ChanBeDu/relevant_section_length · Datasets at Hugging Face

65,733

168,926

26100

Discharge summary

report

Admission Date: [**2166-12-21**] Discharge Date: [**2166-12-26**] Date of Birth: [**2095-1-17**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1363**] Chief Complaint: Pulmonary Embolism Major Surgical or Invasive Procedure: none History of Present Illness: This is a 71 y.o male with h.o metastatic melanoma who presents with "I couldn't walk", noticed to be tachypneic in the ED, underwent CTA found to have multiple PE's. Pt reports he came to the ED as he was too weak to walk. Pt also endorses dysuria for a few days. Otherwise denies f/c/uri/cough, headache, blurred vision, dizziness, CP/palp, SOB, abd pain/n/v/d/c/melena/brbpr, dysuria, hematuria, joint pain, skin rash, paresthesias, bowel/bladder incontinence. . In the [**Name (NI) **], pt found to be tachypneic, RR ~35, CTA found PE, head CT found stable R.frontal lesion. PT's neurooncologist Dr. [**Last Name (STitle) 724**] was [**Name (NI) 653**], who felt that given clinical situation, heparin IV could be initiated. Vitals in the ED, afeb, BP 148/82, HR 85, sat 96% on 4L. Past Medical History: PER OMR- Mr. [**Known lastname 64756**] had a biopsy of a 2-mm Clark'slevel IV melanoma in the right ear with no ulceration one mitosis per square mm in 12/[**2163**]. During his evaluation, he was found to have a secondary primary on his upper back that was 0.6 mm [**Doctor Last Name 10834**] level III with no evidence of ulceration. He underwent wide local excision of the right ear and back at the same time as well as a sentinel lymph node biopsy from the right ear lesion in [**2-/2164**] with no evidence of residual melanoma at the primary site or in the sentinel lymph nodes. In [**8-/2165**], he developed a soft tissue nodule on his right neck just inferior to the scar. He underwent right parotidectomy and facial nerve sparing and right cervical node dissection. Pathology revealed 9 of 57 cervical lymph nodes positive of melanoma with extracapsular extension. The salivary gland had 4 of 9 nodes showing evidence of extracapsular extension as well. He underwent radiation therapy to the right neck and facial region completing in early 10/[**2165**]. He began adjuvant interferon therapy on [**2166-1-8**]. His interferon therapy was discontinued after five weeks due to mental status change and declining performance status. He had a needle biopsy of a lump on the right mid-back in end of [**Month (only) **] [**2166**] that revealed malignant cells. CT torso [**2166-8-18**] showed concerning metastatic lesion in the region of the left kidney as well as a new right hilar adenopathy measuring approximately 1.8 cm in greatest axial dimension concering for metastatic spread. . - metastatic melanoma s/p Right parotidectomy and neck dissection with presumed mets to brain, lung, kidney, and mesentery - resting tremor - ?early dementia - BPH - hypercholesterolemia - back pain - hiatal hernia - diverticuli - Tonsillectomy . Social History: Lives with wife, non-[**Name2 (NI) 1818**], few beers per week, denies drug use. Family History: non-contributory Physical Exam: Vitals: T. 97.7, BP 142/70, HR 79, RR 13, sat 98% on 3L GEN: NAD, lying in bed, speaking in full sentences, appears comfortable. HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: b/l AE +mild scant expiratory wheezing. ABD: +bs, soft, NT, ND EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, "hospital"x2.. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Plantar reflex downgoing. Gait not tested, nor cerebellar fxn due to pt "tired". No tremor. . SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: Admission labs [**2166-12-21**] 06:00PM BLOOD WBC-7.7 RBC-4.39* Hgb-13.4* Hct-39.4* MCV-90 MCH-30.5 MCHC-34.0 RDW-13.3 Plt Ct-184 [**2166-12-21**] 06:00PM BLOOD Neuts-85.8* Lymphs-7.4* Monos-3.8 Eos-2.7 Baso-0.4 [**2166-12-21**] 06:00PM BLOOD PT-13.1 PTT-21.5* INR(PT)-1.1 [**2166-12-21**] 06:00PM BLOOD Glucose-87 UreaN-16 Creat-0.9 Na-139 K-3.7 Cl-102 HCO3-29 AnGap-12 [**2166-12-21**] 06:00PM BLOOD Calcium-8.8 Phos-2.9 Mg-2.1 [**2166-12-21**] CT head without contrast: IMPRESSION: Overall interval decrease in size of the known metastatic right frontal lesion with decreased surrounding edema. Other lesions not well defined on this non- contrast study, MR [**First Name (Titles) 151**] [**Last Name (Titles) **] is much more sensitive. [**2166-12-21**] CTA Chest: IMPRESSION: 1. Findings consistent with acute pulmonary embolism. 2. Interval increase in size of the right hilar lymphadenopathy. 3. Right upper lobe opacity is new, and may represent an infarction, alternatively, this could be seen in the setting of infection. 4. Stable appearance of noncalcified right lower lobe pulmonary nodule. Evaluation for small nodule is limited by motion artifact. 5. Stable appearance of a soft tissue adjacent to or arising from the inter polar left kidney. Further imaging/ CT abdomen may be performed to assess. [**2166-12-22**] CXR: FINDINGS: In comparison with the study of [**12-21**], there is little change. Continued prominence of the cardiac silhouette, some of which may be related to the poor inspiration. No evidence of acute pneumonia or vascular congestion. [**2166-12-22**] LENI: IMPRESSION: Normal bilateral lower extremity ultrasound examination. No evidence of DVT. [**2166-12-22**] 11:08 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FECAL CULTURE (Preliminary): REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] AT 0941 [**2166-12-24**]. SALMONELLA SPECIES. Presumptive identification pending confirmation by State Laboratory. CAMPYLOBACTER CULTURE (Final [**2166-12-24**]): NO CAMPYLOBACTER FOUND. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2166-12-23**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). [**2166-12-21**] 7:50 pm URINE Site: CLEAN CATCH URINE CULTURE (Preliminary): ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Brief Hospital Course: Assessment/Plan: This is a 71 y.o male with h.o metastatic melanoma, who presents with difficulty ambulating found to have multiple PE's. . #pulmonary embolism-Discovered at admission after found to be tachypic. Likely secondary to malignancy. Pt notes inability to speak in full sentences for 6 weeks. Family reports noticing some SOB in the days prior to admission. It is unclear whether the PE caused significant weakness or if his weakness if [**3-15**] the Salmonella infection and chronic PE's were incidently discovered. Pros/Cons regarding anticoagulation were weighed. Pt has known melanoma brain mets which have a proclivity to become hemorrhagic. Dr. [**Last Name (STitle) 724**], felt that in the setting of SOB/02 requirement, heparin should be started without a bolus. Upon leaving the [**Hospital Unit Name 153**] the patient was transitioned to lovenox without incident. The Lovenox goal was arbitrarily set at .75mg/kg [**Hospital1 **], which was rounded down to 60mg q12h to fit existing syringe dosing. The patient was continued on nebs prn for wheezing. The pt remained sating well no RA. . #difficulty ambulating-pt denies falls. Reports that on the day of admit, felt weak and unsteady. Denies bowel/bladder incontinence. Likely a result of Salmonella infection tipping this gentlemen with low energy resevres [**3-15**] underlying dx. Pt also has an underlying tremor. Pt/ot consulted who recommended rehabilitation facility. Continue intense PT. . # Salmonella infection: Pt had 2 episodes of diarrhea prior to admission. Reports eating fair amount of scrambed eggs. Denies contact with lizards or sick contacts. Pt had worsening diarrhea in [**Hospital Unit Name 153**] which had resolved by time of transfer to the floor. The patient was started on a 7 day course of ciprofloxacin. Hospital infectious control stated that only standard precautions were necessary. The definitive dx of the salmonella species and sensitivities is still pending from the state laboratory. . #metastatic melanoma with brain mets-not currently undergoing therapy. Pt is s/p cyperknife, and not a candidate fro whole brain radiation because of his previous radiation. The patient should continue Keppra and Decadron at 4mg q12h. Further steroid taper and therapy to be determined by primary oncology. . # Mental status: Per [**Hospital Unit Name 153**] notes was somulent for a few days prior to transfer to floor which had initiated CMO conversation, but now improving. Patient with improving orientation, perhaps [**3-15**] control of the salmonella infection. #)Early Dementia/Resting Tremor: Patient had been getting treatment since they were developed as a side effect of IFN in [**2-18**] when he experience drooling. In past on Aricept and Namenda. Further management as an outpatient. . #)Urinary incontinence: Unclear if neurologic deficit or [**3-15**] weakness from diarrheal illness. Continue to monitor as an outpatient . # FEN: Regular # Code: DNR/DNI, considering CMO # Dispo: rehab, bridge to hospice # Comm: [**Name (NI) **] and family Daughters [**Name (NI) **] [**Telephone/Fax (1) 64757**],H, [**Telephone/Fax (1) 64758**] cell [**Doctor First Name **] [**Telephone/Fax (1) 64759**]- cell [**Doctor First Name 64760**] wife - home [**Telephone/Fax (1) 64761**] . Medications on Admission: dexamethasone 4mg [**Hospital1 **] ezetimibe-simvastatin [**12-1**] dialy finasteride 5mg daily keppra 500mg [**Hospital1 **] pregabalin 75mg [**Hospital1 **] ranitidine 150mg [**Hospital1 **] tolterodine MVI Discharge Medications: 1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pregabalin 75 mg Capsule Sig: One (1) Capsule PO twice a day. 6. Vytorin [**12-1**] 10-20 mg Tablet Sig: One (1) Tablet PO once a day. 7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 days: Your last dose will be on [**12-30**]. Disp:*8 Tablet(s)* Refills:*0* 8. Enoxaparin 60 mg/0.6 mL Syringe Sig: Sixty (60) mg Subcutaneous Q12H (every 12 hours). Disp:*60 Syringes* Refills:*3* 9. Albuterol 90 mcg/Actuation Aerosol Sig: [**2-12**] inhalations Inhalation three times a day as needed for shortness of breath or wheezing. 10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: [**2-12**] inhalations Inhalation every six (6) hours as needed for shortness of breath or wheezing. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**5-18**] hours: not to exceed 4g daily. 12. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO twice a day: This medication was used while in the hospital, and is on prevoius medicaiton lists. Unclear if the patient takes this or Detrol. . Discharge Disposition: Extended Care Facility: Life Care Center of [**Location (un) 5165**] Discharge Diagnosis: metastatic melanoma with brain lesions Pulmonary embolism Salmonella GI infection dementia secondary dx: hyperlipidemia Discharge Condition: good, diarrhea stoped, stable on lovenox Discharge Instructions: You were admitted to the hospital for inability to walk. Upon admission you were found to be short of breath and blood clots (pulmonary embolisms) were found in your lungs. You have successfully been started on blood thinners. You need to continue to be monitored closely as your brain lesions are at high risk of bleeding. You were found to have a Salmonella infection in your stool. You were started on antibiotics for this. It is likely that this infection worsened your weakness that caused you to present to the hospital. The following changes were made to your medication regimen: Ciprofloxacin was added for your salmonella infection Lovenox Injections were started It was unclear which bladder medication you took, whether it was Detrol or Oxytrol. You did well with Oxytrol (Oxybutinin) while in the hospital, so you were continued on this medication on discharge to rehab. Please follow up with your doctors as detailed below. If you develop worsening shortness of breath, chest pain, diarrhea, abdominal pain, fever, headache, confusion, focal weakness, or any other worrisome symptom please call your doctor or seek urgent medical attention. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2167-1-5**] 3:30 Provider: [**Name10 (NameIs) 5005**] [**Last Name (NamePattern4) 5342**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2167-1-5**] 2:00 Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2167-1-5**] 12:35 , PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 40144**] Please contact Dr. [**Last Name (STitle) 10740**] for an appointment as you need or per your regular scheduled follow up. [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1368**] Completed by:[**2166-12-28**]

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Discharge summary

report

Admission Date: [**2127-1-3**] Discharge Date: [**2127-1-8**] Date of Birth: [**2065-11-22**] Sex: F Service: MEDICINE Allergies: Penicillins / Clindamycin / Celery / apple / bees Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: abnormal Venous blood gas at rehab and joint pains and abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: 60F w/ hx of COPD, PAH w/ cor pulmonale, right-sided CHF, CKD, s/p tracheostomy on [**12-25**] in setting of COPD exac and resp failure, who presents with left sided arm pain and question of abnormal VBG suggestive of hypercarbia at rehab. Pt reports pain in her left wrist, left elbow, both feet. Pain feels similar to a gout flair. Also notes abdominal pain which is chronic since [**2116**]. Her daughter reports that she has had increased secretions from her trach lately. Pt has had several recent admission over the last few months. She had a recent admission from [**Date range (1) 49798**] for shortness of breath thought initially to be pneumonia but eventually attributed to COPD exacerbation as opposed to infection. Due to respiratory failure she underwent a tracheostomy on [**12-25**]. . Recent admission [**Date range (1) 66503**] for malfunctioning tracheostomy. At that admission, trach was replaced with [**Last Name (un) 295**] tracheostomy piece. Pt initialy on vent and then weaned off. Found to be anemic, [**1-30**] anemia of chronic disease, she was transfused 1 U PRBC for HCT 24. She also had advancement of dophoff per IR, nutrition adjusted tube feeds. . In the ED, initial VS were: T 98.2 HR 98 102/65, 26 99%, Tm 101.5. VBG performed in ED did not show any signs of hypercarbia. BNP 5000 and CXR with pulm edema, given 20mg IV lasix. CT abd and pelvis was performed (pt was ventilated to allow her to lie flat) and is pending. Pt refused LENI on extremities. UA positive and started on levofloxacin 750mg IV, vanco 1g and cefepime 2g. Pt found to have foul smelling yellow drainage around trach site, covered broadly with vanco/cefepime. After CT head, chest, abd, pelvis, she was transfered to the MICU for close observation. . On arrival to the MICU, pt is comfortable, on the vent. Reports pain in hands and feet, similar to prior gout flairs. Reports some abd pain. Vitals: BP 108/55, HR 84, CMV FiO2 30%, TV 400, PEEP 5, f18, satting 97%. Past Medical History: 1. Morbid obesity (s/p gastric bypass) 2. Obstructive sleep apnea (noctural BiPAP 18/15, home oxygen requirement of 3-4L via nasal cannula) 3. Obesity hypoventilation syndrome 4. Severe pulmonary artery hypertension (attributed to OSA) 5. Cor pulmonale (right heart failure attributed to severe pulmonary hypertension) 6. Asthma 7. Osteoarthritis (bilateral knee involvement) 8. Diastolic heart failure (2D-Echo [**1-/2124**] showing LVEF 70-80%, PAP 64 mmHg) 9. Chronic kidney disease (stage III-IV, baseline creatinine 1.8-2.2) 10. Rosacea 11. Hypertension 12. Iron deficiency anemia 11. s/p ventral hernia repair with mesh and component separation ([**5-/2119**]) 12. s/p gastric bypass surgery ([**2113**]) 13. s/p debridement of anterior abdominal wall and complex repair ([**6-/2119**]) Social History: Coming in from rehab, she has 2 adult children, but adopted 3 so total of 5 children. She notes no toabcco use, rare alcohol use currently but notes a former heavy alcohol history in the distant past. She denies recreational substance use. Family History: Notable for diabetes mellitus in her mother and sister, hypertension in siblings, mother and throughout the maternal family as well as kidney disease. Physical Exam: Admission exam Vitals: Vitals: BP 108/55, HR 84, CMV FiO2 30%, TV 400, PEEP 5, f18, satting 97%. General: no acute distress, obese female, comfortable appearing, responds yes/no to questions, unable to talk bc trach in place, on vent. HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: anterior lung fields sound clear, no crackles. Trach with some mild brown dried secretion around tube. GU: foley Abd: mildly distended, some tenderness throughout to deep palpation, large midline scar from prior gastric bypass surgery Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. Trace pedal edema Joint: Pain in joints of wrists, elbows, ankles. Left wrist is warm, mildly red. Discharge exam Tcurrent: 36.5 ??????C (97.7 ??????F) HR: 83 (80 - 110) bpm BP: 94/59(66) {94/52(64) - 125/88(92)} mmHg RR: 19 (13 - 22) insp/min SpO2: 96% General: no acute distress, obese female, comfortable appearing, responds yes/no to questions, unable to talk [**1-30**] trach in place, on vent. HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: anterior lung fields sound clear, no crackles. GU: foley Abd: mildly distended, some tenderness throughout to deep palpation, large midline scar from prior gastric bypass surgery Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. Trace pedal edema Joint: pain in joints improved. Left wrist is warm Pertinent Results: Admission labs [**2127-1-3**] 12:10AM BLOOD WBC-5.4 RBC-3.10* Hgb-8.5* Hct-28.6* MCV-92 MCH-27.4 MCHC-29.7* RDW-15.8* Plt Ct-305 [**2127-1-3**] 12:10AM BLOOD Neuts-74.0* Lymphs-17.1* Monos-6.8 Eos-1.2 Baso-0.8 [**2127-1-3**] 12:10AM BLOOD Glucose-154* UreaN-40* Creat-1.1 Na-150* K-3.6 Cl-105 HCO3-34* AnGap-15 [**2127-1-3**] 12:10AM BLOOD ALT-17 AST-15 CK(CPK)-31 AlkPhos-82 TotBili-0.4 [**2127-1-3**] 12:10AM BLOOD Lipase-8 [**2127-1-3**] 12:10AM BLOOD cTropnT-<0.01 proBNP-5268* [**2127-1-3**] 12:10AM BLOOD Albumin-2.7* [**2127-1-3**] 03:33PM BLOOD Phos-1.9* Mg-2.1 UricAcd-6.9* [**2127-1-3**] 12:16AM BLOOD Type-[**Last Name (un) **] pO2-67* pCO2-44 pH-7.51* calTCO2-36* Base XS-10 -ASSIST/CON [**2127-1-3**] 06:51AM BLOOD Lactate-0.8 Discharge labs [**2127-1-7**] 02:01AM BLOOD WBC-9.1 RBC-2.72* Hgb-7.8* Hct-24.8* MCV-91 MCH-28.6 MCHC-31.4 RDW-16.0* Plt Ct-309 [**2127-1-7**] 02:01AM BLOOD Plt Ct-309 [**2127-1-7**] 02:01AM BLOOD Glucose-158* UreaN-45* Creat-1.5* Na-141 K-3.7 Cl-95* HCO3-35* AnGap-15 [**2127-1-7**] 02:01AM BLOOD Calcium-8.4 Phos-3.5 Mg-1.7 [**2127-1-7**] 02:27AM BLOOD Lactate-0.8 Studies CXR [**2127-1-3**] Cardiomegaly and pulmonary vascular congestion appears similar compared to most recent prior exam. No pleural effusion or pneumothorax is detected on this view. Tracheostomy appears to be in standard position. Right PICC tip projects over the low right atrium. IMPRESSION: 1. Persistent cardiomegaly and pulmonary vascular congestion. 2. Right PICC terminating in the right atrium. This finding was reported to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7867**] by telephone at 6:02 a.m. on [**2127-1-3**]. CT chest/abd/pelvis [**2127-1-3**] 1. Dilated loops of fluid-filled small bowel with decompressed distal ileum consistent with early or partial small bowel obstruction. The transition point is in the right lower quadrant and is likely due to adhesions. There is no bowel wall thickening, free fluid, or free air. 2. Status post gastric bypass surgery with the nasogastric tube in the jejunum. 3. Enlarged pulmonary artery consistent with patient's known pulmonary hypertension. 4. Bibasilar atelectasis. No evidence of pneumonia. 5. Tracheostomy in standard position. CT head [**2127-1-3**] 1. No evidence of acute intracranial process. 2. Mucosal thickening of paranasal sinuses with aerosolized secretion in the sphenoidal sinuses, might represent acute sinusitis in the appropriate clinical setting. [**Month/Day/Year 5283**] U/S [**2127-1-3**] Distended gallbladder with small shadowing stones. The appearance of the gallbladder is indeterminate for cholecystitis by ultrasound. No specific signs are seen; however, the patient was noted to be tender at the site of the gallbladder on real-time imaging. Consider a HIDA scan if further evaluation is needed of the gallbladder. Wrist XR [**2127-1-7**] Unchanged soft tissue swelling. No definite fractures. No dislocation. No definite erosions identified. No significant degenerative changes. Unchanged alignment. IMPRESSION: No significant interval change. CXR [**2127-1-6**] PICC line has been withdrawn to the approximate level of the superior cavoatrial junction. Lung volumes are low exaggerating mild vascular congestion which is improved, and moderate cardiomegaly and mediastinal venous engorgement which has not. No pleural effusion. Tracheostomy tube in standard placement. Feeding tube passes below the diaphragm and out of view. Brief Hospital Course: 60F w/ hx of COPD, PAH w/ cor pulmonale, right-sided CHF, CKD, s/p tracheostomy on [**12-25**] in setting of COPD exac and resp failure, who presents to ED with polyarthalgias, abdominal pain and question of abnormal VBG suggestive of hypercarbia at rehab although repeat VBG here consistent with baseline. . # Polyarthritis: Pt with pain in small joints of left hand and ankles, similar to prior gout flairs. Pts most recent flair was in [**10/2126**] treated with prednisone 40mg daily and then tapered. Prednisone 40mg PO daily was started, with minimal relief. Rheumatology was consulted and recommended solumedrol 40mg IV daily, as thought that prednisone may not be getting absorbed well. She was continued on allopurinol 300mg daily. XR of left hand was without abnormality. She was discharged to rehab on a 10 day course of solumedrol daily, with f/u with her PCP. . # partial SBO: Pt with her chronic abdominal pain and some distention which she notes since [**2116**]. CT abdomen showed partial SBO, with transition point in the RLQ. She continued to have bowel movements, and was never obstipated. Tube feeds were briefly held but then restarted. Cause of pSBO is thought to be adhesions, though she is a poor surgical candidate and as it seemed to resolve, did not pursue surgical intervention. Symptomatically treated with simethicone, zofran, and bowel regimen PO and PR. Bowel pain was resolved on discharge. . # C dif infection. Pt initially with abd pain and had pSBO, then developed diffuse diarrhea, c dif positive. She was treated with flagyl for a 10 day total course, and diarrhea resolved. . # Pseudomonas growing from trach culture : by the time this culture from [**1-3**] came back for pseudomonas (on [**1-8**]), she had been treated for c dif and had been afebrile, breathing at new baseline, and had no leukocytosis for several days. Thus, does not appear that she has PNA, so abx not started. She is likely colonized with pseudomonas. . # Hypernatremia: Appears to be chronic in nature, discharged with Na 148 (range: 146-150), 150 on admission. Most likely [**1-30**] poor access to water and volume depletion. Resolved with free water boluses per dopoff when taking POs. . # COPD/OSA s/p tracheostomy: Pt with COPD, requiring tracheostomy for resp failure in [**11/2126**] and readmission [**12/2125**] for trach mafunctioning requiring replacement of trach. Also with known OSA and right sided heart failure. She was continued on PSV at night through trach, and on trach mask during the day. Also continued on ipratropium, albuterol, and fluticasone. . # Cor pulmonale/right sided heart failure: TTE in [**2123**] showed estimated right atrial pressure of [**10-18**] mmHg; LV systolic function was hyperdynamic (EF 70-80%), and the RV free wall was hypertrophied with marked dilation and with depressed free wall contractility consistent with severe right-sided dysfunction with cor pulmonale resulting from severe pulmonary HTN and OSA. She was continued on home diruetics of torsemide 40mg daily and [**Hospital1 **] metolazone . # Acute kidney injury: baseline cr around 1.0, was 1.4 during most of admission. Urine lytes suggested she was dry, though her respiratory status is very tenuous and we were hesitant to pull back her home dose of diuretics. She may benefit from discontinuation of metalozone, though this should be done in setting of long-term follow up given the potential for her respiratory status to decline. . # Pumonary artery hypertension: Type III [**1-30**] chronic hypoxemia from obstructive sleep apnea and COPD. Sildenafil had been dc'd in [**11/2126**] with no noted significant changes. . # Iron deficiency anemia: Chronic. Hct 28 on admission, in mid 20's during admission. At baseline. Continued iron supplementation. . # DM2: Has not required long acting in the past, gave ISS while in house. . ======================= Transitional issues # Pt sent out on methylprednisolone 40mg IV daily for 10 days. She will see her PCP ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3029**]) on [**2127-1-14**], and response to steroids and need for taper can be assessed at that time. # F/u kidney function at PCP visit, consider going down on or holding metolazone Medications on Admission: 1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Date Range **]: 1-2 puffs Inhalation every four (4) hours. 2. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler [**Date Range **]: 1-2 puffs Inhalation every six (6) hours. 3. fluticasone 110 mcg/Actuation Aerosol [**Date Range **]: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO once a day as needed for constipation. 5. allopurinol 100 mg Tablet [**Hospital1 **]: Three (3) Tablet PO DAILY (Daily). 6. metolazone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day. 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1) Capsule, Delayed Release(E.C.) PO once a day. 8. torsemide 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO twice a day. 9. Roxicet 5-325 mg/5 mL Solution [**Hospital1 **]: [**5-8**] ml PO every six (6) hours as needed for pain. Disp:*400 ml* Refills:*0* 10. simethicone 40 mg/0.6 mL Drops, Suspension [**Month/Year (2) **]: Eighty (80) mg PO four times a day as needed for indigestion. 11. phenobarb-hyoscy-atropine-scop 16.2-0.1037 -0.0194 mg/5 mL Elixir [**Month/Year (2) **]: Five (5) ml PO three times a day. 12. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid [**Month/Year (2) **]: Five (5) ml PO once a day. 13. Miralax 17 gram/dose Powder [**Month/Year (2) **]: Seventeen (17) grams PO once a day. 14. Insulin Per insulin sliding scale worksheet. 15. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. Discharge Medications: 1. metolazone 5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a day). 2. torsemide 20 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO BID (2 times a day). 3. allopurinol 300 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 4. methylprednisolone sodium succ 40 mg Recon Soln [**Month/Year (2) **]: One (1) Recon Soln Injection Q24H (every 24 hours) for 9 days. 5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Month/Year (2) **]: Two (2) puffs Inhalation every four (4) hours. 6. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler [**Month/Year (2) **]: [**12-30**] Inhalation every six (6) hours. 7. fluticasone 110 mcg/Actuation Aerosol [**Month/Day (2) **]: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 8. bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 9. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 10. oxycodone-acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 MLs PO Q6H (every 6 hours) as needed for pain. 11. simethicone 80 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable PO QID (4 times a day) as needed for indigestion/abdominal pain. 12. insulin lispro 100 unit/mL Solution [**Last Name (STitle) **]: . . Subcutaneous ASDIR (AS DIRECTED): per sliding scale. 13. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid [**Last Name (STitle) **]: One (1) PO DAILY (Daily). 14. polyethylene glycol 3350 17 gram/dose Powder [**Last Name (STitle) **]: One (1) PO DAILY (Daily). 15. heparin (porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1) Injection TID (3 times a day). 16. ondansetron HCl (PF) 4 mg/2 mL Solution [**Last Name (STitle) **]: One (1) Injection Q8H (every 8 hours) as needed for nausea, vomiting. 17. metronidazole 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q8H (every 8 hours) for 7 days. Tablet(s) 18. Respiratory support Mechanical Ventilation: CPAP w/ & w/o PS Pressure support level: 15-20 cm/h2o PEEP: 5 cm/h2o FIO2: 30 % PSV as needed for increased work of breathing/hypoventilation when sleeping. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: partial small bowel obstruction; c dif infection; pulmonary hypertension; obesity hypoventilation syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Dear Ms [**Known lastname **], It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted for abdominal pain and concern for respiratory distress. You were found to have a partial small bowel obstruction, and you were treated medically for this. Your respiratory status was found to be at baseline, and no major new interventions were made. You were also found to have an intestinal infection called "C dif", and for this you will take antibiotics. The following changes were made to your medications ** START FLAGYL (antibiotic) 3 times daily for 8 more days Please follow up with your doctors [**Name5 (PTitle) **] the [**Name5 (PTitle) 648**] section below. Appointments have been made for you. Followup Instructions: Department: [**Hospital3 249**] When: TUESDAY [**2127-1-14**] at 10:20 AM With: [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: RHEUMATOLOGY When: MONDAY [**2127-1-27**] at 4:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 34216**], MD [**Telephone/Fax (1) 2226**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: [**Hospital Ward Name 706**] When: MONDAY [**2127-2-3**] at 9:50 AM With: [**Year (4 digits) 706**] [**Telephone/Fax (1) 327**] Building: [**Hospital6 29**] [**Location (un) 861**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital Ward Name 706**] When: MONDAY [**2127-2-3**] at 10:30 AM With: [**Year (4 digits) 706**] [**Telephone/Fax (1) 327**] Building: [**Hospital6 29**] [**Location (un) 861**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "278.01", "403.90", "428.0", "695.3", "327.23", "799.02", "008.45", "416.8", "V44.0", "493.20", "584.9", "280.9", "V45.86", "560.81", "250.00", "599.0", "V46.11", "428.32", "274.01", "278.03", "276.0", "715.36", "585.4", "V85.43" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.71" ]

icd9pcs

[ [ [] ] ]

17022, 17094

8832, 13071

386, 393

17245, 17245

5269, 8809

18235, 19598

3488, 3640

14760, 16999

17115, 17224

13097, 14737

17490, 18212

3655, 5250

277, 348

421, 2398

17370, 17466

2420, 3215

3231, 3472

19,491

193,697

28676

Discharge summary

report

Admission Date: [**2186-7-23**] Discharge Date: [**2186-7-27**] Date of Birth: [**2112-9-16**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2932**] Chief Complaint: Planned admission for interventional pulmonary intervention Major Surgical or Invasive Procedure: R mainstem bronchus stent placement Bronchoscopy X 2 History of Present Illness: 73 year old male initially presented in [**Month (only) 958**] with weight loss and difficulty swallowing food. Patient was found to have a mediatinal mass which was biopsied and came back as B cell lymphoma. Pt had PEG tube placed secondary to dysphagia and now takes almost all of his nutrition via PEG. He was treated with chemotherapy with a combination of mitoxantrone, vincristine, cyclophosphamide, cortical steroids, and Rituxan and following three treatments he transferred his care to the Cancer Center with Dr. [**Last Name (STitle) 69369**]. He has subsequently completed 6 full cycles of chemotherapy and is now being considered for XRT. His last dose of chemotherapy was one month prior to admission at [**Hospital3 25354**]. Despite the chemotherapy, the mediastinal mass has not improved and it was felt that perhaps the area could be rebiopsied to confirm diagnosis (as first biopsy done in [**State 108**]). . The patient has had intermittent episodes of dull chest pain in varied locations across his chest, radiating to his back when it is particularly severe, which became notably worse this past Friday. No diaphoresis, radiation to jaw or arms, or nausea associated with the chest pain. He also has frequent episodes of nausea, with vomiting on an almost daily basis. Otherwise he feels well. Denies any cough or cold symptoms except for some very mild intermittent rhinorrhea, no fevers or cough; denies hematemesis, hemoptysis, BRBPR, melana, or hematuria. He was admitted to [**Hospital1 18**] on [**7-23**] for planned IP stent given patient's increasing difficulty with breathing. He had the stent placed on [**7-24**] and he reports his breathing feels much improved. Past Medical History: HTN hypercholesterolemia 3.4 cm infrarenal AAA (pt denies this dx, will investigate) s/p clean cath in [**2183**] constipation s/p Peg placement in [**2186-3-4**] Social History: 1+ PPD/50 years but stopped in [**3-9**], hx of asbestos exposure (X 2 months) Family History: Father died from a stroke secondary to a brain aneurysm; mother unknown CA; no hx of lung disease Physical Exam: 97.3F Tmax 97.7F HR 98 (79-99) BP 104/71 (91-122/12-71) RR 24 96/RA GEN: elderly man in NAD HEENT: PERRLA, EOMI with + 3 beats R horizontal nystagmus, thick white coat on tongue and back of oropharynx CV: RRR, s1 s2 normal, no m/g/r Lungs: decreased breath sounds on the L compared to the R, Abdomen: soft, NT, ND, + BS Ext: + 1 distal pulses, no edema Neuro: alert, oriented, CN grossly intact Pertinent Results: [**2186-7-23**] 05:29PM GLUCOSE-191* UREA N-9 CREAT-0.5 SODIUM-137 POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-23 ANION GAP-15 [**2186-7-23**] 05:29PM CK(CPK)-15* [**2186-7-23**] 05:29PM CK-MB-NotDone cTropnT-<0.01 [**2186-7-23**] 05:29PM CALCIUM-9.6 PHOSPHATE-3.1 MAGNESIUM-1.9 [**2186-7-23**] 05:29PM WBC-8.3 RBC-3.70* HGB-11.1* HCT-32.9* MCV-89 MCH-30.1 MCHC-33.9 RDW-19.2* [**2186-7-23**] 05:29PM PLT COUNT-307 [**2186-7-23**] 05:29PM PT-12.6 PTT-23.7 INR(PT)-1.1 [**7-23**] CT trachea: Large retrotracheal mediastinal mass compressing the right pulmonary artery, encasing the central left pulmonary veins and aorta, producing a high-grade stenosis in the left main bronchus and occulusion of the esophagus. Mild atelectasis in the left lower lobe. Small non-hemorrhagic left pleural effusion. Coronary calcifications. Right adrenal myolipoma [**7-23**] ECG Sinus rhythm Low QRS voltages in limb leads Left atrial abnormality No previous tracing available for comparison [**7-27**] Biopsy of L mainstem mass FNA, Left Main Stem Mass: Atypical lymphocytes suspicious for lymphoma. [**7-30**] FLOW CYTOMETRY REPORT : B cells demonstrate a monoclonal Kappa light chain restricted population. They co-express pan-B cell markers CD19 (dim), 20 (dim), 22 along with CD10 (dim) FMC-7 (subset), HLA-DR. [**Last Name (STitle) 20282**] do not express any other characteristic antigens including CD5. T cells express mature lineage antigens. Immunophenotypic findings consistent with involvement by CD19+(dim)/CD20+(dim)/CD10+(dim), CD5 negative, monoclonal kappa (dim) B cell lymphoma. Brief Hospital Course: 73 y.o. man with hx of HTN, hyperlipidemia, infrarenal AAA, and posterior mediastinal mass with prior biopsy consistent with non-Hodgkin's B cell lymphoma who presented to [**Hospital 189**] Hospital for repeat biopsy, at which time he became acutely short of breath and was transferred to [**Hospital1 18**] for a bronchial stent. 1) Mediastinal Mass: The patient has a large posterior mediastinal mass obstructing esophagus and now compressing bronchi and pulmonary vasculature. This was diagnosed as Non-Hodgkin's B cell lymphoma at outside hospital ([**State 108**]). The patient is now s/p chemotherapy with no radiographic improvement. Following admission, he underwent a left mainstem stent by the interventional pulmonary service on [**7-24**]; repeat bronchoscopy on [**7-27**] showed that the stent was patent and there was no need for a right mainstem stent. The pathology was consistent with lymphoma (see attached report). He will follow-up with Dr. [**Last Name (STitle) **] for a repeat bronchoscopy and possible stent removal. At time of discharge, Mr. [**Known lastname 53636**]; he was provided with home oxygen for ambulation (given oxygen saturation 90% with ambulation). The patient will follow-up with his primary oncologist Dr. [**Last Name (STitle) 69369**] and is scheduled for outpatient radiation therapy (starting Monday [**2186-7-28**]). 2) Relative hypotension: The patient's blood pressures remained in the low 100s, possibly due to poor intake due to nausea or IVC compression from mediastinal mass. His amlodipne was held throughout his hospital course. His blood pressure should be closely monitored as an outpatient, as his PCP may need to restart anti-hypertensive agents. follow-up for his need to re-start. 3) Code: DNR/DNI Medications on Admission: Norvasc 10 QD Allopurinol 300 mg QD Senokot 2 tabs Q AM Ativan PRN Discharge Medications: 1. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day). Disp:*40 Troche(s)* Refills:*0* 3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed for chest/back pain. Disp:*100 ML(s)* Refills:*0* 4. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). Disp:*30 unit* Refills:*2* 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). Disp:*120 nebs* Refills:*0* 6. Ativan 1 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for anxiety/nausea. Disp:*30 Tablet(s)* Refills:*0* 7. Compazine 5 mg/5 mL Syrup Sig: [**4-12**] mL PO q 6 hours prn as needed for nausea. Disp:*100 mL* Refills:*0* 8. Nebulizer machine For ipratropiun nebs 9. Oxygen 2L NC, continuous Discharge Disposition: Home With Service Facility: [**Location (un) **] Nursing Services Discharge Diagnosis: Primary: Non-Hodgkins Lymphoma Secondary: bronchial obstruction, hypoxemia, hypertension Discharge Condition: Hemodynamically stable. Discharge Instructions: Please take all medications as instructed. Several changes were made to your medication regimen. Please note changes on your medication list. If you experience any nausea, vomiting, lightheadedness, chest pain, shortness of breath, or any other concerning symptoms please seek medical attention immediately. Followup Instructions: Please Call the [**Hospital6 204**] Cancer Center tomorrow to confirm your appointment with radiation oncology on Monday, [**2186-7-27**]. Tel. ([**Telephone/Fax (1) 69370**]. Please follow-up with Dr. [**Last Name (STitle) 3450**] within the next week. Tel ([**Telephone/Fax (1) 69371**]. Please follow-up with Dr. [**Last Name (STitle) **] as scheduled for a repeat bronchoscopy. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]

[ "799.02", "491.20", "519.1", "458.8", "V15.84", "787.2", "530.3", "200.00", "285.22", "401.9", "272.4", "787.02" ]

icd9cm

[ [ [] ] ]

[ "33.23", "96.05", "96.6", "33.24", "32.01" ]

icd9pcs

[ [ [] ] ]

7393, 7461

4611, 6379

375, 430

7594, 7620

2994, 4588

7980, 8489

2459, 2558

6497, 7370

7482, 7573

6405, 6474

7644, 7957

2573, 2975

276, 337

458, 2160

2182, 2346

2362, 2443

68,564

114,248

39584

Discharge summary

report

Admission Date: [**2120-5-7**] Discharge Date: [**2120-5-10**] Date of Birth: [**2057-11-21**] Sex: F Service: NEUROSURGERY Allergies: Sulfa (Sulfonamide Antibiotics) / Prochlorperazine / IV Dye, Iodine Containing Contrast Media Attending:[**First Name3 (LF) 78**] Chief Complaint: elective admission for stent assisted coiling of acomm aneurysm Major Surgical or Invasive Procedure: [**2120-5-7**] / stent assisted coiling of ACOMM aneurysm History of Present Illness: 61 year old white female presents for completion of coiling with stent assist, after ruptured acomm aneurysm in [**2119-7-26**]. Past Medical History: Osteoporosis Subarachnoid Hemorrhage [**12-27**] Acomm aneurysm rupture Respiratory Failure Cardiac arrythmias Myocardial infarction Pulmonary edema Protien/Calorie malnutrition Coma Hydrocephalus-transient Drug rash / source not identified on hospitalization of [**2119-7-26**] Anemia requiring transfusion DYSPHAGIA LEFT HEMIPARESIE UTI Social History: Married, worked as a hair dresser, three children Family History: NC Physical Exam: Pt presents awake alert oriented x 3, essentially non focal exam except for some short term memory difficulty. Upon discharge: AOx3, MAE, nonfocal exam, times of confusion with short term memory Pertinent Results: Brief Hospital Course: Pt was admitted through same day admission for elective completion of coiling of Acomm aneurysm / stent assisted. Pt underwent the procedure without difficulty and awoke from anesthesia. She was recovered in the NICU overnight, patient developed a diffused rash, she was given Benadryl. The rash worsened overnight and she became hypotensive. She was started on Neo. Her Heparin gtt was shut off as a precaution early [**5-8**]. She was started on ASA and Plavix. Her exam remained intact and she was asymptomatic from the hypotension. Dermatology was consulted and they recommended Allergy to consult. Allergy initially asked for Decadron 4mg Q6 hrs for 48 hrs, a H2 blocker, and Benadryl. On [**5-9**], there was significant improvement in patient's allergic reaction. She is to continue decardon 4mg q8 IV until tomorrow. On examination, patient remains intact. Urinanalysis and cultures were sent for foul smelling urine, UA was negative. On [**5-10**], she was discharged home with ASA and Plavix x 1 month. She will continue Pepcid/Decadron/Benadryl for one more day with PO dosing. Medications on Admission: Metoprolol Tartrate 25 mg PO BID Calcium Carbonate 500 mg PO BID Vitamin D 400 UNIT PO DAILY Plavix 75 mg PO DAILY Discharge Medications: 1. acetaminophen 325 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain fever. 2. docusate sodium 100 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO BID (2 times a day). 3. oxycodone-acetaminophen 5-325 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q4H (every 4 hours) as needed for pain . Disp:*20 Tablet(s)* Refills:*0* 4. clopidogrel 75 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. metoprolol tartrate 25 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a day). 6. aspirin 325 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. diphenhydramine HCl 25 mg Capsule [**Month/Year (2) **]: Two (2) Capsule PO Q6H (every 6 hours) as needed for pruritis for 1 days. Disp:*10 Capsule(s)* Refills:*0* 8. famotidine 20 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a day) for 1 days. Disp:*2 Tablet(s)* Refills:*0* 9. dexamethasone 4 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO every eight (8) hours for 1 days. Disp:*3 Tablet(s)* Refills:*0* 10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable [**Month/Year (2) **]: One (1) Tablet, Chewable PO BID (2 times a day). 11. cholecalciferol (vitamin D3) 400 unit Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 12. hydrocortisone 2.5 % Cream [**Month/Year (2) **]: One (1) APPL Topical QID PRN as needed for itching: APPLY TO BODY. Disp:*1 TUBE* Refills:*3* 13. hydrocortisone 1 % Lotion [**Month/Year (2) **]: One (1) APPL Topical four times a day as needed for itching: APPLY TO FACE. Disp:*1 TUBE* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: ACOMM ANEURYSM Diffused allergic rash Hypotension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Angiogram with Embolization and/or Stent placement Medications: ?????? Take Aspirin 325mg (enteric coated) once daily. ?????? Take Plavix (Clopidogrel) 75mg once daily. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs. ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). ?????? After 1 week, you may resume sexual activity. ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate. ?????? No driving until you are no longer taking pain medications What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site *SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call our office. If bleeding does not stop, call 911 for transfer to closest Emergency Room! ******* YOU ARE ALLERGIC TO CONTRAST DYE, AND WILL REQUIRE PRE-MEDICATION FOR ALL FUTURE IMAGING OR PROCEDURES THAT REQUIRE DYE. ***** Followup Instructions: PLEASE CALL THE OFFICE TO BE SEE BY DR [**First Name (STitle) **] IN 4 WEEKS WITH MRA OF THE BRAIN WITH DR. [**First Name (STitle) **] PROTOCOL AT [**Telephone/Fax (1) **] Completed by:[**2120-5-10**]

[ "437.3", "733.00", "693.0", "E947.8", "458.29", "E849.7" ]

icd9cm

[ [ [] ] ]

[ "39.76", "88.41" ]

icd9pcs

[ [ [] ] ]

4305, 4311

1344, 2440

420, 480

4405, 4405

1321, 1321

6704, 6907

1085, 1089

2605, 4282

4332, 4384

2466, 2582

4556, 5626

5652, 6681

1104, 1216

317, 382

1232, 1301

508, 638

4420, 4532

660, 1001

1017, 1069

76,333

188,704

40769

Discharge summary

report

Admission Date: [**2178-3-25**] Discharge Date: [**2178-4-4**] Date of Birth: [**2108-11-29**] Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3190**] Chief Complaint: Bilateral leg weakness Major Surgical or Invasive Procedure: 1. Posterior thoracolumbar fusion with instrumentation and tumor debulking T3-L2 2. C6 corpectomy with ACDF C4-7 3. C4-7 posterior decompression and fusion with instrumentation History of Present Illness: The pt is a 69M with a 1 week h/o progressive leg weakness who was found to have metastatic disease to his spine. This weakness occured after a one month h/o midline back pain with posterior leg numbness. He initially presented to [**Hospital3 **] ED where an MRI showed a T11 compression fx with cord impingement as well as multi-level (cervical and thoracic) spinal cord masses with spinal cord narrowing and cord compression. Of note he also passed blood clots in urine on the day prior to admission, but denies fecal incontinece. Past Medical History: - h/o back injury in [**2171**] - residual foot drop - cataracts - seasonal allergies - prostatic disease (difficulty urinating, but no h/o prostate exam, had enlarged prostate on MRI in [**2171**]) - elevated PSA here Social History: Lives in [**Hospital1 8**] with his wife. Retired operating engineer at [**University/College **]. 2 kids. Non-smoker, occasional EtOH. No other drugs. Family History: Father died of bladder cancer at age 82. Mother died of dementia at age 89. Sister with asthma. Kids healthy. Physical Exam: VS: 98.2 115/67 84 20 98%RA GENERAL: Well-appearing man wearing C-collar in NAD, comfortable and appropriate. HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear. NECK: Limited exam due to C-collar. HEART: RRR, no MRG, nl S1-S2. LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored. ABDOMEN: Soft, nontender, no rebound/guarding. EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses. SKIN: Large abrasion on anterior aspect of right calf with ecchymoses LYMPH: Small right sided inguinal lymphadenopathy, none on left or in axilla. NEURO: Awake, A&Ox3, CNs II-XII intact. 5/5 strength in RUE except for triceps 4+/5 LUE more weak compared to right with 4+/5 throughout. 3-/5 strength in BLE flexors with inability to lift leg off the bed. Some ability to dorsiflex right foot. Reflexes symmetric but hyporeflexic in BUE, hyporeflexic bilateral LEs. Numbness in 1st and 2nd digits of left hand. Also numbness on BLE from thighs downward, with most notable numbness over medial aspect of left calf and lateral aspect of left thigh. Pertinent Results: [**2178-4-3**] 06:15AM BLOOD WBC-10.2 RBC-3.88* Hgb-11.8* Hct-34.1* MCV-88 MCH-30.3 MCHC-34.5 RDW-14.6 Plt Ct-272 [**2178-4-2**] 06:00AM BLOOD WBC-8.9 RBC-4.00* Hgb-11.9* Hct-35.2* MCV-88 MCH-29.6 MCHC-33.7 RDW-14.8 Plt Ct-228 [**2178-3-31**] 06:20AM BLOOD WBC-6.3 RBC-3.52* Hgb-10.8* Hct-31.1* MCV-88 MCH-30.5 MCHC-34.6 RDW-14.5 Plt Ct-211 [**2178-3-29**] 05:20AM BLOOD WBC-6.2 RBC-3.17* Hgb-9.9* Hct-28.2* MCV-89 MCH-31.2 MCHC-35.1* RDW-14.6 Plt Ct-148* [**2178-3-27**] 02:51PM BLOOD WBC-8.9 RBC-3.61* Hgb-11.4* Hct-31.1* MCV-86 MCH-31.5 MCHC-36.5* RDW-15.1 Plt Ct-123* [**2178-3-26**] 02:16AM BLOOD WBC-6.6 RBC-2.97* Hgb-9.4* Hct-24.9* MCV-84 MCH-31.6 MCHC-37.6* RDW-14.7 Plt Ct-102* [**2178-4-3**] 06:15AM BLOOD Glucose-116* UreaN-17 Creat-0.6 Na-134 K-3.9 Cl-96 HCO3-29 AnGap-13 [**2178-4-1**] 04:54PM BLOOD Glucose-114* UreaN-23* Creat-0.7 Na-138 K-4.3 Cl-106 HCO3-26 AnGap-10 [**2178-3-29**] 05:20AM BLOOD Glucose-90 UreaN-20 Creat-0.7 Na-140 K-3.9 Cl-106 HCO3-28 AnGap-10 [**2178-3-27**] 02:12AM BLOOD Glucose-114* UreaN-19 Creat-0.7 Na-144 K-3.7 Cl-107 HCO3-32 AnGap-9 [**2178-4-2**] 06:00AM BLOOD Calcium-8.2* Phos-3.4 Mg-1.9 [**2178-3-28**] 02:52AM BLOOD Calcium-8.4 Phos-2.1* Mg-1.9 [**2178-3-26**] 02:16AM BLOOD Calcium-8.9 Phos-4.3# Mg-2.3 CT C spine [**2178-3-25**]: 1. Destructive lesion involving the C5, C6 vertebral bodies and posterior elements, with epidural extension at C6 level, causing mild spinal canal narrowing at that level. The above findings are concerning for metastatic disease. 2. No pathologic fracture is identified. NOTE ADDED IN ATTENDING REVIEW: As on the virtually-concurrent (and technically adequate) enhanced MR is extensive replacement of the left lateral aspect of both the C5 and C6 vertebral bodies and their left and bilateral posterior elements, respectively, including the spinous processes and interspinous region. Extensive associated parosseous soft tissue component completely occupies the left neural foramina at these levels, likely encroaching upon the exiting left C6, C7 and likely, C8 nerve roots. Significanly better-demonstrated on the MR study is contiguous involvement of the left dorsolateral epidural space at the C6 level, with displacement and some compression of the spinal cord. Finally, there is relatively well-defined luceny involving the left paramedian and central aspect of the base of dens and body of C2, with apparent focal cortical discontinuity, dorsally, but no pathologic fracture. However, there is no convincing signal or enhancement abnormality on the MR study to specifically confirm similar marrow replacement, and this may simply represent asymmetric fat. CXR [**2178-3-25**]: There is mild elevation of the left hemidiaphragm. Otherwise normal lung volumes. No evidence of pleural effusions. Borderline size of the cardiac silhouette. The lung parenchyma appears normal, there are no nodules or masses. The mediastinal contours appear unremarkable. The right hilus is minimally enlarged as compared to the left side. Given the clinical presentation of the patient CT of the thorax should be considered. No evidence of osteodestructive lesions. MRI C/T/L spine [**2178-3-25**]: Multifocal bone destruction, presumably representing metastatic disease, as on the prompting very recent studies, most significantly including: 1. T7: Marked destruction of this vertebral body with replacement and expansion of its posterior elements, in combination with substantial epidural soft tissue component, severely narrows the spinal canal, compressing the spinal cord which demonstrates faint T2 hyperintensity, likely representing edema. 2. T11: Extensive bone destruction with central compression, but no significant angulation; slightly retropulsed dorsal cortex, in combination with epidural soft tissue, narrows the ventral canal with no frank cord compression or definite intrinsic signal abnormality. 3. C5-C6: Extensive bone destruction, particularly on the left, with large paraosseous soft tissue mass significantly encroaching upon the left neural foramina and likely exiting neural impingement, as detailed above. There is also a component involving the left lateral and dorsal aspect of the spinal canal displacing and effacing the thecal sac. There is suggestion of slight T2-hyperintensity within the central cord substance which, again, may represent edema. 4. Very small hydromyelic central canal of the spinal cord localized to the T5 level, which may relate to the severe compression at T7, as well as the presence of a focal disc herniation at the T3-4 level. Brief Hospital Course: Mr. [**Known lastname 80255**] was admitted to the [**Hospital1 18**] Spine Surgery Service on [**2178-3-25**] and taken to the Operating Room for thoracolumbar decompression and fusion T3-L3 The surgery was without complication and the patient was transferred to the PACU in a stable condition. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were given per standard protocol. Initial postop pain was controlled with a PCA. On HD#2 he returned to the operating room for a scheduled C6 corpectomy and anterior fusion C4-7. Please refer to the dictated operative note for further details. The second surgery was also without complication and the patient was transferred to the PACU in a stable condition. Postoperative HCT was low and he was transfused multipe units of PRBCs and platelets. He was kept NPO until bowel function returned then diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. He subsequently was taken back to the OR for a scheduled C4-7 posterior decompression and fusion with instrumentatiion. Foley remained in place and will be managed at rehab. He was fitted with a TLSO brace. Physical therapy was consulted for mobilization OOB to ambulate. Hospital course was otherwise unremarkable. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Medications on Admission: - probiotics, ginko, saw [**Location (un) 6485**], stinging nettle, bioflavanoid, vitamin B complex, vitamin C, calciu, magnesium, omega3 Discharge Medications: 1. bicalutamide 50 mg Tablet Sig: One (1) Tablet PO daily () as needed for Metastatic Prostate Cancer for 30 days days. 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever, pain. 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) syringe Injection [**Hospital1 **] (2 times a day). 8. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for spasm. 9. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q12H (every 12 hours). 10. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital1 **] Nursing & Therapy Center - [**Hospital3 4414**] ([**Hospital3 4414**] Rehabilitation and Nursing Center) Discharge Diagnosis: Metastic CA with tumor masses T7, T9 and C6 Prostate CA Acute post-op blood loss anemia Discharge Condition: Good Discharge Instructions: You have undergone the following operation: 1. Posterior thoracolumbar fusion with instrumentation and tumor debulking T3-L2 2. C6 corpectomy with ACDF C4-7 3. C4-7 posterior decompression and fusion with instrumentation Immediately after the operation: -Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. -Rehabilitation/ Physical Therapy: o2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. oLimit any kind of lifting. -Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. -Brace: You have been given a brace. This brace is to be worn for comfort when you are walking. You may take it off when sitting in a chair or while lying in bed. -Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. -You should resume taking your normal home medications. No NSAIDs. -You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please 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 or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: Activity: Activity: Out of bed w/ assist Thoracic lumbar spine: when OOB Cervical collar: when OOB Treatments Frequency: Please continue to inspect the incisions daily. Followup Instructions: With Dr. [**Last Name (STitle) 363**] in 10 days. Call [**Telephone/Fax (1) **] for an appointment. Completed by:[**2178-4-3**]

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icd9cm

[ [ [] ] ]

[ "80.99", "81.05", "81.03", "81.64", "03.53", "77.79", "81.62", "81.02", "84.52", "84.51" ]

icd9pcs

[ [ [] ] ]

9943, 10091

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331, 510

10223, 10230

2696, 7257

12542, 12673

1502, 1613

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116,472

37479

Discharge summary

report

Admission Date: [**2180-2-5**] Discharge Date: [**2180-2-9**] Date of Birth: [**2126-9-27**] Sex: F Service: NEUROSURGERY Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 1271**] Chief Complaint: slip and fall Major Surgical or Invasive Procedure: none History of Present Illness: 53 year old s/p slip and fall while ice skating today.Struck back of head on ice, +LOC for approximately 30 seconds.Emesis x2. CT scan at OSH found large IPH x2, transferred by [**Location (un) **] for further managment. Reports pain in the back of her head where she struck the ice, minimal headache. Denies other injuries or pain. Past Medical History: s/p appendectomy Social History: Social Hx: Lives with husband in [**Name (NI) 5169**], [**Name (NI) **]. Works as sign language translator. Occ EtOH. Denies tob/drugs. Family History: NC Physical Exam: PHYSICAL EXAM: O: T: 96.9 BP: 124/71 HR: 60 R: 16 O2Sats: 95% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs: Full Neck: Supple, c-collar in place. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Somnolent but arousable, cooperative with exam, normal affect. Orientation: Oriented to person, "St. [**Hospital **] medical center", and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2mm bilaterally. 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**]: Trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-24**] throughout. No pronator drift Sensation: Intact to light touch bilaterally. Reflexes: B T Br Pa Ac Right 2+ -------> Left 2+ -------> Toes downgoing bilaterally Pertinent Results: Labs: CBC: 12.2>12.5/38.4<267 BMP: 144/3.5/104/24/18/0.8<119 Coags: 12.4/22.7<1.0 CT head without contrast: 45x20mm right fronal IPH with approximately 8mm of subfalcine shift to left, 24x11mm left temporal IPH. Minimal effacement of basal cistern. Left occipital fracture. Brief Hospital Course: Ms. [**Known lastname 33858**] was admitted to ICU for IPH and Q1hr neuro checks. Her neurologic exam remained intact. Head CT was repeated and this was stable. She was transferred to the floor [**2180-2-7**]. She had bradycardia to 39 on IV Dilaudid. This bradycardia recurred at 50 on [**2180-2-8**] and telemetry showed 2.66 sec pause. She was asymptomatic. Cardiology was consulted. They flet that she had sinus arrythmia and no intervention was needed as long as she remained asymptomatic. On [**2180-2-9**] She was cleared by PT. She was tolerating her diet. She was neurologically stable. She was discharged to home on this date. Medications on Admission: None Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*0* 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for Pain/fever. 5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 6. Outpatient Lab Work Dilantin Level Reason: ICH Discharge Disposition: Home Discharge Diagnosis: Traumatic cerebral hemorrhage Bradycardia Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent 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 were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin prior to your injury, you should not reume taking this until see in in clinic ?????? 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. [**Last Name (STitle) 739**], 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. [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2180-2-9**]

[ "E885.9", "E003.0", "787.03", "801.12", "427.89" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

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3750, 3756

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312, 319

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3777, 3821

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259, 274

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737, 874

15,046

183,190

50745

Discharge summary

report

Admission Date: [**2190-4-24**] Discharge Date: [**2190-5-8**] Date of Birth: [**2124-2-1**] Sex: F Service: MEDICINE Allergies: Tetracyclines / Zinc Attending:[**First Name3 (LF) 898**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: PICC line placement Central line placement History of Present Illness: 66 yo F with Castleman's disease s/p splenectomy, h/o anaplastic thyroid CA, esophageal web/dysmotility s/p esophageal dilatation, and recurrent aspiration PNAs s/p PEG presents with hypoxic respiratory distress. She was brought in by her Caretaker who reports she ate candy this am despite being strictly NPO. She also reports fever and coarse breath sounds. In the ED; Initial O2 sat was 70% on RA which improved to 95% on a 50% Venti Mask. Chest CT revealed no central or segmental PE, new RLL > LLL consolidation with small right pleural effusion c/w aspiration PNA. ABG 7.36/49/70, lactate 2.1, WBC 18.8. She received Levofloxacin 500mg, Metronidazole 500mg, Vancomycin 1g, Albuterol and Ipratropium Nebs. Blood cultures sent prior to ABX. Pt is refusing intubation but according to her HCP she is a full code. She is A&Ox3. Currently she [**First Name3 (LF) **] SOB, CP, cough, belly pain, nausea, and vomiting. She reports low back and bilateral hip pain at baseline. Past Medical History: 1. Castleman's disease (unicentric) s/p splenectomy in [**2176**]. Lymph node bx revealed reactive lymph tissue; followed in Heme/Onc by Dr. [**Last Name (STitle) 410**] 2. H/O anaplastic thyroid cancer s/p radical neck dissection; age 15 3. Esophageal webs and esophageal dysmotility s/p multiple dilatations 4. Recurrent aspiration pneumonias s/p PEG (sputum with klebsiella sensitive to Meropenem, MRSA, strep pneumo, [**Last Name (STitle) **]) 5. Chronic Respiratory Disease; bronchiectasis, [**Last Name (STitle) 1570**]'s revealed Restrictive physiology, ?interstitial lung disease. On 2L home O2 at baseline 6. MRSA osteomyelitis of olecranan s/p multiple debridements 7. Bipolar d/o 8. GERD 9. ?Seizure d/o (may be in setting of hypoglycemia) 10. Hx Grave's disease 11. Osteoporosis: has broken both hips, left in [**11-7**], right with failed ORIF and redo at [**Hospital1 2025**]; s/p short gamma nail fixation of a left hip basicervical fracture [**9-7**] 12. h/o zoster 13. HTN Social History: Used to work as a social worker at the VA. Now lives at home with a home health aide 24 hrs/day. No tobacco or EtOH. Family History: NC Physical Exam: Tm 103 (rectally) Tc 100.1 BP 120/49 HR 63 RR 15 Sat 100% NRB Gen: cachetic woman lying comfortably in bed, no resp distress HENNT: dry MM, Left eye injected with discharge, anicteric Neck: no LAD, no JVD CV: RRR, nl S1S2, No M/R/G Lungs: rhoncherous breath sounds throughout, no wheezes, bibasilar crackles Abd: soft, ND, PEG C/D/I, minimal diffuse tenderness, no rebound or guarding, +BS, No HSM Ext: no edema, strong DP/PT pulses bilaterally Neuro: A&Ox3, no focal deficits Pertinent Results: CXR [**2190-4-24**]: Consolidation in the right lower lobe with effusion. CTA [**2190-4-24**]: No central or segmental PE. New RLL > LLL consolidation with small right pleural effusion c/w aspiration PNA. Phlegmons vs. masses at bilateral sternoclavicular joints are stable since [**2190-4-21**]. Brief Hospital Course: 66 yo F with Castleman's disease s/p splenectomy, h/o anaplastic thyroid CA, esophageal web/dysmotility s/p esophageal dilatation, recurrent aspiration PNAs s/p PEG presents with hypoxic respiratory distress secondary to aspiration. . Hypoxic Respiratory Failure likely secondary to aspiration PNA; likely chronic aspiration of oral secretions. CTA revealed RLL consolidation with effusion, no evidence of PE. No evidence of sepsis. The patient was continued on non-invasive positive pressure ventilation and did not require intubation. She was given vancomycin and meropenem (recent h/o pan-resistent klebsiella except to meropenem). She also recently grew stenotrophomonas from her sputum - also started on DS bactrim once a day in the ICU. Her sputum grew MRSA only, and her antibiotic regimen was adjusted to vancomycin only with good response. She remained afebrile although her white count remained elevated. As WBC started to rise again and the pt had a new episode of hypoxia with a new LLL infiltrate on CXR, Meropenem was restarted. A 14 day course should be completed. A CT of her chest did not show any evidence of loculation of the infection or empyema. . Leukocytosis: Pt was started on Meropenem and Vanco as above. MRI of joints negative for septic joint and osteomyelitis. CXR with new LLL infiltrate. Cdiff negative 3x. UA repeatedly negative. TTE without evidence of vegetation. ESR/CRP markedly elevated. CT torso without source of infection other than lung, no evidence of loculation/empyema. Possible chronic pancreatitis, but would not explain acute findings and had been present in the past. All blood cultures were negative. ID was consulted and followed the pt's course. WBC remained elevated, associated with thrombocytosis, but as the pt was afebrile and clinically stable, no further imaging such as a white blood cell scan was obtained. Also, the pt would not be a surgical candidate and therefore an occult abscess would not be pursued at this point. A 14 day course should be completed ([**5-3**] day 1). . Conjunctivitis of left eye - The patient refused to have her contact lens removed from her left eye even after being informed that the eye was infected. It was eventually removed the day after admission. She was started on vanco and erythromycin eye drops; ophthalmology recommended continuing on current treatment. Conjunctivitis resolved and treatment was discontinued. . L elbow pain/L shoulder pain: pt with erythema, and painful ROM. MRI negative for osteomyelitis and septic joint in both elbow and shoulder. Pt refused steroid injections in shoulder offered by rheumatology. SPEP was repeated and was pending. A [**Month (only) 500**] scan should be considered as an outpatient. . Acute renal failure - Pt's Cr was 1.3 initially; baseline 1.0. Likely secondary to prerenal azotemia from infection and resolved with IVF. . Hyperkalemia: Initially resolved after receiving kayexalate and aggressive bowel regimen. Then controlled on standing Kayexylate. No evidence of adrenal insufficiency. Possible increased catabolism with overwhole wasting. No evidence of acidosis/RTA. Changed tube feeds to low K boost plus. . Hypercalcemia. PTH 49, probably supressed in the context of hypercalcemia - possible high steady-state with parathyroid hyperplasia/ primary HPTH. No adrenal insufficiency. Changed tube feeds to low Calcium boost plus. Peristently elevated. As pt no surgical candidate at this point and surgery would be extremely difficult given past neck dissection, will defer Sestamibi scan and possible surgical evaluation for after discussion about code and further management with Dr. [**Last Name (STitle) 2987**]/Pulmonary/Lawyers which is going to take place by the end of [**Month (only) 116**]. A [**Month (only) 500**] scan should be considered as an outpatient. SPEP was send and was pending. . HTN - Held BB initially given current infection. Then BP started to trend up. CBB could be considered if persistently high. BB would not be a good choice as it can increase calcium as well. . Questionable Sz disorder - Continued her home dose of Lamictal. Pt at increased risk for seizure while on Meropenem. . Chronic pain - Continued Gabapentin, Fentanyl patch, lidocaine patch; pt required additional doses of oxycodone for elbow pain. . Hypothyroidism - Continued Synthroid. . Code: Full. Discussion about code and further management with Dr. [**Last Name (STitle) 2987**]/Pulmonary/Lawyers which is going to take place by the end of [**Month (only) 116**]. . Communication: Sister [**Name (NI) **] [**Name (NI) 48714**] [**Telephone/Fax (1) 105567**]; POA/HCP lawyer [**First Name8 (NamePattern2) **] [**Name (NI) 105568**] (h) [**0-0-**], (w) [**Telephone/Fax (1) 105569**]; friend [**Name (NI) 2048**] [**Name (NI) **] [**Telephone/Fax (1) 105570**] Medications on Admission: Home Meds (need to confirm with VNA in am; taken from last D/C summary from [**2-8**]): 1. Metoclopramide 10 mg PO QID 2. Senna 8.6 mg PO BID as needed. 3. Acetaminophen 325 mg 1-2 Tablets PO Q4-6H as needed. 4. Venlafaxine 37.5 mg PO BID 5. Cholecalciferol (Vitamin D3) 400 unit PO DAILY 6. Levothyroxine 100 mcg PO DAILY 7. Ipratropium Inhalation Q6H 8. Albuterol 1-2 Puffs Inhalation Q6H 9. Lidocaine 5 %(700 mg/patch) Adhesive Patch Q12H 10. Gabapentin 300 mg PO HS 11. Polysaccharide Iron Complex 150 mg PO DAILY 12. Fentanyl 75 mcg/hr Patch Q72H 13. Docusate Sodium 100 mg PO BID as needed. 14. Enoxaparin 40 mg/0.4 mL DAILY 15. Lamotrigine 100 mg PO DAILY 16. Lansoprazole 30 mg PO DAILY 17. Atenolol 25 mg PO once a day. Discharge Medications: 1. Acetaminophen 325 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 2. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Month/Year (2) **]: Two (2) Tablet PO DAILY (Daily). 3. Levothyroxine 100 mcg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 4. Ipratropium Bromide 0.02 % Solution [**Month/Year (2) **]: One (1) Inhalation Q6H (every 6 hours). 5. Albuterol Sulfate 0.083 % Solution [**Month/Year (2) **]: One (1) Inhalation Q4H (every 4 hours). 6. Gabapentin 400 mg Capsule [**Month/Year (2) **]: Two (2) Capsule PO HS (at bedtime). 7. Ferrous Sulfate 325 (65) mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 8. Fentanyl 75 mcg/hr Patch 72HR [**Month/Year (2) **]: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 9. Lamotrigine 100 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 10. Lansoprazole 30 mg Susp,Delayed Release for Recon [**Month/Year (2) **]: One (1) PO DAILY (Daily). 11. Metoclopramide 10 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Month/Year (2) **]: One (1) Adhesive Patch, Medicated Topical Q12 (). 13. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Year (2) **]: One (1) Injection TID (3 times a day). 14. Quetiapine 100 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO HS PRN (). 15. Lorazepam 0.5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO TID (3 times a day): hold for sedation. 16. Oxycodone 5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 17. Venlafaxine 37.5 mg Capsule, Sust. Release 24HR [**Month/Year (2) **]: One (1) Capsule, Sust. Release 24HR PO BID (2 times a day). 18. Alendronate 70 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO QSAT (every Saturday): stop tube feeds at least 4 hours before dose and have pt remain upright for 30 mins after dose. Wait 1 hour before restarting tube feeds. . 19. Sodium Polystyrene Sulfonate 15 g/60mL Suspension [**Month/Year (2) **]: One (1) PO DAILY (Daily). 20. Prochlorperazine Edisylate 5 mg/mL Solution [**Month/Year (2) **]: One (1) Injection Q6H (every 6 hours) as needed for nausea: hold for sedation. 21. Meropenem 500 mg Recon Soln [**Month/Year (2) **]: One (1) Recon Soln Intravenous Q6H (every 6 hours) for 7 days. 22. 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. 23. Vancomycin 500 mg Recon Soln [**Month/Year (2) **]: One (1) Recon Soln Intravenous Q 24H (Every 24 Hours). Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Aspiration pneumonia Inflammatory joint disease, no evidence of infection on MRI Hyperkalemia of unclear etiology Hypercalcemia, possible primary hyperparathyroidism HTN Conjunctivits, L sided ............................... Recurrent aspiration pneumonia, s/p PEG Castleman's disease (unicentric) s/p splenectomy in [**2176**], stable H/O anaplastic thyroid cancer s/p radical neck dissection at age 15 Esophageal webs and esophageal dysmotility s/p multiple dilatations Chronic Respiratory Disease; bronchiectasis. On 2L home O2 at BL. Discharge Condition: stable, O2 requirement back to baseline Discharge Instructions: Please tell your doctors if [**Name5 (PTitle) **] have any worsening abdominal pain, any shortness of breath, fevers, chills, worsening joint pain or any other concerns. . Please take all medications as instructed. Followup Instructions: Please follow up with your providers. You should discuss options for further care with them: Provider: [**First Name8 (NamePattern2) 2671**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1954**] Date/Time:[**2190-6-2**] 12:20 Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2190-6-14**] 1:40 Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2190-6-14**] 2:00

