-30**] 09:40PM PT-17.4* PTT-44.8* INR(PT)-1.6* [**2173-3-30**] 06:00PM GLUCOSE-158* UREA N-68* CREAT-8.3* SODIUM-137 POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-20* ANION GAP-21* [**2173-3-30**] 06:00PM cTropnT-1.10* EKG: [**2173-3-23**]: NSR STD I,avL,V3-V6 [**2173-3-26**]: NSR STD V4-V6 [**2173-3-27**]: NSR STD <1mm V4-V6 [**2173-3-30**]: NSR STD II,III,aVF, V4-V6 [**2173-3-30**] at [**Hospital1 18**]: NSR STD I,V4,V5. <0.5mm STD V6. TWI aVL . CARDIAC CATH: LMCA: diffuse moderate disease approx 50% LAD: ostial 90%; proximal 70%, small D1 with 90% ostial disease LCx: Large dominant with no significant disease RCA: Not injected. Known small non-dominant with severe disease Cypher stent placed in more distal proximal LAD lesion and then second stent placed from LM ostium into proximal LAD. . HEMODYNAMICS: AO pressure: 186/46 Mean:100 TTE: The left atrium and right atrium are normal in cavity size. There is mild symmetric left ventricular hypertrophy with normal cavity size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF>75%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). There is mild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild symmetric LVH with hyperdynamic LV systolic function. Diastolic dysfunction with elevated filling pressures. Mild aortic valve stenosis with mild aortic regurgitation. Brief Hospital Course: 81yo F with h/o ESRD on HD, HTN, HL, acute CHF exacerbation 1 month ago, admitted from OSH with NSTEMI now s/p cath with DES in LAD and LMCA # CORONARIES: S/P NSTEMI and DES to LMCA and LAD. Unclear timing of NSTEMI and may have been on prior admission (see below). Continued aspirin, statin, increased beta blocker. No role of ACE as had bilateral nephrectomies. She will need to continue plavix for at least 1 year. Throughout her stay she continued to complain of chest pain, but admitted that this was very mild ([**12-26**]) and remained stable without intervention. # PUMP: Had EF 56% on adenosine stress test at OSH per report less than one month ago. In retrospect admission for "multifocal PNA" was more likely for acute CHF exacerbation. With trops elevated on this admission but CKs not more likely that she had an ischemic event on last admission leading to acute CHF and now the only enzyme elevated is troponin because 1) its half life is longer than CK and 2) she had renal failure. TTE the day after cath showed diastolic dysfunction and LVH consistent with her history of HTN but no WMA. # RHYTHM: NSR during but h/o AF. Was continued amiodarone. Not on coumadin because of history of GIB. ASA for anti-coagulation # Hypertensive Emergency: Patient with h/o severe HTN and elevated pressures in cath lab so was started on nitro gtt. Was weaned off nitro gtt quickly, however, because of hypotension. During dialysis the next day no fluid was removed and her BPs afterward were severely elevated. In this setting the patient had chest pain and lateral ST depressions. She was replaced on the nitro drip with good bp response and resolution of the chest pain and EKG changes. She was placed on higher [**Month/Year (2) 4319**] of nifedipine CR and labetalol with better bp control. She became hypotensive after dialysis and large bowel movements, thus labetalol was decreased to 100mg twice daily. Her long-acting nifedipine was also discontinued as it was felt that better titration could be achieved with short acting agents in the short term. She is being discharged on labetalol 100 [**Hospital1 **]. Please monitor bp especially in the peridialysis period. If severely hypertensive may attempt nitroglycerin 2% TP on an as needed basis, per physician [**Name Initial (PRE) 8469**]. Please note that she had episodes of asymptomatic hypotension after dialysis. # AMS: On admission there were multiple etiologies for AMS but most likely were: 1. multiple sedating medications during both caths, 2. No dialysis for 3 days (longest she's ever gone without dialysis), 3. Pseudodementia from depression. LFTs were wnl. Sedating medications were held overnight. In the morning patient was back to baseline. Had dialysis and then her hearing aid batteries were replaced the next morning and after these interventions she was able to mentate appropriately. Did continue to be tearful and psych/social work were consulted. They did not feel there was an acute psychiatric problem and did not change any medications. The patient's mental status continued to improve and she was discharged at her baseline mental status. #. C. Diff: Patient developed large amounts guaiac positive loose stools and leukocytosis. Stool was positive for C. Diff. She was started on PO vancomycin as flagyl would be dialyzed off in HD. Her abdominal exam remained benign and the diarrhea resolved quickly. A two week course is planned for vancomycinin (D0=[**2173-4-5**]) #. ESRD: Was continued on T/Th/Sat HD schedule. #. GERD: continued PPI and added GI cocktail for pill-dysphagia. #. HL: continued statin ACCESS: peripheral line in foot and Right IJ triple lumen which was placed at OSH [**2173-3-30**], a-line PROPHYLAXIS: -DVT ppx with pneumoboots -Bowel regimen with colace, lactulose per home regimen CODE: DNR/DNI - confirmed with daughter. Reversed only for cath. Communication: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone #[**Telephone/Fax (1) 82674**]; #[**Telephone/Fax (1) 82675**] Medications on Admission: MEDICATIONS at home: Zoloft 150mg QHS Amiodarone 200mg daily Aspirin 81mg daily Phoslo 667mg three times daily Colace 100mg daily Lactulose 30mL daily Nephrocaps one tablet daily Nifedipine XL 60mg twice daily Protonix 40mg daily REquip 0.25mg QHS Albuterol PRN Metoprolol 75mg twice daily Renagel 1600mg three times daily Neurontin 200mg qhs Requip 0.25mg PO qhs MEDICATIONS ON TRANSFER: Amiodarone 200mg daily Nephrocaps 1 tab daily Phoslo 667mg PO TID before meals Plavix 75mg daily Clotrimazole 10mg 5X daily Metoprolol Tartrate 75mg three times daily Nifedipine SR 60mg twice daily Pantoprazole 40mg daily Prednisone 10mg daily Ropinirole 0.25mg QHS Sertraline 150mg daily Renagel 1600mg three times daily Aspirin 81mg daily Colace 100mg twice daily Senokot 2 tabs QHS Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking unless instructed by Dr. [**Last Name (STitle) **]. 4. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 6. Sertraline 50 mg Tablet Sig: Three (3) Tablet PO QHS (once a day (at bedtime)). 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 8. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 10. Maalox Advanced 200-200-20 mg/5 mL Suspension Sig: 15-30cc MLs PO QID (4 times a day) as needed for chest pain. 11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for evidence of thrush. 12. Nitroglycerin 2 % Ointment Sig: One (1) inch Transdermal Q8H (every 8 hours) as needed for SBP> 160. 13. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN (as needed). 14. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 15. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 2 weeks: first dose [**2173-4-5**]. 16. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold SBP<100, HR <60. 17. Neurontin 100 mg Capsule Sig: Two (2) Capsule PO at bedtime. 18. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Non-ST elevation Myocardial Infarction End Stage Renal Disease with Hemodialysis Depression Discharge Condition: stable Discharge Instructions: You were admitted because you had a heart attack. We evaulated the arteries that supply your heart and placed stents in the ones that were occluded. You were also found to have an elevated blood pressure and were given medications to treat this. We continued your dialysis regimen. You were found to have an infection of your large bowel cousing you to have diarrhea and we gave you oral antibiotics. Please call your regular doctor or return to the emergency room if you have fevers, chills, diarrhea, low or high blood pressure, chest pain or any other concerning symptoms. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Followup Instructions: Primary Care: [**Last Name (LF) 10000**],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 53192**] Date/time: Please call the office to schedule an appt 1 week after you are discharged from rehabilitation Cardiology: [**Doctor First Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**Apartment Address(1) 82676**] [**Hospital1 3597**], [**Numeric Identifier 82677**] ([**Telephone/Fax (1) 29073**] Date/time: [**4-26**] at 1:45pm. Completed by:[**2173-4-7**]

[ "458.29", "300.4", "285.21", "427.31", "714.0", "780.97", "E874.2", "530.81", "008.45", "585.6", "998.11", "403.91", "410.71", "V45.73", "414.01" ]

icd9cm

[ [ [] ] ]

[ "00.41", "88.55", "00.66", "37.22", "00.46", "39.95", "36.07" ]

icd9pcs

[ [ [] ] ]

13875, 13922

7124, 11152

325, 360

14058, 14067

4593, 7101

14812, 15300

3928, 4043

11978, 13852

13943, 14037

11178, 11178

14091, 14789

11199, 11543

4058, 4574

3109, 3405

275, 287

388, 2995

3436, 3674

11568, 11955

3017, 3089

3690, 3912

57,317

145,974

40284

Discharge summary

report

Admission Date: [**2140-12-7**] Discharge Date: [**2140-12-14**] Date of Birth: [**2079-2-8**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4393**] Chief Complaint: UGIB Major Surgical or Invasive Procedure: Transhepatic intrajugular portosystemic shunt History of Present Illness: 61F spanish speaking presented to [**Hospital3 **] after having epigastric pain followed by an episode of large-volume melena and one episode of hematemesis after which she briefly lost consciousness and then called EMS. She was in her USOH before the belly pain on Monday, and had actually (subjectively) gained weight in recent weeks/months. Patient had been taking 1200 mg motrin qhs for "tendonitis" for which she had had surgery. At the OSH her hematocrit dropped from 35 on arrival to 31 with active bleeding seen from the NG tube and she was transfused 2 units of pRBCs. An EGD showed grade [**2-24**] varices without evidence of active bleeding but also showed a "large tangled mass" which was concerning for either varices or tumor. She received a 3rd unit of rPRBCs for an HCT today of 30.6. She was started on octreotide and protonix drips. On the morning of transfer she remained afebrile, was in sinus tachycardia, had SBPs 130s-150s and was saturating 100% on room air. . Per OSH discharge summary she was: s/p GIB with new onset esophageal varices and vascular mass versus tumor in the gastric cardia. Past Medical History: Asthma Diabetes HTN CHF Hysterectomy, tubal ligation, vein stripping Social History: No h/o EtOH, smoking, or drug use. [**Country **] Rican, moved to US to be with her children. Father is very ill in [**Male First Name (un) 1056**] and she is hoping to get out of hospital soon to go visit. Family History: Mother died of MI at 67. Brother died of cirrhosis at young age w/o drinking alcohol. Denies cancer hx or hx of clotting/bleeding disorders. Physical Exam: VS: T98.8, BP 118/53, HR 92, RR 11, Sao2 96% RA Gen: dishelved, obese woman, looking her age HEENT: EOMI, MMM, no discharges CV: RRR, S1/S2, no m/g/r Resp: Moving air appropriately, diffuse crackles Abd: +bs, soft, sightly distended, non-tender Ext: wwp, 2+ PD Urinary: Foley in place, draining dark urine ACCESS: 3 x PIV (18 G) Pertinent Results: 1. Labs on admission: [**2140-12-7**] 03:25PM BLOOD WBC-9.9 RBC-3.84* Hgb-11.2* Hct-33.6* MCV-88 MCH-29.1 MCHC-33.2 RDW-15.4 Plt Ct-114* [**2140-12-9**] 05:26AM BLOOD WBC-9.0 RBC-4.03* Hgb-12.1 Hct-35.2* MCV-87 MCH-30.1 MCHC-34.5 RDW-15.4 Plt Ct-152 [**2140-12-9**] 04:59PM BLOOD Hct-30.7* [**2140-12-10**] 09:47PM BLOOD Hct-33.7* [**2140-12-7**] 03:25PM BLOOD PT-15.7* PTT-26.2 INR(PT)-1.4* [**2140-12-10**] 03:35AM BLOOD PT-17.8* PTT-24.4 INR(PT)-1.6* [**2140-12-10**] 03:35AM BLOOD Plt Ct-140* [**2140-12-7**] 03:25PM BLOOD Glucose-117* UreaN-12 Creat-0.6 Na-141 K-3.4 Cl-108 HCO3-26 AnGap-10 [**2140-12-10**] 03:35AM BLOOD Glucose-112* UreaN-9 Creat-0.7 Na-140 K-3.7 Cl-105 HCO3-25 AnGap-14 [**2140-12-7**] 03:25PM BLOOD ALT-32 AST-70* CK(CPK)-170 AlkPhos-92 Amylase-199* TotBili-1.4 [**2140-12-10**] 03:35AM BLOOD ALT-47* AST-122* LD(LDH)-328* AlkPhos-127* TotBili-3.5* [**2140-12-7**] 03:25PM BLOOD Lipase-62* [**2140-12-7**] 03:25PM BLOOD Albumin-3.3* Calcium-8.4 Phos-2.3* Mg-1.6 [**2140-12-8**] 04:00PM BLOOD Iron-40 [**2140-12-9**] 04:59PM BLOOD Calcium-7.4* Phos-4.9* Mg-1.4* [**2140-12-8**] 04:00PM BLOOD calTIBC-273 Ferritn-381* TRF-210 [**2140-12-8**] 04:00PM BLOOD HBsAg-NEGATIVE [**2140-12-7**] 03:25PM BLOOD TSH-0.51 [**2140-12-8**] 04:35AM BLOOD HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-POSITIVE [**2140-12-8**] 04:00PM BLOOD AMA-NEGATIVE Smooth-PND [**2140-12-8**] 04:35AM BLOOD Smooth-POSITIVE * [**2140-12-8**] 04:35AM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:40 [**Last Name (un) **] [**2140-12-8**] 04:00PM BLOOD IgG-1412 [**2140-12-8**] 04:35AM BLOOD HCV Ab-NEGATIVE [**2140-12-7**] 04:02PM BLOOD Glucose-113* Lactate-2.0 K-3.4* [**2140-12-7**] 04:02PM BLOOD freeCa-1.07* . 2. Labs on discharge: [**2140-12-14**] 04:30AM BLOOD WBC-8.6 RBC-3.45* Hgb-10.5* Hct-30.0* MCV-87 MCH-30.4 MCHC-34.9 RDW-16.0* Plt Ct-140* [**2140-12-14**] 04:30AM BLOOD Plt Ct-140* [**2140-12-14**] 04:30AM BLOOD PT-18.8* PTT-26.7 INR(PT)-1.7* [**2140-12-14**] 04:30AM BLOOD Glucose-101* UreaN-7 Creat-0.5 Na-137 K-3.3 Cl-100 HCO3-28 AnGap-12 [**2140-12-14**] 04:30AM BLOOD ALT-75* AST-191* AlkPhos-215* TotBili-2.6* [**2140-12-14**] 04:30AM BLOOD Calcium-8.5 Phos-2.3*# Mg-1.9 [**2140-12-8**] 04:00PM BLOOD calTIBC-273 Ferritn-381* TRF-210 [**2140-12-8**] 04:00PM BLOOD HBsAg-NEGATIVE [**2140-12-8**] 04:35AM BLOOD HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-POSITIVE . 3. Imaging/diagnostics: - EGD: Varices at the middle third of the esophagus, lower third of the esophagus and gastroesophageal junction. Varices at the fundus. Friability, erythema, congestion and mosaic appearance in the stomach compatible with portal gastropathy. Ulcer in the pylorus. Otherwise normal EGD to third part of the duodenum . - Echocardiogram: The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . - Abdominal ultrasound with Doppler: Lobulated and coarsened liver, suggestive of fibrosis/cirrhosis. No focal hepatic lesions. Normal Doppler evaluation. . - Wrist X-ray: No evidence of acute fracture or dislocation. . - Liver biopsy: not available at the time of discharge. Brief Hospital Course: 61F PMH of CHF and [**Hospital **] transfer from OSH for UGIB with unclear findings on EGD. # UGIB: Hct stable throughout hospitalization. EGD showed varices in the esophagus and gastroesophageal junction that were not amendable to banding. Patient placed on octreotide and pantoprazole drips and then stopped after Hct remained stable. TIPS was placed without complications. Post-TIPS pressure gradient 7 mmgHg. . # Cirrhosis: Patient had no previous history of cirrhosis. Workup included viral hepatitis serologies, which were negative. [**Doctor First Name **] mildly postive at 1:40 dilution. anti-SMA mildly positive at 1:20 dilution. Iron studies unremarkable. RUQ u/s with doppler showed cirrhosis with patent portal veins. No history of alcohol use, however, has family history of death from cirrhosis. Biopsy performed which is still pending. This will be followed up in clinic on [**12-21**]. # Diabetes: on glipizide (5mgh PO daily) at home. Held oral hypoglycemics in setting of acute illness and managed with an insulin sliding scale. . # HTN: Home regimen of metoprolol 100mg [**Hospital1 **], HCTZ 12.5 daily, Cozaar 50 daily. Currently low-to-normal BPs with SBPs ranging 100s-120s off home regimen. . # Asthma: mild chronic, rarely uses inhalers, no wheeze on exam. Treated with albuterol/ipratropium nebulizers. Medications on Admission: Trazadone 50-100 mg PO Metformin 500mg [**Hospital1 **] Metoprolol 100mg [**Hospital1 **] Glipizide 5mgh PO daily HCTZ 12.5 daily Discharge Medications: 1. trazodone 50 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for insomnia. 2. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 3. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day. 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: Cirrhosis Esophageal varices Gastric varices Diabetes mellitus Asthma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname **], you were transferred to the [**Hospital1 771**] because you had blood in your stool. We found that you have blood vessels in your esophagus and stomach that bleed. We placed a shunt into your liver to release the pressure and prevent future bleeding. Your liver was also found to have scarring. . We made the following changes to your medications: STOPPED: - Ibuprofen 600 mg twice a day as needed - Tramadol 50 mg by mouth per day . STARTED: - pantoprazole 40 mg by mouth twice a day\ . Please HOLD your the following medications (for your blood pressure): - Metoprolol 100 mg by mouth twice a day - HCTZ 12.5 mg by mouth daily - Losartan 50 mg by mouth per day We would like you to follow-up with your primary care physician [**Last Name (NamePattern4) **] [**2140-12-22**] to discuss resuming these medications one at a time. Followup Instructions: PCP [**Name Initial (PRE) **]: Thursday, [**12-22**] at 11:15am with: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **],MD Location: GREATER [**Hospital1 **] FAMILY HEALTH Address: [**Street Address(2) **], [**Hospital1 **],[**Numeric Identifier 66038**] Phone: [**Telephone/Fax (1) 66039**] Department: LIVER CENTER When: WEDNESDAY [**2140-12-21**] at 3:00 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**] Completed by:[**2140-12-14**]

[ "278.00", "456.8", "572.3", "428.0", "401.9", "537.89", "789.2", "531.90", "456.20", "571.5", "250.00", "493.90", "719.43" ]

icd9cm

[ [ [] ] ]

[ "39.79", "45.13", "39.1", "88.64", "50.13", "00.69" ]

icd9pcs

[ [ [] ] ]

8130, 8213

6202, 7536

320, 368

8327, 8327

2357, 2365

9364, 10157

1850, 1992

7717, 8107

8234, 8306

7562, 7694

8478, 8829

2007, 2338

8858, 9341

276, 282

4083, 6179

396, 1516

2379, 4064

8342, 8454

1538, 1608

1624, 1834

27,472

174,806

8771

Discharge summary

report

Admission Date: [**2123-6-10**] Discharge Date: [**2123-6-17**] Date of Birth: [**2066-4-27**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3913**] Chief Complaint: SOB Major Surgical or Invasive Procedure: none History of Present Illness: Mr [**Known lastname 976**] is a 57-year-old gentleman with a CML s/p allogeneic BMT in [**9-/2121**], course c/b chronic GVHD (affecting skin and liver), who presented to the [**Hospital 3242**] clinic for routine follow up when he was noted to be very SOB. His O2 sats were in low 80% range; his other VS were normal and he was afebrile. He stated that his symptoms began 2 days ago when he noticed some congestion and a cough productive of green sputum. He states that his SOB was markedly worse today upon waking up. He was also complaining of nausea and a headache. He vomited x1 and had tenesmus with loose stools x3 this morning. His brother in-law (lives in same house) with a "bronchial thing" earlier this week. The patient was put on 5L NC and his sats increased to 94%. On exam in the clinic, his lungs with diffuse coarse crackles. He was sent to the ED. Of note, the patient has been on Coumadin for recent PE and continued immunosuppression for GVHD. . In the ED, his vitals 98.9, 85, 105/61, 16, 100% on NRB. ABG pO2 60s unclear on how much oxygen he was on at the time. In the ED, he was given Azithromycin 500mg, Cefepime, Decadron 10 mg IV for concern re: GVHD of lung, bactrim and a combivent neb. Blood cultures were obtained. A cardiac consult was obtained for concern re: MI and they felt that he was not having ACS. Past Medical History: PAST ONCOLOGICAL HISTORY # CML diagnosed in 1/[**2120**]. During the [**2120-8-17**] the patient first noticed some lower extremity swelling and began to feel quite fatigued. However he did not have insurance at the time and did not go to his physician for evaluation. In [**Month (only) 404**] [**2120**] he presented to [**Hospital6 204**] with an acute onset of dyspnea, lower extremity edema, and confusion. Workup was consistent with pneumonia and anemia with a hematocrit of 23. He had an elevated white count, elevated platelet count, increased basophils, and splenomegaly at that time. Further workup and bone marrow biopsy were consistent with CML. His peripheral blood was [**Location (un) 5622**] chromosome positive. He was started on Hydrea, allopurinol, and Gleevec. He initially required a Gleevec dose of 800 mg daily but his disease was never fully controlled on this medication. He has been noted several times since [**2121-1-15**] to have a platelet count of 700,000- 1,000,000. . In [**2121-6-17**], his Gleevec was stopped and he was started on Sprycel 70 mg twice a day with improved platelet response. His Hydrea was also tapered and stopped at this time. He is now s/p myeloablative allogeneic stem cell transplant for CML refractory to bcr/abl targeted therapies. He tolerated this as above with diarrhea, rash on upper torso, and abdominal pain. His diarrhea is now well controlled with qmonthly photopheresis. . OTHER PAST MEDICAL HISTORY # GVHD- chronic diarrhea and liver involvement (chronic transaminitis) # Chronic RUQ pain- since [**2113**] with extensive workup and pain clinic evaluations. No cholecystectomy. No prior abd surgeries. # GERD- [**Doctor Last Name **] esophagus, offered Nissen fundoplication but not done, takes pantoprazole # HTN # Hx of recent PE [**4-25**] - on coumadin. Social History: Lives with his sister and brother-in-law. Used to work in manufacturing but now out on disability. Denies EtOH. Long smoking history - quit 14 years ago. Smoked 1 PPD for many years. Family History: Father with diabetes mellitus, BPH, alive at 85yrs Mother with h/o breast cancer; d. TIAs and CVD at 75yrs Sister with h/o breast cancer in her 50s, atrial fibrillation Two brothers with h/o melanoma Physical Exam: Vitals: T: 94.6 BP: 98/70 HR: 103 RR: 18 O2Sat: low 90s 5L NC GEN: Well-appearing, well-nourished, no acute distress HEENT: NCAT, EOMI, PERRL, sclera anicteric, pharynx with tachy mucosa, no erythema NECK: No JVD, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 bilat PULM: diffuse rhonchi bilat to mid->upper lung zones; diffuse end-expiratory wheezes. ABD: Soft, mildy distended, mild tenderness to palpation diffusely, worse in RUQ +BS, no HSM, no masses EXT: 2+ pitting edema to mid-tibia. No C/C NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. SKIN: No jaundice, cyanosis. large area of dermatitis on back r/t GVHD. Purpura on arms bilat. Pertinent Results: # LABS ON ADMISSION: . HEMATOLOGY: CBC: [**2123-6-10**] 11:00AM BLOOD WBC-5.1 RBC-3.11* Hgb-10.2* Hct-31.5* MCV-101* MCH-32.8* MCHC-32.5 RDW-15.8* Plt Ct-291 Diff: [**2123-6-10**] 11:00AM BLOOD Neuts-78* Bands-16* Lymphs-2* Monos-2 Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-0 Coags: [**2123-6-10**] 11:00AM BLOOD PT-21.7* INR(PT)-2.1* ANC: [**2123-6-10**] 11:00AM BLOOD Gran Ct-4794 . CHEMISTRY: [**2123-6-10**] 11:00AM BLOOD Glucose-143* UreaN-34* Creat-1.5* Na-140 K-4.9 Cl-101 HCO3-28 AnGap-16 [**2123-6-10**] 11:00AM BLOOD Albumin-4.0 Calcium-9.4 Phos-2.4* Mg-1.8 UricAcd-8.4* . LFTs: [**2123-6-10**] 11:00AM BLOOD ALT-92* AST-69* LD(LDH)-327* AlkPhos-670* TotBili-0.4 . Cardiac enzymes: [**2123-6-10**] 12:50PM BLOOD cTropnT-0.18* CK(CPK)-71 [**2123-6-10**] 04:25PM BLOOD cTropnT-0.12* CK(CPK)-29* [**2123-6-10**] 10:45PM BLOOD CK-MB-4 cTropnT-0.07* CK(CPK)-34* [**2123-6-11**] 05:27AM BLOOD CK-MB-4 cTropnT-0.06* CK(CPK)-31* . . # LABS ON DISCHARGE: . HEMATOLOGY. CBC: [**2123-6-17**] 06:20AM BLOOD WBC-3.5* RBC-2.89* Hgb-9.3* Hct-28.0* MCV-97 MCH-32.3* MCHC-33.4 RDW-15.7* Plt Ct-314 DIFF: [**2123-6-17**] 06:20AM BLOOD Neuts-78.7* Lymphs-8.8* Monos-11.1* Eos-1.3 Baso-0.1 COAGS: [**2123-6-17**] 11:00AM BLOOD PT-14.5* PTT-29.3 INR(PT)-1.2* . CHEMISTRY: [**2123-6-17**] 06:20AM BLOOD Glucose-101 UreaN-19 Creat-1.1 Na-137 K-5.1 Cl-101 HCO3-31 AnGap-10 [**2123-6-17**] 06:20AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.8 . LFTs: [**2123-6-17**] 06:20AM BLOOD ALT-64* AST-32 LD(LDH)-309* AlkPhos-554* TotBili-0.3 . . # MICROBIOLOGY: . BLood culture negative . [**6-15**] - Nasopharyngeal aspirate --> Parainfluenza virus antigen POSITIVE . . # RADIOLOGY: [**6-10**] IMPRESSION: No acute cardiopulmonary process. . . . CARDIOLOGY: . TTE [**6-11**] The left atrium is elongated. 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 root is mildly dilated at the sinus level. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. Mildly dilated thoracic aorta. Mild aortic regurgitation. . . . RADIOLOGY: [**6-11**] CTA Chest 1) No evidence of pulmonary embolism. 2) Emphysema. 3) Indeterminate 4mm LLL nodule as above. Not seen on recent priors. Given underlying emphysema, patient requires a 12 month follow up CT scan per current guidelines. . [**6-12**] CT Sinus MPRESSION: Opacification of the frontal, ethmoidal, maxillary and mastoid air cells as described above. Brief Hospital Course: 57 year old male with CML s/p allo BMT [**9-23**] complicated by chronic GVHD of skin and liver presented with hypoxia and dyspnea for two days as well as loose stools. Patient was admitted to [**Hospital Unit Name 153**] monitoring for desaturations to 80% on room air, where he improved significantly no ABx and increased dose of steroids. He was transferred to the floor for further care on HD#2. # Hypoxic respiratory distress: Given patient's history, bandemia, bronchiectasis (predisposes to infection) and immunosuppression, bacterial PNA was considered the most likely cause of his hypoxia, SOB, however, no evidence of consolidation on CT scan. Atypical bacterial PNA, viral PNA or bronchitis vs underlying GVHD of lung (which can have neg CT/CXR finding, requires High Resolution CT) that may make him more prone to a pneumonitis when he has a respiratory infection were also considered. PE was ruled out by CTA. Other causes include cardiac ischemia but felt to be unlikely given lack of sx, EKG changes and recent [**12-25**] nl echo. Pt ruled out for MI. Finally, since patient was c/o nasal congestion, a set of nasal washings and cultures revealed parainfluenza virus antigen positivity. ID consult recommended conservative management. Pt's condition improved on steroids and montelukast. Was discharged with mid-90% O2sat on RA with pulmonary followup. Patient was continued on ceftriaxone and azithromycin with plan for total of 7 and 5 days respectively. His steroid dose was increased to 10mg [**Hospital1 **] of prednisone. For occasional wheezing, patient was placed on ipatropium/albuterol nebs Q6hr PRN. . # Bandemia: On admission it was felt that PNA was the most likely etiology. Other possible sources considered included GI given sx or urine. Sputum, blood cx, u/a and urine cx, stool cx & c. diff toxin were all negative. . # CML and GVHD - no acute exacerbations noted during hospital stay, but possibly contributing to respiratory distress. Patient was continued on outpatient immunosuppressives and the increased dose of prednisone. . # HTN: well controlled during hospital stay. Pt was continued on metoprolol, lasix. . # Osteoporosis & compression fx - continued outpatient pain meds and Ca and Vit D. . # GERD: asymptomatic during admission, continued PPI. . # Recent PE: Elevated INR of 2.1 was noted on HD#3, patient on Warfarin for PE. Eleveated INR most likely [**12-19**] starting azithromycin for pulmonary infection. Coumadin was held on HD#3 and INR on discharged was 1.2 # PPx: Hep SQ, PPI, Bowel regimen, acyclovir, posaconazole. Patient was discharged from the hospital in stable condition on HD# 8. Medications on Admission: 1. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H 2. Pentamidine Inhalation Q month 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID prn 4. Pantoprazole 40 mg Tablet daily 5. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS 6. Cyclosporine Modified 50 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). 7. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS prn 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID 9. Mycophenolate Mofetil 250 mg Tablet Sig: 1 PO BID 10. Posaconazole 200 mg/5 mL Suspension Sig: One (1) tablets PO TID 11. Calcium Citrate- Vit D3 315-200 unit tab PO TID 12. Lasix 20 mg PO BID 13. Prednisone 5 mg Tablet Sig: One (1) Tablet [**Hospital1 **] 14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) daily 15. Morphine 15 mg Tablet Sig: Three (3) Tablet PO Q4H prn 16. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily 17. Morphine 60 mg Tablet Sustained Release Sig: Three (3) Tablet Sustained Release PO twice a day: Take 3 pills in the 19. bisacodyl 10mg Supp PR [**Hospital1 **] PRN 20. Polyethylene glycol 17 g daily. Discharge Medications: 1. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Morphine 30 mg Tablet Sustained Release Sig: Five (5) Tablet Sustained Release PO Q12H (every 12 hours). 6. Morphine 15 mg Tablet Sig: 1-3 Tablets PO Q6H (every 6 hours) as needed. 7. Cyclosporine Modified 25 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 8. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 10. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) injection Subcutaneous Q12H (every 12 hours) for 2 doses. Disp:*2 injection* Refills:*0* 11. Prednisone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 12. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Pentamidine 300 mg Recon Soln Sig: One (1) inh Inhalation once a month. 14. Posaconazole 200 mg/5 mL Suspension Sig: One (1) tab PO TID (3 times a day). 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID:PRN as needed for constipation. 16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 17. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 18. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 19. Outpatient Lab Work Please have your INR checked and faxed to [**First Name8 (NamePattern2) 3235**] [**Last Name (NamePattern1) 3236**] @ [**Telephone/Fax (1) 30658**]. Discharge Disposition: Home Discharge Diagnosis: CMPL GVHD Pulmonary embolism Chronic right sided pain Hypertension Reflux Discharge Condition: afebrile, hemodynamically stable, good oxygenation on room air Discharge Instructions: You were admitted to [**Hospital1 18**] with symptoms of congestion and productive cough that resulted in respiratory distress with low oxygen values in your blood. You were started on antibiotics for suspected infection, however, they were discontinued because we did not find a bacterial infection. You were found to have a parainfluenza virus infection for which supportive care is recommended. We continued you on an increased dose of 10mg prednisone [**Hospital1 **] and also started you on montelukast 10mg QD to help your breathing. . You have successfully been weaned off oxygen. You were discharged with normal oxygenation at room air. Should you experience fevers, chills, nausea, vomiting, lightheadedness, new diarrhea, cough, chills, shortness of breath, chest pain, new or worsening abdominal pain, new rashes in your skin, burning or pain with urination, or any other symptom concerning to you, please call your primary care provider or go to the nearest emergency room. Followup Instructions: Please check you INR regularly and take Coumadin as directed by your physicians. . Please follow up with the following providers: Provider: [**First Name11 (Name Pattern1) 2671**] [**Last Name (NamePattern4) 11064**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2123-6-24**] 1:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2123-7-7**] 11:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2123-8-13**] 8:30 Completed by:[**2123-11-5**]