[ "584.9", "296.80", "750.3", "244.0", "733.00", "288.8", "276.7", "785.6", "401.9", "518.82", "275.42", "716.99", "530.81", "719.41", "V44.1", "507.0", "372.30", "494.0", "V10.87" ]

icd9cm

[ [ [] ] ]

[ "96.6", "93.90", "38.93" ]

icd9pcs

[ [ [] ] ]

11712, 11791

3384, 8214

298, 343

12373, 12414

3059, 3361

12677, 13185

2527, 2531

8994, 11689

11812, 12352

8240, 8971

12438, 12654

2546, 3040

239, 260

371, 1360

1382, 2374

2390, 2511

8,722

103,750

17495+17496

Discharge summary

report+report

Admission Date: [**2200-5-14**] Discharge Date: [**2200-5-19**] Date of Birth: [**2154-5-21**] Sex: F Service: [**Hospital Ward Name **] ICU HISTORY OF PRESENT ILLNESS: The patient is a 45 year-old female with a past medical history significant for metastatic melanoma to the lung, liver, pancreas and bone who presents from [**Hospital **] Rehab with dyspnea. She had a pleural tap one and a half weeks prior to this admission at [**Hospital3 2576**] [**Hospital3 **] when 650 cc of fluid was removed. On admission here the patient denies fever. However, she did admit to increased dyspnea over the past week. She had also been complaining of severe baseline constipation for which she uses Fleet enemas every other day. Her last bowel movement was two days ago. She stated that her abdomen yesterday was not as distended as usual. She admits to fevers, shaking chills, which started at 4:00 p.m. on the day of admission. She felt that the right side of her chest was tender to palpation and that it was difficult to take in a deep breath. The patient arrived to [**Hospital1 69**] Emergency Room on the morning of admission when she had a chest x-ray showing a large right sided pleural effusion. Her initial vital signs in the Emergency Room were temperature 99, blood pressure 104/30, heart rate 125, respiratory rate 21, oxygen saturation 95% on 6 liters nasal cannula. A pleurocentesis was performed in the Emergency Room, yielding 1000 cc of bloody fluid, with a post procedure chest x-ray showing decreased size in the effusion and no pneumothorax. The patient was then transferred to the floor on the Oncology Service for further monitoring. At about 3:30 p.m. on the day of admission the Intensive Care Unit team was called to see the patient secondary to decreased oxygen saturations. (On arrival to the floor the patient was sating 96% on 6 liters after which she proceeded to have undetectable oxygen saturations). Her blood pressure was undetectable, whereas on arrival to the floor her blood pressure is 110/62. She had increased work of breathing with shallow breaths. The patient was mentating sufficiently to answer questions. Anesthesia was called and the patient was electively intubated for airway protection. An arterial blood gas performed prior to intubation with dagging was pH 7.22, PCO2 54, oxygen saturation PAO2 465. A neo-synephrine drip was started with an increase in her blood pressure to systolic in the 70s. An echocardiogram done at the bedside prior to transfer to the unit showed right ventricular dilatation with mild to moderate right ventricular free wall hypokinesis. The patient was subsequently transferred to the [**Hospital Ward Name 332**] Intensive Care Unit for further monitoring. On transfer to the Intensive Care Unit the patient had been intubated and on a neo-synephrine drip with intravenous normal saline running wide open through a femoral line and a PICC line. The patient remained hypotensive despite titrating up the neo-synephrine to 2.45 micrograms per kilogram per minute. An arterial blood gas done after intubation on assist control with tidal volume 400, respiratory rate of 20, FIO2 of 100% was pH 7.38, PCO2 33, PAO2 410. A hematocrit done on the arterial blood gas was 18, with a repeat CBC showing a hematocrit of 14 with an INR of 1.3. Her anemia was thought to be secondary to her hemothorax given the increased effusion on her chest x-ray and recent intervention. Cardiothoracic surgery was consulted and a right sided chest tube was placed, which drain 2 liters of dark bloody fluid. The patient persisted to be hypotensive. During the initial part of her Intensive Care Unit stay she received a total of 10 units of packed red blood cells, 11 liters of intravenous normal saline. On her laboratory examinations she was noted to be slightly more coagulopathic with her INR rising from 1.3 to 1.9, PTT increasing from 27 to 35 and fibrinogen of 93 with a D-dimer greater than [**2196**]. The patient was felt to be in DIC secondary to a consumptive coagulopathy secondary to the large collection of blood in her pleural space as well as a dilutional coagulopathy secondary to intravenous fluid resuscitation with large amounts of intravenous normal saline. The patient subsequently received four bags of fresh frozen platelets and two bags of platelets. A repeat arterial blood gas after resuscitation with fluid and blood products was pH 6.96, PCO2 68, PO2 124. She was thought to have a respiratory acidosis and a dilutional anion gap metabolic acidosis secondary to large amounts of intravenous normal saline. Her ventilator settings were changed to increase her respiratory rate to 34 to allow increased ventilation after which her arterial blood gas improved to a pH of 7.1, PCO2 of 37, PO2 of 194. The patient was given two amps of sodium bicarb after which her pH increased to 7.27 and then 7.33. After receiving 10 units of packed red blood cells, her hematocrit increased to 36. Her blood pressure then improved to systolics between 120 and 140. Her peak inspiratory pressures increased to 50 with a plateau pressure of 40 and auto PEEP of 12. A bronchoscopy was performed on the day of transfer to the MICU showing some degree of airway edema, erythematous and hemorrhagic mucosa. Her systolic blood pressure subsequently increased to 200. Her sedation was subsequently increased along with her paralytics with a slight decrease in her blood pressure and peak inspiratory pressures. Lasix 20 mg intravenous was given after which the patient diuresed 1 liter and her peak inspiratory pressures decreased to 35 to 40 and her systolic blood pressure decreased to high 90s. PAST MEDICAL HISTORY: 1. Melanoma diagnosed in [**2188**]. Her melanoma was initially located on her left scapula. In [**2199-12-1**] she had hemoptysis. In [**2200-3-1**] a PET scan showed metastasis to the lung, sternum, left humerus, three lumbar vertebra, left proximal femur, liver and nodal metastasis. A chest CT performed in [**2200-3-1**] showed a region in the right hilum with associated adenopathy. On [**2200-3-19**] bronchoscopy with biopsy revealed malignant melanoma. On [**2200-3-20**] the patient was started on palliative radiation therapy to her spine. 2. L3 compression fracture. 3. Allergic rhinitis. 4. Asthma. 5. Malignant hypercalcemia treated with Pamidronate. MEDICATIONS ON ADMISSION: 1. Heparin 5000 units subq b.i.d. 2. Albuterol and Atrovent meter dose inhalers q.i.d. 3. Flovent 110 micrograms two puffs q.d. 4. Serevent 25 micrograms two puffs b.i.d. 5. Fentanyl patch 125 micrograms q 72 hours. 6. Lactulose 30 cc po q.i.d. 7. Prevacid 15 mg po q.d. 8. Levofloxacin 500 mg po q.d. 9. Reglan 10 mg intravenous q.i.d. 10. Vioxx 25 mg po q.d. 11. Morphine PCA. 12. Scopolamine patch. 13. Ambien prn. 14. Dilaudid 1 to 4 mg intravenous q 3 to 4 hours prn. 15. Oxycodone 5 to 20 mg po q 3 hours. 16. Ibuprofen 600 mg q 8 hours prn. ALLERGIES: Sulfa and Penicillin cause a rash. FAMILY HISTORY: Father had prostate cancer. Uncle had a thoracic malignancy. SOCIAL HISTORY: The patient is married and has two twin children. One son is autistic. She is a dietitian in [**Hospital1 1474**]. She denies tobacco use. PHYSICAL EXAMINATION ON TRANSFER TO THE INTENSIVE CARE UNIT: Temperature 98. Blood pressure 111/85. Heart rate 110. Respiratory rate 24. Oxygen saturation 100% on AC with tidal volume of 400, respiratory rate of 20, PEEP of 5, FIO2 of 100%. General, the patient was intubated and awake responding to questions with nodding and shaking her head. Head and neck examination pupils are equal, round and reactive to light. Sclera anicteric. Oropharynx is clear. Cardiac examination normal S1 and S2. Tachycardic. No murmurs, rubs or gallops. Lungs decreased breath sounds throughout the right lung anteriorly, left lung was clear to auscultation. Abdomen slightly tense and distended with mild left lower quadrant tenderness. There were decreased breath sounds throughout. Extremities 2+ edema bilaterally to the knees. Neurological examination full range of motion in all four extremities. LABORATORY EXAMINATIONS ON ADMISSION: White blood cell count 4, hematocrit 29.4, platelets 82, sodium 127, potassium 4.1, chloride 94, bicarbonate 23, BUN 12, creatinine 0.4, glucose 110. PT 14.1, PTT 27.1, INR 1.3, calcium 7.4, magnesium 1.5, phosphorus 1.8, erythrocyte sedimentation rate 61, ALT 95, AST 160, LD 1220, alkaline phosphatase 556, amylase 16, lipase 16, pleural fluid with 325 white blood cells, 737,500 red blood cells, 65% polys, 3% bands, 21% lymphocytes, 4.1 protein, glucose 52 and LD 805. Gram stain of pleural fluid without any polys or microorganisms. Fluid culture pending. Arterial blood gas on the above ventilator settings were pH 7.22, PCO2 54, O2 465. IMAGING: Chest x-ray on transfer to the Intensive Care Unit showing interval enlargement of right pleural effusion with only a small amount of residual aerated right lung. Endotracheal tube was at the level of the carina. There was interval improvement in aeration in the left lower lung. There were left lower lung nodules consistent with metastatic disease. Electrocardiogram showing sinus tachycardia at 120 beats per minute, normal axis and intervals, T wave flattening in 3, AVL and V2. HOSPITAL COURSE: This is a 45 year-old female with a history of metastatic melanoma to the spine, lungs, liver, pancrease, presenting with increased dyspnea from [**Hospital3 **]. She was found to have a recurrent large right pleural effusion status post pleurocentesis with removal of 2 liters of fluid about one and a half weeks ago. She is status post recurrent pleurocentesis today with removal of 1 liter of bloody fluid. The patient was found to be hemodynamically unstable several hours after her pleurocentesis with hypotension, shallow and labored breathing. A repeat chest x-ray showed increased size of her pleural effusion after her tap, a 14 point drop in her hematocrit. Her hypotension and respiratory distress were likely secondary to blood loss. The patient was also found to be increasing coagulopathic likely secondary to consumption of her coagulation factors by large collection of blood in her thorax as well as a dilutional coagulopathy secondary to resuscitation with large amounts of bicarbonate free fluid. After stabilization in the Intensive Care Unit, the patient was hemodynamically stable after chest tube placement and resuscitation with blood products and intravenous fluids. 1. Hypotension: The patient was initially hypotensive secondary to massive blood loss likely secondary to distributive shock. However, septic shock was also a contributing factor, given that the patient was immunocompromised and reported rigors and chills with fevers on admission. The patient was resuscitated with 10 units of packed red blood cells and 11 liters of intravenous normal saline. She was initially placed on a neo-synephrine drip, which was quickly titrated off and the patient subsequently never needed pressors during her Intensive Care Unit stay. She was also placed on broad spectrum antibiotics with intravenous Levaquin, Flagyl and Vancomycin to cover for the possibility of septic shock. The patient had intermittent episodes of hypotension with systolic blood pressures into the 70s, which responded well to intravenous fluid boluses. Toward the end of her Intensive Care Unit stay it was decided not to administer any more intravenous fluid boluses as the patient was becoming increasingly edematous, which was decreasing her chest wall compliance and impairing ventilation. 2. Respiratory failure: The patient was initially hypercarbic respiratory failure. She was placed on AC ventilation initially with intermittent increased CO2 levels, which corrected with increasing respiratory rate on the ventilator settings. During her hospital stay the patient was noted to have increased peak inspiratory pressures. A transesophageal balloon was transduced revealing that her increased peak inspiratory pressures were likely secondary to extrinsic compression secondary to her increased abdominal distention and decreased chest wall compliance secondary to chest wall edema from massive fluid resuscitation. Her PEEP was increased to 20 to allow for increased alveolar recruitment. On increasing her PEEP to 25 her systolic blood pressure dropped into the 60s. Therefore her positive end expiratory pressure was maintained at 20. The patient was not sent down for a CT angiogram to evaluate for a pulmonary embolism as she was deemed to be too unstable to go to the CT scanner. Her FIO2 was weaned from 100% to 40% with stable oxygenation. It was decided not to treat her with Lasix for her total body volume overload as she was felt to have leaky capillary secondary to an inflammatory response. She was allowed to autodiurese. Toward the end of her hospital stay she started stooling with decreased abdominal distention. The patient was finally tried on pressure support of 15 with a PEEP of 5 and failed. She was then changed back to assist control ventilation. On [**5-19**] the patient's ventilator alarm secondary to high pressures. Her airways were suctioned with removal of blood from her airway. She was bagged without success. Her vital signs rapidly deteriorated over the next one to two minutes. A respiratory therapist was unable to ventilate the patient. She subsequently became asystolic on monitor with no pulse. She passed away at 12:32 a.m. on [**5-19**]. 3. Renal: The patient had stable renal function with good urine output throughout her Intensive Care Unit stay. 4. Infectious disease: The patient reported fevers and chills at rehab with a bandemia on admission. She subsequently had decreased white blood cell count suggestive of sepsis versus dilutional secondary to massive fluid resuscitation. She grew out one out of two bottles positive for gram positive cocci in pairs and clusters. Possible sources for sepsis included her pleural effusion, a hidden infiltrate or pneumonia under her effusion, versus an abdominal source given her obstipation and potential feeding of bowel. An abdominal ultrasound was done, which showed no ascites. The patient was covered broadly with antibiotics with Vancomycin, Levaquin and Flagyl. She was followed closely for emerging sources of infection. Toward the end of her hospital stay she spiked high temperatures to 103 and 104. Potential sources were thought to be her left femoral line, which was removed. It was decided to not further broaden her antibiotic coverage and to follow surveillance culture results and treat accordingly. She was given Tylenol prn for her fevers. 5. Gastrointestinal: The patient had abdominal distention and tenderness on admission. She had no bowel movements in two days. An initial KUB showed a nonspecific bowel gas pattern. She could not be sent for an abdominal CT as she was thought to be too unstable. She was broadly covered with Vanco, Levo and Flagyl to cover a possible abdominal sources for sepsis. She was started on a bowel regimen and eventually started stooling toward the end of her Intensive Care Unit stay. She was placed on an nasogastric tube to suction. 6. Hematology: The patient was initial anemic secondary to blood loss and coagulopathic secondary to consumption by large amount of sequestered blood in her thorax as well as dilution secondary to massive fluid resuscitation. The decrease in her white blood cell count was also thought to be secondary to sepsis versus dilutional. The patient's hematocrit remained stable after initial resuscitation with blood products. Her coagulopathy improved, but persisted. The patient transferred her oncology care from [**Hospital1 2025**] to [**Hospital1 1444**] secondary to dissatisfaction with care. Her current oncologist was Dr. [**Last Name (STitle) **] at the [**Hospital1 1444**] who frequently came to visit the patient during her Intensive Care Unit stay. 7. Endocrine: A.M. Cortisol level was checked and was 29 ruling out adrenal insufficiency as a cause of her hypotension. 8. Fluids, electrolytes and nutrition: A Swan-Ganz catheter was placed to assess hemodynamics revealing increased pulmonary artery pressures to 50/30, pulmonary capillary wedge pressure of 22, with a cardiac output of 6 and cardiac index of 3 and SVR of 665 indicating that the patient was retaining sufficient fluid in her intravascular space, but was still demonstrating septic physiology secondary to a systemic inflammatory response. She initially had a nonanion gap metabolic acidosis, which was likely dilutional. Her acidosis subsequently improved. She was initially treated with 2 amps of sodium bicarbonate. She was also hypocalcemic initially secondary to massive resuscitation with blood products. Her electrolytes were repleted as needed. 9. Code status: The patient was initially a full code. Frequent family discussions were held with the family, and they continued to understand the grave prognosis of the patient. However, they maintained that they wanted at all times everything possible to be done for her. Furthermore they suggested that they wished for things to take their natural course as well. Toward the end of her hospital stay they decided that they did not want any pressors, CPR or defibrillation or ventilator changes. The patient passed away on [**2200-5-19**]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2691**] Dictated By:[**Name8 (MD) 2692**] MEDQUIST36 D: [**2200-9-3**] 06:30 T: [**2200-9-4**] 10:28 JOB#: [**Job Number 48850**] Admission Date: [**2200-5-14**] Discharge Date: [**2200-5-19**] Date of Birth: [**2154-5-21**] Sex: F Service: [**Hospital Ward Name **] ICU HISTORY OF PRESENT ILLNESS: The patient is a 45 year-old female with a past medical history significant for metastatic melanoma to the lung, liver, pancreas and bone who presents from [**Hospital **] Rehab with dyspnea. She had a pleural tap one and a half weeks prior to this admission at [**Hospital3 2576**] [**Hospital3 **] when 650 cc of fluid was removed. On admission here the patient denies fever. However, she did admit to increased dyspnea over the past week. She had also been complaining of severe baseline constipation for which she uses Fleet enemas every other day. Her last bowel movement was two days ago. She stated that her abdomen yesterday was not as distended as usual. She admits to fevers, shaking chills, which started at 4:00 p.m. on the day of admission. She felt that the right side of her chest was tender to palpation and that it was difficult to take in a deep breath. The patient arrived to [**Hospital1 69**] Emergency Room on the morning of admission when she had a chest x-ray showing a large right sided pleural effusion. Her initial vital signs in the Emergency Room were temperature 99, blood pressure 104/30, heart rate 125, respiratory rate 21, oxygen saturation 95% on 6 liters nasal cannula. A pleurocentesis was performed in the Emergency Room, yielding 1000 cc of bloody fluid, with a post procedure chest x-ray showing decreased size in the effusion and no pneumothorax. The patient was then transferred to the floor on the Oncology Service for further monitoring. At about 3:30 p.m. on the day of admission the Intensive Care Unit team was called to see the patient secondary to decreased oxygen saturations. (On arrival to the floor the patient was sating 96% on 6 liters after which she proceeded to have undetectable oxygen saturations). Her blood pressure was undetectable, whereas on arrival to the floor her blood pressure is 110/62. She had increased work of breathing with shallow breaths. The patient was mentating sufficiently to answer questions. Anesthesia was called and the patient was electively intubated for airway protection. An arterial blood gas performed prior to intubation with dagging was pH 7.22, PCO2 54, oxygen saturation PAO2 465. A neo-synephrine drip was started with an increase in her blood pressure to systolic in the 70s. An echocardiogram done at the bedside prior to transfer to the unit showed right ventricular dilatation with mild to moderate right ventricular free wall hypokinesis. The patient was subsequently transferred to the [**Hospital Ward Name 332**] Intensive Care Unit for further monitoring. On transfer to the Intensive Care Unit the patient had been intubated and on a neo-synephrine drip with intravenous normal saline running wide open through a femoral line and a PICC line. The patient remained hypotensive despite titrating up the neo-synephrine to 2.45 micrograms per kilogram per minute. An arterial blood gas done after intubation on assist control with tidal volume 400, respiratory rate of 20, FIO2 of 100% was pH 7.38, PCO2 33, PAO2 410. A hematocrit done on the arterial blood gas was 18, with a repeat CBC showing a hematocrit of 14 with an INR of 1.3. Her anemia was thought to be secondary to her hemothorax given the increased effusion on her chest x-ray and recent intervention. Cardiothoracic surgery was consulted and a right sided chest tube was placed, which drain 2 liters of dark bloody fluid. The patient persisted to be hypotensive. During the initial part of her Intensive Care Unit stay she received a total of 10 units of packed red blood cells, 11 liters of intravenous normal saline. On her laboratory examinations she was noted to be slightly more coagulopathic with her INR rising from 1.3 to 1.9, PTT increasing from 27 to 35 and fibrinogen of 93 with a D-dimer greater than [**2196**]. The patient was felt to be in DIC secondary to a consumptive coagulopathy secondary to ............ of her coagulation factor and the large collection of blood in her pleural space as well as a dilutional coagulopathy secondary to intravenous fluid resuscitation with large amounts of intravenous normal saline. The patient subsequently received four bags of fresh frozen platelets and two bags of platelets. A repeat arterial blood gas after resuscitation with fluid and blood products was pH 6.96, PCO2 68, PO2 124. She was thought to have a respiratory acidosis and a dilutional anion gap metabolic acidosis secondary to large amounts of intravenous normal saline. Her ventilator settings were changed to increase her respiratory rate to 34 to allow increased ventilation after which her arterial blood gas improved to a pH of 7.1, PCO2 of 37, PO2 of 194. The patient was given two amps of sodium bicarb after which her pH increased to 7.27 and then 7.33. After receiving 10 units of packed red blood cells, her hematocrit increased to 36. Her blood pressure then improved to systolics between 120 and 140. Her peak inspiratory pressures increased to 50 with a plateau pressure of 40 and auto PEEP of 12. A bronchoscopy was performed on the day of transfer to the MICU showing some degree of airway edema, erythematous and hemorrhagic mucosa. Her systolic blood pressure subsequently increased to 200. Her sedation was subsequently increased along with her paralytics with a slight decrease in her blood pressure and peak inspiratory pressures. Lasix 20 mg intravenous was given after which the patient diuresed 1 liter and her peak inspiratory pressures decreased to 35 to 40 and her systolic blood pressure decreased to high 90s. PAST MEDICAL HISTORY: 1. Melanoma diagnosed in [**2188**]. Her melanoma was initially located on her left scapula. In [**2199-12-1**] she had hemoptysis. In [**2200-3-1**] a PET scan showed metastasis to the lung, sternum, left humerus, three lumbar vertebra, left proximal femur, liver and nodal metastasis. A chest CT performed in [**2200-3-1**] showed a region in the right hilum with associated adenopathy. On [**2200-3-19**] bronchoscopy with biopsy revealed malignant melanoma. On [**2200-3-20**] the patient was started on palliative radiation therapy to her spine. 2. L3 compression fracture. 3. Allergic rhinitis. 4. Asthma. 5. Malignant hypercalcemia treated with Pamidronate. MEDICATIONS ON ADMISSION: 1. Heparin 5000 units subq b.i.d. 2. Albuterol and Atrovent meter dose inhalers q.i.d. 3. Flovent 110 micrograms two puffs q.d. 4. Serevent 25 micrograms two puffs b.i.d. 5. Fentanyl patch 125 micrograms q 72 hours. 6. Lactulose 30 cc po q.i.d. 7. Prevacid 15 mg po q.d. 8. Levofloxacin 500 mg po q.d. 9. Reglan 10 mg intravenous q.i.d. 10. Vioxx 25 mg po q.d. 11. Morphine PCA. 12. Scopolamine patch. 13. Ambien prn. 14. Dilaudid 1 to 4 mg intravenous q 3 to 4 hours prn. 15. Oxycodone 5 to 20 mg po q 3 hours. 16. Ibuprofen 600 mg q 8 hours prn. ALLERGIES: Sulfa and Penicillin cause a rash. FAMILY HISTORY: Father had prostate cancer. Uncle had a thoracic malignancy. SOCIAL HISTORY: The patient is married and has two twin children. One son is autistic. She is a dietitian in [**Hospital1 1474**]. She denies tobacco use. PHYSICAL EXAMINATION ON TRANSFER TO THE INTENSIVE CARE UNIT: Temperature 98. Blood pressure 111/85. Heart rate 110. Respiratory rate 24. Oxygen saturation 100% on AC with tidal volume of 400, respiratory rate of 20, PEEP of 5, FIO2 of 100%. General, the patient was intubated and awake responding to questions with nodding and shaking her head. Head and neck examination pupils are equal, round and reactive to light. Sclera anicteric. Oropharynx is clear. Cardiac examination normal S1 and S2. Tachycardic. No murmurs, rubs or gallops. Lungs decreased breath sounds throughout the right lung anteriorly, left lung was clear to auscultation. Abdomen slightly tense and distended with mild left lower quadrant tenderness. There were decreased breath sounds throughout. Extremities 2+ edema bilaterally to the knees. Neurological examination full range of motion in all four extremities. LABORATORY EXAMINATIONS ON ADMISSION: White blood cell count 4, hematocrit 29.4, platelets 82, sodium 127, potassium 4.1, chloride 94, bicarbonate 23, BUN 12, creatinine 0.4, glucose 110. PT 14.1, PTT 27.1, INR 1.3, calcium 7.4, magnesium 1.5, phosphorus 1.8, erythrocyte sedimentation rate 61, ALT 95, AST 160, LD 1220, alkaline phosphatase 556, amylase 16, lipase 16, pleural fluid with 325 white blood cells, 737,500 red blood cells, 65% polys, 3% bands, 21% lymphocytes, 4.1 protein, glucose 52 and LD 805. Gram stain of pleural fluid without any polys or microorganisms. Fluid culture pending. Arterial blood gas on the above ventilator settings were pH 7.22, PCO2 54, O2 465. IMAGING: Chest x-ray on transfer to the Intensive Care Unit showing interval enlargement of right pleural effusion with only a small amount of residual aerated right lung. Endotracheal tube was at the level of the carina. There was interval improvement in aeration in the left lower lung. There were left lower lung nodules consistent with metastatic disease. Electrocardiogram showing sinus tachycardia at 120 beats per minute, normal axis and intervals, T wave flattening in 3, AVL and V2. HOSPITAL COURSE: This is a 45 year-old female with a history of metastatic melanoma to the spine, lungs, liver, pancrease, presenting with increased dyspnea from [**Hospital3 **]. She was found to have a recurrent large right pleural effusion status post pleurocentesis with removal of 2 liters of fluid about one and a half weeks ago. She is status post recurrent pleurocentesis today with removal of 1 liter of bloody fluid. The patient was found to be hemodynamically unstable several hours after her pleurocentesis with hypotension, shallow and labored breathing. A repeat chest x-ray showed increased size of her pleural effusion after her tap, a 14 point drop in her hematocrit. Her hypotension and respiratory distress were likely secondary to blood loss and hemothorax as a complication of her procedure. The patient was also found to be increasing coagulopathic likely secondary to consumption of her coagulation factors by large collection of blood in her thorax as well as a dilutional coagulopathy secondary to resuscitation with large amounts of bicarbonate free fluid. After stabilization in the Intensive Care Unit, the patient was hemodynamically stable after chest tube placement and resuscitation with blood products and intravenous fluids. 1. Hypotension: The patient was initially hypotensive secondary to massive blood loss likely secondary to distributive shock. However, septic shock was also a contributing factor, given that the patient was immunocompromised and reported rigors and chills with fevers on admission. The patient was resuscitated with 10 units of packed red blood cells and 11 liters of intravenous normal saline. She was initially placed on a neo-synephrine drip, which was quickly titrated off and the patient subsequently never needed pressors during her Intensive Care Unit stay. She was also placed on broad spectrum antibiotics with intravenous Levaquin, Flagyl and Vancomycin to cover for the possibility of septic shock. The patient had intermittent episodes of hypotension with systolic blood pressures into the 70s, which responded well to intravenous fluid boluses. Toward the end of her Intensive Care Unit stay it was decided not to administer any more intravenous fluid boluses as the patient was becoming increasingly edematous, which was decreasing her chest wall compliance and impairing ventilation. 2. Respiratory failure: The patient was initially hypercarbic respiratory failure. She was placed on AC ventilation initially with intermittent increased CO2 levels, which corrected with increasing respiratory rate on the ventilator settings. During her hospital stay the patient was noted to have increased peak inspiratory pressures. A transesophageal balloon was transduced revealing that her increased peak inspiratory pressures were likely secondary to extrinsic compression secondary to her increased abdominal distention and decreased chest wall compliance secondary to chest wall edema from massive fluid resuscitation. Her PEEP was increased to 20 to allow for increased alveolar recruitment. On increasing her PEEP to 25 her systolic blood pressure dropped into the 60s. Therefore her positive end expiratory pressure was maintained at 20. The patient was not sent down for a CT angiogram to evaluate for a pulmonary embolism as she was deemed to be too unstable to go to the CT scanner. Her FIO2 was weaned from 100% to 40% with stable oxygenation. It was decided not to treat her with Lasix for her total body volume overload as she was felt to have leaky capillary secondary to an inflammatory response. She was allowed to autodiurese. Toward the end of her hospital stay she started stooling with decreased abdominal distention. The patient was finally tried on pressure support of 15 with a PEEP of 5 and failed. She was then changed back to assist control ventilation. On [**5-19**] the patient's ventilator alarm secondary to high pressures. Her airways were suctioned with removal of blood from her airway. She was bagged without success. Her vital signs rapidly deteriorated over the next one to two minutes. A respiratory therapist was unable to ventilate the patient. She subsequently became asystolic on monitor with no pulse. She passed away at 12:32 a.m. on [**5-19**]. 3. Renal: The patient had stable renal function with good urine output throughout her Intensive Care Unit stay. 4. Infectious disease: The patient reported fevers and chills at rehab with a bandemia on admission. She subsequently had decreased white blood cell count suggestive of sepsis versus dilutional secondary to massive fluid resuscitation. She grew out one out of two bottles positive for gram positive cocci in pairs and clusters. Possible sources for sepsis included her pleural effusion, a hidden infiltrate or pneumonia under her effusion, versus an abdominal source given her obstipation and potential feeding of bowel. An abdominal ultrasound was done, which showed no ascites. The patient was covered broadly with antibiotics with Vancomycin, Levaquin and Flagyl. She was followed closely for emerging sources of infection. Toward the end of her hospital stay she spiked high temperatures to 103 and 104. Potential sources were thought to be her left femoral line, which was removed. It was decided to not further broaden her antibiotic coverage and to follow surveillance culture results and treat accordingly. She was given Tylenol prn for her fevers. 5. Gastrointestinal: The patient had abdominal distention and tenderness on admission. She had no bowel movements in two days. An initial KUB showed a nonspecific bowel gas pattern. She could not be sent for an abdominal CT as she was thought to be too unstable. She was broadly covered with Vanco, Levo and Flagyl to cover a possible abdominal sources for sepsis. She was started on a bowel regimen and eventually started stooling toward the end of her Intensive Care Unit stay. She was placed on an nasogastric tube to suction. 6. Hematology: The patient was initial anemic secondary to blood loss and coagulopathic secondary to consumption by large amount of sequestered blood in her thorax as well as dilution secondary to massive fluid resuscitation. The decrease in her white blood cell count was also thought to be secondary to sepsis versus dilutional. The patient's hematocrit remained stable after initial resuscitation with blood products. Her coagulopathy improved, but persisted. The patient transferred her oncology care from [**Hospital1 2025**] to [**Hospital1 1444**] secondary to dissatisfaction with care. Her current oncologist was Dr. [**Last Name (STitle) **] at the [**Hospital1 1444**] who frequently came to visit the patient during her Intensive Care Unit stay. 7. Endocrine: A.M. Cortisol level was checked and was 29 ruling out adrenal insufficiency as a cause of her hypotension. 8. Fluids, electrolytes and nutrition: A Swan-Ganz catheter was placed to assess hemodynamics revealing increased pulmonary artery pressures to 50/30, pulmonary capillary wedge pressure of 22, with a cardiac output of 6 and cardiac index of 3 and SVR of 665 indicating that the patient was retaining sufficient fluid in her intravascular space, but was still demonstrating ............ physiology secondary to a systemic inflammatory response. She initially had a nonanion gap metabolic acidosis, which was likely dilutional. Her acidosis subsequently improved. She was initially treated with 2 amps of sodium bicarbonate. She was also hypocalcemic initially secondary to massive resuscitation with blood products. Her electrolytes were repleted as needed. 9. Code status: The patient was initially a full code. Frequent family discussions were held with the family, and they continued to understand the grave prognosis of the patient. However, they maintained that they wanted at all times everything possible to be done for her. Furthermore they suggested that they wished for things to take their natural course as well. Toward the end of her hospital stay they decided that they did not want any pressors, CPR or defibrillation or ventilator changes. The patient passed away on [**2200-5-19**]. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-761 Dictated By:[**Name8 (MD) 2692**] MEDQUIST36 D: [**2200-9-3**] 06:30 T: [**2200-9-4**] 10:28 JOB#: [**Job Number 48850**]

[ "197.2", "198.5", "998.0", "998.11", "285.1", "511.8", "198.3", "518.81", "560.1" ]

icd9cm

[ [ [] ] ]

[ "34.04", "34.91", "96.6", "96.72" ]

icd9pcs

[ [ [] ] ]

24932, 24995

24302, 24915

27256, 35668

18009, 23577

26094, 27238

23599, 24276

25012, 26079

17,146

124,490

5522

Discharge summary

report

Admission Date: [**2170-3-8**] Discharge Date: [**2170-3-15**] Date of Birth: [**2126-2-11**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Penicillins / Codeine Attending:[**Doctor First Name 6716**] Chief Complaint: chronic pelvic pain abnormal uterine bleeding Major Surgical or Invasive Procedure: diagnostic hysteroscopy dilation & curettage diagnostic laparoscopy exploratory laparotomy lysis of adhesions left oophorectomy left ureterolysis History of Present Illness: 44yo G4P3 with hx irregular menses/abnormal uterine bleeding, chronic pelvic pain, endometriosis presented with persistent abnormal bleeding and increasing pelvic pain. Pelvic U/S revealed nl sized uterus w/nl endometrium, L ovarian cyst c/w endometrioma. Past Medical History: Multiple sclerosis with voiding dysfunction Endometriosis s/p C-section Social History: Married, does not use tobacco, observes Sabbath (cannot travel following sundown Friday) Family History: Lymphoma, Diabetes, coronary artery disease Physical Exam: 100/58 78 16 NAD CTA B/L RRR soft, +BS, no organomegaly nl adult female ext genitalia good vaginal support physiologic discharge in vaginal vault no CMT AV uterus upper limits of nl size no adnexal masses or tenderness, ?L adnexal fullness; exam limited 2/voluntary guarding nl anal sphincter tone Pertinent Results: [**2170-3-9**] 01:36AM BLOOD WBC-13.7*# RBC-3.38* Hgb-9.8* Hct-27.8* MCV-82 MCH-28.9 MCHC-35.2* RDW-13.4 Plt Ct-265 [**2170-3-12**] 10:30PM BLOOD WBC-4.5 RBC-3.06* Hgb-9.0* Hct-25.5* MCV-83 MCH-29.2 MCHC-35.1* RDW-13.8 Plt Ct-323# [**2170-3-9**] 01:36AM BLOOD Neuts-92.2* Bands-0 Lymphs-6.1* Monos-1.6* Eos-0 Baso-0.1 [**2170-3-12**] 10:30PM BLOOD Neuts-75.8* Lymphs-16.9* Monos-2.9 Eos-4.2* Baso-0.3 Abd XR [**3-10**]: A large amount of free intraperitoneal air is seen, which is consistent with patient's history of second day after operation. The bowel gas pattern appears within normal limits. CTA [**3-13**]: No evidence of pulmonary embolism. There is a small right-sided pleural effusion with associated atelectasis. There is free air within the abdomen consistent with the patient's postoperative state. Brief Hospital Course: Pt underwent dx hysteroscopy, D&C, dx laparoscopy which was converted to operative laporatomy secondary to copious adhesions and L endometrioma on [**2170-3-7**]. As noted in HPI, pt initally presented secondary to chronic pelvic pain and irregular bleeding. Pt tolerated the operation well - see operative note for full details. 1) Pulm - on POD #0, pt received 8 mg Morphrine for adequate pain control and a drop in RR rate to 6 when asleep was noted. Her O2 saturation was 92% on room air. Pt was tranferred to [**Hospital Unit Name 153**] for close monitoring. Apnea resolved and was thought to be likely related to strong response to narcotics with possible component of MS playing a role. CXR at this time was clear and O2 sat increased to 98% on RA. -on POD #5, pt complained of pleuritic chest pain and dyspnea. Her vital signs were stable and O2 saturation 100%RA. EKG was checked wnl and CTA was negative for pulmonary embolus. She had just had a fever to 100.7 and urine and blood cultures were rechecked and negative to date. WBC 4.5. Further CTA identified some atelectasis and pt was encouraged to ambulate and use IS. Rib pain resolved later in the day. 2) Fever - Pt had temp to 101.9 on POD #2 and temp 100.7 on POD #5. Blood and urine cultures/Urinalysis were checked at both these episodes and were negative. As noted above, CXR was wnl. In addition, on POD#5 w/u for PE was performed which was negative. Incision was C/D/I without erythema or exudate throughout entire hospital course. Pt did have pain control issues and had not been ambulating or using IS as much as recommended. CTA did show atelectasis and likely this was a source of fever. Clear etiology not identified. Pt remained afebrile after POD #5 without further treatment and increased in ambulation. 3) Neuro/MS - Pts neurologist [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] aware of hospitalization. Pt was evaluated by physical therapy and found to be stable - no acute or home PT needs. Pt continued her home dose of Rebif while in house. No signs of MS flare. 4) GI - On POD #2 pt experienced increased abdominal distention and pain and nausea. KUB was not consistent with post op ileus. Pt was made NPO/bowel rest. No signs of infection. Pt Hct was stable. Nausea resolved spontaneouly with bowel rest and was likely do to flatus buildup. Pt was advanced to clear liquids in afternoon and tolatered well. After that episode pt's diet was advanced to general and pt tolerated well. Pt was later started on Colace to help counter constipation. 5) Pain - Pain control was an issue with this patient. Pain was initally controlled with low doses of Morphine though pt was very drowsy with Morphine and did not find the control adequate. Given previous episode of apnea with high amounts of Morphine, pt was given only 1 mg q4-6 hours prn. OTC Tylenol. Pt was then transitioned to Toradol once Hct was deemed to be stable in order to better control pain. Once course of Toradol expired, pt was tried on trial of Percocet. She tolerated Percocet well and Motrin was added - no signs of allergy to Percocet, about which pt was concerned. Chronic pain consultation was undertaken and OTC Motrin and Percocet was recommended for 2-3 days then prn medication. Pts pain was controlled well on Percocet and Motrin on discharge. Pt to follow up with Dr. [**Last Name (STitle) 1004**] [**Name (STitle) **] and it will be deemed if further appointments with chronic pain will be necessary as outpt. 6) Dispo - pt was discharged home in stable condition, afebrile, pain controlled, tol po without N/V, ambulating, voiding on POD #7. Medications on Admission: Rebif 44 mcg/).5 mL SC 3x/week Ibuprofen 800 mg 4x/day Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours): Take every 4-6 hours consistently for first 2 days then every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:*60 Tablet(s)* Refills:*2* 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: endometriosis left endometrioma chronic pelvic pain abnormal uterine bleeding postoperative narcosis postoperative fever Discharge Condition: good, stable Discharge Instructions: Please take all medications as prescribed. No heavy lifting for 6 weeks. Nothing in vagina for 2 weeks. Call your doctor or come to the emergency room if you experience fever of 101 or higher, chills, nausea and vomiting preventing you from drinking, drainage or redness around your incision, or any other symptoms that worry you. Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] OB/GYN PPS CC8 (SB) Where: OB/GYN PPS CC8 (SB) Date/Time:[**2170-3-20**] 4:45 [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 6721**]

[ "V64.41", "E937.8", "617.1", "780.09", "593.89", "568.0", "617.8", "626.8", "626.4", "340" ]

icd9cm

[ [ [] ] ]

[ "65.39", "68.12", "69.09", "59.02", "54.59" ]

icd9pcs

[ [ [] ] ]

6503, 6509

2211, 5864

341, 489

6674, 6688

1372, 2188

7067, 7326

992, 1037

5969, 6480

6530, 6653

5890, 5946

6712, 7044

1052, 1353

256, 303

517, 774

796, 870

886, 976

62,447

141,916

2100

Discharge summary

report

Admission Date: [**2192-1-24**] Discharge Date: [**2192-1-28**] Date of Birth: [**2124-10-14**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor First Name 1402**] Chief Complaint: cardiac tamponade Major Surgical or Invasive Procedure: pulmonary vein isolation pericardiocentesis pericardial drain placement History of Present Illness: Pt is a 67 yo man with hx of paroxysmal Afib, HTN, and hyperlipidemia who is a pt of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11366**] and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11367**] who presented today for pulmonary vein isolation, procedure complicated by presumed [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 11368**] and cardiac tamponade s/p pericardiocentesis. Per the medical record, he is an otherwise healthy man who had been undergoing therapy for his paroxysmal Afib with propafenone and diltiazem (and maintained on Coumadin), however continued to have symptomatic episodes of Afib with feelings of palpitations and anxiety and decision was made to have pulmonary vein isolation and ablation. He also had sx of upper respiratory congestion in the week prior to presentation. Please see Dr.[**Name (NI) 11369**] note for details re: procedure. Briefly, femoral access was obtained without difficulty. A PFO was identified and wire advanced from RA to LA. It was felt that there was perforation of the posterior left atrium. During the ablation the patient's BP began to decline and he was found to have a large pericardial effusion on ECHO. His SBP reached a nadir of approx 65mmHG (<5min) and he was placed on pressors including phenylephrine, ephedrine, and epinephrine. Once pericardiocentesis was initiated, SBP rose again steadily allowing discontinuation of ephedrine and epinephrine. His heparin was reversed with 50mg of protamine during the procedure. He also received a total of 3500cc of IVFs (LR). A total of approx 950 cc of blood was expressed over 30min and a pericardial drain was placed. A repeat ECHO showed essential complete resolution of pericardial effusion. Upon transfer to the ICU the patient was maintained on phenylephrine which was discontinued on arrival with SBPs in 90s. The patient arrived intubated and sedated with propofol. Past Medical History: 1. CARDIAC RISK FACTORS:: (-) Diabetes, (+) Dyslipidemia, (+)Hypertension 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: - Hypertension - Hyperlipidemia - Renal calculi Social History: Semi-retired electrician, denies tobacco or alcohol hx. Married Family History: Mother with atrial fibrillation Physical Exam: VS: T= 96.6 BP= 122/64 HR= 80 RR= 11 O2 sat= 100% on FiO2 100% GENERAL: Intubated, sedated. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 7 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. Distant HS, +friction rub. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. A-line L femoral SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [**2192-1-24**] 01:24PM BLOOD WBC-11.0 RBC-3.68* Hgb-11.4* Hct-32.0* MCV-87 MCH-31.0 MCHC-35.7* RDW-12.6 Plt Ct-261 [**2192-1-24**] 07:30AM BLOOD PT-18.5* PTT-25.6 INR(PT)-1.7* [**2192-1-24**] 01:24PM BLOOD Glucose-133* UreaN-30* Creat-1.3* Na-139 K-4.0 Cl-108 HCO3-27 AnGap-8 [**2192-1-24**] 01:24PM BLOOD CK-MB-NotDone cTropnT-0.06* [**2192-1-24**] 01:24PM BLOOD CK(CPK)-88 [**2192-1-24**] 01:24PM BLOOD Calcium-7.7* Phos-2.5* Mg-1.6 [**2192-1-27**] 04:37AM BLOOD Triglyc-81 HDL-27 CHOL/HD-3.9 LDLcalc-62 LDLmeas-55 [**2192-1-24**] 11:58AM BLOOD Lactate-1.6 Na-135 K-3.4* Cl-107 [**2192-1-24**] 01:33PM BLOOD Lactate-0.7 . ECHO [**1-24**]: Large pericardial effusion with right ventricular collapse on initial views. SBP 80 mmHg during initial views. Left ventricular cavity size is small with grossly preserved biventricular systolic function. SBP up to 140 after drainage of pericardial effusion. Trivial residual effusion and no RV collapse seen. At 11 minutes post active draining of pericardial effusion, the effusion continues to be trivial. . ECHO [**1-24**] (post pericardiocentesis): The left ventricular cavity size is normal. The right ventricular cavity is dilated There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade . ECHO [**1-25**]: Overall left ventricular systolic function is normal (LVEF>55%). There is a very small pericardial effusion. The effusion is partially echo dense. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2192-1-24**], the pericardial effusion is slightly larger. . ECHO [**1-26**]: Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). No aortic regurgitation is seen. Physiologic mitral regurgitation is seen (within normal limits). There is a very small, partially echo filled pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2192-1-25**], the effusion is slightly smaller (but may be related to technical/imaging factors rather than a true change). . ECHO [**1-27**] (PRELIM): Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is a small pericardial effusion. The effusion is echo dense, consistent with coagulated blood. IMPRESSION: Small echodense pericardial effusion. Compared with the prior study (images reviewed) of [**2192-1-26**], findings are similar. Brief Hospital Course: # CARDIAC TAMPONADE: The patient presented for pulmonary vein isolation for treatment of paroxysmal atrial fibrillation. His procedure was complicated by presumed [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 11368**] and subsequent cardiac tamponade. He was treated briefly with pressors in the EP lab, then underwent urgent pericardiocentesis with approx 950cc of oxygenated blood expressed, and a pericardial drain was placed. His blood pressure rose promptly, pressors discontinued and repeat ECHO showed complete resolution of his pericardial effusion. He was given a total of 75mg of protamine to reverse the heparin that had been administed and his Coumadin was held for several days. He was transferred to the cardiac ICU for further monitoring. His drain output over the first 24 hours was approx 300cc asnd pericardial drain maintained in place for an additional day. He was mechanically ventilated overnight and had borderline low SBPs secondary to sedation, requiring fluid boluses (total of 5L post-procedure). His hematocrit dropped from 27 pre-procedure and stablized at 28 without need for transfusion. Repeat ECHO the morning after the procedure showed trace effusion, and he was extubated without difficulty and BP remained stable. Drain output diminished over the subsequent 24 hours and drain was discontinued on [**1-27**]. Repeat ECHO on [**1-27**] showed small stable effusion. He remained stable throughout the remainder of his hospital stay and did not require further colchicine for pain or discomfort. . # RHYTHM: Pt with history of known paroxysmal Afib, s/p ablation procedure which was terminated early secondary to cardiac tamponade as above. He was in sinus rhythm post procedure, but reverted back to Afib [**1-25**], then with evidence of conversion to atrial flutter with rates up to 130. He was restarted on his home diltiazem (uptitrated to 360mg daily) as well as propafenone which was increased to 225mg tid. His rate was adequately controlled on this regimen, and in fact converted to sinus rhythm prior to discharge. Coumadin was restarted at his home dose on [**1-27**]. . # HYPERTENSION: All home antihypertensives were held initially, then diltiazem restarted for atrial flutter. . # HYPERLIPIDEMIA: Continued Lipitor at home dose. Lipid panel showed low HDL 27 and LDL 55. . # CHRONIC COUGH: Pt was started on a PPI and on flonase nasal spray Medications on Admission: Coumadin 2.5mg 6 days/week (nothing on Day 7), last dose Friday [**1-20**] Diltiazem 360mg po daily Lipitor 10mg po daily Lisinopril 40mg po daily HCTZ 12.5mg po daily Propafenone 150mg po tid Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Propafenone 225 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 3. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAYS (MO,TU,WE,TH,FR,SA). 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 5. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). Disp:*1 bottle* Refills:*2* 6. Diltiazem HCl 360 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: 1) Cardiac tamponade 2) Atrial fibrillation/atrial flutter 3) Hypertension 4) Chronic cough 5) Dyslipidemia Discharge Condition: Stable, afebrile Discharge Instructions: You were admitted to the hospital for an ablation of your atrial fibrillation. You had a complication of your procedure called cardiac tamponade, a collection of blood around your heart that required emergent drainage and a drain placement. You were intubated and on a mechanical ventilator for a short time. You did very well and had stable echocardiograms showing almost complete resolution of your pericardial effusion (fluid around the heart). You did had both atrial fibrillation and atrial flutter after your procedure and your dose of propafenone was increased to 225mg three times daily. You were continued on your home dose of Diltiazem. You other blood pressure medications, lisinopril and hydrochlorothiazide, were held because you had normal blood pressures. Talk to your primary care doctor [**First Name (Titles) 5001**] [**Last Name (Titles) 11370**]g these medications. Your Lipitor was continued and Coumadin restarted on Friday [**1-27**]. Flonase nasal spray and omeprazole (an antacid) were started to help with chronic cough. It is important that you see your PCP and cardiologist in follow-up in the next 1-2 weeks. If you experience chest pain, shortness of breath, lightheadedness, worsening palpitations, sweats, or if you feel worse in any way, seek immediate medical attention. Followup Instructions: Please call to schedule a follow-up appointment with your cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11367**] at [**Telephone/Fax (1) 5985**] within the next 1-2 weeks Please call to schedule a follow-up appointment with your primary care doctor, Dr. [**Last Name (STitle) 11366**] in the next 1-2 weeks at [**Telephone/Fax (1) 11371**] You have a follow-up appointment with Dr. [**Last Name (STitle) **] on [**3-2**] at 2pm

[ "745.5", "997.1", "458.29", "420.99", "272.4", "V58.61", "427.31", "427.32", "423.3", "786.2", "401.9" ]

icd9cm

[ [ [] ] ]

[ "37.34", "37.27", "37.0", "37.12", "96.71", "37.28", "96.04" ]

icd9pcs

[ [ [] ] ]

9503, 9561

6191, 8589

335, 408

9713, 9732

3645, 6168

11087, 11554

2739, 2772

8833, 9480

9582, 9692

8615, 8810

9756, 11064

2787, 3626

2489, 2562

278, 297

436, 2373

2593, 2642

2395, 2469

2658, 2723

65,261

168,393

38757

Discharge summary

report

Admission Date: [**2129-6-3**] Discharge Date: [**2129-6-4**] Date of Birth: [**2053-9-17**] Sex: M Service: CARDIOTHORACIC Allergies: Lisinopril / Zocor Attending:[**First Name3 (LF) 165**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: coronary artery bypass grafting [**6-3**] History of Present Illness: Mr. [**Known lastname **] was a 75 year old male with long standing chest and abdominal pain. He reported that he had difficulty discerning between angina symptoms and his gastric reflux. He underwent a cardiac catheterization as part of a pre-op work-up for elective knee surgery. This cardiac catheterization revealed significant coronary artery disease, including a tight left main lesion. He was transferred to [**Hospital1 18**] for surgical evaluation with his right groin sheath intact. Past Medical History: Hypercholesterolemia, coronary artery disease, insulin dependent diabetes mellitus since the [**2099**], hypertension, history of deep vein thrombosis and pulmonary embolism on coumadin, peripheral vascular disease, chronic renal insufficiency, gastric reflux, obstructive sleep apnea on CPAP, Gout, Depression, osteoarthritis, appendectomy, hernia repair, R knee surgery [**2124**], bare metal stent in the proximal left anterior descending in [**1-12**], percutaneous intervention to right coronary artery in [**2118**], percutaneous intervention [**2120**], percutaneous intervention [**2121**] Social History: Mr. [**Known lastname **] was never a smoker. He drank heavily in the past, but has been abstinent for the past 20 years. Family History: Mr. [**Known lastname 48642**] mother died in her 30s of an unknown cause and his father died in his 50s of alcoholism. His sister has diabetes mellitus. Physical Exam: Pulse:68 Resp:20 O2 sat: 100 B/P Right: 90/54 Height:5'8" Weight:247 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] 2+ LE Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: 2+ Left:2+ DP Right: 1+ Left:1+ PT [**Name (NI) 167**]: 1+ Left:1+ Radial Right: 2+ Left:2+ Carotid Bruit Right: - Left: - Right Groin Sheath/a-line Pertinent Results: [**2129-6-3**] 06:02PM PT-22.9* PTT-150* INR(PT)-2.2* [**2129-6-3**] 06:02PM WBC-5.6 RBC-3.24* HGB-10.7* HCT-31.6* MCV-98 MCH-33.1* MCHC-33.9 RDW-14.5 [**2129-6-3**] 06:02PM %HbA1c-7.6* eAG-171* [**2129-6-3**] 06:02PM GLUCOSE-163* UREA N-26* CREAT-1.9* SODIUM-141 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-29 ANION GAP-12 [**2129-6-3**] 06:02PM ALT(SGPT)-66* AST(SGOT)-318* LD(LDH)-542* ALK PHOS-47 TOT BILI-0.3 Cardiac Catheterization: Date:[**6-3**] Place:MW LM 70%, prox LAD w severe in stent stenosis, LCx 80%, RCA 99% in stent stenosis Brief Hospital Course: Mr. [**Known lastname **] was transferred via ambulance from [**Hospital3 **] left main and three vessel disease with active chest pain, ruling in for a myocardial infarction. He continued to have intractable chest pain and was brought emergently to the operating room. There he underwent emergent coronary artery bypass grafting. Please see the operative note for details. In summary, he arrested with induction and CPR was performed while he was placed on bypass. He tolerated the operation poorly and returned to the cardiac surgery intensive care unit in electro-mechanical dissociation. Despite heroic measures he was pronounced at 7:05AM. Medications on Admission: ASA 325mg daily, nitrostat SL PRN, Regular Insulin 6 units PRN, Lasix 80mg daily, coumadin, atenolol 25mg daily, zantac daily, Novolin insulin 58 units AM, 20 units PM, allopurinol 500mg daily Discharge Medications: deceased Discharge Disposition: Expired Discharge Diagnosis: acute myocardial infarction coronary artery disease Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2129-6-5**]

[ "311", "V58.61", "443.81", "250.70", "403.90", "785.51", "327.23", "530.81", "410.91", "427.41", "V45.82", "585.9", "414.01", "272.0", "274.9", "V12.51", "V58.67" ]

icd9cm

[ [ [] ] ]

[ "37.61", "39.61", "36.11", "99.63", "88.72", "37.91", "99.62", "36.15" ]

icd9pcs

[ [ [] ] ]

3972, 3981

3043, 3695

293, 336

4077, 4087

2467, 3020

4144, 4273

1643, 1800

3939, 3949

4002, 4056

3721, 3916

4111, 4121

1815, 2448

243, 255

364, 863

885, 1486

1502, 1627

29,530

115,144

77

Discharge summary

report

Admission Date: [**2102-4-13**] Discharge Date: [**2102-4-17**] Date of Birth: [**2026-1-20**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 922**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: [**4-13**] MVR (29mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] porcine) History of Present Illness: 76 yo F walking to dentists office [**3-22**] and had SOB/CP/diaphoresis. Transferred to [**Hospital1 18**] where cath showed 4+MR. Referred for MVR. Past Medical History: # HTN # Bipolar Disorder, had been on lithium, now on risperdal # h/o syncope in [**2091**] while driving - Some ? of HOCM per [**2091**] ECHO w/ LV mid cavity gradient increase from 57 to 91 with valsalva - [**2092**] repeat echo with diminished gradient - Per Dr. [**Last Name (STitle) 911**], she does not have HOCM. # venous insufficiency w/ history of LLE ulcer # h/o BRBPR with c-scope in [**8-15**] with grade 1 hemorrhoids # Grave's Disease based on 38% iodine uptake, followed s/p thyroid ablation now on thyroid replacement # Left Medial/Lateral meniscal tear s/p arthroscopy in [**2090**] due to OA of the knee s/p MVA in [**2083**] # s/p b/l TKR in [**2091**] # s/p Left Tibial IM rod # Rectopexy for prolapsed rectum in [**2092**] # Microhematuria - b/l echogenic kidneys with only mildly diminished renal function # urinary retention # OA # GERD # s/p TAH [**2077**] # s/p Appy . Social History: She is a nun. Lives in [**Location 912**] at [**Hospital1 913**]alone. No tobacco, EtOH, or drugs. Family History: Sister with breast cancer. Father died of MI at 80. Brother died of MI at 40. Physical Exam: HR 57 RR 15 BP 153/79 NAD Lungs CTAB ant/let Heart RRR, + murmur Abdomen Obese, well healed [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 924**] warm, no edema; LLE cellulitis & statis changes; well healed bilateral TKR scars Pertinent Results: [**2102-4-16**] 08:45AM BLOOD WBC-6.0 RBC-2.98* Hgb-8.6* Hct-25.3* MCV-85 MCH-28.8 MCHC-34.0 RDW-15.0 Plt Ct-131* [**2102-4-16**] 08:45AM BLOOD Plt Ct-131* [**2102-4-16**] 08:45AM BLOOD Glucose-118* UreaN-10 Creat-0.7 Na-135 K-3.9 Cl-103 HCO3-23 AnGap-13 CHEST (PORTABLE AP) [**2102-4-15**] 10:02 AM CHEST (PORTABLE AP) Reason: s/p removal of chest tubes [**Hospital 93**] MEDICAL CONDITION: 76 year old woman pod 2 s/p MVR, now s/p chest tube removal REASON FOR THIS EXAMINATION: s/p removal of chest tubes EXAMINATION: AP chest. INDICATION: Mitral valve replacement. Status post chest tube removal. Single AP view of the chest is obtained [**2102-4-15**] at 10:30 hours and compared with the prior radiograph of [**2102-4-13**] at 14:20 hours. Patient has been extubated and chest tubes have been removed as has a right-sided Swan-Ganz catheter. Patient is status post cardiac surgery. Increased retrocardiac density in the left side with obscuration of the left hemidiaphragm persists and is consistent with postsurgical atelectasis in the left base. Small left pleural effusion may also be present. In the upper abdomen there is colon interposition on the right side. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 925**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 926**] (Complete) Done [**2102-4-13**] at 10:21:00 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 177**] [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2026-1-20**] Age (years): 76 F Hgt (in): 64 BP (mm Hg): 132/74 Wgt (lb): 162 HR (bpm): 56 BSA (m2): 1.79 m2 Indication: Intra-op TEE for MVR ICD-9 Codes: 440.0, 424.1, 424.0 Test Information Date/Time: [**2102-4-13**] at 10:21 Interpret MD: [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW02-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *5.5 cm <= 4.0 cm Left Atrium - Four Chamber Length: 5.1 cm <= 5.2 cm Left Ventricle - Inferolateral Thickness: 0.7 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.9 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.8 cm Left Ventricle - Fractional Shortening: *0.22 >= 0.29 Left Ventricle - Ejection Fraction: 55% >= 55% Left Ventricle - Stroke Volume: 102 ml/beat Left Ventricle - Cardiac Output: 5.72 L/min Left Ventricle - Cardiac Index: 3.19 >= 2.0 L/min/M2 Aorta - Annulus: 1.8 cm <= 3.0 cm Aorta - Sinus Level: 3.1 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.5 cm <= 3.0 cm Aorta - Ascending: 3.4 cm <= 3.4 cm Aorta - Arch: 2.6 cm <= 3.0 cm Aorta - Descending Thoracic: *2.6 cm <= 2.5 cm Aortic Valve - Peak Velocity: *2.2 m/sec <= 2.0 m/sec Aortic Valve - LVOT pk vel: 1.30 m/sec Aortic Valve - LVOT VTI: 36 Aortic Valve - LVOT diam: 1.9 cm Aortic Valve - Valve Area: *1.5 cm2 >= 3.0 cm2 Findings LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV cavity size. Normal regional LV systolic function. Overall normal LVEF (>55%). [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. Normal aortic arch diameter. 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. Mild AS (AoVA 1.2-1.9cm2). No AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Severe mitral annular calcification. Eccentric MR jet. Effective regurgitant orifice is >=0.40cm2. MR vena contracta is >=0.7cm Severe (4+) MR. TRICUSPID VALVE: Physiologic TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. See Conclusions for post-bypass data The post-bypass study was performed while the patient was receiving vasoactive infusions (see Conclusions for listing of medications). Conclusions PRE-BYPASS: 1. The left atrium is moderately dilated. No spontaneous echo contrast is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 2. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] 3. Right ventricular chamber size and free wall motion are normal. 4. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. There is mild aortic valve stenosis (area 1.2-1.9cm2). No aortic regurgitation is seen. 6. The mitral valve leaflets are moderately thickened. There is severe mitral annular calcification. An eccentric,anterior directed jet and a central jet are seen The effective regurgitant orifice is >=0.40cm2 The mitral regurgitation vena contracta is >=0.7cm. Severe (4+) mitral regurgitation is seen. 7. There is no pericardial effusion. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine. 1. A well-seated bioprosthetic valve is seen in the mitral position with normal leaflet motion. No mitral regurgitation is seen. 2. Left ventricular systolic function is normal. Right ventricular systolic function is normal. 3. Aorta is intact post decannulation. 4. [**Location (un) 109**] is still mildly decreased with no gradient (Peak of 12 mm of Hg). 4. Other findings are unchanged Brief Hospital Course: She was taken to the operating room on [**4-13**] where she underwent a MVR. She was transferred to the ICU in stable condition. She was extubated that night. She was transferred to the floor on POD #2. She was confused intermittently and required a sitter. Her confusion improved, she otherwise did well postoperatively and was ready for discharge to rehab on POD #4. Medications on Admission: Aspirin 325', Zocor 20', Desmopressin 0.1', Risperidone 1 am, Risperidone 3 pm, Atenolol 25', Ditropan XL 15', Imipramine HCl 25', Fosamax 70 qSun, Levothyroxine 100', Zantac 150', 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. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Imipramine HCl 25 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 5. Risperidone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Risperidone 3 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Zocor 80 mg Tablet Sig: One (1) Tablet PO once a day. 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. DDAVP 0.1 mg Tablet Sig: One (1) Tablet PO at bedtime. 10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 11. Ditropan XL 15 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days: then reassess need for diuresis. 13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day) for 10 days: while on lasix. 14. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week: every sunday. Discharge Disposition: Extended Care Facility: [**Location (un) 931**] House Nursing & Rehabilitation Center - [**Location (un) 932**] Discharge Diagnosis: MR s/p MVR HTN, Bipolar Disorder, syncope, venous insufficiency, LLE ulcer, hemorrhoids, [**Doctor Last Name 933**] Disease, urinary retention, GERD, OA Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon. Followup Instructions: Dr. [**First Name (STitle) **] 2 weeks Dr. [**Last Name (STitle) 911**] 2 weeks Dr. [**Last Name (STitle) 914**] 2 weeks Already scheduled appointments: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2102-6-15**] 1:30 Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**] Date/Time:[**2102-9-18**] 11:15 Completed by:[**2102-4-17**]

[ "285.9", "715.36", "530.81", "296.80", "V45.77", "V45.89", "593.9", "455.6", "459.81", "298.9", "440.0", "276.1", "424.0", "401.9" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.24", "39.63", "39.64" ]

icd9pcs

[ [ [] ] ]