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Discharge summary

report

Admission Date: [**2168-5-3**] Discharge Date: [**2168-5-27**] Date of Birth: [**2093-3-2**] Sex: M Service: CARDIOTHORACIC Allergies: Ampicillin / Golytely / Fortaz / Levaquin / Fluconazole / Clindamycin Attending:[**First Name3 (LF) 4679**] Chief Complaint: Progressive worsening dysphagia Major Surgical or Invasive Procedure: [**2168-5-4**] Redo neck exploration; laparotomy with extensive lysis of adhesions, harvesting of right and left colon, substernal colonic interposition with cervical anastomosis, colojejunostomy, ileocolostomy, and feeding jejunostomy. [**2168-5-7**] Right pleural effusion with pigtail placement. [**2168-5-13**] Tracheostomy #8 Portex cuffed nonfenestrated. Rigid bronchoscopy and placement of covered tracheal metal stent, 20 x 40 mm, covering the fistula. History of Present Illness: The patient is a 75-year-old gentleman who underwent a transhiatal esophagectomy by Dr. [**Last Name (STitle) **] in [**2167-6-17**] for esophageal cancer. Postoperatively he developed a severe stricture involving the proximal 3 cm of his conduit. This was dilated by Dr. [**Last Name (STitle) **] and a tracheoesophageal fistula resulted. This ultimately healed with placement of endoscopic stents but the patient had severe dysphagia and was unable to tolerate saliva. The stricture was unable to be safely dilated and after a lengthy discussion with the patient and family, he was brought to the operating room today for substernal colon interposition. Past Medical History: Esophageal cancer with esophagectomy 7.09 COPD hx of CHF but normal EF and echo in [**2168-4-16**] HTN Hyperlipidemia PVD with history of stents Horseshoe kidney cataract surgery tonsillectomy as a child Social History: Lives at home with his sister History of 1.5 PPD x 60 years, none now. Occasional EtOH Denies illicit drug use No recent foreign travel Two dogs at home Family History: Non-contribitory Physical Exam: PHYSICAL EXAM: T 97.2, BP 126/80, HR 76, RR 20, O2 sats humidified trach collar: 100% Physical Exam: Gen: pleasant in NAD Neck: trach intact, sutures removed. Incision healing without redness, purulence or drg. Lungs: rhonchi throughout. CV: RRR S1, S2, no MRG or JVD Abd: soft, NT, ND, incisions healing without redness, purulence or drg. Jtube sutured intact without redness, purulence or drainage. Ext: warm, no edema Pertinent Results: Discharge labs: [**2168-5-27**] 06:20AM BLOOD WBC-7.8 RBC-3.76* Hgb-10.6* Hct-32.6* MCV-87 MCH-28.2 MCHC-32.5 RDW-15.7* Plt Ct-683* [**2168-5-27**] 06:20AM BLOOD Glucose-122* UreaN-16 Creat-0.5 Na-135 K-4.6 Cl-101 HCO3-29 AnGap-10 [**2168-5-27**] 06:20AM BLOOD Mg-2.1 [**2168-5-3**] 05:32PM BLOOD calTIBC-395 Ferritn-28* TRF-304 Pertinent micro: GRAM STAIN (Final [**2168-5-10**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [**2168-5-23**]): 10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora. COLISTN AND AZTREONAM Susceptibility testing requested by DR.[**Last Name (STitle) 82204**],[**First Name3 (LF) **] [**2168-5-13**]. PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. AZTREONAM Intermediate. sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENT TO [**Hospital1 4534**] FOR COLISTIN SENSITIVITY [**2168-5-17**]. COLISTIN SENSITIVE AT <=2 MCG/ML, Sensitivities performed by [**Hospital1 **] laboratories. PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. 2ND MORPHOLOGY. AZTREONAM Resistant. sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENT TO [**Hospital1 4534**] LABS FOR COLISTIN SENSITIVITY [**2168-5-17**]. COLISTIN = SENSITIVE AT <=2 MCG/ML, Sensitivities performed by [**Hospital1 **] laboratories. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | PSEUDOMONAS AERUGINOSA | | AMIKACIN-------------- 16 S 32 I CEFEPIME-------------- 8 S 16 I CEFTAZIDIME----------- 2 S 4 S CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ =>16 R =>16 R MEROPENEM------------- =>16 R =>16 R PIPERACILLIN/TAZO----- 32 S 32 S TOBRAMYCIN------------ =>16 R =>16 R Chest xray [**2168-5-23**]: right upper lobe consolidation as well as in right pleural effusion and bibasal atelectasis. The left PICC line tip is at the level of mid SVC. There is no evidence of pneumothorax or mediastinal air present. The pleural effusion at least partially loculated within the fissure is redemonstrated. [**2168-5-25**] Video Swallow IMPRESSION: Profound aspiration into the airway with minimal passage of contrast into the esophagus. Because of these findings, it was determined that standard barium esophagram to evaluate for fistula would not be possible. With phonation, there appears to be incomplete movement of the right vocal cord and no movement of the left vocal cord. Brief Hospital Course: Mr. [**Known lastname 82149**] was admitted on [**2168-5-3**] for bowel prep prior to his planned colonic interposition. On [**2168-5-4**] the patient was taken to the operating room where he underwent re-do neck exploration, re-do laparotomy with harvesting of left colon and substernal colon interposition. The patient was transfered to the SICU for continued care. He was extubated on POD1; however, due to respiratory distress and for airway protection, he was reintubated that evening. He underwent a series of therapeutic and diagnostic bronchoscopies ([**Date range (1) 22229**]). Bronchoscopies did show a recurrent fistula that was stented in the operating room on [**2168-5-13**]. Due to ventilator dependence, he was taken for a tracheostomy on [**5-13**]. Please see the operative notes for details. Patient was transferred to the general surgical floor on [**2168-5-23**]. Please refer to following review of systems for brief summary of his hospital course. Neuro: Pain was initially controlled with epidural. While intubated, propofol and fentanyl were used. Due to hypotension, regimen switched to versed. Precedex used briefly for anxiolytic wean which he did not tolerate. Patient improved with Ativan for his agitation control. His epidural was removed on [**2168-5-8**]. On discharge, he was then maintained on a roxicet down his j-tube for pain control. Patient with no neurological deficits during this hospital course. CV: History CHF. Volume status closely monitored. Fluid bolus provided for hypotension and pressors avoided to perserve conduit vascular flow. Lopressor resumed with hold parameters. TTE on [**5-6**] showing EF 55% and normal RV function. He remained HD stable for the rest of this hospitalization. He did receive lasix for diuresis mid hospital course but appears euvolemic on dishcharge. Pulmonary: Patient resumed on his home nebulizer regimen. Extubated POD1 but required re-intubation due to respiratory distress. CXR showed worsening right sided infiltrates. Bronchoscopy performed for lavage and cultures, which returned Multi-drug resistant Pseudomonas. ID consulted for antibiotic regimen and due to many allergies, started on aztreonam. CXR did show an impressive R pleural effusion. Interventional pulmonary performed a diagnostic thoracentesis, removing 500ml of exudative fluid. A pigtail chest tube was then placed and drained > 1500ml during his stay and was subsequently removed on [**5-11**]. With failure to wean from ventilator, excessive airway secretions and CXR findings, several bronchoscopies performed to remove secretions, the patient required tracheostomy. Bilious secretions were found in the airway, suggesting a re-occurence of his tracheo-gastric fistula. With ventilator dependence and respiratory failure, he was taken to the operating room on [**5-13**] for tracheal stenting and a percutaneous tracheostomy. Since then, he was able to be weaned to trach collar breathing without ventilator support. Had been fitted for a PM valve and continues to use it without complications. GI/FEN: Pt is s/p colonic interposition for esophageal condiut. Post-operatively, the patient was made NPO with IV fluids. PPI was started for prophylaxis. He was started on trophic tubefeeds to J-tube. NGT left in for gastric decompression. Nutrition followed the patient and he was advanced and tolerated goal tube feeds. He did have diarrhea but tested cdif negative several times. This resolved with tube feed regimine change. His conduit was assessed for viability by an endoscope. A swallow study performed prior to discharge, which he failed. ENT also scoped him but visualization of vocal cords was difficult. Last BM was on date of discharge. Renal: Foley left in place to measure input and output closely. Received several boluses of fluid and albumin for low urine output. While attempting to wean him from the ventilator, he was diuresed with lasix with a goal of 2-3L/day and reached his dry weight. Lasix was discontinued and he effectively auto-diuresed. Foley was discontinued and the patient was voiding fine. ID: The patient's white blood count and fever curves were closely watched for signs of infection. He was given pre-operative antibiotics of ancef and flagyl. With an elevated wbc and RLL infiltrate, he was started empirically on flagyl and aztreonam for pneumonia. Due to his many allergies, Infectious Disease consulted for recommendations. BAL cultures returned with a multi-drug resistant Pseudomonas. He was maintained on that antiobiotic regimen with vancomycin added for broader coverage. Patient developed fever to 103 with elevated wbc 25, with worsening CXR, he received another bronchoscopy. This showed reoccurence of a tracheal gastric fistula. As this was stented, he was afebrile and wbc normalized. He continued on aztreonam, Flagyl, and inhaled tobramycin which was dc'd on [**2168-5-25**]. Endocrine: The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. He had no issues. He did not require insulin on discharge. Hematology: The patient was transfused with blood on [**2168-5-6**] for hypotension, hct of 27% and to prevent ischemia around his anastamosis. No obvious signs of bleeding. Maintained on SQH. No other issues. Venodyne boots were used for DVT prophylaxis. Wound: JP drains were removed on POD15 after amylase levels were checked and confirmed no evidence of any anastomotic leaks. The staples from his abdominal incision were removed and steri-strips applied. Neck staples near the trach were removed the date of his discharge. IV: Left dual lumen PICC line inserted [**2168-5-14**] and should be dc'd upon rehab admission. Thank you. Disposition: Dr. [**First Name (STitle) **] deemed the patient stable for transfer to [**Hospital **] rehab. This plan was communicated to the patient, his sister [**Name (NI) 4489**], and report called to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] the accepting physician. Medications on Admission: ATORVASTATIN 10 mg Tablet once a day CARVEDILOL 12.5 mg Tablet twice daily DIGOXIN 250 mcg Tablet once a day FLUTICASONE-SALMETEROL 250 mcg-50 mcg/Dose 2 times every 12 hours LANSOPRAZOLE LISINOPRIL 5 mg Tablet once a day OMEPRAZOLE 20 mg Capsule once a day TIMOLOL 1 gtt once a day Discharge Medications: 1. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection [**Hospital1 **] (2 times a day): while in rehab and not as mobile. 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed for sob, wheezing. 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q4H (every 4 hours) as needed for sob, wheezing. 6. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed for pain. 7. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every 6 hours): keep giving for tracheal stent. 8. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day: crush and give via j-tube. 10. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day: crush and give via j-tube. 11. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1) inhalation Inhalation twice a day. 12. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day: give via jtube. 13. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO once a day. 14. Colace 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a day as needed for constipation: pt has had hx of loose stool. use cautiously. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Esophageal cancer with esophagectomy 7.09 COPD hx of CHF but normal EF and echo in [**2168-4-16**] HTN Hyperlipidemia PVD with history of stents Horseshoe kidney cataract surgery tonsillectomy as a child 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: Call Dr. [**First Name (STitle) **] if you have fevers, chills, nightsweats, shakes, incision drains, or becomes red, or if you have difficulties swallowing, tolerating tube feedings, cough, shortness of breath or any other problems/concerns. Call if J-tube is clogged or falls out immediately. Phone number is [**Telephone/Fax (1) 2348**] Ambulate with Physical Therapy. Trach care per facility. J-tube care: flush with 50ml water q 8hr, or before and after tubefeeding. When using passey muir valve ALWAYS deflate cuff. Followup Instructions: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**] Date/Time:[**2168-6-7**] 10:00 [**Hospital1 18**] [**Hospital Ward Name 516**]. Get CXR at 9:30 am [**Location (un) **] [**Hospital Ward Name 23**] (Same building). Follow up with Dr. [**Last Name (STitle) 1837**]. We are trying to arrange this appointment. We will call you with this, but call in one week for appt time if you don't have appointment. Completed by:[**2168-5-27**]

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icd9cm

[ [ [] ] ]

[ "42.65", "31.1", "34.91", "96.72", "46.39", "33.24", "34.04", "45.93", "54.59", "96.6", "31.99" ]

icd9pcs

[ [ [] ] ]

13309, 13381

5420, 11431

366, 831

13628, 13628

2406, 2406

14354, 14830

1930, 1948

11765, 13286

13402, 13607

11457, 11742

13804, 14331

2422, 5397

2065, 2387

295, 328

859, 1516

13643, 13780

1538, 1743

1759, 1914

29,463

192,911

46327

Discharge summary

report

Admission Date: [**2154-7-22**] Discharge Date: [**2154-8-3**] Date of Birth: [**2090-6-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7333**] Chief Complaint: fatigue, shortness of breath, fever Major Surgical or Invasive Procedure: Endotrachial intubation Cardioversion - [**7-24**] Trans esophageal Echocardiogram History of Present Illness: 64-year-old M with h/o single-vessel CABG in [**2139**], hypertension, hyperlipidemia, diabetes, as well as PAF who presented with 3 days of fatigue and shortness of breath along with recent onset of fevers. He was not feeling well in general over several days, but got acutely ill at a barbeque with his family. He was sitting in a chair at the event and he felt so weak that he could not stand. He needed multiple family members to help him up out of the chair and noted that he felt extremely hot at this time. He has had chills at home on a relatively regular basis since the late [**2134**]. He endorsed fever to 101 over the weekend as well as nausea and decreased PO intake with one day of diarrhea. . In the ED, initial vitals were 98.9 77 105/74 24 99%RA. On monitor SBP in 70s. He went into afib with RVR 176 at fastest. Given 4L fluid and HR decrease 120-130, SBP to 100-119. Given calcium, dilt 10mg(5mg+5mg) IV. Took asa today. Spiked to 102.7 in ED and CXR showed lingular opacity. After about 4L fluid his O2 sats dropped and he was given an atrovent neb, his HR increased to 180 and he was started on a dilt drip at 5mg/hr. On transfer to the CCU he is [**Age over 90 **]-100% on NRB, HR 158, BP 139/118, T 102.7, RR 28. Past Medical History: Cardiac Risk Factors: (+)Diabetes, (+)Dyslipidemia, (+)Hypertension . Cardiac History: CABG in [**2139**] . Other Past History: #. CAD s/p CABG [**2139**] at [**Hospital1 2025**], stress test in [**11-25**] negative for ischemia #. CHF, EF 60 % on stress test in [**11-25**] #. HTN #. Hyperlipidemia #. Type 2 diabetes mellitus - on lantus #. CRI - baseline mid 2s, peak at 4.1 #. b/l leg ulcers w/chronic peripheral edema #. Neuropathy Social History: He is retired retail manager. He is married and lives in [**Location 3146**]. He has 3 adult children. -Tobacco history: He used to smoke three packs a day for several years, but has quit 15 years ago -ETOH: He drinks alcohol in social situations only. -Illicit drugs: None. No Hx of IVDU. No Hx of recent travel, no tick bites. No Hx of MSM. Only international travel Hx to [**Country 2559**] many years ago. No sick contacts. Family History: There is no family history of sudden cardiac death, premature CAD or arrhythmias, even though diabetes is strong in his family. Physical Exam: VS: T=97.0 BP=116/71 HR=84 RR= 20 O2 sat= 99% 3L NC GENERAL: Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, slightly injected, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP not visible, No cervical LAD. CARDIAC: Regular rate and rhythm. No M/R/G LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Bibasilar inspiratory crackles ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: Bilateral 2+ pitting edema- currently wrapped. Stasis ulcer on R shin and surrounding erythema. PULSES: Right: Carotid 2+ DP dopplerable PT dopplerable Left: Carotid 2+ DP dopplerable PT dopplerable Pertinent Results: ECHO [**7-22**]: The left atrium is mildly dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. . Tib/fib X-ray [**7-22**]: No radiographic evidence of osteomyelitis. . CT torso [**7-23**]: 1. Airspace opacification at the right lung base with air bronchogram, and possible cavitation. Small right pleural effusion. Scattered lymph nodes in mediastinum, with prominent lymph nodes in the right hilum, could be reactive. 2. Enlarged kidneys with perinephric stranding. 3. Stable appearance of calcified splenic lesion. 4. Mass vs abscess, 4 x 4.3 cm size, in liver . RUQ U/S [**7-24**]: 1. Mixed echogenic lesion within the gallbladder fossa is consistent with resolving hematoma as seen on prior CT scan from one year ago. 2. Diffuse fatty infiltration of the liver. Please note that other more severe forms of liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded. . ECHO [**7-24**] (TEE)- No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: No LA/LAA thromubs seen. No valvular vegetations seen on the aortic, tricuspid or mitral valves. Moderate TR seen. . RUQ U/S ([**7-24**]) 1. Mixed echogenic lesion within the gallbladder fossa is consistent with resolving hematoma as seen on prior CT scan from one year ago. 2. Diffuse fatty infiltration of the liver. Please note that other more severe forms of liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded. . CXR [**7-24**]- There has been previous median sternotomy and coronary bypass surgery. New vascular congestion and left-sided interstitial opacities suggest worsening volume status of the patient. There remains marked elevation of the right hemidiaphragm, present dating back to [**2153-2-22**] chest radiograph, with adjacent atelectasis involving right middle and right lower lobes. There is also a small right pleural effusion. . CXR [**7-25**]: There is newly developed left lung consolidation that given its rapid development is highly concerning for massive aspiration. Rapidly progressing infection is unlikely. There is no evidence of pulmonary edema. There is still high position of right hemidiaphragm and stable appearance of cardiomediastinal silhouette. . CXR ([**7-26**])- Slight interval improvement in the extensive left mid and lower lung consolidation, presumably related to massive aspiration, stable large right pleural effusion with new left lower lobe collapse. . CXR ([**7-28**])- There has been some clearing of the left opacities since the two prior chest x-rays. Atelectasis of the right base persists. . [**2154-7-22**] 12:46AM BLOOD WBC-4.3 RBC-3.32* Hgb-8.6* Hct-27.2* MCV-82 MCH-26.0* MCHC-31.8 RDW-16.4* Plt Ct-129* [**2154-7-22**] 10:39AM BLOOD WBC-4.3 RBC-3.07* Hgb-8.0* Hct-25.7* MCV-84 MCH-25.9* MCHC-31.0 RDW-16.6* Plt Ct-128* [**2154-7-23**] 05:20AM BLOOD WBC-3.0* RBC-3.08* Hgb-8.0* Hct-25.7* MCV-84 MCH-25.8* MCHC-30.9* RDW-16.7* Plt Ct-119* [**2154-7-24**] 04:19AM BLOOD WBC-4.4 RBC-3.07* Hgb-8.3* Hct-25.2* MCV-82 MCH-27.0 MCHC-32.8 RDW-17.5* Plt Ct-132* [**2154-7-25**] 04:18AM BLOOD WBC-4.9 RBC-3.24* Hgb-8.7* Hct-27.0* MCV-83 MCH-26.8* MCHC-32.1 RDW-17.2* Plt Ct-123* [**2154-7-26**] 03:00AM BLOOD WBC-4.7 RBC-3.16* Hgb-8.2* Hct-26.8* MCV-85 MCH-26.0* MCHC-30.6* RDW-16.2* Plt Ct-142* [**2154-7-27**] 05:43AM BLOOD WBC-4.0 RBC-2.74* Hgb-7.2* Hct-22.8* MCV-83 MCH-26.4* MCHC-31.8 RDW-16.5* Plt Ct-177 [**2154-7-27**] 02:26PM BLOOD WBC-3.6* RBC-2.69* Hgb-7.0* Hct-22.9* MCV-85 MCH-26.1* MCHC-30.6* RDW-15.7* Plt Ct-179 [**2154-7-27**] 02:26PM BLOOD WBC-3.6* RBC-2.69* Hgb-7.0* Hct-22.9* MCV-85 MCH-26.1* MCHC-30.6* RDW-15.7* Plt Ct-179 [**2154-7-28**] 05:06AM BLOOD WBC-4.4 RBC-2.85* Hgb-7.3* Hct-24.0* MCV-84 MCH-25.7* MCHC-30.5* RDW-15.7* Plt Ct-190 [**2154-7-29**] 05:21AM BLOOD WBC-4.9 RBC-2.91* Hgb-7.4* Hct-24.2* MCV-83 MCH-25.4* MCHC-30.4* RDW-15.7* Plt Ct-214 [**2154-7-30**] 06:41AM BLOOD WBC-5.8 RBC-2.78* Hgb-7.1* Hct-23.2* MCV-84 MCH-25.6* MCHC-30.7* RDW-16.0* Plt Ct-246 [**2154-7-31**] 04:57AM BLOOD WBC-6.0 RBC-2.78* Hgb-7.0* Hct-22.7* MCV-82 MCH-25.1* MCHC-30.8* RDW-17.0* Plt Ct-257 [**2154-8-1**] 05:10AM BLOOD WBC-5.9 RBC-2.92* Hgb-7.2* Hct-24.1* MCV-83 MCH-24.5* MCHC-29.7* RDW-16.2* Plt Ct-242 [**2154-8-2**] 04:41AM BLOOD WBC-5.8 RBC-2.75* Hgb-6.9* Hct-22.2* MCV-81* MCH-25.1* MCHC-31.1 RDW-17.6* Plt Ct-249 [**2154-8-3**] 05:44AM BLOOD WBC-6.2 RBC-2.68* Hgb-6.9* Hct-22.1* MCV-83 MCH-25.6* MCHC-31.0 RDW-16.8* Plt Ct-264 [**2154-7-22**] 10:39AM BLOOD Neuts-83.2* Lymphs-11.9* Monos-4.2 Eos-0.3 Baso-0.4 [**2154-7-26**] 03:00AM BLOOD Neuts-72* Bands-0 Lymphs-19 Monos-9 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2154-7-29**] 05:21AM BLOOD Neuts-42* Bands-3 Lymphs-23 Monos-1* Eos-2 Baso-1 Atyps-2* Metas-0 Myelos-0 Other-26* [**2154-7-30**] 06:41AM BLOOD Neuts-40* Bands-3 Lymphs-50* Monos-2 Eos-2 Baso-1 Atyps-2* Metas-0 Myelos-0 [**2154-7-31**] 04:57AM BLOOD Neuts-32* Bands-4 Lymphs-18 Monos-8 Eos-0 Baso-2 Atyps-36* Metas-0 Myelos-0 [**2154-8-1**] 05:10AM BLOOD Neuts-40* Bands-2 Lymphs-26 Monos-8 Eos-0 Baso-0 Atyps-24* Metas-0 Myelos-0 [**2154-8-2**] 04:41AM BLOOD Neuts-45* Bands-1 Lymphs-33 Monos-10 Eos-1 Baso-1 Atyps-9* Metas-0 Myelos-0 [**2154-7-26**] 03:00AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2154-7-29**] 05:21AM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-NORMAL Ovalocy-OCCASIONAL Schisto-OCCASIONAL [**2154-7-30**] 06:41AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL [**2154-7-31**] 04:57AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-3+ Polychr-1+ Ovalocy-OCCASIONAL Stipple-OCCASIONAL [**2154-8-1**] 05:10AM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-1+ Macrocy-NORMAL Microcy-2+ Polychr-NORMAL Burr-1+ [**2154-8-2**] 04:41AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-NORMAL Microcy-1+ Polychr-NORMAL [**2154-7-22**] 12:46AM BLOOD Plt Ct-129* [**2154-7-22**] 12:46AM BLOOD PT-16.5* PTT-30.3 INR(PT)-1.5* [**2154-7-22**] 10:39AM BLOOD Plt Ct-128* [**2154-7-22**] 08:29PM BLOOD PT-19.2* PTT-124.9* INR(PT)-1.8* [**2154-7-23**] 05:20AM BLOOD PT-22.2* PTT-62.0* INR(PT)-2.1* [**2154-7-23**] 05:20AM BLOOD Plt Ct-119* [**2154-7-24**] 04:19AM BLOOD PT-31.8* PTT-37.4* INR(PT)-3.2* [**2154-7-24**] 04:19AM BLOOD Plt Ct-132* [**2154-7-25**] 04:18AM BLOOD PT-36.2* PTT-45.2* INR(PT)-3.7* [**2154-7-25**] 04:18AM BLOOD Plt Ct-123* [**2154-7-25**] 09:08PM BLOOD PT-44.0* PTT-60.6* INR(PT)-4.7* [**2154-7-26**] 03:00AM BLOOD PT-26.2* PTT-46.4* INR(PT)-2.5* [**2154-7-26**] 03:00AM BLOOD Plt Smr-LOW Plt Ct-142* [**2154-7-27**] 05:43AM BLOOD PT-15.2* PTT-41.7* INR(PT)-1.3* [**2154-7-27**] 05:43AM BLOOD Plt Ct-177 [**2154-7-27**] 02:26PM BLOOD Plt Ct-179 [**2154-7-28**] 05:06AM BLOOD PT-16.8* PTT-50.0* INR(PT)-1.5* [**2154-7-28**] 05:06AM BLOOD Plt Ct-190 [**2154-7-29**] 05:21AM BLOOD PT-18.8* PTT-51.3* INR(PT)-1.7* [**2154-7-29**] 05:21AM BLOOD Plt Smr-NORMAL Plt Ct-214 [**2154-7-29**] 03:37PM BLOOD PT-21.2* PTT->150* INR(PT)-2.0* [**2154-7-29**] 11:54PM BLOOD PT-22.7* PTT-111.7* INR(PT)-2.1* [**2154-7-30**] 06:41AM BLOOD PT-24.5* PTT-127.6* INR(PT)-2.3* [**2154-7-30**] 06:41AM BLOOD Plt Smr-NORMAL Plt Ct-246 [**2154-7-31**] 04:57AM BLOOD PT-28.0* PTT-60.4* INR(PT)-2.8* [**2154-7-31**] 04:57AM BLOOD Plt Smr-NORMAL Plt Ct-257 [**2154-8-1**] 05:10AM BLOOD PT-27.4* PTT-61.4* INR(PT)-2.7* [**2154-8-1**] 05:10AM BLOOD Plt Ct-242 [**2154-8-2**] 04:41AM BLOOD PT-25.9* PTT-53.7* INR(PT)-2.5* [**2154-8-2**] 04:41AM BLOOD Plt Smr-NORMAL Plt Ct-249 [**2154-8-3**] 05:44AM BLOOD PT-20.9* PTT-54.0* INR(PT)-1.9* [**2154-8-3**] 05:44AM BLOOD Plt Ct-264 [**2154-7-22**] 10:39AM BLOOD FDP-0-10 [**2154-7-22**] 10:39AM BLOOD FDP-0-10 [**2154-8-2**] 04:41AM BLOOD ESR-137* [**2154-7-31**] 04:57AM BLOOD Ret Aut-4.4* [**2154-7-22**] 12:30AM BLOOD Glucose-199* UreaN-72* Creat-4.4*# Na-130* K-5.1 Cl-95* HCO3-24 AnGap-16 [**2154-7-22**] 10:39AM BLOOD Glucose-191* UreaN-60* Creat-3.4* Na-136 K-4.2 Cl-108 HCO3-17* AnGap-15 [**2154-7-23**] 05:20AM BLOOD Glucose-180* UreaN-66* Creat-3.4* Na-134 K-4.8 Cl-103 HCO3-19* AnGap-17 [**2154-7-24**] 04:19AM BLOOD Glucose-243* UreaN-59* Creat-3.1* Na-130* K-4.7 Cl-100 HCO3-20* AnGap-15 [**2154-7-25**] 04:18AM BLOOD Glucose-223* UreaN-59* Creat-3.1* Na-133 K-4.8 Cl-101 HCO3-18* AnGap-19 [**2154-7-25**] 09:08PM BLOOD Glucose-130* UreaN-61* Creat-3.4* Na-134 K-4.4 Cl-103 HCO3-21* AnGap-14 [**2154-7-26**] 03:00AM BLOOD Glucose-143* UreaN-61* Creat-3.5* Na-135 K-4.5 Cl-101 HCO3-23 AnGap-16 [**2154-7-27**] 05:43AM BLOOD Glucose-119* UreaN-68* Creat-3.5* Na-136 K-4.2 Cl-100 HCO3-25 AnGap-15 [**2154-7-28**] 05:06AM BLOOD Glucose-116* UreaN-71* Creat-3.4* Na-135 K-4.4 Cl-99 HCO3-25 AnGap-15 [**2154-7-29**] 05:21AM BLOOD Glucose-147* UreaN-71* Creat-3.1* Na-135 K-3.9 Cl-97 HCO3-26 AnGap-16 [**2154-7-30**] 06:41AM BLOOD Glucose-133* UreaN-71* Creat-3.2* Na-131* K-3.9 Cl-93* HCO3-26 AnGap-16 [**2154-7-31**] 04:57AM BLOOD Glucose-191* UreaN-75* Creat-3.3* Na-133 K-4.2 Cl-96 HCO3-28 AnGap-13 [**2154-8-1**] 05:10AM BLOOD Glucose-154* UreaN-79* Creat-4.1* Na-131* K-4.1 Cl-95* HCO3-28 AnGap-12 [**2154-8-1**] 02:14PM BLOOD Glucose-217* UreaN-85* Creat-4.0* Na-129* K-4.6 Cl-94* HCO3-25 AnGap-15 [**2154-8-2**] 04:41AM BLOOD Glucose-154* UreaN-82* Creat-3.6* Na-129* K-4.3 Cl-94* HCO3-28 AnGap-11 [**2154-8-2**] 03:07PM BLOOD Glucose-150* UreaN-80* Creat-3.3* Na-130* K-4.5 Cl-95* HCO3-27 AnGap-13 [**2154-7-22**] 12:30AM BLOOD ALT-16 AST-21 LD(LDH)-261* CK(CPK)-223* AlkPhos-61 TotBili-0.4 [**2154-7-26**] 03:00AM BLOOD ALT-19 AST-21 AlkPhos-52 TotBili-0.5 [**2154-7-27**] 05:43AM BLOOD ALT-20 AST-24 AlkPhos-68 TotBili-0.4 [**2154-7-28**] 05:06AM BLOOD ALT-20 AST-23 LD(LDH)-288* AlkPhos-63 TotBili-0.4 [**2154-7-29**] 05:21AM BLOOD ALT-19 AST-25 AlkPhos-59 TotBili-0.4 [**2154-8-1**] 02:14PM BLOOD ALT-30 AST-43* LD(LDH)-328* AlkPhos-73 Amylase-115* TotBili-0.4 [**2154-8-2**] 04:41AM BLOOD LD(LDH)-335* Amylase-120* [**2154-8-2**] 03:07PM BLOOD AlkPhos-89 Amylase-118* [**2154-8-1**] 02:14PM BLOOD Lipase-149* [**2154-8-2**] 04:41AM BLOOD Lipase-181* [**2154-8-2**] 03:07PM BLOOD Lipase-157* [**2154-7-22**] 12:30AM BLOOD cTropnT-0.19* [**2154-7-22**] 12:30AM BLOOD CK-MB-5 [**2154-7-22**] 10:39AM BLOOD Albumin-2.7* Calcium-6.2* Phos-3.5 Mg-2.0 [**2154-7-23**] 05:20AM BLOOD Calcium-7.6* Phos-3.5 Mg-2.4 [**2154-7-24**] 04:19AM BLOOD Calcium-7.7* Phos-3.0 Mg-2.2 [**2154-7-25**] 04:18AM BLOOD Calcium-8.0* Phos-3.7 Mg-2.4 [**2154-7-26**] 03:00AM BLOOD Albumin-3.7 Calcium-8.2* Phos-4.2 Mg-2.4 [**2154-7-27**] 05:43AM BLOOD Calcium-8.0* Phos-3.2 Mg-2.3 [**2154-7-28**] 05:06AM BLOOD Albumin-3.5 Calcium-8.4 Phos-2.4* Mg-2.4 [**2154-7-29**] 05:21AM BLOOD Albumin-3.4 Calcium-8.5 Phos-2.6* Mg-2.4 Iron-35* [**2154-7-30**] 06:41AM BLOOD TotProt-6.8 Calcium-8.0* Phos-3.0 Mg-2.4 [**2154-7-31**] 04:57AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.5 [**2154-8-1**] 05:10AM BLOOD Calcium-8.3* Phos-3.9 Mg-2.7* [**2154-8-1**] 02:14PM BLOOD Albumin-3.2* Cholest-80 [**2154-8-2**] 04:41AM BLOOD Calcium-8.3* Phos-3.0 Mg-2.7* Iron-45 [**2154-8-2**] 03:07PM BLOOD Calcium-8.4 Phos-2.9 Mg-2.7* [**2154-7-22**] 10:39AM BLOOD Hapto-176 [**2154-7-29**] 05:21AM BLOOD calTIBC-280 Ferritn-126 TRF-215 [**2154-7-30**] 06:41AM BLOOD VitB12-706 Folate-12.3 [**2154-8-2**] 04:41AM BLOOD calTIBC-306 Ferritn-126 TRF-235 [**2154-8-1**] 02:14PM BLOOD Triglyc-330* HDL-9 CHOL/HD-8.9 LDLcalc-5 [**2154-7-23**] 05:20AM BLOOD Osmolal-300 [**2154-8-1**] 02:14PM BLOOD Osmolal-312* [**2154-7-26**] 03:00AM BLOOD TSH-0.42 [**2154-8-1**] 02:14PM BLOOD CRP-27.0* [**2154-7-30**] 06:41AM BLOOD PEP-TRACE ABNO IgG-1629* IgA-146 IgM-275* IFE-TRACE MONO [**2154-7-24**] 01:32AM BLOOD Type-ART pO2-66* pCO2-31* pH-7.40 calTCO2-20* Base XS--3 Brief Hospital Course: 64 yo M with single-vessel CABG in [**2139**], HTN, HLD, DM, PAF, presented with fatigue, fever of unknown origin, found to be in Afib with RVR, s/p cardioversion to NSR, s/p treatment for CAP and aspiration pneumonia. . # Afib with RVR: initially presented with atrial fibrillation with rapid ventricular response (HR 160s). TEE showed no vegetations or atrial clots, and cardioversion performed [**7-24**]. Initially went back into Afib and started on rate control with diltiazem 60mg QID as well as metoprolol. Patient converted into NSR again [**2154-7-31**]. Diltiazem was discontinued and metoprolol was continued. Patient remained hemodynamically stable. Suspect that patient will remain in NSR as amiodarone stores build up. Plan is for patient to continue 400 mg amiodarone until [**8-9**], then he will switch to 200 mg daily indefinitely. He is to continue is home dose metoprolol on discharge. He will remain off diltiazem. . #Fever/atypical lymphocytes/lymphocytic predominance on diff: Likely due to CAP (RLL air bronchograms) and aspiration pneumonia (on later CXR findings, LLL infiltrate, s/p extubation). Patient completed 9 day course of vancomycin, 10 day course of zosyn, and 6 day course of ciprofloxacin (with prior levofloxacin), as per ID recs. With regard to potential source of fevers: Pulmonary was consulted and bronch/right thoracentesis was deferred, as his clinical picture was improving and the fact that his R pleural effusion was chronic/stable. Liver US showed ?abscess vs. resolving hematoma, but after discussion with radiology and ID, the findings were felt to be more c/w resolving hematoma, and US guided needle aspiration was not performed. On chest CT, some question of cavitary lesion/RLL air bronchograms, which was followed by TB rule out with three negative sputum samples. LFTs were wnl, influenza DFA negative, blood cx were negative, urine cx negative, C. diff negative, urinary Legionella negative, RPR negative, CMV IgG/IgM negative, TB sputum x 3 was negative, tib/fib negative for osteomyelitis, TEE negative for vegetations. Patient was afebrile for 72+ hours on discharge. Of note, patient had EBV VCA-IgM Ab positivity, which may suggest recent infection. Discussed positive EBV with ID, who mentioned that it was likely cross-reactivity with other tests, and that his viral syndrome/course will likely be self-limited. HIV was discussed with patient (and risk factors were discussed), but testing was deferred at this time, as per patient request. . # CORONARIES: Troponin leak (peak 0.19) likely [**1-21**] ARF as well as demand given RVR to 160s. Baseline trop about 0.10 and pt. denies chest pain. As such clinical suspicion for ACS was low. Patient was continued on his metoprolol. His lisinopril was, and will be, held given ARF on CKD. His simvastatin was decreased to 10 mg given his unusual lipid panel (LDL 5, HDL 9) which is similar to [**2152**] studies. . # PUMP: CXR with initial signs c/w volume overload and was initially diuresed with IV lasix for pulmonary edema. TEE on [**2154-7-24**] showed preserved EF with normal valvular function, no vegetations. . # Oxygen requirement: possibly secondary to post-pneumonia reactive airways vs. (more likely) deconditioning. He has worked with physical therapy as an inpatient and will be discharged to home with PT services and home oxygen. Of note, patient will likely need PFTs on discharge, and this can be addressed by Dr. [**Last Name (STitle) 303**] (PCP). . # Anemia: H/H 6.9/22.1 on discharge and it is apparent that patient has some component of anemia of chronic disease from his CKD. Renal was consulted and patient is to follow-up with Dr. [**Last Name (STitle) **] for possible Procrit injections and IV iron therapy. Stool guiacs were negative. No signs/symptoms of bleeding. . # Diabetes: Poorly controlled, last A1c 10.5% with complications of nephropathy and neuropathy. Patient's home glargine was increased to 54U QAM, and he will be discharged on this regimen, given his insulin requirements. He is to follow-up with his outpatient endocrinologist and has voiced understanding. . # Hyponatremia: renal feels this may be related to initial hyervolemic hyponatremia (given volume overload), and now possible hyponatremic hyponatremia. PO intake was encouraged near time of discharge, Na was uptrending, and on discharge Na was 131. Patient is to follow-up Na levels with Dr. [**Last Name (STitle) 303**] (in PCP [**Name Initial (PRE) **]) as well as with Dr. [**Last Name (STitle) **] (nephrology). . # ARF on CKD: Baseline Cr~2. Cr jumped to 4.4 on admission and was 3.4 on discharge. Renal was consulted and they felt this was most c/w ATN due to relative hypoperfusion during his afib with rvr as well as possible AIN given his cipro/vanco Abx regimen. Patient will f/u with Dr. [**Last Name (STitle) **] in nephrology clinic. . # Anticoagulation: patient is on anticoagulation for PAF, was bridged with heparin while INR was subtherapeutic. His coumadin requirements were decreased to 3 mg, as his amiodarone stores built up. INR goal [**1-22**] and on discharge, INR 1.9 on discharge. Patient will be discharged on 3 mg coumadin, with close f/u with coumadin clinic. . # Lower extremity edema/ulcers: stable without signs of osteomyelitis on exam or imaging. Wound care was consulted, legs were kept elevated, and wound care recs continued while admitted. . # Dispo - patient will be discharged home with VNA services, PT services, and home oxygen. He is to call for PCP [**Name9 (PRE) 702**] with Dr. [**Last Name (STitle) 303**], and will f/u with Dr. [**Last Name (STitle) **] (nephrology) as he may be candidate for Procrit. He has ID f/u on [**2154-9-9**]. Medications on Admission: Bumetanide 2 mg Tablet 1 Tablet(s) by mouth DAILY Diltiazem HCl [DILT-XR] 180 mg Capsule,Degradable Cnt Release 1 Capsule(s) by mouth daily Insulin Glargine [Lantus] 100 unit/mL Solution 44 units once a day Insulin Lispro [Humalog KwikPen] 100 unit/mL Insulin Pen injection per scale given below before meals 150-199:4 units; 200-249: 8; 250-299: 12; 300-349: 16; 350-400: 20 Lisinopril 10 mg Tablet 1 Tablet(s) by mouth once a day Metoprolol Tartrate 100 mg Tablet 1 Tablet(s) by mouth two times daily pt has been taking 1 tab once a day, had reduced on his own from 200 mg [**Hospital1 **]; advised to do 1 tab [**Hospital1 **] Niacin [Niaspan] 500 mg Tablet Sustained Release one Tablet(s) by mouth daily Pantoprazole 40 mg Tablet, Delayed Release (E.C.) 1 Tablet(s) by mouth every twenty-four(24) hours Simvastatin [Zocor] 40 mg Tablet 1 Tablet(s) by mouth daily Warfarin 5 mg Tablet 1 (One) Tablet(s) by mouth once a day or as directed by [**Hospital 191**] [**Hospital 197**] Clinic Acetaminophen 325 mg Tablet [**12-21**] Tablet(s) by mouth q6 hours as needed for fever or pain Aspirin 325 mg Tablet 1 Tablet(s) by mouth DAILY (Daily) Blood Sugar Diagnostic [One Touch Ultra Test] Strip to test blood sugar tid and prn Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): Take 2 pills daily until [**2154-8-9**], then decrease to 1 pill daily. Disp:*60 Tablet(s)* Refills:*2* 2. Outpatient Lab Work Please check CBC and chem 7 on Wednesday [**2154-8-7**] and call results to Dr. [**Last Name (STitle) 98485**] at [**Telephone/Fax (1) 250**] 3. Humalog KwikPen 100 unit/mL Insulin Pen Sig: One (1) pen Subcutaneous four times a day: as per sliding scale. Disp:*90 cartridges* Refills:*2* 4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Bumetanide 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO four times a day as needed for pain, fever. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM: Or as directed by the coumadin clinic. 9. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 10. Polyethylene Glycol 3350 100 % Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. 11. Niaspan 500 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 12. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day. 13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for itching. Disp:*1 tube* Refills:*0* 14. Lantus 100 unit/mL Solution Sig: Fifty Four (54) units Subcutaneous once a day: Please adjust down if your blood sugars are low. . Discharge Disposition: Home With Service Facility: Greater [**Location (un) 1468**] VNA Discharge Diagnosis: Atrial fibrillation Acute Renal Failure Anemia Hyponatremia [**Doctor Last Name 3271**] [**Doctor Last Name **] Virus positive serologies Discharge Condition: stable Discharge Instructions: You had a pneumonia that was treated with antibiotics. Your atrial fibrillation was very fast which required a cardioversion and treatment with amiodarone, a medicine that slows your heart rate and hopfully will keep you in normal sinus rhythm. You still will need to take your couamdin and follow-up with the coumadin clinic here at [**Hospital1 18**] to keep your INR between 2.0 and 3.0. . Medication changes: 1. Amiodarone: take 2 tablets (400mg total) daily until [**2154-8-9**], then change to one tablet daily to be continued indefinitely. 2. Your simvastatin was decreased to 10 mg 3. Stop taking your Lisinopril because your kidney function is poor. Dr. [**Last Name (STitle) **] will tell you when to start taking the Lisinopril again. 4. Decrease your Bumetanide to 1 mg daily from 2 mg daily 5. Decrease your coumadin to 3mg daily. Your last INR was 1.9 on discharge and you will need less coumadin now that you are on amiodarone. The coumadin clinic will resume responsibility for your coumadin dosing after you leave the hospital. 6. Stop taking your Diltiazem XR 7. Your senna and Miralax should be taken when you are home if you are still constipated. These are available over the counter. 8. Your Lantus was increased to 54 units daily from 44 units daily. Please adjust down if your blood sugars are low at home. . Please call Dr. [**Last Name (STitle) 303**] if you have any chest pain, trouble breathing, palpitations, fevers that you record on a thermometer, new cough, increasing abdominal pain, nausea or inability to eat or drink, or any other unusual symptoms. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day or 6 lbs in 3 days. Please check your blood sugar before each meal and give Humalog insulin according to the sliding scale. . You are being sent home with physical therapy services and home oxygen while you return to your baseline mobility and state of health. Followup Instructions: Primary Care: Dr. [**First Name4 (NamePattern1) 915**] [**Last Name (NamePattern1) 98485**] Phone: [**Telephone/Fax (1) 250**] Date/Time: Please draw CBC with manual diff during appt. Please call the office and make an appointment within 1-2 weeks time. . Nephrology: Dr. [**Known firstname **] [**Last Name (NamePattern1) **] Phone: ([**Telephone/Fax (1) 98486**] Date/time: Office will call you with an appt once you are home. If you do not hear from the office regarding an appointment, please call by Wednesday, [**8-8**]. As discussed, you may qualify for Procrit injections to build up your blood levels. . Infectious Disease: Dr. [**First Name (STitle) **] [**Name (STitle) **] Phone: ([**Telephone/Fax (1) 4170**] Date/Time: Monday [**9-9**] at 11:30am. Infectious Disease Clinic. [**Hospital **] Medical Building, Ground floor. [**Last Name (NamePattern1) 439**], [**Location (un) 86**]. You may park in the parking garage right next to the building. . Endocrinology: Please follow up as scheduled with your outpatient physician. . Cardiology: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 98487**] Phone: ([**Telephone/Fax (1) 5687**] Date/time: please make an appt to be seen in [**12-21**] months. Completed by:[**2154-8-3**]

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icd9cm

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43897

Discharge summary

report

Admission Date: [**2197-1-2**] Discharge Date: [**2197-1-5**] Date of Birth: [**2138-11-23**] Sex: F Service: MEDICINE Allergies: Codeine / Aspirin / Augmentin / Trazodone Hcl / Ibuprofen / Atrovent / Reglan / Ampicillin / Lipitor / Simvastatin / Seroquel / Abilify Attending:[**First Name3 (LF) 783**] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: None History of Present Illness: 57 y.o. female with PMH significant for asthma, diabetes, HTN, CHF (diastolic) on 2liters NC, recurrent PE on coumadin, myopathy, back pain, migraine, depression, sleep apnea on CPAP, GERD, and CRI admitted for hypoxia sp fall. Patient states that over the past week or so she has noted a 10 pounds weight gain with increasing lower extremity edema with increase in her toursemide dose and improvement in her lower extremity edema. She also notes not being able to lie flat forcing her to move to her couch. She decided to come to the hospital after falling today while walking to the bathroom. No chest pain, palpitation during this time. She denies hitting her head though has had bilateral hip pain since that time. She denies any fevers at home. Though she has had a productive cough over the past few weeks. Denies abdominal pain, however endorses non-bloody diarrhea. States she does have neck pain from sleeping on the couch though no stiffness. No changes in vision or headaches. No rashes or sinusitis. No burning with urination or increase in urinary frequency. Pt has had influenza vaccine. After fall patient was transported to the hospital. In the ED initial vitals 98.7 60 168/68 20 95%. Exam patient able to speak in full sentences. Pain with palpation. CXR with evidence of fluid overload. L-Spine and Bilateral Hip films without evidence of fracture. UA negative. Labs with BNP slightly elevated. EKG similar to prior. Patient was admitted to ICU given multiple desats during ED course. Nitro x one. Torsemide 40mg IV x one with 630 cc negative. Vitals prior to transfer Temp 101.1, HR 53, BP 121/51, RR 22, Sat 92% on 6Liters. In the ICU, patient mentating with difficulty. Sating 98% on 4 liters. Appears comfortable in no acute distress. Past Medical History: CAD: cath [**7-2**] with non-flow limiting proximal LAD 40% stenosis CHF: diastolic (last echo [**1-/2193**], EF > 55%, diastolic dysfunction) Hx of Mobitz Type One PE: bilateral acute PE [**11-3**] on coumadin DM type 2, insulin dependent: followed at [**Last Name (un) **], last HbA1c 7.5% on [**2195-1-7**] CRI Asthma Recurrent sinusitis Bipolar disorder HTN GERD Obesity Sleep Apnea Low back pain Uterine Fibroids Migraines Fibromyalgia Anemia OSA: on C-PAP Social History: Lives alone. Former nursing assistant, currently on disability, performes all ADLs. Aunt and daughter live in [**Name (NI) 86**] and provide support. Uses a motorized wheelchair or walker. No alcohol, tobacco, or illicit drug use. Family History: Mother with hypertension and premature coronary disease (passed away at 34 due to MI). Grandmother with angina. Diabetes in family. Physical Exam: ADMISSION: VS: Temp: 101 BP: 121/45 HR:65 RR: 19 O2sat 97% on 4Liters GEN: obese, pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy,obese unable to assess JVP. No nuchal rigidity RESP: Poor air movement bilaterally, with rales left >right base CV: Distant, RR, S1 and S2 wnl, no m/r/g ABD: Obese, Non Tender to palpation. EXT: No lower extremity swelling, normal pulses. SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. No pass-pointing on finger to nose. 2+DTR's-patellar and biceps DISCHARGE: VS: 99.8, BP: 130/80, P: 64, RR: 20, 100% on 3L GA: morbidily obese, AOx3, NAD HEENT: PERRL. MMM. Cards: PMI not palpable [**3-1**] body habitus. distant heart sounds, brady reg rhythm, S1/S2 heard. no murmurs/gallops/rubs. Pulm: decreased breath sounds [**3-1**] habitus but no wheezes, rales, rhonchi Abd: soft, obese, mildly tender, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign. Extremities: wwp, 2+ tibial edema. DPs, PTs 2+. Neuro/Psych: AAOx3, CNs II-XII intact. Pertinent Results: Hematology: [**2197-1-5**] 06:25AM BLOOD WBC-9.6 RBC-3.93* Hgb-11.0* Hct-34.6* MCV-88 MCH-28.0 MCHC-31.8 RDW-15.7* Plt Ct-187 [**2197-1-2**] 10:10AM BLOOD WBC-9.3 RBC-4.08* Hgb-11.9* Hct-37.1 MCV-91 MCH-29.1 MCHC-32.0 RDW-15.5 Plt Ct-185 [**2197-1-2**] 10:10AM BLOOD Neuts-83.0* Lymphs-14.0* Monos-1.9* Eos-0.7 Baso-0.4 [**2197-1-5**] 06:25AM BLOOD PT-16.6* PTT-28.4 INR(PT)-1.5* [**2197-1-4**] 06:33AM BLOOD PT-19.3* PTT-30.4 INR(PT)-1.8* [**2197-1-2**] 05:00PM BLOOD PT-36.4* PTT-38.8* INR(PT)-3.8* [**2197-1-2**] 10:10AM BLOOD PT-34.4* PTT-40.6* INR(PT)-3.5* Chemistries: [**2197-1-5**] 06:25AM BLOOD Glucose-80 UreaN-61* Creat-1.5* Na-143 K-4.0 Cl-102 HCO3-32 AnGap-13 [**2197-1-2**] 10:10AM BLOOD Glucose-236* UreaN-70* Creat-2.0* Na-132* K-5.6* Cl-94* HCO3-25 AnGap-19 [**2197-1-2**] 05:00PM BLOOD ALT-29 AST-25 CK(CPK)-196 AlkPhos-102 TotBili-0.2 [**2197-1-5**] 06:25AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.2 [**2197-1-2**] 05:00PM BLOOD Albumin-3.6 Calcium-8.7 Phos-3.6 Mg-2.3 Cardiac Labs: [**2197-1-3**] 04:01AM BLOOD CK-MB-2 cTropnT-0.02* [**2197-1-2**] 05:00PM BLOOD CK-MB-3 cTropnT-0.04* [**2197-1-2**] 10:10AM BLOOD cTropnT-0.03* [**2197-1-2**] 10:10AM BLOOD proBNP-1799* ABGs: [**2197-1-2**] 05:22PM BLOOD Type-ART Temp-37.6 pO2-119* pCO2-63* pH-7.33* calTCO2-35* Base XS-5 Intubat-NOT INTUBA [**2197-1-2**] 12:44PM BLOOD Type-ART pO2-48* pCO2-60* pH-7.33* calTCO2-33* Base XS-3 ECHO [**2197-1-3**]: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is probably normal (LVEF>55%). 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. There is no pericardial effusion. HEAD CT [**2197-1-2**]: 1. No evidence of acute intracranial abnormalities. 2. Bone remodeling in the left maxillary sinus indicates prior chronic sinusitis. L SPINE XRAY [**2197-1-2**]: MPRESSION: Degenerative disease without definite signs of fracture or malalignment. If there is strong clinical concern for acute pathology, MR is advised. BILATERAL HIP XRAY [**2197-1-2**]: FINDINGS: AP view of the pelvis and two views of each hip were obtained. The bony pelvic ring appears intact. SI joints appear normal. Both hips appear normally aligned with minimal acetabular spurring, right greater than left. Bone mineralization appears normal. Femoral necks appear intact bilaterally. Mild vascular calcification is present. CXR [**2197-1-2**]: FINDINGS: Portable AP upright chest radiograph is obtained. Patient is slightly rotated to her left, limits evaluation as does the underpenetrated technique. Cardiomegaly is noted with pulmonary vascular congestion and pulmonary edema noted diffusely. No definite pleural effusions are seen. No large pneumothorax as well. Aortic calcifications are noted. Bony structures appear intact. IMPRESSION: Findings compatible with congestive heart failure. [**2197-1-2**] EKG: Bigeminal rhythm of uncertain mechanism. Low amplitude atrial wave forms are difficult to assess but may be sinus or ectopic atrial with A-V conduction delay. Left atrial abnormality with atrial bigeminy or ectopic atrial rhythm. Right bundle-branch block. Left anterior fascicular block. Delayed R wave progression with late precordial QRS transition is non-diagnostic. ST-T wave configuration with prolonged QTc interval is probably primary. Clinical correlation is suggested. Since the previous tracing of [**2196-5-18**] the rate is faster and bigeminal pattern is now present. Brief Hospital Course: Patient is a 57 F with a PMH of diabetes, diastolic CHF, on 3L O2 at home, recurrent DVT on coumadin, sleep apnea on CPAP admitted on [**2197-1-2**] after fall and with symptoms of volume overload consident with acute on chronic dCHF. #Acute on chronic diastolic CHF: Patient was admitted with hypoxia thought to be secondary to pulmonary edema from acute diastolic heart failure. Patient had noticed a 10 lb weight gain over the week prior to admission. In the MICU she was diuresed 2.6 L and she was diuresed an additional 2 L on the floor. At discharge, she was back to her 3L oxygen supplementation, which is her home regimen. She had no signs of volume overload, crackles and tibial edema were absent. She was discharged home on torsemide 40 mg po BID. An appointment was also made for her in the [**Hospital 1902**] clinic. # Fever: Patient had a low grade temp in ED and was started on ceft + azithro for possible community acquired pneumonia. This was stopped when she got to the floor as she remained afebrile and her chest x-ray showed no area of focal consolidation. A flu swab was sent and was negative for viral culture. #Chronic renal insufficiency: creatine to 2.0 on admission, elevated from a baseline of 1.7. Her creatinine had improved to 1.5 at discharge. #Diabetes: Last A1c 6.8 on [**2196-9-28**], well controlled. She was continued on home NPH regimen at 55 units [**Hospital1 **]. She was also given humalog sliding scale. Her fingerstick levels were mostly at goal, but the bedtime fingerstick levels were elevated in the low 200s. #Asthma: No sign of exacerbation, she was continued on her home regimen with Fluticasone-Salmeterol Diskus, montelukast and albuterol nebulizer. #Normocytic Anemia: iron studies consistent with anemia of chronic disease. HCT at baseline. # Bradycardia: She has been evaluated by EP in past and is not a candidate for pacer as she is asymptomatic and low HR is preferable for her diastolic CHF. #Hx of recurrent DVTs: on lifelong anticoagulation. Her INR was -hold warfarin as supratherapeutic . # OSA: patient was continued on home 3L O2 during the day and CPAP at night. #CODE: Full (confirmed) Medications on Admission: ALBUTEROL SULFATE nebulizer Q6Hrs ALBUTEROL SULFATE [PROAIR HFA] MDI QID prn SOB FIORICET 325 mg-40 mg-50 mg TID prn headache CALCITRIOL - 0.25 mcg Capsule one capsule 6 days a week CHOLESTYRAMINE LIGHT 4 gram Packet -1 packet by mouth daily CLONAZEPAM 1mg QHS ZETIA 10mg once daily FLUOXETINE 60mg Daily ADVAIR DISKUS 250 mcg-50 mcg/Dose Disk 1 inhalation po twice a day NEURONTIN600 mg Tablet TID INSULIN LISPRO [HUMALOG] Sliding Scale LACTULOSE - 10 gram/15 mL Solution prn constipation LISINOPRIL 10mg once daily SINGULAIR 10 mg Tablet one NITROGLYCERIN [NITROSTAT] - 0.4 mg Tablet, Sublingual prn Chest Pain OMEPRAZOLE - 40 mg Capsule [**Hospital1 **] OXYCONTIN 20 mg Tablet Sustained Release 12 hr [**Hospital1 **] OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - [**1-30**] Tablet Q4-6 hrs RANITIDINE HCL - 300 mg Tablet - 1 Tablet(s) by mouth at bedtime TIZANIDINE - 2 mg Tablet - [**1-30**] Tablet(s) Q4-6hrs prn back pain TORSEMIDE - 40 mg Tablet [**Hospital1 **] TRAZODONE - 100 mg prn insomnia TRIAMCINOLONE ACETONIDE - 0.1 % Cream apply [**Hospital1 **] WARFARIN 4-8 mg Daily DOCUSATE SODIUM [COLACE] - 100 mg Capsule TID FERROUS SULFATE 325mg TID LORATADINE 10 mg Tablet, once daily NPH INSULIN HUMAN RECOMB [HUMULIN N] 55 units twice a day SENNA - 8.6 mg Tablet - 2 Tablet(s) by mouth twice a day Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulization Inhalation every six (6) hours as needed for SOB. 2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**1-30**] puff Inhalation four times a day as needed for shortness of breath or wheezing. 3. Fioricet 50-325-40 mg Tablet Sig: 1-2 Tablets PO three times a day as needed for headache. 4. Cholestyramine Light 4 gram Packet Sig: One (1) packet PO once a day. 5. clonazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime. 6. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. fluoxetine 20 mg Tablet Sig: Three (3) Tablet PO once a day. 8. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1) inhalation Inhalation twice a day. 9. Neurontin 600 mg Tablet Sig: One (1) Tablet PO three times a day. 10. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 11. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 12. Singulair 10 mg Tablet Sig: One (1) Tablet PO once a day. 13. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual three times a day as needed for chest pain. 14. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 15. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 16. ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO at bedtime. 17. tizanidine 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. 18. torsemide 20 mg Tablet Sig: Two (2) Tablet PO twice a day. 19. triamcinolone acetonide 0.1 % Cream Sig: One (1) application Topical twice a day. 20. warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day: please follow instructions per coumadin clinic. 21. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO three times a day. 22. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO three times a day. 23. Humulin N 100 unit/mL Suspension Sig: Fifty Five (55) units Subcutaneous twice a day. 24. senna 8.6 mg Tablet Sig: Two (2) Tablet PO twice a day as needed for constipation. 25. Humalog 100 unit/mL Solution Sig: sliding scale Subcutaneous four times a day. 26. trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary: Acute on Chronic CHF Secondary: Asthma, Obstructive Sleep Apnea Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital after a fall at home. You were also having difficulty breathing and increased leg swelling. These symptoms were caused by an acute worsening of your heart failure. You were treated with diuretics to remove fluid and supplemental oxygen. You were seen by physical therapy who recommended you continue to use your walker. You were also having body aches. We tested you for the flu, which was negative. Please weigh yourself every morning and call your doctor if your weight goes up more than 3 lbs. Please continue to eat a low sodium diet and limit your fluid intake to no more than 2 liters per day. No changes were made to your medications. Please continue to take your medications as directed. Followup Instructions: Please keep the following appointments: Department: REHABILITATION SERVICES When: MONDAY [**2197-1-9**] at 10:50 AM With: [**Name (NI) **] PTA [**Name (NI) 33925**], PTA [**Telephone/Fax (1) 2484**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: TUESDAY [**2197-1-10**] at 3:30 PM With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 1935**] CENTER When: THURSDAY [**2197-1-12**] at 10:20 AM With: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. [**Telephone/Fax (1) 253**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**2197-1-16**] at 10:40a [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], [**Hospital **] [**Hospital 191**] MEDICAL UNIT [**Hospital Ward Name **] BUILDING [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13898, 13956