10244, 10358

8431, 8802

288, 385

10555, 10563

1974, 2334

10876, 11369

1616, 1696

9033, 10221

2371, 2431

10379, 10534

8828, 9010

10587, 10853

1711, 1955

238, 250

2460, 8408

413, 564

586, 1483

1499, 1600

3,597

162,212

12500+12501

Discharge summary

report+report

Admission Date: [**2128-4-16**] Discharge Date: [**2128-5-15**] Date of Birth: [**2093-5-31**] Sex: M Service: Plastic [**Doctor First Name **] ADMITTING DIAGNOSIS: 1. Crush injury to the left lower extremity. DISCHARGE DIAGNOSIS: 1. Crush injury to the left lower extremity. PROCEDURES DURING ADMISSION: 1. Open reduction external fixation, open tib fib fracture left lower extremity [**2128-4-16**]. 2. Left femoral angiogram times two [**2128-4-16**]. 3. Left below the knee popliteal to posterior tibial bypass with non-reverse saphenous vein graft from right lower extremity. 4. Removal external fixation placement of internal plates left lower extremity [**2128-4-21**]. 5. Myocutaneous rectus abdominis free muscle flap from the right abdomen to the left anterior leg with microanastomosis and split thickness skin graft of the entire area of open muscle anterior leg [**2128-4-21**]. 6. Split thickness skin graft left lateral leg with donor site left thigh [**2128-5-3**]. HISTORY OF PRESENT ILLNESS: The patient is a 34 year-old sanitation worker who was struck from behind and pinned between his vehicle and another car. He sustained a crush injury to his left lower extremity and suffered a large degloving injury as well. This is a displaced open tib fracture to his left lower extremity. The patient was brought by ambulance to [**Hospital1 69**]. He was noted to have isolated injury to his left lower extremity. He was evaluated by Orthopedics as well as Vascular Surgery and Plastic Surgery. PAST MEDICAL HISTORY: 1. Anxiety. PAST SURGICAL HISTORY: None. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Paxil. SOCIAL HISTORY: Positive tobacco. PHYSICAL EXAMINATION: On exam the patient is afebrile. His vital signs are stable. He is in moderate discomfort. Cardiovascular - Slight tachycardic but regular, S1, S2. Lungs are clear to auscultation bilaterally. Abdomen is soft, nontender. Neck is supple, nontender, no bony deformity. Pelvis is stable. Back is nontender, no step off. Right lower extremity - no injury. Left lower extremity with large degloving injury with exposed muscle and bone. The patient was able to wiggle his toes. He had loss of active dorsiflexion. He did have full sensation and distribution of the tibial nerve as well as deep peroneal nerve as well as saphenous and sterile distribution. He had loss of sensation in the distribution of the superficial peroneal nerve. He had a palpable PT and a non palpable DP which was dopplerable in the triphasic signal. His femoral pulses were both palpable. LABORATORY DATA: On admission his white count was 9.4 and his crit was 38.6. Platelet count 340,000. His other electrolytes were otherwise normal. His trauma series films were negative but an x-ray of his left lower extremity revealed a left tib fib fracture open and displaced. HOSPITAL COURSE: The patient was admitted to the hospital on [**2128-4-16**] and taken to the operating room by Orthopedic Surgery for open reduction external fixation of left lower extremity open tib, fib fracture. Intraoperatively the patient was noted to have loss of doppler signal to his left foot. Therefore intraoperatively Vascular Surgery was consulted and an intraoperative table angio demonstrated no run off to the distal peroneal trunks. Vascular Surgery proceeded to do a left below the knee popliteal to PT bypass with non-reverse saphenous vein graft from the right lower extremity. The patient had excellent post procedure pulses. Orthopedics then completed his X fix with Vac Sponge dressings placed to the degloving regions in the lateral leg and the anterior leg. The patient was transferred to the Intensive Care Unit, intubated and sedated. He received four units of packed red blood cells intraoperatively. He was stable in the Intensive Care Unit. The patient's pulse exam remained stable. He was taken back to the operating room for a washout of his left lower extremity. Plastic Surgery was consulted for coverage and it was decided that after the wound was cleaned this would be undertaken. On [**2128-4-16**] the patient was noted to be tachycardic, a Cardiology consult was called. It was decided that his tachycardia was likely secondary to pain and anemia and fever. On [**2128-4-18**] the patient was taken back to the operating room for washout and debridement and received another two units of packed red blood cells. He remained on Lovenox. His pulse exam remained good. On [**2128-4-20**] the patient was taken for an angiogram to evaluated blood flow to his left lower extremity and then taken to the operating room for removal of an X fix device with an IM rod placement. He also underwent myocutaneous rectus abdominis free flap to his left lower extremity open wound with exposed hardware. The patient tolerated the procedure well also with a split thickness skin graft to thigh to cover the muscle with the donor site being left lateral thigh. The patient remained on antibiotics throughout his hospital course. The patient's flap remained healthy with a good doppler signal with skin graft covering the flat remained pink. The patient remained on bedrest with lower extremity elevation and a Vac Sponge to his lateral leg wound. Given the patient's prior history of anxiety as well as ETOH abuse, Psychiatry was consulted. It was decided to increase his Paxil dose to 20 milligrams po q day as well as to obtain a pain consult considering the patient's continued pain. On [**2128-5-3**] the patient was taken to the operating room by Plastic Surgery for a split thickness skin graft to his left lateral leg wound. The patient tolerated this procedure well. He was also placed in a posterior splint with his foot at 90 degrees. He was transferred to the floor in stable condition. The patient continued to have good doppler signal in his flap and his skin graft remained pink. He was able to dangle the left lower extremity for five minutes tid, tolerating this well. On [**2128-5-13**] it was decided the patient could begin crutch walking and begin weight bearing on the left lower extremity. He tolerated this well but did complain of pain. On [**2128-5-14**] it was decided the patient was stable for discharge and he was discharged to rehabilitation pending a bed on [**2128-5-15**] on the following medications, with the following instructions in stable condition. DISCHARGE MEDICATIONS: 1. Hydromorphone 2 to 8 milligrams po q three to four hours prn. 2. Colace 100 milligrams po bid. 3. Senna two tablets po q HS prn. 4. Dulcolax 10 milligrams pr q HS prn. 5. Gabapentin 300 milligrams po q HS. 6. Paxil 20 milligrams po q day. 7. Benadryl 25 to 50 milligrams po q HS prn. 8. Tylenol 600 milligrams q four to six hours prn. 9. Aspirin 325 milligrams po q day. 10. Protonix 40 milligrams po q day. The patient was told to be out of bed with weight bearing as tolerated in his left lower extremity. He was told he should work on range of motion with his knee and ankle and keep the multi Podus boot on his foot while in bed at all times at 90 degrees. Advised as well to keep pressure off his left heel. Xeroform, Kerlix and Ace wrap was applied to the left lower extremity and change daily. This is to be continued at rehabilitation as well as flap checks with doppler. The patient was to call Dr. [**Last Name (STitle) 1435**] office for a follow up appointment [**Telephone/Fax (1) 17373**] early next week, the week of [**2128-5-17**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8332**], M.D. [**MD Number(1) 8333**] Dictated By:[**Last Name (NamePattern1) 4985**] MEDQUIST36 D: [**2128-5-14**] 09:55 T: [**2128-5-14**] 09:59 JOB#: [**Job Number 38774**] Admission Date: [**2128-4-16**] Discharge Date: [**2128-5-15**] Date of Birth: [**2093-5-31**] Sex: M Service: Plastic Surgery ADMITTING DIAGNOSIS: Crush injury to the left lower extremity. DISCHARGE DIAGNOSIS: Crush injury to the left lower extremity. PROCEDURES: 1. Left femoral angiogram times two, [**2128-4-15**]. 2. Left below the knee popliteal to posterior tibial with nonreverse saphenous vein graft in right lower extremity bypass. 3. External fixation device and VAC sponge placement to left lower extremity, [**2128-4-16**]. 4. Removal of external fixation device and placement of internal hardware, [**2128-4-21**]. 5. Rectus abdominis myocutaneous free flap to left anterior leg with split thickness skin graft, [**2128-4-21**]. 6. Split thickness skin graft from left lateral thigh to left lateral lower extremity, [**2128-5-3**]. HISTORY OF PRESENT ILLNESS: The patient is a 34 year old male sanitation worker who was struck from behind at around 8 o'clock in the morning on [**2128-4-16**] and his left lower leg was trapped between the car which struck him, and the dump truck. The patient was brought by emergency medical services to the [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] Emergency Room with a known open left tibia-fibula fracture. The patient had no loss of consciousness, no chest pain, no shortness of breath. He was awake and alert on arrival to the Emergency Room. The patient was evaluated by orthopedics. His foot was found to be cool with a palpable posterior tibialis and nonpalpable dorsalis pedis, which was Dopplerable. He was unable to dorsiflex. He had sensation in the distribution of the tibial nerve as well as the deep peroneal nerve. He had loss of sensation in the distribution of the superficial peroneal nerve. The patient was evaluated by orthopedic surgery and taken to the Operating Room for external fixation. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8332**], M.D. [**MD Number(1) 8333**] Dictated By:[**Last Name (NamePattern1) 4985**] MEDQUIST36 D: [**2128-5-14**] 09:36 T: [**2128-5-14**] 06:28 JOB#: [**Job Number **]

[ "285.9", "300.00", "956.3", "823.92", "E819.7", "305.00", "956.2" ]

icd9cm

[ [ [] ] ]

[ "83.45", "79.36", "78.17", "39.29", "79.66", "86.69", "78.57", "88.48", "83.82" ]

icd9pcs

[ [ [] ] ]

6426, 7913

7998, 8641

2896, 6403

1604, 1674

1733, 2878

8670, 10024

7934, 7977

1566, 1580

1691, 1710

21,277

127,461

45320

Discharge summary

report

Admission Date: [**2141-9-10**] Discharge Date: [**2141-10-5**] Date of Birth: [**2063-12-13**] Sex: F Service: MEDICINE Allergies: Penicillins / Codeine / Latex Attending:[**First Name3 (LF) 783**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: PEG placement [**2141-9-27**] Lumbar puncture [**2141-9-11**] History of Present Illness: 77 year old woman with complicated PMHx. including CVA with residual Lt. sided hemiparesis was at home with her daughter when she began exhibiting signs of a URI with sneezing, upper airway congestion, lethargy (evening of [**9-9**]). The following morning, she was noted to be eating less, less energetic, less responsive, and had a fever of 102. At approximately 4 pm on [**9-10**], her daughter called her mother's primary physician's office, and was instructed to bring her mother to the [**Name (NI) **] immediately. For unclear reasons, she did not do so, and continued to try to get her mother to eat and drink and take tylenol, which she was unsuccessful in doing. By approximately 8 pm, her mother was increasingly lethargic and was not responding to voice. Her daughter called EMS, and on arrival they noted that she was responsive only to painful stimuli, and had alot of upper airway secretions and appeared to be in respiratory distress. She was subsequently intubated at the scene and was transported to the [**Hospital1 18**] ED. On arrival in the ED, she was noted to have a fever to 102, and was tachy in AFib with a rapid response in the 170's. Her blood pressure was 160's over palp. 2 peripheral IV's were placed, and she was sedated with propofol and maintained on AC ventilation. 1500 cc of NS were bolused, and she was administered Vancomycin, Levofloxacin, and Flagyl emperically for suspected infectious etiology, and given a stated PCN allergy (dtr. initially related this and then retracted - unclear if she has or not). She had blood cultures drawn X 2 (negative to date), and UA and culture (unremarkable), CXR (clear), and LP (clear). Her anticoagulation for PAF was not reversed (INR on presentation was 3.1) prior to her LP in the ED, but the tap was clear without red cells (nonetheless, she will need to be observed with neuro checks q 2 hours as possible given her propofol sedation to evaluate for emerging possible epidural hematoma formation). A CT of the head and abdomen are currently pending, and after these have been completed, she is planned for admission to the ICU, dx: ams and acute respiratory failure. Past Medical History: Ascending Aortic Aneurysm Polymyalgia Rheumatica Recurrent UTI's on Macrodantin ppx. chronically HTN CVA (multiple?) with residual Lt. hemiparesis and expressive aphasia ? of a seizure d/o Pacemaker for sick sinus syndrome and PAF (overdrive pacing) GERD PAF on coumadin Anxiety PTSD (initial trauma WWII) Depression Multinodular goiter Diabetes (type 2) Social History: Lives with daughter, has 8 grown children, is Italian, and has 'reverted to her native language' since her CVA per dtr. She worked as a laundress. Unknown tob hx./etoh hx (dtr. not available to answer this). Family History: Maternal fatal MI Physical Exam: 100.1 78 135/66 16 94% sat with BMV on 100% O2. Intubated, sedated Thin, elderly No rash Prosthetic Lt. eye, rt eye pupil reactive No LAD CTA [**Last Name (un) **] [**Last Name (un) **], no MR, no S3 Abdomen thin, non-distended, soft, bowel sounds diminished 1+ periperal edema, LE venous stasis changes. Strong (3+) periperal pulses on warm, dry extremities. Pertinent Results: [**2141-9-10**] 11:30PM CEREBROSPINAL FLUID (CSF) PROTEIN-48* GLUCOSE-77 [**2141-9-10**] 11:30PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 POLYS-0 LYMPHS-70 MONOS-30 [**2141-9-10**] 11:30PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 POLYS-0 LYMPHS-70 MONOS-30 [**2141-9-10**] 10:30PM URINE GR HOLD-HOLD [**2141-9-10**] 10:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021 [**2141-9-10**] 10:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2141-9-10**] 10:30PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0-2 [**2141-9-10**] 10:30PM URINE MUCOUS-FEW [**2141-9-10**] 10:30PM URINE MUCOUS-FEW [**2141-9-10**] 10:10PM UREA N-19 CREAT-0.9 [**2141-9-10**] 10:10PM CK(CPK)-33 [**2141-9-10**] 10:10PM AMYLASE-49 [**2141-9-10**] 10:10PM CK-MB-NotDone cTropnT-0.01 [**2141-9-10**] 10:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-6.7 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2141-9-10**] 10:10PM WBC-10.6# RBC-4.93 HGB-12.5 HCT-37.3 MCV-76* MCH-25.3* MCHC-33.4 RDW-14.4 [**2141-9-10**] 10:10PM WBC-10.6# RBC-4.93 HGB-12.5 HCT-37.3 MCV-76* MCH-25.3* MCHC-33.4 RDW-14.4 [**2141-9-10**] 10:10PM PT-21.5* PTT-33.8 INR(PT)-3.1 [**2141-9-10**] 10:10PM FIBRINOGE-518* . Stool C diff [**9-13**]: CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. . AP CXR [**10-3**]: A patchy opacity seen in the right upper lobe, which may be a composite shadow, however, dedicated PA and lateral view would be helpful for evaluation of this. . AP CXR [**10-1**]: Small right pleural effusion is new. Left lower lobe atelectasis has improved. Upper lungs clear. Heart size is top normal. Atrial transvenous pacer lead heads towards the tricuspid valve, however, replacement assessment would require routine radiographs. Ventricular lead apparent standard placement. No pneumothorax. . AP CXR [**9-12**]: 1. Interval increase in right lower lobe consolidation, consistent with pneumonia and/or aspiration. 2. Interval increase in small left pleural effusion. Brief Hospital Course: Briefly, this is a 77 year old woman who presented with MS change, fever, afib with RVR, and increased upper airway secretions who was initially intubated in the field and transferred to the [**Hospital1 18**] MICU. The pt was never started on pressors, she was started on broad spectrum antibiotics (vanc/levo/flagyl), and she was quickly extubated and transferred to the medicine service. The pts CXRs began to shown signs of aspiration pneumonia, so she was treated with a 2 week course of levofloxacin and vancomycin. CXRs near the time of discharge revealed resolved aspiration pneumonia. However, the pt always required frequent suctioning for copious secretions. During her stay the pt also developed C. diff colitis and was treated with a 2 week course of flagyl. The pt remained encephalopathic throughout her hospitalization, never returning to her baseline mental status. She remained on NGT feeds for the majority of her hospitalization as she failed 3 speech and swallow evaluations. The pt finally underwent PEG placement on [**9-27**] and was tolerating her feedings. The pt had finally reached therapeutic levels on coumadin immediately prior to discharge, however pt should remain on a heparin gtt for several days given pts prior h/o multiple strokes in the past. . 1. Respiratory Failure/Aspiration Pneumonia: The pt was intubated in the field prior to the pt coming to the [**Hospital3 **] ED. As is was felt the pt likely had aspiration pneumonia, she was started on broad spectrum antibiotics of vancomycin and levofloxacin. The pt was quickly extubated in the MICU and transferred to the medicine service, again never requiring pressors. Prior to [**9-12**], chest films demonstrated only a suggestion of slight interstitial prominence that may be consistent with an atypical pneumonia. On CXR following [**9-12**] there was evidence of RLL infiltrate and pulmonary engorgement. The pt was continued on a 2 week course of levofloxacin and vancomycin (both discontinued on [**9-28**]) for treatment of aspiration pneumonia. CXR from [**9-15**] revealed a RLL pneumonia improving and small BL pleural effusions. CXR again from [**9-24**] revealed improving bilateral lower lobe aspiration pneumonia. CXR from [**10-1**] revealed a small right sided pleural effusion and resolution of the aspiration pneumonia. Final AP CXR from [**10-3**] revealed a possibled RUL infiltrate vs shadow, however a repeat AP/lateral did not reveal the same infiltrate. Throughout the hospitalization the pt required frequent suctioning for copious secretions. . 2. Fever: Prior to admission, the pt had a fever to 102 at home and was found to be 101 in the ED. Admission UA was clear, admission blood cultures were negative, urine cultures were negative, initial CXR was without focal infiltrates, and CSF fluid from the lumbar puncture was clear. Again, the pt was immediately started on broad spectrum antibiotics of levofloxacin, flagyl, and vancomycin. The pts fever resolved quickly on this regimen. However, the pt again spiked a fever on [**9-25**] to 101.4. The pts WBC also trended up to 16 on [**9-24**]. Blood Cx were drawn and were negative, UA and Urine Cx from [**9-25**] were negative for signs of infections, and CXR from that day had revealed resolving aspiration pneumonia. The pt had many potential sources of infection, including her foley, NG tube, and antibiotics. The source of the fever from [**9-25**] was unclear, but she remained afebrile with a normalized WBC (WBC 11 on [**9-25**] and subsequently ranged 7-9) until the time of discharge. . 3. Altered mentation: It is unclear how many strokes the pt has suffered, but the daughter describes an expressive aphasia and residual Lt. sided weakness as well (at least two different vascular distributions). CT of the head negative for acute bleed. Patient had an EEG on [**2141-9-12**], and that was read as: "Abnormal EEG due to a diffusely and moderately slowed and disorganized record with some additional frontal slowing with blunted sharp components. While there is no evidence of focality, the record does suggest a diffuse encephalopathy of mild degree with superimposed increased irritability involving subcortical or deeper midline structures. This could represent either a vascular etiology or a toxic and metabolic entity although no triphasic waves were seen to suggest a full blown metabolic encephalopathy." There is an unclear explanation for the change in MS, but her change seemed to have coincided with the initial aspiration pneumonia. The pt will need rehabilitation placement for the deficits and impairments associated with this changed in mental status. . 4. Paroxysmal atrial fibrillation - The pt was in rapid ventricular response on presentation, most likely triggered by infection. She responded with rate control, sedation, IVF and abx alone, and was not initially administered any nodal agents. INR was slightly supra-therapuetic on presentation at 3.1 - and this was not reversed prior to LP in the [**Last Name (LF) **], [**First Name3 (LF) **] she was administered FFP and Vitamin K for rapid reversal after the procedure was completed. Following extubation the pt required a diltiazem drip. This was quickly weened off and the pt was started on lopressor and verapamil. These medications were titrated up to a final dose of verapamil 160 mg po q 8 hr and lopressor 50 mg po TID. The pt was also started on a heparin drip following FFP/VitK administration along with her coumadin until she was therapeutic again. Coumadin was held for PEG placement on [**9-27**] and was restarted on [**9-29**] along with a heparin drip to bridge her again. Pts INR only reached therapeutic level of 2 on day of discharge, requiring several more days of heparin gtt given pts h/o multiple prior strokes. . On [**9-24**] the pt had an episode of bradycardia down to 29 while sleeping. Pts PCM was interrogated by EP and it was felt the pts battery was low. The PCM was changed by EP from dual chamber pacing to unipolar VVI40 pacing to extend the battery life. The PCM battery was not changed by EP due to the patient's overall poor prognosis. . 5. C. difficile colitis: Stool culture from [**9-13**] revealed C diff toxin. The pt was started on flagyl 500 mg TID on [**9-14**] and this was continued up until [**9-29**]. Prior to discharge the pt was not experiencing any further episodes of diarrhea. . 6. FEN: The pt was placed on aspiration precautions and NGT was placed for tube feedings. The pt failed speech and swallow evals 3 times(secondary to her mental status) prior to PEG placement on [**9-27**]. The pt was tolerating her tube feeds at 90 cc/hr for 16 hrs/day prior to discharge. Speech and swallow recommended short term rehab with speech therapy at rehab for dysphagia management. . 7. HTN - Initially all antihypertensives were held as it was unclear if she had suffered a stroke. However head CT was negative on admission. The pt was started on po lopressor and verapamil for both blood pressure and rate control, as well as lisinopril. Her medications were titrated up to final doses of lisinopril 20 mg qd, lopressor 50 mg TID, and verapamil 160 mg q 8 hr with good blood pressure control. . 8. DM - She carries the diagnosis of NIDDM, and appeared to be diet controlled at home. The pt was managed on a simple RISS with qid FSBG. Her blood sugars were well controlled throughout the hospitalization. . 9. Anemia: The pt has anemia of chronic disease as her iron is low, ferritin is high, MCV is normal, and transferrin is low. (iron 19, ferritin 298, transferrin 193 [**9-14**]). Her hematocrit remained stable in the low 30s and she did not require transfusion. Medications on Admission: Atenolol 50 daily Warfarin 2 mg daily Lisinopril 10 mg daily Macrodantin 100 mg twice daily Remeron 15 mg HS Olanzapine 5 mg daily Protonix 40 mg daily Restoril PRN Discharge Medications: 1. Phenol-Phenolate Sodium 1.4 % Mouthwash Sig: One (1) Spray Mucous membrane PRN (as needed). 2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Morphine 2 mg/mL Syringe Sig: One (1) mg Injection Q4H (every 4 hours) as needed for pain. 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. Verapamil 80 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours): hold for heart rate less than 55 and SBP less than 100. 8. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO DAILY (Daily). 9. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [**Hospital1 **] (2 times a day) as needed for constipation. 11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for to necessary areas. 12. Lorazepam 2 mg/mL Syringe Sig: 0.5 mg Injection Q4H (every 4 hours) as needed for agitation. 13. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): For finger stick of 150-200 give 2 units of insulin. For FS of 201-250 give 4 units. For FS of 251-300 give 6 units. For FS of 301-350 give 8 units. For FS of 351-400 give 10 units. For FS of greater than 400 give 10 units and call your doctor. . 14. Warfarin Sodium 2.5 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 15. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: One (1) as directed Intravenous ASDIR (AS DIRECTED). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - Acute Rehab Discharge Diagnosis: s/p Aspiration pneumonia s/p C. difficile colitis Encephalopathy Atrial Fibrillation Discharge Condition: stable and improved with resolution of fever and aspiration pneumonia. Mental status not yet at baseline. INR not yet therapeutic on coumadin. Discharge Instructions: Please take all medications as prescribed. Please return to the ED or call your primary doctor if your symptoms return or worsen (ie. cough, difficulty breathing, lethargy) Followup Instructions: After discharge from rehab, you should follow up with your primary care doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3029**], [**Telephone/Fax (1) 250**] [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

[ "725", "401.9", "518.81", "438.11", "V53.31", "008.45", "427.31", "438.20", "250.00", "348.30", "241.1", "276.8", "507.0", "280.9" ]

icd9cm

[ [ [] ] ]

[ "96.6", "99.07", "03.31", "96.71", "43.11" ]

icd9pcs

[ [ [] ] ]

15370, 15443

5692, 13419

312, 375

15572, 15719

3608, 5669

15940, 16256

3190, 3209

13634, 15347

15464, 15551

13445, 13611

15743, 15917

3224, 3589

251, 274

403, 2569

2591, 2947

2963, 3174

57,260

158,142

36713

Discharge summary

report

Admission Date: [**2113-7-1**] Discharge Date: [**2113-7-8**] Date of Birth: [**2030-1-12**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 783**] Chief Complaint: OSH transfer for ? pulomonary stent Major Surgical or Invasive Procedure: Rigid and flex bronchoscopy, with biopsy s/p 2 right sided chest tubes History of Present Illness: 83F h/o HTN, CHF, and recent afib s/p PM implantation who was transferred to [**Hospital3 17921**] Center on [**2113-5-31**] with 1 week of lightheadeness and episodes of syncope. Creatinine was 1.0, BUN 22. . CXR and BNP were consistent with CHF, and TTE showed valve area of 0.75cm2, moderate MR, and EF 55%. LHC on [**5-31**] revealed RCA lesion of 60%. The decision was made to pursue aortic valve replacement on [**6-6**] with a tissue valve, and ascending aorta endarterectomy. She was extubated on [**6-7**]. . Her post-operative course was complicated by worsening pulmoanry function, cough, ?RUL PNA on CXR, and rising WBC to 17K, with concern of retained secretions, and poor cough. On [**6-9**], she underwent bronchoscopy to evaluate for concern for retained secretions, at which time thick secretions, which showed purulent secretions, for which broad spectrum abx were started, and pt was started on BiPaP. . She was also noted to have bilateral pleural fluid collections, ultimately resulting in left thoracentesis [**6-8**] (250cc serosang), left [**Female First Name (un) 576**] on [**6-12**], right side 20 french chest tube on [**6-13**], right side anteriolateral thoracentesis [**6-14**] (100cc serous fluid), left thoracentesis on [**6-5**], and [**6-25**] (250cc serous). . She continued to do poorly from a respiratory standpoint, and CT on [**6-26**] was concerning for right side hemothorax, prompting right thoracotomy and VATs with decortication of the right lung, evacuation of right hemothorax, and repair of the right lung with a xenograft. . On [**6-29**], repeat bronchoscopy was performed which revealed marked thickening and narrowing of the right main and intermediate bronchus, with concern of a mass compressing the right maintstem bronchus. Per d/c summary, the endobronchaial papearance suggested the possibility of neoplasm, and material was aspirated, but biopsy was deferred [**2-13**] INR 1.8. . The patient was also seen by general surgery on [**6-18**] for ?abdominal pain in the setting of kayexalate induced stooling for hyperkalemia, however she denied abdominal pain upon repeat questioning, and no further intervention was performed. She was seen by nephrology pre-operatively with plan to hold lasix, ACE, and potassium. By report, she is alert, and interactive, though had been increasingly tachypneic, agitated on BiPaP was was therefore intubated prior to transfer. . She is transferred to [**Hospital1 18**] for consideration of stenting of the right minstem and intermediate bronchus with possible transbronchial biopsy. . At the time of her transfer, UOP over past 24 hours was 1065 cc, chest tube drainiage was 390 cc. Past Medical History: - Severe aortic stenosis (0.75 cm2) s/p AVR (#19 carpenter) - CHF felt [**2-13**] AS - CAD - 60%RCA disease pre-valve surgery. - H/o afib s/p pacemaker implantation - CRI (baseline 1.0 on [**5-31**]) - HTN - Osteoporosis - Dementia - Cataract surgery Social History: She lives in [**Hospital3 83025**]. She denies tobacco, notes occassional ETOH, denies IVDU. Family History: NC. Physical Exam: Vitals: 97.1 71 135/50 18 98% on AC 650x10 100% PEEP 7 General: intubated, sedated. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: OSH LABS: [**2113-6-30**] CRE 0.8, ALT 25, AST 27, INR 1.5, PT 15.4. by d/c summary, HCT 32.6. [**2113-6-19**] BCx (line) - staphyloccocus [**2113-6-19**] UCx - ngtd. [**2113-6-26**] MRSA swab - negative. [**2113-6-26**] R pleural clot - gram stain - rare polys, no organism. [**2113-6-29**] BAL washings - grams tstain - moderate polys. [**2113-6-8**] catheter tip - no growth. . On Admission: [**2113-7-1**] 03:10PM BLOOD WBC-12.2* RBC-3.06* Hgb-8.6* Hct-26.6* MCV-87 MCH-28.2 MCHC-32.4 RDW-16.6* Plt Ct-282 [**2113-7-1**] 03:10PM BLOOD Neuts-94.8* Lymphs-2.3* Monos-2.6 Eos-0.1 Baso-0.1 [**2113-7-1**] 03:10PM BLOOD PT-14.7* PTT-24.6 INR(PT)-1.3* [**2113-7-1**] 03:10PM BLOOD Glucose-157* UreaN-43* Creat-0.8 Na-146* K-3.6 Cl-109* HCO3-28 AnGap-13 [**2113-7-1**] 03:10PM BLOOD Calcium-8.2* Phos-1.4* Mg-2.1 [**2113-7-1**] 03:10PM BLOOD ALT-15 AST-17 LD(LDH)-370* AlkPhos-101 TotBili-0.7 Albumin-2.5* [**2113-7-1**] 03:34PM BLOOD Lactate-1.7 [**2113-7-1**] 03:10PM BLOOD CK(CPK)-23* CK-MB-4 cTropnT-0.18* . [**2113-7-1**] Blood Culture, Routine (Preliminary): GRAM POSITIVE COCCUS(COCCI). IN PAIRS AND CLUSTERS. Anaerobic Bottle Gram Stain (Final [**2113-7-3**]): REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20488**] @ 0800AM, [**2113-7-3**]. GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. . STUDIES: [**2113-7-1**] CXR FINDINGS: In comparison with the study of [**7-2**], the tip of the endotracheal tube has been pulled back so that it now lies approximately 3.3 cm above the carina. Nasogastric tube has been repositioned so that the side hole is well below the esophagogastric junction. Small right pneumothorax persists with chest tube in place. Otherwise, little change in the appearance of the heart and lungs. . [**2113-7-1**] Chest CT IMPRESSION: 1. Bilateral pleural effusions. The right-sided pleural fluid is loculated in the major fissure and also has a component that is higher attenuation in the dependent aspect, which may represent hemorrhage or complex fluid. Recommend correlation with chest tube output. 2. Small 1.2-cm right hilar node. No obstructing bronchus mass, which was the clinical concern. 3. Heterogeneous nodular thyroid gland. Recommend non-emergent thyroid ultrasound. 4. Complex left renal cystic lesion. Renal ultrasound is recommended for additional evaluation. . [**7-3**] Rigid and Flex Bronch: No significant central airway obstruction, narrowing or collapse. Successful transbronchial needle aspiration of station 11R. Balloon dilatation of right middle lobe orifice. . [**7-3**] U/S LUE: no DVT . [**7-3**] ECHO: no obvious vegetation, but can get TEE if suspicion is high serial CXRs: unchanged extensive opacification in the right lung and left lower lobe . serial CXRs (last one [**2113-7-7**]): extensive opacities in left lower lobe and right lung with no interval changes MICRO: [**7-1**]: 1 bottle gram pos, coag negative cocci, likely Staph epi from OSH [**2028-7-1**]: no growth to date . DISCHARGE LABS ([**2113-7-8**]): . WBC-16.6* RBC-3.91* Hgb-11.0* Hct-35.0* MCV-90 MCH-28.2 MCHC-31.5 RDW-16.3* Plt Ct-436 ([**2113-7-7**]) Neuts-94.8* Lymphs-2.3* Monos-2.8 Eos-0.1 Baso-0.1 Glucose-112* UreaN-24* Creat-0.8 Na-142 K-3.8 Cl-102 HCO3-33* AnGap-11 Calcium-8.5 Phos-2.4* Mg-2.1 Brief Hospital Course: 83F s/p AVR, with post-op course complicated by respiratory failure [**2-13**] pulmonary secretions, recurrent bilateral pleural effusions requiring thoracentesis, and concern for mass compressing right mainstem bronchus. Mass not seen on CT or Bronch, and biopsy showed normal tissue (cartilage, fibrin). Respiratory failure likely secondary to secretions, CHF, pleural effusions. . # Respiratory Failure - This was likely multifactorial, attributed to chronic post-op complications with significant secretions that she is having difficulty clearing, fluid overload due to acute on chronic systolic CHF, COPD exacerbation. She continues to have expiratory wheezing/rhonchi on exam. She had small PTX at R apex with chest tubes in place that improved, and the chest tubes were subsequently removed by Thoracic Surgery ([**7-5**], [**7-6**]). Her CXRs have remained stable after removal of the chest tubes, and her breathing remains the same. Radiologist noted sternal dehiscence, which Thoracic Surgery recommended could be followed as outpatient or if patient experiences symptoms. Pt was placed on steroid taper as her COPD exacerbation was improving. She will be discharged on PO prednisone 40mg daily 40mg daily [**Date range (1) 83026**], 20mg daily [**Date range (1) 83027**], 10mg daily [**Date range (1) 39988**], d/c [**7-30**]. Daily lung exams remain similar - patient has mild respiratory distress and uses accessory muscles, with rhonchorous breath sounds and bibasilar crackles. We have weaned her oxygen requirement down to 2L (95% O2 sat). Respiratory rate 16. Recommend to continue aggressive chest PT, nebulizers, mucomyst, and suction for thick secretions in lung. Continue diuresis as below. . # CHF ?????? Pt is s/p AVR (tissue valve). She responded well to IV Lasix 40mg [**Hospital1 **], reaching her goal of net negative 1L/day. Lisinopril was uptitrated in the Metoprolol was increased to 100 mg po TID to control her BP, which reached SBPmax 180. Recommend strict I/Os with goal of net negative 500-1000ml/day, daily weights, titrate Lasix dose as needed. Discharge Cr 0.8. . # HTN - Patient had elevated BP during her stay, up to SBP 180s. Uptitrated Metoprolol to 100mg TID and Lisinopril to 40mg daily. Current BP in 150s/60s. Continue to moniter as she is being diuresed and titrate as necessary. . # Bacteremia - Single OSH blood culture dated [**6-19**] from "line" reported +staph epi sensitive to vanc/tetracycline on [**6-25**]. [**7-1**] bcx growing GPC in pairs/chains. No stigmata of endocarditis at this time. TTE neg for veg on [**2113-7-3**]. Blood cultures from [**2028-7-1**] have no growth to date. Leukocytosis (11.7-16.6) likely secondary to steroid use, as there are no bands. WBC currently 16.6 with no bands. Recommend close follow up of WBC, f/u temperature closely (patient has not had fever throughout hospital course on the floor): keep low threshold for fever work-up/rule out pneumonia: chest x-ray, blood cultures, antibiotics. Patient is being treated for the initial positive blood cultures with vancomycin for a 2 weeks course, ending on [**2113-7-17**]. . # H/o AFib ?????? Patient is currently rate controlled in normal sinus rythym on metoprolol. Patient was not taking her home dose of amiodarone 200mg PO daily when she was transferred to this hospital, but was restarted on [**2113-7-3**]. [**Country **] score was calculated to [**2-14**], so anticoagulation was restarted at her home dose of Coumadin 2.5mg PO daily. INR subtherapeutic for several days, so Coumadin was increased to 5mg PO daily. Discharge INR is 1.4. Please continue Coumadin 5mg daily until INR>2, then decrease back to initial dose of 2.5mg daily. . # DIFFICULTY SWALLOWING - Patient is tolerating diet recommendations (thin liquid and pureed food, crushed pills mixed with puree, 1:1 supervision while eating, chin tuck, staying upright after meals) well. Consider Barium swallow study in the future - postponed for now due to limited mobility of patient. Please place patient on aspiration precautions. . # Anemia - Patient's baseline HCT is unknown, but per family, patient has a h/o "bleeding from GI system" which was evaluated by GI ~2y ago, with no clear source. Hct remained stable, currently Hct 33.8. . # Hypernatremia - Likely due to volume depletion during intubation. Na level improved with D5W, and patient is now allowed to take free water. Sodium is 142 today. Recommend to continue to monitor sodium, as it may rise as the patient continues to be diuresed. # CRI - By report, but currently creatinine is 0.8. Cr has been within normal limits throughout hospital stay. Please follow electrolytes with further diuresis. # DM - Pt has no h/o DM as per family, but was started on SSI at OSH, likely secondary to steroid use. FS range between 107-264. Recommend to continue sliding scale insulin and wean as steroids are tapered. # UPPER EXTREMITY EDEMA - Pt has upper extremity edema, left>right. DVT was ruled out with left upper extremity Doppler. Edema is improving with diuresis. Medications on Admission: Medications at Home: - Actonel qmonthly - Aspirin 81mg po qdaily - Amiodarone 200mg po qdaily - KCl daily - Lasix 80mg po qam, 40mg po qpm - MVI - Protonix 40mg po qdaily - Toprol 200mg po - Coumadin 2.5mg po - Lisinopril 20mg po - Zocor 40mg po . . Medications on Transfer: - Albuterol/Atrovent Duoneb INH Q6H - Pulmozyme 2.5mg IH [**Hospital1 **] - Epogen 20,000U SC x 1 ([**6-30**] 6PM) - Lasix 20mg iv x 1 ([**2113-7-1**] 12AM) - Imipenem-Cilastin 500mg IV Q8HR - Methylprednisolone 60mg IV Q8H (start [**2113-7-1**]) - Methylprednisolone 20mg IV BID (start [**2113-7-3**]) - Metoprolol 50mg po bid - Pantoprazole 40mg iv qdaily - Vitamin c 500mg po qdaily - Aspirin 81mg po qdaily - Colace 100mg po bid - Ferrous sulfate 325mg po qdaily - Lisinopril 2.5mg po qdaily - Simvastain 20mg po qdaily - Tylenol prn - Bisacodyl prn - Nicardipine gtt (started [**6-30**] 9AM) - Phenylephrine gtt (started [**6-27**] 11AM) -> not receiving on arrival - TPN gtt @ 65ml/hr - SSI - Ativan 0.25mg po qhs prn insomnia - Ativan 1mg po q6hr prn agitation Discharge Medications: 1. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Three (3) ML Miscellaneous Q 8H (Every 8 Hours). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) NEB Inhalation Q 8H (Every 8 Hours). 4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) NEB Inhalation Q6H (every 6 hours) as needed for wheezing. 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day) as needed for constipation. 9. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 10. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: One (1) dose PO DAILY (Daily). 11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) dose Injection TID (3 times a day). 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) NEB Inhalation Q6H (every 6 hours). 13. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 15. Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day. 16. Warfarin 2.5 mg Tablet Sig: 1-2 Tablets PO once a day: take 5mg/day until INR>2, then decrease to 2.5mg/day. 17. Furosemide 10 mg/mL Solution Sig: Four (4) ml Injection [**Hospital1 **] (2 times a day). 18. Prednisone 10 mg Tablet Sig: Four (4) Tablet PO once a day for 3 weeks: Steroid taper: week 1 ([**Date range (1) 83026**]): 40mg/day week 2 ([**Date range (1) 83027**]): 20mg/day week 3 ([**Date range (1) 39988**]): 10mg/day week 4: d/c . 19. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q 12H (Every 12 Hours) for 10 days: for 2 week course, end date: [**7-17**]. 20. Actonel 150 mg Tablet Sig: One (1) Tablet PO once a month. 21. Insulin Lispro 100 unit/mL Solution Sig: as directed by insulin sliding scale units Subcutaneous ASDIR (AS DIRECTED). 22. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane Q 12H (Every 12 Hours). 23. Outpatient Lab Work Please recheck INR, CBC with DIFF, CHEM7 with diuresis on [**7-9**], and afterwards as needed to follow INR, leukocytosis, and lytes. 24. Heparin Flush 10 unit/mL Kit Sig: Two (2) ml Intravenous every eight (8) hours. 25. Saline Flush 0.9 % Syringe Sig: Ten (10) ml Injection every 6-8 hours. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) **] Discharge Diagnosis: Primary diagnosis: respiratory failure pleural effusions Secondary diagnoses: acute on chronic systolic congestive heart failure hypertension bacterial infection: Staph epidermidis bacteremia atrial fibrillation s/p 2 chest tubes anemia s/p aortic valve replacement Discharge Condition: Improved, stable Discharge Instructions: You were treated at the hospital for respiratory failure due to a combination of recent chest surgery, fluid backup from your heart failure, and thick secretions in your lungs. While you were here, you underwent a bronchoscopy to take a look inside your lungs and to take a biopsy of a small lymph node. They did not see a mass, as it was previously thought you might have from previous studies at the outside hospital. The biopsy that they took showed normal tissue - cartilage, blood, and fibrin. Two chest tubes that were draining fluid from your lungs were removed, and your chest xrays have remained stable. Your breathing has continued to improve with the current medications, chest physical therapy, and suction. You were also evaluated for your swallowing ability while you were here. Be sure to continue the following recommendations: 1. 1:1 supervision while eating/drinking 2. you can have thin liquids and pureed food 3. crush pills and mix with puree 4. use chin tuck and stay upright after meals You have received a PICC line (semi-permanent IV line), so you have IV access for your antibiotics. The following changes were made to your medications: - You were started on Vancomycin, which is an antibiotic that you will receive through your PICC line until [**7-17**]. - You were given steroids (methylprednisolone) to help with your breathing. You will be discharged on Prednisone 40mg daily for 1 week and tapered down as tolerated. - Your dose of Warfarin was increased to 5mg daily until your INR>2. Then it can be decreased back to your normal done of 2.5mg daily. - Your dose of Lasix was changed to 40mg IV twice a day - Your dose of Toprol was changed to Metoprolol 100mg three times a day and Lisinopril to 40mg daily to control your blood pressure - You were started on a sliding scale of Insulin to control your high blood sugars, likely secondary to the steroid use. If you have difficulty breathing/worsening shortness of breath, chest pain, fevers, chills, or any other concerning symptoms, please call your physician or return to the hospital. It was a pleasure meeting you and taking part in your care. Followup Instructions: - strict I/Os with goal of net negative 500-1000ml/day, daily weights, titrate Lasix dose as needed - f/u temperature closely (patient has not had fever throughout hospital course on the floor): keep low threshold for fever work-up/rule out pneumonia: chest x-ray, blood cultures, antibiotics - INR checks: when INR>2, decrease Warfarin dose from 5mg to 2.5mg daily - aggressive chest PT, nebulizers, mucomyst, and suction for thick secretions in lung - oral predinose taper: 40mg daily [**Date range (1) 83026**], 20mg daily [**Date range (1) 83027**], 10mg daily [**Date range (1) 39988**], d/c [**7-30**] - IV vancomycin until [**7-17**] Please follow-up with your primary care physician and your cardiology, Dr. [**Last Name (STitle) 13310**] ([**Telephone/Fax (1) **]), within 1-2 weeks of discharge. Please follow-up any chest discomfort. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

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icd9cm

[ [ [] ] ]

[ "33.91", "96.05", "40.11" ]

icd9pcs

[ [ [] ] ]

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7379, 12418

348, 421

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32457

Discharge summary

report

Admission Date: [**2113-9-29**] Discharge Date: [**2113-10-2**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 9853**] Chief Complaint: Shortness of Breath. Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Name14 (STitle) 75755**] is a [**Age over 90 **] y.o. F from NH with CAD s/p MI, DM type 2, CVA (nonverbal at baseline), presenting with respiratory distress and shortness of breath. Pt noncommunicative at baseline so history obtained from ED records, NH records and per ED resident. Pt was found with labored breathing with RR 43 and O2 sat 88% on 2 L NC. Ipratropium neb provided at NH without any effect. Continued to have respiratory distress with sats in 70-81%. Nonrebreather improved sat to 81-84%. VS 132/109 and tachy at 113. Noted to be clammy and sweating profusely. FS 223 at that time. Per NH notes, pt had similar episode earlier in day. Gave mag citrate with 1 large BM and vomiting x 1. . In the ED: VS T 100 rectally BP 146/82 HR 99 RR 32 99% 15 L NRB Per ED notes, audible crackes. EKG done that did not show any acute changes. Foley inserted. Portable CXR completed with possible effusion/consolidation. CT head negative. Had already been started on Keflex 500 TID at NH on [**2113-9-27**] for unknown reason. Also on Valtrex for H. zoster since [**9-27**]. Given ceftriaxone, vancomycin, and azithromycin. BCx and UCx drawn. DNR status confirmed by ED resident with HCP, but intubation acceptable. Per ED nurses, pt appears at her baseline as she is frequently in ED. . On arrival to ICU, pt appears comfortable. Was initially on NRB and now currently on 4 L NC with O2 sats in high 90s. Past Medical History: 1. Coronary artery disease with 4 stents placed [**2111-8-1**] at [**Hospital1 2025**] 2. Hypertension 3. Diabetes mellitus type 2 4. CVA [**9-/2111**] (nonverbal at baseline) 5. Macular degeneration, legally blind 6. G-tube placement (all nutrition via G-tube per GI) 7. Hypothyroidism 8. Hyperlipidemia 9. Anemia 10. Depression Social History: From [**Hospital1 **] NH. Son is HCP. [**Name (NI) 4084**] smoked, minimal prior alcohol use, no illicit drugs. Of Latvian descent and has devoted children. Lives at [**Hospital1 **] senior care. Retired from working at histology lab at [**Hospital1 2025**]. Was very independent prior to CVA. Family History: Noncontributory Physical Exam: VITALS: T: 93.2 Ax --> 99.8 Rectally BP: 148/90 HR: 82 RR: 28 O2Sat: 96% 4 L NC GEN: NAD, unresponsive to voice or sternal rub; when trying to open eyes, pt does try to shut them. HEENT: unable to assess EOMI, but pupils reactive to light. R pupil deviated inward while L pupil in center. unable to assess OP, no LAD CHEST: rhonchi in middle-lower lung fields with scattered exp wheezes and soft inspiratory crackles at bases CV: RRR, no m/r/g appreciated ABD: NDNT, soft, NABS EXT: no c/c/e NEURO: unknown baseline, but noncommunicative to voice or sternal rub SKIN: no rashes noted Pertinent Results: [**2113-9-29**] 08:45PM WBC-9.2 RBC-4.26 HGB-12.6 HCT-39.0 MCV-92 MCH-29.5 MCHC-32.3 RDW-20.5* [**2113-9-29**] 08:45PM cTropnT-0.04* [**2113-9-29**] 08:45PM GLUCOSE-249* UREA N-49* CREAT-1.2* SODIUM-143 POTASSIUM-6.2* CHLORIDE-110* TOTAL CO2-15* ANION GAP-24* [**2113-9-29**] 10:10PM URINE RBC-0 WBC-[**12-21**]* BACTERIA-FEW YEAST-FEW EPI-[**4-5**] [**2113-9-29**] 10:10PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM HEAD CT WITHOUT IV CONTRAST [**2113-9-29**]: There is again demonstrated a large chronic infarction of the left temporoparietal region. There is no hemorrhage, evidence of acute edema, mass effect, or shift of normally midline structures. The ventricles and sulci are prominent and consistent with age-related parenchymal atrophy. There is periventricular hyperdensity in a pattern consistent with chronic small vessel ischemic disease. Numerous carotid calcifications are identified. The visualized paranasal sinuses are clear. Soft tissues are remarkable only for evidence of prior cataract surgery. IMPRESSION: No evidence of fracture, hemorrhage, or edema. CXR [**2113-9-29**] IMPRESSION: Left basilar opacification may represent atelectasis or aspiration pneumonia. A left sided effusion is not excluded. Hazy left upper lobe opacification could represent superimposed asymmetric pulmonary edema. CXR: [**2113-9-30**] IMPRESSION: Interval improvement in pulmonary vascular congestion. Persistent left pleural effusion. The retrocardiac area is not well penetrated and atelectasis or consolidation in the left lower lobe cannot be excluded. [**2113-10-2**] 06:50AM BLOOD WBC-10.3 Hgb-10.6* Hct-36.0 MCHC-31.8 Plt Ct-257 [**2113-10-2**] 06:50AM BLOOD Glucose-171* UreaN-52* Creat-1.2* Na-144 K-4.0 Cl-110* HCO3-22 AnGap-16 Brief Hospital Course: # SOB: Resolved by time of arrival in ICU. BNP>[**Numeric Identifier **]. SOB responded to IV lasix. Given nebulizers, CE x3 negative. BUN and Creat slightly higher than baseline at 52/1.2. Currently receiving lasix 40 mg daily and received an extra dose of 20 mg today for episode of congestion and SOB with O2sat of 82%. With 02 via NC replaced she returned to 02 sat of 94%. Pt. frequently removes the oxygen. Her pattern of breathing (intermittent tachypnea) has been noted in the past and may be due to intermittent discomfort (e.g., from constipation). She may receive supplemental oxygen prn at her nursing home. # CHF, acute on chronic, diastolic and systolic: EF 20-25% on [**12/2112**] echo. - continued ACE-I, lasix and spironolactone - received IV diuresis in the ICU and BP remained stable. SOB and 02 sat improved and she was restarted on usual dose of lasix per peg tube. # Diabetes, type 2 - has been covered with regular insulin sliding scale. Tube feedings have been gradually titrated to 60 cc/hr with rising blood sugar today to 300. She does not show any signs of active infection. She has remained afebrile and her WBC is normal at 10.3. # UTI: When admitted she was already on cephalexin and the urine culture done here grew yeast with UA positive for bacteria and WBCs. UCx grew 10,000 - 100,000 yeast. She was treated with Ceftriaxone on admission. She continued on cephalexin throughout her hospital stay and the 7th and final day is today, [**2113-10-2**]. # Herpes zoster, left T7-8 dermatome: Last day of Valtrex is today. Lesions have scabbed over, she does not require precautions. # Diarrhea: C diff x1 negative. Diarrhea was resolved by [**10-1**]. # Depression: She is on effexor, but her MS at this time is impossible to evaluate. She is non verbal and does not interact in any meaningful fashion. Consideration should be given to discontinuing antidepressant medication if it is not known to be beneficial for her. # stage II decubitus pressure ulcers: sacrum and mid-back, local wound care continued. # Advanced Care Planning: She and her son may benefit from a palliative care consultation to clarify the goals of care. # Code status: DNR, may be intubated. Medications on Admission: Timolol 0.25% eye drops 1 drop in each eye [**Hospital1 **] Venlafaxine 37.5 mg via GTube Vit D 50,000 unit capsule 1 capsule via G-tube once a month (due on [**2113-10-9**]) Metoclopramide 5 mg [**Hospital1 **] KCl 20 meq/15 ml concentration; 7.5 ml daily Spironolactone 25 mg daily Protonix 40 mg daily Acetaminophen 650 mg po q4 hours prn Milk of Magnesia 30 ml daily prn constipation Dulcolax 10 mg prn Fleet Enema prn Albuterol sulfate neb q6 hour prn Ipratropium neb q6 hour prn ASA 81 mg daily Carvedilol 12.5 mg [**Hospital1 **] Ferrous sulfate 7.5 ml daily Furosemide 40 mg dialy Keppra 250 mg oral solution daily Levothryroxine 125 mcg daily Lisinopril 20 mg daily Vicodin 5/500 mg 1 tablet q4 hours prn pain Valtrex 1 gm TID x 1 week (uncertain when doses started/ended) Keflex 500 mg TID x 1 week (uncertain when doses started/ended) . Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY as needed. 2. Senna 8.6 mg Tablet Sig: One Tablet PO BID (2 times a day) as needed. 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One Injection TID (3 times a day). 4. Timolol Maleate 0.25 % Drops Sig: One Drop Ophthalmic [**Hospital1 **] (2 times a day). 5. Venlafaxine 37.5 mg Tablet Sig: One Tablet PO BID (2 times a day). 6. Metoclopramide 10 mg Tablet Sig: One Tablet PO BID (2 times a day). 7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One Tablet, PO DAILY. 8. Docusate Sodium 50 mg/5 mL Liquid Sig: One PO BID (2 times a day). 9. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: One PO DAILY 10. Levetiracetam 100 mg/mL Solution Sig: One PO DAILY 11. Levothyroxine 125 mcg Tablet Sig: One Tablet PO DAILY 12. Insulin Regular Human 100 unit/mL Solution Sig: One Injection AS DIRECTED. 13. Carvedilol 12.5 mg Tablet Sig: One Tablet PO BID (2 times a day). 14. Furosemide 40 mg/5 mL Solution Sig: One PO DAILY 15. Lisinopril 10 mg Tablet Sig: Two (2) Tablet PO DAILY 16. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One Inhalation PRN for wheezing. 17. Ipratropium Bromide 0.02 % Solution Sig: One Inhalation Q6H (as needed for wheezing. 18. Valacyclovir 500 mg Tablet Sig: One Tablet PO TID (3 times a day): last dose [**2113-10-2**] pm. 19. Cephalexin 500 mg Capsule Sig: One Capsule PO Q8H (every 8 hours): last dose [**2113-10-2**] pm. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] of [**Location (un) 55**] Discharge Diagnosis: Primary Diagnoses: Acute on Chronic Diastolic and Systolic Congestive Heart Failure Secondary Diagnosis: Urinary Tract Infection Herpes zoster Left T7-8 dermatome Coronary artery disease with 4 stents placed [**2111-8-1**] at [**Hospital1 2025**] Hypertension Diabetes mellitus type 2 CVA [**9-/2111**] (nonverbal at baseline) Macular degeneration, legally blind G-tube placement (all nutrition via G-tube per GI) Hypothyroidism Hyperlipidemia Anemia Depression Discharge Condition: Removes O2 and becomes SOB at times. Desats to low 80's, returns to normal with O2 in place. Tolerating tube feeds well. Episodic hyperglycemia treated with sliding scale regular insulin. Discharge Instructions: Monitor for weight gain, edema, cough, congestion. Followup Instructions: To be seen by nursing home MD

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

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50011

Discharge summary

report

Admission Date: [**2130-2-18**] Discharge Date: [**2130-2-22**] Service: MEDICINE Allergies: Aspirin / Codeine / Penicillins / Actonel Attending:[**First Name3 (LF) 689**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 89 yo F with PMH of [**Last Name (un) 309**] Body dementia, asthma, HTN, RA who had recently been in the a rehab facility for 3 weeks following a [**1-26**] d/c from [**Hospital1 18**] for failure to thrive and dehydration, who was discharged to home the day prior, now p/w with hypoxia and SOB. States that she developed a cough 2-3 days prior that was productive of a green phlegm which she attributes to an asthma flair. States that she often gets phlegm with her asthma and thinks this presentation is quite similar. Denies F/Ch, N/V, diarrhea, dysuria, constipation or other systemic complaint. Son, [**Name (NI) **], states she took in minimal oral intake the day prior and had newly started Lasix 20mg [**Hospital1 **] x approximately 10 days for LE swelling, which has improved. This AM complained of SOB and home health aide thought she looked unwell so called EMS. Had sat 91% on RA and was given supplemental O2. Initial EMS VS 96/62, 74, 24 and 91%/RA and noted to be in AFib (no EKG to verify). Brought to [**Hospital1 18**], triage VS 98.3, 99/64, 74, 16 and 100/4L. On initial ED exam was wheezing and rhonchorous. Got Combivent and felt much better. Given 40mg po KCl. 120mg Methylprednisone, 750mg Levofloxacin. She was then noted to have decreased BP, with low of 75/45. She was given 2L NS, still SBP 70s, RR 20, 100/4L, and HR 102 when trying to get on bed pan. CXR limited due to hiatal hernia. Has one PIV. Per ED resident, thinks BP is low at baseline. Upon transfer VS 79/44 and HR 91. On arrival to the ICU, patient conversant and able to relay story as above. Denies any CP or other new complaint. Thinks she should have acted more quickly about the SOB, and tightness in her breathing. Son, [**Name (NI) **], is at bedside and helps with relaying history. Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: Past Medical History: - [**Last Name (un) 309**] body dementia: previously on Aricept, stopped for diarrhea, did not tolerate galamantine either - Distant history of H. pylori related gastric ulcer - Diarrhea, chronic and of unclear etiology. - Osteoporosis with spinal compression fractures. T score @ Lspine -1.2, at femoral neck -3.3, stopped Actonel [**12-26**] diarrhea - Rheumatoid arthritis/CPPD: Prednisone and plaquenil initiated [**2128**], prednisone since tapered off - Anemia: seen by hematology, thought to be [**12-26**] inflammation and CKD - Failure to thrive - Asthma: denies any h/o intubation or daily Albuterol use - Hypertension Social History: She never smoked, does not drink, lives with her husband who has himself been hospitalized recently. She lays in bed most of the day and requires assistance to go to the bathroom. Family History: Significant for gastric cancer in her sister who died of the disease. Physical Exam: Vitals: T: 95.3 BP: 73/45 --> 91/45 P: 85 R: 15 O2: 97/3L NC General: Alert, oriented, no acute distress but appears chronically unwell with eyes closed, answers appropriately to questions HEENT: Sclera anicteric, MM mildly dry, oropharynx clear Neck: supple, JVP flat, no LAD Lungs: with notable inspiratory and expiratory wheeze on exam, no rale or ronchi; severe kyphosis CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present but hypoactive, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis; 1+ edema in RLE, none in LLE Skin: Pale, dry; one 2cm laceration with minimal surrounding erythema and some serous drainage on L medial distal calf Pertinent Results: ADMISSION LABS [**2130-2-18**] 06:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.007 BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-SM [**2130-2-18**] 06:45PM URINE RBC-0 WBC->50 BACTERIA-MANY YEAST-NONE EPI-0 TRANS EPI-0-2 [**2130-2-18**] 04:10PM LACTATE-1.8 [**2130-2-18**] 03:55PM GLUCOSE-116* UREA N-23* CREAT-1.2* SODIUM-141 POTASSIUM-2.9* CHLORIDE-99 TOTAL CO2-35* ANION GAP-10 [**2130-2-18**] 03:55PM WBC-7.8# RBC-3.56* HGB-11.1* HCT-33.3* MCV-94 MCH-31.4 MCHC-33.5 RDW-14.8 [**2130-2-18**] 03:55PM NEUTS-67.9 LYMPHS-27.1 MONOS-2.5 EOS-2.4 BASOS-0.2 [**2130-2-18**] 03:55PM PLT COUNT-212 [**2130-2-18**] 03:55PM PT-12.1 PTT-28.6 INR(PT)-1.0 [**2130-2-20**] 05:00AM BLOOD WBC-8.3 RBC-2.79* Hgb-8.8* Hct-26.3* MCV-95 MCH-31.7 MCHC-33.6 RDW-15.1 Plt Ct-176 [**2130-2-20**] 05:00AM BLOOD Glucose-97 UreaN-20 Creat-1.0 Na-142 K-3.8 Cl-109* HCO3-27 AnGap-10 [**2-19**] Urine culture: No growth [**2-18**] Blood cultures x2 pending on discharge [**2-20**] CXR FINDINGS: As compared to the previous radiograph, there are signs of moderate overhydration. The size of the cardiac silhouette is unchanged. Bilateral partial atelectasis, a small pleural effusion might be present bilaterally. There is no evidence of newly occurred focal parenchymal opacities. Brief Hospital Course: 89 yo F with FTT and asthma, admitted with productive cough and hypotension. 1. Hypotension: resolved. Likely due to failure to thrive and chronic poor intake, in the setting of continuing antihypertensives. She was also found to have a UTI on admission. The son confirms that she has had poor po intake, and recently started lasix 20mg [**Hospital1 **] x10 days for LE edema, and patient appeared hypovolemic on admission. The patient was admitted to the MICU and fluid resuscitated. She completed a course of Levaquin for UTI. The patient developed pulmonary edema subsequent to IV fluids and required 4 L supplemental oxygen but remianed comfortable. She was treated for possible asthma exacerbation with albuterol and prednisone taper. The patient was also noted to be in acute renal failure in the setting of diuretics and poor oral intake, which resolved with hydration. On the day of transfer to the floor, the patient received 5mg IV Lasix to aid with diuresis and was resting comfortably. -Please follow up blood cultures from [**2-18**] 2. History of Hypertension: Patient initially hypotensive on admission. HCTZ and Lasix were held. After stabilization with IV fluids, BPs ranged from 130s-160s/50s-90s. However, given that she presented with hypotension and dehydration, all antihypertensives were held. Patient can resume lasix at 20mg po every other day. Discontinue HCTZ. Please assess fluid status, kidney function, blood pressure. If appears fluid depleted, consider discontinuing lasix. . # Asthma: Patient was treated with Albuterol and Ipratropium nebulizers, and prednisone taper. She will need to finish 2 more days of Prednisone 20mg po qd after discharge. She was not require oxygen for 48 hours prior to discharge. . # Acute Renal Failure: resolved. Likely [**12-26**] Lasix, HCTZ and poor po intake. With elevated bicarbonate c/w contraction alkalosis. Resolved with IV fluids. No further fluids given volume overload. Patient was encourage to take oral fluids. . # [**Last Name (un) 309**] Body Dementia: Continued on Methyldopa & Seroquel. . # Rhuematoid arthritis: Continued on Plaquinel. . # Osteoperosis: With score @ Lspine -1.2, at femoral neck -3.3. Did not tolerate Actonel. Continued on Calcium / Vitamin D . Medications on Admission: Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig: One (1) spray Nasal DAILY (Daily): alternate nostrils. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal [**Hospital1 **] (2 times a day). Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)Capsule, Delayed Release(E.C.) PO DAILY (Daily). Ipratropium Bromide 0.02 % Solution Sig: One (1)Inhalation Q6H (every 6 hours) as needed. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS HCTZ 25 mg daily Hydroxychloroquine 200 mg daily Moexipril 7.5 mg daily Calcium 600 mg, VitD 200 U Loperamide PRN Methyldopa 500 mg twice daily Lasix 20mg po BID (started about 10 days prior) Discharge Medications: 1. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig: One (1) spray Nasal DAILY (Daily). 2. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal [**Hospital1 **] (2 times a day). 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 6. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 11. Prednisone 20 mg Tablet Sig: One (1) Tablet PO daily () for 2 days: Please administer on [**2-23**] and 3rd. 12. Lasix 20 mg Tablet Sig: One (1) Tablet PO every other day. Discharge Disposition: Extended Care Facility: [**Hospital3 2732**] & Retirement Home - [**Location (un) 55**] Discharge Diagnosis: Primary diagnosis: 1. Asthma exacerbation 2. Urinary tract infection 3. Hypotension 4. Acute renal failure Secondary diagnosis: Anemia of chronic disease [**Last Name (un) 309**] body dementia Rheumatoid arthritis Osteoperosis Discharge Condition: Stable. Breathing comfortably on room air. Discharge Instructions: You were admitted with an asthma exacerbation and with low blood pressure. You were in the intensive care unit and given IV fluids to get your blood pressure up. We treated your asthma with albuterol, ipratropium inhalers, and steroids. You were transferred out of the intensive care unit and your blood pressure and breathing stabilized. You will need to continue taking steroids for 2 more days after discharge, to help with your breathing. Your HCTZ and lasix were stopped during your hospital stay. Please do not start taking this again until you see your primary care doctor. We are restarting your lasix at 20mg every other day. If the patient develops difficulty breathing, shortness of breath, cough, fevers, chills, lightheadedness, chest pain, or any other symptoms that concern you please call the primary care provider or send the patient to the emergency room. Followup Instructions: You have an appointment with Dr. [**Last Name (STitle) **] on [**3-3**] at 9:30am. The clinic phone number is [**Telephone/Fax (1) 50382**]. Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 1690**] Date/Time:[**2130-3-3**] 9:30 Completed by:[**2130-2-22**]

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Discharge summary

report

Admission Date: [**2108-2-4**] Discharge Date: [**2108-2-7**] Date of Birth: [**2036-7-11**] Sex: M Service: NEUROLOGY Allergies: Haldol / Prolixin / Sulfasalazine / Thorazine Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: Right sided weakness and dysarthria Major Surgical or Invasive Procedure: None History of Present Illness: Neurology at bedside for evaluation after code stroke activation within: 5 minutes Time (and date) the patient was last known well: 1300 (24h clock) NIH Stroke Scale Score: 6 (on initial exam) t-[**MD Number(3) 6360**]: No Reason t-PA was not given or considered: Hx of b/l SDH [**2100**], improvement in symptoms I was present during the CT scanning and reviewed the images instantly within 20 minutes of their completion. NIH Stroke Scale score at 1600 was 6: 1a. Level of Consciousness: 0 1b. LOC Question: 0 1c. LOC Commands: 0 2. Best gaze: 0 3. Visual fields: 0 4. Facial palsy: 1 5a. Motor arm, left: 0 5b. Motor arm, right: 1 6a. Motor leg, left: 0 6b. Motor leg, right: 1 7. Limb Ataxia: 2 8. Sensory: 0 9. Language: 0 10. Dysarthria: 1 11. Extinction and Neglect: 0 HPI: [**Known firstname **] [**Known lastname **] is a 71y M with a history of CAD s/p CABGx2, HTN, DM, b/l SDH in [**2100**] and paranoid schizophrenia. He presents today s/p fall at his group home with right sided weakness and new dysarthria. At 1300 today, pt was observed by facility supervisor ([**Doctor Last Name 8214**]) to be dragging his right leg when returning to his room. She asked him if his leg was in pain and he said it was. He was last seen normal at 1215 when they went out to lunch at a restaurant. The supervisor had worked with him earlier that morning and had not noticed any abnormalities. Since [**2101**], he has used a walker for an unsteady gait. Between 1500 and 1530, the patient had an unobserved fall in his room. He knocked on the wall to get the attention of his nurse. She found him on the floor without any obvious trauma. He could not stand up on his own, so she called EMS. When they arrived and started asking him questions, she noticed that he was slurring his words. At the time, he confirmed weakness in his right arm and leg. He has a bilateral tremor and tardive dyskinesia at baseline, but the tremor appeared worse to her at the time. The patient was brought to the hospital, where his initial vitals were BP 137/87 HR 82 RR 18 O2 90%. A code stroke was called at 1600; the ED calculated NIHSS as 4. On exam, he showed right-sided mild weakness (?face, +drift, +leg drift) and right-sided ataxia. His labs were notable for a Glucose of 372 and a Cr of 2.0 (baseline CKD with b/l Cr ~2.1). He was taken for a non-contrast head CT, which did not show an acute intracranial hemorrhage or acute infarct (see below). We added CT-P and CT-A (see below), which were unrevealing. By 1700, his exam showed increased strength (no more drift) and less ataxia in right arm and leg. His tremors (primarily Left pill-rolling and jaw/[**Year (4 digits) **] TD-type movements) persisted. Due to the improvemed exam and more imprortantly the history of prior bilateral subdural hematoma, t-PA was not given. The patient has not had surgery in the last three weeks. As far as his group home worker knows, he does not have a history of stroke (the Right-parietal hypodensity on CT was apparently a silent or undocumented infarct). He had a b/l subdural hematoma after a fall in [**2100**] that may have been traumatic though unclear. [**Name2 (NI) **] did take his Aspirin and Plavix this morning. Past Medical History: # CAD/CHF -- on Lasix, dig, BB, ASA/Plvx --Last echo @OSH ([**Hospital1 **]) in [**2106-10-18**] showed EF of 40%, mild TR and AR. Moderate diastolic dysfunction. - TTE ([**2102-7-14**])- poor windows. Decreased systolic function could not be quantified. 2+ MR (? underestimated), 3+ TR --[**2102-6-9**] CABGx2 (SVG->LAD, SVG->OM) and MV Repair (27mm Duran ancore band) - TEE ([**6-9**] intraop)- EF 25% - TTE ([**2102-6-7**])- EF 25-30% - TEE ([**7-22**]): LVEF 30-35% mod global HK, 2+ MR # Hypertension # Hyperlipidemia on statin # Mental retardation # Paranoid schizophrenia on risperdone # Diabetes mellitus. Currently on 75-25 Humalog (6U at 7:30AM and 3U at 4PM) and Lopid # Subdural hematomas [**7-22**]. Described by Neurosurgery at that time as being chronic, though SDH was found after fall. # h/o MSSA bacteremia # Chronic renal insufficiency. Last CrCl was 54 (Cr 2.1) in [**2101**]. # Hypothyroidism on Synthroid #Lower GI bleed. Admitted to [**Hospital1 **] [**Location (un) 620**] in [**9-/2106**] for GI bleed and anemia from internal hemorrhoids. Last colonoscopy in [**2105**] showed multiple colon polyps and internal hemorrhoids. Social History: Lives at [**Location 11292**] group home. Has roomate. [**First Name4 (NamePattern1) 8214**] [**Last Name (NamePattern1) 8389**] = supervisor ([**Telephone/Fax (1) 93356**]. Able to dress and shower himself. He does need assisstance with cleaning and cooking. Family History: noncontributory Physical Exam: ADMISSION EXAM: Vitals: T (initially afebrile-->)102.8 BP 137/87 HR 82 RR 18 O2 90% General: Well-appearing, awake, alert. Quiet, but polite and responsive to pointed questions. TD-type jaw movements. Pill-rolling tremor of left index fgr/thumb. Neck: supple, no meningismus. No goiter. No LAD. No bruits appreciated in loud ED. CV: RRR w/o loud M/R/G appreciated in loud ED. Lungs: CTA anteriorly. Non-labored. Abdomen: Soft, NT/ND. Extr: Warm and well-perfused. No edema. Smooth/hairless shins. Dry feet. (PAD-type appearance). Good distal pulses. Neurologic exam: MS: Awake and alert. Oriented to "[**Known firstname **] [**Known lastname **]" [**2107**], [**Month (only) 956**]. Tracks in all directions. Follows most simple commands, but exam is highly limited by motor perseveration on recent tasks. Inattentive to DOWbw (gives fw). Naming intact to all NIHSS items except cactus. Repetion intact to "today is a sunny day in [**Location (un) 86**]." Fluent, but no spontaneous speech and short responses. CN: II: PERRL. Visual fields grossly full on limited exam (makes saccades to fingers moving on either side of direction of primary gaze, up and down on each side). III, IV, VI: EOMs grossly full and conjugate, no nystagmus (limited exam [**1-19**] perseveration/inattention). difficult to assess because patient moves gaze. V: symmetrically intact to pinprick V1-V2-V3. VII: difficult to assess due to TD jaw/lip-smacking movements. [**Month (only) 116**] be weaker on the Left than right, unclear. [**Name2 (NI) **] tremor. Speech was mildly dysarthric initially, but improved on re-examination after CT. IX/X/XII: palate elevates symmetrically and [**Name2 (NI) **] protrudes midline. Motor: Exam limited by inattention, motor perseveration, ?lack of effort, and tremor. - Right pronates and drifts down initially; on repeat testing, it pronates, but he keeps it up (left does not pronate/fall). Both delts are breakable ([**3-22**] ?effort) whereas triceps are full ([**4-21**]) bilaterally. - Initially unable to hold Right leg up against gravity for more than a second or two (left leg holds indefinitely), but improved on re-examination to same as left. Initially decreased tone in Right leg only, but improved on re-examination. Both IPs are breakable ([**3-22**] ?effort). Cerebellar: Grossly dysmetric FNF and HKS in the Right arm and leg. Left side has tremor, which abated with FNF, no dysmetria. LLE HKS smoother, but exam limited by cooperation/attention. Reflexes: symmetrically brisk, non-pathologic. Right toes mute-to-?up / left toes equivocal-to-?down. Sensory: Pt reports symmetric prinprick and light touch in all extremities. Otherwise limited exam. DISCHARGE EXAM: Able to hold all extremities anti-gravity and against resistance, though has some difficulty understanding all commands. Mild dysmetria bilaterally, right slightly greater than left. Pertinent Results: ADMISSION LABS: [**2108-2-4**] 04:15PM BLOOD WBC-14.4* RBC-3.27* Hgb-11.3* Hct-32.1* MCV-98 MCH-34.5* MCHC-35.1* RDW-12.5 Plt Ct-211 [**2108-2-5**] 02:04AM BLOOD Neuts-83.2* Lymphs-10.7* Monos-5.1 Eos-0.7 Baso-0.3 [**2108-2-4**] 04:15PM BLOOD PT-11.7 PTT-26.9 INR(PT)-1.1 [**2108-2-5**] 02:04AM BLOOD Glucose-108* UreaN-50* Creat-1.8* Na-142 K-3.8 Cl-105 HCO3-27 AnGap-14 [**2108-2-5**] 02:04AM BLOOD ALT-11 AST-22 AlkPhos-133* TotBili-0.2 [**2108-2-5**] 02:04AM BLOOD cTropnT-0.03* proBNP-1866* [**2108-2-5**] 02:04AM BLOOD Albumin-3.8 Calcium-8.8 Phos-3.4 Mg-2.1 Cholest-103 [**2108-2-5**] 02:04AM BLOOD Triglyc-76 HDL-32 CHOL/HD-3.2 LDLcalc-56 [**2108-2-5**] 02:04AM BLOOD TSH-0.49 [**2108-2-4**] 04:15PM BLOOD Digoxin-0.5* [**2108-2-4**] 04:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2108-2-4**] 04:29PM BLOOD Glucose-372* Na-139 K-4.9 Cl-95* calHCO3-30 DISCHARGE LABS: [**2108-2-7**] 06:45AM BLOOD WBC-11.9* RBC-2.96* Hgb-10.0* Hct-28.5* MCV-96 MCH-33.8* MCHC-35.2* RDW-12.6 Plt Ct-187 [**2108-2-7**] 06:45AM BLOOD Glucose-137* UreaN-42* Creat-1.7* Na-135 K-4.5 Cl-98 HCO3-29 AnGap-13 [**2108-2-6**] 05:10AM BLOOD ALT-8 AST-17 AlkPhos-105 TotBili-0.2 [**2108-2-7**] 06:45AM BLOOD Calcium-9.0 Phos-2.9 Mg-1.8 IMAGING: CT/CTA/CTP non-con head: 1. no ICH; grey-white appears preserved; equivocal dense L MCA. 2. if CTA performed, IV hydration recommended given the Cr of 2.0. CTA: anterior and posterior circulations patent; calcified atherosclerotic disease of both cavernous internal carotid arteries. CTP: no blood flow, blood volume, or mean transit time asymmetries. CXR: FINDINGS: Frontal and lateral views of the chest were obtained. There are right greater than left upper lobe patchy opacities, raising concern for underlying infection. Patient is status post median sternotomy and CABG. Prosthetic mitral valve is unchanged in appearance. No pleural effusion or pneumothorax is seen. Cardiac and mediastinal silhouettes are grossly stable MRI Brain: IMPRESSION: 1. No acute infarct. Nonspecific FLAIR hyperintense foci as described above. 2. MR angiogram of the head and neck, is suboptimal due to reasons mentioned above. Within this limitation, major arteries are patent without focal flow-limiting stenosis. Please see the prior CT angiogram study for subsequent details. The P1 segment of the right posterior cerebral artery is diminutive in size, with a fetal PCA pattern and prominent posterior communicating artery. 3. Focal prominence of the ACOM complex is likely related to confluence of the arteries. Brief Hospital Course: Mr. [**Known firstname **] [**Known lastname **] is a 71 year old man with a history of CAD s/p CABG, HTN, DM, bilateral SDH in [**2100**] and paranoid schizophrenia presenting with right sided weakness and dysarthria. NEURO: On the day of arrival he was noted to be dragging his right leg and was brought to the ED where a Code Stroke was called. He had a CT scan, CTA, and CT perfusion which showed no sign of an infarct, and he rapidly improved on arrival to the [**Last Name (LF) **], [**First Name3 (LF) **] no tPA was given. He was admitted to the Neurology service, where he underwent an MRI of the brain, which showed no signs of an acute infarct. He did develop a fever of 102.8 shortly after arrival, and was found to have a UTI and pneumonia. His neurologic exam rapidly improved with treatment of these infections, and it was thought that his symptoms were primarily due to this. CV: He has a history of CAD and CHF. His aspirin was continued. Given the initial concern for stroke, his Lasix was held, however was restarted when it was determined that infection was the primary etiology of his symptoms. He had a very slight troponin increase on arrival that was thought to be related to his underlying renal failure. Respiratory: He had a chest x-ray which showed evidence for pneumonia. He was stable on room air. ID: His U/A grew e coli that was sensitive to cephalosporins, and he was started on ceftriaxone, to be transitioned to cefpodoxime as an outpatient, to continue through [**2-10**]. For his community acquired pneumonia he was started on doxycycline, to be continued through [**2-17**]. Psych: He was continued on his home regimen of risperdal, zoloft, ativan and neurontin, without incident. Rehab goals: He will not require more than 30 days of rehab. Medications on Admission: Humalog 75/25 (3U at 4:30PM, 6U at 7AM) Aspirin 162 mgs daily (AM) Plavix 75mg daily (AM) Toprol XL 50 mg Daily (PM) Zocor 40 mg daily (PM) Lasix 60 mg (M-F, AM) Lopid 600 mg [**Hospital1 **] Digitek 0.0625 mg daily (AM) Kayexalate 40 cc powder (MWF in AM) Neurontin 800 mg [**Hospital1 **] Risperdal 0.5mg daily at 8PM Zoloft 100 mg Daily at 8pm Ativan 0.5 mg [**Hospital1 **] Tramadol 50 mg PRN q6hrs Ranitidine HCl 300 mg (Daily AM) Synthroid 0.025 mg daily (AM) Colace 100 mg PRN Milk of Magnesia 30 mL PRN every 12 hours Robitussin 2 tsp PRN q4h Simethicone 40 mg TID Tylenol 650 mg PRN q4hrs Vit B12 1000 mg daily (PM) Vitamin D 1200 IU daily (AM) Calcitriol 0.025 mg (MWF in AM) Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 2. Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: Three (3) units Subcutaneous 4:30 PM. 3. Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: Six (6) units Subcutaneous 7 am. 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO HS (at bedtime). 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lasix 20 mg Tablet Sig: Three (3) Tablet PO once a day: Give Mon-Fri. 8. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. sodium polystyrene sulfonate 15 g/60 mL Suspension Sig: One (1) dose PO MWF (Monday-Wednesday-Friday). 11. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 12. risperidone 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. sertraline 50 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 14. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO twice a day. 15. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain; home med. 16. ranitidine HCl 300 mg Capsule Sig: One (1) Capsule PO once a day. 17. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 19. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) mL PO every twelve (12) hours as needed for constipation. 20. simethicone 80 mg Tablet, Chewable Sig: 0.5 Tablet, Chewable PO TID (3 times a day). 21. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever >101. 22. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 23. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Three (3) Tablet PO DAILY (Daily). 24. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO MWF IN AM (). 25. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 10 days: Through [**2-18**]. Disp:*20 Capsule(s)* Refills:*0* 26. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day for 3 days: Through [**2-10**]. Disp:*6 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital 11851**] Healthcare & Rehabilitation Center - [**Location (un) 620**] Discharge Diagnosis: Urinary tract infection Pneumonia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you. You were admitted with right sided weakness and slurred speech. You had a CT scan and MRI of the brain, which showed no signs of a stroke. You were found to have a urinary tract infection and a pneumonia, for which you were treated with antibiotics, with clinical improvement. The following medication changes were made: STARTED Doxycycline 100mg [**Hospital1 **] to be continued through [**2-17**] STARTED Cefpodoxime 200mg [**Hospital1 **] to be continued through [**2-10**] If you notice any of the warning signs listed below, please call your PCP or come to the nearest ED for further evaluation. Followup Instructions: Please call [**Telephone/Fax (1) 2574**] to schedule a follow-up appointment in the [**Hospital 878**] clinic with Dr. [**Last Name (STitle) **] in [**3-23**] weeks. Please see your PCP within one week of discharge.