8060, 10223

403, 410

14073, 14073

4281, 8037

15013, 16337

2952, 3087

11584, 13875

13977, 14052

10249, 11561

14255, 14990

3102, 4262

355, 365

438, 2200

14088, 14231

2222, 2686

2702, 2936

29,030

109,151

21066

Discharge summary

report

Admission Date: [**2141-6-8**] Discharge Date: [**2141-7-4**] Service: SURGERY Allergies: Penicillins / Benadryl Attending:[**First Name3 (LF) 1**] Chief Complaint: Diarrhea, rigors Major Surgical or Invasive Procedure: Intubation NGT placement Central venous lines Total abdominal colectomy open cholecystectomy History of Present Illness: Ms. [**Name14 (STitle) 55941**] is an 85 yo female with recent hospitalization for C. diff colitis (from [**Date range (1) 29129**]/08; discharged to rehab; sent home on [**2141-5-31**]). Today she presented from home with rigors and diarrhea. The diarrhea has been non-bloody and began 2-3 days ago; it has not been associated with abd pain/cramping or nausea/vomiting. This morning she developed rigors and a fever of 100.7. In the ED, she was febrile to 102, SBP was in the 80's initially, and lactate was 3.8. She was started on vanco/levo/flagyl. She was given 2L NS but blood pressure remained in the 70 - 80's systolic; a right IJ was placed and she was placed on a code sepsis, with initiation of levophed. Of note, on presentation at the last admission, there was concern for ischemic bowel initially, and she was started on IV flagyl/vanco and cipro. She was taken off the flagyl and cipro once stool studies were returned with C. diff, and she completed a two week course of PO vanco for the C. diff (ended on [**2141-5-30**]). Her course then was c/b hypotension in the 80's, for which she received IVF but was never on pressors. Prior to the [**Month (only) **] hospitalization, she was on Keflex x 1 week for an infected left toe, as well as doxycycline for Lyme disease. Past Medical History: Hypertension Hypercholesterolemia Hypothyroidism H/o pneumonias-- c/b AFib Right rotator cuff tear-- [**2141-2-4**]; on percocet PRN Osteoarthritis Psoriasis Chronic kidney disease (baseline uncertain; ~1.4 in prior d/c summary) Social History: Social History: Former smoker, 2ppd x67years (135-pack-years), quit 4years ago. Occasional EtOH. Family History: Adopted and unsure of biological family hx Physical Exam: ADMISSION PHYSICAL EXAM: General: elderly, comfortable but appears tired Lungs: crackles at bases b/l; otherwise CTA Heart: soft HS; rate regular; no m.r.g. appreciated Abd: hyperactive BS; totally soft, NT to deep palpation, no rebound/guarding Extremities: [**12-7**]+ LE edema; 1+ distal pulses Neuro: CN II - XII . At Discharge: Vitals: T-98.9, HR-71, BP-130/70, RR-20, 2LNC-96% Gen: NAD, A/Ox3 CV: AFIB, no m/r/g RESP: Congested bases b/l, productive cough, clear otherwise ABD: +BS, soft, NT/ND Incision: Extrem: no c/c/e Pertinent Results: ADMISSION LABS: [**2141-6-8**] 02:50PM BLOOD WBC-21.1* RBC-3.74* Hgb-10.4* Hct-32.0* MCV-86 MCH-27.8 MCHC-32.5 RDW-14.4 Plt Ct-408 [**2141-6-8**] 02:50PM BLOOD Neuts-74* Bands-10* Lymphs-5* Monos-9 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 NRBC-1* [**2141-6-8**] 02:50PM BLOOD PT-32.6* PTT-28.8 INR(PT)-3.4* [**2141-6-8**] 02:50PM BLOOD Glucose-112* UreaN-16 Creat-1.3* Na-130* K-8.4* Cl-95* HCO3-25 AnGap-18 [**2141-6-8**] 06:00PM BLOOD ALT-11 AST-15 AlkPhos-48 TotBili-0.5 [**2141-6-14**] 04:18AM BLOOD Lipase-31 [**2141-6-8**] 02:50PM BLOOD Calcium-8.6 Phos-3.2 Mg-2.1 [**2141-6-8**] 06:00PM BLOOD Cortsol-45.7* [**2141-6-8**] 06:00PM BLOOD CRP-171.6* . CARDIAC ENZYMES: [**2141-6-8**] 02:50PM BLOOD CK(CPK)-150* [**2141-6-9**] 03:22AM BLOOD CK(CPK)-26 [**2141-6-8**] 02:50PM BLOOD CK-MB-2 cTropnT-<0.01 [**2141-6-9**] 03:22AM BLOOD CK-MB-2 cTropnT-<0.01 . MICROBIOLOGY: [**2141-6-8**] Blood Cultures: two sets, NGTD [**2141-6-8**] Urine Cultures: negative [**2141-6-9**] C. diff toxin A: positive [**2141-6-14**] Blood cultures: two sets, NGTD . IMAGING: [**2141-6-8**] ADMISSION CXR: No acute cardiopulmonary process. Poorly aerated retrocardiac region, limiting evaluation of left lower lobe. Lateral views would aid further evaluation. . [**2141-6-9**] CT ABD/PELVIS: 1. Findings consistent with pseudomembraneous colitis. No pneumoperitoneum or marked dilatation of the transverse colon to establish toxic megacolon, but clinical correlation is important. 2. Fibroid uterus, including a cavitating fibroid, but of doubtful clinical significance. [**2141-6-14**] TTE: 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 borderline low (2.0-2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. Cannot exclude mild aortic stenosis, but this does not appear to be severe. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a fat pad. Compared with the prior study (images reviewed) of [**2141-5-15**], the findings are similar. . [**2141-6-23**] CT CHEST: Persistent, extensive, and severe emphysema is observed. There is increase in the bilateral effusion with moderate atelectatic changes as compared to the previous CT. The NG tube and endotracheal tubes are seen in place. There are mild left lower lobe infiltrative changes. Two right lower lobe non-calcified pulmonary nodules are seen, which are 6 mm in size (series 2, image 40). . [**6-27**] CXR: Worsening pulmonary vascular congestion with probable bilateral pleural effusions. . [**2141-7-4**] 07:30AM BLOOD PT-13.1 INR(PT)-1.1 Brief Hospital Course: [**6-9**]- 85 yo female with recent admission for C. diff colitis, admitted with sepsis in the setting of recurrent diarrhea. Sepsis/Fevers/Leukocytosis from recurrent C. diff given severely elevated WBC. Hyponatremia of 130 on admission; likely hypovolemic in setting of sepsis treated with NS. UA on admission weakly c/w infection but pt asymptomatic; CXR with possible b/l infiltrates but more likely atalectasis given small lung volumes and lack of [**Last Name (un) **] sx. Pt thought to have ischemic bowel with possible gut translocation. [**6-10**]- Taken to OR for Total abdominal colectoym and cholecystectomy. PT remained intubated and was transferred to the [**Hospital Unit Name 153**] for ICU monitoring. Urine, blood cultures. C. diff assay and covereage with vanco/flagyl IV as well as cipro started. CVP maintained from 10 - 12, with boluses of IV NS to maintain. BP maintained with levophed. Fentanyl and versed boluses fo pain control. UOP maintained 20-30 cc per hr. [**Date range (1) 25044**] weaned off pressors. Continued reusctiation with IVF. PT in AFib throughout course at [**Hospital1 18**] rate controlled to low 100s with lopressor. [**6-14**] -11: [**Month/Day (4) **] diuresis with IV lasix. TPN started. [**6-17**]- [**6-21**] Elevated WBC, tube feeds begun adn advanced to goal. Vent weaned as tolerated with prolonged difficulty weaning from vent, continued diuresis. Fever workup unrevealing. [**6-23**]: WBC down, has not been afebrile 24 hours; suspect transient bacteremia from central line; [**6-23**] CT torso unrevealing. Pt placed on vanco IV for presumed line infection and IV flagyl for c. diff; Central line changed [**6-23**]. Pt treated with PRN lasix to volume goal -2L x 24 hrs. Started on liquid diet. transferred to the floors [**6-24**] Staples removed from abdominal wound, steristrips placed. [**6-25**]: extubated without difficulty or complication. [**2141-6-26**] Tolerating respiratory criteria. Placed on oxygen to help with breathing. Liquid diet started with aspiration precautions. [**6-27**] Regular diet with aspiration precattions. [**2141-6-28**]. Pt transferred to surgical floors. Placed on [**1-9**] L of oxygen. Progressed to regular diet. Calorie counts initiated to aim at daily caloric and protein requirements. Patient was re-tested for C.diff and was negative. Ample stool and gas through ostomy bag. Rehabilitation screen initiated to assist with patient conditioning. [**6-29**]: Pt devoloped rash c/w hives. Sarna lotion applied to decreased discomfort. Pt allergic to benadryl and anticholinergic risk thought to outweigh benefit of hydoxizine. [**2141-6-30**]: PT's roxicet discontinued due to concern of sundowning. Improved cognition once narcotic dc'd. Itching temporarily relieved. [**Date range (1) 20941**]: Pt continued to recuperate. [**Name (NI) **] PT continued. Tolerating regular diet and Ensure supplements. No sign of aspiration. Continue to monitor as precaution. [**7-3**]:Plans to send patient to rehab for conditioning, awaiting available REHAB bed. Coumadin started. INR monitored for adjustments. Patient OOB with PT and Nursing. Fatigued by end of day, knees buckled during transfer from Chair to Bed. Patient gently guided to floor. No trauma or injury sustained. Transferred back to bed safely. Continue to monitor for FALL risk. [**7-4**]: INR-1.1 today. Continue Coumadin dose titration. Rehab bed available. Patient remains stable, and cleared for transfer to Rehab today. Medications on Admission: HOME MEDICATIONS (confirmed with patient): Primidone 100 mg QD Nexium 40 mg QD Aspirin 325 mg QD Hexavitamin QD Ferrous Sulfate 325 mg QD Percocet 5-325 mg PRN Levothyroxine 100 mcg QD Metoprolol Tartrate 25 mg [**Hospital1 **] Lasix 40 mg QD Lisinopril 40 mg QD Coumadin Discharge Medications: 1. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for anxiety. 2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day) as needed for shortness of breath or wheezing. 5. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Acetaminophen 160 mg/5 mL Solution Sig: 20mL PO Q6H (every 6 hours) as needed for fever or pain: Do not exceed 4000mg in 24hours. 8. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)) as needed for Atrial Fibrillation: Adjust dose according to INR. Goal INR = [**1-8**]. 9. Trazodone 50 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for insomnia: Hold for somnolence. 10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 9 days: Give with meals . 12. Primidone 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 13. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 16. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day: Titrate up to 40mg (usual dose) as indicated. Hold for HR <55 or SBP < 100 . 17. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): hold for HR <55 or SBP < 100 . Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**] Discharge Diagnosis: Primary: Medically refractory Clostridium difficile colitis Sepsis-fever and leukocystosis Post-op respiratory failure-ventilatory dependency Post-op Atrial fibrillation Post-op tachycardia Toxic Megacolon Acute Renal Failure . Secondary: HTN, hypercholesterolemia, hypothyroidism, PNA, Afib, R rotator cuff tear, OA, psoriasis, CKD, Parkinson's Disease Discharge Condition: Stable Tolerating regular diet, and Ensure supplements. Aspiration Precautions. Pain well controlled with oral non-narcotic medication 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 steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. . Monitoring Ostomy output/Prevention of Dehydration: -Keep well hydrated. -Replace fluid loss from ostomy daily. -Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. -Try to maintain ostomy output between 1000mL to 1500mL per day. -If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16mg/24 hours. . HTN/AFIB Management: -Patients taking 40mg of PO Linisopril prior to surgical admission. Discontinued during admission. -Lopressor dose increased for rate control related to Atrial Fibrillation. -Titrate Lisinopril back up to pre-admission dose as blood pressure tolerates. -Consult with Primary doctor with concerns. -Titrate Lisinopril and Lopressors as needed. Followup Instructions: 1. Please make a follow-up appointment with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 9**] in [**12-7**] weeks. 2. Follow-up with your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1549**] [**Telephone/Fax (1) 55940**] one week after discharge from REHAB. 3. Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 43**] & [**Doctor Last Name **] (Neurologist) Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2141-7-10**] 4:00 4. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. (Cardiology) Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2141-9-20**] 11:20 Completed by:[**2141-7-4**]

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icd9cm

[ [ [] ] ]

[ "99.15", "38.93", "96.6", "96.04", "46.20", "45.8", "96.72", "51.22" ]

icd9pcs

[ [ [] ] ]

11235, 11347

5631, 9125

242, 336

11745, 11882

2653, 2653

14174, 14867

2046, 2090

9447, 11212

11368, 11724

9151, 9424

11906, 13048

13063, 14151

2130, 2424

2438, 2634

3324, 5608

185, 204

364, 1662

2669, 3307

1684, 1915

1947, 2030

21,666

174,565

29126+29127

Discharge summary

report+report

Admission Date: [**2176-4-26**] Discharge Date: [**2176-4-29**] Date of Birth: [**2103-11-23**] Sex: M Service: SURGERY Allergies: Penicillins / Macrolide Antibiotics / Quinolones / Ursodiol / Tape / Neomycin/Polymyxin/Dexameth Attending:[**First Name3 (LF) 695**] Chief Complaint: Bloody bowel movements s/p needle biopsy of prostate on [**2176-4-25**] Major Surgical or Invasive Procedure: [**2176-4-25**]: transrectal prostate biopsy (prior to admission) [**2176-4-26**]: Flex sigmoidoscopy History of Present Illness: Pt is 72 yo M with a history of cirrhosis s/p liver transplnat in [**2174-10-29**] (Dr.[**First Name (STitle) **]) who presents with BRBPR on [**4-26**], one day after the Pt had a transrectal prostate ultrasound with bx x 12 by Urology. Pt had an elevated PSA this past [**Month (only) 404**]. The procedure was painful due to internal hemorrhoids. Two hours after the procedure, pt had a bowel movement mixed with blood. Yesterday morning (PPD #1) pt had 4 more bowel movements progressively converting to frank blood and clot. During the last few of episodes, pt was near-syncopal as he reports being lightheaded having to sit on the bathroom floor though he [**Month (only) **] any loss of consciousness. Pt denied any fever, chills, abominal pain, diarrhea prior to the procedure. He had one episode of n/v after breakfast yeaterday which was nonbloody and non bilious. He denied any CP, SOB, headaches. . He presented to [**Hospital3 10310**] Hospital. On arrival to OSH, BS were BP 79/49, HR 90, RR 18, 100% O2 sat. Pt received 1L NS and VS improved to BP range of 95/52 to 120/59, HR range of 70s-80s. HCT was 27, and patient received 1 unit of PRBCs. . In [**Hospital1 18**] ED, initial VS were: 98.3 78 114/92 18 100. HCT upon arrival was 31.8. INR of 1.2 at 2:30pm. Pt continued to pass clot and red blood per rectum, repeat HCT at 8pm was 30.5. Pt admitted to MICU service, reveived 3 units of PRBC since 8pm. A felxible sigmoidoscopy was done at the bedside which showed blood in the rectum, sigmoid, descending and distal transverse colon. There was profuse bleeding at the beginning of the procedure but no active bleeding noted at the end of the 1.5 hour scope. GI/Hepatology recommending RBC Scan if bleeding returns. His SBPs have ranged from the 70s to 120s with HR 70s to 103 while in the MICU. Evaluated by Urology in ED who feels that bleeding source is likely the internal hemorrhoids and not the biopsy site and recommends rectal packing if bleeding returns. Past Medical History: 1. ETOH induced ESLD with portal hypertension, refractory ascites, now s/p orthotopic liver transplant in [**2174-10-10**] 2. Upper GI bleed ([**2174**]) s/p variceal banding at [**Hospital1 2025**], second UGIB s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] and TIPS on [**2174-1-14**] - EGD with varices in lower 3rd of esophagus, portal gastropathy 3. Candidemia [**8-16**], no evidence of ocular involvement on exam, TTE clean, s/p IV fluconazole 4. h/o alcohol abuse, quit with dx of liver disease 5. Biliary Colic s/p biliary stenting -- now removed 6. Cholangitis complicated elective ERCP 7. h/o hyponatremia as low as 119 8. Herniated discs between L3/L4 9. Psoriasis 10. L eye retinal repair ~[**2174-11-28**], s/p retinal lasering recently, s/p L cataract repair Social History: Significant history of alcohol use, drinking from the age of 25 until recently, stopping approximately one year ago. He has no history of illicit drug use. He smoked half a pack of cigarettes per day for 20 years, but has been off them for 20 years. He never received a blood transfusion prior to [**2157**]. Family History: His father was an alcoholic. There is no known family history of liver disease. Physical Exam: Temp 97.1, HR 79, BP 110/75, RR 16, O2 100% on 2lit NC Gen: Well, NAD, A&O, Conversive CV: RRR, No R/G/M RESP: Lungs CTAB ABD: Well healed chevron insicion, non-tender, non-distended EXT: No edema Pertinent Results: On Admission: [**2176-4-26**] WBC-5.8 RBC-3.84* Hgb-10.5* Hct-31.8* MCV-83 MCH-27.3 MCHC-33.0 RDW-14.4 Plt Ct-246 PT-13.6* PTT-27.2 INR(PT)-1.2* Glucose-97 UreaN-20 Creat-2.1* Na-137 K-4.7 Cl-108 HCO3-21* AnGap-13 ALT-19 AST-33 LD(LDH)-189 AlkPhos-101 TotBili-0.3 Albumin-3.9 Calcium-8.5 Phos-3.9 Mg-2.2 On Discharge [**2176-4-29**] WBC-3.1* RBC-3.45* Hgb-10.1* Hct-28.6* MCV-83 MCH-29.2 MCHC-35.1* RDW-15.2 Plt Ct-140* Glucose-102 UreaN-19 Creat-1.7* Na-139 K-4.0 Cl-111* HCO3-21* AnGap-11 ALT-14 AST-26 AlkPhos-58 TotBili-0.3 Brief Hospital Course: 72 y/o male s/p liver transplant about 18 months ago who underwent transrectal biopsy of the prostate the day prior to admission and was having rectal bleeding and weakness. His hematocrit dipped as low as 24% and he received 7 units of packed RBCs over the 4 day course of his hospitalization. The patient underwent a flex sigmoidoscopy with the GI service on the day of admission which showed "Clotted and fresh blood was seen in the rectum, distal sigmoid colon, distal descending colon, splenic flexure and distal transverse colon. Protruding Lesions, Medium non-bleeding grade [**1-12**] internal & external hemorrhoids with skin tags were noted." He was also seen by the urology service in followup to the prostate biopsy and as it was felt the bleeding was due to the hemorrhoids seen on scope and not bleeding from the biopsy, they had no further intervention at this time. His hematocrit was stable [**4-28**] and [**4-29**] and he was discharged to home, tolerating diet, ambulating and having no evidence of current/active bleeding. Medications on Admission: Cellcept [**Pager number **] mg [**Hospital1 **], Sirolimus 3 mg daily, Bactrim 400mg-80mg daily, Lysine 500 mg [**Hospital1 **] Discharge Medications: 1. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Sirolimus 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Apraclonidine 0.5 % Drops Sig: One (1) Drop Ophthalmic TID (3 times a day). 5. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic TID (3 times a day). 6. Tobramycin-Dexamethasone 0.3-0.1 % Ointment Sig: One (1) Appl Ophthalmic DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: s/p prostate biopsy with post procedure bleeding, determined to be hemorrhoidal bleeding Discharge Condition: Stable/Good Discharge Instructions: Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever > 101, chills, nausea, vomiting, blood in stool or urine, dizzy or light-headed or any other concerning symptoms Continue labwork per transplant clinic guidelines Followup Instructions: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2176-5-8**] 9:00 [**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 1669**] Date/Time:[**2176-5-8**] 10:15 EYE IMAGING Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2176-5-29**] 8:30 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2176-4-30**] Admission Date: [**2176-4-29**] Discharge Date: [**2176-5-5**] Date of Birth: [**2103-11-23**] Sex: M Service: SURGERY Allergies: Penicillins / Macrolide Antibiotics / Quinolones / Ursodiol / Tape / Neomycin/Polymyxin/Dexameth Attending:[**First Name3 (LF) 695**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: [**2176-5-2**]: Exam under anesthesia [**2176-5-4**]: EGD [**2176-5-1**]: Colonoscopy History of Present Illness: 72M who was discharged earlier this morning after being admitted for lower GI bleed thought to be the result of bleeding from a prostate biopsy or hemorrhoid. He reports feeling well today, however around 3PM he had a bowel movement where he passed normal stool with some blood. He subsequently had 4 more bowel movements where he passed only blood and clot. He report feeling tired afterwards, however [**Month/Day/Year **] dizziness, lightheadedness, chest pain, shortness of breath, nausea, vomiting or abdominal pain. He called an ambulance and was transferred to OSH where he had a pressure in 60s but was otherwise stable. He was started on IVFs and was transferred to [**Hospital1 18**]. Past Medical History: 1. ETOH induced ESLD with portal hypertension, refractory ascites, now s/p orthotopic liver transplant in [**2174-10-10**] 2. Upper GI bleed ([**2174**]) s/p variceal banding at [**Hospital1 2025**], second UGIB s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] and TIPS on [**2174-1-14**] - EGD with varices in lower 3rd of esophagus, portal gastropathy 3. Candidemia [**8-16**], no evidence of ocular involvement on exam, TTE clean, s/p IV fluconazole 4. h/o alcohol abuse, quit with dx of liver disease 5. Biliary Colic s/p biliary stenting -- now removed 6. Cholangitis complicated elective ERCP 7. h/o hyponatremia as low as 119 8. Herniated discs between L3/L4 9. Psoriasis 10. L eye retinal repair ~[**2174-11-28**], s/p retinal lasering recently, s/p L cataract repair Social History: Significant history of alcohol use, drinking from the age of 25 until recently, stopping approximately one year ago. He has no history of illicit drug use. He smoked half a pack of cigarettes per day for 20 years, but has been off them for 20 years. He never received a blood transfusion prior to [**2157**]. Family History: His father was an alcoholic. There is no known family history of liver disease. Physical Exam: T 97.6 P 73 BP 121/65 RR 18 O2 100% RA PE: Gen - Alert and oriented times 3 CV - RRR Pulm - CTAB Abd - Soft, nontender, nondistended, no rebound/guarding Rectal - External hemorrhoids, guaiac positive but no gross blood, no stool felt in rectal vault, no palpable masses Ext - No edema Labs: 7.9 141 114 18 >----< ---|---|---<125 24.0 4.6 19 1.6 Pertinent Results: [**2176-4-28**] 02:48AM BLOOD WBC-3.9* RBC-3.42* Hgb-9.7* Hct-27.6* MCV-81* MCH-28.4 MCHC-35.1* RDW-14.9 Plt Ct-128* [**2176-4-28**] 02:48AM BLOOD Glucose-82 UreaN-24* Creat-1.9* Na-138 K-4.1 Cl-111* HCO3-20* AnGap-11 [**2176-4-29**] 05:05AM BLOOD ALT-14 AST-26 AlkPhos-58 TotBili-0.3 [**2176-5-5**] 04:56AM BLOOD Glucose-106* UreaN-9 Creat-1.7* Na-139 K-3.8 Cl-109* HCO3-25 AnGap-9 [**2176-5-5**] 04:56AM BLOOD WBC-3.4* RBC-3.54* Hgb-10.4* Hct-29.7* MCV-84 MCH-29.5 MCHC-35.1* RDW-14.9 Plt Ct-138* [**2176-5-5**] 04:56AM BLOOD rapmycn-7.1 Brief Hospital Course: 72M with continued bleeding per rectum after prostate biopsy on [**4-26**]. He was admitted to transplant surgery and given PRBC for a hct fo 24. GI was consulted and recommended a colonoscopy. He continued to have bloody output from his rectum. Colonoscopy showed a large amout of fresh red blood and clots in the whole colon, but no active bleeding. Blood was larger in quantity in the left colon. Source of bleeding could not be determined but was likely in the rectum or sigmoid colon. The examined colonic mucosa was normal. More than 50% was obscured by blood. He was then transferred to the SICU where he continued to receive PRBC and volume for low BP that was responsive to these treatments. While in the SICU, he received multiple blood transfusions continued to keep HCT at 30. On [**5-1**], an angio of the inferior mesenteric artery, superior mesenteric artery, and bilateral internal iliac arteries demonstrated hyperemia of the rectal mucosa with irregularity of small arterial branches feeding the rectum but no evidence of extravasation or pseudoaneurysm. No intervention was performed. A CT of the ABD was then done to assess for hematoma or active extravasation. No source of bleeding was identified. The liver transplant vasculature was normal. There was no evidence of the prostate to suggest hemorrhage. There was very mild non-specific periprostatic fat stranding. No retroperitoneal hemorrhage was identified. On [**3-4**], he was taken to the OR for colonoscopy, examination under anesthesia and rigid sigmoidoscopy. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Multiple diverticulae were identified with no finding of obvious bleeding source. It was presumed that this was a diverticular bleed. He then underwent inferior mesenteric arteriogram which demonstrated no active bleeding visualized at any of its branches, and hyperemia was visualized at the rectum during arteriogram. Hematocrit stabilized at 29-30. Urology was consulted. GI bleed was not felt to have been caused by the transrectal biopsy. Pathology results of the prostate from [**2176-4-25**] were finalized significant for K) Left base lateral: Adenocarcinoma, [**Doctor Last Name **] Score 7 (3+4), involving 80% of the core and L) Left base medial: [**Doctor Last Name **] Score 7 (3+4 ), involving 40% of the core. Please refer to complete pathology report. Findings were discussed with the patient by Urology. Urology was to arrange a follow up. He was transferred out of the SICU to the med-[**Doctor First Name **] unit where diet was advanced and tolerated. He was having nonb-bloody bms. Vitals remained stable. He was discharged with no source of hematochezia identified. He was instructed to call the Transplant Office to schedule follow up appointment. Medications on Admission: Cellcept [**Pager number **] mg [**Hospital1 **] Sirolimus 3 mg daily Bactrim 400mg-80mg daily Lysine 500 mg [**Hospital1 **] Discharge Medications: 1. Sirolimus 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Lower GI Bleed prostate adenoca Discharge Condition: Good Discharge Instructions: Please [**Name8 (MD) 138**] MD or visit ER if you experience any of the following: Fevers, chills, mausea/vomiting, bloody bowel movements, chest pain, shortness of breath, inability to tolerate food. Followup Instructions: Please call [**Telephone/Fax (1) 63791**], to arrange for a follow up appointment with Dr. [**First Name (STitle) **]. Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2176-5-8**] 9:00 Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1669**] Date/Time:[**2176-5-8**] 10:15 Provider: [**Name10 (NameIs) **] IMAGING Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2176-5-29**] 8:30 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2176-5-9**]

[ "455.3", "185", "585.9", "303.93", "564.89", "562.10", "455.0", "V42.7", "562.12" ]

icd9cm

[ [ [] ] ]

[ "45.13", "88.47", "99.04", "45.23" ]

icd9pcs

[ [ [] ] ]

13895, 13901

10649, 13456

7591, 7681

13978, 13985

10085, 10626

14234, 14887

9565, 9646

13633, 13872

13922, 13957

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7546, 7553

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4031, 4546

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9238, 9549

18,547

171,656

22544+57303

Discharge summary

report+addendum

Admission Date: [**2103-6-27**] Discharge Date: [**2103-7-5**] Service: CSU HISTORY OF PRESENT ILLNESS: This is an [**Age over 90 **]-year-old white male who has been working out with a trainer for the past two years, and over the past several months has complained of shortness of breath. He has had lower extremity edema which improves with Lasix. The patient had a stress test on [**2103-1-1**] which revealed a reversible inferoapical perfusion deficit. He had a positive exercise tolerance test and had an ejection fraction of 70 percent. An echocardiogram on [**2103-5-1**] revealed preserved ejection fraction with mitral calcification with mild mitral regurgitation, left atrial enlargement, and a left renal cyst. The patient is now admitted for a cardiac catheterization. PAST MEDICAL HISTORY: Significant for a history of hypertension, hypercholesterolemia, history of diverticulitis, status post hernia repair six weeks prior to admission, status post cataract surgery. ALLERGIES: He has no known drug allergies. MEDICATIONS ON ADMISSION: 1. Lasix 20 mg by mouth once per day. 2. Lopressor 25 mg by mouth twice per day. 3. Lipitor 10 mg by mouth once per day. 4. Aspirin 81 mg by mouth once per day. FAMILY HISTORY: Unremarkable. SOCIAL HISTORY: He does not smoke cigarettes. He does not drink alcohol. REVIEW OF SYSTEMS: Unremarkable. PHYSICAL EXAMINATION ON ADMISSION: The patient is an elderly white male in no apparent distress. Vital signs were stable. He was afebrile. Head, eyes, ears, nose, and throat examination revealed normocephalic and atraumatic. The extraocular movements were intact. The oropharynx was benign. The neck was supple with full range of motion. There was no lymphadenopathy or thyromegaly. Carotids were 2 plus and equal bilaterally with no bruits. The lungs had diffuse rales half the way up bilaterally. The abdomen was soft and nontender. There were positive bowel sounds. There were no masses or hepatosplenomegaly. The extremities were without clubbing, cyanosis, or edema. The pulses were 2 plus and equal bilaterally throughout. The neurologic examination was nonfocal. SUMMARY OF HOSPITAL COURSE: The patient underwent cardiac catheterization on [**6-27**] which revealed the left main was normal. The left anterior descending had diffuse moderate proximal and mid disease. The left circumflex had an ostial 80 percent lesion. The right coronary artery had an ostial 50 percent lesion. Dr. [**Last Name (STitle) 70**] was consulted, and on [**6-28**] the patient underwent a coronary artery bypass graft times three with a left internal mammary artery to the left anterior descending, reversed saphenous vein graft to the posterior descending artery and obtuse marginal. Cross-clamp time was 64 minutes. Total bypass time was 85 minutes. The patient was transferred to the Cardiac Surgery Recovery Unit in stable condition on propofol, nitroglycerin, and Neo-Synephrine. He was extubated on his postoperative night. On postoperative day one, he was in stable condition. He had his chest tubes discontinued on postoperative day two. He was AV-paced at 90, and that was slowly weaned off. He then went into rapid atrial fibrillation. He was started on Lopressor and amiodarone and converted to a sinus rhythm. The patient was transferred to the floor on postoperative day three. He kept an occasional heart rate in the 50s and 60s, and had his amiodarone decreased down to 200 once per day. He had his wires discontinued on postoperative day three. On postoperative day five, he was bradycardic down to the 30s. His blood pressure was around 90. He was transferred to back to the Cardiac Surgery Recovery Unit for observation. His Lopressor was discontinued and his amiodarone was discontinued. He was seen by Electrophysiology who recommended him to be discharged on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor and just followed for bradycardia. His heart rate over the next day rebounded to the 70s and 80s with a good blood pressure, and he was transferred back to the floor in stable condition. DISCHARGE DISPOSITION: On postoperative day six, he was discharged to rehabilitation in stable condition. LABORATORY DATA ON DISCHARGE: His laboratories on discharge revealed a hematocrit of 30.2, his white blood cell count was 6600, his platelets were 183,000. Sodium was 141, potassium was 4.1, chloride was 102, bicarbonate was 31, blood urea nitrogen was 52, creatinine was 1.8, and blood glucose was 126. MEDICATIONS ON DISCHARGE: 1. Lasix 20 mg by mouth twice per day (for seven days). 2. Potassium 20 mEq by mouth twice per day (for seven days). 3. Colace 100 mg by mouth twice per day. 4. Aspirin 325 mg by mouth once per day. 5. Percocet one to two tablets by mouth q.4-6h. as needed (for pain). 6. Plavix 75 mg by mouth once per day (for three months). 7. Norvasc 5 mg by mouth once per day. 8. Lipitor 10 mg by mouth once per day. DISCHARGE FOLLOWUP: The patient will be followed by Dr. [**Last Name (STitle) 9125**] in one to two weeks, by Dr. [**Last Name (STitle) 11493**] in two to three weeks, and by Dr. [**Last Name (STitle) 70**] in six weeks. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Hypertension. 3. Hypercholesterolemia. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**] Dictated By:[**Last Name (NamePattern1) 18588**] MEDQUIST36 D: [**2103-7-4**] 17:28:59 T: [**2103-7-4**] 18:29:40 Job#: [**Job Number 58506**] Name: [**Known lastname 10806**],[**Known firstname **] Unit No: [**Numeric Identifier 10807**] Admission Date: [**2103-6-27**] Discharge Date: [**2103-7-6**] Date of Birth: [**2018-6-18**] Sex: M Service: CSURG Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2724**] Chief Complaint: see primary discharge summary Major Surgical or Invasive Procedure: see primary discharge summary Physical Exam: T98.6 P87 SR, BP140/70 RR 18 RASpO297% N:Awake, alert, orientedX3, no focal deficits CV:RRR, no rub or murmur, extremities warm and well perfused Resp:BS decreased bilateral bases, no wheezes, rhonchi or rales GI+BS, soft, NTND, toll regular diet and having normal BM Sternal incision C/D/I no erythema, no drainage, sternum stable RLE vein harvest site C/D/I no erythema, no drainage bilateral LE [**11-24**]+ edema Pertinent Results: [**2103-7-6**] 06:15AM BLOOD WBC-8.1 RBC-3.87* Hgb-11.4* Hct-34.1* MCV-88 MCH-29.5 MCHC-33.5 RDW-15.0 Plt Ct-270 [**2103-7-6**] 06:15AM BLOOD Plt Ct-270 [**2103-7-6**] 06:15AM BLOOD Glucose-136* UreaN-32* Creat-1.7* Na-139 K-4.9 Cl-99 HCO3-31* AnGap-14 [**2103-7-6**] 06:15AM BLOOD ALT-31 AST-22 AlkPhos-65 TotBili-0.7 [**2103-7-6**] 06:15AM BLOOD PT-13.4 PTT-30.9 INR(PT)-1.1 Brief Hospital Course: On the evening of [**7-4**], Mr. [**Known lastname **] had an episode of rapid atrial fibrillation, with a heart rate in the 140s. He remained hemodynamicaly stable, and required IV lopressor to convert to SR. The electrophysiology service recomended that the patient be placed on 200 mg amiodarone daily, with no beta-blockers, and that he be anticoagulated. The patient's plavix was discontinued, he was started on coumadin and continued on low dose aspirin. He was started on amiodarone on [**7-5**], and with no further episodes of atrial fibrillation or bradycardia, he is cleared for discharge on [**7-6**]. He will be dischared to rehab with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts Monitor. Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days then decrease to once a day. 2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (once a day). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 6. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO QD (once a day). 7. Lipitor 20 mg Tablet Sig: .5 Tablet PO once a day. 8. Ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 9. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO QD (once a day). 10. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once: check PT/INR [**7-7**]-dose coumadin for goal INR 2.0-2.5. Discharge Disposition: Extended Care Facility: [**Hospital6 5025**] & Rehab Center - [**Location (un) **] Discharge Diagnosis: Coronary artery disease. s/p CABG post op atrial fibrillation post op bradycardia chronic renal insufficiency Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. You may not drive for 1 month. You may not lift more than 10 lbs. for 3 months. You should shower, let water flow over wounds, pat dry with a towel. Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) 2028**] for 1-2 weeks. Make an appointment with Dr. [**Last Name (STitle) 1653**] for 2-3 weeks. Make an appointment with Dr. [**Last Name (STitle) 71**] for 6 weeks. Make an appointment with Dr. [**Last Name (STitle) 86**] in 4 weeks [**Doctor Last Name **] of Hearts Monitor with daily recordings to Dr. [**Last Name (STitle) 86**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2727**] MD [**MD Number(1) 2728**] Completed by:[**2103-7-6**]

[ "272.0", "427.89", "427.31", "593.9", "997.1", "414.01", "562.11" ]

icd9cm

[ [ [] ] ]

[ "36.15", "88.56", "37.23", "36.12", "39.61" ]

icd9pcs

[ [ [] ] ]

8629, 8714

6935, 7672

6051, 6082

8868, 8875

6534, 6912

9118, 9661

1254, 1269

5247, 5965

7695, 8606

8735, 8847

4592, 5003

1074, 1237

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6097, 6515

2194, 4151

4290, 4566

1365, 1401

5982, 6013

5024, 5226

117, 801

1416, 2165

824, 1048

1286, 1345

69,219

188,153

53715

Discharge summary

report

Admission Date: [**2167-3-29**] Discharge Date: [**2167-4-23**] Date of Birth: [**2100-12-16**] Sex: M Service: MEDICINE Allergies: Sulfa(Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 31014**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Endotracheal intubation Cardiac catheterization with bare metal stent to LAD Intra-aortic balloon pump placement Central venous line placement Arterial line placement Pulmonary artery catheter placement AICD placement History of Present Illness: 66 yo M with chronic low back pain who presented to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] with chest pain, and collapsed in triage apneic and pulseless. Ventilation and CPR was initiated, with monitor showing wide-complex tachycardia at 240 bpm. Pulse and spontaneous respirations returned quickly, and patient was shocked twice with 120 and 150 J without improvement in rhythm. He was bolused with 150mg IV amiodarone, then started on an amiodarone drip at 1mg/min. Blood pressures remained in the 130s systolic. Post arrest CXR showed pulmonary edema. Bolused with heparin 4000 unit then started on drip at 1032 units per hour. He also received aspirin 60mg rectally and atorvastatin 80mg. ECG after initiation of amiodarone showed sinus tachycardia with wide complex. Trop-I of 3.5 after cardioversion. . Pt noted some dyspnea on exertion about 5 days ago while out walking his dog. He had never experienced similar symptoms. On morning of admission to [**Hospital1 **], he had substernal chest pain like someone sitting on his chest, which he had also never experienced. . On arrival to the floor, patient is without chest pain or dyspnea. He is mentating well. Past Medical History: Chronic lower back pain from compression fractures Osteoporosis h/o EtOH abuse Social History: Previously worked in investment banking, but retired about 10 years ago. Lives with his wife. -Tobacco history: Smoked 1 PPD for 20 yrs, quit 30 yrs ago -ETOH: Heavy drinking in the past, quit 5 years ago. Withdrawal seizure in [**2158**]. -Illicit drugs: None Family History: Father died of heart attack at unknown age, otherwise non-contributory. Physical Exam: ADMISSION EXAM: VS: 37.1 118 122/73 19 94% on facemask GEN: obese, somewhat agitated, comfortable, no acute distress HEENT: moist mucus membranes, anicteric, no JVD CV: tachycardic, regular rhythm, no murmurs audible LUNGS: clear to ausculation bilaterally ABD: obese, non tender, non distended, positive bowel sounds EXT: no edema SKIN: warm and dry, erythema over his chest and stomach DISCHARGE EXAM: Tmax: 36.6 ??????C (97.8 ??????F) Tcurrent: 36.4 ??????C (97.5 ??????F) HR: 67 (65 - 87) bpm BP: 98/50(62) {83/47(58) - 113/68(76)} mmHg RR: 14 (11 - 20) insp/min SpO2: 97% Heart rhythm: SR (Sinus Rhythm) Wgt (current): 72 kg (admission): 84.5 kg Height: 68 Inch General Appearance: Deconditioned, breathing comfortably with NC and in no acute respiratory distress, speaking full sentences without pauses or SOB Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: RRR, S1S2 clear and of good quality, no murmurs, rubs or gallops appreciated Peripheral Vascular: Diminished LLE pulses but full pulses bilateral UE and RLE Respiratory / Chest: ctab, no crackles/wheezes/rhonchi Extremities: no LE edema b/l Pertinent Results: ADMISSION LABS: [**2167-3-29**] 05:15PM BLOOD WBC-19.3* RBC-4.87 Hgb-13.3* Hct-41.4 MCV-85 MCH-27.3 MCHC-32.1 RDW-13.7 Plt Ct-295 [**2167-3-30**] 12:20PM BLOOD Neuts-85.0* Lymphs-10.0* Monos-4.6 Eos-0.1 Baso-0.3 [**2167-3-29**] 05:15PM BLOOD PT-13.5* PTT-70.0* INR(PT)-1.3* [**2167-3-29**] 05:15PM BLOOD Glucose-188* UreaN-15 Creat-1.1 Na-139 K-3.5 Cl-103 HCO3-23 AnGap-17 [**2167-3-30**] 02:56AM BLOOD ALT-22 AST-35 CK(CPK)-195 AlkPhos-81 TotBili-0.8 [**2167-3-29**] 05:15PM BLOOD Calcium-9.0 Phos-2.9 Mg-1.6 Cholest-157 [**2167-3-29**] 05:15PM BLOOD HDL-31 CHOL/HD-5.1 LDLmeas-127 [**2167-3-29**] 05:15PM BLOOD TSH-3.0 . ENZYMES & BILIRUBIN ALT AST LD(LDH) AlkPhos TotBili [**2167-4-22**] 05:30 26 23 157 103 0.7 [**2167-4-19**] 04:03 33 21 98 0.5 [**2167-4-17**] 03:41 37 26 93 0.5 Source: Line-aline [**2167-4-16**] 04:07 34 23 136 86 0.6 . CPK ISOENZYMES CK-MB MB Indx cTropnT proBNP [**2167-4-12**] 12:20 2 0.30*1 Source: Line-aline [**2167-4-12**] 04:30 4 0.28*2 Source: Line-art [**2167-4-3**] 12:38 1 1.79*1 Source: Line-aline [**2167-4-1**] 03:13 7090*3 Source: Line-art [**2167-3-30**] 21:46 8 2.61*1 Source: Line-art [**2167-3-30**] 12:20 16* 6.3* Source: Line-aline [**2167-3-30**] 02:56 17* 8.7* LFT'S ADDED ON AT 5:45 A.M. [**2167-3-30**] [**2167-3-29**] 17:15 7 1.14*4 . DISCHARGE LABS: [**2167-4-22**]: WBC 10.8, Hb/Hct 12.0/38.8, Plt 237 [**2167-4-22**]: INR 1.8 [**2167-4-22**]: Na 132, K 4.3, Cl 98, HCO3 22, BUN 46, Cr 1.8 [**2167-4-23**]: Cr 1.2 . MICRO: [**2167-4-1**] 3:55 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2167-4-3**]** GRAM STAIN (Final [**2167-4-1**]): <10 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final [**2167-4-3**]): Commensal Respiratory Flora Absent. KLEBSIELLA PNEUMONIAE. MODERATE GROWTH. YEAST. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _______________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . GRAM STAIN (Final [**2167-4-8**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. RESPIRATORY CULTURE (Final [**2167-4-10**]): Commensal Respiratory Flora Absent. YEAST. SPARSE GROWTH. KLEBSIELLA PNEUMONIAE. RARE GROWTH. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . C. diff [**4-10**] and [**4-16**]: negative . Blood cultures ([**3-31**], 18, 20, 21, 24, [**4-16**]): negative Urine cultures ([**3-31**], [**4-3**], [**4-7**], [**4-16**], [**4-18**]): negative . [**3-29**] TTE: There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is severely depressed (LVEF= 15-20 %) secondary to hypo to akinesis of the mid-distal LV segments and apex. The basal-mid inferior and infero-lateral walls are hyperdynamic. A left ventricular mass/thrombus cannot be excluded. There is no resting LVOT obstruction. Right ventricular chamber size and free wall motion are normal. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-15**]+) mitral regurgitation is seen. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Poor image quality due to body habitus. Moderate left ventricular dilatation with severe regional and global systolic dysfunction c/w multivessel CAD. Hyperdynamic right ventricular systolic function. Mild-moderate mitral regurgitation (possibly underestimated). As the apical endocardium was poorly visualized, if clinically indicated, a contrast study could be performed to exclude LV thrombus. [**3-29**] KUB: There is gastric distention. There is no evidence of bowel obstruction. There is nonspecific bowel gas pattern with nondistended small bowel loops in the mid abdomen. Degenerative changes are present in the lumbar spine. . Cardiac Cath ([**3-30**]): COMMENTS: 1.Selective coronary angiography of this right dominant system demonstrated a one vessel disease. The LMCA was normal. The LAD had a 95% focal lesion between D1 and D2. The LCX and RCA had no angiographically apparent flow limiting stenosis. 2. Resting hemodynamics revealed elevated right and left filling pressures with RVEDP 16 mmHg and PCW 23 mmHg. There was moderate pulmonary artery systolic hypertension with PASP 44 mmHg. The cardiac output was low with CI 2.3 L/min/m2 (using assumed o2 consumption). 3. 3. Successful PCI to the mLAD with 2.75x12mm Integrity BMS. 4. Placement of IABP for hemodynamic support. 5. No complications. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Successful PCI to the mLAD with Integrity BMS. 3. IABP placement in the RFA. 4. Patient to remain on aspirin indefintely and clopidogrel for at least 9 months uniterrupted. . ECHO ([**4-1**]): The left atrium is mildly dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Left ventricular wall thicknesses and cavity size are normal. There is severe regional left ventricular hypokinesis with near akinesis of the distal 2/3rds of the ventricle with apical aneurysm/mild dyskinesis. The basal inferior and inferoseptal walls contract best (LVEF = 20%). The estimated cardiac index is borderline low (2.0-2.5L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. CONCLUSIONS: Normal left ventricular cavity size with apical aneurysm and severe regional systolic dysfunction c/w CAD (prox-mid LAD distribution). Pulmonary artery hypertension. Mild mitral regurgitation. No evidence of interatrial defect. Increased PCWP. Compared with the prior study (images reviewed) of [**2167-3-30**] the findings are similar. . Cardiac Cath ([**4-3**]): COMMENTS: 1. Selective coronary angiography of this right dominant system demonstrated a patent mid LAD stent with 40% disease beyond the stent and a 90% jailed ostial diagonal. The LMCA and LCX had no angiographically apparent disease. The RCA was known to have no significant disease and was not evaluated. 2. Successful IABP placement via the left CFA (see Interventional comments). FINAL DIAGNOSIS: 1. One vessel coronary artery disease with patent stent in LAD. 2. Successful IABP placement; attempt to wean pressors which may alleviate persistent arrythmias. . ECHO ([**4-3**]): The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. The left ventricular cavity size is normal. There is severe regional left ventricular systolic dysfunction with near akinesis of the distal 2/3rds of the left ventricle, and apical aneurysm/dyskinesis. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal image quality. Extensive left ventricular systolic dysfunction c/w CAD (proximal LAD distribution). Compared with the prior study (images reviewed) of [**2167-4-1**], left ventricular systolic function is similar. The heart rate is much higher. . LLE DOPPLER [**2167-4-6**]: Patent common femoral artery through to proximal popliteal artery. Waveforms are triphasic distally; however, there is significant tibial disease which cannot be determined whether this is chronic and/or embolic. However, there is no arterial injury at the site of balloon placement which can be seen on this study. . ECHO ([**4-5**]): The left atrium is mildly dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is an extensive expansile apical left ventricular aneurysm. Overall left ventricular systolic function is severely depressed (LVEF= 20 %) secondary to extensive septal, anterior, and apical akinesis, with the aforementioned extensive apical aneurysm. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal with normal free wall contractility. 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 mildly thickened. There is no mitral valve prolapse. An eccentric, posteriorly directed jet of mild to moderate ([**12-15**]+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: extensive left ventricular contractile dysfunction with a large expansile apical aneurysm; right ventricular structure and function are well-preserved . ECHO ([**2167-4-20**]) IMPRESSION: Extensive regional left ventricular systolic dysfunction c/w CAD (mid-LAD distribution). Atrial enlargement. Compared with the prior study (images reviewed) of [**2167-4-5**] regional and global left ventricular systolic functon is slightly improved. The severity of mitral regurgitation is now reduced. CLINICAL IMPLICATIONS: 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) **]. . CXR ([**2167-4-22**]): Left ICD tip is in the right ventricle. There is no pneumothorax or pleural effusion. Mild-to-moderate cardiomegaly is stable. Pulmonary edema has markedly improved. Bibasilar atelectases have improved. Aeration of the lower lobes has markedly improved. Opacities projecting over the second and third right anterior ribs are likely related to the ribs. Lung abnormality can also be present. This is unchanged from prior study. Brief Hospital Course: BRIEF HOSPITAL COURSE: Mr. [**Known lastname 24735**] is a 66y/o gentleman who was transferred from [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] after presenting with chest pain, and collapsed in triage apneic and pulseless. Here, he underwent cardiac catheterization with BMS to LAD. His course has been complicated by ventricular tachycardia/ventricular fibrillatio arrest on [**2167-4-3**] and [**2167-4-4**], requiring intubation. During this stay, his ventricular tachycardia was treated, and he was extubated with no complications. He is hemodynamically stable with no more episodes of ventricular tachycardia, but he is deconditioned so he is being discharged to rehab. # Ventricular Arrythmia with Cardiac Arrest and shock: now resolved. Originally presented at OSH with monomorphic VT. He was started on an amiodarone load, but continued to have episodes of atrial tachycardia and NSVT. The patient then had an episode of polymorphic VT degenerating to VF cardiac arrest on [**2167-4-3**]. CPR was performed for approximately one minute. He was then defibrillated with ROSC. Following this episode, he required additional pressor support with norepiephrine, and transiently sustained HR ranging from 160-180 bpm (felt to be VT vs. SVT with abberancy). He was taken to the cath lab for IABP placement and no instent thrombosis was found. He remained stable on pressors but then began to have increased frequency of ventricular ectopy (~10 beat runs of NSVT). His levophed was discontinued and he was given additional amiodarone. Overnight on [**2167-4-4**], the patient again developed pulseless polymorphic VT degenerating to VF. He was shocked and chest compressions were initiated. He had ROSC after approximately three mins of CPR and he was started on a lidocaine gtt and his sedation was increased to help decrease his circulating catacholamines. The etiology of his arrest was still unclear but likely [**1-15**] reperfusion injury after stent placement, as well as underlying QTc prolongation (Methadone might have been contributing). He was maintained on lidocaine drip then transitioned to PO mexelitine and ultimately discharged with an AICD placed on [**2167-4-20**] but no mexelitine or amiodarone per EP consult recs. He has an appointment to follow up with Atrius Cardiology after discharge. # Hypoxemic respiratory failure: resolved. The patient intially required significant ventilatory support following his initial respiratory failure when he was intubated on [**2167-3-29**]. His PCWP average between 16-20. He was diuruesed, but continued to require high levels of Fi02s and PEEP. His ventilatory support requirements gradually decreased. Etiology was likely [**1-15**] ARDS, acute CHF, atalectasis, and pneumonia (see section on pneumonia below). He was extubated [**2167-4-10**] and was gradually weaned to nasal canula. He is being discharged on 2L nasal canula oxygen with goal O2 sat >90%. he might have an element of OSA and might benefit from sleep study as an outpatient. # Acute Kidney Injury: likely prerenal. Creatinine 1.1 on admission, but trended upward during initial ICU stay. Most likely etiology was prerenal azotemia from hypotension, as well as a possible component from contrast induced nephropathy. No evidence of AIN without urine eos and urine sediment showed no muddy browns. He continued to make good urine volumes and his creatinine as trended down from a peak of 2.0 to 1.0, and then Cr increased again in the setting of low PO intake (secondary to procedure) to 1.2 again the day of discharge. We held his diuretics and encouraged PO hydration. # Acute Congestive Heart Failure: EF 30%. The patient developed significant pulmonary edema in the setting of his cardiac arrest, necessitating intubation. It was felt that the patient had a possible underlying cardiomyopathy in setting of alcohol abuse and coronary artery disease, His pre-event cardiac function is not known, although the apical wall thinning does imply that this is like a chronic problem. A [**Name2 (NI) **] catheter was placed and revealed a PCWP ranging from 16-20. The patient was diuresed as he hemodynamically tolerated. His heart failure regimen was optimized with ACEi and eplerenone, as well as Beta blocker (metoprolol). His lisinopril dose of 10mg was held starting [**2167-2-20**] secondary to worsening renal function. # Apical aneurysm: now on Warfarin. Due to apical aneurysm on TTE, the patient has been started on coumadin, and he is currently on 2.5mg coumadin PO qd, with an INR of 1.8 the day prior to discharge. Goal INR is [**1-16**]. # Pneumonia: resolved. The patient was felt to have a possibly sustained an aspiration event in the setting of his first VT arrest. He was noted to have Klebsiella in his sputum. He was treated with a Vanc ([**Date range (1) 46466**]) and Zosyn ([**Date range (1) 110273**]). # Pain: chronic LBP, also chest wall pain from chest compressions: controlled. Compression fractures from osteoporosis thought to be related to heavy alcohol use. Uses percocet and methadone PRN at home. He was maintained on fentanyl for pain control while intubated. Given concern of VFib related to QTc, it was felt that Methadone would no longer be a good drug for his pain control. Not to be used without prior discussion with his cardiologist. The patient continues on a regimen of fentanyl patch, MS contin and morphine (PRN breakthrough dose). He has an appointment to follow-up at Pain [**Hospital 9085**] clinic after discharge. # PVD: weak left lower extremity pulses. After IABP removal he was noted to have cool/mottled left foot. Doppler did not suggest acute thrombus. Resolved with time. Note that patient has intermittently palpable pulse but always Dopplerable LLE pulses, and per wife this is baseline. # Procedure complication: no harm done to patient. During femoral line change-over-wire, the wire was left in patient and noticed 3 days later. Was removed in the cath lab. No harm was done to patient. Ongoing Quality Improvement investigation is taking place. TRANSITIONS OF CARE: 1. Consider sleep study to evaluate for sleep apnea. Patient had frequent but transient O2 sat drops to 80s at night while sleeping 2. Consider restarting ACE-inhibitor and potassium-sparing diuretic if he has improved renal function, BP tolerates, and is not hyperkalemic 3. Should have daily weights (consider Lasix 80mg PO daily if weight increases >[**2-16**] lbs) 4. Methadone is contraindicated due to QT prolongation. Medications on Admission: Methadone 10-20mg TID prn pain Oxycodone-acetaminophen 1-2 tabs q4hr prn pain Levothyroxine 75 mcg daily Stool softener Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Capsule(s) 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain, fever. 6. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 7. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 10. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q8H (every 8 hours). 11. morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 12. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 14. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain: if you develop chest pain please take a tab, then repeat every 5 minutes for a total of 3 doses. Please seek medical help if you develop chest pain. Discharge Disposition: Extended Care Facility: [**Hospital 66**] Rehab & Nursing Center - [**Hospital1 392**] Discharge Diagnosis: cardiac arrest ventricular tachycardia acute congestive heart failure hypoxic respiratory failure acute kidney injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname 24735**], It was a pleasure taking care of you. You were transferred from another hospital to [**Hospital1 69**] after having a cardiac arrest and being found to be in an abnormal heart rhythm. You underwent cardiac catheterization and were found to have a heart artery blockage, which was openend with a bare metal stent (since you have this stent, you will need to be on Plavix for AT LEAST one month, and on Aspirin for life). You intermittently had an abnormal heart rhythm (ventricular tachycardia) for which you required defibrillation and CPR a few times, as well as intubation (breathing tube). Medications are now controlling yor heart rhythm properly and you have had no more episodes of ventricular tachycardia for many days. Your breathing tube was able to be removed without any complication. You had an AICD (implanted defibrillator) implanted, which will be able to shock you out of abnormal rhythms at home. Due to your prolonged hospitalization and deconditioning, you are being discharged to rehab to work on your strength and mobility. Please note that you have been started on Warfarin (also called Coumadin, a blood thinner) in order to prevent blood clots from forming in your heart. The level of this medication (called INR) needs to be followed by your doctor, with a goal level of [**1-16**]. We made the following changes to your medications: -STOP Methadone (this can contribute to abnormal heart rhythm) -STOP Oxycodone-Acetaminophen -START Aspirin 81mg daily (this will help keep the stent open; do not stop Aspirin without discussing with your Cardiologist) -START Clopidogrel (also called Plavix, this will help keep the stent open; you will need to be on this for AT LEAST one month - please discuss with your Cardiologist) -START Metoprolol (to protect the heart and slow the rate) -START Atorvastatin (for cholesterol) -START Fentanyl patch, MS Contin, and MS IR for pain control -START Nitroglycerin as needed for chest pain -START Warfarin (also called Coumadin, a blood thinner) -START Ambien as needed for sleep Followup Instructions: CARDIOLOGY Name: [**Last Name (LF) **], [**Name8 (MD) **] MD Location: [**Hospital1 641**]/CARDIOLOGY Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 6425**] Phone: [**Telephone/Fax (1) 2258**] When: [**Last Name (LF) 2974**], [**2167-5-1**]:00 PM PAIN MANAGEMENT Name: [**Last Name (LF) **], [**First Name3 (LF) **] & [**Last Name (LF) **],[**Known firstname **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Location (un) 2274**] [**Location (un) 2277**]/ PAIN MANAGEMENT Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 86416**] When: Wednesday, [**6-3**], 9:00 AM *You will see Dr. [**Last Name (STitle) 57287**] at 9:00 and Dr. [**Last Name (STitle) **] at 10:00. PRIMARY CARE Please follow up with your PCP upon discharge from rehab. Completed by:[**2167-4-23**]