[ "V58.67", "428.0", "599.0", "244.9", "428.22", "414.00", "319", "250.00", "E947.9", "403.90", "295.32", "333.85", "486", "V45.81", "041.49", "781.0", "585.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

15450, 15558

10608, 12404

349, 356

15636, 15636

8011, 8011

16457, 16677

5067, 5084

13144, 15427

15579, 15615

12430, 13121

15789, 16434

8926, 10585

5099, 5651

7807, 7992

274, 311

384, 3596

8028, 8910

15651, 15765

5669, 7791

3618, 4773

4789, 5051

3,781

175,324

19379+57047

Discharge summary

report+addendum

Admission Date: [**2160-3-20**] Discharge Date: [**2160-3-25**] Service: Trauma Surgery HISTORY OF PRESENT ILLNESS: The patient is an 83 year old male status post motor vehicle crash with no loss of consciousness, [**Location (un) 2611**] coma scale 15, right femur fracture, subsplenic hematoma. PAST MEDICAL HISTORY: Coronary artery disease, diabetes mellitus, hypertension, paroxysmal atrial fibrillation, congestive heart failure, ejection fraction of 35% with aortic stenosis 1 cm, 1+ aortic insufficiency plus mitral regurgitation and tricuspid regurgitation. PAST SURGICAL HISTORY: Coronary artery bypass graft, carotid endarterectomy in [**2151**]. MEDICATIONS ON ADMISSION: Lasix 20 mg q.d.; Imdur 30 mg q.d.; Accupril 10 mg t.i.d.; Lipitor 40 mg q.d.; Toprol XL 100 mg q.d.; Amiodarone 200 mg q.d.; Mirtazapine 15 mg q.d.; Coumadin 2 mg q.d.; Levoxyl 50 mg q.d.; Aspirin 81 mg q.d.; Oxycodone prn. LABORATORY DATA ON ADMISSION: White blood cells 10.8, hemoglobin 11.9, hematocrit 36.8, platelet count 110. PT 17.3, PTT 35.6 and INR 2.0. Fibrinogen 428, glucose 219, urea 36, creatinine 1.2, sodium 139, potassium 4.5, chloride 107, bicarbonate 24, anion gap of 13. CPK 96, amylase 67, calcium 8.2, phosphorus 4.2 and magnesium 1.8. Toxicology screen was negative. There was no pertinent microbiology. Radiology - Trauma Series performed without comparison showed a right femoral fracture, essentially subtrochanteric although a portion of the lesser trochanter appears to be attached to the distal fragment. Radiographs of the right hand reviewed showed a fracture at the base of the right fifth metacarpal. Computerized tomography scan of the abdomen revealed a right femoral fracture as described above, subcapsular splenic hematoma and contusion, slight enlargement of the right psoas with small areas of focal enhancement probably representing soft tissue injury associated with right femoral fracture, and chronic changes of the lungs at the bases. Radiographs of the spine revealed cervical spine, minimal anterolisthesis of C4 on C5, degenerative changes and osteopenia, no fracture detected. Thoracic spine with mild anterior wedge compression fractures of two upper thoracic vertebra bodies, questionable T4 and T5. These are of indeterminate acuity. Lumbar spine, osteopenia, no fracture detected. The sacrum was obscured. A computerized tomography scan reconstruction was cone on the spine computerized tomography scan, and showed no evidence of fracture, Grade 1 C4 on C5 anterolisthesis, degenerative changes most pronounced at C5-6 and C6-7 areas. The thyroid gland appears enlarged with multiple locations and a flexion, extension comparison of the cervical spine showed multilevel instability of the cervical spine with flexion, multilevel degenerative changes of the cervical spine. HOSPITAL COURSE: On [**2160-3-21**], an intramedullary rod was used to fixate the right subtrochanteric femur fracture by the Orthopedic Service without incident. The right fifth metacarpal fracture was splinted on [**2160-3-20**]. Flexion and extension views of the cervical spine were viewed by Dr. [**First Name (STitle) 1022**] of the Orthopedic Team and it was decided that the collar may come off. The patient was also cleared clinically with removal of the cervical collar. DISCHARGE DIAGNOSIS: 1. Right femoral fracture. 2. Subcapsular splenic hematoma. 3. Right fifth metacarpal fracture. 4. Questionable compression fracture of T4-5. 5. Coronary artery disease. 6. Diabetes mellitus. 7. Hypertension. 8. Paroxysmal atrial fibrillation. 9. Congestive heart failure. An addendum will be added upon discharge of the patient. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**] Dictated By:[**Last Name (NamePattern1) 52643**] MEDQUIST36 D: [**2160-3-25**] 07:36 T: [**2160-3-25**] 07:49 JOB#: [**Job Number 52699**] Name: [**Known lastname 9805**], [**Known firstname 33**] Unit No: [**Numeric Identifier 9806**] Admission Date: [**2160-3-20**] Discharge Date: [**2160-3-26**] Date of Birth: [**2076-5-24**] Sex: M Service: Trauma Surgery DISPOSITION: Patient was discharged to rehab center. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSES: 1. Right femur fracture. 2. Subcapsular splenic hematoma. 3. Questionable compression fracture of T4-5. 4. Diabetes mellitus. 5. Hypertension. 6. Congestive heart failure. 7. Coronary artery disease. 8. Paroxysmal atrial fibrillation. DISCHARGE MEDICATIONS: 1. Mirtazapine 15 mg tablet one tablet p.o. h.s. 2. Amiodarone 200 mg one tablet p.o. q.d. 3. Quinapril 10 mg tablet p.o. q.d. 4. Polyvinyl alcohol 1.___% drops 1-2 drops prn. 5. Furosemide 20 mg tablet p.o. q.d. 6. Enoxaparin 40 mg/0.4 mL syringe q.d. subq, hold if INR is greater than or equal to 2.0. 7. Levothyroxine 50 mcg one tablet p.o. q.d. 8. Aspirin 81 mg tablet p.o. q.d. 9. Metoprolol 50 mg tablet one tablet p.o. b.i.d. 10. Isosorbide mononitrate 30 mg tablet one tablet p.o. q.d. 11. Acetaminophen 500 mg tablet two tablets p.o. q.6h. 12. Coumadin 2 mg tablet p.o. q.d. 13. Potassium 20 mEq packet two packets p.o. q.d. Hold for potassium over 5.0. FOLLOW-UP PLANS: Patient is to see Hand Clinic within two weeks at phone number [**Telephone/Fax (1) 5721**]. Patient is also to followup with Trauma Clinic within two weeks, [**Telephone/Fax (1) 5721**]. Patient will see the [**Hospital **] Clinic within two weeks, [**Telephone/Fax (1) 809**], and patient was also instructed to followup with his primary care provider within two weeks. Primary care provider was [**Name (NI) 178**] yesterday, and is aware that patient is being discharged and final condition, and diagnoses, and treatments. [**First Name11 (Name Pattern1) 1080**] [**Last Name (NamePattern4) 3711**], M.D. [**MD Number(1) 3712**] Dictated By:[**Last Name (NamePattern1) 9794**] MEDQUIST36 D: [**2160-3-26**] 09:37 T: [**2160-3-26**] 11:42 JOB#: [**Job Number 9807**]

[ "397.0", "398.91", "820.22", "V45.81", "401.9", "427.31", "E816.0", "865.00", "396.8" ]

icd9cm

[ [ [] ] ]

[ "99.04", "99.07", "79.35" ]

icd9pcs

[ [ [] ] ]

4340, 4576

4599, 5264

3350, 4287

701, 943

2862, 3329

605, 674

5282, 6092

128, 310

958, 2844

333, 581

4312, 4319

22,007

160,134

7212

Discharge summary

report

Admission Date: [**2158-8-3**] Discharge Date: [**2158-8-9**] Service: MED Allergies: Tetanus Toxoid / Penicillins / Vancomycin Hcl / Levofloxacin / Flagyl Attending:[**First Name3 (LF) 905**] Chief Complaint: hemetemesis Major Surgical or Invasive Procedure: EGD [**2158-8-4**] EGD [**2158-8-8**] with variceal banding History of Present Illness: 80 y/o female with a past medical history of metastatic cholangiocarcinoma who was 1 week s/p d/c from [**Hospital1 18**] with cholangitis who presented on this admission to OSH with hemetemesis x 2 (~500 cc of blood and clots). Pt went to [**Hospital3 **] where she was found to by hypotensive, received 2 L NS and 2 [**Location **]. Hct was 36.6 pre transfusion, and patient had no hypoxia. Patient was hemodynamically stable and transferred to [**Hospital1 18**] where her primary care is located. Past Medical History: 1. Metastatic cholangiocarcinoma to liver (extensive mets) and LN status post resection/chemo (taxol & xeloda) and multiple biliary stents (last [**5-5**] via ERCP by Dr. [**Last Name (STitle) **] 2. Recurrent cholangitis (last d/c 1 week pta, levoquin) 3. History of thyroid nodule 4. Status post breast cyst resection 5. Rheumatoid arthritis 6. Known portal vein thrombosis Social History: The patient previously worked as a director of admissions at a college. She denies any current tobacco or drug use. She drinks a glass of wine each evening. She lives with her husband. [**Name (NI) **] brother is an ophthomologist in [**Name (NI) 2848**] (one of the founders of the ophtho program there).` Family History: noncontributory Physical Exam: 98.7, 168/78, 82, 21, 98%2L gen cachectic, fatigued but arousable, nad, sleepy HEENT PERRLA EOMI, pink conjunctiva, mild scleral icterus, no JVD RR, tachy CTAB Abd soft nt nd bs wnl, mild ttp Right flank on edematous confined area of chronic swelling from stent placement, neg [**Doctor Last Name **] sign ext thin, weak, no edema neuro nonfocal grossly intact Pertinent Results: [**8-4**]-- wbc 7.4, hgb 12.9, hct 37.7, plt 172 na 137, k 4.5, cl 108, hco3 18, bun 22, creat 0.5, gluc 91 pt 13.6, ptt 28.5, inr 1.2 alt 16, ast 48, ap 416, tb 3.3, alb 3.2, ldh 208 Brief Hospital Course: Pt was admitted to MICU for evaluation of hemodynamic stability s/p two large episodes of hematemesis, 2u prbc, 2 L NS. Patient was hypotensive and fatigued but otherwise in no acute distress, and had no further episodes of hematemesis. Overnight hypotension resolved, and pt had two episodes of BRBPR (75 cc and 150cc),but remained hemodynamically stable though with no significant hct bump despite 2 units at osh (though no drop either). Transferred to floor service for further evaluation of GIB and cholangiocarcinoma with GI and ONC input. Had EGD same day which showed: 4 cords of grade III varices were seen in the lower third of the esophagus and middle third of the esophagus. The varices were not bleeding. 6 bands were successfully placed. Otherwise normal EGD to second part of the duodenum. Patient was started on nadolol and octreotide. She was continued on octreotide for 72 hours and continued on nadolol without further bleeding and without requiring further transfusions. She was also continued on protonix and sucralfate. Patient was assessed by phyical therapy who determined she was safe to go home. Patient was discharged with close follow up with her GI doctors and [**Name5 (PTitle) 3390**] and for further hematocrit checks. Medications on Admission: Motrin PRN pain Levoquin Discharge Medications: 1. Nadolol 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 2. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 3. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Outpatient Lab Work hematocrit check in (Friday), with results sent to Dr. [**Last Name (STitle) **] -- fax number ([**Telephone/Fax (1) 26728**] , phone number ([**Telephone/Fax (1) 2904**] Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: esophageal varices metastatic cholangiocarcinoma Discharge Condition: stable Discharge Instructions: Your new medication is nadolol 20 mg once a day. YOu should also continue with carafate and protonix. Follow up with GI (Dr. [**Last Name (STitle) **] as recommended by Dr. [**Last Name (STitle) 3815**]. Return to the ER or call your [**Last Name (STitle) 3390**] if you have vomit blood again or have bloody or black stools or other concerning symptoms. Followup Instructions: 1. With Dr. [**Last Name (STitle) **] in [**1-3**] days for hematocrit check (rx attached). 2. With Dr. [**Last Name (STitle) **] as recommended by Dr. [**Last Name (STitle) 3815**]. [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

[ "276.2", "196.2", "578.0", "572.3", "285.1", "197.7", "155.1", "456.20" ]

icd9cm

[ [ [] ] ]

[ "42.33", "45.13" ]

icd9pcs

[ [ [] ] ]

4174, 4232

2261, 3516

281, 343

4325, 4333

2035, 2238

4737, 5017

1621, 1638

3592, 4151

4253, 4304

3542, 3569

4357, 4714

1653, 2016

230, 243

371, 875

897, 1277

1293, 1605

15,046

103,875

50746+50747

Discharge summary

report+report

Admission Date: [**2190-9-10**] Discharge Date: [**2190-9-10**] Date of Birth: [**2124-2-1**] Sex: F Service: MEDICINE Allergies: Tetracyclines / Zinc Attending:[**First Name3 (LF) 5301**] Chief Complaint: Fall Major Surgical or Invasive Procedure: none History of Present Illness: 66 year-old F with Castelman's syndrome, recurrent aspiration PNA, HTN who presents s/p fall. She fell yesterday while trying to get up from bed and was put back to bed by her Home Health Aid; today she fell again and her aid 'dragged' her to bed and called EMS. Some head and L hip trauma (no LOC). . In the ED she received MSO4 2 mg IV for pain. Her C-spine was cleared. Head CT and hip films were negative. Fall was thought to be mechanical and social work was consulted re question of elder abuse/neglect. At midnight pt spiked to 102 rectal, received tylenol. CXR and UA negative. She was admitted for observation and placement. . Of note, pt was recently discharged from [**Hospital1 **] on [**2190-8-27**] for Pseudomonas PNA. . ROS: Pt is poor historian. She c/o L hip pain. She [**Date Range **] fever/ chills/ sweats. Denied headache, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness. Denied nausea, vomiting, diarrhea, or constipation. No dysuria or rash. Past Medical History: Past Medical History: 1. Castleman's disease (unicentric) s/p splenectomy in [**2176**]. Lymph node bx revealed reactive lymph tissue; followed in Heme/Onc by Dr. [**Last Name (STitle) 410**] 2. H/O anaplastic thyroid cancer s/p radical neck dissection; age 15 3. Esophageal webs and esophageal dysmotility s/p multiple dilatations 4. Recurrent aspiration pneumonias s/p PEG (sputum with klebsiella sensitive to Meropenem, MRSA, strep pneumo, [**Last Name (STitle) **]) 5. Chronic Respiratory Disease; bronchiectasis, [**Last Name (STitle) 1570**]'s revealed Restrictive physiology, ?interstitial lung disease. On 2L home O2 at baseline 6. MRSA osteomyelitis of olecranan s/p multiple debridements 7. Bipolar d/o 8. GERD 9. ?Seizure d/o (may be in setting of hypoglycemia) 10. Hx Grave's disease 11. Osteoporosis: has broken both hips, left in [**11-7**], right with failed ORIF and redo at [**Hospital1 2025**]; s/p short gamma nail fixation of a left hip basicervical fracture [**9-7**] 12. h/o zoster 13. HTN Social History: Social History: Used to work as a social worker at the VA. Was at [**Hospital1 **] until [**6-9**] when she was discharged to home. Home health aide 24 hrs/day. No tobacco or EtOH. Family History: NC Physical Exam: Vitals: T: 98.9 ax P: 80 BP: 128/72 RR: 18 SaO2: 100% 2L NC General: very thin, chronically-ill appearing female, lying in bed with hyperextended neck, awake, in NAD. HEENT: NC/AT, PERRL + L cataract, EOMI. MMM, OP without lesions. Neck: able to rotate and flex neck. Pulm: diffuse fine crackles, no rhonchi or wheezes Cardiac: RRR, nl S1/S2, 2/6 SEM Abdomen: soft, NT/ND, + BS. PEG in place, site c/d/i. Ext: No edema b/t, L hip without ecchymosis Skin: multiple areas of bruises in various stages of healing Pertinent Results: [**2190-9-10**] 01:20AM WBC-21.6 Hct-29.1 MCV-90 RDW-16.3 Plt Ct-211 . [**2190-9-9**] 06:45PM PT-12.8 PTT-26.2 INR(PT)-1.1 . [**2190-9-10**] 05:05AM Glucose-102 UreaN-34 Creat-1.7* Na-138 K-4.7 Cl-104 HCO3-27 AnGap-12 [**2190-9-9**] 06:45PM CK-MB-4 cTropnT-0.02* proBNP-225 . [**2190-9-10**] 01:20AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017 [**2190-9-10**] 01:20AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG . Brief Hospital Course: 66 yo F with Castleman's syndrome, recurrent aspiration PNA, HTN who presents s/p fall with concern for elderly neglect, and fever. . * s/p fall: mechanical in nature. Neg head CT, hip films, C-spine imaging. No infection on CXR or UA. EKG unremarkable. She ruled out for MI with two sets of negative troponins. She was continued on her home pain regimen. She denied abuse by her caretaker. . * Fever: leukocytosis with left shift. no localizing si/sx. CXR and UA negative for infection. nl lactate. given recent Abx for PNA, there is concern for CDiff. In looking back, her white count is normal and likely secondary to her lymphoproliferative disorder. She was not given antibiotics. . * Recurrent aspiration PNA: Had speech and swallow eval on last admission recommending no POs, but she continues to eat. No clinical evidence of PNA. . * Restrictive Lung Dz: unclear etiology. on 2L home O2. Continued on O2 by NC. Continued ipratropium and albuterol nebs. . * Hypothyrodism: post thyroid Ca tx. Continued home levothyroxine. . * ARF: Cr of 1.7 on admission, up from baseline of 1.3. likely prerenal. s/p 1L IVF in ED. came back to baseline. . * HTN: cont metoprolol . Medications on Admission: 1. Acetaminophen 650 mg Suppository Rectal Q4-6H as needed. 2. Cholecalciferol 800 unit PO DAILY (Daily). 3. Levothyroxine 100 mcg PO DAILY 4. Ipratropium Bromide 0.02 % Inhalation Q6H (every 6 hours). 5. Albuterol Sulfate 0.083 % Inhalation Q6H as needed. 6. Gabapentin 400 mg PO HS 7. Ferrous Sulfate 325 (65) mg Tablet PO DAILY (Daily). 8. Lamotrigine 100 mg Tablet PO DAILY 9. Lansoprazole 30 mg Susp,One PO DAILY (Daily). 10. Metoclopramide 10 mg Tablet PO QIDACHS 11. Quetiapine 200 mg PO HS as needed. 12. Sodium Polystyrene Sulfonate 15 g/60mL Suspension PO DAILY 13. Prochlorperazine 5 mg PO Q6H as needed. 15. Oxycodone 10 mg PO Q4-6H as needed. 16. Venlafaxine XR 150 QD 17. Lorazepam 2 mg PO QID 18. Alendronate 70 mg PO QSAT 19. Metoprolol Tartrate 12.5mg PO BID 21. Polyvinyl Alcohol 1.4 % Drops 1-2 Drops Ophthalmic PRN 22. Fentanyl 50 mcg/hr Patch 72HR Discharge Medications: 1. Acetaminophen 325 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 2. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times a day). 3. Levothyroxine 100 mcg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily). 4. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Day/Year **]: Two (2) Puff Inhalation QID (4 times a day). 5. Albuterol Sulfate 0.083 % Solution [**Month/Day/Year **]: One (1) Inhalation Q6H (every 6 hours) as needed. 6. Ferrous Sulfate 300 mg/5 mL Liquid [**Month/Day/Year **]: One (1) PO DAILY (Daily). 7. Lamotrigine 100 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily). 8. Lansoprazole 30 mg Susp,Delayed Release for Recon [**Month/Day/Year **]: One (1) PO DAILY (Daily). 9. Metoclopramide 10 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 10. Quetiapine 200 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO QHS (once a day (at bedtime)) as needed. 11. Sodium Polystyrene Sulfonate 15 g/60mL Suspension [**Month/Day/Year **]: One (1) PO DAILY (Daily). 12. Prochlorperazine 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q6H (every 6 hours) as needed. 13. Oxycodone 5 mg/5 mL Solution [**Month/Day/Year **]: Two (2) PO Q4-6H (every 4 to 6 hours) as needed. 14. Venlafaxine 75 mg Capsule, Sust. Release 24HR [**Month/Day/Year **]: Two (2) Capsule, Sust. Release 24HR PO DAILY (Daily). 15. Lorazepam 1 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO QID (4 times a day). 16. Metoprolol Tartrate 25 mg Tablet [**Month/Day/Year **]: 0.5 Tablet PO BID (2 times a day). 17. Polyvinyl Alcohol 1.4 % Drops [**Month/Day/Year **]: 1-2 Drops Ophthalmic PRN (as needed). 18. Fentanyl 50 mcg/hr Patch 72HR [**Month/Day/Year **]: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 19. Alendronate 70 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a week: Saturday. 20. Gabapentin 400 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO at bedtime. Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: s/p fall x 2 Castleman's syndrome s/p splenectomy [**2176**]. followed by Dr [**Last Name (STitle) 410**]. recurrent aspiration PNA - s/p PEG (sputum with pseudomonas, klebsiella sensitive to Meropenem, MRSA, strep pneumo, [**Last Name (STitle) **]) anaplastic thyroid Ca s/p radical neck dissection - 50 yrs ago bipolar disorder OA HTN esophageal webs and esophageal dysmotility s/p multiple dilatations chronic Respiratory Disease; bronchiectasis, [**Last Name (STitle) 1570**]'s revealed Restrictive physiology, ?interstitial lung disease. On 2L home O2 at baseline h/o MRSA osteomyelitis of olecranan s/p multiple debridements ?Seizure d/o (may be in setting of hypoglycemia) H/o Grave's disease Osteoporosis: has broken both hips, left in [**11-7**], right with failed ORIF and redo at [**Hospital1 2025**]; s/p short gamma nail fixation of a left hip basicervical fracture [**9-7**] h/o zoster Discharge Condition: fair Discharge Instructions: Continue your home medications. You need to seriously consider rehab since you are likely to fall at home again soon. Followup Instructions: Please schedule an appointment in the next 2 weeks: PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 2936**]. Admission Date: [**2190-9-11**] Discharge Date: [**2190-9-27**] Date of Birth: [**2124-2-1**] Sex: F Service: MEDICINE Allergies: Tetracyclines / Zinc Attending:[**First Name3 (LF) 2160**] Chief Complaint: Hypoxic Repiratory Failure Major Surgical or Invasive Procedure: Intubation History of Present Illness: This is a 66 y/o female well known to [**Hospital1 18**] with Castleman's syndrome, recurrent aspiration PNA, HTN, who presented to the ED this AM with fever and hypoxic respiratory distress. She was recently admitted to the medicine service from [**2190-9-9**] to [**2190-9-10**] s/p fall x 2 at home. She reportedly fell on [**2190-9-8**] while trying to get up from bed and was put back by her HHA; she fell again on [**2190-9-9**] and was down for approx 3 hours, and was put back into her bed by her HHA. EMS was then called. No LOC. CT of the head, c-spine, b/l hips were unremarkable. Fall was felt to be mechanical in nature and SW was consulted re: question of elder abuse/neglect (denied by patient to SW). At midnight that night, she spiked to 102 and was pan-cultured and received tylenol. U/A was unremarkable but urine cx was significant for 10,000-100,000 GNR. CXR was unremarkable. She was further admitted to the medicine service for observation and placement. She was subsequently discharged to home in stable condition yesterday evening. . Of note, she was also recently at [**Hospital1 18**] from [**2190-8-19**] to [**2190-8-27**] for aspiration PNA, fever, and subsequently grew out MRSA (pt has h/o MRSA in sputum in past) and pseudomonas (sensitive to ceftaz/cefepime/meropenem, resistant to levofloxacin). . She was brought to the ED this AM by her HHA for a temp to 102 at home this AM. She was also found to be hypoxic at 80%/RA by EMS. On arrival to the ED, she was intubated for hypoxic respiratory distress. Her VS in the ED were T 102, BP 150/62, HR 140, RR 26, SaO2 80%/RA. She had transient hypotension with SBP's to the 90's, thought to be secondary to per-intubation and received 3 L NS with good response of her SBP to the 110's. Sepsis protocol was initiated. She received 1 gm Vanc, 500 mg Flagyl, 500 mg Levofloxacin, Ceftaz 2 gm IV, Versed/Fentanyl gtt, and 1 gm Tylenol pr. Past Medical History: Past Medical History: 1. Castleman's disease (unicentric) s/p splenectomy in [**2176**]. Lymph node bx revealed reactive lymph tissue; followed in Heme/Onc by Dr. [**Last Name (STitle) 410**] 2. H/O anaplastic thyroid cancer s/p radical neck dissection; age 15 3. Esophageal webs and esophageal dysmotility s/p multiple dilatations (however, per OMR notes, nl motility study) 4. Recurrent aspiration pneumonias s/p PEG (sputum with klebsiella sensitive to Meropenem, MRSA, strep pneumo, [**Last Name (STitle) **]) Per GI notes, thought to be d/t orophyarngeal dysphagia from prior neck irraditation 5. Chronic Respiratory Disease; bronchiectasis, [**Last Name (STitle) 1570**]'s revealed Restrictive physiology, ?interstitial lung disease. On 2L home O2 at baseline 6. MRSA osteomyelitis of olecranan s/p multiple debridements 7. Bipolar d/o 8. GERD 9. ?Seizure d/o (may be in setting of hypoglycemia) 10. Hx Grave's disease 11. Osteoporosis: has broken both hips, left in [**11-7**], right with failed ORIF and redo at [**Hospital1 2025**]; s/p short gamma nail fixation of a left hip basicervical fracture [**9-7**] 12. h/o zoster 13. HTN Social History: Social History: Used to work as a social worker at the VA. Was at [**Hospital1 **] until [**6-9**] when she was discharged to home. Home health aide 24 hrs/day. No tobacco or EtOH. Family History: NC Physical Exam: Upon Arrival to the [**Hospital Unit Name 153**] Vitals: Tc 98.3, BP 118/79, HR 92, RR 19, SaO2 100%/AC 500 x 15/PEEP 5/FiO2 40% General: Very thin, chronically-ill appearing female, intubated, awakens to verbal stimuli HEENT: NC/AT, PERRL. Intubated. MMM, OP without lesions. Neck: supple, no JVD Chest: diffuse fine crackles at bases, no rhonchi or wheezes CV: RRR, nl S1/S2, 2/6 SEM Abdomen: soft, NT/ND, + BS. PEG in place, site c/d/i. Ext: No edema b/l, pulses 1+ b/l, w/w/p Neuro: sedated, though arousable Pertinent Results: [**2190-9-10**] 05:05AM BLOOD Glucose-102 UreaN-34* Creat-1.7* Na-138 K-4.7 Cl-104 HCO3-27 AnGap-12 [**2190-9-18**] 06:40AM BLOOD Glucose-112* UreaN-24* Creat-0.9 Na-134 K-4.7 Cl-100 HCO3-26 AnGap-13 [**2190-9-10**] 01:20AM BLOOD WBC-21.6* RBC-3.22* Hgb-9.8* Hct-29.1* MCV-90 MCH-30.3 MCHC-33.6 RDW-16.3* Plt Ct-211 [**2190-9-10**] 01:20AM BLOOD Neuts-84* Bands-3 Lymphs-12* Monos-1* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2190-9-18**] 06:40AM BLOOD Neuts-55 Bands-0 Lymphs-20 Monos-12* Eos-11* Baso-0 Atyps-1* Metas-1* Myelos-0 . GRAM STAIN (Final [**2190-9-11**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 2+ (1-5 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Final [**2190-9-15**]): OROPHARYNGEAL FLORA ABSENT. STAPH AUREUS COAG +. HEAVY GROWTH. YEAST. MODERATE GROWTH. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | PSEUDOMONAS AERUGINOSA | | CEFEPIME-------------- 4 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- =>4 R CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S =>16 R IMIPENEM-------------- =>16 R LEVOFLOXACIN---------- =>8 R MEROPENEM------------- 8 I OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- 8 S RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TOBRAMYCIN------------ =>16 R VANCOMYCIN------------ <=1 S . Admission CXR INDICATION: 66-year-old woman with hypoxia, shortness of breath and fever status post endotracheal intubation and left internal jugular line placement. . Portable AP chest dated [**2190-9-11**] at 9:37 a.m. is compared to the same examination from two hours earlier. The endotracheal tube terminates 8.1 cm above the carina. Again seen is a linear density adjacent to the endotracheal tube which terminates at the thoracic inlet. Again this may represent a malpositioned nasogastric tube that perhaps is coiled in the posterior pharynx. It is not seen below the thoracic inlet. There has been interval placement of a left internal jugular central venous catheter which terminates at the brachiocephalic-SVC junction. The cardiomediastinal silhouette is unchanged. Again, the lung fields show platelike atelectasis within the left mid lung zone. There is no pneumothorax or pleural effusion. The surrounding osseous structures are unremarkable. Again, the soft tissue surrounding structures show mild gastric distention. . CT Pelvis: FINDINGS: Several acute fractures are identified. There is a nondisplaced fracture of the left sacrum extending through several sacral ala. There is a comminuted fracture of the anterior column of the left acetabulum with minimal displacement. There is an acute mildly displaced fracture of the left inferior pubic ramus. Chronic fracture deformities of the right inferior pubic ramus, right superior pubic ramus, and the right proximal femur are also identified. Postoperative changes status post intramedullary rod fixation of the left proximal femur are seen including a proximal gamma nail and femoral neck screw. No hardware-related complication is seen. No additional fracture or dislocation is noted. Multilevel degenerative changes of the lower lumbar spine are seen including facet joint hypertrophic changes. A [**Month/Day/Year 500**] island is seen in the left side of the sacrum. A faint lucent tract in the proximal right femur likely reflects previous hardware. No additional lytic or sclerotic lesions are seen. . SOFT TISSUES: A focus of gas is seen in the subcutaneous soft tissues of the anterior abdomen, likely reflecting recent subcutaneous injection. There is a fat-containing umbilical hernia. Contrast is seen within the colon. The pelvic soft tissues are otherwise unremarkable. There is a Foley catheter in place. . IMPRESSION: 1. Acute nondisplaced fractures of the left sacrum, anterior column of the left acetabulum, and left inferior pubic ramus. 2. Chronic fracture deformities of the right proximal femur, left proximal femur, left superior pubic ramus, and left inferior pubic ramus. Status post ORIF of an intertrochanteric fracture of the left proximal femur with no evidence of hardware-related complication . CT Neck: FINDINGS: The patient has had a radical neck dissection on the right. There is metallic artifact from dental hardware. This obscures a portion of the parotid gland on both sides, however, there are no masses in the visualized portions of the gland. There is no asymmetry in the appearance of the glands. At the level of the hyoid and on the right, there is 1.1 cm soft tissue mass just posterior to the internal carotid artery. This is felt to represent lymphadenopathy in this patient. Smaller higher density lymph nodes are seen along the left jugulodigastric chain, not significantly changed since a prior CT of the cervical spine, [**2190-9-9**]. However, the lymph node on the right does appear enlarged for this patient and has slightly lower density. This could represent a lymph node associated with the patient's history of Castleman's syndrome. This lesion was probably present on the prior CT of the cervical spine, although it is difficult to visualize due to the lack of IV contrast on that study. . No enhancing masses are identified. There are no fluid collections. There are multilevel degenerative changes in the cervical spine without a definite fracture. There is dental hardware in place. There is scarring at both lung apices. . IMPRESSION: Well-defined soft tissue mass posterior to the carotid, just below the level of the hyoid, in the right neck likely represents an enlarged level IV lymph node. No other lymphadenopathy is identified. The patient is status post right radical neck dissection. PORTABLE SEMI-UPRIGHT CHEST RADIOGRAPH: No significant interval change is seen. There is chronic left hemidiaphragmatic elevation and bibasilar atelectasis. No pleural effusion is seen. The aorta is generally large but no focal or anastomotic dilatation is apparent. Surgical staples in the upper abdomen are again noted. IMPRESSION: No significant interval change. Persistent bibasilar atelectasis and left hemidiaphragmatic elevation. STUDY: Right knee CT without intravenous contrast. [**2190-9-22**]. HISTORY: 66-year-old woman with right knee swelling and erythema. Evaluate for fracture or focal lesion. FINDINGS: Multiple contiguous 2.5-mm axial images were obtained through the right knee without the administration of intravenous contrast. Subsequently coronal and sagittal reformatted images were obtained. No bony fractures are seen. There are no focal bony lesions identified. The patient is demineralization which is most prominent in the distal femur and proximal tibia. There is a [**First Name8 (NamePattern2) 30272**] [**Hospital Ward Name 4675**] cyst. There is no joint effusion. There is narrowing of the joint space with some subchondral sclerosis in the medial and lateral compartments. Small marginal osteophytes are identified. There are some vascular calcifications. The visualized soft tissues are grossly within normal limits. There is some minimal subcutaneous fatty stranding seen within the medial aspect of the knee. IMPRESSION: 1. Osteopenia. 2. No signs for acute bony injury or joint effusion. 3. Mild degenerative changes. RIGHT KNEE, THREE VIEWS. There are mild degenerative changes, with slight medial compartment narrowing and small marginal spurs. There is probable diffuse osteopenia. No acute fracture or dislocation is identified. No focal lytic or sclerotic lesion is detected. Incidental note is made of some spurring along the proximal fibula posteriorly. No joint effusion is seen. If there is clinical concern for a patellar fracture, then further assessment with an axial image of the patellofemoral joint could help for more detailed assessment. However, no patellar fracture is identified on the current images. PATELLA (AP, LAT & SUNRISE) RI; -77 BY DIFFERENT PHYSICIAN Reason: r/o fracture [**Hospital 93**] MEDICAL CONDITION: 66 year old woman with knee swelling REASON FOR THIS EXAMINATION: r/o fracture INDICATION: 66-year-old female with knee swelling. COMPARISON: [**2190-9-21**]. FIVE VIEWS RIGHT KNEE: Again seen are mild degenerative changes manifested by medial compartment narrowing and small marginal spurs. There is no knee joint effusion. There is no fracture or dislocation. Brief Hospital Course: Hospital course, by problem: #. Hypoxic respiratory distress - most likely [**2-4**] aspiration event, given her history and CXR findings of no focal infiltrates. Baseline requirement of 2 L NC due to underlying restrictive lung disease, and she did well post extubation and was at baseline O2 requirements. In the ICU, she was originally covered with broad-spectrum abx (Vanc/Levo/Flagyl/Ceftaz), given h/o MRSA/klebsiella/pseudomonas in sputum in past. Although she grew MRSA/Pseudomonas in her sputum culture, it was felt that these are most likely colonizers given a) the likely aspiration event and b) no focal infiltrates on CXR. While on the floor, Vancomycin d/c'd and she was continued on Levo/Flagyl without recurrent fever, hypoxia, or leucocytosis. She will complete a 14 day courseo of abx for treatment of her aspiration event. Given mild CHF noted on CXR (nl Echo [**5-8**]), she was diursed gently. ID followed her on the floor and agreed with the above recommendations. . # L hip pain s/p fall - Pelvic CT was obtained per ortho and showed acute nondisplaced fractures of the left sacrum, anterior column of the left acetabulum, and left inferior pubic ramus, along with chronic fracture deformities of the right proximal femur, left proximal femur, left superior pubic ramus, and left inferior pubic ramus. There was no evidence of a hardware-related complication from her prior ORIF of her left intertrochanteric fracture of the proximal femur. Seen by ortho; recommended partial WBAT on her Left hip. She will follow up with Dr. [**Last Name (STitle) **] in two weeks as an outpatient for follow-up XR and further plan. Pain control was achieved with opioids via PEG tube . #Eosinophilia: likely secondary to antibiotics. She has no rash to warrant discontinuation of her abx. This should be followed up in clinic. . #Resting Tremor: On examination, she was noted to have a resting tremor of (B) UE and her jaw with increased rigidity and cogwheeling. Neurology was consulted, who felt at the very least she has Parkinsonism (had been on long-standing reglan) +/- Parkinsons Disease. She was started on Sinemet in house, and will follow up with Neurology as an outpatient. Whether this Parkinsons disease is the culprit for her orophyarngeal dysphagia is unclear, the neurology team thought that it could be. . #. HTN - restarted metoprolol at home dose of 12.5mg [**Hospital1 **]. HCTZ 12.5 mg daily was added but [**Doctor Last Name 8196**] stopped because of hypercalcemia. BP remained well controlled despite this. . #Osteoporosis: Ca Carbonate 500 mg TID was added to her regimen of Vitamin D and her bisphonate. # Hypercalcemia / primary hyperparathyroidism - she has a h/o primary hyperparathyroidism - seen in the endocrinology clinic/ not an operative candidate. Endocrinology was consulted in house and they recommended stopping HCTZ. Vit D levels were ordered and pending at the time of discharge. She was advised follow-up in clinic. . #. Chronic pain/depression - continue gabapentin, lamotrigine, effexor. Fentanyl patch was increased to 75 mcg/daily to treat her hip pain, along with NSAIDs/Tylenol/Oxycodone. # herpes - During the hospital stay, herpetic vesicles were noted on her right knee, confirmed by dermatology who recommended stating valacyclovir. She is to complete a 7 day course. DFA was negative and cultures for zoste and HSV were pending at discharge. # Cervical LN - this should be followed with further work-up in clinic. PT evaluated her and recommended dc home with 24 hour supervision. She has [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], [**First Name3 (LF) 96555**] who takes care of her at home. [**First Name3 (LF) 96555**] was explained details by PT. Medications on Admission: 1. Tylenol prn 2. Vitamin D3 400 U [**Hospital1 **] 3. Levothyroxine 100 mcg qd 4. Atrovent inh 2 puffs q 4 hrs 5. Albuterol inh 1 puff qid prn 6. Ferrous sulfate 300 mg/5mL qd 7. Lamotrigine 100 mg qd 8. Lansoprazole 30 mg qd 9. Metoclopramide 10 mg qid 10. Quetiapine 200 mg qHS prn 11. Sodium Polystyrene Sulfonate 15 g/60mL qd 12. Prochlorperazine 5 mg q6 prn 13. Oxycodone 5 mg/5 mL q4-6 hrs prn 14. Venlafaxine ER 150 mg qd 15. Lorazepam 1 mg qid 16. Metoprolol 12.5 mg [**Hospital1 **] 17. Fentanyl 50 mcg/hr patch q72 hrs 18. Alendronate 70 mg q Saturday 19. Gabapentin 400 mg qHS 20. Polyvinyl Alcohol 1.4 % gtt prn Discharge Medications: 1. Docusate Sodium Oral 2. Lansoprazole 30 mg Susp,Delayed Release for Recon [**Hospital1 **]: One (1) PO once a day. 3. Morphine 10 mg/5 mL Solution [**Hospital1 **]: Two (2) PO Q 6 H () as needed for pain. Disp:*30 10* Refills:*0* 4. Ibuprofen 100 mg/5 mL Suspension [**Hospital1 **]: One (1) PO Q8H (every 8 hours) as needed for pain. Disp:*60 * Refills:*0* 5. Fentanyl 75 mcg/hr Patch 72HR [**Hospital1 **]: One (1) Patch 72HR Transdermal Q72H (every 72 hours). Disp:*10 Patch 72HR(s)* Refills:*0* 6. Metronidazole 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a day) for 2 days. Disp:*6 Tablet(s)* Refills:*0* 7. Levofloxacin 250 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q24H (every 24 hours) for 2 days. Disp:*2 Tablet(s)* Refills:*0* 8. Levothyroxine 100 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 9. Ferrous Sulfate 300 mg/5 mL Liquid [**Hospital1 **]: One (1) PO DAILY (Daily). 10. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 11. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours). 12. Lamotrigine 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 13. Gabapentin 400 mg Capsule [**Hospital1 **]: One (1) Capsule PO HS (at bedtime). 14. Alendronate 70 mg Tablet [**Hospital1 **]: One (1) Tablet PO QSAT (every Saturday). 15. Polyvinyl Alcohol 1.4 % Drops [**Hospital1 **]: 1-2 Drops Ophthalmic PRN (as needed). 16. Venlafaxine 75 mg Capsule, Sust. Release 24HR [**Hospital1 **]: Two (2) Capsule, Sust. Release 24HR PO DAILY (Daily). 17. Lorazepam 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO QID (4 times a day). 18. Quetiapine 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for prn insomnia. 19. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 20. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO TID (3 times a day). 21. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 22. Carbidopa-Levodopa 25-100 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*0* 23. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 24. Senna 8.6 mg Tablet [**Hospital1 **]: 1-2 Tablets PO BID (2 times a day). 25. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain. 26. Albuterol Sulfate 0.083 % Solution [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours). 27. Valacyclovir 1 g Tablet [**Hospital1 **]: One (1) Tablet PO three times a day for 2 days: via PEG tube. Disp:*6 Tablet(s)* Refills:*0* 28. medications Take all your medications via PEG tube not by mouth. Discharge Disposition: Home With Service Facility: Caritas Home Care Discharge Diagnosis: Primary Diagnoses 1. Aspiration Pneumonitis, requiring intubation 2. s/p Fall with acute nondisplaced fractures of the left sacrum, anterior column of the left acetabulum, and left inferior pubic ramus 3. Resting Tremor, ?parkinsonism vs parkinsons disease 4. 1.1 cm R neck Lymph note 5. herpetic vesicles right knee) 6. Hypercalcemia (h/o primary hyperparathyroidism) Secondary Diagnoses: 1. Castleman's syndrome s/p splenectomy [**2176**] 2. Recurrent aspiration PNA - s/p PEG 3. Sputum with Pseudomonas/MRSA: likely colonizers 4. Anaplastic thyroid Ca s/p radical neck dissection - 50 yrs ago 5. Bipolar disorder 6. OA 7. HTN 8. Esophageal webs and ?esophageal dysmotility (NL Esophageal Motility [**3-8**] by Dr [**Last Name (STitle) 10689**] s/p multiple dilatations 9. Chronic Respiratory Disease; bronchiectasis 10. h/o MRSA osteomyelitis of olecranan s/p multiple debridements 11. ?Seizure d/o (may be in setting of hypoglycemia) 12. h/o Grave's disease 13. Severe osteoporosis: has broken both hips, left in [**11-7**], right with failed ORIF and redo at [**Hospital1 2025**]; s/p short gamma nail fixation of a left hip basicervical fracture [**9-7**] 14. h/o zoster Discharge Condition: stable Discharge Instructions: Please contact Dr. [**Last Name (STitle) 2903**] should you have any fevers, chills, night sweats, difficulty breathing, or any other complaints. It is very important that you follow up with Dr. [**Last Name (STitle) 2903**] regarding the lymph node in the right side of your neck and elevated eosinophils in blood. You are advised not to eat or drink anything by mouth to avoid the risk of aspiration and lung infections. All your medications should be given thru the PEG tube. Followup Instructions: Please make an appointment to follow up with Dr [**Last Name (STitle) 2903**] within 10 days to follow up the Lymph node in your neck and for eosinophilia. Please follow up with Neurology regarding treatment of your parkinsons diease. Someone from their clinic should be calling you to make an appointment. If someone does not call, please call ([**Telephone/Fax (1) 2528**]. Provider: [**Name10 (NameIs) 5865**] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2190-10-14**] 12:20 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2190-10-14**] 12:40 Please make an appointment with your endocrinologist, Dr [**Last Name (STitle) **] [**Name (STitle) 7711**]. Call ([**Telephone/Fax (1) 74299**] to schedule an appointment to discuss the high calcium levels and also the thyroid medication and to follow-up for the results of lab work done in the hospital.

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Discharge summary

report

Admission Date: [**2159-1-31**] Discharge Date: [**2159-2-10**] Date of Birth: [**2108-11-3**] Sex: M Service: SURGERY Allergies: Bactrim / Aspirin Attending:[**First Name3 (LF) 5569**] Chief Complaint: Central venous occlusion right SVC and Right IJ Major Surgical or Invasive Procedure: [**2159-2-1**]: Right femoral temporary dialysis line placed [**2159-2-8**]: Right femoral tunneled dialysis line placed History of Present Illness: 50M with HIV, ESRD s/p failed renal transplant , who has had numerous access problems in the past including a history of SVC syndrome on the left side requiring ligation of left access. Pt now presents with likely central venous thrombus of the right side extending into the subclavian, brachiocephalic, SVC and bilateral IJs. Patient was diagnosed with new central clot today during attempted thrombectomy of his right AVG. He has a known stent in Right brachiocephalic and has had repeat thrombectomy and angioplasty of his current graft. Patient was amidst thrombectomy when patient acutely became SOB with O2 saturations in the high 80s. Per report patient was given heparin 3000, 1gr ancef, 2mg versed and 100mcg Fentanyl" during the thrombectomy. The procedure was terminated. He was urgently transferred by EMS to [**Hospital1 18**] on a non-rebreather with O2 sats registering 92%. He improved over the next 1/2 hour, and is now off oxygen 100% on ra. Pt denies symptoms of hand swelling, arm pain, sob or facial swelling prior to today's procedure. He was last dialyzed [**Name (NI) 766**] unclear if full run. He does not void. He refuses to answer further questions throughout the interview limiting history. He is now off o2 with O2 sat of 100% on ra, but still subjectively feels SOB. Initial triage vitals: 98.4 80 80/60 20 92% (unk if nonrebreather or ra) Past Medical History: 1. HIV diagnosed in [**2139**] 2. End-stage renal disease status post ECD transplantation on [**2156-5-21**], episode of acute rejection which was aggressively treated, currently has nephrotic syndrome, biopsy showed collapsing GN 3. History of disseminated TB in [**2140**] with right peritonitis 4. History of pyelonephritis 5. Hypertension 6. Osteoarthritis 7. Status post gunshot wound to the abdomen (per records; patient denies) 8. History of depression 9. SVC syndrome requiring stent placement, status post occlusion of the left innominate vein stent, status post angioplasty of the left arm fistula, status post ligation of the left arm fistula, [**11/2156**] 10. Upper GI bleed with duodenal ulcers 11. Recent lower GI bleed from the internal hemorrhoids 12. Circumcision for HPV penile lesions - followed by [**Hospital **] clinic Social History: Lives alone in an apartment in JP. Married, wife lives in area with 2 sons- aged 10 and 17-who are HIV negative. Denies ETOH, IVDU but smokes marajuana daily. Has a past smoking history but states he quit ~ 2 years ago. Disabled on SSDI since [**2140**]. Came to the US in [**2124**], first having lived in [**State 531**] and since in [**Location (un) 86**]. His wife also has HIV. Family History: Non-contributory. Both parents are deceased. Patient is unable to contibute any information about his FH. Physical Exam: 86 143/106 17 100%NonRb GEN: NAD, A&o X 3 Speaking without difficulty. CVS: RRR no m/r/g Pulm: Clear anteriorly HEENT: prominent veins right UE, Shoulder, chest, and right IJ engorged. Swelling of Left parotid area and inferior portion of face. ABD: Well healed kidney transplant scar, Midline incision . No hernias, soft, NT, ND. Deferred rectal per patient EXT: 2+ pulses bilaterally, graft RUE without thrill/bruit. Pertinent Results: LABS: 12.6 7.2>-----< 178 39.0 N:76.1 L:19.1 M:3.3 E:1.1 Bas:0.4 PT: 12.8 PTT: 47.1 INR: 1.1 Fibrinogen: 268 134 91 35 -------------<88 5.4 26 7.6 Brief Hospital Course: Mr [**Known lastname 10133**] was admitted to the Transplant Surgery service directly from AV Care. On [**2159-1-31**], HD1, he underwent angiogram which showed significant thromboses and stenoses of central and peripheral upper extremity veins. See Dr[**Name (NI) 10136**] report for further details. A TPA infusion catheter was left in place with continuous TPA running overnight while he was monitored in the surgical ICU. The following day, HD2, he underwent balloon angioplasty and further thrombolysis, again with Dr [**Last Name (STitle) **]. His RUE graft could not be fully opened, so a temporary hemodialysis line was placed in his right groin to facilitate HD. He was monitored closely in the SICU with serial cardiac enzymes sent which remained unchanged during hospitalization. He was begun on a heparin drip to attempt chemical thrombolysis of his extensive clots. On [**2159-2-4**], HD5, he was transferred from the SICU to the floor. He remained afebrile with stable vital signs and underwent HD per his home schedule. He was maintained on his home tacrolimus dose of 2mg/2mg, with levels ranging from 2.9 and <2.0. His hematocrit was stable at 25.0 after leaving the SICU; he was transfused 2u PRBC with dialysis on [**2159-2-9**]. His blood pressure remained mildly elevated so he was begun on metoprolol while in house and instructed to continue with Toprol once returning home. On [**2159-2-8**], HD9, he returned to interventional radiology for another attempt at thrombolysis of RUE AVG. This was again unsuccessful, so his temporary right femoral HD line was exchanged for a tunneled HD line. He tolerated this procedure well and underwent dialysis the following day. Following dialysis on the evening of the 25th (during which he received 2u PRBC), he was fatigued so was kept overnight for observation. On the day of discharge, he was tolerating a regular diet, ambulating without assistance, and in good understanding of his condition and plan of care. His previously established home RN was contact[**Name (NI) **] prior to discharge and was in agreement with the discharge plan. Medications on Admission: Dapsone 100 mg Tab Epivir HBV 100 mg Tab Remeron 15 mg Tabq hs Aldara 5 % Topical Packet three times per week use after showering Plavix 75 mg Tab Sustiva 600 mg Tab Ziagen 600 mg Tab Pantoprazole 40 mg Tab, Delayed Release Prograf 2 mg Cap" Crestor 5 mg Tab Sensipar 90 mg Tab Renvela 1600 mg Tab'" Prednisone 5 mg Tab Zolpidem 10 mg Tabqhs Docusate Sodium 100 mg Cap" Oxycodone 5 mg Cap [**12-17**] Capsule(s) by mouth q4-6 hr Zidovudine 300 mg Tab qpm Nephrocaps 1 mg Cap daily Discharge Medications: 1. dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. imiquimod 5 % Cream in Packet Sig: One (1) Topical 3x per week: three times per week use after showering. 5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 9. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 10. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 12. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 13. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 16. zidovudine 100 mg Capsule Sig: Three (3) Capsule PO QPM (once a day (in the evening)). 17. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 18. oxazepam 15 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 19. oxycodone 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 20. Toprol XL 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Discharge Disposition: Home Discharge Diagnosis: ESRD s/p failed renal transplant [**5-23**] currently on HD Thrombosed RUE AVG Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever, chills, increased right arm or leg pain, swelling or redness. Report nausea, vomiting, diarrhea, inability to take or keep down medications, food or fluids. Report any swelling in legs, face or abdomen. Followup Instructions: LM [**Hospital Unit Name **], [**Location (un) **], Transplant Medicine [**2159-2-27**] 11:00a DR [**Last Name (STitle) **] [**2159-2-27**] 10:20a DR [**Last Name (STitle) 970**]

[ "585.6", "996.1", "272.0", "996.73", "785.0", "453.87", "458.29", "996.81", "424.1", "459.2", "V12.01", "403.91" ]

icd9cm

[ [ [] ] ]

[ "39.90", "39.50", "38.95", "00.40", "00.45", "99.10", "38.91", "88.67", "39.95" ]

icd9pcs

[ [ [] ] ]

8164, 8170

3892, 6002

325, 448

8293, 8293

3702, 3869

8747, 8935

3135, 3243

6533, 8141

8191, 8272

6028, 6510

8444, 8724

3258, 3683

238, 287

476, 1851

8308, 8420

1873, 2718

2734, 3119

25,662

198,249

28008

Discharge summary

report

Admission Date: [**2171-10-28**] Discharge Date: [**2171-11-12**] Date of Birth: [**2109-12-2**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 301**] Chief Complaint: medical refractory GERD Major Surgical or Invasive Procedure: 1. Subtotal gastrectomy. 2. Adhesiolysis--3 hours. 3. Dor fundoplication. 4. central line placement 5. foley catherer placement x2 History of Present Illness: The patient is a 61-year-old gentleman, who has previously undergone vagotomy and pyloroplasty and other upper abdominal procedures, who presents with poor gastric emptying and severe reflux. On EGD, he has some erythema of the stomach, and he was referred for antireflux procedure. Past Medical History: GERD PUDz HTN hyperchol COPD Social History: 2 PPD x 25yrs (quit in 99) ETOH abuse in past- quit in [**2154**] Family History: non-contrib Physical Exam: AVSS WD, WN, NAD CTAB, no w/c/r, good resp effort slightly tachy (pt. at baseline), regular, no m/r/g abd soft, non-distended, normal bowel sounds, inferior portion of incision with small area weeping and small area in middle of incision with packing -> no erythema; healing well no c/c/e Pertinent Results: [**2171-11-10**] 02:10PM BLOOD WBC-8.7 RBC-3.48* Hgb-10.2* Hct-28.6* MCV-82 MCH-29.3 MCHC-35.6* RDW-14.3 Plt Ct-328 [**2171-11-10**] 02:10PM BLOOD Plt Ct-328 [**2171-11-6**] 08:38AM BLOOD PT-15.0* PTT-26.8 INR(PT)-1.3* [**2171-11-10**] 02:10PM BLOOD Glucose-139* UreaN-18 Creat-0.7 Na-134 K-4.6 Cl-97 HCO3-25 AnGap-17 [**2171-11-3**] 02:45AM BLOOD ALT-44* AST-24 CK(CPK)-475* AlkPhos-118* Amylase-27 TotBili-0.8 [**2171-11-3**] 02:45AM BLOOD Lipase-33 [**2171-11-10**] 02:10PM BLOOD Calcium-9.0 Phos-3.9 Mg-2.1 [**2171-11-9**] 06:40AM BLOOD PSA-2.0 [**2171-11-10**] 08:50AM BLOOD Vanco-7.6* [**2171-11-7**] 5:15 am CATHETER TIP-IV Source: right cvl. **FINAL REPORT [**2171-11-9**]** WOUND CULTURE (Final [**2171-11-9**]): STAPH AUREUS COAG +. >15 colonies. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. Please contact the Microbiology Laboratory ([**6-/2471**]) immediately if sensitivity to clindamycin is required on this patient's isolate. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=1 S blood and wound cultures pending at time of discharge Brief Hospital Course: Patient admitted on [**10-28**] for his operation. Surgical findings were: Extensive adhesions in the upper and lower abdomen, an 18 inch Roux limb, a 21 circular stapled gastrojejunostomy. No leak on methylene blue checks. Post op the patient was made NPO, had an NGT, Foley and epidural for pain. The patient was tachycardic to 111 (pre-op was 118). His BP decreased- had a stable HCT and the epidural was then discontinued. A PCA was started for pain managment. On POD2 the patient remained tachycardic and his lopressor was increased. On POD3 the patient had an episode of desaturation to the high 80's. A CXR was obtained which shoed pulmonary edemma. Lasix was given with good response. The patient was also started on nebulizer treatments. The CXR also showed evidence or a right upper lobe pneumonia. Levofloxacin was started for a 5 day course. On POD5 the patient became tachycardic to the 140's. A CTA of the chest and abdomen was obtained. The results were: 1. No evidence for pulmonary embolus. 2. Bilateral layering pleural effusions. Hazy ground-glass opacification of the right upper lobe is compatible with pneumonia, less likely atypical edema or alveolar hemorrhage. 3. No evidence for a leak. Soft tissue stranding about the stomach is compatible with patient's recent surgery. The patient was transferred to the ICU for closer monitoring and a CVL was placed. The patient was given more lasix and the patient beta blocker was increased. An NGT was placed to remove the contrast from the patient's stomach. Pulmonary medicine was also consulted. An echo was obtained which showed an EF>55% and no wall abnormalities. Cardiac enzymed were also cycled which came back normal. The patient HR came under control and he started passing gas. His NGT was d/c and his diet was advanced. He was transferred out of the unit in stable condition. The patient PCA was stopped, his foley discontinued and he was switched to oral medication. A one time dose of vitamin K was given for an INR of 1.8. The patient was advanced to a stage III diet which he tolerated. Overnight of [**11-7**] the pt. again became tachycardic and was unable to void. A foley catheter was replaced and the central line was removed with the tip sent for culture and the pt. was started on Vancomycin. Blood and catheter tip cultures from that night grew out MRSA and the vancomycin was continued. Urology was consulted and recommended that the pt. be sent home with the foley and follow-up in clinic for removal. Leg bag teaching was initiated. Repeat blood cultures were drawn for the next several days - all of which from [**11-9**] on showed no growth to date on the day of discharge. The pt. was advanced to a Stage IV diet that he tolerated well, was given a bowel regimen, and by POD 15 was ready for discharge to home with VNA for dressing changes. He was sent with instructions regarding follow-up appointments with surgery, urology, and his primary care physician; post-operative medications including pain medication, beta-blockers, and flomax that was started while in house; and post-operative care regarding activity level, diet, and wound care. The pt. understood these instructions. Medications on Admission: Protonix 40 QD Lipitor 10 QD Lisinopril 10 QD Reglan Albuterol Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2* 6. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs puffs Inhalation q 6 hours prn. 9. Linezolid 600 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 9 days: it is very important that you take all of this medication. Disp:*18 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Reflux s/p subtotal gastrectomy post operative urinary retention post operative atrial fibrilation central line infection h/o hypertension h/o copd h/o dyslipidemia Discharge Condition: stable Discharge Instructions: - You will be discharged to home - Please take all prescriptions as prescribed - You will be given pain medication. This can make you drowsy- please no driving while taking medication. You may restart your home medications. - every day you take pain medication you should also take a stool softener: colace, senna, milk of magnesia are all good options - You may shower. Please no soaking in the tub or swimming. Please no heavy lifting for six weeks - VNA services will help you with dressing changes for the next few days - Please stay on a Stage IV diet until your follow up appointment. - it is very important for you to remain active once you are home -> walking daily and slowly increasing your level of activity each day - If you have a fever>101.4, nausea, vomitting, increased abdominal pain, increased redness around incision, difficulty breathing or chest pain please call Doctor's office or return to the ED Followup Instructions: **You will need to call and confirm these appointments** - Please call Dr. [**Last Name (STitle) **] office for a follow up appointment in [**12-10**] weeks. ([**Telephone/Fax (1) 9000**] - Please make a follow up appointment with your PCP to review your home medications and adjust accordingly - You need to make a follow-up appointment with the Dr. [**Last Name (STitle) 4229**] of Urology -> he will see you regarding removal of the foley catheter. Please call his office at ([**Telephone/Fax (1) 4230**] to schedule an appointment this week. Completed by:[**2171-11-13**]

[ "038.11", "427.31", "530.81", "788.20", "272.0", "997.5", "401.9", "996.62", "486", "496", "V09.0", "428.0", "997.1", "995.91" ]

icd9cm

[ [ [] ] ]

[ "38.93", "54.59", "43.7", "44.66" ]

icd9pcs

[ [ [] ] ]