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icd9cm

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icd9pcs

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196,841

10545+56158

Discharge summary

report+addendum

Admission Date: [**2137-4-16**] Discharge Date: [**2137-4-25**] Date of Birth: [**2058-9-25**] Sex: M Service: HISTORY OF PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname 34713**] is a 75-year-old male with metastatic renal cell carcinoma transferred from rehabilitation after he was found to have reddish-brown hemoptysis, tachypnea with a respiratory rate of 36, and requiring 35% oxygen. The patient was recently on the Thoracic Surgery Service at [**Hospital6 1708**] between [**4-1**] through [**4-16**]. Course at [**Hospital6 1708**] was notable for intermittent intubation, bronchoscopy that demonstrated left main stem proximal abnormality, and a right main stem involved with metastatic disease including the bronchus intermedius. Purulent secretions were also noted in the right middle lobe and right lower lobe. However, there was no definitive source of hemorrhage found, and the patient was discharged to a rehabilitation facility with 3 liters by nasal cannula. Within hours of being transferred to rehabilitation, the patient again began tachypneic and started with hemoptysis with an increased oxygen requirement. He was sent to [**Hospital1 1444**] for further evaluation and was admitted directly to the Medical Intensive Care Unit. PAST MEDICAL HISTORY: 1. Renal cell carcinoma; diagnosed in [**2130**], now metastatic. a. Status post radical nephrectomy demonstrating a clear cell type. b. Status post left wedge resection for a pulmonary nodule consistent with metastatic clear cell carcinoma in [**2132-3-31**]. c. A computed tomography of the abdomen an pelvis showed no mass at that time. d. Status post interleukin-2 and .................... times five doses beginning in [**2132-5-31**], which the patient was unable to tolerate. e. [**2133-12-2**] revealed a right pleural effusion which was tapped. Six weeks later, he was found to have a recurrent effusion. A computed tomography of the chest showed a loculated right pleural effusion with a subcarinal mediastinal mass as well as a right lower lobe lesion and focal lobar lesion. f. The patient has undergone photodynamic therapy, brachy therapy, left lung wedge resection, and YAG laser therapy for his endobronchial lesions but continued to have intractable hemoptysis. 2. Small-bowel obstruction; status post partial bowel resection. 3. Endobronchial lesion; status post photodynamic therapy, brachy therapy, left lung wedge resection, YAG laser therapy. 4. Status post percutaneous endoscopic gastrostomy tube placement on [**2137-4-10**]. 5. Status post prostatectomy for benign prostatic hypertrophy in [**2124**]. 6. History of deep venous thrombosis 20 years ago. 7. Myelodysplastic syndrome. 8. Gastroesophageal reflux disease. 9. Pacemaker for symptomatic bradycardia. 10. Basal cell carcinoma. 11. Atrial fibrillation. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Tylenol as needed. 2. Mucomyst 10% intravenous q.4h. 3. Xanax 0.25 mg twice per day. 4. Amiodarone 200 mg by mouth once per day. 5. Codeine phosphate 15 mg to 30 mg by mouth q.6h. as needed. 6. Pepcid 20 mg twice per day. 7. Heparin 5000 units subcutaneously three times per day. 8. Reglan 10 mg intravenously q.6h. as needed. 9. Lopressor 25 mg q.8h. 10. Morphine 10 mg intravenously q.6h. as needed. 11. Ocean Spray. 12. Senna at hour of sleep. 13. Remeron 30 mg at hour of sleep. 14. Atrovent nebulizers q.6h. SOCIAL HISTORY: The patient denies a history of drinking or tobacco use. He has a health care proxy who is his daughter [**Name (NI) **] [**Name (NI) **]. CODE STATUS: The patient is full code. PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 96.8, his heart rate was 101, his blood pressure was 123/39, his respiratory rate was 33, and his oxygen saturation was 95% on 100% nonrebreather. In general, the patient was in moderate respiratory distress. While receiving nebulizers, he was speaking in short sentences and sitting upright. Head, eyes, ears, nose, and throat examination the pupils were equally round and reactive to light. The extraocular movements were intact. The mucous membranes were moist. The neck was supple, and the patient was using accessory muscles with respiration. Cardiovascular examination with a irregular and irregular rate with a 2/6 systolic murmur that starts at the apex. Lungs with diffuse expiratory wheezing bilaterally. Abdominal examination revealed a scaphoid abdomen, percutaneous endoscopic gastrostomy tube intact without erythema, nontender. Difficult examination due to upright position. Extremities were warm with 3+ bilateral lower extremity edema. PERTINENT LABORATORY VALUES ON PRESENTATION: Notable for a white blood cell count of 12.5 and a hematocrit of 38.6. Platelets were 95. Arterial blood gas was 7.35/65/62/37. PERTINENT RADIOLOGY/IMAGING: Electrocardiogram showed atrial fibrillation at a rate of 89 with flat T waves in lead III. No acute ST-T wave inversions. A chest x-ray showed multiple pulmonary nodules in the left and right lung with a right lower lobe/right middle lobe opacity. There were bilateral pleural effusions with the right greater than the left, and there was a left rib abnormality. BRIEF SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: 1. HEMOPTYSIS ISSUES: The patient was admitted with intractable hemoptysis despite multiple procedures performed at [**Hospital6 1708**]. The patient has known endobronchial lesions from his metastatic renal cell carcinoma. The patient had been discharged from the [**Hospital6 4193**] after a bronchoscopy showed no further options for intervention from their standpoint. The patient had been discharged to rehabilitation. While at rehabilitation, within hours of arriving, he developed tachypnea and respiratory distress. The patient was intubated for increasing acidosis. He was taken to the operating room for a rigid bronchoscopy shortly after intubation. The bronchoscopy showed multiple tracheal lesions including a carinal lesion with partial obstruction of the left main and almost 95% obstruction of the right main. A Y-stent was placed by Interventional Radiology. The patient was successfully extubated the day following procedure. Following extubation, the patient stated that he felt less short of breath but was still extremely tachypneic and using accessory muscles with respiration. He had no further episodes of gross frank hemoptysis; however, he continued to cough significant amounts of brownish purulent sputum. The patient and his daughter wished to know if there were any possible further interventions that could prolong the patient's life. The asked about embolization which was a procedure that had been discussed in the Medical Intensive Care Unit prior to bronchoscopy. Interventional Pulmonology felt that this was not an option for the patient. They did not have any further aggressive interventions for the time being. They informed the patient and his daughter that should he acutely decompensate again that they would have very little to offer except maybe removal of a mucus plug. The patient's hypoxia improved following the procedure. At the time of discharge, his oxygen saturation was stable on 2 liters of oxygen by nasal cannula. He was still very short of breath and tachypneic at times; especially with exertion. He was still using accessory muscles with respiration. However, the patient symptomatically felt slightly better. He was continued on his albuterol and Atrovent nebulizers as well as cough suppressants throughout the hospitalization. He continued to be aggressively suctioned and a was placed on a scopolamine patch to reduce secretions. 2. ATRIAL FIBRILLATION ISSUES: The patient has a history of atrial fibrillation and is on amiodarone and beta blocker. He had previously been on Coumadin, but his Coumadin was held due to ongoing hemoptysis. It was not restarted during this hospitalization. 3. QUESTION OF A RIGHT LOWER LOBE INFILTRATE ISSUES: The patient had a right lower lobe infiltrate seen on chest x-ray on admission. There was concern that this was possibly due to aspiration. The patient was made nothing by mouth and started on a course of levofloxacin and clindamycin. There may also be a postobstructive component of this due to his multiple lesions in his bronchus. He remained afebrile throughout the remainder of the hospitalization. 4. ANASARCA ISSUES: The patient had generalized anasarca on admission. His albumin was low, and he also had an elevated spot urine protein to creatine ratio. His right upper extremity was most swollen in comparison to his other limbs. An ultrasound of the right upper extremity was negative for deep venous thrombosis. It was believed that his generalized anasarca was due to very poor nutrition and hypoalbuminemia. He was started on tube feeds to assist with improving his nutrition. 5. THROMBOCYTOPENIA ISSUES: The patient had thrombocytopenia on admission which was believed likely due to his myelodysplastic syndrome. However, the patient did not require any platelet transfusions, as his platelets remained greater than 50,000 throughout the remainder of the hospitalization. 6. NUTRITION ISSUES: The patient has had three swallowing studies at [**Hospital6 1708**] earlier this month which he had failed. However, they compromised with the patient and let him eat puree/thick liquids. A swallowing study was repeated here. A video swallow study showed aspiration with thin liquids and nectar consistency despite swallowing maneuvers. Speech and Swallow diagnosed the patient with a moderate/severe pharyngeal dysphagia due to significant pharyngeal weakness resulting in poor airway protection, severe pharyngeal residue, and aspiration of thin and thick liquids. They recommended strict nothing by mouth for nutrition, hydration, and medications. The patient was very reluctant to be nothing by mouth, but given his adamant desire to be a full code and to have everything possible done for him, it was explained to the patient and his daughter that his aspiration was only worsening his pulmonary status. The patient will remain nothing by mouth. He was started on tube feeds to assist with nutrition. It is planned that when his strength improves that a swallowing study could be repeated at a later time. 7. END OF LIFE ISSUES: The patient has a health care proxy who is [**Name (NI) **] [**Name (NI) **] (his daughter). Code status and goals of care were extensively discussed with the patient and his daughter multiple times throughout the hospitalization. Each time, the patient was very adamant about being a full code and wanting anything that could prolong his life to be done within reason. He felt that he derived a significant amount of pleasure from being with family, and even if he is in a debilitated state, it is worth it to him to be alive to be close to his family. The patient will be scheduled for Oncology followup here at [**Hospital1 69**]. They are very interested in learning if there are any further possible options for treatment. The patient's very poor prognosis was discussed and explained to the patient and his daughter. Nevertheless, the patient did wish to continue to get a second opinion from the oncologists at [**Hospital1 190**]. It was explained to the patient that he will continue to have episodes of respiratory distress given his metastatic pulmonary nodules. CONDITION AT DISCHARGE: Out of bed to chair with assistance; oxygen saturation stable on 2 liters of oxygen via nasal cannula; short of breath at rest; tachypneic; using accessory muscles with respiration; hemodynamically stable otherwise. DISCHARGE STATUS: The patient was discharged to an extended care facility. DISCHARGE DIAGNOSES: 1. Metastatic renal cell cancer. 2. Endobronchial lesions; status post Y-stent placement. 3. Atrial fibrillation. 4. Aspiration pneumonia. 5. Postobstructive pneumonia. 6. Gastroesophageal reflux disease. 7. Generalized anasarca due to poor nutrition and hypoalbuminemia. 8. Thrombocytopenia likely due to myelodysplastic syndrome. MEDICATIONS ON DISCHARGE: (Please note that all by mouth medications are to be given through the percutaneous endoscopic gastrostomy tube. The patient is strict nothing by mouth and should not have any pills whatsoever to swallow). 1. Tylenol 650 mg q.4h. as needed. 2. Albumin nebulizers 1 nebulizer inhaled q.3h. 3. Amiodarone 200 mg once per day. 4. Bisacodyl 10 mg once per day as needed. 5. Clindamycin 450 mg q.6h. (times 5 days, to complete a 10-day course). 6. Docusate 100 mg twice per day. 7. Guaifenesin dextromethorphan 5 mg q.6h. as needed (for cough). 8. Ipratropium nebulizer inhaled q.6h. 9. Protonix 40 mg intravenously once per day. 10. Lactulose 30 mL q.8h. as needed (for constipation). 11. Levofloxacin 500 mg q.24h. (times 5 days, to complete a 10-day course). 12. Lorazepam 0.5 mg to 2 mg q.4h. as needed (for anxiety). 13. Metoprolol 25 mg three times per day. 14. Metoclopramide 10 mg intravenously q.6h. as needed. 15. Mirtazapine 30 mg at hour of sleep as needed. 16. Morphine sulfate 2 mg intravenously q.4h. as needed. 17. Phenol septic throat spray as needed (for sore throat). 18. Scopolamine patch transdermally q.48h. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was scheduled to follow up with Dr. [**Last Name (STitle) **] from Oncology. 2. The patient was asked to follow up with his primary care physician. [**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4518**] Dictated By:[**Name8 (MD) 4993**] MEDQUIST36 D: [**2137-4-24**] 11:39 T: [**2137-4-24**] 11:41 JOB#: [**Job Number 34714**] Name: [**Known lastname 6164**],[**Known firstname **] C Unit No: [**Unit Number 6165**] Admission Date: [**2137-4-25**] Discharge Date: [**2137-4-27**] Date of Birth: [**2058-9-25**] Sex: M Service: Internal Medicine, [**Hospital1 **] Firm ADDENDUM: This is a Discharge Summary Addendum covering the hospital dates between [**2137-4-25**] and [**2137-4-27**]. Please see the previous Discharge Summary for the initial portion of the [**Hospital 1325**] hospital course. The patient was not discharged to rehabilitation on [**2137-4-25**] as originally planned. The patient's respiratory status worsened. The medical team again held a family meeting involving the patient and his daughter (who is his primary caregiver as well as health care proxy). Both the daughter and the patient wished to pursue all necessary aggressive interventions to prolong life. The patient was taken for a bronchoscopy again and was found to have growth of his tumor. The stent had migrated because of this growth, and it was removed. However, following bronchoscopy the patient's respiratory status did not symptomatology improve. The patient finally decided that he had had enough, and he was made comfort measures only. The patient died on [**4-27**]. The patient's family was present. The family declined autopsy. [**First Name11 (Name Pattern1) 520**] [**Last Name (NamePattern4) 521**], M.D. [**MD Number(1) 522**] Dictated By:[**Name8 (MD) 1433**] MEDQUIST36 D: [**2137-6-10**] 09:24 T: [**2137-6-10**] 10:02 JOB#: [**Job Number 6166**]

[ "507.0", "284.8", "262", "530.81", "197.0", "518.81", "511.9", "427.31", "238.7" ]

icd9cm

[ [ [] ] ]

[ "98.15", "96.71", "96.05", "38.93", "32.01", "96.04", "96.6" ]

icd9pcs

[ [ [] ] ]

11878, 12219

12246, 13400

2970, 3509

13433, 15471

5351, 11548

11563, 11857

160, 1293

1316, 2943

3526, 5317

57,290

170,337

46747

Discharge summary

report

Admission Date: [**2177-3-12**] Discharge Date: [**2177-3-27**] Date of Birth: [**2113-6-20**] Sex: M Service: MEDICINE Allergies: Minoxidil / Heparin Agents Attending:[**First Name3 (LF) 3984**] Chief Complaint: mental status changes Major Surgical or Invasive Procedure: Bronchoscopy x2 History of Present Illness: 63M h/x HTN, HLD, T2DM, HIT+?, stage IV CKD (previously HD dependent [**First Name8 (NamePattern2) **] [**Hospital1 **] notes), recent C3-C4 fracture in [**Month (only) 956**] with resultant quadraplegia. Patient was admitted to [**Hospital1 18**] from [**2-10**] to [**3-3**] with spinal cord injury, underwent tracheostomy and PEG placement. He was also treated for hospital acquired pneumonia with 8 days of vancomycin and cefepime. He also reportedly had intermittent headaches and word finding difficulties during that admission, but CT head remained unchanged (stable encephalomalacia c/w old infarcts). He was discharged to [**Hospital3 **] on [**3-3**] and per family was making significant improvement, with baseline A&Ox3, and intermittently talking using Passe-Muir Valve. . However, per family there was one incident involving a worker about a week prior to admission where the patient heard a worker complaining about having to suction him so often; he reportedly tried to hold his secretions, and had an episode of LOC. Unclear if this was an aspiration event. Family says he has had a decline in terms of his mood after this episode, but continued to interact with them and make sense. However, yesterday evening his niece visited him at [**Hospital1 **] and felt that he was more sleepy, not making total sense when responding to questions, with a "glassy look" in his eyes. . [**First Name8 (NamePattern2) **] [**Hospital1 **] paperwork, patient was doing well until afternoon [**3-11**], WBC noted to be 2.6 and patient started on levofloxacin PO. Per other notes, patient had recently been diagnosed with VAP and had been on cefepime, but felt this was contributing to leukopenia so changed to levofloxacin. The patient became more lethargic over the course of the evening. In the morning he was more confused, refused to be turned and unable to respond appropriately to questions. They felt he was unable to open L eye as wide as right and were concerned for new facial droop and spasm-like movements in neck and shoulders. He was not in any respiratory distress. His vitals weere stable, but he was sent to the ED because of concern for change in mental status. . In the ED, initial vs were: T98.2, HR 86 BP180/100 R 16 O2 sat. 100% on vent. Patient was not following commands appropriately, seemed somnolent and confused. Labs were notable for leukopenia (wbc 3.1), Hct 28.5 (at baseline), Cr 3.8 (at baseline), INR therapeutic at 3.1, Trop 0.19 (up to 0.08 on prior admission), lactate 2.5 and serum tox negative. Patient was given hydralazine 10 mg IV, Vanco 1 gram IV, Zosyn 4.5 g IV and 1L NS. CT abd/pelvis was reportedly performed because of concern for c diff at [**Hospital1 **] (were empirically treating with flagyl, although c diff negative), but showed no evidence of colitis, small pleural effusions R>L, with bibasilar patchy opacities. CXR showed opacity at right base and CT head showed no bleed but several old infarcts. He was admitted to the MICU for further management. . On the floor, patient intermittently grimacing, opening eyes and turning towards verbal stimuli, but not answering questions appropriately. Not responding to questions regarding symptoms, ROS. Past Medical History: c3-4 Fracture spinal cord injury with quadraparesis ventilator associated pneumonia chronic kidney disease bradycardia atrial fibrillation on warfarin hypertension hyperlipidemia type 2 diabetes obstructive sleep apnea gout hyperparathyroidism asthma congestive heart failure Hx of CVA (watershed infarct) s/p bilateral total hip replacement s/p cholecystectomy stage IV CKD ?HIT Social History: Retired high school math teacher. Smoked 1 ppd x 10 years, quit 20 years ago. Social EtOH. Has lived at [**Hospital1 **] since [**3-3**]. Family History: HTN in father, mother died of uterine cancer. Physical Exam: Vitals: T: 100.9 BP: 172/91 P: 60-80s (fib) R: 20 O2: 99% on PCV/Assist mode with FiO2 50%, 20/5, General: intermittently grimacing, opening eyes and turning towards verbal stimuli, but not responding to commands. Answering yes or no only. appearing uncomfortably. HEENT: pupils constricted but symmmetric and reactive b/l, Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally (anterior exam only) CV: irregularly irregular, normal S1 + S2, no murmurs, rubs, gallops Abdomen: mildly distended, soft, non-tender, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place draining clear yellow fluid Ext: warm, well perfused, ace wraps b/l, trace pitting edema that is difficult to appreciate with wraps in place . VITALS t:97 BP:129/74 P:52 RR:12 SaO2 99% on trach mask General: Alert and interactive HEENT: EMOI PERRL, Sclera anicteric, dry MM Neck: Supple, JVP not elevated, no LAD Lungs: Good breath sounds on anterior exam with few scant rhonchi CV: Irregularly irregular, normal rate, normal S1 and S2. No murmurs, rubs, or gallops Abdomen: Mildly distended, soft, non-tender, bowel sounds present, no rebound tenderness or guarding GU: Foley in place draining clear yellow fluid Ext: Warm and well perfused, LE edema trace, no upper extremity edema, no palpable cords NEURO: CN II-[**Doctor First Name 81**] intact and symmetric, XII not assessed. Sensation to light touch intact to left shoulder, right upper arm, level of umbilicus. Flaccid paralysis of upper and lower extremities BL. DTRs: biceps/bracheo/patella: 0. equivocal babinski Pertinent Results: Admission labs: [**2177-3-12**] 10:20AM BLOOD WBC-3.1* RBC-2.99* Hgb-9.5* Hct-28.5* MCV-95 MCH-31.6 MCHC-33.1 RDW-16.4* Plt Ct-194 [**2177-3-12**] 10:20AM BLOOD PT-34.1* PTT-39.7* INR(PT)-3.5* [**2177-3-12**] 05:40PM BLOOD Glucose-112* UreaN-133* Creat-3.9* Na-145 K-3.8 Cl-102 HCO3-33* AnGap-14 [**2177-3-12**] 05:40PM BLOOD Calcium-8.8 Phos-2.7# Mg-2.7* [**2177-3-12**] 10:29AM BLOOD freeCa-1.13 CT ABD & PELVIS W/O CONTRAST Study Date of [**2177-3-12**] 12:31 PM IMPRESSION: 1. Small bilateral pleural effusions, right greater than left. Bibasilar opacities, concerning for aspiraion and/or infection. 2. No evidence of colitis or megacolon. No bowel obstruction or wall thickening. 3. Small amount of perihepatic fluid and ascites, non-specific. 4. Prominent left adrenal gland with possible nodule, incompletely characterized on current exam. This can be further evaluated with adrenal protocol MRI or CT. Brief Hospital Course: 63 yo M with recent spinal cord injury and resultant quadriplegia, A fib on coumadin, HTN, DM2, HL, ? HIT who presents from [**Hospital3 **] with one day of worsening confusion and disorientation, likely multifactorial. . # Toxic Metabolic Encephalopathy: Differential for patient's confusion is broad, including infection in the setting of poor reserve and stage IV CKD, medication effect, seizure, or other metabolic process. The most likely cause was thought to be psychoactive medications and impaired clearance because of renal impairment. He had multiple medications held (lorazepam, oxycodone, trazodone), and baclofen redosed to 10mg [**Hospital1 **]. Over the course of his ICU stay, his mental status improved and he returned to his baseline. Oxycodone was resumed for pain control. He had been having dystonic like movements of his neck, mouth, and shoulders, and intermittent response to commands. Both of which resolved. Infectious etiology of mental status change was evaluated. He arrived on levofloxacin which was changed to vancomycin and cefepime for coverage of VAP/HAP, sputum culture was negative. C diff negative at [**Hospital1 **]. Urinalysis unremarkable. Given the resolution with holding and redosing his psychoactive medications, and given the lack of culture data, it was most likely toxic metabolic due to medication effect. Lorazepam and trazodone were discontinued and not restarted. Continued oxycodone. . # Paranoia/delirium: Similar to above, the patient had resolution of his dystonic movements and had paranoia with hallucinations (auditory and visual) which were thought to be secondary to ICU delirium, insomnia and medications. Psychiatry was consulted and recommended Seroquel 25mg at bedtime which helped with his insomnia. His paranoia improved dramatically over the course of his stay. Seroquel was not continued at the time of discharge as he was believed to have recovered from delirium. . # Respiratory Failure: Secondary to cervical cord injury. Patient on high volume ventilator at [**Hospital1 **]. He had mucous plugging while in the ICU with bronchoscopy x2 for suction. Culture data was negative throughout his stay. he received an 8 day course of vancomycin and cefepime. He tolerated trach collar for extended periods of time (up to 20 hours per day) and was placed on AC for fatigue and SOB with larger tidal volumes to help prevent atelectasis and mucous plugging. . # Bradycardia: patient was admitted with slow atrial fibrillation with rates ranging 50-60's. Heart rate remained in this range for much of his hospital stay until HD14 when he was noted to have bradycardia to 32bpm while asleep. He was normotensive and asyptomatic. EKG showed slow atrial fibrillation. His medication were reviewed. . # Demand Ischemia: Troponin on admission 0.19 (prior baseline 0.08). ECG unchanged from baseline. Most likely demand ischemia and inability to clear troponin well given his renal dysfunction. He was given ASA 325, continued on his home statin dose. . # Hypertension: He had hypertension throughout his ICU stay and he was continued on his home lisinopril, furosemide, spironolactone, and was initiated on amlodipine. He required IV hydralazine acutely for SBPs above 180 initially. . # Stage IV CKD: Creatinine at baseline, and patient was not fluid overloaded. He was continued on calcitriol, Sodium bicarb, and calcium acetate. . # Communication: Patient -- HCP, brother, [**Name (NI) **] [**Name (NI) 11312**] (cell: [**Telephone/Fax (1) 99221**], work: [**Telephone/Fax (1) 99222**]) -- Niece [**Name (NI) 99223**] (phone: [**Telephone/Fax (1) 99224**]) . # Code: Full code Medications on Admission: acetaminophen 650 q4h prn albuterol/atrovent nebs q4h prn baclofen 10 mg TID Calcitriol 0.25 mcg daily Calcium acetate 667 TID calcium polycarbophil (fibercon) 1259 mg [**Hospital1 **] prn Chorhexidine [**Hospital1 **] rinse Clotrimazole 30 gm tube colace 100 mg [**Hospital1 **] prn neupogen 600 mcg once [**3-10**] furosemide 80 mg [**Hospital1 **] regular insulin q6h sliding scale levofloxacin 750 mg every other day (given [**3-11**]) lidocaine patch 2 patches to neck posteriorly daily lisinopril 20 mg daily lorazepam 0.5-1 mg q4h prn maalox/mylanta liquid 30 ml q4h prn magic bullet 10 mg pr daily metronidazole 500 mg q8h (for presumed c diff) milk of mag 10 ml sdaily prn nystatin topical powder 15 gm [**Hospital1 **] Zofran 4 mg tid prn phenol sore throat spray q2h prn artificial tears TID metamucil Senna 10 [**Hospital1 **] prn simvastatin 10 mg qhs Sodium bicarbonate 650 mg TID Spironolactone 25 mg daily warfarin 3 mg daily oxycodone 5-10 mg q4h prn trazodone 100 mg qhs Discharge Medications: 1. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) neb Inhalation every four (4) hours. 2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a day. 3. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. calcium polycarbophil 625 mg Tablet Sig: Two (2) Tablet PO twice a day. 5. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). 6. Clotrimazole AF 1 % Cream Sig: One (1) appl Topical once a day. 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 8. furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: Two (2) Adhesive Patch, Medicated Topical DAILY (Daily): Apply to neck bilaterally. 10. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Maalox Maximum Strength 400-400-40 mg/5 mL Suspension Sig: Thirty (30) PO every four (4) hours as needed for heartburn. 12. Magic Bullets 10 mg Suppository Sig: One (1) Rectal once a day as needed for constipation. 13. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) mL PO once a day as needed for constipation. 14. nystatin topical powder 15 gm [**Hospital1 **] 15. Zofran 4 mg Tablet Sig: One (1) Tablet PO three times a day as needed for nausea. 16. Artificial Tears Drops Sig: One (1) drop Ophthalmic three times a day: in each eye. 17. Metamucil Powder Sig: One (1) tbsp PO once a day: Dissolve in 8oz water . 18. Senna Lax 8.6 mg Tablet Sig: One (1) Tablet PO once a day. 19. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a day. 20. warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day. 21. oxycodone 5 mg/5 mL Solution Sig: [**10-11**] mL PO Q4H (every 4 hours) as needed for pain. 22. baclofen 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 23. simvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 24. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 25. Outpatient Lab Work Please check INR [**2177-3-29**] and adjust warfarin to maintain goal INR [**1-30**]. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Delirium Pneumonia . c3-4 Fracture spinal cord injury with quadraparesis chronic kidney disease bradycardia atrial fibrillation on warfarin hypertension Discharge Condition: Activity Status: Bedbound. able to move shoulders, flacid paralysis throughout. Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: As you know, you were admitted from [**Hospital3 **] to the intensive care unit at [**Hospital1 **] for confusion. We treated you for pneumonia which you may have acquired from the ventilator. You were evaluated by neurology who did not think that your confusion was related to a problem with your brain. Psychiatry recommended a trial of a medication called seroquel at bedtime. We discontinued your lorazepam and trazodone as these medications may have been contirbuting to your confusion. With time your confusion resolved. We belive that the change is related to delirium which has now resolved. . MEDICATION CHANGES START Amlodipine 10mg daily for blood pressure CHANGE Baclofen to 10mg twice daily STOP Trazodone STOP lorazepam Followup Instructions: Please follow up with your primary care provider [**Last Name (NamePattern4) **] [**2-28**] weeks. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

[ "272.4", "E929.3", "427.31", "518.83", "934.1", "403.90", "907.2", "V55.0", "V58.61", "427.89", "297.1", "289.84", "790.5", "252.00", "292.85", "E939.0", "780.97", "493.90", "E939.4", "250.00", "349.82", "344.00", "585.4", "327.23", "997.31", "781.0", "274.9", "V55.1" ]

icd9cm

[ [ [] ] ]

[ "96.72", "33.24", "96.6" ]

icd9pcs

[ [ [] ] ]

13706, 13776

6828, 10475

310, 327

13973, 14053

5891, 5891

14920, 15148

4155, 4203

11515, 13683

13797, 13952

10501, 11492

14161, 14897

4218, 5872

248, 272

355, 3578

5907, 6805

14068, 14137

3600, 3982

3998, 4139

63,692

134,833

34338

Discharge summary

report

Admission Date: [**2171-11-1**] Discharge Date: [**2171-11-12**] Date of Birth: [**2098-5-11**] Sex: M Service: SURGERY Allergies: Epinephrine / Keflex Attending:[**First Name3 (LF) 668**] Chief Complaint: Decreased UOP and increasing LE edema Major Surgical or Invasive Procedure: [**11-2**]: Paracentesis [**11-4**]: ERCP [**11-4**]: Paracentesis History of Present Illness: 73 yo man POD 11 s/p exlap, liver bx, mesenteric bx, portal exploration ([**10-22**]) for metastatic cholangiocarcinoma, s/p ERCP/common hepatic stent ([**10-24**]) coming in with decreased UOP and increasing LE edema. Pt was discharged from [**Hospital1 18**] on [**10-29**]. Since then family describes patient with decreased PO intake secondary to poor appetite, but pt without nausea, vomiting, or diarrhea. Has had regular but small BM since discharge; not taking much pain meds. Also c/o decreased UOP consistently since discharge. Concurrently family describes pt w/increasing abdominal girth and increasing serous drainage from medial portion of wound incision with movement, requiring dressing changes 3x/day, 3x/night. Also with increasing LE edema b/l. For this reason pt saw cardiologist 1 day PTA, who gave him "IV Lasix" in office. Todaypt returned and saw PCP who put him on "antibiotic". Today pt took two doses of nl lasix. Otherwise no med changes. ROS: denies SOB/CP/N/V/D/constipation/dysuria/myalgias/arthralgias/ fever/chills Past Medical History: -cholangiocarcinoma -Diabetes mellitus II (oral meds) -Atrial fibrillation (on amiodorone) -Chronic left ventricular systolic heart failure (last EF 35% per daughter) -h/o pneumonia and effusion which was tapped in [**State 108**] recently -Mass encircling the biliary stent which was biopsied and found to be cholangiocarcinoma, s/p biliary stent c/b infection s/p stent removal [**2171-9-11**] -Depression -Hyperlipidemia -Prior MI by EKG -Hypertension -Anemia PSurgH: -Status post cholecystectomy -[**2171-10-22**]: Exploratory laparotomy, liver biopsy and lymph node biopsy. Social History: Italian but speaks some English. He is a retired truck driver. He denies smoking or illicit drug use. He uses [**12-12**] glasses of wine per day. He lives with his wife; daughter is nearby. Family History: Positive for colon cancer, diagnosed in his 50's. No other family members with rectal cancer, colon cancer or HNPCC-related cancers. The patient states he has never had a colonoscopy. Physical Exam: Sleepy but arousable 98.8 100 104/59 18 100% PERRL, anicteric, moist mucus membranes, no JVD, no sublingual incteris, CN grossly intact, no LAD tachycardia + soft systolic murmur no r/g bibasilar rales no wheezes/rhonchi soft but distended + diffuse TTP + BS no HSM appreciated incision c/d/i, no gross oozing noted GU-Foley in place b/l loss of dermis at buttocks b/l 2+ edema to mid calf Pertinent Results: On Admission: [**2171-11-1**] WBC-10.2 RBC-3.66* Hgb-11.4* Hct-32.3* MCV-88 MCH-31.0 MCHC-35.2* RDW-15.2 Plt Ct-343# PT-13.1 PTT-27.7 INR(PT)-1.1 Glucose-171* UreaN-29* Creat-2.3*# Na-127* K-4.9 Cl-91* HCO3-23 AnGap-18 ALT-61* AST-72* LD(LDH)-257* CK(CPK)-67 AlkPhos-941* TotBili-5.0* Albumin-3.2* Calcium-8.6 Phos-3.4 Mg-1.8 At Discharge: [**2171-11-12**] WBC-10.5 RBC-4.04* Hgb-12.1* Hct-35.5* MCV-88 MCH-29.9 MCHC-34.1 RDW-16.6* Plt Ct-109* Glucose-120* UreaN-52* Creat-4.6* Na-140 K-4.2 Cl-112* HCO3-18* AnGap-14 ALT-29 AST-42* AlkPhos-884* TotBili-2.7* Calcium-7.9* Phos-3.5 Mg-1.7 Brief Hospital Course: 73 y/o male with known cholangiocarcinoma who underwent ex-lap with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2171-10-22**] and was unable to be resected. Since his discharge on the 18th he was noted to have increased abdominal girth, lower extremity swelling and poor appetite as reported by family. Ultrasound of abdomen on admission shows new ascites. He had a paracentesis on [**11-2**] with the removal of 4 liters of fluid. Culture done on the fluid revealed E coli. He had empirically been started on Vanco and Zosyn which was narrowed to Zosyn with a 14 day recommended course. Following the paracentsis he was transferred to the SICU for hypotension to the 80's most likely due to SBP On [**11-3**] he underwent a gall bladder scan which showed findings consistent with a bile leak and was sent on [**11-4**] for ERCP. He had a bare metal stent placed on his previous admission once he was found to be unresectable. During ERCP;, the previous uncovered metal stent was visualized and noted to be patent in the left hepatic system within the common hepatic duct stricture. The right hepatic system did not fill with contrast. Large bile duct leak in the mid common bile duct, probably at the site of lymph node biopsy. Successful placement of a 10mm x 60mm biliary covered Wallstent in the common bile duct within the previously placed uncovered metal stent 8mm x 60mm. On the same day he underwent placemnt of a pigtail drain into the collection in his abdomen (right flank) which immediately drained about 800 cc of bilious appearing fluid. Large volumes were being drained daily of [**2-12**] Liters. He was receiving albumin and fluid replacements. The drain was removed on [**11-8**] and insertion sutured, with no leak. He was transferred back out of the SICU and was making daily improvements in appetite, ambulation and bowel function. He was seen by the Renal team for acute on chronic renal failure. Management included some medications to be renally dose and the addition of bicarbonate to his regimen. He did not require renal replacement therapy. At the current time of discharge the plan is to keep patient off diuretics with monitoring of his labs and reinstitution once the kidney function improves. In regards to his known CHF, digoxin and amiodarone were renally dosed and volume status carefully monitored. Diuretics will stay on hold per renal recommendations until kidney function improves. Daily weights will be requested. He was also seen by cardiology during this admission for medication management. He was seen by the wound care nurse [**First Name (Titles) **] [**Last Name (Titles) 79019**] Stage II decubitus ulcers. Stage II pressure ulcer: Duoderm gel/Allevyn foam dressing. Change q 3 days Medications on Admission: Amiodarone 100', digoxin 0.125', Lasix 40', Glipizide 7.5", Metformin 750", Lopressor 25", atorvastastin 80', Aspirin 325', lisinopril 5', plavix 75' Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Unresectable cholangiocarcinoma Chronic heart failure (Systolic, EF 45%) Acute on Chronic renal failure, currently off diuretics Stage II decubitus ([**Location (un) 79019**]) ulcer. Bile leak, E coli recovered from fluid Unresectable cholangiocarcinoma Chronic heart failure (Systolic, EF 45%) Acute on Chronic renal failure, currently off diuretics Stage II decubitus ([**Location (un) 79019**]) ulcer. Bile leak, E coli recovered from fluid Unresectable cholangiocarcinoma Chronic heart failure (Systolic, EF 45%) Acute on Chronic renal failure, currently off diuretics Stage II decubitus ([**Location (un) 79019**]) ulcer. Bile leak, E coli recovered from fluid Discharge Condition: Stable Discharge Instructions: Weigh patient daily. Call if greater than 3 pound weight gain in a day Call Dr [**Last Name (STitle) 9411**] office at [**Telephone/Fax (1) 673**] for fever > 101, chills, nausea, vomiting, diarrhea, yellowing of skin or eyes, increased abdominal pain or other concerning symptoms Monitor insion for redness, drainage or bleeding. Top portion of incision has been opened and requires a NS wet to dry dressing twice daily Nutritional status important, assure patient receiving supplements three times daily. Please note patient has appointment with Dr [**Last Name (STitle) **] [**11-13**] (Wednesday) in addition to other appointments in next 2 weeks Followup Instructions: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2502**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2171-11-13**] 4:30 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Telephone/Fax (1) 673**] Date/Time [**2171-11-22**] 3:20 PM DR. [**First Name (STitle) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2171-11-28**] 1:30 [**Last Name (LF) **],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 3183**] Call to schedule appointment Completed by:[**2171-11-12**]

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icd9cm

[ [ [] ] ]

[ "51.87", "54.91" ]

icd9pcs

[ [ [] ] ]

6493, 6565

3524, 6292

318, 386

7277, 7286

2913, 2913

7985, 8517

2299, 2484

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241, 280

414, 1469

2927, 3239

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22,547

189,895

535

Discharge summary

report

Admission Date: [**2113-11-29**] Discharge Date: [**2113-12-2**] Date of Birth: [**2058-2-22**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4421**] Chief Complaint: Nausea and Vomiting. Major Surgical or Invasive Procedure: None. History of Present Illness: 55 year-old female with recently diagnosed stage IIIA fallopian tube adenocarcinoma who presented to oncology clinic complaining of ongoing nausea, vomiting, and weakness. She received her first cycle of chemotherapy consisting of intravenous Taxol and carboplatin on [**2113-11-1**], and last week received her second cycle consisting of intravenous Taxol and intraperitoneal cisplatin, followed by aggressive antiemetics with dolasetron, Emend, and compazine. Ever since her recent chemotherapy, she has had some abdominal pain, nausea, vomiting, and was feeling tired. She has not been able to keep any food down, but has been tying to drink Boost and Ensure as tolerated. She has not had any diarrhea. She describes also intermittent fevers/chills at home, without any headache, change in vision, chest pain, SOB, excessive thirst or urination, or change in her bowel habits. In oncology clinic she was found to be dehydrated, with a serum sodium in the 108 range and potassium in the low 2 range, and is admitted for further management. . In the ED she was afebrile, with normal vital signs, and a normal mental status exam (per her husband). She was given IV normal saline, potassium replacement, and was admitted to the [**Hospital Unit Name 153**] for further management. The patient's sodium improved with normal saline. The etiology of her hyponatremia and hypokalemia was unclear but was possibly secondary to SIADH, exacerbated by dehydration and electrolyte loss (vomiting), or secondary to a component of Fanconi's syndrome. Hypertonic saline and democycline were not necessary. The patient's cortisol stimulation test and TSH were within normal limits. Celexa was discontinued due to its association with SIADH. The patient's IVF were discontinued at noon the day of transfer to the OMED floor with sodium improving to 128 and normalization of her potassium. Past Medical History: 1. Stage IIIA grade III left-sided fallopian tube cancer, status post total abdominal hysterectomy, bilateral salpingo-oophorectomy, left pelvic lymph node dissection, peritoneal washings and omental biopsy on [**2113-10-10**]. 2. Hypertension 3. Major Depression 4. History of gastrointestinal bleed Social History: She lives in [**Doctor Last Name 792**]with husband and two of her three sons. [**Name (NI) **] husband is a cardiologist. She denies tobacco or EtOH use. Family History: NC Physical Exam: VITAL SIGNS: 98 85 160/100 20 98% RA GENERAL: Pale female with alopecia, tired-appearing, in NAD HEENT: MM dry with cracked red lips, anicteric, no sinus tenderness NECK: Supple, no LAD, JVP flat HEART: RRR with a flow murmur, no S3 or S4 CHEST: Clear to ausculatation and percussion bilaterally ABDOMEN: Soft, obese, NT, ND, palpable IP port in LUQ without erythema EXTREMITIES: No c/c/e, pale nail beds, normal cap refill NEUROLOGIC: AAO x 3, appropriate, CN intact, strength 5/5 in bilateral upper and lower extremities. No sensory defect. Did not assess gait SKIN: Flushed, erythematous apearance of neck MUSCULOSKELETAL: No joint effusions noted Pertinent Results: [**2113-11-29**] 12:30PM SODIUM-108* POTASSIUM-2.0* CHLORIDE-65* [**2113-11-29**] 03:15PM GLUCOSE-175* UREA N-22* CREAT-1.0 SODIUM-109* POTASSIUM-2.8* CHLORIDE-66* TOTAL CO2-29 ANION GAP-17 [**2113-11-29**] 03:25PM GLUCOSE-171* LACTATE-3.2* K+-2.6* [**2113-11-29**] 09:35PM URINE OSMOLAL-381 [**2113-11-29**] 09:35PM URINE HOURS-RANDOM UREA N-386 CREAT-27 SODIUM-60 POTASSIUM-39 PHOSPHATE-39.1 [**2113-11-29**] 10:25PM TSH-1.4 [**2113-11-29**] 10:25PM calTIBC-397 FERRITIN-391* TRF-305 [**2113-11-29**] 10:25PM GLUCOSE-140* UREA N-19 CREAT-0.9 SODIUM-111* POTASSIUM-2.9* CHLORIDE-73* TOTAL CO2-26 ANION GAP-15 [**2113-11-29**] 10:25PM BLOOD Glucose-140* UreaN-19 Creat-0.9 Na-111* K-2.9* Cl-73* HCO3-26 AnGap-15 [**2113-11-30**] 05:21AM BLOOD Glucose-111* UreaN-16 Creat-0.8 Na-113* K-2.7* Cl-79* HCO3-27 AnGap-10 [**2113-11-29**] 10:25PM BLOOD Glucose-140* UreaN-19 Creat-0.9 Na-111* K-2.9* Cl-73* HCO3-26 AnGap-15 [**2113-11-30**] 05:21AM BLOOD Glucose-111* UreaN-16 Creat-0.8 Na-113* K-2.7* Cl-79* HCO3-27 AnGap-10 [**2113-11-30**] 10:41AM BLOOD Na-114* K-3.8 [**2113-11-30**] 04:12PM BLOOD Na-116* K-3.4 [**2113-11-30**] 08:19PM BLOOD Na-122* K-3.7 [**2113-12-1**] 12:34AM BLOOD Na-122* K-3.9 [**2113-12-1**] 04:31AM BLOOD Glucose-98 Creat-1.1 Na-123* K-4.0 Cl-92* HCO3-23 AnGap-12 [**2113-12-1**] 09:48AM BLOOD Na-124* K-3.4 [**2113-12-1**] 02:02PM BLOOD Na-128* K-3.5 . [**2113-11-29**] CXR: IMPRESSION: No acute cardiopulmonary disease. Gas distended loops of small bowel with air-fluid levels within the upper abdomen. Unclear of the etiology of this finding; however, it may be related to her history of ovarian cancer and correlation with past imaging studies and patient history is recommended. . ECG: NSR, mild LAD, prolonged QTc, delayed RWP . Brief Hospital Course: 55 year-old female patient with history of hypertension, depression, and recent diagnosis of stage IIIA fallopian tube cancer who presents with one week of nausea, vomiting, and malaise and laboratory abnormalities of hyponatremia and hypokalemia. This was likely secondary to either SIADH or Fanconi's syndrome. 1. Hyponatremia. The patient's baseline sodium is 128 per previous records. The patient was asymptomatic on presentation. The patient was followed by the renal team throughout admission. Cortisol stimulation was performed with appropriate response. TSH was within normal limits. Her serum osmolality was low, and her urine osmolarity was high. Her urine sodium was > 60 with FENa > 2%. Citalopram was discontinued for its association with SIADH. Hydrochlorothiazide were discontinued because of hyponatremia and dehydration. The patient was initially treated with normal saline with slow correction of hyponatremia. Liberal salt intake was encouraged. Hypertonic saline and demecycline were not necessary. The patient's creatinine increased to 1.4 the day of discharge, possibly secondary to recent cisplatin treatment. The patient will have repeat labwork after discharge to monitor this. . 2. Hypokalemia. This is most likely related to GI and renal potassium. The patient will have outpatient labwork as above. . 3. Nausea/vomiting. Likely secondary to chemotherapy and hyponatremia. The patient was given anti-emetics as needed. This was improved prior to discharge. . 4. Fallopian tube cancer. The patient was followed by Dr. [**Last Name (STitle) **] while she was in the intensive care unit. The patient will follow-up with Drs [**Last Name (STitle) **] and [**Name5 (PTitle) **]. The patient's blood counts remained stable throughout. . 5. Hypertension. The patient was continued on Diovan. The patient's hydrochlorothiazide was held because of the patient's hyponatremia and dehydration. . 6. Depression. She has a long history of major depression including one drug overdose. She denied suicidal ideation. The patient's citalopram was held due to its association with SIADH. The patient was continued on Remeron. The patient will follow-up with an outpatient psychiatrist. . 7. Hypothyroidism. The patient's TSH was within the normal range. The patient was continued on her outpatient dose of levothyroxine. . 8. Erythema of neck and back. Patient states this is related to anxiety. The patient was given atarax as needed with good effect. . 9. History of gastrointestinal bleed. No active issues. The patient was continued on Protonix. . Code: Full, discussed with patient Medications on Admission: 1. Diovan/HCTZ 320/25 2. Celexa 20mg 3. Remeron 15mg 4. Synthroid 0.1mg 5. Motrin 800mg prn 6. Vicodin 5/500 prn abdominal pain 7. Compazine prn 8. Zofran prn 9. Ativan 1mg tid prn 10. Temazepam 30mg qhs Discharge Medications: 1. Outpatient Lab Work Please obtain blood work in [**Doctor Last Name 792**]as instructed. Please call Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] with results; phone number ([**Telephone/Fax (1) 4422**]. 2. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety, nausea. Disp:*30 Tablet(s)* Refills:*0* 7. Temazepam 30 mg Capsule Sig: One (1) Capsule PO at bedtime. Disp:*30 Capsule(s)* Refills:*2* 8. Hydroxyzine HCl 25 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for anxiety. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*2* 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*60 Capsule(s)* Refills:*2* 11. 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* 12. Anzemet 100 mg Tablet Sig: One (1) Tablet PO once a day as needed for nausea for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Hyponatremia secondary to Fanconi's syndrome versus SIADH . Secondary: 1. Stage IIIA grade III left-sided fallopian tube cancer 2. Hypertension 3. Major Depression 4. History of gastrointestinal bleed Discharge Condition: Afebrile, vital signs stable. Electrolytes stable. Discharge Instructions: Please contact a physician if you experience fevers, chills, increased confusion, change in vision, increased nausea, or any other concerning symptoms. . Please take your medications as prescribed. - Your celexa and hydrochlorothiazide were discontinued because they can contribute to low sodium (salt) in your blood. - You can take anzemet 100 mg once daily as needed for nausea. - You can take ativan 1 mg every six hours as needed for nausea. Please contact your psychiatrist about a refill for this medication if he feels it is medically necessary. - You should take colace and senna as needed for constipation while taking pain medications. . Please increase your salt intake as much as possible; add table salt to foods, eat foods high in sodium such as [**Last Name (un) 4423**]. . Please have your blood checked early next week. You have a prescription written for labwork. Dr. [**First Name8 (NamePattern2) 4424**] [**Name (STitle) **] will follow-up these results. . Please keep your follow-up appointments as below. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4425**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2113-12-20**] 10:00 Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2113-12-20**] 10:00 Provider: [**Name Initial (NameIs) 4426**] 19 Date/Time:[**2113-12-20**] 10:00

[ "244.9", "296.20", "270.0", "787.01", "276.1", "253.6", "276.51", "401.9", "E933.1", "V10.44" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9671, 9677

5260, 7859

337, 344

9930, 9983

3462, 5237

11058, 11471

2766, 2770

8114, 9648

9698, 9909

7885, 8091

10007, 11035

2785, 3443

277, 299

372, 2251

2273, 2575

2591, 2750

19,255

102,967

26675+57509

Discharge summary

report+addendum

Admission Date: [**2119-1-30**] Discharge Date: [**2119-3-14**] Date of Birth: [**2046-12-23**] Sex: F Service: CARDIOTHORACIC Allergies: Shellfish Attending:[**First Name3 (LF) 922**] Chief Complaint: Back and flank pain Major Surgical or Invasive Procedure: [**2119-1-31**] Repair of thoracoabdominal aortic aneurysm with a 26 mm Dacron tube graft(Vascutek Gelweave)using partial right heart bypass. [**2119-2-1**] Abdominal aortogram via open right common femoral arterial approach. Hemodialysis (on going) Plasmapheresis (discontinued) [**2119-2-23**] Insertion of RIJ Permacath History of Present Illness: This is a 72 year old female with known descending thoracic aortic aneurysm. The patient was evaluated by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD at [**Doctor Last Name **] [**Location (un) **] Hospital approximately one year ago and offered elective repair. Patient declined surgery at that time. On [**1-27**], she presented to outside hospital in [**State 108**] complaining of severe back and flank pain. She admits to having chronic back and flank pain for the past month prior to presentation. A CT scan showed a large thoracic aortic aneurysm measuring 12 centimeters; dissection could not be ruled out. A left sided pleural effusion and moderate amount of pericardial fluid were concomitantly noted. She was subsequently admitted to the ICU and started on intravenous therapy for blood pressure and heart rate control. She was stabilized and eventually transferred to the [**Hospital1 18**] via med flight for cardiac surgical intervention. Past Medical History: Thoracic Aortic Aneurysm Hypertension Hyperlipidemia History of Heavy Tobacco Abuse Carotid Artery Disease Urinary Tract Infections Bronchitis Social History: The patient lives in [**State 108**]. She has a 15-pack year smoking history but quit 15 years ago. She denies EtOH use. She is widowed and lives alone. Family History: The patient's mother died at 71 of stroke. Her father died of myocardial infarction at 69 Physical Exam: On admission: v/s 37.0 C, 80 sinus, 119/67, 20, 97% room air Gen: WD/WN, pleasant, NAD Skin: no rashes HEENT: PERRLA, no icterus, no trachial deviation, MMM Neck: no masses, no LAD, no bruit CV: RRR, no murmur Pulm: CTAB Abd: soft, NT/ND, no masses GU: Foley to gravity MS: strength equal bilaterally Vascular: palpable distal pulses Neuro: grossly non-focal Pertinent Results: [ truncated; please contact medical records department for full details ([**Telephone/Fax (1) 65758**]] [**2119-1-30**] 07:44PM BLOOD WBC-13.5* RBC-4.00* Hgb-11.3* Hct-33.9* MCV-85 MCH-28.3 MCHC-33.3 RDW-15.2 Plt Ct-207 [**2119-1-31**] 02:44PM BLOOD WBC-23.2*# RBC-3.86*# Hgb-12.0# Hct-32.1*# MCV-83 MCH-31.2 MCHC-37.5* RDW-15.3 Plt Ct-130*# [**2119-2-1**] 10:51AM BLOOD WBC-20.2* RBC-4.38 Hgb-13.0 Hct-36.4 MCV-83 MCH-29.8 MCHC-35.8* RDW-15.9* Plt Ct-60* [**2119-2-8**] 02:47AM BLOOD WBC-20.6* RBC-3.18* Hgb-9.2* Hct-26.7* MCV-84 MCH-29.1 MCHC-34.7 RDW-17.4* Plt Ct-59* [**2119-2-28**] 05:40AM BLOOD WBC-6.9 RBC-3.32* Hgb-9.9* Hct-29.4* MCV-89 MCH-29.7 MCHC-33.5 RDW-20.9* Plt Ct-205 [**2119-2-28**] 06:32PM BLOOD WBC-7.3 RBC-2.80* Hgb-8.3* Hct-24.2* MCV-86 MCH-29.5 MCHC-34.2 RDW-21.2* Plt Ct-178 [**2119-3-1**] 05:10PM BLOOD WBC-8.6 RBC-4.53# Hgb-13.2# Hct-39.3# MCV-87 MCH-29.3 MCHC-33.7 RDW-19.0* Plt Ct-153 [**2119-3-2**] 08:05AM BLOOD WBC-9.8 RBC-4.53 Hgb-13.4 Hct-39.8 MCV-88 MCH-29.6 MCHC-33.7 RDW-19.1* Plt Ct-150 [**2119-3-6**] 05:02AM BLOOD Hct-34.6* [**2119-1-30**] 07:44PM BLOOD PT-14.1* PTT-20.3* INR(PT)-1.2* [**2119-3-2**] 08:05AM BLOOD PT-12.7 INR(PT)-1.1 [**2119-1-30**] 07:44PM BLOOD Fibrino-451* [**2119-2-18**] 05:25AM BLOOD Fibrino-203 [**2119-1-30**] 07:44PM BLOOD Glucose-128* UreaN-19 Creat-0.8 Na-141 K-3.6 Cl-104 HCO3-22 AnGap-19 [**2119-2-1**] 03:30PM BLOOD Glucose-69* UreaN-35* Creat-2.3* Na-137 K-5.5* Cl-104 HCO3-23 AnGap-16 [**2119-2-3**] 03:25AM BLOOD UreaN-44* Creat-3.4* Na-138 K-5.0 Cl-104 HCO3-24 AnGap-15 [**2119-2-8**] 02:47AM BLOOD Glucose-108* UreaN-38* Creat-2.3* Na-135 K-4.3 Cl-100 HCO3-26 AnGap-13 [**2119-2-9**] 02:16AM BLOOD Glucose-107* UreaN-38* Creat-2.4* Na-144 K-3.8 Cl-107 HCO3-28 AnGap-13 [**2119-2-16**] 12:14AM BLOOD Glucose-110* UreaN-44* Creat-3.3*# Na-144 K-3.8 Cl-104 HCO3-29 AnGap-15 [**2119-2-18**] 03:13AM BLOOD Glucose-108* UreaN-29* Creat-3.1* Na-153* K-3.8 Cl-113* HCO3-30 AnGap-14 [**2119-2-26**] 05:12AM BLOOD Glucose-60* UreaN-18 Creat-3.3* Na-140 K-4.0 Cl-103 HCO3-25 AnGap-16 [**2119-2-28**] 05:40AM BLOOD Glucose-71 UreaN-18 Creat-3.6* Na-141 K-4.0 Cl-107 HCO3-25 AnGap-13 [**2119-3-2**] 08:05AM BLOOD Glucose-77 UreaN-19 Creat-3.6* Na-142 K-4.2 Cl-105 HCO3-25 AnGap-16 [**2119-3-3**] 07:45AM BLOOD Glucose-71 UreaN-27* Creat-4.0* Na-139 K-6.7* Cl-104 HCO3-21* AnGap-21* [**2119-3-4**] 05:45AM BLOOD Glucose-76 UreaN-14 Creat-2.6*# Na-143 K-3.1* Cl-105 HCO3-26 AnGap-15 [**2119-3-6**] 05:02AM BLOOD Glucose-92 UreaN-36* Creat-3.5* Na-138 K-4.6 Cl-103 HCO3-23 AnGap-17 [**2119-1-30**] 07:44PM BLOOD ALT-43* AST-66* LD(LDH)-382* AlkPhos-86 TotBili-0.7 [**2119-2-1**] 10:51AM BLOOD ALT-35 AST-131* LD(LDH)-1295* AlkPhos-64 Amylase-57 TotBili-3.1* [**2119-2-3**] 03:25AM BLOOD ALT-39 AST-98* LD(LDH)-2323* AlkPhos-68 TotBili-1.9* [**2119-2-22**] 02:57AM BLOOD ALT-19 AST-28 LD(LDH)-325* AlkPhos-70 TotBili-0.6 [**2119-3-1**] 05:10PM BLOOD ALT-20 AST-24 LD(LDH)-360* AlkPhos-86 Amylase-112* TotBili-0.4 DirBili-0.2 IndBili-0.2 [**2119-2-1**] 10:51AM BLOOD Lipase-37 [**2119-2-2**] 07:31AM BLOOD Lipase-22 [**2119-3-1**] 05:10PM BLOOD Lipase-103* [**2119-1-30**] 07:44PM BLOOD Albumin-3.6 [**2119-2-1**] 10:51AM BLOOD Albumin-3.1* Phos-3.4 Mg-2.3 [**2119-2-2**] 07:31AM BLOOD Albumin-2.3* [**2119-3-1**] 05:10PM BLOOD Albumin-3.0* [**2119-2-10**] 03:27PM BLOOD calTIBC-164* VitB12-393 Folate-12.9 Hapto-<20* Ferritn-[**2103**]* TRF-126* [**2119-2-21**] 10:34AM BLOOD Hapto-91 [**2119-1-30**] 07:44PM BLOOD %HbA1c-6.2* [Hgb]-DONE [A1c]-DONE [**2119-2-3**] 04:00PM BLOOD Cortsol-54.4* [**2119-3-3**] 04:10PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE [**2119-2-1**] 03:41PM BLOOD C3-103 C4-17 MICROBIOLOGY: [**2-15**] urine: > 100,000 yeast [**2-17**] urine: 10-100,000 yeast [**3-1**] blood: negative [**2-20**] pleural fluid: negative [**2-28**] urine Cx: negative RADIOLOGY: [**2119-1-30**] Carotid Ultrasound: 1. Occluded left internal carotid artery. 2. Atherosclerotic plaque is present in the left common and external carotid arteries. 3. Atherosclerotic plaque is present in the right internal carotid artery with findings of at least 40-59% stenosis (likely closer to 60% stenosis). [**2119-1-30**] MRA: 1. Extensive aneurysmal dilation of the descending thoracic aorta measuring up to 11.1 cm. There is extensive thrombus formation within the descending thoracic aorta with areas of focal ulceration within the thrombus. The branch vessels of the aortic arch are normal in appearance. There is no clear evidence of dissection. 2. Supra- and infrarenal aneurysmal dilation of the abdominal aorta with an intervening segment of more normal caliber aorta. Extensive thrombus formation, some of which appears to be of varying stages of formation, is also present within the abdominal aorta. The celiac, superior mesenteric, and renal artery origins appear normal. There is no clear evidence of dissection. 3. Small left pleural effusion and associated atelectatic changes in the left lung. [**2119-1-30**] CXR: 1. Large descending thoracic aneurysm. 2. No evidence of acute cardiopulmonary process. [**2119-1-31**] CXR: 1. Swan-Ganz catheter, and chest tubes in standard positions without evidence of pneumothorax. 2. Opacification of the left lung secondary to a layering pleural effusion versus pulmonary hemorrhage. 3. Low position of the endotracheal tube tip located 1.5 cm above the level of the carina. [**2119-2-1**] Renal Ultrasound: 1. Color Doppler suggests diminished renal blood flow bilaterally. Given patient's inability to have CT or MR, if renal blood flow is of clinical concern, a nuclear medicine blood flow study can be performed. 2. No evidence for obstruction. Trace free fluid about right kidney. [**2119-2-13**] Videoswallow Eval: Video oropharyngeal swallow exam was performed in conjunction with speech and swallow therapy. Varying consistencies of barium were administered under constant video fluoroscopic monitoring. Aspiration of thin liquids despite use of chin tuck was seen, likely secondary to impaired vocal cord closure. There is significant vallecular residue. No spontaneous cough was observed. Functional swallowing ability was seen with ground solids and extra thick liquids if patient swallowed with chin to her chest and alternating between 1 bite and 1 sip rate. Following this study, there is also evidence of retained barium still within the esophagus [**2119-2-24**] CXR: Fluoroscopic guidance was provided for Dr. [**Last Name (STitle) 914**] for Perm-A- Catheter placement without a radiologist present. Two fluoroscopic scout images demonstrate a dual-chamber right Perm-A-Catheter terminating in the SVC. No final diagnostic images were obtained. [**2119-2-28**] CXR: Right subclavian line terminating in the superior vena cava. Left lower lung lobe opacity consistent with atelectasis and effusion. Additional persistence of left mid lung zone opacity most consistent with a loculated component to the left pleural effusion, stable. CARDIOLOGY: [**2119-1-31**] TEE: Prebypass Study Examination of the heart was limited because the thoracic aneurysm was compressing on the left atrium and left ventricle. Transgastric views prebypass showed normal LV and RV function. The ascending aorta is normal in size with a well formed sinotubular junction and there is no aortic regurgitation. 12 cm aneurysm seen in the thoracic portion of the descending aorta with spontaneous echo contrast within the lumen. Post Bypass There is a graft seen on the thoracic portion of the descending aorta. LV and RV function are preserved. No atrial septal defect is seen by 2D or color Doppler. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. [**2119-2-1**] TTE: The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is mildly depressed with mild global hypokinesis more prominent in the basal to mid septum (may be due to conduction defect). The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. The descending thoracic aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The estimated pulmonary artery systolic pressure is normal. There is a moderate sized pericardial effusion. There are no echocardiographic signs of tamponade. CYTOLOGY: [**2-20**] Pleural Fluid: negative for malignancy Brief Hospital Course: This is the brief summary of this prolonged hospital course for this pleasant 2-year old female who underwent a thoracoabdominal aneurysm repair on [**2119-1-31**] complicated by post-op renal failure due to TTP requiring plasmapheresis and hemodialysis, as well as pulmonary and infectious complications. On day of discharge the patient was tolerating a regular diet, comfortable, hemodynamically stable, and requiring rehab placement for ongoing dialysis. On [**2119-1-31**] Ms. [**Known lastname **] went to the operating room where she underwent a left thoracotomy and thoracoabdominal aneurysm repair with a #26 gelweave graft (please see the operative note of Dr. [**Last Name (STitle) 914**] for full details). On POD #1 she had decreased urine output and ATN was noted, a renal artery scan showed obstruction of flow for which she was taken back to the operating room for an abdominal angiogram via open right CFA (please see the operative note of Dr. [**Last Name (STitle) **] for full details). Patent BL renal arterties with 50% stenosis were found. She was seen in consultation by renal medicine who recommended dialysis, which began on [**2119-2-2**]. Her platelet count was low at 66,000, a HIT screen was negative. She also had some confusion post-operatively , after extubation on post-op day 5. Hematology was consulted and her findings were consistent with TTP. He platelet counts improved with plasmapheresis and eventually normalized. She required intermittent neosynephrine and nitroglycerine for BP management while on CVVHD, but eventually was hemodynamically stable and restarted on lopressor as part of her discharge regimen. Her renal failure improved and she was able to make marginal urine (approximately 500 cc/day) prior to discharge. From a GI standpoint she was unable to tolerate a regular diet initially after extubation. A bedside swallow evaluation on [**2-6**] recomended continued tube feeds, but small amounts of pureed and nectar thickened liquids with modifications. She was seen in consultation by ENT and found to have vocal cord paralysis but no immediate intervention was recommended. A Dobhoff tube was placed for tube feeding, and eventually this was removed and a regular diet was resumed. Nutrition consultation was obtained and nutritional supplements such as Carnation instant breakfast were recommended. She had no major pulmonary issues post-operatively, but did develop a left-sided pleural effusion. This was tapped for approximately 1 liter on [**2119-2-20**] and she symptomatically did better. She had no documented post-operative pneumonia. From an infectious disease standpoint she had some fevers around 2 weeks post-operative. Full workup revealed only significant yeast in her urine and she was treated appropriately with Fluconazole. She also had empiric vancomycin around the peri-operative period. The patient worked with physical therapy and was able to ambulate well with some assistance prior to discharge. Social work services were obtained early in her hospital course and case management assisted with finding appropriate rehabilitation, as the patient originally is from [**State 108**]. The patient was discharged over 1 month post-operatively in stable condition, tolerating a regular diet, ambulatory, with good pain control, and normal cardio-pulmonary function. Her major issues upon discharge included ongoing need for hemodialysis, assistance with physical therapy, and assistance with nutritional support. She has planned follow-up with Cardiac Surgery. All questions were answered to her satisfaction upon discharge. Medications on Admission: Verapamil 240 mg po qdaily Flexaril Vitorin (stopped 3 weeks prior) Discharge Medications: 1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**11-21**] Puffs Inhalation Q6H (every 6 hours) as needed. 8. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 13. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) injection Subcutaneous ASDIR (AS DIRECTED): per sliding scale (as printed). 14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 16. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 17. Diphenhydramine HCl 25 mg Capsule Sig: 0.5 Capsule PO Q6H (every 6 hours) as needed for itching. 18. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 19. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 20. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift Discharge Disposition: Extended Care Facility: [**Hospital1 599**] of [**Hospital1 789**] RI Discharge Diagnosis: Primary: Thoracic Aortic Aneurysm - s/p repair Secondary: Postoperative Renal Failure TTP Vocal Cord Paralysis Failure to Thrive Hypertension Hyperlipidemia History of Heavy Tobacco Abuse Carotid Artery Disease Preoperative Urinary Tract Infection Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Followup Instructions: Follow-up with your Cardiac surgeon, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**] in [**2-22**] weeks. Follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 65759**] in [**12-23**] weeks. Follow-up with ENT , Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], in [**12-23**] weeks [**Telephone/Fax (1) 41**] Nephrology management per rehabilitation hospital Nephrologist Completed by:[**2119-3-7**] Name: [**Known lastname 5711**],[**Known firstname **] Unit No: [**Numeric Identifier 11535**] Admission Date: [**2119-1-30**] Discharge Date: [**2119-3-14**] Date of Birth: [**2046-12-23**] Sex: F Service: CARDIOTHORACIC Allergies: Shellfish Attending:[**First Name3 (LF) 1543**] Addendum: Addendum: Patient waited in house for another 7 days until an appropriate rehab bed was available. She continued to follow an HD schedule and was followed by renal, vascular and hematology services. She had back/chest pain on [**3-10**] on HD, so discharge was delayed. CTA of chest and abd done on [**3-12**]: loculated pleural effusions and s/p TAA repair, moderate pericardial effusion, infrarenal AAA, left renal cysts, divericulosis, bilat. groin seromas, spinal degeneration. Despite, pre-treatment, she still developed erythema over her face and trunk post- dye. This delayed her discharge another 2 days. Discharged to rehab in stable condition on [**2119-3-14**]. Discharge Medications: 1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**11-21**] Puffs Inhalation Q6H (every 6 hours) as needed. 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 12. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) injection Subcutaneous ASDIR (AS DIRECTED): per sliding scale (as printed). 13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 14. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 15. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 16. Diphenhydramine HCl 25 mg Capsule Sig: 0.5 Capsule PO Q6H (every 6 hours) as needed for itching. 17. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 18. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 19. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital1 **] of [**Hospital1 **] RI Discharge Diagnosis: Primary: Thoracic Aortic Aneurysm - s/p repair Secondary: Postoperative Renal Failure TTP Vocal Cord Paralysis Failure to Thrive Hypertension Hyperlipidemia History of Heavy Tobacco Abuse Carotid Artery Disease Preoperative Urinary Tract Infection Discharge Condition: Stable Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Followup Instructions: Follow-up with your Cardiac and vascular surgeons, Drs. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and [**First Name8 (NamePattern2) **] [**Doctor Last Name **] in [**2-22**] weeks. [**Telephone/Fax (1) 1477**] Follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 11536**] in [**12-23**] weeks. Follow-up with ENT , Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], in [**12-23**] weeks [**Telephone/Fax (1) 1848**] Nephrology management per rehabilitation hospital Nephrologist Dr. [**Last Name (STitle) 2682**] (HemeOnc) 4 weeks [**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**] Completed by:[**2119-3-14**]