7486, 7557

3038, 6233

339, 476

7766, 7775

1277, 3015

8743, 9322

940, 953

6346, 7463

7578, 7745

6259, 6323

7799, 8720

968, 1258

276, 301

504, 789

811, 841

857, 924

78,419

126,041

6766

Discharge summary

report

Admission Date: [**2179-6-6**] Discharge Date: [**2179-6-14**] Date of Birth: [**2120-3-16**] Sex: F Service: SURGERY Allergies: Penicillins / Iodine / Talwin Attending:[**First Name3 (LF) 5569**] Chief Complaint: Liver failure Major Surgical or Invasive Procedure: liver [**First Name3 (LF) **] Past Medical History: Group B streptococcal cellulitis/ left leg cellulitis in [**2177**].; alcoholic hepatitis, hepatitis C with cirrhosis, portal hypertension, hepatic encephalopathy, COPD, previous IV drug abuse Past Surgical History:vaginal hysterectomy [**2168**] Social History: married, smokes. Previous heavy alcohol use,. Stopped 1 1/2 years back. Previous cocaine use. Family History: non contributory Physical Exam: VS: 98.4 80 140/85 22 100 RA General: awake, alert, NAD HEENT: NCAT, EOMI, sclerae icteric Heart: RRR, NMRG Lungs: CTAB, normal excursion, no respiratory distress Abdomen: soft, no masses or hernias Pelvis: no evidence of perineal infection Extremities: WWP, no CCE, no tenderness, moderate discoloration, previous cellulitis appears well healed. Skin: no rashes/lesions/ulcers Labs: 134 / 99 / 12 5.5 >------< 76 -------------< 100 26.6 3.4 / 27 / 1.0 PT, PTT, INR: pending Imaging: CXR pending U/A: negative AST: 61 ALT: 39 Tbili: 14.0 AP: 173 Alb: 2.7 HCG: <5 Pertinent Results: [**2179-6-14**] 07:20AM BLOOD WBC-10.3 RBC-3.10* Hgb-9.9* Hct-29.0* MCV-94 MCH-32.0 MCHC-34.2 RDW-18.2* Plt Ct-85* [**2179-6-14**] 07:20AM BLOOD PT-12.0 PTT-26.4 INR(PT)-1.0 [**2179-6-14**] 07:20AM BLOOD Glucose-127* UreaN-33* Creat-1.3* Na-136 K-4.2 Cl-101 HCO3-27 AnGap-12 [**2179-6-14**] 07:20AM BLOOD ALT-56* AST-30 AlkPhos-100 TotBili-3.1* [**2179-6-14**] 07:20AM BLOOD Albumin-2.8* Calcium-8.0* Phos-2.4* Mg-1.2* [**2179-6-14**] 07:20AM BLOOD tacroFK-7.1 [**2179-6-6**] 4:46 pm SWAB Source: Stool. **FINAL REPORT [**2179-6-9**]** R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2179-6-9**]): ENTEROCOCCUS SP.. Sensitivity testing performed by Etest. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | VANCOMYCIN------------ >256 R Brief Hospital Course: 59 y/o F with history of HCV and EtOH cirrhosis who presented for liver [**Month/Day/Year **]. On [**2179-6-6**], she underwent orthotopic liver [**Date Range **]. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] assisted by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please refer to operative notes for details. Postop, she was sent to the SICU for management. LFTs initially increased then trended down. Liver duplex demonstrated patent vasculature. She was extubated and transferred out of the sicu to the med [**Doctor First Name **] floor where here postop course progressed well. Prograf was initiated on postop day 0. Dose was adjusted to up to 7mg [**Hospital1 **]. Cellcept was tolerated. Steroids were tapered per protocol. Diet was advanced and tolerated. She required insulin for hyperglycemia. She was taught how to check blood sugars and administer insulin. JP drains were removed and drain sites sutured. Abdominal incision remained intact without redness. Lasix iv was given for anasarca. Weight and edema decreased. IV lasix was switched to po lasix at time of discharge. She became ambulatory. PT cleared her for home. VNA services were arranged. She was discharged to home on postop day 7. Medications on Admission: ferrous sulfate 300", folate', rifaximin 550", quetiapine 25", albuterol, ipratropium (not currently taking, lactulose 10 gm/15 mL 30''', miconazole powder topical'', pantoprazole 40 EC', furosemide 40', aldactone 100', calcium carbonate 200''''prn Discharge Medications: 1. prednisone 20 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 DAILY (Daily). 3. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. Disp:*10 syringes* Refills:*2* 6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 9. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:*70 Tablet(s)* Refills:*0* 10. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. ondansetron 4 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0* 12. tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 13. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO twice a day. 14. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. NPH insulin human recomb 100 unit/mL Suspension Sig: Twelve (12) units Subcutaneous once a day. Disp:*1 bottle* Refills:*2* 16. Humalog 100 unit/mL Solution Sig: follow sliding scale units Subcutaneous four times a day. Disp:*1 bottle* Refills:*2* 17. Insulin Syringes Supply low dose syringes, needle 25-26 gauge for qid insulin supply 1 box refill 2 18. One Touch Ultra Test Strip Sig: One (1) Miscellaneous three times a day. Disp:*1 box* Refills:*2* 19. One Touch UltraSoft Lancets Misc Sig: One (1) Miscellaneous three times a day. Disp:*1 box* Refills:*2* 20. One Touch Ultra System Kit Kit Sig: One (1) kit Miscellaneous four times a day. Disp:*1 kit* Refills:*1* 21. Kayexalate Powder Sig: Four (4) teaspoons PO as directed as needed for high potassium: take only as directed by [**Hospital1 1326**] Team-. Disp:*1 bottle* Refills:*2* 22. FreeStyle Lite Strips Strip Sig: One (1) strip Miscellaneous four times a day. Disp:*2 Bottles* Refills:*5* 23. lancets Misc Sig: One (1) lancet Miscellaneous four times a day: For freestyle lite kit. Disp:*2 bottles* Refills:*5* Discharge Disposition: Home With Service Facility: [**Hospital **] Healthcare Discharge Diagnosis: HCV/ETOH cirrhosis GI bleeding 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: [**Hospital **] [**Name (NI) **] Health Nursing Services has been arranged to help you at home Please call the [**Name (NI) 1326**] Office [**Telephone/Fax (1) 673**] if you have any fevers (101 or greater), chills, nausea, vomiting, inability to take any of your medications, increased abdominal pain, jaundice, incision redness/bleeding/drainage or blood sugars consistently over 200 or less than 80. You will need to have blood drawn for labs drawn every Monday and Thursday No driving. You may shower with soap and water, pat dry. Do not apply powder/lotion/ointment to incision. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2179-6-21**] 9:50 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2179-6-28**] 11:00 Provider: [**Name10 (NameIs) **] SOCIAL WORKER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2179-6-28**] 11:40 Completed by:[**2179-6-15**]

[ "303.93", "416.9", "790.29", "E932.0", "070.70", "401.9", "571.2", "496", "584.5", "785.0" ]

icd9cm

[ [ [] ] ]

[ "00.93", "50.59" ]

icd9pcs

[ [ [] ] ]

6415, 6472

2357, 3631

302, 334

6547, 6547

1391, 2334

7338, 7785

734, 753

3932, 6392

6493, 6526

3658, 3909

6730, 7315

572, 606

768, 1372

249, 264

6562, 6706

356, 550

622, 718

32,395

105,867

32432

Discharge summary

report

Admission Date: [**2121-10-29**] Discharge Date: [**2121-11-4**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 371**] Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: None History of Present Illness: 85 yo female, reportedly with witnessed fall from 4 steps per the family, +LOC. Family reports after fall patient stated "it hurts" repetitively, then began speaking nonsensical sentences, with increased confusion to incoherence. She was brought to an area hospital where found to have a small Left SDH, acute IPH with small SAH. She was then transported to [**Hospital1 18**] for further care. Past Medical History: Neck injury with fusion TMJ GERD Family History: Noncontributory Pertinent Results: [**2121-11-3**] ECHOCARDIOGRAM The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-10mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is mild mitral valve prolapse. Mild to moderate ([**11-26**]+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. . [**2121-11-2**] AP/LAT PELVIS IMPRESSION: No fracture. . [**2121-10-30**] CT HEAD IMPRESSION: 1. Stable appearance of left temporal intraparenchymal hematomas, left-sided subdural hematoma, and diffuse subarachnoid hemorrhage. 2. Longitudinal fracture through the right temporal bone. . [**2121-10-29**] CXR IMPRESSION: Overriding fracture through the midshaft of the right clavicle. . [**2121-10-29**] 10:20AM POTASSIUM-4.5 [**2121-10-29**] 10:20AM PHENYTOIN-22.4* [**2121-10-29**] 08:03AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.033 [**2121-10-29**] 08:03AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2121-10-29**] 08:03AM URINE RBC-[**10-14**]* WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0 [**2121-10-29**] 08:03AM URINE MUCOUS-RARE [**2121-10-29**] 06:45AM CALCIUM-8.5 PHOSPHATE-3.6 MAGNESIUM-2.1 [**2121-10-29**] 06:45AM GLUCOSE-154* UREA N-20 CREAT-0.6 SODIUM-139 POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-25 ANION GAP-13 [**2121-10-29**] 06:45AM WBC-10.3 RBC-3.87* HGB-11.6* HCT-35.2* MCV-91 MCH-29.9 MCHC-32.9 RDW-13.6 [**2121-10-29**] 06:45AM NEUTS-90.8* BANDS-0 LYMPHS-6.4* MONOS-2.6 EOS-0.1 BASOS-0 Brief Hospital Course: She was admitted to the Trauma Service. Neurosurgery and Orthopedics were consulted due to her injuries. Her injuries were non operative. She was loaded with Dilantin; serial head CT scans were followed and were stable. There were no observed or reported seizure activity. The Dilantin will need to continue for at least another 4 weeks until follow up with Dr. [**Last Name (STitle) **], Neurosurgery; she will have an repeat head CT scan at that time. Her Orthopedic injuries were managed non operatively as well. Once the swelling subsided she was casted because of her olecranon fracture. She will be non weight bearing on her right upper extremity and will follow up with Dr. [**Last Name (STitle) **], Orthopedics, in 2 weeks. She was started on Calcium and Vitamin d for bone prophylaxis. Geriatrics was consulted given her age and mechanism of injury. Several recommendations were made pertaining to her medications. Physical and Occupational therapy evaluated her and have recommended rehab stay after acute hospitalization. Medications on Admission: Unknown Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 2. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*2* 3. Metoprolol Tartrate 25 mg Tablet Sig: [**11-26**] Tablet PO twice a day for 1 months. Disp:*30 Tablet(s)* Refills:*2* 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 5. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime: hold for loose stools. 6. Milk of Magnesia 400 mg/5 mL Suspension Sig: 20-30 ML's PO twice a day as needed for constipation. 7. Calcium Carbonate 650 (1,625) mg Tablet Sig: One (1) Tablet PO three times a day. 8. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: Normandy Senior Care Center - [**Location (un) **] Discharge Diagnosis: s/p Fall down stairs Intraparenchymal hematoma Subdural hematoma Subarachnoid hematoma Right clavicular fracture Right olecranon fracture Discharge Condition: Good Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **], Orthopedic Surgery, in 2 weeks. Please call ([**Telephone/Fax (1) 2007**] to schedule an appointment. Follow up in 4 weeks with Dr. [**Last Name (STitle) **], Neurosurgery, in 4 weeks. Please call [**Telephone/Fax (1) **] to schedule an appointment. You will need a Non-Contrast Head CT prior to this appointment. Completed by:[**2121-11-4**]

[ "530.81", "424.2", "293.0", "V45.4", "733.00", "E880.9", "810.02", "801.22", "813.01" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

4845, 4922

2997, 4035

270, 277

5104, 5111

810, 2974

5134, 5527

774, 791

4093, 4822

4943, 5083

4061, 4070

222, 232

305, 701

723, 758

20,649

177,831

105

Discharge summary

report

Admission Date: [**2154-12-14**] Death Date: [**2154-12-15**] Service: MEDICINE/[**Doctor Last Name 1181**] HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old male with a history of encephalitis, oral cancer, presenting to Intensive Care Unit with shortness of breath and hypoxia secondary to a large pleural effusion. While in the Intensive Care Unit, the patient had transient hypotension and had a large O2 requirement secondary to the large effusion and multiple pulmonary nodules almost certainly representing metastatic disease. The patient was stabilized with IVF and supplemental O2. The medical situation including presumed widely metastatic cancer with likely malignant effusion was discussed with the patient. Mr. [**Known lastname 1182**] firmly delined further diagnostic interventions or therapies to work up and treat this. Based on his firmly expressed opinion, his code status was made DNR/DNI and primary driver changed to maintaining comfort. On [**2154-12-15**], the patient was stable for transfer to floor for further care. He remained with a high supplemental FiO2 requirement in order to maintain borderline sats. Mr. [**Known lastname 1182**] frequently removed his face mask saying that he just wanted to be comfortable. He expressed understanding that going without supplemental Oxygen would put him at risk for respiratory or cardiac arrest. On [**2154-12-15**] at 11:05 pm, the senior resident was called to see patient for unresponsiveness. The patient had continued to refuse oxygen during the day into the evening. He had only intermittently complied with wearing the mask secondary to comfort concerns. as he had done in the MICU, and earlin the On evaluation by the sernior resident, the patient had no respirations. The patient had no response to voice or sternal rub or other painful stimuli. The patient had no heart sounds. Pupils were fixed and dilated. The patient was pronounced dead. The Attending was notified and family contact[**Name (NI) **]. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-948 Dictated By:[**Last Name (NamePattern1) 1183**] MEDQUIST36 D: [**2155-2-12**] 10:54 T: [**2155-2-12**] 11:12 JOB#: [**Job Number 1184**]

[ "276.5", "584.9", "799.4", "486", "780.39", "V10.02", "197.2" ]

icd9cm

[ [ [] ] ]

[ "34.91" ]

icd9pcs

[ [ [] ] ]

146, 2260

19,117

149,094

30338

Discharge summary

report

Admission Date: [**2112-8-3**] Discharge Date: [**2112-8-7**] Date of Birth: [**2034-5-16**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 99**] Chief Complaint: Respiratory Failure Major Surgical or Invasive Procedure: Bronchoscopy, Central Venous Line History of Present Illness: 78 yoM w/ h/o esophageal cancer complicated by left mainstem endobronchial tumor and known extension to right, s/p stent placement [**7-26**] by Dr. [**Last Name (STitle) **] at [**Hospital1 18**] who was brought to outside hospital for respiratory distress. Outpatient bronch on [**7-27**] showed stent migration proximally. 12 hours later, patient developed acute resp distress. Was admitted to [**Hospital 1474**] hospital and was intubated. In ED, spiked temp to 102, pancultured. Sputum + MRSA [**7-27**]. SBP in 90s, went into Afib, and was started on Vanco/Zosyn. Of note, patient completed a course of Linezolid [**7-22**] for MRSA pna (diagnosed during [**Hospital1 18**] admission [**Date range (1) 29438**]. At [**Hospital1 1474**], CXR showed almost complete consolidation or opacification of left lung with diffuse right sided infiltrates. In [**Hospital1 1474**] ICU, ad right subclavian placed [**7-26**]. Initially managed with levophed and vasopressin. [**Last Name (un) **] stim normal. Ruled out for MI. Pressors stopped prior to transfer. He was then transferred back to [**Hospital1 18**] for further management. Patient arrived to [**Hospital1 18**] SICU off pressors and intubated. . Currently, patient is intubated, sedated, afebrile, and hemodynamically stable. Past Medical History: # Esophageal adenocarcinoma s/p Ivor-[**Doctor Last Name **] esophagectomy [**4-12**] - recurrence [**2110**], currently undergoing chemotherapy - last chemo by wife report w/ Xeloda in [**6-16**] - s/p left mainstem bronchus stenting [**2-17**] [**2-12**] tumor invasion, complicated by cardiogenic shock # h/o MRSA PNA treated at [**Hospital1 18**] w/ Linezolid # h/o prostate CA on casodex # h/o laryngeal CA 15y ago treated with XRT and surgery # GERD # left bundle branch block # atrial fibrillation Social History: The patient [**Doctor Last Name **] with family ( wife and grand-daughter). He is a vacuum system mechanic,and was in the Navy before that. Patient reports being exposed to asbestos about 30 years prior, during his time in Navy shipyards. Patient admitted to ETOH use, approximately 4 cans per day. He has a 25 pack/year history of tobacco use, but quit in [**2096**]. Family History: Patient had a brother who died of esophageal cancer at age 65. Patient also mentioned that multiple deceased family members had carried a diagnosis of cancer,but he could not recall the specifics. Physical Exam: PE: T: 98.8 BP: 128/59 HR: 78 RR: 24 O2 94% on 50% FiO2 Gen: intubated. sedated. opens eyes to voice HEENT: No conjunctival pallor. No icterus. MMM. Pupils equal, minimally reactive. ET and OG tubes in place NECK: Supple, No LAD, Cannot assess JVP but + JVD ~14 cm H2O. R subclavian line CDI CV: Irreg irreg. nl S1, S2. II/VI sys murmur loudest at base LUNGS: minimal breath sounds throughout L lung fields. Diffusly rhonchorous on R. ABD: hypoactive bowel sounds. soft. Nondistended EXT: warm. 3+ UE and LE edema bilat. NEURO: opens eyes to voice. face symmetric. pupils equal and minimally reactive. Pertinent Results: [**2112-8-3**] 11:34PM TYPE-ART PO2-131* PCO2-44 PH-7.36 TOTAL CO2-26 BASE XS-0 [**2112-8-3**] 11:34PM LACTATE-1.2 [**2112-8-3**] 11:34PM freeCa-1.25 [**2112-8-3**] 11:24PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.025 [**2112-8-3**] 11:24PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-6.0 LEUK-NEG [**2112-8-3**] 09:41PM TYPE-ART PO2-76* PCO2-48* PH-7.32* TOTAL CO2-26 BASE XS--1 [**2112-8-3**] 09:41PM LACTATE-1.1 [**2112-8-3**] 09:41PM freeCa-1.30 [**2112-8-3**] 09:30PM ALT(SGPT)-11 AST(SGOT)-14 ALK PHOS-201* TOT BILI-0.4 [**2112-8-3**] 09:30PM ALBUMIN-2.1* CALCIUM-8.7 PHOSPHATE-3.2 MAGNESIUM-2.0 [**2112-8-3**] 09:30PM PLT COUNT-211 [**2112-8-3**] 09:30PM PT-11.9 PTT-28.6 INR(PT)-1.0 [**2112-8-3**] 09:30PM FIBRINOGE-976* Brief Hospital Course: Pt transferred to [**Hospital1 18**] intubated, treatment continued for presumed pna, pt became more difficult to ventilate. Bronchoscopy showed further migration of L mainstem bronchus stent. Stent now obstructing both right and left mainstem bronchi at level of carina. IP felt that surgical removal would cause excessive morbidity/mortality. After discussion with family, pt made CMO. Pt was extubated and then expired. Medications on Admission: Bicalutamide Chlorhexidine Gluconate Docusate Sodium (Liquid) 100 twice daily Fentanyl Citrate gtt Heparin SC three times daily Lansoprazole 30 mg daily Metoclopramide 10 mg Q6H Midazolam gtt Nystatin Oral Suspension Zosyn Vancomycin Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: Respiratory Failure. Discharge Condition: Expired. Discharge Instructions: Expired. Followup Instructions: Expired

[ "038.9", "518.81", "V10.21", "427.31", "530.81", "197.0", "197.1", "482.41", "995.92", "197.3", "V10.46", "V10.03" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

5004, 5013

4261, 4687

288, 324

5078, 5089

3416, 4238

5146, 5157

2579, 2778

4972, 4981

5034, 5057

4713, 4949

5113, 5123

2793, 3397

229, 250

352, 1648

1670, 2176

2192, 2563

59,252

152,015

38492

Discharge summary

report

Admission Date: [**2189-9-7**] Discharge Date: [**2189-9-14**] Date of Birth: [**2117-7-8**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**9-7**] Resection of pseudoaneurysm with pericardial patch repair of left ventricle History of Present Illness: 72 year old male with admission to [**Hospital6 **] in early [**Month (only) 547**] for heart failure. He had a positive persantine stress at that time which showed large inferior and inferolateral defects with no reversibility. A subsequent cardiac catheterization revealed severe coronary artery disease with an left ventricular aneurysm. Since that time he has been taking Lasix with some improvement. Currently his symptoms have remained stable since last seen. Past Medical History: Coronary Artery Disease with previous Myocardial Infarction Hypertension Dyslipidemia CRI(1.3) Obesity Question history of stroke [**2169**] Chronic obtructive pulmonary disease Social History: Lives with: wife and son [**Last Name (un) 85647**] [**Name (NI) 85648**]) Occupation:retired manager Tobacco: Quit 2 mo ago, 1.5ppd x40yrs ETOH:none Drugs: none Family History: 9 siblings, 1 died of MI, 1 died of CA, 1 has cardiomyopathy. Recent family member died following CABG in [**Country 3399**] Physical Exam: Pulse: 74 Resp: 18 O2 sat: 20 99%-RA B/P Right: 114/71 Left: 117/78 Height: 5'6" Weight: 100Kg/216 lbs General: WDWN in NAD Skin: Warm, Dry and Intact HEENT: NCAT, PERRLA, EOMI, sclera anicteric oropharynx benign Neck: Supple [x] Full ROM [x] Chest: diminished in bases but otherwise clear Heart: RRR, NlS1-S2, No M/R/G Abdomen: Soft[x] non-distended[x] non-tender[x] bowel sounds + [x] Obese Extremities: Warm [x], well-perfused [X] Edema: Trace Varicosities: Some branch varicosities of LLE and spider varicosity along GSV below knee on right Neuro: Grossly intact, non focal exam Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: trace Left: trace Radial Right: 2+ Left: 2+ Carotid Bruit none appreciated Right: 2+ Left: 2+ Pertinent Results: [**9-7**] Echo: PREBYPASS: The left atrium is moderately dilated. No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is an infero-apical left ventricular aneurysm extending from the apex of the heart at least 6-8 cm inferiorly containing a large thrombus. It is unclear if there is flow between the ventricle and the aneurysm. Overall left ventricular systolic function is severely depressed (LVEF= 25-30%). The anterior wall appears to be akinetic. Transgastric views are poor likely due to the presence of the aneurysm making it difficult to evaluate regional wall motion from mid-ventricle to apex. Right ventricular systolic function is normal with normal free wall contractility. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen.There is no pericardial effusion. POSTBYPASS: The patient is A-paced on milrinone and phenylephrine infusions. The left ventricular aneurysm is no longer seen. However, transgastric and mid-esophageal views of the left-ventricle continue to be poor. Anterior akinesis persists. LV systolic function is slightly improved and is estimated at 30-35%. Right ventricular systolic function continues to be normal. Mitral regurgitation is now mild (1+). Normal aortic contours. [**2189-9-14**] 04:35AM BLOOD WBC-6.4 RBC-3.63* Hgb-10.5* Hct-32.5* MCV-89 MCH-29.0 MCHC-32.4 RDW-16.2* Plt Ct-279 [**2189-9-7**] 12:37PM BLOOD WBC-9.0 RBC-3.34*# Hgb-10.1*# Hct-29.4* MCV-88 MCH-30.1 MCHC-34.2 RDW-15.1 Plt Ct-207 [**2189-9-14**] 04:35AM BLOOD Plt Ct-279 [**2189-9-14**] 04:35AM BLOOD PT-26.4* PTT-30.7 INR(PT)-2.6* [**2189-9-7**] 11:30AM BLOOD Plt Ct-159 [**2189-9-7**] 11:30AM BLOOD PT-15.4* PTT-42.6* INR(PT)-1.4* [**2189-9-7**] 11:30AM BLOOD Fibrino-207 [**2189-9-14**] 04:35AM BLOOD Glucose-100 UreaN-28* Creat-1.1 Na-141 K-4.6 Cl-102 HCO3-31 AnGap-13 [**2189-9-7**] 12:37PM BLOOD UreaN-22* Creat-1.3* Na-142 K-3.8 Cl-109* HCO3-26 AnGap-11 [**2189-9-12**] 10:45AM BLOOD Mg-2.0 [**2189-9-9**] 01:06AM BLOOD Calcium-8.6 Phos-4.2 Mg-1.9 [**2189-9-7**] 09:10PM BLOOD Mg-2.8* Brief Hospital Course: Admitted same day surgery and underwent resection of the left ventricular pseudoaneurysm with pericardial patch repair. Of note bypasses were not performed due to anatomy. See operative for further details. He received cefazolin for perioperative antibiotics and was transfered to the intensive care unit for post operative management. In the first twenty four hours he was weaned from sedation, awoke, and was extubated without complications. He remained in the intensive care for few days as vasopressors and inotropes were progressively weaned off. He continued to progress slowly and was ready for transfer to the floor on post operative day three. Physical therapy worked with him on strength and mobility. He was started on coumadin for aneurysmectomy with clots. He continued to progress and was ready for discharge home with services on post operative day seven. Unable to start ace inhibitor due to blood pressure. Medications on Admission: Carvedilol 12.5mg twice daily Lisinopril 20mg daily ASA 81mg daily Lasix 40mg daily Allopurinol 300mg daily Zocor 40mg daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*30 Capsule(s)* Refills:*0* 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 6. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2 weeks. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 10. Ace inhibitor unable to start ace inhibitor due to blood pressure will need to be reevaluated as outpatient 11. Outpatient Lab Work Labs: PT/INR for Coumadin ?????? indication LV aneurysmectomy Goal INR 2.0-3.0 First draw day after discharge [**2189-9-16**] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by [**Hospital1 **] heart center coumadin clinic Results to [**Hospital1 **] heart center coumadin clinic Phone [**Telephone/Fax (1) 6256**] 12. Coumadin 4 mg Tablet Sig: One (1) Tablet PO once a day for 1 days: please take 4mg on [**9-15**] then lab draw [**9-16**] for further dosing . Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital **] Hospice and VNA Discharge Diagnosis: Resection of pseudoaneurysm with pericardial patch repair of left ventricle Chronic systolic heart failure Coronary Artery Disease with previous Myocardial Infarction Hypertension Dyslipidemia Chronic Renal Insufficiency (1.3) Obesity stroke [**2169**] Chronic obstructive pulmonary disease Discharge Condition: Alert nonfocal Ambulating with steady gait Incisional pain managed with ultram and tylenol prn Incisions: Sternal - healing well, no erythema or drainage 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 until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] on [**2189-10-1**] thrusday at 9 am - [**Hospital1 **] heart center [**Telephone/Fax (2) 6256**] Please call to schedule appointments with your Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4610**] in [**1-24**] weeks [**Telephone/Fax (1) 6256**] **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 LV aneurysmectomy Goal INR 2.0-3.0 First draw day after discharge [**2189-9-16**] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by [**Hospital1 **] heart center coumadin clinic Results to [**Hospital1 **] heart center coumadin clinic Phone [**Telephone/Fax (1) 6256**] Completed by:[**2189-9-14**]

[ "278.00", "414.10", "414.01", "V12.54", "V15.82", "412", "585.9", "496", "272.4", "428.0", "285.9", "278.01", "428.22", "403.90", "458.29" ]

icd9cm

[ [ [] ] ]

[ "37.32", "39.61" ]

icd9pcs

[ [ [] ] ]

7719, 7781

4742, 5676

339, 426

8116, 8273

2288, 4719

9027, 9953

1317, 1443

5851, 7696

7802, 8095

5702, 5828

8297, 9004

1458, 2269

280, 301

454, 921

943, 1122

1138, 1301

12,510

140,963

46822+58951

Discharge summary

report+addendum

Admission Date: [**2144-6-9**] Discharge Date: [**2144-6-13**] Service: NSU HISTORY OF PRESENT ILLNESS: The patient is an 86-year-old woman with an incidental finding of a 2.8-cm right middle cerebral artery aneurysm. The patient was previously at [**Hospital6 **] and was taken to the operating room for a necrotic bowel and underwent an anastomosis with small- bowel resection on [**5-30**]. She was returned to the operating room on [**5-31**] complications. The patient was extubated on postoperative day six. She was lethargic. They got a head computer tomography which showed this right middle cerebral artery aneurysm. She had a magnetic resonance imaging/magnetic resonance angiography that suggested a 2.5- cm aneurysm, and the patient was transferred to [**Hospital1 346**] for further management. PAST MEDICAL HISTORY: The patient has a past medical history of osteoporosis, chronic obstructive pulmonary disease, and colon cancer. ALLERGIES: She has no known drug allergies. PHYSICAL EXAMINATION ON PRESENTATION: Her temperature was 97.9, her blood pressure was 160/80, her heart rate was 94, her respiratory rate was 32, and her oxygen saturation was 97 percent. The patient was confused but following commands intermittently. She was moving all extremities times four. Unable to answer questions. Her strength was 3 plus/5 throughout. There was no clonus. Her sensation appeared to be intact. Her face was symmetric. She was oriented times one. Cardiovascular examination revealed a regular rate and rhythm. The lungs were clear to auscultation. The abdomen was soft and nontender. SUMMARY OF HOSPITAL COURSE: The patient was admitted to the Intensive Care Unit for close neurologic observation. She remained neurologically stable. There was a long discussion had with the patient's family who felt that they did not want to pursue any treatment for this aneurysm. Therefore, the patient was transferred to the regular floor. DISCHARGE DISPOSITION: The patient was screened for rehabilitation. She will require a [**Hospital 3058**] rehabilitation prior to discharge to discharge home. DISCHARGE FOLLOWUP: The patient was instructed to follow up with Dr. [**Last Name (STitle) **] - her GI surgeon - will be in two weeks for staple removal. She was to follow up with her primary care physician as needed. She will not require any neurosurgical followup. MEDICATIONS ON DISCHARGE: 1. Lopressor 25 mg by mouth twice per day. 2. Albuterol inhaler q.6h. as needed. 3. Colace 100 mg by mouth twice per day. 4. Famotidine 20 mg by mouth twice per day. 5. Heparin 5000 units subcutaneously twice per day. 6. Senna one to two tablets by mouth twice per day as needed. 7. Vitamin B12 injection once per month. 8. Multivitamin one tablet by mouth once per day. CONDITION ON DISCHARGE: The patient's condition was stable at the time of discharge. [**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**] Dictated By:[**Last Name (NamePattern1) 6583**] MEDQUIST36 D: [**2144-6-12**] 17:01:43 T: [**2144-6-12**] 17:40:17 Job#: [**Job Number 99369**] Name: [**Known lastname **], [**Known firstname 6691**] Unit No: [**Numeric Identifier 15914**] Admission Date: [**2144-6-9**] Discharge Date: [**2144-6-13**] Date of Birth: [**2058-2-12**] Sex: F Service: NSU The patient has been febrile intermittently. PHYSICAL EXAMINATION: Upon examination, the patient was noted to have a slight discharge and a slight erythematous region around one-third from the upper pole of the incision. The two staples were removed, and the wound was probed. The wound was approximately 2 cm to 3 cm in depth and 1 cm in width. There was a slight purulent drainage, which was sent for cultures. Otherwise, she has been doing well. It was discussed with her general surgeon, Dr. [**Last Name (STitle) **]. He agrees that she may go to Rehab and follow up within two weeks and require b.i.d. dressing changes. The wound appears suprafascial. He preferred not to start antibiotics at this point. She is currently stable for discharge to Rehab. [**Name6 (MD) **] [**Last Name (NamePattern4) 2483**], [**MD Number(1) 2484**] Dictated By:[**Last Name (NamePattern1) 10056**] MEDQUIST36 D: [**2144-6-13**] 10:50:44 T: [**2144-6-13**] 12:04:01 Job#: [**Job Number 15915**]

[ "780.6", "V12.79", "437.3", "733.00", "496", "V10.05" ]

icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

2005, 2144

2442, 2816

1661, 1981

3473, 4428

2165, 2416

117, 828

851, 1632

2841, 3450

31,047

189,877

30873

Discharge summary

report

Admission Date: [**2140-7-5**] Discharge Date: [**2140-7-7**] Date of Birth: [**2099-7-9**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 30**] Chief Complaint: sepsis Major Surgical or Invasive Procedure: none History of Present Illness: 40M with chronic venostasis disease, PVD s/p R bypass graft, who p/w sepsis from ED. He originally had an accident at his work at a contruction site when he fell and had a complex R tibial plateau fracture in [**2139-6-2**]. He was continued on vanc for 2 weeks post-op, but continued to have poor wound healing and concern for continued infection so remained on abx until mid [**Month (only) 205**], followed by the ID service. He was admitted on [**2140-2-18**] for septic arthritis with pseudomonas and he continued a roughly 6 week course of abx because an MRI f the knee was concerning for osteomyelitis in the distal femur, patella, proximal tibia. He was seen in [**Date Range **] clinic today for routine follow-up though was referred to his ID physician because of tender L groin lymphadenopathy and fever to 99.0. He was referred to the ED and was noted to have initial VS: t 98.2 p 107 bp 114/68 rr 18 98% RA. Temp rose to 102.7, HR rose periodically to 120s, BP ranged from 92/49 to 135/65. He was given 6L IVF in the ED. He was admitted to MICU team for further evaluation and treatment. Past Medical History: Peripheral vascular disease s/p right bypass graft about 10 years ago s/p complex right tibial plateau fracture s/p ORIF [**6-8**] s/p R knee manipulation [**2140-2-12**] Glass removed R eye as child - no residual deficit Social History: Lives with wife and 3 kids (age 12,13,16. Not currently working. Denies past or present tobacco use. Denies any illicit drugs or alcohol use. Stairs to enter house Family History: Father, deceased 62 cancer (either lung or melanoma had black spots/lumps under his skin on chest wall, patient unsure type of cancer) Mother, deceased 46 brain aneuyrsm, h/o varicose veins Sister - [**Name (NI) 4522**] Brother - Healthy Physical Exam: VS: Temp: 99.2 BP: 106/57 HR: 101 RR: 16 O2sat: 97 2L GEN: pleasant, awake, alert, NAD HEENT: PERRL, EOMI, MMM RESP: CTA b/l CV: tachy, RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: dry skin notable for lack of hair, LLE warm, erythematous without distinct margin. R knee with well healing scar, no pain with active or passive motion at joint. SKIN: diffuse erythema Pertinent Results: [**2140-7-5**] 10:25AM WBC-7.5 RBC-5.85 HGB-14.7 HCT-46.3 MCV-79* MCH-25.1* MCHC-31.6 RDW-14.7 [**2140-7-5**] 10:25AM NEUTS-73* BANDS-0 LYMPHS-9* MONOS-12* EOS-4 BASOS-1 ATYPS-1* METAS-0 MYELOS-0 [**2140-7-5**] 10:25AM PLT SMR-NORMAL PLT COUNT-165 [**2140-7-5**] 10:25AM SED RATE-1 [**2140-7-5**] 12:00PM GLUCOSE-99 UREA N-22* CREAT-1.0 SODIUM-144 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-28 ANION GAP-16 . STUDIES: * Left lower extremity venous ultrasound: In the left groin, in the region of the patient's pain, there are two markedly enlarged lymph nodes measuring 2.3 x 2.8 x 1.9 cm and 2.1 x 2.4 x 1.4 cm, with moderate vascularity. These nodes are not significantly increased in size compared to [**9-/2139**], however they are directly in the area of the patient's pain and likely represent inflamed/infected lymph nodes. The left common femoral vein, superficial femoral vein, and popliteal veins demonstrate normal wall-to-wall flow with normal respiratory variability. The common and popliteal veins were not interrogated for compressibility due to patient discomfort. The left SFV was compressible Brief Hospital Course: 40M with chronic venostasis disease, PVD s/p R bypass graft, who presented with cellulitis. . Cellulitis: Pt initially presented with fever to 102.7, signs of cellulitis on physical exam. There was concern initial for sepsis given BP which fluctuated between 90s systolic and 130s systolic. However, Pt's BP runs low at baseline in 90s to 100s. He was initially monitored in the ICU overnight, but was hemodynamically stable and did not require any pressors.He was treated with IV Vancomycin and ciprofloxacin, did very well clinically and called out to medical floor. On the medical floor, he remained afebrile. All other sources of infection were negative including CXR shows no PNA, UA negative, No leukocytosis, lactate 2.1, CRP 7.0. He was switched to PO cipro, PICC line placed and he was discharged with plan for 2 weeks total of PO cipro and IV vancomycin. Follow up appointments were arranged for orthopedics and ID. Medications on Admission: none Discharge Medications: 1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 12 days. Disp:*24 Tablet(s)* Refills:*0* 2. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*1 tube* Refills:*2* 3. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours) for 12 days. Disp:*24 bags* Refills:*0* 4. PICC Care Please do usual PICC care as per IV nurse protocol 5. Sodium Chloride 0.9 % 0.9 % Solution Sig: 5-10 MLs Injection SASH PRN as needed for line flush for 2 weeks. Disp:*qs ML(s)* Refills:*0* 6. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: 3-5 MLs Intravenous SA SH PRN as needed for line flush for 2 weeks. Disp:*qs ML(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Primary: cellulitis Discharge Condition: well, afebrile, pain free Discharge Instructions: You had cellulitis of your left leg which has improved on antibiotics. You will need antibiotics for 2 weeks total. One of these is an intravenous medication called Vancomycin. Please call you primary doctor or go to the ED if you have any worsening redness, swelling, pain of you legs, joints. Also, if you have any fever, chills, nausea, vomiting, diarrhea, or any other concerning symptoms. Followup Instructions: Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1005**] on Tuesday, [**7-12**] at 3:25PM. Please follow-up with Dr. [**First Name8 (NamePattern2) 4035**] [**Last Name (NamePattern1) 976**] [**8-2**], Tuesday at 10AM. Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2140-10-4**] 8:20 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2140-10-4**] 8:40

[ "459.81", "682.6", "443.9" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

5415, 5467

3682, 4610

274, 281

5531, 5559

2542, 3659

6002, 6527

1856, 2095

4665, 5392

5488, 5510

4636, 4642

5583, 5979

2110, 2523

228, 236

309, 1412

1434, 1658

1674, 1840

46,085

136,655

24199

Discharge summary

report

Admission Date: [**2142-11-21**] Discharge Date: [**2142-11-27**] Date of Birth: [**2077-1-14**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion/angina Major Surgical or Invasive Procedure: [**2142-11-21**] Aortic valve replacement, [**Street Address(2) 11688**]. `[**Hospital 923**] Medical Biocor Epic tissue valve. History of Present Illness: This is a 65 year old male with known aortic stenosis and coronary artery disease. Over the last several months, he has experienced worsening dyspnea on exertion. Serial echocardiograms have shown progression of his aortic valve disease and recent catheterization showed only mild, non-obstructive coronary artery disease. Given his ongoing symptoms, he has been referred for cardiac surgical intervention. Past Medical History: Aortic Stenosis Coronary artery disease, s/p RCA drug eluting stent in [**2141-7-12**] Type II Diabetes mellitus Dyslipidemia Obesity Sleep Apnea GERD Psoriasis Anxiety/Depression Hearing Loss L ear osteoarthritis left knee Bil. great toe neuropathy Social History: Lives: Alone, has nearby girlfriend and son lives downstairs Occupation:retired office worker Tobacco: Quit [**2138-2-12**], 60 PYH ETOH: Rare Family History: father with CAD, died at 86 Physical Exam: Pulse:62 Resp: 18 O2 sat: 98% B/P Right: 168/83 Left: 147/81 Height: 5'[**42**]" Weight:219# General:NAD, well-appearing Skin: Warm[x] Dry [x] intact [x] HEENT: NCAT[x] EOMI [x]anicteric sclera Neck: Supple [x] Full ROM [x]no JVD Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur- 4/6 SEM radiates throughout precordium to carotids Abdomen: Soft [x] obese,non-distended [x] non-tender [x] bowel sounds + [x]no HSM Extremities: Warm [x], well-perfused [x] Edema -none Varicosities: None [x] Neuro: Grossly intact, nonfocal exam, MAE [**5-16**] strengths Pulses: Femoral Right: 1+ Left: 1+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit - murmur radiates to B carotids Pertinent Results: [**2142-11-27**] 04:35AM BLOOD WBC-9.2 RBC-4.18* Hgb-12.0* Hct-36.3* MCV-87 MCH-28.7 MCHC-33.0 RDW-15.1 Plt Ct-261 [**2142-11-26**] 05:10AM BLOOD WBC-8.5 RBC-4.36* Hgb-12.6* Hct-37.9* MCV-87 MCH-29.0 MCHC-33.3 RDW-15.3 Plt Ct-224 [**2142-11-27**] 04:35AM BLOOD Glucose-147* UreaN-18 Creat-1.1 Na-139 K-4.1 Cl-101 HCO3-31 AnGap-11 [**2142-11-26**] 05:10AM BLOOD Glucose-118* UreaN-21* Creat-0.9 Na-140 K-4.3 Cl-99 HCO3-29 AnGap-16 Intra-op TEE 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. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. Trivial mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: No pericardial effusion seen. Grossly normal biventricular systolic function. Brief Hospital Course: The patient was brought to the operating room on [**2142-11-21**] where the patient underwent AVR (23mm St. [**Male First Name (un) 923**] tissue) with Dr. [**Last Name (STitle) **]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. Plavix was resumed for drug eluting stents. Pacing wires were discontinued and the patient immediately had a large amount of bloody chest tube output. He did remain hemodynamically stable. He had a drop in hematocrit from 28% to 22.9%. He received 4 units of packed red blood cells. He developed hypotension with fever and was worked up for transfusion reaction. Pathology determined that this was not an actual transfusion reaction. He was treated with Benadryl and steroids. Echo did not reveal tamponade. He remained hemodynamically stable. Chest tubes were discontinued without complication. The patient was transferred to the telemetry floor for further recovery. Lisinopril, Norvasc and lopressor were titrated for hypertension. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 6 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to home with VNA services in good condition with appropriate follow up instructions. Medications on Admission: PLAVIX 75 mg daily Pepcid 20 mg [**Hospital1 **] Fish Oil [**2132**] mg daily Rosuvastatin 40 mg QHS Lisinopril 10 mg daily Atenolol 25 mg daily Aspirin 325 mg daily Glypizide 5 mg [**Hospital1 **] Metformin 500 mg daily SL NTG prn MVI daily Discharge Medications: 1. Pepcid 20 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 2. Fish Oil 1,000 mg Capsule Sig: Two (2) Capsule PO once a day. Disp:*60 Capsule(s)* Refills:*0* 3. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 6. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 8. glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 10. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*70 Tablet(s)* Refills:*0* 11. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 12. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for DES . Disp:*30 Tablet(s)* Refills:*0* 13. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 3 days. Disp:*6 Tablet(s)* Refills:*0* 14. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:*10 Tablet(s)* Refills:*0* 15. potassium chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day for 5 days. Disp:*5 Capsule, Sustained Release(s)* Refills:*0* 16. Lopressor 100 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Aortic Stenosis s/p AVR Hypertension Coronary artery disease s/p RCA drug eluting stent in [**2141-7-12**] Type II Diabetes mellitus Dyslipidemia Obesity Sleep Apnea Gastroesophageal reflux disease Psoriasis Anxiety/Depression Hearing Loss Left ear Osteoarthritis left knee Bilateral great toe neuropathy Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with dilaudid and tylenol Incisions: Sternal - healing well, no erythema or drainage Edema trace bilateral lower extremities 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 monitor Blood glucose closely - goal to maintain BG < 150 - please follow up with PCP if BG > 200 x2 as hyperglycemia can increase risk of infection **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) **] [**Name (STitle) **] [**12-13**] at 2:30pm Cardiologist: Dr. [**Last Name (STitle) 61466**] [**12-19**] at 10:30 Please call to schedule appointments with your Primary Care Dr [**First Name (STitle) **] in [**4-16**] weeks [**Telephone/Fax (1) 644**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2142-11-27**]

[ "285.9", "272.4", "278.00", "424.1", "414.01", "250.60", "780.61", "V15.82", "V45.82", "389.9", "458.9", "696.1", "300.4", "401.9", "715.36", "357.2", "327.23", "427.31", "518.0" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.21" ]

icd9pcs

[ [ [] ] ]

7018, 7093

3157, 4889

308, 438

7442, 7652

2185, 3134

8650, 9184

1327, 1357

5182, 6995

7114, 7421

4915, 5159

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1372, 2166

241, 270

466, 876

898, 1150

1166, 1311

75,557

122,498

41433

Discharge summary

report

Admission Date: [**2156-8-1**] Discharge Date: [**2156-8-31**] Date of Birth: [**2109-5-26**] Sex: M Service: CARDIOTHORACIC Allergies: Iron Attending:[**First Name3 (LF) 1406**] Chief Complaint: bacteremia Major Surgical or Invasive Procedure: [**2156-8-6**] - Aortic valve replacement with #23mm ST.[**Male First Name (un) 923**] mechanical valve/Mitral valve replacement with #29mm St.[**Male First Name (un) 923**] mechanical valve and pericardial patch closure of aortic valve annular abscess. [**2156-8-29**] - peritoneal dialysis catheter - any questions call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 3618**] History of Present Illness: Mr. [**Known lastname **] is a 47 year old male with End Stage Renal Disease secondary to hypertension, who was admitted to [**Hospital1 498**] [**Hospital1 1559**] with an infected right groin hemodialysis line on [**2156-7-31**]. He has had multiple access procedures, and the most recent hemodialysis line was placed approximately two months ago by [**Hospital1 18**] AV care. Due to his known central stenosis, a groin site was chosen. For approximately one week, he has been having yellow discharge around the catheter. He had HD on Friday, at which time he had a temperature of 101 and yellow discharge. Upon admission to [**Hospital1 498**], blood and wound cultures were obtained, which grew Staph Aureus. He was started on vancomycin, and the catheter was removed. He was transferred to [**Hospital1 18**] with bacteremia from infected hemodialysis line for continued management. Past Medical History: Endocarditis, Mitral Regurgitation, Hypertension, asthma, anemia, restless leg syndrome, ESRD/HD, Gastric Esophageal Reflux Disease, multiple AV grafts bilateral upper extremities, bilateral nephrectomies for renal carcinoma, s/p bilateral parathyroidectomy Social History: Currently incarcerated. History of cocaine use. No alcohol or tobacco Family History: Non-contributory. Physical Exam: Vitals: T 98.1, HR 81 a-fib, BP 100/62, RR 20, O2 94RA Gen: awake/alert/oriented, no acute distress CV: iregular rate and rhythm, no murmur Resp: cta bilaterally, decreased in bases Abd: soft, NT, ND, +BS Extr: AV grafts bilateral upper extremities, thrombosed; palpable radial and pt/dp pulses; left groin catheter site clean/dry/intact, no erythema/induration Pertinent Results: [**2156-8-30**] INR 2.5 130 90 26 -----------<116 4.4 23 1.3 ∆ Mg: 2.2 P: 2.7 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 40% to 50% >= 55% Findings LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA and extending into the RV. PFO is present. LEFT VENTRICLE: Normal LV [**Known lastname **] thickness and cavity size. RIGHT VENTRICLE: Normal RV free [**Known lastname **] thickness. Mildly dilated RV cavity. Mild global RV free [**Known lastname **] hypokinesis. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Normal descending aorta diameter. AORTIC VALVE: Three aortic valve leaflets. Aortic root abscess. No AS. Trace AR. MITRAL VALVE: Severely thickened/deformed mitral valve leaflets. Large vegetation on mitral valve. Abscess cavity adjacent to mitral valve. No MS. Moderate to severe (3+) MR. TRICUSPID VALVE: Mild to moderate [[**2-1**]+] TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: Very small pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The patient received antibiotic prophylaxis. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. patient. REGIONAL LEFT VENTRICULAR [**Known lastname **] MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-CPB:1. The left atrium is mildly dilated. No spontaneous echo contrast is seen in the left atrial appendage. 2. A patent foramen ovale is present. 3. Left ventricular [**Known lastname **] thicknesses and cavity size are normal. 4. The right ventricular free [**Known lastname **] thickness is normal. The right ventricular cavity is mildly dilated with mild global free [**Known lastname **] hypokinesis. 5. There are three aortic valve leaflets. An aortic annular abscess is seen. There is no aortic valve stenosis. Trace aortic regurgitation is seen. 6. The mitral valve leaflets are severely thickened/deformed. There is a large vegetation on the mitral valve. There is an abscess cavity seen adjacent to the mitral valve. Moderate to severe (3+) mitral regurgitation is seen. There is a perforation seen of the anterior leaflet. 7. There is a very small pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results. POST-CPB: On infusion of epi, levo, vasopressin. AV pacing, then sinus rhythm. Well-seated mechanical valve in the mitral position with normal washing jets seen. Aortic valve is poorly seen in the deep transgastric view. There is a small transvalvular gradien of 15 mmHG. There is an eccentric paravalvuklar leak that originates near the anterior mitral leaflet side of the aortic annulus. The jet is mild to moderate. The LVEF is now 40% with inferior hypokinesis. The RV is severely hypokinetic and dilated. There is 2+ TR. The aortic contour is normal post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, on [**2156-8-6**] 13:17 Chest CT scan [**2156-8-30**] A right lower lobe, air-fluid level containing, abscess is unchanged, again 22 x 22mm. Note is also made of bilateral pleural effusions with overlying atelectasis/consolidation. Ground-glass opacities, such as that in the right upper [**Last Name (un) **] (4:56) are new, likely areas of developing infection/inflammation. Note is made of pericardial fluid, similar to [**0-0-0**]. Mediastinal gas has resolved. A substernal hematoma is unchanged from [**0-0-0**]. Appearance of a splenic infarct is unchanged. Patient is status post bilateral nephrectomies, aortic and mitral valve replacements. A right PICC traverses a right brachiocephalic vein stent. Extensive osseous sclerosis is unchanged, consistent with renal osteodystrophy. DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Wet read entered: MON [**2156-8-30**] 10:04 PM Brief Hospital Course: Mr. [**Known lastname **] was transferred from [**Hospital6 15083**] to the transplant surgery service at [**Hospital1 18**] on [**2156-8-1**]. He is a 47 year old male with End Stage Renal Disease secondary to hypertension, who was admitted to [**Hospital1 498**] [**Hospital1 1559**] with an infected right groin hemodialysis line on [**2156-7-31**]. He has had multiple access procedures, and the most recent hemodialysis line was placed approximately 2 months ago by [**Hospital1 18**] AV care. Due to his known central stenosis, a groin site was chosen. For approximately 1 week prior to admission to [**Hospital1 498**] he had been having yellow discharge around the catheter. He had hemodialysis on Friday, at which time he had a temperature of 101 and yellow discharge. Upon admission to [**Hospital1 498**], blood and wound cultures were obtained, which grew Staph Aureus. He was started on vancomycin, and the catheter was removed. He was transferred to [**Hospital1 18**] with bacteremia from an infected hemodialysis line for continued management. He was on the surgical floors for several days when he became septic and hypotensive requiring pressors and a transfer to the surgical intensive care unit. An echo revealed severe mitral regurgitation with large vegetations. A transesophageal echocardiogram also revealed an aortic annular abscess. Infectious disease was consulted. Cardiac surgery was consulted and the usual pre-operative evaluation was initiated. On [**8-6**] he became hypoxic and was intubated. Later that day he was brought emergently to the operating room for aortic and mitral valve replacements with Dr [**Last Name (STitle) **], please see operative report for details. In summary he had: 1. Emergent mitral valve replacement with a 29-mm St. [**Male First Name (un) 923**] mechanical valve, reference number [**Serial Number 90136**]. 2. Aortic valve replacement with a St. [**Male First Name (un) 923**] mechanical valve, reference number [**Serial Number 90137**]. pericardial patch closure of aortic valve annular abscess. His cardiopulmonary bypass time was 159 minutes with a crossclamp time of 134 minutes. He tolerated the operation and post-operatively was transferred to the cardiac surgery ICU on Vasopressin, Epinephrine, Levophed, and Propofol infusions. CVVHD was initiated on the day of surgery. He was labile and hypoxic in the immediate post-op period and was kept sedated. Additionally with any weaning of sedation he would become profoundly agitated and vacillated between hypotension and hypertension requiring resedation. He was also having episodes of Atrial fibrillation which was initially treated with Amiodarone that lead to bradycardia and discontinuation of the Amiodarone. Electrophysiology was consulted and they advised the avoidance of amiodarone. Patient returned to sinus rhythm for a period and then went back into a-fib, he was eventually started on Amiodarone without difficulty and his betablockers were increaed for desired effect. He presently is in rate controlled a-fib with stable hemodynamics on amiodarone taper. His valve cultures grew MRSA and he was given Gentamicin and Vancomycin. He was placed on cefepime for ventilator associated pneumonia. He developed VRE bacteremia and enterocus pneumonia in the postop period and required several mores days of pressor therapy. . He was initially extubated a few days after his initial surgery but was reintubated for respiratory distress. He was hemodynamically unstable with rising LFTs and Lactic acid, work-up revealed, percardial hematoma causing tampanade and was brought back to the OR on POD#6 for evacutaion. He returned with improved hemodynamics. He remained intubated for several more days afterwards, due to hypoxia due to fluid overload and agitation. He was again extubated on [**8-19**] and has continued to do well. He required CVVH therapy and was transitioned to HD. He contined to have access issues post-op, left AVF remained clotted, and on POD#18 he had a left groin tunnelled HD cath placed as well as a right PICC. His amylase and lipase spiked in the post-op period which was felt to be chemicially induced, his diet was advanced and they have been trending down slowly. His antibiotics were adjusted per ID, he was switched to cefepime and daptomycin, he was positive for c-diff and started on PO vanco ([**8-18**]) A chest CT done o [**8-22**] as part of his work-up for line placement revealed RLL abscess.A repeat Chest CT was obtain prior to discharge and it showed an unchnaged abcess (see reports. His longterm dialysis plan is to do peritoneal dialysis, therefore a PD cath was placed [**2156-8-28**] (catheter can be used after 3 weeks). The plan is to continue with HD until all antibiotics are dc'd (on [**2156-9-17**] ID will determine this), afterwhich his PD can be initiated. ID has requested that his lines be minimized prior to discharge, therefore his antibiotics were chanaged to accomadate this plan. He was swithced to IV vanco three times a week after dialysis to be infused through his HD line and cefepime was changed to Cipro on day of discharge and he continues on oral vanco for c-diff. All antibiotics are to be discontinued on [**9-17**] after his ID appointment on that day. He will need his peritoneal dialysis cath flushed and dressing changed per policy. Heparin was started for his double mechanical valve and his INR is currently (2.5) therapeutic off heparin his INR goal is 2.5-3.5 . Mr [**Known lastname **] remains in custody but has continued to progress and has been deemed safe to be discharged [**Hospital6 90138**] in [**Doctor First Name 3094**], MA on Rt 57 for further strengthening, conditioning and medical management PO amiodarone started on [**8-25**] for post-op A-fib ***He has an Anti-C antibody which could lead to a delayed transfusion reaction in the future.*** Medications on Admission: Meds on [**Hospital1 498**] transfer: ventolin 60mg daily, asa 81mg daily, sinemet 25/250 2 tabs qhs, benadryl 25mg TID, colace 100mg [**Hospital1 **], labetalol 300mg [**Hospital1 **], sevelamer 4000mg TID, Vancomycin 1g daily, verapamil 480mg daily Discharge Medications: 1. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 5. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QFRI (every Friday). 6. carbidopa-levodopa 25-250 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. heparin (porcine) 1,000 unit/mL Solution Sig: 3000-10,000 unit dwell Injection DAILY (Daily). 8. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 9. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 10. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 13. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): decrease to 400mg daily on [**2156-9-6**] then decrease to 200mg daily ongoing on [**2156-9-13**]. 14. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**2-1**] Puffs Inhalation Q6H (every 6 hours). 15. guaifenesin 600 mg Tablet Extended Release Sig: Two (2) Tablet Extended Release PO BID (2 times a day). 16. vancomycin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 1 days: last dose mid night [**2156-9-1**]. 17. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for dyspnea. 18. warfarin 7.5 mg Tablet Sig: One (1) Tablet PO once a day: Goal INR 2.5-3.5 for mechcanical MVR/AVR IF INR falls below 2.5- needs IV heparin until INR >2.5. 19. Outpatient Lab Work Check INR daily for one week then 3 times weekly then mon/wed/fri for 2 weeks until on stable coumadin dose with stable INR then at least monthly maintenance. 20. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gm Intravenous HD PROTOCOL (HD Protochol): dose through [**2156-9-17**]- and duration will be determined at ID follow up . 21. line flushes Tunneled Access Line (e.g. Hickman), heparin dependent: Flush with 10 mL Normal saline followed by Heparin as above daily and PRN per lumen. 22. Cipro 500 mg Tablet Sig: One (1) Tablet PO once a day: duration will be determined at follow up appointment with infectious disease. 23. oxycodone 5 mg Capsule Sig: One (1) Capsule PO q4hrs as needed for pain. Disp:*65 Capsule(s)* Refills:*0* 24. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO q6hrs as needed for anxiety. Disp:*60 Tablet(s)* Refills:*0* 25. peritoneal dialysis catheter Flushes per protocol [**2156-8-29**] peritoneal dialysis catheter placed- any questions call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 3618**] Discharge Disposition: Extended Care Facility: [**Location (un) 32674**] - [**Location (un) **] Discharge Diagnosis: s/p Aortic valve replacement with #23mm ST. [**Male First Name (un) 923**] mechanical valve/Mitral valve replacement with #29mm St.[**Male First Name (un) 923**] mechanical valve and pericardial patch closure of aortic valve annular abscess. Reoperation for evacuation of mediastinal hematoma PMH: Endocarditis, Mitral Regurgitation, Hypertension, End Stage Renal Disease/Hemodialysis x16 years secondary to hypertensive nephropathy- Asthma, Anemia, Restless leg syndrome, Gastric Esophageal Reflux Disease, s/p bilateral nephrectomies for renal carcinoma, s/p bilateral parathyroidectomy, s/p multiple AortoVenous graft placements- bilateral Upper Extremities Discharge Condition: Alert and oriented x3 nonfocal Ambulating with assist Incisional pain managed with tylenol sensitive to narcotics Incisions: Sternal - healing well, no erythema or drainage healing well, no erythema or drainage. Stage 3 decubitus wound Extremities: Lower extremities: 1+ Edema; +[**3-4**] left upper extremity Discharge Instructions: 1) AFTER YOUR dialysis catheter in your groin is REMOVED: 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 2) Please NO lotions, cream, powder, or ointments to incisions 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart 4) No lifting more than 10 pounds for 10 weeks 5) 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) **] Date/Time:[**2156-9-8**] 1:00 [**Telephone/Fax (1) 170**] [**Hospital **] Medical Building [**Hospital Unit Name **] Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2156-9-20**] 1:20 Infectious Disease Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 457**] [**9-14**] at 10:30am in [**Hospital **] medical office building basement [**Doctor First Name **] Bsoton Ma [**2156-8-29**] - peritoneal dialysis catheter - any questions call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 3618**] Completed by:[**2156-9-1**]

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icd9cm

[ [ [] ] ]

[ "39.61", "33.24", "38.97", "88.72", "39.95", "96.72", "35.39", "54.93", "37.12", "34.04", "35.22", "35.24", "38.95" ]

icd9pcs

[ [ [] ] ]

16167, 16242

6883, 12776

281, 707

16951, 17265

2434, 6860

18021, 18802

2015, 2035

13078, 16144

16263, 16930

12802, 13055

17289, 17998

2050, 2415

231, 243

735, 1629

1651, 1911

1927, 1999

58,580

195,537

44647

Discharge summary

report

Admission Date: [**2166-5-8**] Discharge Date: [**2166-5-13**] Date of Birth: [**2085-2-23**] Sex: M Service: MEDICINE Allergies: Novocain Attending:[**First Name3 (LF) 1646**] Chief Complaint: gi bleed Major Surgical or Invasive Procedure: none History of Present Illness: [**Known firstname **] [**Known lastname 95557**] is a 81 yo Russian Speaking male with multiple medical problems including [**Name2 (NI) **] sinus syndrome s/p pacemaker, CAD, CHF (EF 40-45%), DM, PVD, history of lower GI bleed presenting to ED with chest pressure and found to have a GI bleed. Of note the patient underwent an EGD and a colonoscopy on [**5-1**] for work up of iron deficiency anemia. Colonoscopy showed 5 polyps which were removed and noted internal hemorrhoids. EGD was notable for mild gastritis and biopsy was neg for H pylori. He was feeling well until yesterday. Yesterday, he began feeling lightheaded, dizzy, and had an episode of chest tightness. He also notes 2 episodes of diarrhea last night. He did not note the stool color. He checks his BP daily and it was 90/40 yesterday and was low again this morning; pre-morning meds his bp is often 180/80 and is 110/80 with meds. He had some chest tightness last night and had it again this morning so came to the ED. The CP is not like his previous MI. He denies associated SOB, diaphoresis. No nausea, vomiting or abdominal pain. The patient's daughter states that he was taking some ibuprofen recently for shoulder pain. . In the ED, initial vs were: 97.8 84 125/57 16 100%. Patient was given Aspirin 325mg POx1, morphine 4 mg IV x1 and SL nitro x1, but continues to have mild chest pain. On exam, rectal exam revealed red stool and was guiaic positive. The patient refused NG lavage. GI was consulted and they plan to see him in the ICU. He is cross-matched for 4 units but has not yet received any. He has remained hemodynamically stable. His VS prior to transfer are 69 130/48 16 100% 4L. . In the ICU, he was reporting moderate to severe chest tightness which resolved with 2 NTG tablets. In addition, he was complaining of left shoulder pain which was reproducible to palpation. . Review of sytems: (+) Per HPI and for [**2-12**] pillow orthopnea and PND, left shoulder and back pain, headache and thirst (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: 1. Hypertension. 2. Pacemaker for [**Month/Day (3) **] sinus syndrome - interrogated on [**2165-2-26**], functioning normally with no atrial or ventricular arrhythmias. 3. CAD, status triple-vessel CABG in [**2151**], EF= 40%. Most recent ECHO in [**8-/2163**], showing LV inferior hypokinesis, mild MR, borderline pulm htn. 4. Peripheral vascular disease, status post left femorotibial bypass and status post two toe amputations. 5. Hypothyroid. 6. Diabetes, insulin-dependent. 7. Chronic renal failure: Baseline creatinine 1.8-2.1. 8. Kidney stones. 9. Spinal stenosis. 10. Soft tissue density in the pancreas uncinate. Evaulated by Gastroenterology in [**2159**]. 11. Three pleural based nodules, seen on prior CT scan. 12. History of several pneumonias. 13. CVA in [**2146**] with residual left facial droop and right leg weakness. 14. Osteoarthritis. 15. Chornic Anemia 16. GIB ([**2161**], [**2162**]) - s/p colonoscopies and EGD. Found to have polyps, internal hemorrhoids, and gastritis. Social History: Russian-speaking only. He is a widower, lives alone, has VNA. He has one daughter [**Name (NI) **] who lives in [**Name (NI) 745**]. He emigrated from [**Location (un) 3155**] in [**2147**]. He has a 30-pack-year smoking history, quit 25 years ago. EtOH: very rarely. No IVDU. Family History: Mother: hypertension. Father: died at age 46 in [**Country 532**]. Sister: hypertension and a [**Last Name **] problem. [**Name (NI) **] [**Name2 (NI) 499**] cancer or gastric cancer in his family history. Daughter and grandson also have chronic anemia. Physical Exam: Vitals: AF 67 142/60 17 99% 2L SBP 130 -->120 with change from lying to sitting. General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP 10, no LAD Lungs: no dullness to percussion, bilat crackles in lower [**1-12**], no wheezes/rhonchi CV: Distant heart sounds, Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops. CP not reproducible. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Rectal: normal tone, dark red stool, Guiaic positive. Ext: warm, well perfused, unable to palpate DP or PT bilat, s/p right metatarsal amputation and left foot surgery, no clubbing, cyanosis. [**1-11**]+ LE pitting edema to knees. Pertinent Results: [**2166-5-8**] 07:20AM BLOOD WBC-8.4 RBC-2.30*# Hgb-6.7*# Hct-20.3*# MCV-88 MCH-29.0 MCHC-32.8 RDW-15.9* Plt Ct-188 [**2166-5-8**] 01:54PM BLOOD WBC-8.6 RBC-2.83* Hgb-8.1* Hct-24.9* MCV-88 MCH-28.7 MCHC-32.7 RDW-14.7 Plt Ct-125* [**2166-5-9**] 03:27AM BLOOD WBC-8.7 RBC-3.78*# Hgb-11.6*# Hct-33.3* MCV-88 MCH-30.5 MCHC-34.7 RDW-15.1 Plt Ct-56*# [**2166-5-9**] 03:51PM BLOOD WBC-12.9* RBC-3.99* Hgb-11.8* Hct-33.8* MCV-85 MCH-29.5 MCHC-34.9 RDW-15.0 Plt Ct-149*# [**2166-5-10**] 01:57AM BLOOD WBC-10.8 RBC-3.62* Hgb-11.0* Hct-31.8* MCV-88 MCH-30.4 MCHC-34.5 RDW-15.4 Plt Ct-139* [**2166-5-10**] 07:01AM BLOOD WBC-10.8 RBC-3.61* Hgb-11.0* Hct-30.8* MCV-85 MCH-30.5 MCHC-35.7* RDW-15.2 Plt Ct-137* [**2166-5-8**] 07:20AM BLOOD Glucose-161* UreaN-76* Creat-2.5* Na-140 K-4.4 Cl-108 HCO3-19* AnGap-17 [**2166-5-8**] 01:54PM BLOOD Glucose-124* UreaN-68* Creat-2.0* Na-143 K-4.1 Cl-112* HCO3-20* AnGap-15 [**2166-5-9**] 03:27AM BLOOD Glucose-135* UreaN-64* Creat-2.0* Na-139 K-4.6 Cl-110* HCO3-19* AnGap-15 [**2166-5-10**] 01:57AM BLOOD Glucose-165* UreaN-45* Creat-1.6* Na-138 K-6.4* Cl-109* HCO3-19* AnGap-16 [**2166-5-10**] 07:01AM BLOOD Glucose-99 UreaN-49* Creat-1.9* Na-143 K-3.5 Cl-108 HCO3-23 AnGap-16 [**2166-5-8**] 07:20AM BLOOD cTropnT-0.05* [**2166-5-8**] 01:54PM BLOOD CK-MB-8 cTropnT-0.18* [**2166-5-8**] 06:59PM BLOOD CK-MB-11* MB Indx-7.1* cTropnT-0.30* [**2166-5-9**] 03:27AM BLOOD CK-MB-10 MB Indx-6.5* cTropnT-0.36* [**2166-5-9**] 10:12AM BLOOD CK-MB-11* MB Indx-8.2* cTropnT-0.54* [**2166-5-9**] 03:51PM BLOOD CK-MB-8 cTropnT-0.46* [**2166-5-10**] 01:57AM BLOOD CK-MB-4 cTropnT-0.25* Brief Hospital Course: 81 yo Russian Speaking male with multiple medical problems including [**Name2 (NI) **] sinus syndrome s/p pacemaker, CAD, CHF (EF 40-45%), DM, PVD, history of lower GI bleed presenting to ED with chest pressure and found to have a GI bleed. # Acute blood loss anemia: Secondary to bleeding from GI tract most likely from the site of the polypectomy in the setting of NSAIDS use and plavix. The patient received 4 U RBC's in the ICU and remained hemodynamically stable. A prep was done with intention to do a c-scope, but the patient was thought to be too unstable. He HCT then leveled off as the plavix wore off and he was transferred to the floor. No c-scope was performed as it was assumed that this was a low bleed from the polypectomy site and it had stopped. He will have his HCT checked 2 days after discharge with VNA. # Chest pain: Patient with substantial history of CAD. CP most likely demand ischemia given acute blood loss and in the morning even with hematocrit at baseline his CAD meds had been held and his pressure was 180s. CP releieved initially with nitro gtt then added back isosorbide dinitrate and [**5-10**] started home imdur. Metoprolol restarted at home dose. Biomarkers trended down. continued statin. held plavix. he will continue to hold his plavix until he follow up with Dr. [**Last Name (STitle) 3357**] in 1 week. # [**Last Name (STitle) **] sinus syndrome: A-V paced at HR in 60s. amio continued. # Chronic systolic heart failure: Patient's most recent EF 40-45%. After blood, pt with SOB, orthopnea, rales that required IV lasix dosing for 3 days. At the time of discharge he was on room air and euvolemic. he was discharged on his home lasix dose. # DM, type II: home insulin continued. # Chronic renal insuffiency: Cr stayed approximately at baseline. # Hypothyroid: Continue synthroid. # Glaucoma: Continue eye gtt. # Shoulder pain: [**Last Name 19390**] problem. - morphine and tramadol prn. no NSAIDS. Medications on Admission: # Amiodarone [Cordarone] 200 mg Tablet by mouth daily # Clopidogrel [Plavix] 75 mg Tablet PO daily # Dorzolamide [Trusopt] 2 % Drops 1 drop left eye 4X daily # Epoetin Alfa [Procrit] 10,000 unit/mL Solution 0.5 ml (No longer taking) # Furosemide [Lasix] 40 mg Tablet PO daily # Insulin Glargine [Lantus] 100 unit/mL Solution 36 Units QAM # Insulin Lispro [Humalog] Dosage uncertain # Isosorbide Mononitrate [Imdur] 120 mg Tablet SR PO daily (Pt taking [**1-11**] tab daily) # Levothyroxine 100 mcg Tablet PO daily # Metoprolol Tartrate 50 mg Tablet PO BID # Simvastatin 80 mg Tablet PO once a day # Valsartan [Diovan] 160 mg Tablet PO by mouth DAILY # Iron # Colace # Ibuprofen OTC Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic QID (4 times a day). 3. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. Insulin Glargine 100 unit/mL Solution Sig: Thirty Six (36) units Subcutaneous once a day. 5. Insulin Lispro 100 unit/mL Insulin Pen Sig: One (1) dose from sliding scale as directed with meals Subcutaneous with meals. 6. Imdur 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 9. Diovan 160 mg Tablet Sig: One (1) Tablet PO once a day. 10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for shoulder pain. Disp:*30 Tablet(s)* Refills:*1* 12. Tylenol Extra Strength 500 mg Tablet Sig: Two (2) Tablet PO three times a day. 13. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary Diagnosis: 285.1 ANEMIA, ACUTE BLOOD LOSS Secondary Diagnosis: 414.05 CAD, BYPASS GRAFT Secondary Diagnosis: 401.1 HYPERTENSION, BENIGN Secondary Diagnosis: 250.80 DIABETES TYPE II, CONTROLLED W/ COMPLICATIONS Secondary Diagnosis: 244.9 HYPOTHYROIDISM Secondary Diagnosis: 584.9 ACUTE RENAL FAILURE Secondary Diagnosis: 578.9 BLEEDING, GASTROINTESTINAL NOS Secondary Diagnosis: 287.5 THROMBOCYTOPENIA, UNSPECIFIED Secondary Diagnosis: 410.70 MYOCARDIAL INFARCTION, NSTEMI Secondary Diagnosis: 428.31 HEART FAILURE, (B1) ACUTE DIASTOLIC Discharge Condition: Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted with a bleed from your [**Hospital6 499**]. After stopping your plavix the bleeding stopped without intervention. We recommend that you continue to hold your plavix until you follow up with Dr. [**Last Name (STitle) 3357**] and he will restart that medication. Otherwise, we have made no changes to your medications. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs in 3 days or 5 lbs in a week as this may be a sign that you are collecting fluid. **************** Please avoid all NSAIDS which include all over the counter pain relievers except for tylenolol. No aleve(naproxen), aspirin, or advil(ibuprofen) as this can increase your risk of bleeding again. While you are off your plavix it will place you at higher risk for having stroke and heart attack, but we feel that given the seriousness of the bleed that you had it is necessary to take the risk of doing so. ***************** Also note that because of the large bleed your stools may not be back to normal color, but they should never have red blood. This is a sign of active bleeding an you should come to the ER for this. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] L. Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **] Address: [**State 4607**], [**Location (un) **],[**Numeric Identifier 588**] Phone: [**Telephone/Fax (1) 4606**] Appointment: [**2166-5-19**] 11:30am

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10420, 10486

6625, 8579

277, 283

11075, 11122

5004, 6602

12419, 12688

3961, 4217

9312, 10397

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59,937

154,230

55040

Discharge summary

report

Admission Date: [**2121-7-9**] Discharge Date: [**2121-7-15**] Date of Birth: [**2039-10-6**] Sex: F Service: MEDICINE Allergies: Sulfa(Sulfonamide Antibiotics) / Erythromycin Base / ibuprofen / Proton Pump Inhibitors / Fosamax / Carafate Attending:[**First Name3 (LF) 1436**] Chief Complaint: Pacemaker Failure Major Surgical or Invasive Procedure: [**2121-7-10**] pacemaker lead removal/exchange History of Present Illness: 81 [**Last Name (un) 9232**] with LV CHF (EF 30%) and 3rd degree heart block who was called by pacemaker monitoring system after she was found to have high impedence on RV and LV leads. She said that she has her pacer interrogated by tele monitoring every Wednesday and that she had not been told she had any issues with it prior to [**2121-7-8**]. She was seen in pacer clinic and the pacer was reprogrammed with higher pacer outputs prior to being sent to [**Hospital3 **]. She has been having nausea, vomiting and lightheadedness for the last month, but otherwise denies any chest pain, dizziness, SOB. Per visit to PCP [**Last Name (NamePattern4) **] [**2121-6-26**] was having episodes of dizziness and flushing of unknown etiology. She presented to [**Hospital6 **], her vitals were stable with HR: 60, BP 165/53, T: 98.2, RR 17, 99% RA. She went to the cath lab for temporary pacer wire that was placed via left femoral vein. She is being paced by her intrinsic pacer with the temporary wire as back up if needed. Heart block with Pacemaker years ago with Atrial and ventricular lead. Had lv placed for CRRT and RV lead for ICD. RV ICD lead fractured. Has 4 left sided leads fractured. High pacing thresholds and alarms. Had right femoral temp wire placed. Now needs to have lead extraction and reimplantation on Thursday. Coming from [**Hospital3 **] . On arrival to the floor, patient was feeling well. No lightheadedness, dizziness, SOB, chest pain. . REVIEW OF SYSTEMS as per HPI . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: [**2113**], [**2117**] -PERCUTANEOUS CORONARY INTERVENTIONS: per patient had prior to CABG -PACING/ICD: Dual chamber pacemaker placed [**2113**]/BiV ICD 3. OTHER PAST MEDICAL HISTORY: Gastric ulcers Ichemic cardiomyopathy with EF of 20-35% Osteoporosis Hyperlipidemia CKD (chronic kidney disease) stage 3, GFR 30-59 ml/min Colles' fracture Obesity OSTEOARTHRITIS MIXED CONDUCTIVE AND SENSORINEURAL HEARING LOSS Social History: Lives alone, family on floor below. Has weekly homemaker, does not smoke currently but did in the past, does not drink Family History: family history of early atherosclerosis - father with heart disease in his 40's; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM: GENERAL: pleasant woman Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink NECK: Supple with JVP to pinna lying at 30 degrees. CARDIAC: normal S1, S2. III/VI crescendo/decrescendo murmur heard best at RUSB. LUNGS: Crackles throughout posterior lung fields, no wheezes, rales, rhonchi ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: DP/PT pulses palpable bilaterally, [**1-20**]+ pitting edema to mid shin bilaterally, no cyanosis or clubbing, pacer wire in right groin, area c/d/i. Right: Carotid 2+ Radial 2+ DP 1+ PT 1+ Left: Carotid 2+ Radial 2+ DP 1+ PT 1+ DISCHARGE PHYSICAL EXAM GENERAL: pleasant woman Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink NECK: Supple with no JVP CARDIAC: normal S1, S2. III/VI crescendo/decrescendo murmur heard best at RUSB. LUNGS: Crackles at bases, no wheezes, rales, rhonchi ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: DP/PT pulses palpable bilaterally, [**1-20**]+ pitting edema to mid shin bilaterally, LEFT upper extremity more edematous than right, but improved from day prior. Hematomas bilaterally. no cyanosis or clubbing, Right: Carotid 2+ Radial 2+ DP 1+ PT 1+ Left: Carotid 2+ Radial 2+ DP 1+ PT 1+ Pertinent Results: ADMISSION LABS [**2121-7-9**] 06:50PM BLOOD WBC-8.0 RBC-3.89* Hgb-10.9* Hct-34.5* MCV-89 MCH-28.0 MCHC-31.6 RDW-14.7 Plt Ct-155 [**2121-7-9**] 06:50PM BLOOD Neuts-65.8 Lymphs-24.9 Monos-7.4 Eos-1.5 Baso-0.4 [**2121-7-9**] 06:50PM BLOOD PT-13.2* PTT-26.8 INR(PT)-1.2* [**2121-7-9**] 06:50PM BLOOD Glucose-132* UreaN-43* Creat-1.6* Na-141 K-4.3 Cl-107 HCO3-24 AnGap-14 [**2121-7-9**] 06:50PM BLOOD ALT-39 AST-31 AlkPhos-89 TotBili-0.3 [**2121-7-9**] 06:50PM BLOOD Calcium-9.3 Phos-2.9 Mg-1.8 Discharge labs: [**2121-7-15**] 07:48AM BLOOD WBC-5.6 RBC-3.00* Hgb-9.4* Hct-28.0* MCV-93 MCH-31.4 MCHC-33.6 RDW-15.2 Plt Ct-127* [**2121-7-15**] 07:48AM BLOOD PT-10.9 PTT-26.1 INR(PT)-1.0 [**2121-7-15**] 07:48AM BLOOD Glucose-147* UreaN-18 Creat-1.2* Na-142 K-4.4 Cl-107 HCO3-27 AnGap-12 [**2121-7-14**] 06:37AM BLOOD Calcium-8.5 Phos-2.5* Mg-2.1 IMAGING: CXR [**7-10**]: New pacer leads in the RA and RV. No pneumothorax or effusion. NGT in the stomach with sideholes at the GE junction. TTE [**2121-7-11**]: LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global systolic function (LVEF>55%). No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal diameter of aorta at the sinus, ascending and arch levels. Focal calcifications in aortic root. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild AS (area 1.2-1.9cm2). Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular calcification. No MS. Physiologic MR (within normal limits). TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No TS. Mild [1+] TR. Mild PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: No PS. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Conclusions The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). 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. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. LOWER EXTREMITY ULTRASOUND [**7-11**]: IMPRESSION: No evidence of left groin pseudoaneurysm or AV fistula. [**2121-7-12**] Upper Extremity Doppler: IMPRESSION: No DVT. Brief Hospital Course: PRINCIPLE REASON FOR ADMISSION Ms. [**Known lastname 4887**] is a 81 year old woman with history of Systolic heart failure and 3rd degree heart block who presented to [**Hospital3 **] after pacer monitoring review found her to have high impedence of RV and LV pacer now transferred to [**Hospital1 18**] for lead extraction. # Pacemaker lead problems: [**Name2 (NI) **] pacer settings were increased (RV LOC increase to 2.4/1.0ms and LV LOC @ 6.0/1.0ms) and she had temporary wire placed in her right groin at the OSH prior to transfer. She was noted to pace from her implanted pacer on arrival to [**Hospital1 18**] and did not needed temp wire. On [**7-10**] she went to the OR for extraction of broken leads and replacement by new leads for ICD/PPM. This was accomplished but complicated by massive blood loss (at least 1500 mL) requiring transfusion to 5 units pRBCs and 6 L lactated ringers. When hemostasis was finally acheieved, her hematocrit remained stable for the next several days. She did require vasopressors for the first 24 hours afterwards. Her ICD interrogation was normal. She continued to do well with the new pacer and there were no more complications. # Hct Drop: Patient had bradycardic episode that occurred after going to the bathroom. It was felt to be a vagal event, but her SBP dropped into the 40's. The next morning she had multiple episodes of BRBPR and a small drop in her Hct. It was felt that this was likely ischemic colitis in a watershed area and sloughing of her epithelium. Since it was felt to be an isolated event, we continued to monitor her. Her episodes on BRBPR decreased and then stopped. She continued to have fluctuating hct and she also had increased edema of her LUE. There was concern for DVT vs. hematoma spread from her subclavian hematoma that occurred when ICD placed. Doppler study was negative for clot. Her arm was elevated and her edema improved. Her hct remained stable and she was ready for discharge home with follow up in the outpatient setting. # CAD: Patient is s/p CABG x2 and currently being followed by Dr. [**Last Name (STitle) **] in the outpatient setting. She is not having active symptoms concerning for ischemia. Continued metoprolol tartrate 100mg PO BID, simvastatin 40mg PO QHS, lisinopril 5mg PO Daily, Aspirin 81mg PO daily, although metoprolol and lisinopril were frequently held due to hypotension. As her blood pressures normalized, her medications were re-initiated. She did well on that regiment and was discharged home. # Aortic stenosis: On transfer, reported to have history of AS with decreased LVEF. She was felt to be somewhat volume overloaded and diuresed with 40 of IV lasix prior to lead exchange. Following procedure, she was started on 20mg po lasix daily. TTE was obtained which showed normal systolic function with mild AS ([**Location (un) 109**] 1.6cm2). # Chronic kidney disease (CKD): Baseline Cr 1.2-1.5. She was admitted with Cr 1.6. Her creatinine progressively improved to 1.2 at the time of admission. # Diabetes: sliding scale in house. ASA 81 mg daily. She was restarted on her home medications at the time of discharge. # Dyslipidemia: Continued simvastatin # Hypertension: Hospitalization complicated by acute blood loss and hypotension as above. We continued metoprolol and lisinopril as above, which were frequently held due to strict holding parameters. # OSTEOARTHRITIS: Inactive. Home regimen include tylenol and tramadol. Continued tylenol prn. # GERD: currently asymptomatic and not on home medications TRANSITIONAL ISSUES: - Follow up her hct in the outpatient setting - follow up with [**Hospital **] clinic. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientAtrius OSH records. 1. Metoprolol Tartrate 100 mg PO BID 2. GlipiZIDE 2.5 mg PO DAILY 3. TraMADOL (Ultram) 50 mg PO BID 4. Simvastatin 40 mg PO DAILY 5. Lisinopril 2.5 mg PO DAILY 6. Glucosamine 1500 Complex *NF* (glucosamine-chondroit-vit C-Mn) 500-400 mg Oral Daily 7. Multivitamins 1 TAB PO DAILY 8. Aspirin 81 mg PO DAILY 9. Furosemide 20 mg PO DAILY 10. Alendronate Sodium 70 mg PO QSUN Discharge Medications: 1. Outpatient Lab Work Please check CBC and Chem-7 on Friday [**7-18**] with results to Dr. [**First Name (STitle) **] at Phone: [**Telephone/Fax (1) 23012**] Fax: [**Telephone/Fax (5) 112356**].01 ICD-9 2. Aspirin 81 mg PO DAILY 3. Metoprolol Tartrate 100 mg PO BID 4. Multivitamins 1 TAB PO DAILY 5. Simvastatin 40 mg PO DAILY 6. Lisinopril 5 mg PO DAILY RX *lisinopril 5 mg one Tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 7. Furosemide 20 mg PO DAILY 8. GlipiZIDE 2.5 mg PO DAILY 9. Glucosamine 1500 Complex *NF* (glucosamine-chondroit-vit C-Mn) 500-400 mg Oral Daily 10. TraMADOL (Ultram) 50 mg PO BID 11. Cefpodoxime Proxetil 400 mg PO Q24H Duration: 3 Days RX *cefpodoxime 200 mg two Tablet(s) by mouth daily Disp #*8 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Fractured pacemaker leads Chronic systolic congestive heart failure Chronic Kidney disease Acute blood loss anemia Hypovolemic shock Ischemic lower GI bleed 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: Your pacemaker leads have fractured and you needed to have them removed and replaced in the operating room. The replacement went well but you had a lot of bleeding and low blood pressure after the procedure and needed to have blood transfusions, a breathing tube and medicine to keep your blood pressure up in the CCU. You have recovered well and the bleeding in your chest and arm area is resolved. You had some bloody diarrhea that we think is because of a lack of blood flow to your bowel that has also resolved. Followup Instructions: Department: CARDIAC SERVICES When: FRIDAY [**2121-7-18**] at 11:30 AM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD When: Tuesday [**7-22**] at 3:20pm Location: [**Location (un) 2274**] [**Hospital1 **] Address: [**Country 23010**], 3RD FL, [**Hospital1 **],[**Numeric Identifier 23011**] Phone: [**Telephone/Fax (1) 23012**] Name: [**Doctor Last Name **],[**Last Name (NamePattern4) 112357**] MD When: Thursday [**8-21**] at 11am Location: [**Hospital3 **] Phone: [**Telephone/Fax (1) 5985**]

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icd9cm

[ [ [] ] ]

[ "37.87", "37.77", "37.78" ]

icd9pcs

[ [ [] ] ]

12136, 12194

7156, 10713

387, 436

12395, 12395

4265, 4756

13118, 13822

2825, 2935

11360, 12113

12215, 12374

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329, 349

464, 2143

12410, 12554

2443, 2671

2165, 2231

2687, 2809

64,191

186,864

54841

Discharge summary

report

Admission Date: [**2102-4-21**] Discharge Date: [**2102-5-3**] Date of Birth: [**2032-8-12**] Sex: M Service: MEDICINE Allergies: Bactrim Attending:[**Doctor First Name 2080**] Chief Complaint: confusion, elevated creatinine Major Surgical or Invasive Procedure: none History of Present Illness: 69 year old male with a history of HTN, HLD, prostate cancer s/p TURP in [**3-2**], who presents with increasing confusion over last few weeks. Per history, patient has had recent scrotal infection treated with ciprofloxacin and Bactrim. Labs drawn at his PCP's office showed creatinine of 16, WBC 15K. He was seen at at [**Hospital1 **] [**Location (un) 620**], and was hypotensive on presentation with MAPs in the 50s, and right IJ was placed. Patient received 5 liters IVFs before transfer to [**Hospital1 18**]. Potassium was noted to be 6.7, with improvement to 5.2 with fluid administration. His venous pH was 7.14. There was noted scrotal erythema, with no perineal involvement, but an indurated left testicle, for which he was started on vancomycin/cefepime. Patient was a daily alcohol drinker for many years, but reportedly has not had a drink in two weeks. . At [**Hospital1 18**], initial VS were T 96.4, HR 81, BP 126/49 on levophed, RR 20, Sat 100% 2 liters. Patient was slow to respond in questioning, AOx1-2. There were noted tremors, and patient is a daily alcohol drinker. Physical exam showed scrotal erythema with no subcutaneous emphysema, with an indurated and firm left testicle. WBC count was 24K with 97% neutrophils, hematocrit was 31. INR was 1.2. Potassium was 5.8, with creatinine 12.9, with BUN 181. Bicarbonate was 6, with anion gap 26. Albumin was 3.3. Lipase was 80. Serum alcohol level was negative. Urology was consulted and did a rectal, with tenderness to palpation of the prostate, concerning for possible prostatitis or abscess. Renal was also consulted, and recommended 3 amps NaHCO3 push, and NaHCO3/D5W 150 cc/hr for 2-3 liters, with urine lytes and osmolality pending. Urine output was 600 cc. Clindamycin given for possible Fournier's gangrene. Urine and blood cultures were sent and are pending. Urinalysis was with pyuria, large blood, moderate leukocytes, and moderate bacteria. Current vitals are BP 98/48, P 73, Sat 97% on 2 liters. Access is right IJ, 18 g in right hand, 18 g in left forearm. Patient has a Bair hugger. Foley is in place. Patient has received two liters at [**Hospital1 18**], for a total 7 liters. CT is to be performed, and scrotal ultrasound is ordered. . On arrival to the MICU, patient is without pain. He reports no current problems. Past Medical History: Prostate cancer s/p TURP Hypertension Hyperlipidemia (ETOH abuse by report) Social History: - Tobacco: none reported - Alcohol: several drinks per day, but reported to have not had a drink in two weeks - Illicits: none reported Family History: non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 97.3 BP: 104/40 P: 79 R: 22 O2: 97% 2 liters O2 General: Alert, oriented x 0-1, no acute distress HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD, IJ in place CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley in place, scrotal erythema with area of pustular drainage, no evidence of necrosis or emphysema, left testicle is indurated and tender to palpation, right testicle unremarkable Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: AOx3, noted left facial droop, otherwise non-focal neuro exam . DISCHARGE PHYSICAL EXAM: Vitals: 98.8 110/59 70 18 99RA General: Alert, laying comfortably in bed, oriented x 2 HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: scrotal erythema, left testicle is indurated and tender to palpation, right testicle unremarkable; no evidence of drainage, crepitus; foley in place draining clear yellow urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: AOx3, noted left facial droop, otherwise non-focal neuro exam Pertinent Results: ADMISSION LABS: [**2102-4-21**] 08:15PM BLOOD WBC-24.8* RBC-3.07* Hgb-10.4* Hct-31.9* MCV-104* MCH-33.8* MCHC-32.5 RDW-13.1 Plt Ct-398 [**2102-4-21**] 08:15PM BLOOD Neuts-97.0* Lymphs-1.8* Monos-1.0* Eos-0.2 Baso-0.1 [**2102-4-21**] 08:15PM BLOOD Glucose-127* UreaN-181* Creat-12.9* Na-138 K-5.8* Cl-106 HCO3-6* AnGap-32* [**2102-4-21**] 08:15PM BLOOD Albumin-3.3* [**2102-4-22**] 02:50AM BLOOD Calcium-6.8* Phos-9.3* Mg-2.2 . PERTINENT [**2102-4-21**] 08:15PM BLOOD PT-13.2* PTT-27.3 INR(PT)-1.2* [**2102-4-21**] 08:15PM BLOOD ALT-25 AST-40 CK(CPK)-161 AlkPhos-49 TotBili-0.2 [**2102-4-22**] 04:14PM BLOOD CK(CPK)-869* [**2102-4-24**] 04:43AM BLOOD CK(CPK)-226 [**2102-4-21**] 08:15PM BLOOD Lipase-80* [**2102-4-21**] 08:15PM BLOOD CK-MB-7 [**2102-4-21**] 08:15PM BLOOD cTropnT-0.06* [**2102-4-22**] 02:50AM BLOOD CK-MB-53* MB Indx-9.9* cTropnT-1.63* [**2102-4-22**] 08:41AM BLOOD CK-MB-90* MB Indx-10.4* cTropnT-3.59* [**2102-4-24**] 04:43AM BLOOD CK-MB-15* MB Indx-6.6* cTropnT-2.99* [**2102-4-23**] 09:47AM BLOOD VitB12-GREATER THAN [**2089**] [**2102-4-23**] 09:47AM BLOOD TSH-0.12* [**2102-4-24**] 11:06AM BLOOD T4-5.3 T3-56* [**2102-4-21**] 08:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2102-4-21**] 08:26PM BLOOD Lactate-1.3 [**2102-4-21**] 08:15PM URINE Color-Straw Appear-Cloudy Sp [**Last Name (un) **]-1.010 [**2102-4-21**] 08:15PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG [**2102-4-21**] 08:15PM URINE RBC-29* WBC->182* Bacteri-MOD Yeast-NONE Epi-0 [**2102-4-21**] 08:15PM URINE CastHy-8* [**2102-4-21**] 08:15PM URINE WBC Clm-OCC Mucous-RARE [**2102-4-21**] 08:15PM URINE Eos-NEGATIVE [**2102-4-21**] 10:18PM URINE Hours-RANDOM Creat-49 Na-94 K-10 Cl-74 [**2102-4-21**] 10:18PM URINE Osmolal-365 [**2102-4-21**] 10:18PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG [**2102-4-23**] 11:15 am RAPID PLASMA REAGIN TEST (Pending): negative . Discharge Labs: [**2102-5-3**] 05:51AM BLOOD WBC-5.4 RBC-2.31* Hgb-7.6* Hct-23.1* MCV-100* MCH-32.7* MCHC-32.7 RDW-13.5 Plt Ct-184 - transfused 1 unit PRBCs for above HCT [**2102-5-3**] 05:51AM BLOOD PT-11.7 PTT-27.8 INR(PT)-1.1 [**2102-5-3**] 05:51AM BLOOD Glucose-96 UreaN-17 Creat-0.9 Na-136 K-3.9 Cl-104 HCO3-23 AnGap-13 [**2102-5-3**] 05:51AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.6 . MICRO [**2102-4-30**] 6:00 am BLOOD CULTURE: Pending . [**2102-4-28**] AND [**2102-4-29**] URINE CULTURE: No growth. . [**2102-4-25**] 1:32 am BLOOD CULTURE: NO GROWTH. . URINE CULTURE (Final [**2102-4-22**]): NO GROWTH. Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final [**2102-4-24**]): Negative for Chlamydia trachomatis by PCR. . NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final [**2102-4-24**]): Negative for Neisseria Gonorrhoeae by PCR. . [**Location (un) **]: [**2102-4-21**]-> URINE CULTURE : Final 06/03/12-1027 No growth; [**2102-4-21**] BLOOD CULTURE Preliminary 06/02/12-1200 No Growth to Date. . ECG [**2102-4-21**] Sinus rhythm. QS deflections in leads V1-V3 with T wave inversion suggesting an anteroseptal myocardial infarction, age indeterminate. Low QRS voltage in the precordial leads. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 77 172 80 [**Telephone/Fax (2) 112063**] 68 . [**Location (un) **] CXR [**2102-4-21**]: There is a right internal jugular catheter projecting into the upper aspect of the right hemithorax. The tip overlies the area of the SVC. Both lungs are currently clear. There are no obvious effusions. IMPRESSION: CENTRAL LINE PROJECTION AT THE LEVEL OF THE SVC. NO ACUTE PROCESS OR SIGNIFICANT CHANGE SEEN IN EITHER LUNGS SINCE THE LAST EXAMINATION. . CT ABD & PELVIS W/O CONTRAST [**2102-4-21**] IMPRESSION: 1. Limited examination. Nonspecific diffuse mesenteric and retroperitoneal fat stranding. Mild prominence of the pancreatic head could indicate acute pancreatitis. 2. Possible sigmoid colitis or mass. Recommend colonoscopy after resolution of patient's acute symptoms. 3. Scrotal cellulitis and hydroceles, but no drainable fluid or gas. 4. Severe atherosclerosis. 5. Small pleural effusions and lower lobe aspiration. 6. Non-obstructing bilateral renal stones. . ECHOCARDIOGRAM [**2102-4-22**] The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with probable mild hypokinesis of the mid to distal anterior septum. 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. . IMPRESSION: Suboptimal image quality. Probable mild regional left ventricular systolic dysfunction (distal LAD disease). No pathologic valvular abnormality. . CT HEAD W/O CONTRAST [**2102-4-22**] IMPRESSION: No evidence of acute intracranial hemorrhage. No evidence of acute major vascular territory infarction. Please note that MRI is more sensitive for the detection of acute infarction and should be considered in the correct clinical setting. . SCROTAL U.S.; DUPLEX DOP ABD/PEL LIMITED [**2102-4-22**] The right testis measures 2.6 x 3.2 x 4.0 cm and is of normal echogenicity. It has normal vascular flow. The right epididymis is unremarkable. The left testis measures 3.1 x 3.0 x 4.0 cm and has normal echogenicity; however, has markedly increased vascular flow throughout as well as increased vascular flow in the epididymis. There is also a small left mildly complex hydrocele. No intratesticular masses are identified however non-shadowing calcification are noted in the left. . IMPRESSION: Marked hyperemia of the left testis and epididymis consistent with orchitis/epididymitis. . RENAL U.S. [**2102-4-23**] FINDINGS: The right kidney measures 12.6 cm. The left kidney measures 11.9 cm. There is no evidence of hydronephrosis, renal masses, or nephrolithiasis. There is no perirenal fluid. A Foley is present within the bladder. The bladder is collapsed. IMPRESSION: No evidence of hydronephrosis, renal masses, or nephrolithiasis. . CXR [**2102-4-26**]: A right upper extremity PICC is in place with its tip just beyond the level of the cavoatrial junction. This might be withdrawn 3 cm to ensure a lower SVC location. A right IJ central venous catheter is unchanged in appearance with its tip in the mid SVC. The lungs are notable for left basilar opacity, likely atelectasis. There are probable small bilateral effusions, which could be confirmed with a lateral view. The cardiac silhouette is normal in size, the mediastinal contours are normal. There is no pneumothorax. . PROSTATE ULTRASOUND [**2102-4-29**]: The prostate is of normal size, measuring 3.1 x 3.1 x 4.4 cm, with a calculated volume of 22 cc and a predicted PSA of 2.65. Small right-sided calcifications are seen. No masses or nodules are otherwise present within the prostate. The seminal vesicles are normal. A Foley is seen within the bladder. Brief Hospital Course: 69 year old man with a history of prostate cancer s/p TURP in [**3-2**] who presented with increasing confusion, acute kidney injury, leukocytosis, found to be in septic shock secondary epididymo-orchitis. Patient was initially cared for in the ICU for a 5 day course. His course was complicated by [**Last Name (un) **], NSTEMI, and delirium. . # Sepsis due to Epididymo-orchitis: Patient s/p TURP approximately 4 weeks prior to presentation complicated by a scrotal infection treated with ciprofloxacin/Bactrim. Patient presented with increasing confusion, leukocytosis and hypotension, consistent with sepsis. Exam revealed erythematous and indurated left scrotum. Urology evaluated the patient and did not feel there were signs of necrotizing fasciitis. Ultrasound revealed changes suggestive of epididimoorchitis. Patient was treated with vancomycin/cefepime/clindamycin. Patient initially required Levophed but was weaned off within 48 hours. Urine cultures ultimately unyielding. GC and Chlamydia PCRs were negative. ID was consulted regarding full course of treatment and recommended continuing cefepime and vancomycin IV for a 21 day course. Clindamycin was discontinued on [**4-26**]. Repeat Prostate ultrasound was unremarkable. The patient will complete his course of antibiotics on [**2102-5-11**]. # Acute kidney injury/AINb with Frank Hematuria: Patient presented with creatinine of 12. Renal failure likely secondary to ATN in the setting of septic shock, and AIN from bactrim (prescribed as outpatient). There was also concern for some component of obstructive uropathy with some evidence of retention on placement of foley. Renal ultrasound revealed no hydronephrosis. Patient did not require dialysis. His creatinine improved rapidly with fluid administration. The patient developed a post-ATN diuresis with significant urine output requiring close monitoring and aggressive volume repletion. Creatinine improved to 1.0 on day of discharge. He continued to suffer from urinary retention, with an inflamed prostate. A 3-way catheter was placed for urinary retention the day prior to discharge and drained dark red urine (merlot in color). Urine cleared almost immediately without further intervention (urine light yellow at time of discharge). He required 1 unit RBCs. The patient should keep foley catheter in place until follow up with urology in 2 weeks. Repeat creatinine should be drawn in rehab on [**2102-5-4**]. NSTEMI: On [**2102-4-22**], the patient had an NSTEMI with peak troponin 5.5 in the setting of renal failure due to increased cardiac stress and hypotension from sepsis. Cardiology was consulted and recommended a heparin drip x 48 hours. Patient was continued on ASA, plavix, statin. He was started on Metoprolol. His cardiac enzymes down-trended, and the patient remained stable from a cardiovascular standpoint for the remainder of admission. Due to hematuria the day prior to discharge, plavix was held for 5 days. The patient should resume plavix 75 mg PO daily on [**2102-5-7**]. The patient was transfused 1 unit PRBCs prior to discharge for anemia to decrease stress on heart. Acute encephalopathy: Patient with waxing and [**Doctor Last Name 688**] mental status, agitation, pulling at venous access lines during admission to ICU. He was intermittently oriented to person/place/time. Patient with numerous risk factors for delirium, including age, sepsis, uremia, history of stroke, ETOH abuse, electrolyte abnormalities, and ICU environment. Patient was initially treated with escalating doses of haldol and zyprexa; however these medications were unsuccessful. Seroquel standing and prn doses provided some benefit. On transfer to the floor, with resolution of acute kidney injury and improvement in infection the patient's delirium began to clear. At time of discharge, he was alert, oriented x 2, and pleasant, without agitation. He no longer required Seroquel. The patient was discharged on trazodone 25 mg qHS as needed for insomnia to help with day/night reversal. # EtOH abuse/dependence: Patient is a reported daily alcohol drinker, but with negative serum alcohol level. This history was unclear at the time of presentation and patient was not placed on CIWA protocol on admission. He was started on folate, thiamine, and a multivitamin. The patient should avoid alcohol intake in the future. # Hypertension: Initially held antihypertensives in setting of acute kidney injury and hypotension. He was started on metoprolol 12.5 mg [**Hospital1 **] in the setting of NSTEMI. The patient's metoprolol was continued at discharge. Enalapril and hydrochlorothiazide were held at discharge. The patient should discuss resuming these medications with his PCP as an outpatient. # Hyperlipidemia: Chronic. The patient was continued on home atorvastatin. # Possible Colon Mass: Incidental finding on CT scan during initial work up. Unclear if actually a mass or not. Recommend COLONOSCOPY once acute issues stabilize to exclude malignancy. ============================================= TRANSITION OF CARE ISSUES - the patient should follow up with cardiology and urology as scheduled - Patient with 3-way Foley catheter placed day prior to discharge ([**2102-5-2**]). Foley draining clear yellow urine on day of discharge. Foley should remain in place until patient follows up with urology, as he has history of urinary retention s/p TURP. - PICC line placed [**2102-4-26**] in anticipation of prolonged course of antibiotics. The patient should continue IV vancomycin and cefepime until [**2102-5-11**]. - Please check creatinine, CBC, vancomycin trough on [**2102-5-5**]. - Patient to undergo physical therapy at rehab - Please START Plavix 75 mg daily on ([**2102-5-7**]) - COLONOSCOPY once medically stable to exclude underlying colon cancer Medications on Admission: Atorvastatin 80 mg PO QHS Enalapril 20 mg PO daily Clopidogrel 75 mg PO daily Hydrochlorothiazide 25 mg PO daily Finasteride 5 mg PO dailyi Ciprofloxacin 500 mg PO BID Trimethoprim-sulfamethoxazole 800 mg-160 mg PO BID Mentax 1% topical cream Discharge Medications: 1. Atorvastatin 80 mg PO HS 2. Aspirin 81 mg PO DAILY 3. CefePIME 2 g IV Q12H 4. Vancomycin 1000 mg IV Q 12H 5. Docusate Sodium 100 mg PO BID 6. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 7. Metoprolol Tartrate 12.5 mg PO BID hold for sbp<100, HR<60 8. Multivitamins 1 TAB PO DAILY 9. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 10. Thiamine 100 mg PO DAILY 11. traZODONE 25 mg PO HS:PRN insomnia 12. FoLIC Acid 1 mg PO DAILY 13. Tamsulosin 0.4 mg PO HS 14. Finasteride 5 mg PO DAILY 15. Clopidogrel 75 mg PO DAILY PLEASE START ON [**2102-5-7**]!! 16. Senna 1 TAB PO BID:PRN constipation Discharge Disposition: Extended Care Facility: [**Doctor First Name 3548**] [**Doctor Last Name 3549**] Nursing & Rehabilitation Center - [**Location (un) 1110**] Discharge Diagnosis: Septic orchitis Acute interstitial nephritis non-ST elevation myocardial infarction delirium Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname **], . You were admitted to the hospital with a severe infection of your left testicle, confusion, and renal failure. You were treated with antibiotics for your testicular infection, and it improved. You will remain on 8 more days of IV antibiotics while you are at rehab. You should follow up with urology regarding the infection as scheduled below. . Your renal failure was likely due to your severe infection and an allergic reaction to a medication used to treat your testicular infection before you came to the hospital (BACTRIM). The medication was stopped, and your renal function improved to normal. Please ADD BACTRIM TO YOUR ALLERGY LIST. . While you were in the ICU, your infection caused enough strain on your heart to have a small heart attack. You should continue aspirin, metoprolol, and atorvastatin. Your plavix was stopped at discharge. PLEASE RESTART YOUR PLAVIX 75 mg daily on [**2102-5-7**]. Followup has been arranged with your cardiologist as below. . You did have significant confusion for much of your hospital stay. This was likely due to a combination of the severe infection, renal failure and being in a new unfamiliar place. As your infection and renal function improved, your thinking cleared. . You did have urinary retention and blood in your urine prior to discharge. You should stop your plavix for 5 days, and restart it on [**2102-5-7**] to help prevent more bleeding. You should keep your foley catheter in place until you follow up with urology in 2 weeks. . Several of your home medications were changed this hospital admission: START cefepime 2gm IV every 12 hours for 8 days (STOP [**2102-5-11**]) START vancomycin 1gm IV every 12 hours for 8 days (STOP [**2102-5-11**]) START aspirin 81 mg daily START metoprolol 12.5 mg twice a day START folic acid 1gram daily START thiamine 100 mg daily START a daily multivitamin START tamsulosin 0.4 mg daily START trazodone as needed for insomnia START plavix 75 mg daily on [**2102-5-7**] STOP Enalapril until further instructed by your PCP STOP Hydrochlorothiazide until further instructed by your PCP STOP Ciprofloxacin STOP Trimethoprim-sulfamethoxazole. PLEASE ADD THIS MEDICATION TO YOUR HOME ALLERGY LIST. Followup Instructions: Please follow up with your primary care physician on [**Name9 (PRE) **] from rehab: [**Last Name (LF) **],[**First Name3 (LF) **] A. [**Telephone/Fax (1) 5294**] . SCHEDULED APPOINTMENTS: . Department: CARDIAC SERVICES When: MONDAY [**2102-5-22**] at 3:20 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], 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: SURGICAL SPECIALTIES When: MONDAY [**2102-5-22**] at 1:30 PM With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 921**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

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Discharge summary

report

Admission Date: [**2199-5-7**] Discharge Date: [**2199-5-10**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2534**] Chief Complaint: s/p Fall Major Surgical or Invasive Procedure: None History of Present Illness: 84 yo female s/p unwitnessd fall down stairs; ? LOC, GCS 15 at scene. She was taken to an area hospital and later transferred to [**Hospital1 18**] for further care. Past Medical History: HTN Osteoporosis h/o Falls Rib fractures Pneumothorax Family History: Noncontributory Pertinent Results: [**2199-5-7**] 07:13PM GLUCOSE-186* LACTATE-3.3* NA+-138 K+-3.5 CL--96* TCO2-28 [**2199-5-7**] 07:10PM UREA N-8 CREAT-0.5 [**2199-5-7**] 07:10PM AMYLASE-51 [**2199-5-7**] 07:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2199-5-7**] 07:10PM WBC-23.2* RBC-4.77 HGB-17.3* HCT-49.8* MCV-104* MCH-36.2* MCHC-34.7 RDW-15.2 [**2199-5-7**] 07:10PM PLT COUNT-304 [**2199-5-7**] 07:10PM PT-12.5 PTT-23.2 INR(PT)-1.1 [**2199-5-7**] 07:10PM FIBRINOGE-224 CHEST (PORTABLE AP) Reason: ? shoulder fx [**Hospital 93**] MEDICAL CONDITION: 86 year old woman with s/p fall from bed, unwitnessed, hit head, c/o neck pain but unreliable PE REASON FOR THIS EXAMINATION: ? shoulder fx REASON FOR EXAMINATION: Trauma. Portable AP chest radiograph compared to [**2199-5-7**]. The heart size is normal. The mediastinal contours are unremarkable. The aorta is calcified. The hila are slightly enlarged bilaterally, most likely due to dilatation of the pulmonary veins, which may be related to pulmonary hypertension. The lungs are essentially clear but over inflated, which may represent emphysema. There is no sizeable pleural effusion or pneumothorax. CT HEAD W/O CONTRAST Reason: S/P FALL UNWITNESSED EVAL FOR BLEED [**Hospital 93**] MEDICAL CONDITION: 83 yF s/p fall from bed, unwitnessed, hit head, forehead lac, unreliable physical exam REASON FOR THIS EXAMINATION: ? bleed CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Status post fall from bed. COMPARISON: Non-contrast head CT from yesterday. FINDINGS: Again seen is stable focal hemorrhage in the splenium of the corpus collosum. There is no mass effect or shift of normally midline structures, or acute major vascular territorial infarction. The density values of the brain parenchyma again show periventricular white matter hypodensity consistent with chronic microvascular infarction. Again seen is enlargement of the lateral and third ventricles which may be related to communicating hydrocephalus or age-related involutional change. The surrounding soft tissue structures again show a large left parietal scalp hematoma and new soft tissue swelling overlying the left frontal bone. There is no skull fracture. IMPRESSION: 1. Stable hemorrhage in the splenium of the corpus callosum without evidence for new hemorrhage. 2. New soft tissue swelling overlying the left frontal bone. Stable left parietal scalp hematoma. 3. Again seen is enlargement of the lateral and third ventricles which may be related to communicating hydrocephalus or age-related involutional change. Clinical correlation is recommended. CT C-SPINE W/O CONTRAST Reason: S/P FALL EVAL FOR FX [**Hospital 93**] MEDICAL CONDITION: 86 year old woman with s/p fall from bed, unwitnessed, hit head, c/o neck pain but unreliable PE REASON FOR THIS EXAMINATION: ?fx CONTRAINDICATIONS for IV CONTRAST: None. C-SPINE TECHNIQUE: Multidetector axial CT images were obtained through the cervical spine. Coronal and sagittal reformatted images were obtained. COMPARISON: CT C-spine from [**2199-5-7**]. CT C-SPINE: There is no evidence of fracture, malalignment, or prevertebral soft tissue swelling. The vertebral bodies and disc space heights are normal. There are extensive degenerative changes in the cervical spine which are stable. Again seen are calcifications within the bilateral carotid arteries and within the posterior longitudinal ligament. Again seen is scarring in the bilateral lung apices. The visualized outline of the thecal sac is unremarkable; however, CT is not able to provide any intrathecal detail. IMPRESSION: No evidence for cervical spine fracture or malalignment. CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Reason: ? injury Field of view: 32 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 86 year old woman with s/p fall down flight of stairs REASON FOR THIS EXAMINATION: ? injury CONTRAINDICATIONS for IV CONTRAST: None. CT ABDOMEN AND PELVIS WITH CONTRAST INDICATION: 86-year-old woman with status post fall down flight of stairs. Rule out injury. COMPARISON: Not available. TECHNIQUE: MDCT axial images of abdomen and pelvis were obtained following the administration of 130 cc of Optiray intravenously. Coronal and sagittal reformatted images were obtained. CT ABDOMEN WITH INTRAVENOUS CONTRAST: The liver, spleen, adrenal glands, stomach, abdominal loops of large and small bowel are unremarkable. Kidneys enhance equally and excrete contrast normally. There is no free fluid in the abdomen, and no pathologically enlarged mesenteric or retroperitoneal lymphatic nodes. CT PELVIS WITH INTRAVENOUS CONTRAST: The rectum, urinary bladder are unremarkable. There is a high density material in the iliacus muscle, adjacent to the left ilium, likely representing hematoma. There is no free pelvic fluid. BONE WINDOWS: Demonstrate no suspicious lytic or sclerotic lesions. There are extensive degenerative changes, as well as rotatory scoliosis. There is a compression deformity of vertebral body of L1 of uncertain chronicity, but most likely chronic, with extensive vertebral body sclerosis. There is a lucent line, in the left ilium, extending from the mid-aspect of the ilium, reaching the acetabular roof. There is no significant displacement. There is another lucent line extending to the superior-posterior aspect of the ilium, with minimal displacement of the fracture fragments. No other fractures are noted on this study. IMPRESSION: 1. No evidence of traumatic injury of solid abdominal organs. 2. Two separate, and apparently discrete, essentially non-displaced fractures of the left ilium, one of which involves the left acetabular roof, with associated iliacus muscle hematoma. 3. Chronic-appearing L1 compression fracture. COMMENT: Findings were discussed with the Trauma Surgery team at the time of the completion of the scan, at 20:15h, [**2199-5-7**]. Brief Hospital Course: She was admitted to the Trauma service. Neurosurgery and Orthopedic Surgery were consulted because of her injuries. Repeat head CT imaging was performed which revealed a stable intracranial hemorrhage; the injury was non operative. It was recommended that she follow up in 4 weeks with Dr.[**Last Name (STitle) **], Neurosurgery, at which time she will have an MRI of her brain. She will also be evaluated for normal pressure hydrocephalus based on a finding on head CT. Orthopedic Surgery was consulted for her left ilium fracture; this injury was deemed nonoperative; she is to remain touchdown weight bearing and will require follow up with Dr. [**Last Name (STitle) 1005**] in 2 weeks. She was also started on bone prophylaxis with Calcium and Vitamin D. Physical and Occupational therapy were consulted and have recommended rehab stay after discharge from the hospital. Medications on Admission: Dilt 60 Celexa 10 Aricept 10 Lisinopril 10 Protonix 40 Discharge Medications: 1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day): hold fro SBP <110 & HR <60. 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection [**Hospital1 **] (2 times a day). 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for constipation. 9. Aricept 10 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: s/p Fall Large left parietal sub-galeal hematoma Small intracranial hemorrhage left splenium/corpus collosum Nondisplaced left ilium fracture involving the acetabular roof Discharge Condition: Stable Discharge Instructions: You may ONLY touchdown weight bear on your left lower extremity. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **], Neurosurgey in 4 weeks. Inform the office that you will need an MRI of the brain w/ and w/out contrast and that also you will need evaluation for possible normal pressure hydrocephalus. Call [**Telephone/Fax (1) 1669**] for an appointment. Follow up with Dr. [**Last Name (STitle) 1005**], Orthopedic Surgery, in 2 weeks. Call [**Telephone/Fax (1) 1228**] for an appointment.

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icd9cm

[ [ [] ] ]

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icd9pcs

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Discharge summary

report

Admission Date: [**2197-12-17**] Discharge Date: [**2197-12-29**] Service: MEDICINE Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 1148**] Chief Complaint: CC:[**CC Contact Info 60684**] Major Surgical or Invasive Procedure: central line placement History of Present Illness: Ms. [**Known lastname **] is a 85 yo female with PMH of CAD s/p CABG, CHF who was in USOH until 1 week ago when she started experiencing cough and sob. She states that over the course of the week she experienced progressing shortness of breath and chills. She states that on the day PTA, she lost her balance and fell and lay there as she was unable to make it to the phone for about 6 hours. Her daughter found her. The next day, her daughter found her to be febrile to 103 and brought her to [**Location (un) 20026**] Hospital. . Initially, on admission to NWH, she was febrile but normotensive. CXR revealed both PNA and fluid overload. BNP 1099. LENI's of her lower extremities were performed due to complaint of calf pain with ambulation; both extremities negative for DVT. She was given Lasix 40 mg IV, and her BP dropped to 60's and she was started on dopamine. She also was treated with Vancomycin, ceftriaxone, and azithromycin. She was placed on NRB for her oxygentation and heparin gtt in the setting of elevated troponins (TropI to 0.9) and transferred to [**Hospital1 18**] for further care. . On arrival to the [**Hospital1 18**] ER, she had a head CT and CXR and started on CPAP prior to her transfer to the MICU. At this time, she reported that her shortness of breath was improving. She denied chest pain, and ROS revealed only one loose BM per day for the past 1 week. . In the MICU, she required mask ventilatory support and Levophed for BP support. A right subclavian CVL and left A-line were placed. Levophed was quickly titrated off, and she was transferred to the general medicine service on 4L NC for further care. Past Medical History: 1. Coronary Artery Disease s/p Coronary Artery Bypass Graft on [**3-5**] 2. Post-op Atrial Fibrillation requiring electrical cardioversion 3. CHF 4. Osteoarthritis 5. Carpal tunnel syndrome 6. Shingles right arm [**2191**] . PSH: s/p pacemaker placement s/p Left knee replacement in [**2192**] s/p Thyroidectomy [**2169**] s/p Cholecystectomy [**2163**] s/p Hysterectomy [**2192**] for ?uterine cancer Social History: She has two children, and currently resides with daughter. She quit smoking 40 yrs ago, previously smoked 1 ppd for 20 years. She admits to occasional EtOH, denies illicit drug use. She ambulates without assistance at baseline. Family History: Father died of MI at age 69. Physical Exam: VS: T 96.9, 132/62, HR 66, RR 20, SpO2 94% on 4L GEn: Elderly obese WF female reclining in bed, pleasant, HOH, NAD. HEENT: moist mucous membranes, clear OP CHEST: bilateral expiratory wheezes, Exp>Insp CVR: rrr, nl s1, s2; no JVD ABdomen: soft, obese, nontender, nondistended Ext: trace edema bilaterally, chronic venous insufficiency changes. Neuro: A&O x 3, moves all ext, 5/5 strength upper and lower ext. Mentating at baseline, per daughter. Pertinent Results: EKG - nsr, left axis, rbbb with lafb, no sig changes compared to previous. . [**12-17**] - CXR: Mild cardiomegaly. Increased opacities in bilateral lower lobes, especially on the right with effusion and atelectasis. Increased vascular markings in upper lobes. These findings can be explained worsening CHF, however, there is a possibility of right lower lobe pneumonia. . Head CT - Chronic small vessel ischemia. No evidence of hemorrhage. . [**12-18**] Echo: 1. The left atrium is moderately dilated. The left atrium is elongated. The right atrium is markedly dilated. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] 3.The right ventricular cavity is markedly dilated. There is focal hypokinesis of the apical free wall of the right ventricle. Right ventricular systolic function appears depressed. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. 4.The ascending aorta is moderately dilated. 5.The aortic valve leaflets are mildly thickened. Trace aortic regurgitation is seen. 6.The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. 7.Moderate to severe [3+] tricuspid regurgitation is seen. 8.There is moderate pulmonary artery systolic hypertension. 9.There is no pericardial effusion. There is an anterior space which most likely represents a fat pad. . CXR [**2197-12-20**]: 1. Marked worsening of pulmonary edema. 2. Worsening of bibasilar consolidation, which may be due to an infectious process or aspiration. . TTE [**2197-12-22**]: There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. The right ventricular cavity is moderately dilated. There is mild global right ventricular free wall hypokinesis. There is abnormal septal motion/position. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2197-12-18**], the degree of tricuspid regurgitation and pulmonary hypertension are less. The RV is still dilated and hypokinetic. . CXR [**2197-12-23**] Persistent pulmonary edema. Bilateral pleural effusions. The slight interval increase in the left-sided pleural effusion may be attributable to differences in patient positioning. . CXR [**2197-12-27**] Compared with [**2197-12-23**], the posterior left pleural effusion appears grossly unchanged. No significant increase is seen involving the much smaller right pleural effusion. The right lower lobe atelectasis/infiltrate is grossly unchanged. Brief Hospital Course: 85 year old woman with h/o CHF, CAD s/p CABG admitted with pneumonia & CHF exacerbation. . 1. Pneumonia: Likely community acquired PNA. She has been treated with azithromycin, vancomycin, and ceftriaxone; vancomycin d/c'd after 7 days as patient is low-risk for nosocomial MRSA pneumonia. Gram stain and sputum cultures unrevealing. Influenza DFA negative. She completed a 10d of Cef/Azithro. She required supplement O2 at discharge to maintain SpO2>92% (she was down to 1.5L). This should continue to be titrated down. After completing her treatment, she remained afebrile. . 2. CHF: Patient with known h/o CHF. Echo performed during this hospital course show RV dysfunction and dilation (see ECHO reports). Abnormal septal motion/position was felt to be consistent with RV pressure/volume overload. This pulm HTN was not new as she had previously PA HTN from prior to CABG in [**2196**] and in [**6-/2197**] - per ECHO done by her primary cardiologist. LVEF normal. It is possible that cause of RV failure is acute pulmonary disease; however, the differential diagnosis includes PE vs. ischemic disease. She had positive trops, but only mildly elevated without EKG changes and thus was felt to be demand related. At [**Hospital1 18**], our goal for her was for a negative fluid balance, particularly in the setting of worsened pulmonary edema on most recent CXR. After coming off pressors and transfer to floor, the patient was aggressively diuresed with 40mg [**Hospital1 **] IV of lasix. We diuresed her with a goal of -2L per day. She still required oxygen upon discharge, but with continued diuresis, this should be able to be weaned down. She was discharged on Lasix 80mg PO BID; Once she is euvolemic and no longer requiring oxygen, she should be switched back to her home dose of Lasix 40mg po daily. She should have repeat electrolytes on [**1-1**] to ensure her kidney function is stable. She should follow up with her cardiologist in the next 1-2 weeks and have a repeat echocardiogram at that time once she is euvolemic. Initially held BB & [**Last Name (un) **] in the setting of hypotension and ?sepsis. These were restarted before discharge. Continued amiodarone per prior regimen. Weight on discharge was 236lb. She was maintained on a low sodium diet. . 3. CAD: Patient with known h/o CAD, s/p CABG. Patient presented with troponin leak (peaking at 0.15) but asymptomatic with no associated EKG changes. She was on a heparin gtt at outside hospital but this was discontinued once enzymes downward trending. Troponin leak was likely secondary to demand ischemia in the setting of pneumonia. Continued ASA, Zetia, Lipitor and BB. . 4. Acute renal failure: Cr elevated to 2.3 on admission (baseline 1.1) with pre-renal etiology (FeNa <1%). Creatinine did continue to increase with diuresis, and on discharge was 1.4. It is likely indicative of appropriate diuresis with relative hypovolemic state, necessary in this patient to keep her dry and prevent pulmonary edema. . 5. Atrial fibrillation: Rate controlled with beta blocker and amiodarone. In sinue rhythm during this hospitalization. Not clear as to why the patient is not anticoagulated as she was anticoagulated in the past. This should be readressed with her cardiologist. . 6. Pulmonary effusion: R sided effusion; ultrasound shows little layering of the fluid. Followed by XRays. Relatively stable on discharge. . 7. Hypothyroidism: continue levothyroxine. . 8. Code Status: Full code. . 9. Communication with daughter [**Name (NI) **] ([**Telephone/Fax (1) 60685**]. PCP: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] in [**Hospital1 **]. . 10. Dispo: To extended care facility in good condition, on 1.5L of O2 by NC. Medications on Admission: 1. Synthroid 200mcg 2. Lipitor 40 3. Zetia 10 4. Prilosec 40 5. Toprol XL 25 mg daily 6. Lasix 40 daily 7. Amdiodarone 200 mg daily 8. ASA 81 mg daily 9. Avapro 300 mg daily Discharge Medications: 1. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 7. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. Avapro 300 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital 5399**] Nursing Home - [**Hospital1 **] Discharge Diagnosis: PRIMARY: Pneumonia Acute renal failure CHF exacerbation . SECONDARY: CAD Discharge Condition: Stable Discharge Instructions: You were admitted with pneumonia and a CHF exacerbation. You should weigh yourself daily, and call your doctor if you gain more than three pounds in one day. Please call your primary care doctor if you become short of breath, have chest pain, abdominal pain, nausea, vomiting, fever >101, chills, increase in swelling in your lower legs. . You should have a repeat electrolyte panel on [**Last Name (LF) 766**], [**1-1**], to ensure that your kidney function is doing well. . You should continue to have your supplemental oxygen weaned off. . Once you are off oxygen you should be switched back to your home dose of lasix, which is 40mg po daily. Followup Instructions: You have an appointment to follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], on Thursday, [**1-4**] @ 1:45. You can reach his office at [**Telephone/Fax (1) 26303**]. . You should make an appointment to follow up with your cardiologist, Dr. [**Last Name (STitle) **] within the next two weeks. You can reach his office at: ([**Telephone/Fax (1) 42003**]. You will need a repeat echocardiogram at that time.

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Discharge summary

report

Admission Date: [**2168-3-14**] Discharge Date: [**2168-4-25**] Date of Birth: [**2104-9-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 943**] Chief Complaint: hypotension and hypoxia Major Surgical or Invasive Procedure: PICC line placement Paracentesis Transfusion of packed RBC Post pyloric feeding tube placement Foley catheter placement History of Present Illness: 63 yo M with h/o cirrhosis, DM, h/o 1st degress AV block, who presetned with 1 day of fever. Today, lethargic and confused, but oriented. Sent to ED for further evaluation. . He was recently d/c from [**Hospital1 18**] where his course was notable for acute on chronic renal failure (thought to be prerenal, resolved on its own); hyperkalemia; a negative abd US; anemia with guiac + stools and 2 units PRBCs. . While at home, he took 80 mg lasix x 2 days and aldactone 200 mg x 2 days per his renal physician. . In the ED, 102.1, 127, 101/64, 88% RA. Paracentesis done which showed some WBC, but no SBP. JVP elevated in ED. BP dropped to mid 70's/40-60's after paracentesis. Desatted to 80's on 4 L NC and placed on NRB. Given 1 gm vancomycin, levofloxacin 500 mg IV, flagyl 500 mg IV and tylenol 650 mg. Surgical consult recc. CT abd and abx. 2500 cc IVF given. . On arrival, pt was arousable, answered questions and was oriented. He stated his breathign was bad since d/c, denied CP, +nausea, not eating much by mouth. He easily was drowsy making it difficult to obtain other history. . Admitted to the MICU for sepsis. Past Medical History: Cryptogenic cirrhosis ?[**1-28**] MTX toxicity -Upper endoscopy [**2166**]: Grade 1 varices -U/S abdomen [**4-/2167**] cirrhotic appearing liver, no masses h/o cholecystitis s/p biliary stent h/o bacteremia secondary to biliary sepsis rheumatoid arthritis aortic valvular disease with mild stenosis h/o 1st degree AV block, recent stress test Cataracts bilaterally Splenomegaly Childhood polio mild gastric varices (grade 1) s/p [**Year (4 digits) 4448**] placement lower extremity ulcers, TMA in [**11-29**], TMA debridement with Dr [**Last Name (STitle) 21080**] in [**12/2167**] Social History: Denies alcohol, intravenous drug use. Has a 40 pack-year history of smoking. The patient lives at home with his wife. Denies history of alcohol abuse; used to drink socially before liver diagnosis. Has one son and one grandchild. Works as a sales manager for a liquor wholesaler (but does not drink). Family History: Cirrhosis, Crohn's, cholecystitis (father); diabetes (sister); heart disease Physical Exam: 97.8/101.1 m, 105/71 (0.087 levofed), 104, CVP23 100% FM 98%; RR 11-12 sleeping, arousable, O x 3 Neck: RIJ in place, diff to assess JVP CV: 3/6 SEM across precordium, regular crackles on left side of chest, greatest at base abd: guaic neg per ED, + BS, distended, + fluid wave, obese 2+ edema to knee, left foot wrapped in bandage moves all extremities, no asterixis Pertinent Results: Labs on admission: [**2168-3-13**] 05:30AM WBC-6.7 RBC-2.85* HGB-8.9* HCT-25.5* MCV-90 MCH-31.1 MCHC-34.8 RDW-19.6* [**2168-3-13**] 05:30AM PLT COUNT-74* [**2168-3-13**] 05:30AM GLUCOSE-86 UREA N-83* CREAT-2.4* SODIUM-134 POTASSIUM-4.9 CHLORIDE-102 TOTAL CO2-20* ANION GAP-17 [**2168-3-13**] 05:30AM CALCIUM-8.3* PHOSPHATE-4.5 MAGNESIUM-2.6 [**2168-3-14**] 07:50PM NEUTS-79* BANDS-14* LYMPHS-2* MONOS-3 EOS-0 BASOS-1 ATYPS-1* METAS-0 MYELOS-0 [**2168-3-14**] 07:50PM ALBUMIN-3.2* CALCIUM-8.1* PHOSPHATE-4.1 MAGNESIUM-2.2 [**2168-3-14**] 07:50PM ALT(SGPT)-18 AST(SGOT)-39 ALK PHOS-200* AMYLASE-41 TOT BILI-3.1* [**2168-3-14**] 07:50PM LIPASE-35 [**2168-3-14**] 09:03PM ASCITES TOT PROT-2.6 GLUCOSE-162 LD(LDH)-83 [**2168-3-14**] 09:00PM URINE HOURS-RANDOM [**2168-3-14**] 09:03PM ASCITES WBC-124* RBC-931* POLYS-7* LYMPHS-48* MONOS-40* MESOTHELI-5* . Labs on discharge: Na 133, K 4.2, Cl 101, HCO3 22, BUN 99, Cr 2.5, T bili 0.9, WBC 6.9, Hct 30.5, Plts 43, PT 18.2, PTT 34.1, INR 1.7 . Microbiology: [**2168-3-14**] blood cultures - 4/4 bottles MSSA [**2168-3-14**] Peritoneal Fluid - gram stain negative, culture negative [**2168-3-15**] blood culture - negative [**2168-3-15**] Fungal/AFB blood culture - NGTD [**2168-3-15**] Urine culture - 10K-100K yeast [**2168-3-15**] Stool - negative for C Diff [**2168-3-15**] MRSA screen - negative x 2 [**2168-3-16**] Stool - negative for C Diff [**2168-3-16**] Blood culture - negative [**2168-3-16**] swab from [**Month/Day/Year 4448**] pocket - MSSA [**2168-3-16**] [**Month/Day/Year 4448**] lead culture - MSSA [**2168-3-16**] peritoneal fluid - gram stain negative, culture negative [**2168-3-19**] peritoneal fluid - gram stain 4+ PMN, culture negative [**2168-3-21**] urine culture - > 100K yeast . Studies: [**3-14**] CXR: IMPRESSION: Moderate/mild pulmonary edema. . EKG#1: 1st degree AVB, sinus tachy, [**Street Address(2) 4793**] dep in I, [**Street Address(2) 1766**] dep in v1-2, priors were paced . EKG #2: tachycardic, NSR with 1st degree AVB, ST elevation in v1/v2 1-2 mm . [**3-14**] Abd US: IMPRESSION: 1. 1.5-cm focus adherent to the anterior wall of the gallbladder is again seen and unchanged that may represent a polyp. 2. Sludge and debris within the gallbladder with no gallbladder wall edema. 3. No biliary ductal dilatation. 4. Ascites with a cirrhotic liver. . [**2168-3-15**] ECHO: Conclusions: The left atrium is elongated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is severe global left ventricular hypokinesis (ejection fraction 20 percent) with relative sparing of contractile function at the base of the left ventricle. The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. The main pulmonary artery is dilated. The branch pulmonary arteries are dilated. There is no pericardial effusion. No definite valvular vegetations seen. Compared with the findings of the prior study (images reviewed) of [**2167-10-29**], the left ventricular ejection fraction is markedly reduced; the effective aortic valve orifice area is reduced further. The absence of a vegetation by 2D echocardiography does not exclude endocarditis if clinically suggested. . [**2168-3-17**] Renal U/S: CONCLUSION: 1. Normal kidneys. 2. Ascites. . [**2168-3-19**] MRI Left foot: IMPRESSION: 1. Abnormal signal and enhancement within the distal first, second, fourth and fifth metatarsals, as described above. Involvement is more extensive in the fourth and fifth metatarsals. Findings most consistent with osteomyelitis. No drainable fluid collections are identified. 2. Extensive erosive and osteoarthritic changes within the foot, as described above. Findings consistent with history of rheumatoid arthritis, although there likely is a component of neuropathic arthropathy. . [**2168-3-21**] Post pyloric NGT placement: IMPRESSION: Successful [**Last Name (un) **]-intestinal tube placement. . [**2168-3-22**] ECHO: Conclusions: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate to severe regional left ventricular systolic dysfunction with near akinesis of the distal half of the septum and anterior walls. The apex is mildly aneurysmal and akinetic. The remaining segments are mildly hypokinetic. No definite thrombus is seen. The right ventricular cavity is moderately dilated with free wall hypokinesis. The aortic root and ascending aorta are mildly dilated. The aortic valve appears functionally bicuspid with fused right and non-coronary raphe. The leaflets are severely thickened/deformed. There is severe aortic stenosis with mild to moderate ([**12-28**]+) aortic regurgitation directed toward the anterior mitral leaflet. The mitral valve leaflets are mildly thickened. There is no mitral stenosis. There is severe mitral annular calcification. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is mild pulmonary artery systolic hypertension. The pulmonic valve leaflets are thickened. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is a small echodense inferolateral pericardial effusion. Compared with the prior study (images reviewed) of [**2168-3-15**], left ventricular systolic function is slightly improved and the severity of aortic regurgitation is increased. The severity of aortic stenosis and mitral regurgitation are similar. Brief Hospital Course: # Sepsis/bacteremia: He was hypotensive in the MICU, thought secondary to cardiogenic and septic shock, and required pressors. His cortisol stimulation test was suggestive of adrenal insufficiency and he was given hydrocort and Fludrocort for 1 week. He was initially started on Zosyn and vancomycin for broad spectrum coverage as the source of his sepsis was unknown. He was then found to have high-grade MSSA bacteremia (4/4 bottles from [**3-14**]). This bacteremia was initially thought secondary to aortic valve endocarditis vs possible seeding of [**Month/Year (2) 4448**] leads (as patient has recently undergone [**Month/Year (2) 4448**] placement 10 days prior to presenation) vs. left foot osteomyelitis (patient had recently had left trans-metatarsel amputation in [**2167-11-26**], complicated by wound infection requiring debridement in [**2167-12-27**]). He was subsequently switched to oxacillin to cover the MSSA, later switched to cefazolin to decrease his salt load given his history of CHF. EP consulted for MSSA bacteremia with recent [**Year (4 digits) 4448**] placement, and he underwent [**Year (4 digits) 4448**] explantation on [**3-16**], with subsequent [**Month/Year (2) 4448**] lead culture also growing MSSA. [**Month/Year (2) **] was also initially consulted given ?osteomyelitis and recorded that the surgery site looked clean and uninfected. Patient underwent Left foot MRI on [**2168-3-19**] that did demonstrate findings consistent with osteomyelitis. Upon review of records patient was noted to have pathology from his recent TMA return with evidence of osteomyelitis for which he was treated with linezolid for 2 weeks. Therefore, it was thought that this osteomyeltis likely caused his MSSA, which then seeded his [**Date Range 4448**] leads. His antibiotics were therefor changed to Unasyn 3gm q8hr, which he will complete a 6 week course. Trans-esophageal echocardiogram was deferred as he was a poor candidate for this procedure given his underlying medical conditions, and the results would not change his management as he is to complete a 6 week course of antibiotics anyways. On [**3-27**], he again developed elevated WBC, no localizing symptoms. Urine and blood cultures were sent which demonstrated no growth. Subsequently, patient re-spiked with rigors on [**4-6**] - cultures demonstrated GPC in pairs and chains. He therefore had his PICC line and central line with HD catheter removed and had his antibiotics changed from unasyn to vancomycin and zosyn, with defervesence of his fevers and resolution of his bacteremia per surveillance blood cultures. He was also ruled out for c diff with 3 sets of negative stool samples. The patient's antibiotics were eventually changed to daptomycin and unasyn when speciation of the bacteria was complete. He completed a 2wk course of daptomycin in house and will finish a 6+ week course of unasyn as an outpatient. He will f/u with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2505**] as a outpatient. . # Osteomyelitis: As above, patient underwent left transmetatarsal amputation in [**11-29**], complicated by wound infection requiring I&D in [**1-1**]. Management as above. [**Date Range **] surgery saw the patient just prior to his d/c and were comfortable w/ the progress of his foot and felt another debridement was not necessary. . # CHF: Patient had trans-thoracic echocardiogram on [**3-15**] showed an EF of 20%, which was new compared to previous echo in [**10-30**], also demonstrated aortic stenosis (see below). He was evaluated by Cardiology who felt his new depressed EF could be explained by sepsis. He was started on po Lasix (20mg daily) to attempt gentle diuresis, but his creatinine began to trend up again. Therefore his lasix was stopped. The patient remained breathing comfortabley throughout hospital course and was discharged without oxygen requirement. He did have extensive lower extremity edema, but this was thought to be contributed to by his poor nutritional status. He was not started on afterload reduction because he could not be on ACE I due to his poor renal function, could not be on nitrates due to his aortic stenosis, and could not tolerate hydralazine due to his low blood pressure at baseline. The patient had a repeat ECHO on [**3-22**] that demonstrated minimal improvement in his EF to 25-30%, continued aortic stenosis, and aortic regurgitation [**12-28**]+. Again, no afterload reduction could be started because of above. Patient began to experience symptomatic CHF following his 3rd large volume paracentesis and albumin administration, after developing worsening acute renal failure/oliguria. This was thought due to volume overload from his ARF. This was treated with dialysis (see below) and his symptoms resolved. He remained asymptomatic from his CHF requiring minimal oxygen and his LE edema resolved w/ CVVH as below. . # Aortic stenosis: Patient was noted to have aortic stenosis with valve area of 1.1 cm on ECHO in [**10-30**]. Repeat ECHO [**3-15**] demonstrated AS with valve area of 0.5cm. Per cardiology, believed that this was not an acute worsening of his aortic stenosis, but that the ECHO in [**10-30**] had overestimated his valve area, and instead this was stable, severe aortic stenosis. Repeat ECHO on [**3-22**], as above, demonstrated continued aortic stenosis with valve area of 0.5cm. As above, no afterload reduction could be initiated. Nitrates were avoided due to preload dependence. He was not deemed a good surgical candidate for valvuloplasty given his numerous other ongoing medical conditions. . # 1st degree AV block: Patient has a history of 1st degree AV block associated with syncope and therefore had [**Month/Year (2) 4448**] placement just prior to presentation, as above. With MSSA, [**Month/Year (2) 4448**] was removed. Therefore nodal agents were avoided throughout hospital course. Per cardiology, it is not necessary and there are no plans for re-placement of [**Month/Year (2) 4448**] upon resolution of infection. Patient was noted to have weinkebach, type II heart block. At times, he became bradycardic, with heart rate into the 40's. He remained asymptomatic and EP was notified. They determined nothing needed to be done as long as the patient remained asymptomatic. In the ICU, patient developed symptomatic bradycardia requiring atropine, which resolved both his bradycardia and symptoms. EP at this time wanted to re-place his [**Month/Year (2) 4448**]. However, given his recurrent bacteremia, were unable to. Therefore he was monitered on telemetry with atropine at the bedside in case he re-develops symptomatic bradycardia, with plans to have [**Month/Year (2) 4448**] re-placed upon completion of his antibiotics therapy for his bacteremia. Just prior to d/c, the patient decided to change his code status to DNR/DNI and he was taken off telemetry . # Elevated troponin: Noted troponin peak of 1.27 on [**3-16**]. CK and MB remained flat. It was thought that this troponin leak was secondary to either his CHF or to demand ischemia from his tachycardia/sepsis. He has no known CAD, good lipid profile, and a stress ECHO in [**9-28**] did not demonstrate any inducible ischemia. He was therefore monitered without any problems throughout remainder of hospital course. . # Acute on chronic renal failure: Patient has known chronic kidney disease, with a baseline creatinine of 1.3-1.6. He had ARF on admission, with a peak creatinine of 4.0. Renal dysfunction was initially thought secondary to a prerenal state, but did not improve with IV fluids. Hepatorenal was then considered, and patient was tried on octeotride with levophed, with some improvement. Mitodrine was not started for concern for exacerbation of volume overload given his history of CHF. ATN was thought to be another possible etiology. Upon transfer to the floor, he had improving creatinine and urine output. His creatinine began to climb again after a couple of days on the floor. Again, the etiology of this acute renal failure was unclear. Possible etiologies included pre-renal due to the lasix he was receiving or due to poor forward flow from his CHF vs post-renal/obstructive, as patient had foley removed and was unable to void, so therefore had foley replaced vs AIN from antibiotic vs ATN vs hepatorenal. AIN was assessed with urine eosinophils and peripheral differential which did not show elevated eosinophils so that was ruled out. The patient's creatinine improved following re-placement of the foley catheter and holding the lasix, so these 2 etiologies were considered the most likely cause of this acute renal failure, although hepatorenal syndrome remained a consideration. The patient's Cr continued to decrease to a low of 2.5. However, he then underwent his 3rd large volume paracentesis (with albumin administration) and following this, his urine output dropped and his Cr rose again. Urine output did not increase with a trial of further albumin administration. At this time, patient was symptomatically in CHF as well, so fluids were not used given his tenuous status. He then became clinically with evidence of uremia, including encephalopathic with increased confusion and evidence of volume overload/CHF as described. He was started initially on CVVH and dialyzed w/ good result. When called out to the floor, his creatinine again rose to ~ 4.5 in the context of a therapeutic paracentesis and he became progressively oliguric in the context of SBP ~ 90. He was assumed to have hepatorenal syndrome and empirically started on octreotide/midodrine and bolused several times w/ albumin/PRBC. He responded well to this therapy w/ increases in his systolic BP, increased UOP, and stabilization of his creatinine ~ 2.9 . # Liver failure: Patient presented with decompensated cirrhosis with refractory ascites and encephalopathy, likely acute worsening of his encephalopathy secondary to his sepsis, as above. He is followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] as an outpatient. He underwent a large volume paracentesis for comfort on [**3-16**] with peritoneal fluid showing no evidence for SBP. Another large volume paracentesis was performed on [**3-19**], again with peritoneal fluid negative for SBP. He had a 3rd large volume paracentesis performed on [**2168-3-24**]. Each large volume paracentesis was followed by albumin administration (8gms per liter removed). Peritoneal fluid cultures were negative for any bacterial growth. He was maintained on rifaximin and lactulose for encephalopathy with resolution of his encephalopthy and was discharged on these medications, titrate to [**2-27**] bowel movements/day. He was previously under consideration for transplant, but currently off the list secondary to his acute medical issues, including bacteremia. Possible evidence of hepatorenal syndrome as above, given his worsening of acute renal failure. Unfortunately the patient is not a transplant candidate give his numerous medical issues listed above. . # Anemia: Patient appears to have a baseline Hct in the low 30's. With his known low platelets and elevated INR due to his liver disfunction, the patient was monitered for bleeding, but remained without signs of bleeding, including negative guiac tests of his stool, throughout his hospital course. The patient required a number of transfusions of pRBC throughout his hospital course to keep his Hct above 25. He was eventually started on epo on the thought that his anemia was likely contributed to by his renal dysfunction. Epo dose was titrated up throughout hospital course. His anemia remained, with baseline hct dropping. He was transfused periodically to keep his Hct greater than 21-24. . # Thrombocytopenia: Patient presented with baseline has been 50s-70s over the past couple of years, likely due to his renal dysfunction. He had values of 135-142 on admission, which then trended down - possibly initially high values were due to hemoconcentration in setting of sepsis/hypovolemia, but unclear. A HIT antibody was checked, and was negative. His INR was also elevated throughout admission. It was thought that both the thrombocytopenia and the elevated INR were secondary to his end stage liver disease. They were both monitered throughout the hospital course. No platelet or FFP transfusions were required. . # Hyponatremia: Patient was noted to become hyponatremic during hospital course, with Na down to 130. This was thought possibly secondary to SIADH. He improved to baseline with 1.5L fluid restriction, which was eventually discontinued on starting tube feeds. . # DM2: On Lantus 100u QD at home. Was managed by [**Last Name (un) **] consult during hospital course, with numerous alterations of his lantus and ISS dosing based on his PO intake and tube feeds. . # FEN: Patient was noted throughout hospital course to have poor PO intake and poor overall nutritional status. Attempted augmentation of nutrition with supplemental shakes. Initiated caloric count, and then placed post-pyloric feeding tube for nutrional supplementation with tube feeds (Nepro). The patient pulled to feeding tube multiple times, however, so PO intake was encouraged. . # Code status: The patient has decided to change his code status to DNR/DNI and is being d/c home w/ transition to hospice services. Medications on Admission: folic acid 1 mg qd epo 10,000 u q M/W/F lactulose 30 ml q8 hrs PPI lantus 100 units q pm darvocet Discharge Medications: 1. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 2. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID (3 times a day). 3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day): Titrate to [**2-27**] bowel movements/day. Disp:*QS QS* Refills:*2* 4. Insulin Regular Human Injection 5. Insulin Glargine 100 unit/mL Cartridge Sig: Twenty Six (26) units Subcutaneous twice a day. Disp:*1000 units* Refills:*2* 6. PICC line PICC line care per protocol 7. Ampicillin-Sulbactam [**1-27**] g Recon Soln Sig: Three (3) grams Injection once a day for 17 days: to go thru [**5-11**]. Disp:*17 injection* Refills:*0* 8. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 10. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours). Disp:*QS QS* Refills:*2* 11. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). Disp:*QS QS* Refills:*2* 12. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN (as needed). Disp:*QS QS* Refills:*2* 13. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 14. Epoetin Alfa 10,000 unit/mL Solution Sig: [**Numeric Identifier 7923**] ([**Numeric Identifier 7923**]) units Injection QMOWEFR (MO,WE,FR). Disp:*QS QS* Refills:*2* 15. Octreotide Acetate 100 mcg/mL Solution Sig: Two (2) mL Injection Q8H (every 8 hours). Disp:*QS QS* Refills:*2* 16. Midodrine 5 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day). Disp:*225 Tablet(s)* Refills:*2* 17. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 18. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 19. Acetaminophen 160 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every six (6) hours as needed for pain. 20. Ativan 1 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for anxiety: can be given sublingually. Disp:*60 Tablet(s)* Refills:*2* 21. Compazine 25 mg Suppository Sig: One (1) tablet Rectal every six (6) hours as needed for nausea. Disp:*30 tab* Refills:*3* 22. Roxanol Concentrate 20 mg/mL Solution Sig: 5-20 mg PO 1 hr prn as needed for pain. Disp:*50 ml* Refills:*3* 23. PICC line care per protocol 24. Hospital bed 25. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*60 Tablet, Chewable(s)* Refills:*2* 26. [**Doctor Last Name **] lift Sig: One (1) lift prn as needed for lifting patient: [**Doctor Last Name **] lift to be used as protocol. Disp:*1 lift* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 511**] Home Health Services Discharge Diagnosis: Methicillin sensitive staph aereus bacteremia Osteomyelitis Liver failure Congestive heart failure Aortic stenosis Acute on chronic renal failure Hepatorenal syndrome Discharge Condition: Stable. Tolerating minimal PO and OOB w/ 2 assists. Discharge Instructions: Please contact physician if experience shortness of breath, chest pain/pressure, fevers, lightheadedness/dizziness, weight gain greater than 3 pounds in 1 day, any other questions/concerns. . Please weigh yourself each morning. Contact your physician if gain greater than 3 pounds, have increased lower leg edema. . Please adhere to low salt diet (less than 2grams per day) . Please take medications as directed . Please follow up with appointments as directed Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD (GI/Liver) Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2168-5-18**] 1:20 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4340**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2168-5-17**] 9:00