[ "584.5", "511.9", "478.30", "112.2", "441.03", "693.0", "401.9", "446.6", "E947.8", "453.8", "724.5" ]

icd9cm

[ [ [] ] ]

[ "38.45", "39.95", "34.91", "89.64", "96.6", "88.42", "39.59", "33.22", "99.71", "99.04", "99.05", "39.61", "38.95", "88.45", "99.07", "88.72" ]

icd9pcs

[ [ [] ] ]

21058, 21124

11284, 14891

296, 622

21416, 21425

2468, 11261

21743, 22506

1983, 2074

19176, 21035

21145, 21395

14917, 14986

21449, 21720

2089, 2089

237, 258

650, 1630

2103, 2449

1652, 1797

1813, 1967

12,367

131,308

5256

Discharge summary

report

Admission Date: [**2187-8-19**] Discharge Date: [**2187-8-28**] Date of Birth: [**2149-2-15**] Sex: F Service: MEDICINE Allergies: Haldol / Penicillins / Motrin Attending:[**First Name3 (LF) 1253**] Chief Complaint: Fevers Major Surgical or Invasive Procedure: [**8-19**] Intubation [**8-22**] Removal of left indwelling line [**8-22**] Fluoroscopic-guided placement of right midline line (removed [**8-28**]) History of Present Illness: 38yoF with h/o paranoid schizophrenia, NIDDM, brought in from Psych facility [**Hospital1 **] for fevers. She was at [**Hospital1 **] apparently after having downed 2 bottles of Advil and was cleared from [**Hospital **] Hospital, then transferred to [**Hospital1 **]. She has been seen several times in the ED for self inflicted laceration to her forehead. Pt was having neck pain the night before admission and noted to be febrile. ED vitals: Febrile to 105, 112/66, tachy to 136, with RR 46 and 99% 2L. Got BCx's, UCx, and LP in the ED which was normal, CSF pending but unremarkable to date. Got 5-6L NS and 1g Vanc and 2g CTX. Lactate 2.2, some abnmls of K, Mg, Phos. WBC count was 13 with neutrophilia and low grade bandemia. Not in renal failure; LFT's normal. CXR shows RML opacity and a L sided retained cathter, and R portacath in place. Was admitted to the floor and given lyte repletion. WBC's rose to 19.7, now down to 16. Febrile through the afternoon. BCx's ended up growing 6 bottles of GPC's in pairs and clusters. Access has been an issue, and despite many attempts, unable to get peripherals and the only 22g PIV has blown. Continued Vanc and CTX on the floor but apparently didn't get further IVF's. She currently feels cold and is anxious. She denies SOB, CP, palpitations, n/v/abd pain. Pt also states that she has neck pain on R that started yesterday, however the 1:1 sitter in the room states she's been in the ED numerous times recently with neck pain which is supported by the numerous CT's of her neck. She has been seen several times in the past couple months for acute on chronic head laceration from repetitive banging her head. ROS as above, otherwise negative or unobtainable. Past Medical History: Per OMR records - Schizophrenia Paranoid Type with -Recurrent command auditory hallucinations -Hospitalized [**7-9**] at [**Hospital1 **] - Head laceration due to repetitive banging head on wall - H/o previous suicide attempts - Diabetes - Polyneuropathy - Seizure Disorder vs Pseudoseizures Social History: Recently eloped from a crisis unit, then was at [**Hospital1 **] Psych facility. Per mother, was high functioning, living in group home, has 3 children. Is divorced. She states her father and siblings were heroin abusers. Family History: Unknown Physical Exam: ADMISSION PHYSICAL EXAM: VS: 101.4-->104 short time later, 131/79, 116, 20, 99% RA Gen: ill appearing woman lying in bed snoring, intermittently wakes up and says somewhat non-sensical things, multiple blankets covering HEENT: PERRL, EOMI. large well healed linear laceration healing by second intention, no erythema, warmth, MMM. Neck: some pain with passive flexion of neck Chest: CTAB, but exam is limited by poor inspiratory efforts Cardiovascular: Tachycardic, normal S1 S1, no m/g/r Abdominal: Soft, Nontender, Nondistended GU/Flank: No costovertebral angle tenderness Skin: extremely warm to the touch, no petechiae or rash seen Neuro: lethargic, oriented to self but not to place, time, or situation (we're on a basketball court, its fall, I'm her mom). 1+ reflexes UE and LE, symmetric. No clonus. Some ?increased tone of LE but not UE. Couldn't formally assess strength 2/2 mental status, but moving all extremities and strenght appears full. Psych: decreased mentation DISCHARGE PHYSICAL EXAM: VS: T 97.8 BP 109/77 HR 84 RR 18 O2 sat 99% RA Gen: Obese female lying bed comfortably. HEENT: periorbital puffiness, MMM. laceration in middle of her forehead is uncovered, healing. Neck: large and unable to evaluate JVD Pulm: CTAB, no wheezes, rales or rhonchi Cards: RRR, no murmurs, gallops or rubs Abd: obese, NT ND, benign Extremities: warm, dry, hands very swollen Neuro: unchanged Pertinent Results: LABS: Admission Labs: [**2187-8-19**] 02:53AM BLOOD WBC-13.3*# RBC-3.90* Hgb-10.9* Hct-32.2* MCV-83 MCH-27.9 MCHC-33.8 RDW-15.5 Plt Ct-250 [**2187-8-19**] 02:53AM BLOOD Neuts-90* Bands-2 Lymphs-6* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2187-8-19**] 02:53AM BLOOD Glucose-128* UreaN-15 Creat-0.9 Na-133 K-3.2* Cl-98 HCO3-24 AnGap-14 [**2187-8-19**] 02:53AM BLOOD ALT-21 AST-19 LD(LDH)-169 CK(CPK)-72 AlkPhos-91 TotBili-0.2 [**2187-8-19**] 02:53AM BLOOD Lipase-19 [**2187-8-19**] 02:53AM BLOOD Calcium-9.0 Phos-1.7*# Mg-1.5* [**2187-8-19**] 02:53AM BLOOD TSH-1.4 [**2187-8-19**] 02:53AM BLOOD Cortsol-31.1* [**2187-8-19**] 02:53AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . Dicharge labs: [**2187-8-27**] 05:10AM BLOOD WBC-6.3 RBC-3.29* Hgb-9.2* Hct-26.9* MCV-82 MCH-27.9 MCHC-34.1 RDW-16.3* Plt Ct-341 [**2187-8-27**] 05:10AM BLOOD Glucose-119* UreaN-6 Creat-0.6 Na-142 K-4.1 Cl-106 HCO3-28 AnGap-12 [**2187-8-28**] 07:09AM BLOOD Albumin-3.5 [**2187-8-28**] 07:09AM BLOOD Phenyto-3.7* Microbiology results: [**2187-8-19**] Blood Culture, Routine (Final [**2187-8-21**]): STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- 1 I GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S Coag + staph grew in [**4-16**] bottles from [**2187-8-19**] . [**2187-8-20**] 1:23 am BLOOD CULTURE Source: Line-poc. STAPH AUREUS COAG +. [**8-21**], [**8-22**], [**8-23**] Blood cultures: no growth [**8-22**] retained L catheter tip culture: STAPH AUREUS COAG +. <15 colonies. Sensitivities: CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S . [**8-19**] Urine culture: negative [**8-19**] CSF culture: negative IMAGING: [**8-19**] CXR: Right infrahilar opacity is consistent with pneumonia. [**8-20**] CTA chest: Abandoned left subclavian catheter terminating at cavoatrial junction. No evidence of left subclavian vein thrombosis in the or superior vena cava / mediastinitis / mediastinal abscess. [**8-20**] Liver/gallbladder US: Normal appearance of the liver parenchyma and gallbladder. No evidence of acute cholecystitis. No ascites. [**2187-8-21**] TEE IMPRESSION: No echocardiographic evidence of endocarditis. Normal biventricular function. [**8-22**] Fluoro guided placement of R midline, removal of L line 1. Right midline venous catheter placement via the right brachial vein. 2. Complete, likely chronic, occlusion of the superior vena cava. The right port-a-cath was kept in place to preserve access across this occlusion. 2. Complete removal of left subclavian venous catheter remnant. Brief Hospital Course: 38yoF with history of paranoid schizophrenia and non-insulin dependent diabetes admitted from her inpatient psych facility with fevers to 105 and altered mental status, found to have high grade MSSA bacteremia/sepsis with retained catheter fragment in L subclavian. . ACTIVE ISSUES: . #. MSSA Sepsis: Fever to 105 on admission with borderline hypotension and somnolence/altered mental status. Blood cultures grew S. aureus within 12 hours of admission, and she was started on vancomycin. Potential sources of infection include the laceration on her forehead or either of her indwelling lines (left catheter tip did eventually grow S. aureus). She was aggressively fluid resuscitated on the floor, however there were multiple issues with adequate intravenous access due to poor veins and questionably infected right port-a-cath with retained line in left subclavian (see below). She was transferred to the MICU where she was intubated for procedures,received fluids but not pressors. TTE and TEE did not show any vegetations. Pt was taken to IR for removal of the L subclavian line fragment. The R sided indwelling portacath was could not be removed because it was maintaining central access in the setting of nearly complete SVC clot (found on fluro). Antibiotics slowly narrow to cefazolin. Initial plan was to give antibiotics through her a right midline, however given SVC clot, the port-a-cath is a preferable means of delivery. Midline was pulled on [**8-28**]. She will need to complete a 6 week course of intravenous antibiotics (from last pos blood culture through [**2187-10-1**]) and have weekly lab monitoring (CBC w diff, liver enzymes, and BUN/Cr) faxed to ID nurse at [**Telephone/Fax (1) 1419**]. #. Schizophrenia: She was admitted from [**Hospital1 **] on a large list of psychiatric medications. Psych was consulted and recommended paring down her list to only risperidone and Klonapin, with PRNs of both available for agitation, anxiety. She has been very stable psychiatrically since admission. She has had a 1:1 patient observer at all times and has not exhibited any self-injurious behaviors. She was admitted as Section 21, so she will need to be transfered to an inpatient psychiatric facility for further evaluation now that she is medically stable. . # Possible Seizure/Mental Status Changes: Patient has a vague history of seizures and was on dilantin on admission. Following transfer to the floor from the MICU, the patient had 2 episodes of blank staring, tongue clicking, and ?post-ictal confusion. No shaking, incontinence or tongue biting to indicate tonic clonic seizure activity. Glucose and lytes WNL except Ca a bit low. The following morning she had another event of staring and clickin of her tongue, however she remained response and was able to walk back to her room (was in he [**Doctor Last Name **]). Neurology was consulted, believed the first two events to be consistent with partial seizures, however the third event was likely a pseudoseizure/non-convulsive seizure. They recommended restarting phenytoin and doing a video EEG, however she refused lead placement for the EEG. Ativan PRN was ordered for breakthrough seizures, however she did not exhibit any further activity concerning seizures. . # Retained cathether fragment: On admission, patient was noted to have only a right-sided port-a-cath, but another line was seen in the left subclavian on initial chest xray (not seen exiting the skin). Upon speaking with the on-call radiologist, they verified that this appeared to be a retained line from a previous left port-a-cath. The line was seen on an old CXR from [**2179**], however no information what known from the intervening years. The patient could not give much information on why this line was placed or when. Per mother, she has the current portacath in because "she was hard to draw blood from" but she had no idea of the previous catheter. It is unknown whether it broke off when being removed or if the patient perhaps cut off the external portion herself. The retained portion of the line was succesfully removed on [**8-22**], and a culture of the tip subsequently grew <15 colonies of S. aureus. It is unclear if this could have been a source of her sepsis or if she was instead bacteremic for a long time and secondarily seeded the line. . # SVC clot: During fluroscopic guided placement of right midline discovered SVC clot. Patient not deemed longterm anticoagulation candidate, accordingly port was left in place to maintain central access. If port is removed, likely there can be no further attempts at central access. . # Forehead Laceration: Wound consult was obtained for proper dressing and care of the head wound. Healing well by secondary intention. Medications on Admission: From [**Hospital1 **] Amdission note - Dilantin ER 200 mg PO bid - Geodon 80mg PO bid - Risperdal oral 1mg PO bid - Risperdal Consta, last injxn unknown - Vistaril 25 mg PO tid prn anxiety - Zoloft 50 mg PO qam - Ativan 1mg PO tid prn anxiety - Recently discontinued off Seroquel XR Medications from [**Hospital1 **] discharge list - Clonazepam 1mg tid prn - Zoloft 50 mg qam - Cogentin 2mg qhs - Dilantin EX 300 mg daily, 400 mg at hs - Risperdal 2mg qam - Risperdal 4 mg hs - Valproic Acid 250 mg in 5 mL tid - Neurontin 300 mg [**Hospital1 **] - Bacitracin ointment - Oxycodone 5 mg PO q4 prn - Trazadone 50 mg hs prn - Mylanta - Milk of Magnesia - Thorazine 100 mg q6 prn - Trimethobenzamide 300 mg q6 prn nausea/vomiting - Loperamide 2mg prn - Benadryl 50 mg q6 prn Discharge Medications: 1. risperidone 2 mg Tablet Sig: One (1) Tablet PO twice a day. 2. clonazepam 1 mg Tablet Sig: One (1) Tablet PO three times a day. 3. clonazepam 1 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety, agitation. 4. risperidone 1 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet, Rapid Dissolve PO BID (2 times a day) as needed for agitation. 5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 6. cefazolin 1 gram Recon Soln Sig: Two (2) grams Intravenous every eight (8) hours for 5 weeks: Please continue until [**2187-10-1**]. 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 9. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily) as needed for constipation. 10. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Two (2) ml Injection Q8H (every 8 hours) as needed for nausea. 11. phenytoin 125 mg/5 mL Suspension Sig: Eight (8) ml PO Q8H (every 8 hours). 12. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 14. Outpatient Lab Work She will need to complete a 6 week course of intravenous antibiotics (from last pos blood culture through [**2187-10-1**]) and have weekly lab monitoring (CBC w diff, liver enzymes, and BUN/Cr) faxed to ID nurse at [**Telephone/Fax (1) 1419**]. Discharge Disposition: Extended Care Discharge Diagnosis: Primary diagnoses: MSSA sepsis Seizure Secondary diagnoses: Schizophrenia Diabetes Mellitus type II Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname **], It was a pleasure to take care of you during your stay at [**Hospital1 18**]. You were admitted to the hospital because of very high fevers. We found that you had a severe infection that went to your blood and made you very sick. We think that the infection may have come from the wound on your forehead, but it also may have come from one of the lines in your chest-- either the right-sided port-a-cath or the line that was left in your left chest from an old port-a-cath. You spent a few days in our intensive care unit to make sure that you did okay while we started treating you with antibiotics. You did remarkably well. Because of how bad your infection was, you will need to take intravenous antibiotics for 5 more weeks, until [**2187-10-1**]. You will also need weekly lab monitoring done and sent to the infectious diseases nurse until you are done with your antiobiotics. Changes to your medications: START cefazolin 2 g IV every 8 hours until [**2187-10-1**] Followup Instructions: Please make an appointment with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], once you are going to be discharged from your inpatient psychiatric facility. PCP: [**Name10 (NameIs) **],[**First Name3 (LF) 5684**] J Location: [**Hospital **] MEDICAL ASSOCIATES Address: [**Last Name (un) 21477**], N. [**University/College **],[**Numeric Identifier 21478**] Phone: [**Telephone/Fax (1) 21479**] Fax: [**Telephone/Fax (1) 21480**] Infectious Disease follow up: An appointment will be made for you to follow up with the Infectious Disease doctors, you will be notified while you are in inpatient psychiatry.

[ "V90.89", "486", "345.90", "729.6", "357.2", "V14.0", "999.31", "250.60", "E849.9", "785.52", "453.87", "295.30", "038.11", "E879.8", "305.60", "304.10", "518.81", "292.0", "995.92" ]

icd9cm

[ [ [] ] ]

[ "96.04", "38.97", "88.72", "86.05", "03.31", "96.71" ]

icd9pcs

[ [ [] ] ]

14248, 14263

7062, 7330

297, 448

14408, 14408

4226, 4233

15593, 16065

2774, 2784

12639, 14225

14284, 14324

11842, 12616

14559, 15481

2824, 3787

14345, 14387

16076, 16225

15510, 15570

251, 259

7345, 11816

476, 2192

4249, 7039

14423, 14535

2214, 2518

2534, 2758

3812, 4207

12,164

125,514

53310

Discharge summary

report

Admission Date: [**2130-1-18**] Discharge Date: [**2130-1-22**] Date of Birth: [**2054-8-27**] Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 4748**] Chief Complaint: Patient presented to the [**Hospital1 18**] ER with shortness of breath. Major Surgical or Invasive Procedure: none History of Present Illness: transfered from radiation theraphy for breast cnacer c/o difficulty in breathing and complaintes of diarrhea, anorexia, and weakness and fatigue. Past Medical History: CHF- EF 26% on cath in [**2126**] w/mild MR; no CAD DM 2 HTN ,uncontrolled breast ca ,s/p bilateral breast lumpectomies,s/p xrt,s/p CMP ( ef25%) hyperlipidemia history of depression history of CHF Social History: h/o tobacco 10pkys, quit 14yrs ago. Social EtOH, approx 3drinks/wk. No drug use. Family History: Mother with breast cancer and heart disease, father with "heart disease," sister with diabetes Physical Exam: vital signs 99.1-86-20 B/P 128/80 O2 sat 100% on 2L/min Gen: lying in bed mild distress HEENT: unremarkable Lungs: diminished breath sound @ bases bilaterally, no aventitious sounds Heart: RRR ABD; soft nontender , nodistened PV : pulses palpable bilaterally Neuro: Ox3, nonfocal Pertinent Results: [**2130-1-18**] 02:15AM GLUCOSE-115* UREA N-9 CREAT-0.9 SODIUM-142 POTASSIUM-3.3 CHLORIDE-103 TOTAL CO2-30 ANION GAP-12 [**2130-1-18**] 02:15AM CALCIUM-8.8 PHOSPHATE-3.5 MAGNESIUM-2.4 [**2130-1-18**] 02:15AM PLT COUNT-340 [**2130-1-18**] 02:15AM PT-14.1* PTT-31.0 INR(PT)-1.2* [**2130-1-17**] 11:15PM CK(CPK)-62 [**2130-1-17**] 11:15PM CK-MB-NotDone cTropnT-<0.01 [**2130-1-17**] 10:59PM LACTATE-0.8 [**2130-1-17**] 04:35PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011 [**2130-1-17**] 04:35PM URINE RBC-0-2 WBC-[**1-30**] BACTERIA-OCC YEAST-NONE EPI-0-2 [**2130-1-17**] 03:15PM GLUCOSE-114* UREA N-10 CREAT-1.0 SODIUM-139 POTASSIUM-3.3 CHLORIDE-98 TOTAL CO2-32 ANION GAP-12 [**2130-1-17**] 03:15PM estGFR-Using this [**2130-1-17**] 03:15PM CK(CPK)-78 [**2130-1-17**] 03:15PM CALCIUM-9.4 PHOSPHATE-3.1 MAGNESIUM-2.4 [**2130-1-17**] 03:15PM VIT B12-413 [**2130-1-17**] 03:15PM TSH-1.2 [**2130-1-17**] 03:15PM WBC-7.2 RBC-4.49 HGB-12.5 HCT-36.9 MCV-82 MCH-27.8 MCHC-34.0 RDW-15.4 [**2130-1-17**] 03:15PM NEUTS-81.8* LYMPHS-9.6* MONOS-6.0 EOS-2.4 BASOS-0.2 [**2130-1-17**] 03:15PM MICROCYT-1+ [**2130-1-17**] 03:15PM PLT COUNT-328# [**2130-1-17**] 03:15PM PT-13.6* PTT-29.5 INR(PT)-1.2* Brief Hospital Course: [**2130-1-17**] evaluated in ER. CT scan done to r/o Pulmonary embolus demonstrated aortic dissection distal from great vessels to above iliac bifurcation of abdominal aorta. Vascular consulted. Patient began on Esmolol IV gtt for b/p contron then transitioned to labetolol drip for better blood pressure control and admitted to ICU. [**2130-1-19**] B/p stable off esmolo gtt and on po antihypertensives. delined and transftered to RNF for continued care. [**2130-1-20**] Presented at Vascular conferance. Recommendations open repair vs medical managment,recommendations to be discussed with the patient. [**2130-1-21**] Patient and family will discuss recommendations regarding operative repair. Patient's blood pressure well controlled with home medications and increased amount of carvedilol. Patient given specific instruction regarding follow up with primary care provider in the next two days. Patient to follow up with Dr. [**Last Name (STitle) 1391**] as an outpatient. Medications on Admission: same as d/c meds Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Valsartan 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Carvedilol 12.5 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Company **] Discharge Diagnosis: aortic dissection hypertension history of congestive heart failure history of DM2 history of etoh use history of formerd/c x [**2102**]'s smoking 13 pack years history of hyperlipdemia history of depression history of arthritis history of breast cancer s/p bilateral lumpectomies s/p XRT and CTX(CMP) Ef 25% Discharge Condition: stable Discharge Instructions: Take all medications as directed Follow-up with your PCP for continued blood pressure monitoring and antihypertensive medication adjustment, appointment with PCP should be within two days of discharge from hospital, otherwise follow up with Dr. [**Last Name (STitle) 1391**] [**1-24**]. Followup Instructions: Please follow up with you Primary care provider in the next two days for blood pressure checks. Your blood pressure must be closely managed. Please call Dr.[**Name (NI) 1392**] office in order to schedule a follow up appointment. (if you cannot see you PCP this week, Dr. [**Last Name (STitle) 1391**] can see you [**1-24**], call ([**Telephone/Fax (1) 4852**] to schedule appointment.

[ "428.0", "250.00", "174.8", "401.9", "441.02", "272.4" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

4100, 4145

2548, 3527

353, 360

4497, 4506

1282, 2525

4841, 5231

870, 967

3594, 4077

4166, 4476

3553, 3571

4530, 4818

982, 1263

241, 315

388, 535

557, 755

771, 854

2,912

194,048

8120

Discharge summary

report

Admission Date: [**2194-3-8**] Discharge Date: [**2194-3-22**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 301**] Chief Complaint: 1. Incarcerated right inguinal hernia, giant. 2. Complete bowel obstruction. 3. Meckel's diverticulum Major Surgical or Invasive Procedure: 1. Exploratory laparotomy. 2. Reduction of hernia and adhesiolysis. 3. Repair of hernia with mesh, right. 4. Closure with retention sutures. History of Present Illness: The patient is an 86-year-oldgentleman with a twenty-year history of a right reducible groin hernia which over the last several years he has been unable to reduce. He presents to the Emergency Room with 24hours of "food poisoning", however, on examination he has a large incarcerated hernia and significant bowel distention. The patient is adamant about not undergoing surgery but agreed to a CAT scan to document whether obstruction was complete as suspected. CAT scan demonstrated completeobstruction. The family and internist became actively involved in discussions with the patient and the patient then agreed to exploratory laparotomy and repair of hernia. The patient preoperatively was evaluated by Cardiology and deemed at very high risk for cardiac problem perioperatively, given the history of coronary artery disease, congestive heart failure, and ventricular tachycardia. Past Medical History: CAD, s/p stents, CHF, EF 25%, HTN, hyperlipid, AF Physical Exam: PE: 98.1, 108, 110/50, 26, 97% on NRB Cacehtic: mild resp distress with purse-lip breathing Irreg, irreg, no m/r/g Bibasilar crackles Abd decreased bsm soft ntnd R scrotum with large, irreducible hernia. Rectal guaic pos, no mass Ext no edema Brief Hospital Course: 87 yo M w/ hx CAD a/w incarcerated hernia on [**2194-3-8**] and SBO, s/p repair [**2194-3-9**]. Post-op remained intubated for CHF and ? UGIB [**2-5**] ? perforated esophagus in OR, NGL clear w/ 250cc, extubated [**2194-3-12**]. Speach and swallow eval w/ aspiration --> pt NPO. Post-op course c/by AF with RVR s/p cardioversion w/out effect on dilt and amio gtt, NSTEMI w/ Trop 0.73 on heparin gtt. CXR [**2194-3-18**] w/ CHF on levo/flagyl for asp pna and transferred to medicine [**2194-3-19**]. Over the course of the day w/ progressive hypoxia/SOB 93% 4L NC-> 85% on NRB w/ orthopnea, LE edema and non productive cough. Improvement in sats w/ diuresis (-1.7L w/ 80IV lasix and O2 improvement to 94% NRB) and mucus plugging. Admitted to MICU on [**3-20**] for resp failure, AF with RVR and NSTEMI. Remained hypotensive despite multiple pressors and in respiratory distress/ARDS. After discussions with family, family decided patient should be CMO. He was taken off pressors and placed on pressure control ventilation with morphine gtt. He expired on [**2194-3-22**] at 1835. Family did not request an autopsy. Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: Deceased Completed by:[**2194-7-17**]

[ "414.00", "578.9", "428.0", "751.0", "427.31", "507.0", "401.9", "518.5", "V45.82", "997.1", "410.71", "997.3", "550.10" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "53.05", "38.93", "93.90", "99.15" ]

icd9pcs

[ [ [] ] ]

2911, 2920

1772, 2888

361, 503

2972, 3011

2941, 2951

1505, 1749

220, 323

531, 1417

1439, 1490