[ "995.92", "707.03", "572.2", "253.6", "038.11", "V58.67", "428.0", "424.1", "286.7", "714.0", "571.5", "570", "287.5", "250.00", "785.52", "730.17", "426.11", "584.5", "785.51", "997.69", "996.61", "403.91", "572.4" ]

icd9cm

[ [ [] ] ]

[ "38.93", "54.91", "37.77", "38.95", "99.07", "99.04", "96.6", "39.95", "37.89" ]

icd9pcs

[ [ [] ] ]

25711, 25786

9196, 22622

338, 460

25997, 26052

3034, 3039

26562, 26847

2553, 2631

22770, 25688

25807, 25976

22648, 22747

26076, 26539

2646, 3015

275, 300

3922, 9173

488, 1612

3053, 3903

1634, 2217

2233, 2537

5,966

141,764

51793

Discharge summary

report

Admission Date: [**2139-11-24**] Discharge Date: [**2139-12-6**] Date of Birth: [**2069-1-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Cough, weight loss, left LE edema/erythema/pain Major Surgical or Invasive Procedure: Thoracentesis of Left Pleural Space History of Present Illness: 70 y/o male smoker with PVD, CAD S/P CABG ([**2125**]), CHF (EF 25-30%, sxs with minimal activity), h/o Head/Neck CA (hard palate SCC 10 yrs ago s/p XRT/seeds), seveer PVD, who has had a productive cough for approx 10 months, worse in the past week, associated with a 20 lb wt. loss over several months, increasing SOB with exertion, and left LE swelling/erythema over the past 2-3 weeks that is increasingly painful. Denies chest pain or pressure. Denies anginal symptomes at home. . Reports history of incarceration/employment in TB [**Hospital1 **]. Denies hemoptysis or night sweats. Past Medical History: Smoker 55yrs 2ppd PVD CAD S/P CABG [**2125**] - LIMA to LAD, SVG to OM, SVG to PDA. CHF - EF 25-30% (in [**2125**]) - now essentially has Class III failure Hard palate SCC -dx. during intubation for CABG in [**2125**]; resected and XRT ETOH abuse (currently drinks 2 drinks per day, last yesterday S/P appendectomy S/P Hernia repair Social History: Lives with Wife [**Location (un) 6409**]. ETOH use of two drinks per day. Smokes 2 ppd for 55 years, Used to drive cab. Family History: Non contributory Physical Exam: T 99 HR 105 BP 102/52 RR 16 SAT 99% RA Elderly man with mult. pigmented lesions of the face and chest, NAD CTA, mild expiratory wheezes RRR, occ premature beat, mid-peaking crescendo-decrescendo murmur, [**12-28**] Abd soft, nt, nd, bs+ Thin, wasted extremities, mult. stigmata of vascular insuficiency: dry, lichanified, skin, warm, but non-palpable pulses, Lt. LLE painful to touch, erythematous, open lesion b/t 4th and 5th toes, no purulence, but serous drainage. Pertinent Results: ADMISSION LABS: [**2139-11-24**] 04:00PM WBC-6.2 RBC-3.41* HGB-9.3* HCT-28.8* MCV-84 MCH-27.2 MCHC-32.3 RDW-16.7* [**2139-11-24**] 04:00PM NEUTS-79.8* LYMPHS-15.3* MONOS-3.3 EOS-1.2 BASOS-0.4 [**2139-11-24**] 04:00PM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-1+ MICROCYT-1+ [**2139-11-24**] 04:00PM PLT COUNT-468* [**2139-11-24**] 04:00PM PT-13.5* PTT-24.6 INR(PT)-1.2 [**2139-11-24**] 04:00PM GLUCOSE-110* UREA N-18 CREAT-0.9 SODIUM-133 POTASSIUM-4.2 CHLORIDE-92* TOTAL CO2-33* ANION GAP-12 [**2139-11-24**] 04:00PM CALCIUM-9.2 PHOSPHATE-3.6 MAGNESIUM-2.1 . EKG: Sinus rhythm. Ventricular premature beats. Left atrial abnormality. Low limb lead QRS voltage is non-specific. Modest non-specific low amplitude lateral T wave changes. Since the previous tracing of [**2135-12-20**] limb lead QRS voltage is lower making assessment for possible prior inferior wall myocardial infarction more difficult, and lateral T wave amplitude is lower. . CXR: Large left effusion, obscuring the left mid and lower lung. . LEFT FOOT FILM: No fracture of the left foot is identified. There are degenerative changes at the tarsometatarsal joints. There is a pes cavus. Clips are noted within the medial left ankle soft tissues. Otherwise, soft tissues are unremarkable, and no ulcers are visualized. There is no osseous destruction visualized to confirm osteomyelitis. . CT CHEST: There is a large layering left pleural effusion causing eversion of the left hemidiaphragm and extending into the azygoesophageal recess. There is atelectasis of the left lower lobe and lingula. A 2.6 x 2 cm lobulated, pleural-based solid mass is seen in the left upper lobe abutting the mediastinal pleura, however, without any invasion of the mediastinal pleura or the lateral chest wall. A 4-mm noncalcified pulmonary nodule is seen in the right lower lobe (image 2:36). The airways are patent up to the subsegmental bronchi. There is an enlarged 11-mm subcarinal lymph node. There is no hilar lymphadenopathy. There is no pericardial effusion. The heart and great vessels are unremarkable. . ABI/PVR: Findings consistent with significant aortobi-iliac level arterial disease. In addition, there is most likely significant tibial level arterial disease bilaterally. . ECHO: The left atrium is mildly dilated. The left ventricular cavity is moderately dilated. There is mild regional left ventricular systolic dysfunction. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Resting regional wall motion abnormalities include basal to mid inferior and inferolateral akinesis/hypokinesis. Right ventricular chamber size is normal. The mitral valve leaflets are mildly thickened. There is moderate/severe mitral valve prolapse. There is partial mitral leaflet flail. Moderate to severe (3+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . CAROTID DOPPLER: Findings as stated above which indicate 60-69% ICA stenoses bilaterally Brief Hospital Course: Shortly after admission, Mr. [**Known lastname **] developed respiratory distress in the setting of aspiration and a large pleural effusion, requiring intubation and transfer to ICU. While in the ICU his pleural effusion was drained and found to have malignant cells. Recently the medical team had discovered a lung mass by imaging studies and this was felt to be the likely primary. After drainage of the effusion and placement of a pleuridex catheter pt was able to be extubated. Shortly after extubation pt required re-intubation for hypercarbic respiratory failure. At that time the patient was found to have a re-accumulation of the pleural fluid as well as pulmonary edema. Pt was initially admitted for severe peripheral vascular disease and resultant necrosis of the distal toes. The legs were mottled, with markedly diminished pulses, and amputation was advised but refused by the patient. Antibiotics were administered in an attemt to cover likely infection given the increasinglt gangrenous appearance of his feet. On [**2139-12-6**] while pt was intubated, sedation was lightened and family was able talk to him about his wishes. After a family meeting with the ICU team, family requested extubation, fully understanding that he would likely not survive long of of the ventilator. Pt was extubated and died shortly therafter. Medications on Admission: None Prescribed Medications In Past: (very poor compliance) Zestril Coreg 6.25 mg [**Hospital1 **] Singulair Combivent Wellbutrin Per patient, he is not taking any of these medications. Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: peripheral vascular disease malignant pleural effusion Discharge Condition: na Discharge Instructions: na Followup Instructions: na Completed by:[**2140-1-3**]

[ "496", "518.84", "507.0", "440.24", "162.3", "197.2", "682.7", "285.22", "305.00", "305.1", "428.0", "250.00", "799.4", "V45.81", "V10.83", "427.5", "424.0", "518.0" ]

icd9cm

[ [ [] ] ]

[ "96.71", "33.24", "99.04", "34.91", "96.04", "34.09", "96.6" ]

icd9pcs

[ [ [] ] ]

6779, 6788

5162, 6512

364, 401

6886, 6890

2051, 2051

6941, 6973

1528, 1546

6750, 6756

6809, 6865

6538, 6727

6914, 6918

1561, 2032

276, 326

429, 1018

2067, 5137

1040, 1374

1390, 1512

24,588

151,610

3149

Discharge summary

report

Admission Date: [**2165-4-13**] Discharge Date: [**2165-4-19**] Date of Birth: [**2104-2-16**] Sex: M Service: MEDICINE Allergies: Iodine Attending:[**First Name3 (LF) 106**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: 61 y.o. male smoker presents with accelerating chest pain for 2 weeks to an OSH, found to have STEMI V2-V4. He was in his USOH until 11pm on [**4-12**] when he started to experience sub-sternal chest pain; he states that he has had intermittent CP for the past 2 weeks that radiated to his shoulders bilaterally, described as "ripping." This was worse with lifting/exertion. He also stated that the felt as if his arms were heavy, and he had left arm paresthesias with exertion. On presentation to OSH, his pain was [**10-7**]. EKG was concerning for ST elevations in v1-v4, and he was started on heparin, integrillin, plavix and transferred to [**Hospital1 18**]. At cath found to have chronic TO of LCX and new thrombus in LAD, stented with Cypher x 2. Hemodynamics: CO/CI 3.4/1.8, PCWP 30, PAD 30. He was transferred to the CCU post procedure for further monitoring. Past Medical History: Bronchitis Tobacco Abuse Social History: Married, lives with wife, works in maintenance Smokes 2 ppd Family History: Paternal GM with MI age 54 Paternal GF with MI age 58 Father with MI age 58 Uncle with MI age 46 Physical Exam: VS: afebrile, 120/74 80 12 95% 2L Gen: NAD, pleasant male, lying in bed HEENT: PERRL, OP clear Neck: JVD-7cm Lungs: bilateral crackles at bases CV: RRR, nl s1/s2, no m/r/g Abd: soft, nt/nd, nabs Extr: no c/c/e, DP 1+ bilat Groin: right: no hematoma/bruit Pertinent Results: [**2165-4-13**] 11:25PM UREA N-14 CREAT-0.8 POTASSIUM-4.5 [**2165-4-13**] 11:25PM CK(CPK)-4740* [**2165-4-13**] 11:36AM GLUCOSE-111* UREA N-17 CREAT-0.8 SODIUM-135 POTASSIUM-4.7 CHLORIDE-101 TOTAL CO2-22 ANION GAP-17 [**2165-4-13**] 11:36AM ALT(SGPT)-106* AST(SGOT)-549* CK(CPK)-5737* [**2165-4-13**] 03:20PM CK(CPK)-6831* [**2165-4-13**] 11:36AM TRIGLYCER-122 HDL CHOL-53 CHOL/HDL-3.6 LDL(CALC)-114 [**2165-4-13**] 11:36AM WBC-9.4 RBC-3.92* HGB-12.3* HCT-35.4* MCV-90 MCH-31.3 MCHC-34.7 RDW-13.2 [**2165-4-13**] 11:36AM PLT COUNT-265 Echo:1. A patent foramen ovale is present. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is severely depressed (25%). Severe, global hypokinesis to akinesis is present with some preservation of basal wall motion, especially the basal lateral wall. 3. The aortic valve leaflets are mildly thickened. 4. Compared with the findings of the prior report (tape unavailable for review) of [**2164-8-3**], left ventricular systolic function has deteriorated. Brief Hospital Course: 1. Cardiovascular: a) Ischemia: Cardiac catheterization revelaed LAD with subtotal occlusion and 70% occlusion at ostial D1. 2 cypher stents were placed in this vessel. He alos had 70% proximal occlusion of the LcX and 40% RCA (no stents). PCW was 30 with CO/CI of 3.4/1.8. He was started on integrillin post procedure and ASA, Plavix, ACEI, BB, and statin. He was chest pain free after procedure with improvement in his EKG. CK peak was 6831 with MB=13.4 and tnt=21.0. Fasting lipid profile was checked, and smoking cessation was encouraged. On [**4-17**] pt had chest pain similar to prior chest pain. He was placed on nitro gtt. His EKG unchanged. He went to cath which showed patent LAD, and a jailed D2 which was ballooned opened with kissing balloons. His old LCx lesion was also noted. b) Pump: On 2nd cath, his wedge was 11, CI >2.5, and had normal filling pressures suggesting a significant improvement from his inital right heart cath results. c) Rhythm: He was monitored on telemetry post-MI. 2. Drug Rash: He developed an urticarial rash 1 day after admission and received 1 dose of steroids with multiple doses of Benadryl. Rash resolved after this treatment. It was unclear what the inciting medication was; it was most likely iodine (from dye), for the rash was mostly in the groin area. 3. Hyperlipidemia: He was started on Lipitor, and fasting lipid profile was checked. 4. Tobacco Use: Smoking cessation was encouraged in-house 5. Disposition: to home with cardiac rehab in 2 weeks and he will follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. 6. Code: Full Medications on Admission: None PRN Alleve ADmission to [**Hospital1 18**] from OSH: ASA BB Plavix Statin Integrillin Heparin Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*6* 3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). Disp:*7 Patch 24HR(s)* Refills:*0* 6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 7. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-30**] Sprays Nasal TID (3 times a day) as needed. 8. Nicotine 7 mg/24 hr Patch 24HR Sig: One (1) patch Transdermal once a day for 14 days: Start after using 14mg patches for one week. Do not use while smoking. Disp:*14 patches* Refills:*0* 9. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 10. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Combivent 103-18 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation four times a day as needed for shortness of breath or wheezing. Disp:*1 mdi* Refills:*3* 12. Outpatient Lab Work Please check INR on [**2165-4-22**]. Fax results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]: tel: [**Telephone/Fax (1) 10548**] / fax: [**Telephone/Fax (1) 14873**] 13. Medical equipment Blood pressure cuff 14. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tab Sublingual PRN (as needed) as needed for chest pain: for chest pain: take 1 tab, may repeat in 5 minutes. If chest pain is not relieved after 2nd tab, call 911. Disp:*100 tab* Refills:*3* Discharge Disposition: Home Discharge Diagnosis: Acute myocardial infarction Discharge Condition: Stable Discharge Instructions: Please seek medical attention for fevers>101.4, for chest pain unrelieved by nitroglycerin, or for anything else medically concerning. Please take your medications as directed. Followup Instructions: 1) Please have your blood drawn on Monday, [**2165-4-22**] and have the results faxed to Dr. [**Last Name (STitle) **]. 2) You should start cardiac rehab in 2 weeks. 3) Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 10548**] Date/Time:[**2165-5-23**] 11:00

[ "514", "492.8", "708.0", "428.0", "305.1", "414.01", "300.00", "481", "458.8", "410.11" ]

icd9cm

[ [ [] ] ]

[ "88.56", "88.55", "36.01", "36.07", "37.23" ]

icd9pcs

[ [ [] ] ]

6543, 6549

2863, 4501

277, 302

6620, 6628

1745, 2840

6854, 7253

1350, 1448

4651, 6520

6570, 6599

4527, 4628

6652, 6831

1463, 1726

227, 239

330, 1209

1231, 1257

1273, 1334

68,184

155,784

35821+58034

Discharge summary

report+addendum

Admission Date: [**2148-3-31**] Discharge Date: [**2148-4-7**] Date of Birth: [**2088-8-3**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2195**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 59yo M PMHx Stage IV NSLC s/p L pneumonectomy ([**7-/2147**]), recent diagnosis of PE ([**3-/2148**]) now on coumadin, CT at time of diagnosis suggesting cancer recurrence, recently seen in thoracic clinic with cough and shortness of breath and prescribed levofloxacin for presumed bronchitis ([**2148-3-28**]), now presenting with increasing dyspnea and cough. Patient reports cough is chronic for past 2 months, although worsening since hospitalization with yellow, non-bloody sputum production. Patient denies fevers and chills but states that he is unable to walk more than a few feet. Prior to the PE, patient was able to walk 200 feet but was started on 2L NC at time of discharge. Patient states that his shortness of breath has been progressive and not acute. Of note, patient has been taking levofloxacin with sputum becoming less yellow and a one time episode of nausea following dinner last night. Initial vital signs on presentation to [**Hospital1 18**] ED were HR132 84%onRA. EKG demonstrated sinus tachycardia to 120s. Labs were remarkable for WBC 11.7 (90N), Hct 33.6, Plt 171, Na 132, Cr 1.2, BUN 69, INR 4.0, Lactate 1.6, BNP 437. CXR showed increased consolidation of RLL suggestive of infection. Case was discussed with thoracic surgery, who felt that MICU admission was warranted. Patient was given vanco, ceftriaxone for treatment of presumed pnuemonia. Vital signs on transfer: 97.6 134 36 112/68 95%NRB On arrival to the ICU patient is tachypnic to 30s and satting 100% on non-rebreather. He is speaking in 2 word sentences although does not appear tiring. Of note, patient endorses 20 pound weight loss over the past 2 months or so. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain, chest pressure, palpitations, or weakness. Denies diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Past Medical History: - poorly-differentiated carcinoma of the lung - DM2 - HTN - HLD - s/p CVA ([**2140**]) w residual LUE weakness and numbness . Onc History [**1-/2145**] - diagnosed with cardiac tamponade, PET/CT w left upper lobe lung mass, multiple enlarged lymph nodes, brain MRI negative for mets [**2-/2145**] - s/p 6 cycles carboplatin/alimta, XRT 6000cGy, follwed by taxol [**2-/2147**] - Enlarging LUL mass, started on Tarceva [**7-/2147**] - 1. Left thoracotomy/left pneumonectomy. 2. Buttressing of bronchial stump with intercostal muscle. Social History: He is married and has no children. He previously worked in construction before his diagnosis. He is originally from [**Country 6257**] and is accompanied by his friend [**Name (NI) **] [**Name (NI) **] (W: [**Telephone/Fax (1) 81460**], x16; C: [**Telephone/Fax (1) 81461**]), who he has authorized us to speak with about his health matters. He previously smoked [**2-12**] packs per day x 42 years, quitting in [**2144**]. He drinks 3 bottles of wine per week. Family History: No family history of lung cancer. His father had a history of strokes. His mother had type 2 diabetes. He has no children. Physical Exam: Admission: Vitals: T: BP: 99/61 P: 128 R: 30 O2: 99% General: Alert, oriented, using accessory muscles to breath HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, Left supraclavicular lymphnode Lungs: No sounds on left, right side with rhonchi throughout CV: tacyhcardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or 1+ edema Discharge: Pertinent Results: [**2148-3-31**] 07:45PM BLOOD WBC-11.7*# RBC-4.43*# Hgb-11.3* Hct-33.6* MCV-76*# MCH-25.5* MCHC-33.7 RDW-14.7 Plt Ct-171 [**2148-3-31**] 07:45PM BLOOD Neuts-90.0* Lymphs-4.3* Monos-3.4 Eos-1.8 Baso-0.5 [**2148-3-31**] 07:45PM BLOOD PT-41.2* PTT-33.6 INR(PT)-4.0* [**2148-3-31**] 07:45PM BLOOD Glucose-195* UreaN-69* Creat-1.2 Na-132* K-3.9 Cl-94* HCO3-26 AnGap-16 [**2148-3-31**] 07:45PM BLOOD cTropnT-0.01 proBNP-437* [**2148-3-31**] 07:45PM BLOOD Calcium-8.9 Phos-3.9 Mg-2.0 [**2148-3-31**] 11:29PM BLOOD Type-ART Temp-37.7 pO2-298* pCO2-36 pH-7.45 calTCO2-26 Base XS-2 Intubat-NOT INTUBA Comment-AXILLARY T [**2148-3-31**] 11:29PM BLOOD Lactate-1.2 K-3.5 [**2148-3-31**] 07:58PM BLOOD Lactate-1.6 [**2148-3-31**] 11:29PM BLOOD O2 Sat-99 [**2148-3-31**] 11:29PM BLOOD freeCa-1.12 Blood cultures pending x2 CHEST (PORTABLE AP) Study Date of [**2148-3-31**] 7:54 PM FINDINGS: Single frontal view of the chest demonstrates complete Preliminary Reportopacification of the left hemithorax and leftward cardiomediastinal shift Preliminary Reportconsistent with post-pneumonectomy change. The right lung demonstrates Preliminary Reportincreased consolidation in the lower lobe and possibly also the middle lobe Preliminary Reportsuggestive of infection. This distribution would be atypical for edema. Preliminary ReportThere is no pneumothorax or large right effusion. Preliminary ReportIMPRESSION: Preliminary Report1. Stable post-pneumonectomy changes in the left lung. Preliminary Report2. Right lower lung consolidation, suggestive of new infection. Brief Hospital Course: 59yo M PMHx Stage IV NSLC s/p L pneumonectomy ([**7-/2147**]) with recurrence in supraclavicular node, recent diagnosis of PE ([**3-/2148**]) on coumadin, and pneumonia. # Hypoxia Stage IV lung cancer with nodal recurrance recently s/p L pneumonectomy, as well as a new right sided pneumonia. Admitted to the [**Hospital Unit Name 153**] and started on IV vanc/zosyn/levaquin for HCAP. Anticoag was held for elevated INR, but PE was likely a contributing factor to hypoxia. Very high oxygen requirements, with desats with any movement. Vancomycin was stopped with no evidence of MRSA. Levaquin stopped after 6 days. Zosyn continued for 10 days. Lasix attempted for diuresis without improvement, and worsening of congestion. No improvement in oxygenation over the course of about a week. Palliative care consult was called and patient and family decided to pursue hospice, while continuing to treat pneumonia and PE. Lab draws, vitals, and non-comfort medications were stopped. Patient was called out to the floor. Overnight he became much less responsive, and his work of breathing increased. Antibiotics were stopped and a morphine drip and glycopyrrolate were started. He was seen by the Catholic chaplain and received the anointing of the sick with his family present. Mr.[**Known lastname 32665**] passed away peacefully on the afternoon of [**2148-4-7**] with his family at his bedside. Medications on Admission: glimepiride 2 mg Tablet daily levofloxacin 500 mg Tablet daily lisinopril-hydrochlorothiazide 20 mg-12.5 mg daily simvastatin 80 mg Tablet warfarin 5 mg Tablet aspirin 81 mg Tablet daily hydromorphone 2mg PRN Discharge Disposition: Expired Discharge Diagnosis: Metastatic lung cancer Discharge Condition: Expired. Name: [**Known lastname 13046**],[**Known firstname **] Unit No: [**Numeric Identifier 13047**] Admission Date: [**2148-3-31**] Discharge Date: [**2148-4-7**] Date of Birth: [**2088-8-3**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1824**] Addendum: Pulmonary Embolism: Unable to specify whether an acute or chronic pulmonary embolism was present and/or contributing to the patient's presentation as this diagnosis was not pursued in the context of his goals of care. Discharge Disposition: Expired [**First Name11 (Name Pattern1) 634**] [**Last Name (NamePattern4) 1837**] MD [**MD Number(2) 1838**] Completed by:[**2148-4-30**]

[ "799.02", "V15.82", "V58.61", "272.4", "V45.76", "196.0", "486", "438.89", "V12.55", "785.0", "V10.11", "250.00", "729.89", "276.1", "790.92", "V49.86", "401.9" ]

icd9cm

[ [ [] ] ]

[ "38.97" ]

icd9pcs

[ [ [] ] ]

8118, 8287

5758, 7153

310, 316

7488, 8095

4180, 5735

3464, 3590

7442, 7467

7179, 7389

3605, 4161

2034, 2387

263, 272

344, 2015

2431, 2965

2981, 3448

9,889

193,825

52821

Discharge summary

report

Admission Date: [**2189-12-1**] [**Month/Day/Year **] Date: [**2189-12-6**] Date of Birth: [**2117-9-11**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8961**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: 72yo F with ESRD on HD, hypertension, h/o CVA presents to ED with altered mental status, headahce and unresponsiveness . In ED, vital signs were T97.6 P76 BP231/161 R18 100%on NRB. Her initial K was 7(hemolyzed) with peaked Ts on EKG. She received 2 rounds of D50, insulin, bicarbonate, kayexelate. She was intubated for airway protection. Code stroke was called given the h/o CVA and acute AMS. Head CT and MRI were unremarkable. CXR show left sided infiltrate and WBC 24 and she was started on vanco and ceftriaxone. Patient was last dialyzed on Saturday. Of note, patient was recently admitted for dyspnea and tremors, treated for pneumonia and hyperkalemia as well. . Past Medical History: 1. HTN 2. Hypothyroidism 3. DM2 4. ESRD on HD T, Th, Sat x 1 year 6. s/p CVA 2 years ago 7. Gait disorder 8. s/p splenectomy in [**2145**] after trauma, has never been prescribed/used prophylactic abx 9. s/p thyroidectomy in [**2173**] 10. s/p Left loop forearm arteriovenous graft [**2187-8-24**] 11. myoclonus on klonopin . Social History: Lives at home alone locally. Had 8 children, 1 son died in the past year. Daughter comes to see her frequently, helps with grocery shopping, etc. She is a nonsmoker and no EtOH. Family History: Noncontributory Physical Exam: T96.3 P60 BP179/67 R18 AC 500x18/0.3/5 Gen- intubated, sedated, african american female lying comfortbaly in bed HEENT- anicteric, injected conjuctiva, PERRLA, moist mucus membrane, neck supple, JVD cannot be appreciated CV- regular, no r/m/g,left tunnled line does not appear inflammed/tender RESP- crackle L>R ABDOMEN- soft, nontender, nondistended, good bowel sounds, no hepatsplenomegaly NEURO- awake to voice, obey commands, able to move all 4 to commands, unable to test stregth, too tired to fully comply to cranial nerve exam, toes downgoing bilaterally EXT- no edema, DP 2+ bilaterally . Pertinent Results: [**2189-12-1**] 02:09AM K+-5.1 [**2189-12-1**] 01:41AM TYPE-ART PO2-276* PCO2-36 PH-7.46* TOTAL CO2-26 BASE XS-2 -ASSIST/CON INTUBATED-INTUBATED [**2189-12-1**] 12:30AM COMMENTS-GREEN TOP [**2189-12-1**] 12:30AM K+-6.1* [**2189-11-30**] 11:22PM LACTATE-1.5 K+-7.2* [**2189-11-30**] 11:15PM GLUCOSE-233* UREA N-76* CREAT-10.1*# SODIUM-126* POTASSIUM-8.1* CHLORIDE-90* TOTAL CO2-21* ANION GAP-23* [**2189-11-30**] 11:15PM estGFR-Using this [**2189-11-30**] 11:15PM CK(CPK)-67 [**2189-11-30**] 11:15PM CK-MB-NotDone cTropnT-0.03* [**2189-11-30**] 11:15PM CALCIUM-8.8 PHOSPHATE-6.2*# MAGNESIUM-3.2* [**2189-11-30**] 11:15PM WBC-24.5*# RBC-4.50 HGB-14.5# HCT-42.5 MCV-95 MCH-32.1* MCHC-34.0 RDW-14.8 [**2189-11-30**] 11:15PM NEUTS-83* BANDS-3 LYMPHS-12* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2189-11-30**] 11:15PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL BURR-1+ [**2189-11-30**] 11:15PM PLT COUNT-329 [**2189-11-30**] 11:15PM PT-12.8 PTT-29.9 INR(PT)-1.1 Brief Hospital Course: 72yo F with ESRD on HD, HTN now presents with unresponsiveness, headache and agitation in the setting of leukocytosis, lung infiltrate. 1) Altered mental status: DDx initially included toxic metabolic, stroke, meningitis, encephalitis, non-convulsive seizures, central venous thrombophlebitis, traumatic brain injury. Unremarkable head CT and MRI without evidence of CVA. Patient presented with hyperkalemia (possibly consistent with toxic-metabolic etiology), leukocytosis and pulmonary infiltrate (pointing to possible infectious etiology). Patient was intubated for airway protection and admitted to the ICU, in the setting of agitation. She was extubated the following day with evidence of improved mental status and was transferred out of the ICU. Following extubation, she was evaluated and followed by Neurology Consult and felt to be at cognitive baseline, with no indication for further intervention. Her hyperkalemia was treated with urgent HD. Given the leukocytosis, left-shift and left lung infiltrate, she was also treated empirically for community-acquired pneumonia; however, repeat CXR revealed this infiltrate to be consistent with unilateral pulmonary edema after diuresis, and antibiotic course was limited to 7 days of levofloxacin. . 2) Hyponatremia: likely hypovolemic given hemoconcentration, worsening Cr and clinically does not appear volume overloaded. Resolved with gentle fluid. . 3) ESRD: on HD T, Th, Sat. Patient does not appear clinically volume overloaded, however, hyperkalemic with peaked Ts on admission and unilateral pulmonary edema. Hypervolemia & hyperkalemia resolved with urgent HD. Continued sevelemer and calcium. . 4) Hypertension: continue on Bumetanide, Lisinopril, Isosorbide, Norvasc and Metoprolol 75 mg [**Hospital1 **]. . 5) Hypothyroid: continue on Synthroid. . 6) Diabetes: Insulin SSI. Oral medications resumed at [**Hospital1 **]. . Full code. Medications on Admission: Bumetanide 2 mg Lansoprazole Levothyroxine 100 mcg Sevelamer 800 mg TID Calcium Carbonate 500 mg TID Lisinopril 40 mg Isosorbide Mononitrate 60 mg Glipizide 2.5 mg Amlodipine 10 mg Metoprolol 75 mg [**Hospital1 **] Aspirin 81 Clonazepam 1 mg [**Hospital1 **] [**Hospital1 **] Medications: 1. Bumetanide 2 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 3. Levothyroxine 100 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 20 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). 5. Sevelamer 800 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day). 6. Calcium Carbonate 500 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable PO TID (3 times a day). 7. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO BID (2 times a day). 8. Amlodipine 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). 9. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24HR [**Last Name (STitle) **]: One (1) Tab,Sust Rel Osmotic Push 24HR PO once a day. 10. Aspirin 81 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 11. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Last Name (STitle) **]: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 12. Insulin Lispro (Human) 100 unit/mL Solution [**Last Name (STitle) **]: One (1) Subcutaneous ASDIR (AS DIRECTED). 13. Clonidine 0.2 mg/24 hr Patch Weekly [**Last Name (STitle) **]: Two (2) Patch Weekly Transdermal QTUES (every Tuesday). Disp:*8 Patch Weekly(s)* Refills:*0* 14. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR [**Last Name (STitle) **]: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2* 15. Levaquin 250 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day for 1 days: please take this dose on tuesday after dialysis. Disp:*1 Tablet(s)* Refills:*0* [**Last Name (STitle) **] Disposition: Home With Service Facility: [**Location (un) 1468**] VNA [**Location (un) **] Diagnosis: Altered mental status Hyperkalemia ESRD Hypertension Transaminitis [**Location (un) **] Condition: Stable [**Location (un) **] Instructions: You were found with altered mental status at home, and you were briefly intubated in the ICU to protect your airway. CT and MRI of your brain were both negative for any evidence of a stroke. Your potassium level was very high on admission, and this resolved with urgent dialysis. After you were extubated, your mental status was back to normal. You were evaluated by the Neurology service who recommended no further intervention. . Take all medications as instructed. . You should seek immediate medical attention if you experience shortness of breath, heart palpitations, chest pain, or severe dizziness. Followup Instructions: You should call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 14049**], to set up a follow-up appointment for next week: ([**Telephone/Fax (1) 108907**]. Your liver function tests were slightly elevated during this admission; you should have Dr. [**Last Name (STitle) 14049**] recheck these at your next visit. . Resume HD Tuesday, Thursday, Saturday [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 8965**]

[ "276.2", "276.7", "403.91", "276.1", "244.0", "584.9", "585.5", "486", "276.52", "250.00", "428.0" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "39.95" ]

icd9pcs

[ [ [] ] ]

3368, 3515

349, 355

2272, 3345

8322, 8818

1622, 1639

5305, 5566

1654, 2253

7544, 7613

288, 311

7645, 7654

5596, 7512

7689, 8299

383, 1057

3530, 5279

1079, 1407

1423, 1606

15,381

126,422

10649

Discharge summary

report

Admission Date: [**2188-7-25**] Discharge Date: [**2188-7-28**] Date of Birth: [**2120-9-15**] Sex: F Service: CA/TH [**Doctor First Name 147**] HISTORY OF PRESENT ILLNESS: The patient is a 67 -year-old female with a history of breast cancer diagnosed in 07/96. She is status post lobectomy and chemotherapy. The patient has complained of increasing left upper quadrant pain which has radiated to the back. Chest x-ray was negative. CT scan showed a left lower lobe mass in the chest. The patient denies shortness of breath, cough, hemoptysis, weight loss, or anorexia. PAST MEDICAL HISTORY: 1. Hypertension. 2. Depression. PAST SURGICAL HISTORY: Cholecystectomy. ADMITTING MEDICATIONS: Includes 1) Zoloft 100 mg q day, 2) Toprol 50 mg q day, 3) Zantac 150 mg q day, and 4) Tamoxifen one tablet [**Hospital1 **]. ALLERGIES: No known allergies, but skin irritation to adhesive tape. SOCIAL HISTORY: Negative for tobacco or alcohol. FAMILY HISTORY: Sister with breast cancer and no family history of lung cancer. PHYSICAL EXAMINATION: Initial physical examination showed the patient to be healthy with no acute distress. Head, eyes, ears, nose and throat was negative to lymphadenopathy. Cardiovascular was regular rate and rhythm. Lungs were decreased breath sounds in the left base. Abdomen was soft, nontender. Extremities: negative edema. Neurologic was grossly intact. HOSPITAL COURSE: The patient was admitted on [**7-25**] and was transported to the Operating Room with a preoperative diagnosis of left lower lobe nodule / pleural nodule. Procedure was a left VATS, pleurodesis, and pleural biopsy times one. The patient tolerated the procedure well and was transported to the postoperative area in stable condition. On postoperative day one, the patient was doing well and had O2 saturations in the 90s on two liters. On postoperative day two, the patient complained of increasing shortness of breath and was noted to have difficulty while ambulating. On postoperative day three the patient was assessed by Pain Management who concluded that we should discontinue the Percocet and start Dilaudid 2.0 mg po q three to four hours for better control of the pain. On [**2188-7-29**], the patient continued to have increasing shortness of breath and O2 saturations on room air in the low 80s. On [**2188-7-29**], the patient had a bronchoscopy which showed high grade subglottic stepping secondary to swelling. At this point the patient was transported to the Intensive Care Unit for closer management. The patient spent one day in the Cardiothoracic Intensive Care Unit and was transferred back to the floor on [**2188-7-30**]. On [**2188-7-31**], the patient continued to do well, was tolerating ambulation at a level IV without O2 and on room air had a sitting saturation of 92%. The patient's x-ray on [**7-31**] was normal. During the afternoon, the patient was reassessed and scheduled for discharge. DISCHARGE PHYSICAL EXAMINATION: Maximum temperature 98 F, heart rate 95, respiratory rate 22, blood pressure 147/82, the patient was 93% on five liters and the patient later in the day was 92% on room air. Cardiovascular was regular rate and rhythm. Respiratory was clear to auscultation bilaterally. Abdomen was soft, nontender, nondistended, positive bowel sounds. The incision was clear, dry, and intact. The dressing was also clear and dry. COMPLICATIONS: None. DISCHARGE MEDICATIONS: Included Zantac 150 mg po bid, Zoloft 100 mg po q day, Toprol XL 500 mg po q day, Tamoxifen one tablet po bid, Levaquin 500 mg po q day times seven, Dilaudid 2.0 mg po q three to four hours prn, Albuterol nebulizers q four hours prn, Colace 100 mg po bid with Dilaudid, prednisone taper 40 mg po q day times two days, then 30 mg po q day times two days, then 20 mg po q day times two days, then 10 mg po q day times two days, then off. DISCHARGE CONDITION: Good / stable. DISCHARGE STATUS: To home. FOLLOW-UP: The patient's follow-up will be with Dr. [**Last Name (STitle) 175**] in one week. PRIMARY DIAGNOSIS: Left VATS with pleural biopsy. SECONDARY DIAGNOSES: 1. Hypertension. 2. Depression. [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**] Dictated By:[**Last Name (NamePattern1) 33068**] MEDQUIST36 D: [**2188-7-31**] 18:27 T: [**2188-7-31**] 23:03 JOB#: [**Job Number 34943**]

[ "293.0", "311", "401.9", "V10.3", "486", "197.2", "478.74" ]

icd9cm

[ [ [] ] ]

[ "34.21", "33.23", "34.24", "34.92", "99.29" ]

icd9pcs

[ [ [] ] ]

3924, 4065

985, 1050

3465, 3902

1436, 2976

677, 917

4137, 4452

2999, 3441

195, 597

4084, 4116

619, 654

934, 968

43,122

168,271

13574

Discharge summary

report

Admission Date: [**2101-6-6**] Discharge Date: [**2101-6-13**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 783**] Chief Complaint: Fever and hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname 13162**] is a [**Age over 90 **] yo woman with COPD & hypertension with recent ex-lap and omental patch for perforated duodenal ulcer ([**2101-5-19**]), percutaneous drainage of perihepatic abscess and recent C diff colitis. She was referred to the ED from rehab for fevers x 4 days and hypoxia. She was first noted to have fever to 102 on [**6-2**], she was begun on vancomycin. Levofloxacin was added on [**6-5**] for persistent fever & bilateral infiltrates on CXR. Today her T was noted to be 100.2 and she was hypoxic to 80% on 2L n/c, improved with repositioning. . In the ED she was hypotensive to 77/59, febrile to 102.8, and had atrial fibrillation in 110's. She had numerous failed attempts at a L-IJ CVL; eventually received a L femoral line. She received 3L NS, vancomycin & piperacillin/tazobactam. EKG showed rapid a fib w/o ischemic changes & CE's positive. She received aspirin, but no BB or CCB for her tachycardia. She was started on levophed shortly before transfer for hypotension to 80's systolic. . On transfer to the ICU Ms. [**Known lastname 13162**] complains of feeing fatigued. She also endorses chest pressure & mild dsypnea. She denies light-headedness, syncope, or recent falls. She is unaware of cough, abdominal pain, or diarrhea. She is unsure why she was sent to the hospital, although she is oriented to name, place, and general time. Past Medical History: -COPD/RAD, with prior admissions for Prednisone -Hypertension -Palpitations secondary to frequent APBs -Dysthymia/depression, followed by Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) 40989**], psychiatry, in [**Location (un) 10059**], MA (on escitalopram) -Vertigo -Hearing impairment with R hearing aid -Urge urinary incontinence -PUD -s/p LIH [**5-29**] -s/p exploratory laparotomy, oversew and patch of duodenal perforation [**2101-5-12**] -s/p cataract surgery B eyes Social History: - rare social alcohol use, denies T/D - lives in [**Location **] in senior housing - currently at [**Hospital **] Rehab - former psychologist. retired recently Family History: - non-contributory Physical Exam: T 98.7 BP 96/58 HR 120-150 RR 25 SaO2 96% on 4L n/c General: fatigued, non-toxic. appears much younger than stated age. HEENT: NCAT, PERRL, EOMI Cardiac: tachycardic, irregular rate. No murmurs appreciated Pulmonary: decreased breath sounds at B bases. No wheezing Abdomen: surgical incision healing. soft, non-distended, non-tender Extremity: 2+ BLE edema Skin: LE with venous stasis changes. NO rashes Neuro: A&O x 3. non-focal. Pertinent Results: ADMISSION LABS: . [**2101-6-6**] 12:36PM BLOOD WBC-6.5 RBC-3.60* Hgb-9.9* Hct-30.0* MCV-83 MCH-27.5 MCHC-33.1 RDW-16.3* Plt Ct-279 [**2101-6-6**] 12:36PM BLOOD Neuts-94.2* Lymphs-3.8* Monos-1.5* Eos-0.3 Baso-0.2 [**2101-6-6**] 12:36PM BLOOD PT-13.4 PTT-27.3 INR(PT)-1.1 [**2101-6-6**] 12:36PM BLOOD Glucose-104 UreaN-14 Creat-0.6 Na-131* K-4.0 Cl-95* HCO3-27 AnGap-13 [**2101-6-6**] 12:36PM BLOOD Calcium-7.6* [**2101-6-6**] 12:36PM BLOOD ALT-12 AST-39 AlkPhos-113 TotBili-0.5 [**2101-6-6**] 12:46PM BLOOD Lactate-2.3* [**2101-6-6**] 12:36PM BLOOD CK(CPK)-24* CK-MB-NotDone cTropnT-0.10* TSH . . PERTINENT LABS/STUDIES: . Hct: 30.0 -> 26.0 -> 24.2 -> 23.8 -> 23.7 -> 25.0 Troponin: 0.10 -> 0.12 -> 0.11 -> 0.10 Phos: 3.1 -> 2.1 -> 1.8 -> 2.2 Iron: 18 TIBC: 120 Feritin: 293 TRF: 92 Hapto: 258 Lactate: 2.3 -> 1.5 . Blood Cultures ([**6-6**]): 4/4 bottles STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus and [**Female First Name (un) 564**] species. FINAL SENSITIVITIES. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations Rifampin should not be used alone for therapy. Please contact the Microbiology Laboratory ([**6-/2398**]) immediately if sensitivity to clindamycin is required on this patient's isolate. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S . Urine Culture ([**6-6**]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. LINEZOLID sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R LINEZOLID------------- S NITROFURANTOIN-------- 256 R TETRACYCLINE---------- <=1 S VANCOMYCIN------------ =>32 R . Influenza Swab ([**6-9**]): DIRECT INFLUENZA A ANTIGEN TEST (Final [**2101-6-9**]): Negative for Influenza A viral antigen. DIRECT INFLUENZA B ANTIGEN TEST (Final [**2101-6-9**]): NEGATIVE FOR INFLUENZA B VIRAL ANTIGEN. . CTA chest/abd/pelvis ([**6-6**]): Moderate hiatal hernia. Bilateral pleural effusions. No PE to subsegmental level. Intraabdominal ascites. Nondistended gallbladder, though with pericholecystic fluid, likely third spacing, though correlate with RUQ pain. Moderate hiatal hernia. Bilateral pleural effusions. No PE to subsegmental level. Intraabdominal ascites. Nondistended gallbladder, though with pericholecystic fluid, likely third spacing, though correlate with RUQ pain. . CXR ([**6-6**]): Multiple airspace opacities in the left upper lobe and right lower are new since [**2101-5-25**]. Loss of the right diaphragmatic contour suggests effusion/atelectasis/consolidation. The right upper lung is grossly clear. Large left diaphragm hernia is unchanged since [**2101-5-25**]. The cardiomediastinal silhouette is stable. IMPRESSION: Increasing bilateral airspace opacities are concerning for aspiration pneumonia. . ECHOCARDIOGRAM ([**2101-6-7**]): The left atrium is elongated. The right atrium is moderately dilated. The estimated right atrial pressure is 0-10mmHg. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. The right ventricular cavity is mildly dilated with normal free wall contractility. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. Tricuspid valve prolapse is present. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Normal systolic function (EF 65%). Moderate-severe tricuspid regurgitation. Mild aortic stenosis. Moderate mitral regurgitation. Moderate pulmonary hypertension. . L-Spine MRI ([**6-8**]): 1. No evidence of spondylodiscitis or abscess within the lumbosacral spine. 2. Significant spondylosis with severe canal narrowing, predominantly at L4-L5. The remainder of the lumbar spine as varying degrees of canal or foraminal narrowing as described above. 3. Fluid within the uterine canal, abnormal for the patient's stated age. Pelvic ultrasound can be obtained if clinically indicated. . Left UE U/S ([**6-9**]): Small echogenic brachial veins which do not compress and do not demonstrate venous flow. The small size and increased echogenicity of these veins is suggestive of chronic occlusive thrombus within them. . TEE ([**6-10**]): No intracardiac vegetation. Mild calcific aortic stenosis. Moderate mitral and tricuspid regurgitation . MRI T and C spine ([**6-11**]): 1. No evidence of discitis, osteomyelitis, epidural collection, or paravertebral abscess. 2. Mild spondylosis. 3. Bilateral pleural effusions, as seen on [**2101-6-6**]. Brief Hospital Course: The patient is a [**Age over 90 **] yo woman with h/o recent surgery for perforated ulcer, complicated by perihepatic abscess and CDiff colitis, who presented on [**6-6**] with MRSA septic shock and AFib with RVR. . # Septic Shock: The patient presented with fevers, hypoxia, and hypotension on [**6-6**]. She was placed on Vanc/Zosyn and was admitted to the ICU, where she was started on pressors. She was found to have [**3-26**] blood cultures positive for MRSA as well as a urine culture positive for VRE. Her antibiotics were changed to Linezolid/Zosyn and she defervesced. TTE and TEE were negative for endocarditis, C,T,L-Spine MRIs were negative for epidural abscess, and DFA was negative for influenza. The source of bacteremia continues to be unclear, but it is thought that the patient may have had a line infection from an IV placed prior to presentation. As VRE was considered to be a colonizer rather than pathogen, the patient's antibiotic was changed to Vancomycin. She should continue this until [**2101-6-25**]. . # AFib with RVR: The patient was found to have AFib with RVR on admission. She was loaded with Amiodarone and was transitioned to PO Amiodarone. She was also started on Metoprolol 12.5 mg [**Hospital1 **] for rate control, and she remains tachycardic in the low 100s. The patient most likely went into AFib with RVR as a result of septic shock and subsequent hemodynamic compromise. Her Metoprolol was increased to 50 mg PO BID, and this should be uptitrated as tolerated to achieve HR 70s-80s. She should continue on Amiodarone and Metoprolol and she is scheduled to follow up with her cardiologist, Dr. [**Last Name (STitle) **] on [**2101-6-27**]. . # Anemia: The patient's Hct dropped today from 30 on admission to 23.7. She was found to be guaiac positive and her heparin gtt was discontinued. Repeat hematocrits were stable, and the patient's iron studies were consistent with anemia of chronic disease. The patient is very interested in taking Procrit for her anemia, and she was instructed to ask her PCP about this medication. . #. CDiff: The patient has a history of recent CDiff infection, for which she was taking Flagyl 500 mg TID through [**2101-6-9**]. She developed diarrhea again on [**6-11**] and Flagyl was thus restarted. Her CDiff cultures have been negative x2 to date. She should continue Flagyl until one week after her course of Vancomycin has finished ([**2101-7-2**]). . # NSTEMI: The patient's troponins were elevated on admission. Her ECG showed AFib and diffuse ST-T wave abnormalities. This is most likely secondary to demand ischemia. The patient was started on ASA 325 mg daily, Atorvastatin, and Metoprolol. Her troponins have remained stable. She should continue on these medications until her appointment with Dr. [**Last Name (STitle) **] on [**2101-6-27**]. . # h/o Perforated Ulcer: The patient had a recent perforated ulcer. She was continued on her home dose of PPI, and she had no acute events during this admission. . # COPD/RAD: The patient has a history of COPD, for which she takes Ipratropium, Advair, and Albuterol. On admission, the patient was satting 92% on 4L. Her CXR at this time was consistent with fluid overload. She was thus diuresed daily with 20 mg IV Lasix, and she was continued on her home inhalers. The patient's clinical exam and O2 requirement improved on this admission, and she was satting 93% on RA at the time of discharge. . # Code: FULL, confirmed with patient. Medications on Admission: Diltiazem HCl 240 mg PO DAILY Ipratropium Bromide (2)Puff [**Hospital1 **] Albuterol (2) Puff Inhalation Q4H Advair Diskus 250-50 mcg/Dose twice a day. Pantoprazole 40 mg Tablet PO Q24H Mirtazapine 7.5 mg PO HS Calcium Carbonate 100mg po bid Metronidazole 500 mg PO Q8H till [**2101-6-9**]. Vancomycin since [**6-2**] Levofloxacin since [**6-5**] Discharge Medications: 1. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath. 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 5. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 6. Calcium Carbonate 1,000 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever or pain. 9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 19 days: Please take three times daily until [**2101-7-2**]. 11. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Three (3) Tablet PO DAILY (Daily). 13. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for insomnia. 14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Please hold for HR < 70 or SBP < 95. 15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 16. Vancomycin 1000 mg IV Q 12H 17. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks: Please hold for SBP < 90 or increasing Creatinine. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: Septic Shock with MRSA bacteremia AFib with RVR Secondary: Demand cardiac ischemia Anemia Reactive Airway Disease Discharge Condition: Good. The patient's VS are stable and she no longer has an O2 requirement. Discharge Instructions: You were admitted to the hospital because you had a fever, difficulty breathing, and low blood pressure. You were admitted to the MICU, where you were found to have a bacteria, MRSA, in your blood. We looked at your heart, which did not show any evidence of infection of the valves. We also looked at your spine, which did not show any evidence of infection. We started you on antibiotics, and your clinical picture improved. Your blood pressure is now stable, you haven't spiked a fever in the past five days, and you no longer have an oxygen requirement. While you were here, we made the following changes to your medications: 1. We started you on Vancomycin for your infection. You should continue to take this until [**2101-6-25**] 2. We started you on Aspirin, Atorvastatin, and Metoprolol for your heart. 3. We discontinued your Diltiazem and started you on Amiodarone for your heart rhythm. You have a f/u appointment with Dr. [**Last Name (STitle) **] on [**2101-6-27**] to discuss this medication regimen. 4. We started you on Ambien as needed at night for insomnia 5. We started you on Vitamin D. Please take all medications as prescribed. Please keep all previously scheduled appointments. Please return to the ED or your healthcare provider if you experience shortness of breath, chest pain, increasing fatigue, increasing back pain, confusion, fevers, chills, or any other concerning symptoms. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2101-6-27**] 11:00 Please make an appointment to follow up with your PCP, [**Last Name (NamePattern4) **]. [**Name (NI) **] [**Name (NI) 40991**] ([**Telephone/Fax (1) 608**]) after discharge from rehab. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**] Completed by:[**2101-6-13**]

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Discharge summary

report

Admission Date: [**2208-4-29**] Discharge Date: [**2208-5-13**] Date of Birth: [**2146-4-3**] Sex: F Service: MEDICINE Allergies: Iodine-Iodine Containing / Lisinopril Attending:[**First Name3 (LF) 3151**] Chief Complaint: Melena Major Surgical or Invasive Procedure: upper endoscopy (EGD) x2 colonoscopy video capsule endoscopy History of Present Illness: 62 yo F h/o CAD s/p CABG x3 ([**2195**]), DESx3 to RCA ([**2199**]), and DES to RPDL and PDL ([**2-8**]) on [**Month/Year (2) **] + [**Month/Year (2) **], s/p AVR ([**2195**]) on coumadin, diastolic heart failure p/w substernal chest pain starting this morning, found to have 11 point HCT drop, guaiac positive dark stool, and inferior ST changes on EKG. . Patient was in her usual state of health until one week ago, when she noted increased weakness and dyspnea on exertion (no PND or orthopnea). Three days ago, she woke up around 3:00 AM with substernal CP consistent with her typical anginal systems. She took 1 NTG and pain resolved. Yesterday morning, she woke with the same pain, this time also noticed new weakness and dyspnea on exertion. She took 2 NTG and 1 [**Year (4 digits) **] 325mg and pain resolved. This morning, she awoke with severe [**9-7**] substernal CP radiating to arm and jaw. Pain was unremitting and worsened greatly on exertion. She also had one dark stool this AM (has been on iron pills for past week), unsure if tarry or foul smelling. Endorsed nausea, but no vomiting or hematemesis, no gross BRBPR. Over course of the AM she took 6 NTG and 4 325mg [**Month/Year (2) **] pills, with improvement in pain to [**1-8**]. She called her son who drove her to [**Name (NI) **]. . In the ED, initial SBP was 88. Vital signs checked subsequently were Pulse: 102, RR: 20, BP: 134/63, O2Sat: 100% 2L NC (98% RA). Labs were significant for hematocrit of 18.6 from baseline 29.5. INR was 4.6. White blood cell count was 10.7K. Potassium was 3.2. Anion gap was 16. Creatinine was 1.3 and is at baseline. Troponin was <0.01. She received IV morphine 5 mg x 1. ECG showed inferior ST depressions. Cardiology was consulted and recommended no acute intervention. Patient was going to be started on IV heparin with bolus, but then rectal exam showed guaiac positive dark stool. Two PIVs were placed, she was given pantoprazole 40mg IV x1, 2 units pRBC ordered (not given), and she was transported to MICU for treatment of suspected UGIB. . On arrival to the MICU, patient is hemodynamically stable. Her chest pain is improved since morphine, now [**3-8**]. Denies dyspnea, nausea, abdominal pain. Past Medical History: 1. CAD, status post CABG in [**2195**] (LIMA to LAD, SVG to OM), DES x4 to RCA ([**2199**]), DES to RPDL and PDL ([**2-8**]) on [**Month/Year (2) **] + [**Month/Year (2) **] 2. Aortic valve replacement in [**2195**] with mitral valve ring annuloplasty, on Coumadin 3. Diastolic heart failure with LVEF of 55%. 4. H/O GI bleed, normal EGD/capsule endoscopy/[**Last Name (un) **] 4. Hypertension. 5. Hyperlipidemia. 6. Hypothyroidism secondary to iodine treatment for Graves' disease in the 80s. 7. Depression with psychosis, bipolar disorder. 8. Lupus. 9. PTSD. 10. COPD. 11. T9-T10 disc herniation with chronic pain. 12. Sleep apnea, not on CPAP. 13. Chronic kidney disease. Social History: Lives with her daughter since starting anticoagulation, because needs increased care due to fall risk. Smokes 1 PPD. Denies EtOH or illicits. Family History: Mother with MI. Hypertension, migraines, breast cancer in other relatives. Sister with MI, "enlarged heart" at 42, fatal. Father still alive at 90. Physical Exam: Admission Exam: Vitals: 97.9 117/59 73 21 100% RA General: obese AAF in NAD, AAOx3, talking comfortably HEENT: pale conjunctivae, sclera anicteric, MMM, OP clear, PERRL Neck: no JVD Cardiac: RRR, S1 S2, mechanical murmur heard loudest over LLSB, SEM heard throughout precordium Lungs: CTAB no crackles/wheezes/rhonchi [**Last Name (un) **]: soft, obese, mildly TTP in RUQ, NABS, no organomegaly Extrem: WWP, DP/PT 2+, no C/C/E Neuro: CN II-XII grossly intact, normal strength Discharge Exam: VS: 98.5 122/70 68 20 100%RA 86.6 kg Essentially unchanged, no tenderness to palpation on abdomen. Pertinent Results: EKG: new ~1mm ST depressions in II, aVF, V4, V5, V6 compared with EKG from [**2208-2-19**] Admission labs: [**2208-4-29**] 02:00PM WBC-10.7# RBC-1.97*# HGB-5.1*# HCT-18.6*# MCV-94 MCH-25.9* MCHC-27.5* RDW-20.8* [**2208-4-29**] 02:00PM NEUTS-80.4* LYMPHS-14.0* MONOS-4.0 EOS-1.1 BASOS-0.4 [**2208-4-29**] 02:00PM PLT COUNT-279 [**2208-4-29**] 02:00PM PT-46.9* PTT-39.8* INR(PT)-4.6* [**2208-4-29**] 02:00PM ALT(SGPT)-14 AST(SGOT)-36 LD(LDH)-471* CK(CPK)-103 ALK PHOS-64 TOT BILI-0.1 [**2208-4-29**] 02:00PM cTropnT-<0.01 [**2208-4-29**] 02:00PM CK-MB-1 [**2208-4-29**] 02:00PM HAPTOGLOB-46 Discharge labs: [**2208-5-13**] 06:20AM BLOOD WBC-11.2* RBC-3.66* Hgb-10.1* Hct-32.5* MCV-89 MCH-27.5 MCHC-31.0 RDW-17.0* Plt Ct-343 [**2208-5-13**] 06:20AM BLOOD PT-32.4* PTT-39.8* INR(PT)-3.1* [**2208-5-13**] 06:20AM BLOOD Glucose-113* UreaN-25* Creat-1.4* Na-139 K-4.4 Cl-101 HCO3-27 AnGap-15 Blood counts: [**2208-4-29**] 11:56PM BLOOD WBC-14.2* RBC-2.56*# Hgb-7.1*# Hct-22.3* MCV-87# MCH-27.7 MCHC-31.8# RDW-17.9* Plt Ct-213 [**2208-4-30**] 10:16AM BLOOD WBC-11.6* RBC-3.31*# Hgb-9.4*# Hct-28.6*# MCV-87 MCH-28.5 MCHC-33.0 RDW-17.0* Plt Ct-206 [**2208-4-30**] 03:13PM BLOOD Hct-25.7* [**2208-4-30**] 03:13PM BLOOD WBC-11.9* RBC-3.02* Hgb-8.8* Hct-25.6* MCV-85 MCH-29.0 MCHC-34.2 RDW-17.7* Plt Ct-175 [**2208-4-30**] 06:55PM BLOOD WBC-12.6* RBC-3.00* Hgb-8.4* Hct-25.6* MCV-86 MCH-28.0 MCHC-32.7 RDW-17.3* Plt Ct-211 [**2208-5-1**] 01:09AM BLOOD WBC-11.2* RBC-2.81* Hgb-7.9* Hct-24.3* MCV-87 MCH-28.3 MCHC-32.7 RDW-17.5* Plt Ct-198 [**2208-5-1**] 10:40AM BLOOD Hct-26.5* [**2208-4-29**] CT abdomen/pelvis w/o contrast: IMPRESSION: No evidence of pathology to explain patient's symptoms on this limited non-contrast CT evaluation. AP CXR: FINDINGS: The heart size is mildly enlarged and there is mild pulmonary vascular re-distribution with perihilar haze that is worse when compared to the prior study. There are small bilateral pleural effusions with increased opacity at both bases which likely represents volume loss, although early infiltrate cannot be excluded. The overall impression is that of CHF. RUQ U/S: IMPRESSION: Unremarkable right upper quadrant ultrasound. EGD [**2208-5-2**]: Normal mucosa in the esophagus. Food in the stomach. No stigmata of any recent bleeding in the visualized area of the stomach Normal mucosa in the duodenum. Otherwise normal EGD to third part of the duodenum Colonoscopy [**2208-5-3**]: Polyps in the sigmoid colon and rectum. (No biopsies taken). EGD [**2208-5-3**]: Esophagus: Normal esophagus. Stomach: Normal stomach. Duodenum: Normal duodenum Video capsule study [**2208-5-4**]: 1. Two lymphangiectasias in the middle of small bowel. 2. No active bleeding was seen in the small bowel. 3. Sub-optimal bowel prep in the proximal and distal small bowel Brief Hospital Course: TRANSITIONAL ISSUES: [ ] INR CHECKS, pt has VNA following and will be checking INR on [**5-14**] and [**5-15**]. [ ] Isosorbide and Olmesartan held on discharge, will need to be restarted when pt's BP is improved [ ] monitor BUN/creatinine ================================ 62 yo F h/o CAD s/p CABG x3 ([**2195**]), DESx3 to RCA ([**2199**]), and DES to RPDL and PDL ([**2-8**]) on [**Month/Year (2) **] + [**Month/Year (2) **], s/p AVR ([**2195**]) on coumadin, diastolic heart failure p/w substernal chest pain starting this morning, found to have 11 point HCT drop, guaiac positive dark stool, and inferior ST changes on EKG. Her supratherapeutic INR of 4.2 was reversed with FFP and she was given 6 units of pRBCs total during this hospitalization. No source of bleeding was found but patient's HCT was stabilized so her coumadin was restarted. She was discharged when her coumadin was therapeutic. # ACUTE ON CHRONIC ANEMIA FROM BLOOD LOSS: On admission, patient reported one week of increased weakness and DOE, and increasing chest pain (anginal equivalent) x3 days. Reported dark guaiac positive stool, and had an 11 pt HCT drop over past month. Main concern was for UGIB, particularly in setting of Warfarin (INR 4.6), [**Year (4 digits) **], and [**Year (4 digits) **]. LGIB seemed less likely. Also given high INR and reported recent falls at home, an RP bleed was considered, but CT abdomen was negative. Her chest pain was likely demand ischemia in setting of blood loss. She remained hemodynamically stable. She was seen by gastroenterology who opted for non-urgent endoscopy. She was given pantoprazole 80mg bolus, plus 8mg/hr drip. Had 2 peripheral IVs. Ended up with total transfusion of 6 units PRBCs and 2 units FFP, with INR afterwards down to 2.2. She was bridged with IV heparin and her EGD/colonoscopy/video capsule did not show source of bleeding. Her GI bleed was thought to be due to supratherapeutic INR in setting of multiple other anticoagulations. She will need a close follow up for her HCT and INR. # CHEST PAIN: New ST depressions slightly <1mm noted in inferior and lateral leads on EKG. Trop <0.01. This is most likely demand ischemia in setting of significant blood loss. No need to give heparin now. Troponins remained negative. # S/P MECHANICAL AVR: on Warfarin at home, INR 4.6 on admission. Per GI recs, gave 2 units FFP to reduce risk of bleeding. She was started on heparin gtt bridge when patient stabilized and restarted on coumadin after EGD/colonoscopy/video capsule study did not reveal a source of active bleed. # CAD S/P CABG and DES: Continued home [**Year (4 digits) **], [**Year (4 digits) 4532**] and atorvastatin given recent stenting. Her metoprolol, [**Last Name (un) **] and isosorbide mononitrate were initially held. Her metoprolol was restarted when patient stabilized, but [**Last Name (un) **] and isosorbide was held on discharge given patient's normal BP. It will need to be restarted as an outpatient. # CHRONIC DIASTOLIC CHF: EF>55%. The day after admisssion her home furosemide 60mg PO was restarted and patient remained euvolemic. CHRONIC ISSUES: # COPD: Continued home albuterol and tiotropium # DEPRESSION: Continued home lorazepam, sertraline, seroquel # CHRONIC BACK PAIN: continued on acetaminophen, cyclobenzaprine # MIGRAINE: patient with intermittent headaches during this hospitalization, resolved with acetaminophen/oxycodone prn. # HYPOTHYROIDISM: continued home levothyroxine Medications on Admission: -Albuterol 0.083% neb q4 hrs PRN wheezing -Albuterol inhaler q6 hrs PRN wheezing/dyspnea -Atorvastatin 80mg PO daily -[**Last Name (un) **] 325mg PO daily -Citalopram 10mg PO daily -Clonazepam 1mg PO TID -Clopidogrel 75mg PO daily -Cyclobenzaprine 5mg PO daily PRN muscle pain -Advair 100mcg-50mcg diskus 1 puff [**Hospital1 **] PRN -Folic acid 1mg PO daily -Lasix 60mg PO daily -Gabapentin 100mg PO TID -Hydrocodone-acetaminophen 7.5mg/750mg tab PO BID PRN pain -Isosorbide mononitrate ER 60mg PO daily -Lamotrigine 150mg PO daily -Levothyroxine 125mcg PO daily -Lidocaine 5% patch daily (12 hrs on, 12 hrs off) -Metoprolol succinate 100mg PO daily -Nitroglycerin 0.3 tab PRN -Olmesartan (Benicar) 5mg PO daily -Omeprazole EC 20mg daily -Potassium chloride 10mEq tab PO daily -Seroquel 50-75mg PO qHS -Ranitidine 150mg PO BID -Sertraline 50mg PO qAM -Tiotropium bromide 18mcg capsule 1 inh daily -Warfarin 2mg 4x/week, 3mg 3x/week -Bisacodyl 10mg qHS PRN constipation -Calcium + D -docusate 100mg PO BID Discharge Medications: 1. Atorvastatin 80 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Clonazepam 1 mg PO TID 4. Clopidogrel 75 mg PO DAILY 5. Cyclobenzaprine 5 mg PO HS:PRN muscle spasm 6. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **] 7. FoLIC Acid 1 mg PO DAILY 8. Furosemide 60 mg PO DAILY hold for SBP <100 9. Gabapentin 100 mg PO TID 10. LaMOTrigine 150 mg PO DAILY 11. Levothyroxine Sodium 125 mcg PO DAILY 12. Lidocaine 5% Patch 1 PTCH TD DAILY apply to back, leave on for 12 hours and leave off for 12 hours. 13. Metoprolol Succinate XL 100 mg PO DAILY 14. Nitroglycerin SL 0.3 mg SL PRN chest pain If you have chest pain that needs to be improved by [**Known lastname 97713**]. 15. Docusate Sodium 100 mg PO BID 16. Polyethylene Glycol 17 g PO DAILY:PRN constipation RX *Miralax 17 gram daily Disp #*30 Packet Refills:*0 17. Senna 1 TAB PO BID:PRN constipation RX *Natural Senna Laxative 8.6 mg twice a day Disp #*60 Tablet Refills:*0 18. Sertraline 50 mg PO DAILY 19. Quetiapine Fumarate 50-75 mg PO HS 20. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg daily in the morning Disp #*30 Tablet Refills:*0 21. Tiotropium Bromide 1 CAP IH DAILY 22. Warfarin 3 mg PO DAILY16 RX *Coumadin 1 mg daily Disp #*90 Tablet Refills:*0 23. Outpatient Lab Work CBC and INR check on [**2208-5-14**]. Please call the [**Company 191**] number ([**Telephone/Fax (1) 2010**]) and ask to speak with the doctor on call. Please do INR check on [**2208-5-17**] and [**2208-5-19**] and send the result to [**Hospital 191**] [**Hospital3 **] at phone [**Telephone/Fax (1) 2173**], fax [**Telephone/Fax (1) 3534**]. ICD-9: 996.02 24. Hydrocodone-Acetaminophen (5mg-500mg 1 TAB PO BID:PRN pain do not drink alcohol, drive or require anything that requires you to be alert while taking this medication as it can make you drowsy. 25. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing Discharge Disposition: Home With Service Facility: [**Hospital3 **] Discharge Diagnosis: Primary Diagnosis: gastrointestinal bleeding, mechanical valve replacement on coumadin, diastolic heart failure Secondary Diagnosis: hypertension, coronary artery disease s/p CABG and DES, hypothyroidism, depression/bipolar disease, chronic obstructive pulmonary disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge weight 86.6 kg Discharge Instructions: Dear Mrs. [**Known lastname 97713**], You were admitted to the hospital due to bleeding from your gastrointestinal tract, and acute anemia (low red blood cell count). You had chest pain when you first came in, but your blood tests were negative for cardiac enzyme (marker of damage to your heart). You were given blood transfusions, and also blood products to lower your INR, which was high when you came in. You had colonoscopy, upper endoscopy and capsule endoscopy done which did not show the source of bleeding. However, your bleeding stopped and your red blood cell count remained stable. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. These CHANGES were made to your medications: - STOP imdur (isosorbide mononitrate) and olmesartan for now as your blood pressure were ok. Please discuss restarting this medication with Dr. [**Last Name (STitle) 665**] and Dr. [**First Name (STitle) 437**]. - STOP potassium - STOP zantac (ranitidine) - HOLD coumadin for [**2208-5-13**], then you can follow instructions from [**Company 191**] anticoagulation (coumadin) clinic. - CHANGE aspirin to 81 mg daily - CHANGE prilosec (omeprazole) to protonix (pantoprazole) to protect your stomach START protonix 40 mg daily to protect your stomach START senna twice a day as needed for constipation START miralax daily as needed for constipation Followup Instructions: Department: [**Hospital3 249**] When: [**Hospital3 **] [**2208-5-16**] at 10:20 AM With: [**Name6 (MD) 10160**] [**Name8 (MD) 10161**], NP [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HMFP When: THURSDAY [**2208-5-19**] at 9:00 AM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 15631**], 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: CARDIAC SERVICES When: [**Location (un) **] [**2208-5-23**] at 9:30 AM With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: TUESDAY [**2208-6-21**] at 12:20 PM With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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Discharge summary

report

Admission Date: [**2169-12-2**] Discharge Date: [**2170-1-25**] Date of Birth: [**2116-11-24**] Sex: M Service: MEDICINE Allergies: Lithium Attending:[**First Name3 (LF) 896**] Chief Complaint: Mania Major Surgical or Invasive Procedure: G tube placement [**2169-12-8**] and [**2169-12-22**] History of Present Illness: Mr. [**Known lastname 87162**] is a 53 year old man with a complicated history of severe bipolar disorder requiring treatment with lithium for many years who had a prolonged admission in [**9-/2169**] for anaplasmosis and lithium toxicity, culminating in severe dysphagia (attributed to lithium toxicity) requiring G-tube placement, now admitted for agitation, combativeness at [**Hospital 7137**]. He was recently admitted for G-tube falling out, and anemia to 25 from baseline of 30s, and discharged on [**2169-11-24**]. Because of his lithium toxicity, lithium was discontinued and prolixin was substituted for his bipolar management. His anemia was felt to be secondary to anemia of chronic disease versus iron deficiency anemia and an outpatient EGD/[**Last Name (un) **] was suggested upon discharge. . Since discharge, discussions with [**Hospital3 2558**] staff revealed an increasingly combative patient who would frequently elope the grounds, spit, bite, and threaten staff. Per family, over the past 3-4 days, the patient has been increasingly aggressive, unable to sleep, unable to sit still, sneaking food and drink, trying to escape from his floor. The [**Hospital3 2558**] feels that they can no longer house him in his current state, and the family feels they would like him started on a medication and admitted for a few days until he is settled out. Initial VS in the ED: 96.6 94 110/66 20 98%. Patient was given zyprexa 5mg per NG tube for agitation. Psychiatry was consulted who recommended admission to medicine with close f/u given anemia, edema, and CKD. VS prior to transfer: 96.9 87 121/90 18 99%RA. . On the floor, he complains of bilateral leg pain and dyspnea. He became increasingly agitated and code purple was called and the patient was given zyprexa 5 with no effect. Psychiatry was contact[**Name (NI) **] who recommended zyprexa 10mg IM x 1, plus cogentin 1mg IM x 1. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: - Recent admission for anaplasmosis and lithium toxicity (complicated by cereballar ataxia, swallowing dysfunction and dysarthria attributed to the lithium) - Chronic renal failure (stage 3B) - Nephrogenic diabetes insipidus from lithium toxicity - Bipolar disorder - S/p G-tube placement (NPO at baseline) Social History: After illness [**Date range (1) 91082**] he was living longterm at [**Hospital 7137**]. Brother [**Name (NI) **] [**Name (NI) 87162**] is his [**Name (NI) 18297**] and makes medical decisions on his behalf. Worked at Stop and Shop, owned his own home, drove, lived on [**Location (un) **] until Autumn [**2168**] when he developed anaplasmosis c/b lithium toxicity. Previously smoked 2 packs per day for the past 33 years. Has not had a cigarette since illness. No alcohol. Family History: No relevant family history. Physical Exam: ON ADMISSION: Vitals: 97.6 128/71 97 20 98%RA General: Alert, oriented, in mild distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. Patient with 1+ edema on LLE, and trace edema on RLE. ON DISCHARGE: Patient is awake, alert. He follows simple commands, speaks in simple [**11-20**] word responses. Minimal impulsive behavior, able to sit in a chair for an hour at a time. There is a 2-3cm induration in the left groin inguinal region expressing bloody pus, it is nontender, nonerythematous. Pertinent Results: ADMISSION LABS: [**2169-12-2**] 11:30AM BLOOD WBC-6.8 RBC-2.95* Hgb-8.4* Hct-25.2* MCV-85 MCH-28.6 MCHC-33.4 RDW-13.8 Plt Ct-259 [**2169-12-2**] 11:30AM BLOOD Neuts-67.3 Lymphs-23.6 Monos-5.5 Eos-3.4 Baso-0.4 [**2169-12-2**] 11:30AM BLOOD Glucose-95 UreaN-28* Creat-1.8* Na-137 K-4.1 Cl-98 HCO3-28 AnGap-15 Calcium-9.6 Phos-3.7 Mg-2.1 [**2169-12-2**] 11:30AM BLOOD ALT-14 AST-16 LD(LDH)-142 AlkPhos-76 TotBili-0.3 [**2169-12-2**] 11:30AM BLOOD proBNP-412* [**2169-12-3**] 12:08AM BLOOD CK-MB-3 cTropnT-<0.01 [**2169-12-2**] 11:30AM BLOOD Albumin-3.7 Iron-31* [**2169-12-3**] 12:08AM BLOOD [**2169-12-2**] 11:30AM BLOOD calTIBC-254* Ferritn-393 TRF-195* [**2169-12-3**] 12:08AM BLOOD TSH-2.2 [**2169-12-3**] 12:08AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2169-12-3**] 12:08AM BLOOD Lipase-21 DISCHARGE LABS: [**2170-1-22**] 05:40AM BLOOD WBC-6.2 RBC-3.77* Hgb-11.5* Hct-32.4* MCV-86 MCH-30.6 MCHC-35.6* RDW-15.7* Plt Ct-240 [**2170-1-22**] 05:40AM BLOOD Glucose-94 UreaN-62* Creat-1.8* Na-141 K-5.0 Cl-102 HCO3-28 AnGap-16 [**2170-1-22**] 05:40AM BLOOD Mg-2.5 NOTABLE LABS: [**2169-12-2**] 11:30AM BLOOD calTIBC-254* Ferritn-393 TRF-195* [**2169-12-31**] 06:20AM BLOOD Triglyc-420* HDL-31 CHOL/HD-5.5 LDLmeas-87 [**2169-12-13**] 03:40AM BLOOD Ammonia-31 [**2169-12-3**] 12:08AM BLOOD TSH-2.2 [**2169-12-3**] 12:08AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2169-12-13**] 04:25AM BLOOD freeCa-1.24 REPORTS: [**2169-12-2**] Radiology UNILAT LOWER EXT VEINS IMPRESSION: No evidence of deep venous thrombosis in the left lower extremity. [**2169-12-3**] Radiology CHEST (PORTABLE AP) FINDINGS: Heart size, mediastinal and hilar contours are normal, and lungs are clear. Percutaneous feeding tube is seen in the upper abdomen. [**2169-12-3**] Cardiovascular ECG [**2169-12-5**] . Sinus tachycardia. Baseline artifact. Otherwise, tracing is probably within normal limits. Compared to the previous tracing of [**2169-10-10**] there is no significant change. [**2169-12-10**] Chest Xray IMPRESSION: AP chest compared to [**12-3**] and 21. Lung volumes are lower today than they were on either [**12-3**] or 21, and interstitial edema which was more evenly distributed on [**12-9**] is now more basal dependent. Nevertheless azygous distention indicates continued elevation of central venous pressure or volume making volume overload and cardiac decompensation the likely explanation. Heart size however is normal. Catheter tubing projecting over the upper midline abdomen is unknown to me but could be a gastrostomy tube. [**2169-12-18**] Chest Xray FINDINGS: Since [**2169-12-10**] mild interstitial edema and azygos distention suggesting volume overload with cardiac decompensation has substantially improved. Heart size is normal. There are no new lung opacities concerning for pneumonia. There is no pleural abnormality. Mediastinal and hilar contours are stable. [**2169-12-19**] Head CT IMPRESSION: No acute intracranial injury. [**2169-12-22**] Chest Xray Compared to the prior study increased lung markings are again seen in both lower lungs that could represent areas of atelectasis or aspiration similar in appearance compared to prior with no new infiltrate. [**2169-12-25**] Chest Xray IMPRESSION: AP chest compared to [**12-22**] and 4: Pulmonary vascular congestion is mild, heart size is normal, mediastinal veins top normal caliber. No pulmonary edema or appreciable pleural effusions. No evidence of pneumonia. VIDEO SWALLOW [**2170-1-18**] In conjunction with speech and swallow pathology, barium of various oral consistencies was administered during fluoroscopic evaluation. Bolus formation and swallow initiation were delayed. Residue remains in the oral cavity, on the tongue, hard and soft palates and in the vallecula and piriform sinuses. Penetration of nectar occurred and aspiration also occurred which was silent. IMPRESSION: 1. Impaired oropharyngeal function. 2. Aspiration and penetration. Brief Hospital Course: HOSPITAL SUMMARY: Mr. [**Known lastname 87162**] is a 53 year old man with a complicated history of bipolar disorder requiring treatment with lithium for many years who had a prolonged admission in [**9-/2169**] for anaplasmosis and lithium toxicity, culminating in severe dysarthria and dysphagia (attributed to lithium toxicity) requiring G-tube placement, now admitted for agitation and combativeness at [**Hospital3 2558**] on [**2169-12-2**]. He was initially medically stable and awaiting placement at a psychiatric inpatient facility. However, his agitation led him to break the tube feed pump, and he was without tube feeds for a few days. His tube feeds were then adjusted to bolus dosing, and his free water flushes were adjusted as well. He had initially received free water flushes of 200cc q4h at [**Hospital3 2558**], and he was switched to free water flushes of 150cc q6h. In this setting, his underlying nephrogenic diabetes insipidus led to rapid hypernatremia and was difficult to correct. On [**2169-12-8**] his agitation led him to pull out his G-tube, which had to be replaced under anaesthesia. While he was in the PACU following the procedure, he becamse hypotensive. He was stabilized in the PACU with fluids, but the following day he developed new oxygen requirement and fever suggestive of a possible aspiration event. He was briefly stabilized in the MICU but was able to be transfered again to the floor. His hospital course by problem is as follows: 1. BIPOLAR with ACUTE MANIA & later ENCEPHALOPATHY: This was thought to be initially secondary to poorly controlled bipolar disease, following discontinuation of lithium in [**Month (only) **]. The cause for his worsening in house was initially unclear, though he had a negative infectious workup. His delirium worsened with the development of severe hypernatremia. Early in his course, he was restrained at the wrists for aggressiveness and agitation. Psychiatry consultation was sought who stopped his fluphenazine and started on Haldol; depakote was later added to this regimen, however his transaminases became elevated and so the depakote was stopped out of concern for liver damage. He was maintained on Haldol 5mg TID. Propranolol 40mg [**Hospital1 **] was started Over the course of his hospitalization, the agitation lessened considerably. However, he continued to try to get out of bed even in a weakened state, leading to several falls with no head trauma. He did manage to remove his G tube twice, and so a rapid-disconnecting adaptor was incorporated with no further issue. The psychiatry service continued to follow him and by the time of discharge they confirmed that there was no need for a psychiatric placement, as the manic episode had resolved. However, as an outpatient he will need to be eventually treated with a longterm mood stabilizer when his delirium improves. There was some discussion amongst specialists about the feasibility of returning to the use of lithium, and this option could be considered by his caregivers in the future. By the end of his hospitalization, he was alert, calm, and able to interact with staff. His speech is dysarthric and difficult to understand, but he can answer questions with 1-2 word responses. He follows simple commands. He was kept in a veiled-in bed during his last week of hospitalization which prevented him from falling out of bed- a product of his earlier agitation and desire to walk. He can sit in a chair for an hour without 1:1 supervision, and his impulsiveness has considerably improved. We cannot anticipate neither the extent nor the pace of his mental recovery- his course is marked by slow and minor improvement over the course of weeks, and while his recovery seems to have slowed during the last week, he may yet clear further. He is being discharged on haldol and propranolol, which have improved his agitation. We tried to taper these doses several times though each attempt led to increased agitation. These doses can be tapered in the future with more consistent clearing of his mental status, at which point he may need a longer term treatment for his bipolar disease. 2. ASPIRATION PNEUMONIA: He had initial dyspnea which seemed secondary to agitation in the setting of acute mania. Work-up for his SOB included CXR, EKG, CK-MB and troponin levels which were all normal. Following anesthesia in the PACU on [**2169-12-8**], he was noted to have new O2 requirement the following day. There was high concern for aspiration given the patient's underlying dysphagia. Broad spectrum antibiotics (vancomycin, Zosyn) were started and completed through [**2169-12-17**]. Mr. [**Known lastname 87162**] had no further episodes of acute dyspnea and he was able to rapidly wean off the oxygen. 3. DIABETES INSIPIDUS/HYPERNATREMIA: He has severe DI from lithium toxicity. Mr. [**Known lastname 87162**] [**Last Name (Titles) 1834**] adjustments to his tube feeds and free water flushes as above in the setting of altered mental status. Chem-7 panel was initially stable. Between [**2169-12-5**] and [**2169-12-7**] his sodium increased from 140 to 165. Free water flushes were increased to his [**Hospital3 2558**] dosing of 200cc Q4H (on which he had been stable previously) and he was started on D5W gtt for correction. However, the following day he pulled out his G-tube and was no longer able to receive enteral free water. This fact combined with increased insensible losses caused his sodium to be slow to correct. G-tube was placed on [**12-8**]. He was slowly repleted with a combination of D5W @200cc/hr and tube flushes per above. Over time we were able to discontinue the D5W and replete his free water solely through the G-tube. His sodium levels have been stable since [**2169-12-20**]. At time of discharge, his free water repletion regimen is 250cc of water via PEG every TWO HOURS. Compliance with this regimen is paramount due to his inability to drink. 4. GROIN ABSCESS: a small 2-3cm area of induration expressing pus was found one week prior to discharge. It is nontender and not red. It has been slowly improving with warm packs applied QID and expression of the pus. 5. ACUTE-ON-CHRONIC RENAL FAILURE: In the setting of hypernatremia and signficant free water deficit, creatinine rose from baseline of ~1.8 to a peak of 3.5. Renal consult was called as above and felt this was likely prerenal in the setting of dehydration from free water losses due to diabetes insipidus. He slowly corrected as he became more euvolemic and hypernatremia/free H20 deficit was corrected. His creatinine improved until it was stable at ~1.6. 6. LEFT LOWER EXTREMITY SWELLING: Mr [**Known lastname 91083**] lower leg sweeling on presentation was most likely due to CRF given the absence of significant warmth or swelling. LENI showed no DVT. The leg swelling resolved entirely during the first several days of this admission. 7. ATYPICAL MOLE: During his hospital stay, a medical student noticed that Mr. [**Known lastname 87162**] had a hyperpigmented nevus on the dorsum of his left foot. The mole is a 4mm, dark brown slightly irregular papule with lightening of color at the edges. Dermatology confirmed that such atypical moles are generally biopsied on an outpatient basis and we strongly recommend that Mr. [**Known lastname 87162**] follow-up as an outpatient to have this mole evaluated by a dermatologist. CHRONIC ISSUES: 1. Anemia: This was most likely due to anemia of chronic disease. His guaic stool test was negative. His anemia was monitored by serial HCTs and his iron supplements were continued. 2. Bipolar disorder: Mr [**Known lastname 87162**] has a long history of bipolar disorder, treated for 33 years with lithium. he was treated at first here with valproate but this had to be discontinued due to elevated LFTs. He was switched to a regimen of standing Haldol, initally Haldol 5mg QID, with PRN doses available. He stabilized eventually on a regimen of Haldol 5mg TID, with no need for PRNs. He was also started on Propranolol for anxiety, and is doing well on 40mg daily. His manic episode resolved early in the hospitalization and per the psychiatry team, he does not need psych placement. He will need a longterm mood stabilizer in the future. PENDING TESTS AT DISCHARGE: NONE TRANSITIONAL ISSUES: - Mr. [**Known lastname 87162**] should follow-up as an outpatient with [**Hospital 2652**] Clinic concerning the mole on his left foot. This is an atypical mole and it should be biopsied. - Brother [**Name (NI) **] [**Name (NI) 87162**] is an alternate [**Name (NI) 18297**] as well as alternate HCP, and as he lives closer prefers to be the first called in the care of his brother. [**Name (NI) **]/HCP is brother [**Name (NI) **] [**Name (NI) 87162**] (H:[**Telephone/Fax (1) 91080**]; C:[**Telephone/Fax (1) 91081**]). Alternative contact is sister-in-law [**Name (NI) 5969**] [**Name (NI) 87162**] (H: [**Telephone/Fax (1) 91080**]) or brother Dr. [**First Name4 (NamePattern1) **] [**Known lastname 87162**] (H:[**Telephone/Fax (1) 91084**]; C:[**Telephone/Fax (1) 91085**]). - Patient was full code during this admission (confirmed with his guardians). - tapering of haldol/propranolol eventually Medications on Admission: 1. fluphenazine HCl 2.5 mg/5 mL Elixir Sig: Two (2) mg PO once a day. 2. ergocalciferol (vitamin D2) 8,000 unit/mL Drops Sig: Six (6) ml PO once a week: On thursdays x 6 weeks. 3. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**4-27**] hours as needed for pain. 5. benztropine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day: Dose 20 mg/day; formulation must be compatible with G-tube. Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 3. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 4. haloperidol 5 mg Tablet Sig: One (1) Tablet PO three times a day. 5. propranolol 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily) as needed for constipation. 7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Primary diagnoses: - Acute mania - Agitation/delerium Secondary diagnoses: - bipolar disorder - Fungal infection of the foot - Anemia - Diabetes insipidus from lithium toxicity Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear [**Known firstname 140**], It was a pleasure to take care of you here at [**Hospital1 18**]. You have had a difficult hospitalization, but have done well and slowly recovered. You were admitted for acute mania. We did extensive testing, including EKGs, x-rays, urine analysis, blood work which did not reveal a medical cause of your acute mania. You had a poor effect from a previous medication called lithium, which led to a severe sodium abnormality. Such levels of sodium possibly damaged your brain, causing a prolonged state of confusion that has slowly improved. During this time, you often needed to be physically restrained in order to keep you safe and to allow us to give you proper treatment. Twice, in your agitation, you pulled out your feeding tube, which had to be replaced in the operating room. We worked hard to balance your sodium levels by using IV fluids and water flushes through your feeding tube, in the hopes that the delerium would clear. We also treated your bipolar disorder and agitation with valproate, which unfortunately we could not continue because it started to affect your liver. We switched to Haldol, which you did very well on. You slowly began to come out of the delirium, becoming more aware and alert and interactive each day. The Physical Therapy team worked with you to help you regain your strength and the Speech and Swallow team helped you to work on your swallowing muscles and speaking. You will need to continue to work with therapists for speech and swallowing after your discharge. Multiple changes were made to your medication list -start haldol -start propranolol -stop all previous psychiatric medications inclusind fluphenazine, lithium, benztropine You have several follow-up appointments as listed below. Followup Instructions: Department: WEST [**Hospital 2002**] CLINIC When: THURSDAY [**2170-2-22**] at 2:00 PM With: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: DERMATOLOGY When: TUESDAY [**2170-3-20**] at 2:15 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8157**], M.D. [**Telephone/Fax (1) 1971**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "97.02", "96.6" ]

icd9pcs

[ [ [] ] ]

19059, 19129

8451, 15858

274, 329

19351, 19351

4418, 4418

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3502, 3531

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3010, 3486

81,662

184,911

9603

Discharge summary

report

Admission Date: [**2108-8-4**] Discharge Date: [**2108-8-5**] Date of Birth: [**2063-4-22**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5608**] Chief Complaint: tranfer to MICU for overdose, somnolence Major Surgical or Invasive Procedure: none History of Present Illness: 45 yo F physician admitted to [**Name9 (PRE) **] 4 for overdose on [**2108-8-3**]. Transferred to the MICU for overdose while in the psych [**Hospital1 **]. Patient was intially BIBA after and episode of LOC at a grocery store. No head trauma. Did not require intubation. She denies any intentional overdose but unable to explain why she took the pills. Recently started seeing a new psychiatrist Dr. [**Last Name (STitle) 10166**] three weeks ago. Husband states that he was gone all weekend to a wedding and left the patient at home. She is on seroquel, zoloft, wellbutrin. Also recently prescribed neurontin by her psychiatrist. Per report, she states she saw a friend, went to an AA meeting, but was unable to clearly articulate what she did that weekend. Husband found [**Name2 (NI) 32549**] looking for medications and for suicide. The patient in the ED reportedly had pills as follows -- 3 different types of pills; 90 pills of carisoprodol (Soma) 350 mg, 16 pills of phentermine HCL 37.5 mg, and 36 pills of Ativan 2 mg or Wellbutrin or Iprindole or Promazine. Some of the pills were ordered from [**Country 11150**]/[**Location (un) 32550**]. . The evening of transfer, the patient was noted to be alert and interactive in the guest room in [**Hospital1 **] 4. Later that evening, she was found unresponsive in her room. A code blue was called at 5:44 PM -- patient never lost a pulse or blood pressure. VS at the time of the code were significant for a BP of 130/80 RR of 12 satting 100% on RA and later 100% also on a NRB. FS was 115. Neuro exam was significant for dilated pupils that were even and reactive to light, and hyperreflexic patellar reflexes ([**2-16**]+) with clonus bilaterally. Narcan 0.5 mg IV x1 was given without minimal response. Pt was transferred to the ICU for monitering of respiratory status. . On the floor, patient remained lethargic but pulled out the IV placed during the code. She was noted to have 15 pills of the adipex left, 21 of the 'ativan pills left, and 68 of the 'soma' pills left. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Depression (recent hospitalization at [**Hospital3 **] Psychiatry Unit in [**7-/2108**]) Anxiety Chronic EtOH Dependence Benzodiazepine Dependence (abuse of Ativan in the past) Social History: ob/gyn physician at [**Hospital1 **]. married with 2 kits - Tobacco: unknown - Alcohol: previous hx of EtOH dependence - Illicits: unknown; Family History: unknown Physical Exam: General: lethargic F HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: dilated pupils, reactive BL; opening eyes briefly to command then closing them. [**2-16**]+ patellar reflexes; +clonus. Exam at discharge: 112/74 88 98% RA A and O x 3 HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: dilated pupils, reactive BL. 2+ reflexes. no asterixis Pertinent Results: [**2108-8-3**] 11:15AM URINE RBC-[**11-3**]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2108-8-3**] 11:15AM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2108-8-3**] 11:15AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006 [**2108-8-3**] 11:15AM URINE GR HOLD-HOLD [**2108-8-3**] 11:15AM URINE HOURS-RANDOM [**2108-8-4**] 06:44PM PT-12.4 PTT-25.7 INR(PT)-1.0 [**2108-8-4**] 06:44PM PLT COUNT-295 [**2108-8-4**] 06:44PM WBC-5.9 RBC-4.49 HGB-12.3 HCT-36.9 MCV-82 MCH-27.5 MCHC-33.5 RDW-13.1 [**2108-8-4**] 06:44PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2108-8-4**] 06:44PM ALBUMIN-4.1 CALCIUM-8.9 PHOSPHATE-3.3 MAGNESIUM-1.9 [**2108-8-4**] 06:44PM ALT(SGPT)-30 AST(SGOT)-61* LD(LDH)-478* ALK PHOS-83 TOT BILI-0.4 [**2108-8-4**] 06:44PM GLUCOSE-94 UREA N-17 CREAT-0.7 SODIUM-130* POTASSIUM-5.2* CHLORIDE-96 TOTAL CO2-27 ANION GAP-12 [**2108-8-4**] 08:54PM URINE HYALINE-0-2 [**2108-8-4**] 08:54PM URINE RBC-[**2-17**]* WBC-[**5-24**]* BACTERIA-MOD YEAST-NONE EPI-[**11-3**] [**2108-8-4**] 08:54PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [**2108-8-4**] 08:54PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021 [**2108-8-4**] 08:54PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2108-8-4**] 08:54PM URINE HOURS-RANDOM Labs at discharge: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 4.4 4.62 12.7 38.0 82 27.5 33.4 13.1 283 Glucose UreaN Creat Na K Cl HCO3 AnGap 146 10 0.7 139 4.2 107 23 13 ASA Ethanol Acetmnp Bnzodzp Barbitr Tricycl NEG NEG1 NEG NEG NEG NEG2 Images: Head CT: [**8-2**] - FINDINGS: There is no acute major vascular territory infarction, acute foci of hemorrhage, shift of normally midline structures, discrete masses, mass effect, or brain edema. Ventricles and sulci appear normal in size and configuration. Bilateral mastoid air cells appear clear. Visualized osseous structures are unremarkable. . IMPRESSION: No acute intracranial pathology. . CXR ([**8-2**]): FINDINGS: There may be streaky densities within the retrocardiac left lower lobe, possibly representing atelectasis. No consolidation or edema is evident. The mediastinum is unremarkable. The cardiac silhouette is within normal limits for size. No effusion or pneumothorax is noted. No displaced fractures are evident. Brief Hospital Course: 45 yo F with depression, anxiety, polysubstance abuse transferred from psychiatry service to MICU for possible overdose in-house. . # Overdose: Patient took possibly 3 different types of pills that remained with her even after admission from the ED. Possible pills taken include phenteramine (1 pill), soma (90-68), and possibly ativan/wellbutrin/phenothiazine (TCA) (36 -21). Known ativan abuser in the past. Patient does not have capacity to leave hospital given second possible overdose in the past three days. Per toxicology, main treatment will be benzodiazepines and monitoring of respiratory status. Per possible overdose pill: Some leads to obtundation, and myoclonic jerks, and treatment is to watch respiratory status, benzodiazapien withdrawal with ativan. Adipex may lead to agitation, may treat with benzos as needed. Wellbutrin lowers seizure threshold and has serotonin like activity, but toxicology would not treat currently for serotonin like activity and recommended benzodiazapines as well. Following transfer to ICU, continued 1:1 sitter with suicide precautions. Toxicology was consulted and recommended supportive measures and deferring flumazenil. Patient was placed on CIWA scale with ativan, and did not require any benzodiazepines. She received maintenance IVF overnight. Report was sent regarding patient's retention of pills, and pharmacy still needs to help identify pills. The day after her episode of somnolence, the patient was alert and oriented x 3 and was no longer somnolent. She continued to endorse active suicidal ideation. She required no additional medical support, improved, and was discharged on [**2108-8-5**] to be transferred back to the inpatient psychiatry unit for continued management of her active suicidality. Gabapentin was started per psychiatry prior to her transfer. . # Depression: Hold wellbutrin and zoloft and neurontin for now. . # FEN: IVFs, regular diet, replete electrolytes # Prophylaxis: ambulatory # Access: peripherals # Communication: Patient/Husband # Code: Full (discussed with patient) Medications on Admission: Home Medications: Neurontin 200 mg PO TID Sertraline 50 PO BID Wellbutrin 50 mg PO BID . Also found pills for Carisoprodol 350 mg, Phentermine (Adipex) 37.5 mg, and Ativan 2 mg vs Wellbutrin. . Medications on Transfer: Sertraline 50 mg PO BID Wellbutrin 50 mg PO BID Acetaminophen 650 mg PO Q4H:PRN pain Milk of Magnesia 30 ml PO Q8H:PRN constipation Aluminum-Magnesium Hydrox.-Simethicone 30 ml PO Q4H:PRN indigestion Diazepam 10 mg PO/NG Q4H:PRN CIWA>10 planted PPD on [**Hospital1 **] 4 Discharge Medications: 1. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day for 2 days. Discharge Disposition: Extended Care Discharge Diagnosis: Primary Diagnosis: Somnolence Depression with active suicidal ideation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the ICU from the inpatient psychiatric facility following an episode of somnolence. You were monitored overnight in the ICU, and did not require any medical intervention. You were monitored for 24 hours, with improvement in your mental status noted during that time. You were then discharged from the ICU on [**2108-8-5**] and transferred back to the inpatient psychiatry unit for continued management of your depression. Followup Instructions: continued care in inpatient psychiatry unit

[ "300.4", "303.93", "E980.9", "304.61", "V62.84", "989.9", "780.09" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9703, 9718

6917, 8988

354, 360

9833, 9833

4385, 5862

10454, 10501

3262, 3271

9528, 9680

9739, 9739

9014, 9014

9984, 10431

3286, 3848

9032, 9208

3862, 4366

2441, 2888

274, 316

5881, 6154

388, 2422

6163, 6894

9758, 9812

9848, 9960

9233, 9505

2910, 3088

3105, 3246

13,251

194,852

7685+7686+55865

Discharge summary

report+report+addendum

Admission Date: [**2126-7-8**] Discharge Date: [**2126-7-21**] Service: CHIEF COMPLAINT: DKA with rule out MI. HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old female with past medical history significant for hypertension, hypothyroidism, CVA, insulin dependent diabetes mellitus and abnormal EKG findings. The patient stated that earlier on [**7-8**] she had nausea, vomiting with coffee ground emesis and an unwitnessed fall. EMS was called to her house and she was noted to be confused and had a fasting blood sugar of 480. The patient was given insulin and taken to [**Hospital3 27946**]. In the Emergency Room the patient had a positive EKG with significant/diffuse ST depression. The patient was treated for the DKA and started on Nitro drip. After stabilization the patient was transferred to the MICU at [**Hospital1 69**]. PAST MEDICAL HISTORY: Diabetes mellitus, diagnosed at age 25, history of DKA in [**2117**] and [**2123**] DR. [**Last Name (STitle) **] Dictated By:[**Last Name (NamePattern1) 27947**] MEDQUIST36 D: [**2126-7-19**] 23:00 T: [**2126-7-20**] 07:23 JOB#: [**Job Number 10650**] Admission Date: [**2126-7-8**] Discharge Date: [**2126-7-22**] Service: CT SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 77 year old female with a past medical history significant for hypertension, hypothyroidism, cerebrovascular accident, insulin dependent diabetes mellitus, transferred from [**Hospital3 27946**] Hospital for evaluation of diabetic ketoacidosis and abnormal electrocardiogram findings. The patient in the morning of [**2126-7-9**], had nausea and vomiting and coffee ground emesis. The patient also had an unwitnessed fall and was transported by EMS to the local Emergency Department. The patient's blood sugar was 480 at the time. The patient was then transferred to [**Hospital1 346**] for evaluation for diabetic ketoacidosis and rule out myocardial infarction. PAST MEDICAL HISTORY: 1. Diabetes mellitus diagnosed twenty-five years ago. 2. History of cerebrovascular accident with transient aphasia which resolved [**5-/2124**]. 3. Hypertension. 4. Hypothyroidism. 5. Coronary artery disease with myocardial infarction in 12/99, status post percutaneous transluminal coronary angioplasty with stent to left circumflex for 90% lesion. Last echocardiogram with an ejection fraction of 45%. MEDICATIONS ON ADMISSION: 1. Synthroid 100 mcg q.d. 2. Aspirin 325 mg q.d. 3. Fosamax 10 mg p.o. q.d. 4. Multivitamins p.o. q.d. 5. Insulin 50/50 18 units q.a.m. and 8 units q.p.m. 6. Lopressor 25 mg p.o. t.i.d. 7. Sliding scale insulin. PHYSICAL EXAMINATION: On admission, the patient was alert, not oriented and agitated. Head, eyes, ears, nose and throat - the pupils are equal, round, and reactive to light and accommodation. No jugular venous distention. Pulmonary clear to auscultation bilaterally. Cardiovascular was regular rate and rhythm, no murmurs or rubs. Abdomen - tenderness to palpation in the left lower quadrant, positive bowel sounds, no guarding or rebound. Extremities no peripheral edema, no varicosities. Neurologic - moving all extremities spontaneously. Cranial nerves II through XII are intact. Strength was [**4-13**]. LABORATORY DATA: White blood cell count 14.9, hemoglobin 9.7, hematocrit 31.0, platelets 121,000. Prothrombin time 12.1, INR 1.0, partial thromboplastin time 19.6. The patient's initial glucose at that time was 70, blood urea nitrogen 23, creatinine 0.8, sodium 148, potassium 3.9, chloride 114, CO2 22. The patient's initial Electrocardiogram showed normal sinus rhythm at 94 with 1.[**Street Address(2) 27948**] depression V2 through V5. HOSPITAL COURSE: The patient was admitted on [**2126-7-9**], to the Pulmonary and Critical Care Medicine service. The patient was noted to have three vessel coronary artery disease. The patient continued to be treated in the Coronary Intensive Care Unit. On [**2126-7-16**], the patient was transported to the operating room with initial diagnosis of coronary artery disease with three vessel disease with pancreatitis. The patient had a coronary artery bypass graft times three with saphenous vein graft to left anterior descending, OM1 and right posterior descending artery. The patient tolerated the procedure well and was transported to the Post Anesthesia Care Unit in stable condition. On postoperative day one, the patient did well in the Intensive Care Unit and was transferred to the floor. On postoperative day two, the patient's blood sugar had increased to over 450 and she was started on insulin sliding scale. At that point, [**Last Name (un) **] was consulted and the blood sugar continued to be difficult to control and the patient was transferred to the Intensive Care Unit for closer management. On postoperative day three, the patient was stabilized with blood sugar and transferred back to the floor. On postoperative day four, the patient continued to do well after being transferred out and was set up for rehabilitation. Discharge physical examination reveals temperature 98.6, pulse 78, respiratory rate 16, blood pressure 146/66, 98% in room air, positive 3 kilograms. Blood sugar ranged from 103 to 220. Cardiovascular regular rate and rhythm. Lungs were clear to auscultation bilaterally. The abdomen was soft and nontender, nondistended. Extremities negative peripheral edema. Incision was intact, dry and clean. COMPLICATIONS: Hyperglycemia with difficult control requiring an Intensive Care Unit stay and [**Last Name (un) **] consultation. DISCHARGE MEDICATIONS: 1. Lipitor 10 mg p.o. q.h.s. 2. Synthroid 100 mcg p.o. q.d. 3. Insulin sliding scale 150 to 200 - three units, 201-250 six units, 251-300 ten units, greater than 300 twelve units. 4. Lopressor 25 mg p.o. b.i.d. 5. Lasix 20 mg p.o. b.i.d. times seven days. 6. [**Doctor First Name 233**]-Ciel 20 meq p.o. b.i.d. times seven days. 7. Colace 100 mg p.o. b.i.d. 8. Protonix 40 mg p.o. q.d. 9. Aspirin 81 mg p.o. q.d. 10. NPH 8 units subcutaneous q.a.m. and 3 units subcutaneous q.p.m. 11. Tylenol 650 mg p.o. q4-6hours p.r.n. 12. Regular insulin 4 units subcutaneous q.a.m., 3 units subcutaneous q.p.m. 13. Milk of Magnesia 30 cc p.o. q.h.s. 14. Dulcolax one time p.r.n. q.d. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Last Name (NamePattern4) 959**] MEDQUIST36 D: [**2126-7-20**] 14:54 T: [**2126-7-20**] 16:04 JOB#: [**Job Number 27949**] Name: [**Known lastname 4862**], [**Known firstname 565**] Unit No: [**Numeric Identifier 4863**] Admission Date: [**2126-7-8**] Discharge Date: Date of Birth: [**2047-7-7**] Sex: F Service: DISCHARGE CONDITION: Good, stable to rehabilitation PRIMARY DISCHARGE DIAGNOSIS: 1. Coronary artery bypass graft times three SECONDARY DIAGNOSIS: 1. Diabetes mellitus 2. Status post hypertension 3. Hypothyroidism 4. Coronary artery disease FOLLOW UP: With Dr. [**Last Name (STitle) 71**] in three to four weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2727**], M.D. [**MD Number(1) 2728**] Dictated By:[**Last Name (NamePattern1) 4864**] MEDQUIST36 D: [**2126-7-20**] 14:56 T: [**2126-7-20**] 16:15 JOB#: [**Job Number 4865**]

[ "577.0", "410.01", "V45.82", "285.9", "410.71", "250.13", "244.9", "401.9", "414.01" ]

icd9cm

[ [ [] ] ]

[ "88.53", "36.13", "37.22", "39.61", "88.57" ]

icd9pcs

[ [ [] ] ]

6843, 6883

5641, 6821

6904, 6950

2442, 2662

3744, 5618

7082, 7419

2685, 3726

99, 122

1297, 1983

6971, 7070

2005, 2416

42,268

146,373

9458

Discharge summary

report

Admission Date: [**2177-1-17**] Discharge Date: [**2177-1-24**] Date of Birth: [**2102-9-15**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3376**] Chief Complaint: Afib w/ RVR, for amiodarone Major Surgical or Invasive Procedure: Abdominoperineal resection History of Present Illness: 74 yo M with H/o CAD s/p stent, AFib, HTN, hypercholesterolemia, new diagnosis of rectal CA s/p anterior pelvic resection on [**2177-1-17**] converted to open who developed fever to 102 and atrial fibrillation with rapid ventricular rate on POD#1. On the floor, he was treated with 2 doses of 5mg Lopressor which brought his heart rate down from 140s to 120s and dropped his systolic bp to 90s from 120s. He was transferred to the [**Hospital Unit Name 153**] for amiodarone gtt and closer monitoring. Of note, his po home amiodarone dose had been held peri-op and he did receive a dose of cefazolin pre-op. . On arrival to the [**Hospital Unit Name 153**], patient was noted to be febrile to 102 and diaphoretic. Blood and urine cultures were sent. CXR was obtained. EKG showed Afib w/ RVR to 130s. Patient reported [**12-8**] abdominal surgical pain, [**6-7**] with sitting upright. He denies palpitations, chest pain, shortness of breath. He was passing minimal stool through his new LUQ colostomy. . Review of sytems: (+) Per HPI, recent intermittent fevers at home, nasal congestion (-) Denies headache, sinus tenderness, rhinorrhea. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias Past Medical History: AF - not on coumadin at home CAD s/p coronary stent [**2169**], BMS to LAD here at [**Hospital1 18**] Prostate CA s/p XRT hypothyroid HTN Hypercholesterolemia syncope gout Social History: Former pipe smoker for many years, quit 3 years ago. Remote ETOH, quit 23 years ago. NO illicits. Lives at home with his wife, owns his own septic tank business. Family History: NC Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMD, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Irreg, irreg, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Mild-line abdominal incision, b/l lower quadrant laproscopy incisions, RLQ with JP drain, LUQ colostomy, soft, tender diffusely GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2177-1-17**] 08:50AM HCT-35.7* [**2177-1-17**] 09:20AM freeCa-1.18 [**2177-1-17**] 09:20AM HGB-11.8* calcHCT-35 [**2177-1-17**] 09:20AM GLUCOSE-107* LACTATE-1.8 NA+-138 K+-4.1 CL--104 [**2177-1-17**] 09:20AM TYPE-ART PO2-190* PCO2-44 PH-7.40 TOTAL CO2-28 BASE XS-2 INTUBATED-INTUBATED VENT-CONTROLLED [**2177-1-17**] 01:23PM HCT-32.6*# [**2177-1-17**] 01:23PM MAGNESIUM-1.8 [**2177-1-17**] 01:23PM POTASSIUM-4.0 [**2177-1-17**] 11:30PM HCT-33.9* MICRO: [**2177-1-22**] URINE URINE CULTURE-PENDING INPATIENT [**2177-1-22**] SWAB WOUND CULTURE-PRELIMINARY {PSEUDOMONAS AERUGINOSA} INPATIENT: PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. [**2177-1-22**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2177-1-20**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT [**2177-1-20**] URINE URINE CULTURE-FINAL INPATIENT [**2177-1-20**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2177-1-20**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2177-1-19**] URINE URINE CULTURE-FINAL INPATIENT [**2177-1-19**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2177-1-18**] URINE URINE CULTURE-FINAL INPATIENT [**2177-1-18**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2177-1-18**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2177-1-18**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT CXR [**2177-1-19**]: PA AND LATERAL VIEWS. Comparison with [**2177-1-18**]. Lung volumes are somewhat low. There is streaky density consistent with subsegmental atelectasis, as before. Interstitial markings appear more prominent but this is difficult to assess in the face of low lung volumes. The cardiac silhouette is prominent but may be exaggerated by AP technique. The heart and mediastinal structures are stable in appearance. The bony thorax is grossly intact. IMPRESSION: Increased interstitial markings but may represent pulmonary vascular congestion. No definite focal consolidation. CT HEAD [**2177-1-19**]: 1. No acute intracranial abnormality. 2. Aerosolized secretions in the left maxillary sinus and mucosal thickening in the bilateral ethmoid sinuses. Recommend clinical correlation. MRI/MRA HEAD/NECK [**2177-1-19**]: MRA NECK: Neck MRA demonstrates normal flow in the carotid and vertebral arteries without stenosis or occlusion. IMPRESSION: Normal MRA of the neck. MRA HEAD: Head MRA demonstrates normal flow in the arteries of anterior and posterior circulation. No evidence of vascular occlusion, stenosis, or an aneurysm greater than 3 mm in size are seen. IMPRESSION: Normal MRA of the head. CXR AP [**2177-1-22**]: FINDINGS: As compared to the previous radiograph, there is a minimal increase in density at the right lung base, potentially suggesting increased atelectasis, notably in the light of minimal overall decrease of lung volumes. Otherwise, the radiograph is unchanged. No pulmonary edema. No evidence of infection. Moderate cardiomegaly. No evidence of pleural effusions. ECHO [**2177-1-23**]: The left atrium is moderately dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with normal global and regional biventricular systolic function. No clinically-significant valvular disease seen. Moderate biatrial enlargement. [**2177-1-22**] 6:41 am SWAB Source: sacrum. WOUND CULTURE (Preliminary): PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. Brief Hospital Course: 74M with AFib, CAD s/p LAD stent [**69**], HTN, hyperlipidemia, POD#1 s/p [**Month (only) **] for rectal [**Hospital **] transferred to the MICU for Afib w/ RVR in setting of fever to 102. . # Afib w/ RVR: Patient went into afib w/ RVR likely from fluid shifts post-operatively. He was initially managed amiodarone bolus and gtt. He failed transition to beta blocker and so was re-bolused and placed on a drip. His outpatient cardiologist was contact[**Name (NI) **] who recommended starting: amiodarone 200mg [**Hospital1 **], trial digoxin and diltiazem. Patient remained in and out of a fib and so he was started on a diltiazem gtt. Diltiazem gtt was stopped [**1-22**] and he was maintained successfully on a regimen of amiodarone and dilt po. Coumadin was not started as an inpatient, given he was on asa/Plavix. This can be addressed as an outpatient given his elevated risk for CVA with high Chad2 score. . # AMS: Patient was delirious post-operatively in the ICU. Neurology was consulted, a head CT and MRI was not evident for an acute bleed or CVA. His delirium was likely secondary to medications: Ativan and pain meds. He subsequently improved by holding ativan and titrating down pain regimen. . # Fever: Patient spiked a fever [**1-19**] to 101.6. Patient was pan-cultured. His CXR did not show evidence of infiltrates. He was started empirically on Unasyn, though the surgical wound site looked clear. . # CAD s/p BMS [**2169**] to LAD: Patient was restarted on his asa and Plavix post-operatively. His ace-i was held, but he was restarted on his home statin. . # Hypertension: Controlled w/ pain control. . # Rectal CA s/p [**Month (only) **]: Post-operatively, patient's diet was advanced and was maintained on Reglan. He was pain controlled w/ morphine iv, oxycodone, Tylenol and naproxen. Surgical site remained clear. Patient was transferred to the floor he remained stable in sinus rhythm, no tachycardic. Foley was discontinued at midnight, unfortunately he had large amount of urinary incotinence with post void residuals of 700cc, Foley was replace. Please follow recommendation from PCP for urinary retention. Patient was discharge to rehab with 3 more days of PO antibiotics and recommendation for wound care an ambulation. Patient should follow up with cardiologist and PCP as soon as possible. He should have a follow up appointment with Dr. [**Last Name (STitle) 1120**] within 1 week. Medications on Admission: ASA 81 Plavix 75mg daily Amio 100mg every other day norvasc 2.5mg daily synthroid 75mg daily lipitor 20mg daily lisinopril 20mg daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for Pain for 2 weeks. Disp:*75 Tablet(s)* Refills:*0* 8. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea for 2 weeks. 11. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 3 days. Disp:*9 Tablet(s)* Refills:*0* 12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day. 13. Norvasc 2.5 mg Tablet Sig: One (1) Tablet PO once a day: Hold for SBP < 100. 14. Synthroid 75 mcg Tablet Sig: One (1) Tablet PO once a day. 15. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: Life Care Center [**Hospital3 **] Discharge Diagnosis: Rectal Cancer 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: Abdominal Wound: Clean and dry and intact, staples in place. Sacral wound: Moderate drainage. Change dressing every day Dry gauze Foley. Foley is in place for urinary retention. Please follow PCP recommendations and continue flomax every night. Continue antibiotics for anither week. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**4-7**] 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. Followup Instructions: Dr. [**Last Name (STitle) 1120**] PLease call to confirm your appointment in [**2177-2-5**] ([**Telephone/Fax (1) 3378**] Please follow up with your Cardiologist as soon as possible Completed by:[**2177-1-24**]

[ "349.82", "274.9", "401.9", "E849.7", "244.9", "E937.9", "584.9", "414.01", "V10.46", "458.9", "V64.41", "427.31", "272.4", "V45.82", "154.1" ]

icd9cm

[ [ [] ] ]

[ "48.52" ]

icd9pcs

[ [ [] ] ]

10664, 10724

6684, 9118

342, 371

10782, 10782

2662, 6588

13367, 13581

2148, 2152

9302, 10641

10745, 10761

9144, 9279

10955, 12835

12851, 13344

2167, 2643

275, 304

6617, 6661

1421, 1757

399, 1403

10797, 10931

1779, 1953

1969, 2132

24,581

160,527

5689

Discharge summary

report

Admission Date: [**2103-6-15**] Discharge Date: [**2103-6-18**] Service: NME CHIEF COMPLAINT: Headache and intraventricular hemorrhage. HISTORY OF PRESENT ILLNESS: This is an 81-year-old right- handed man, with a history of dementia, Paroxysmal atrial fibrillation, bradycardia status post pacer, and hypercholesterolemia, who was found by his wife this morning on the floor. He had complained of headache last night for which he got Tylenol and then went to bed. At 9:00 am, he was waking up, but told his wife that he wanted to sleep more, and when she checked on him at 10:00 am, she found him on the floor supine and awake. He could talk and move everything, but initially did not recall how he got to the floor. Later on, he told doctors that [**Name5 (PTitle) **] had fallen. His wife called EMS, and he was brought to [**Hospital 4068**] Hospital, where a noncontrast head CT showed blood in the third, fourth and left lateral ventricle. REVIEW OF SYSTEMS: The patient denies any fever, chills, nausea, vomiting, neck pain, weakness, numbness, tingling, dizziness, visual changes, hearing changes, chest pain, shortness of breath, abdominal pain, dysuria, hematuria or diarrhea, bright red blood per rectum, or bowel/bladder problems. PAST MEDICAL HISTORY: COPD. Paroxysmal atrial fibrillation. Bradycardia, status post pacemaker placement with punctured lung and confusion as complication. Hypercholesterolemia. Dementia. ?Parkinsonism. FAMILY HISTORY: No strokes or bleeds. SOCIAL HISTORY: He is a retired architect who lives with his wife in [**Name (NI) 8**]. He quit smoking in [**2084**], and drinks [**1-5**] alcoholic beverages a day. There is no drug use. MEDICATION AT HOME: 1. Zoloft 75 mg po qd. 2. Lipitor 10 mg po qd. 3. Amiodarone 100 mg po qd. 4. Sinemet 25/100 mg [**Hospital1 **]. 5. Aricept 5 mg po qd. 6. Prilosec 20 mg po qd. 7. Colace 100 mg po bid. 8. Klonopin 0.5 mg po qd. ALLERGIES: None. EXAM ON ADMISSION: The patient was afebrile, with blood pressure 128/78, pulse 80, respiratory rate 10, 96 percent on room air. Generally, this was a pleasant man in no acute distress. Neck was supple without carotid bruits. Heart had a regular rate and rhythm with no murmurs. Lungs were clear to auscultation bilaterally. Abdomen soft, nontender, nondistended. Extremities showed no clubbing, cyanosis or edema. Neurologic examination - the patient was awake and alert, cooperative with exam. He was oriented to person, place and date. He was able to do the month's of the year backward in [**4-9**] minutes. His recall was 0/3 at 1 minute. His language was fluent with good comprehension and repetition. Naming was intact. There was no dysarthria or paraphasic errors. There was no apraxia or neglect. On cranial nerve exam, pupils were equally round and reactive to light, 4-3 mm bilaterally. Visual fields were full to confrontation. Funduscopic exam showed clear optic discs with some diminishing path of the blood vessels into the fundus, suggestive of early papilledema. Extraocular eye movements intact bilaterally without nystagmus. Facial sensation was intact and symmetric. There was a right facial droop. Hearing was intact to finger rub bilaterally. Palatal elevation symmetric. Sternocleidomastoid and trapezius normal bilaterally. Tongue was midline without fasciculations. On motor exam, he had normal bulk and tone bilaterally. He had full power of [**5-9**] throughout with no pronator drift. There was slight cogwheel rigidity in the upper extremity with distraction. On sensory exam, he was intact to light touch, pinprick, cold temperature, vibration and proprioception. On the reflex exam, he was [**2-7**] throughout except at the plantar reflex he was [**1-7**] bilaterally. On coordination, normal finger-nose test. Gait, again, was not assessed. LABS UPON ADMISSION: White count 7.6, hematocrit 44.8, platelet 191, INR 1.2, PTT 26.9, PT 13.5, sodium 144, potassium 4.1, chloride 105, bicarb 30, BUN 13, creatinine 0.7, glucose 102. Urinalysis was negative for any infection. CHEST X-RAY: Showed no infiltrate. NONCONTRAST HEAD CT: Showed worsening blood in the temporal region in the left lateral ventricle, third and fourth ventricle with hydrocephalus of the ventricle except at the fourth ventricle. HOSPITAL COURSE: The patient was admitted initially to the intensive care unit for frequent neurology checks. He had a CTA which showed no evidence of aneurysm. His blood pressure was initially controlled with Lopressor, but later on he did not require any to keep blood pressure less than 140. A repeat noncontrast head CT was performed 1 day later which was found to be stable. He was ruled out for myocardial infarction. It was felt that the patient likely had a traumatic head bleed that neurologically looked quite stable. He is to have a follow-up noncontrast head CT in 1 month, and follow-up within the [**Hospital 878**] Clinic. The patient's Sinemet was held throughout the hospital course, and he did not have any worsened symptoms of parkinsonism, so it was felt that he did not have any parkinson's. It was recommended that Sinemet be discontinued. DISCHARGE DIAGNOSES: Traumatic intraventricular hemorrhage. Paroxysmal atrial fibrillation. Dementia. DISCHARGE MEDICATIONS: Same as admission medication, except for: Sinemet which discontinued. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: To home. FOLLOW UP: The patient is to follow-up with a noncontrast head CT in 1 month. Follow-up with primary care doctor in 1 week. Follow-up with the [**Hospital3 **] [**Hospital 878**] Clinic in [**2103-8-5**]. DR.[**Last Name (STitle) **],[**First Name3 (LF) 4224**] 13-303 Dictated By:[**Last Name (NamePattern1) 11265**] MEDQUIST36 D: [**2103-6-18**] 14:42:56 T: [**2103-6-18**] 15:59:44 Job#: [**Job Number 22722**]

[ "294.8", "272.0", "427.31", "853.01", "332.0", "331.4", "V45.01", "E884.4", "496" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5416, 5454

1487, 1510

5215, 5299

5323, 5394

4340, 5193

5466, 5899

986, 1265

107, 150

179, 966

4149, 4322

3882, 4139

1288, 1470

1527, 1962

64,906

191,071

35775

Discharge summary

report

Admission Date: [**2133-12-8**] Discharge Date: [**2133-12-23**] Service: MEDICINE Allergies: Penicillins Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: AMS Major Surgical or Invasive Procedure: none History of Present Illness: 84 M w/ pmh of known SDH, h/o DVT's, prostate cancer, dementia who presented with ARF, fevers, and hypernatremia (Na 159), found also to have recurrent bilateral lower extremity DVT's. Was initially admitted to the neurosurgery service but was transferred to medicine on [**12-13**] for further management. He is currently on heparin - coumadin bridge for dvts but his hematocrit was noted to have dropped from 28 to 21.5. He was taken down to CT for CT ab/pelvis and CT head which did not show RP or new head bleed. He was in the process of receiving a transfusion for bleed of unknown source. His mental status was noted to be even worse today than usual. During a routine check, he was noted to be in respiratory distress and his O2 sats dropped to the 40s. Respiratory agressively suctioned and were able to retrieve 3 very large mucus plugs with improvement in his O2 sats. He was transferred to the ICU for further management. . On the floor, he is not able to give any further history and ROS not obtainable. Per floor nursing staff, at baseline he might respond yes or no but not reliably. He was running a low-grade fever this morning (vitals sheet not available). Past Medical History: - coronary artery disease s/p MI and CABG [**44**] yrs ago - subdural hematoma in [**10/2133**], now s/p emergent burrhole placement x2 on [**2133-11-23**] for acute worsening of hematoma - lower extremity DVT in [**8-/2133**] (now off anticoagulation due to SDH; bliateral LENIs earlier this month show no clot) - colon cancer (stage, therapy, status otherwise unknown) - hyperlipidemia - hypertension - chronic kidney disease, stage II with baseline creatinine 1.2 Social History: lives alone, retired, son either lives with him or nearby, no smoking, no illicit drug use Family History: Non-Contributory Physical Exam: Vitals: T: 95.9 BP: 129/100 P: 95 R: 23 O2: 100% on 2L NC General: Lethargic, lying on his R side, does not follow commands or give verbal responses HEENT: pinpoint pupils, dry MM Neck: supple, JVP not elevated Lungs: decreased breath sounds bilaterally, no wheezes, rales, ronchi CV: distant heart sounds, regular rate, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Head CT [**2133-12-9**]: IMPRESSION: 1. Left subdural collection with hyperdense focus anteriorly that is not significantly changed in comparison to [**2133-12-1**], with mass effect upon the cerebral sulci and lateral ventricle. 2. Small hypodense right subdural collection. 3. 6mm rightward shift of midline structures. . Head CT [**2133-12-11**]: IMPRESSION: Overall no significant interval change in the extent and size of the left sided subdural with minimal mass effect on the sulci and the ventricle and minimal midline shift as described previously. No evidence of herniation identified. Tiny right-sided subdural is again seen unchanged. Other changes as described above. . Head CT [**2133-12-16**]: IMPRESSION: Unchanged extent and size of chronic bilateral subdural hematomas and their minimal mass effect and shift of midline structures. The acute component in the anterior left frontal subdural compartment is unchanged. . Abd CT [**2133-12-16**]: IMPRESSION: 1. No retroperitoneal hematoma or intra-abdominal free gas. 2. Bilateral atelectasis. 3. Capacious rectum, appearing impacted with retained fecal material. . CXR [**2133-12-22**]: FINDINGS: In comparison with the study of [**12-21**], there is continued opacification just above the minor fissure consistent with right upper lobe pneumonia. Brief Hospital Course: This is a 84 M w/ pmh of recent SDH s/p boreholes X 2, also w/ recurrent DVTs s/p IVC filter, here w/ persistently altered mental status, now s/p hypoxia in the setting of large mucus plugs. . # Hypoxia/Pneumonia: The initial event was thought to be secondary to very large mucus plugs (X 3) as evidenced by suctioning. Initially his hypoxia resolved, however the patient then developed a large right sided pneumonia, likely secondary to aspiration. Treated empirically with vanc/aztreonam/flagyl/cipro for empiric coverage per ID. Frequent suctioning was performed by nursing. He was maintained on humidified air and supplemental O2 as needed. The patient became hypotensive, an arterial line was placed and he was started on pressors. After discussion with the family, the decision was made to make the patient DNR/DNI as the pneumonia was worsening and his pressor requirement was increasing. Eventually, the decision was made to withdraw pressor support. Within hours the patient's [**Date Range **] pressure decreased, he went into respiratory arrest and subsequent cardiac arrest. The patient was not resuscitation per the family's request. . # AMS: Most likely thought to be secondary to antiseizure medications. Mental status improved initially while in the MICU, however deteriorated once the patient's pneumonia developed. EEG did not show evidence of seizure. Held Keppra and Alzheimer's medications. After much discussion the decision was made not to escalate care and to make the patient DNR/DNI. . # Anemia: Unclear etiology of [**Date Range **] loss. GI consulted. The did not see the efficacy in scoping the patient. Hct remained stable. Discontinued heparin and coumadin given recurrent bleeding. . # Recurrent DVTs: stopped coumadin and heparin in the setting of recurrent SDH and unclear [**Name2 (NI) **] loss. S/p IVC filter. . # Recurrent SDH: Likley was the underlying cause of his poor overall functional and mental status. Per CT head he had no acute bleed. Neurosurgery was consulted. Speech and swallow would not even evaluate him secondary to his mental status, the patient was maintained on tube feeds. . # Transaminitis: Unclear etiology. ALT 135, AST 140 on [**12-7**] at OSH. Ultrasound performed on [**12-9**] was unremarkable. . # FEN: IVF, repleted electrolytes, Tube feeds via dopoff . # Prophylaxis: pneumoboots, IVC filter . # Access: double-lumen PICC . # Communication: HCP [**Name (NI) **] ([**Telephone/Fax (1) 81359**] Medications on Admission: Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. Order date: [**12-13**] @ 0938 Insulin SC (per Insulin Flowsheet) Sliding Scale Order date: [**12-12**] @ 2137 500 mL NS Bolus 500 ml Over 30 mins Order date: [**12-16**] @ 0313 Influenza Virus Vaccine 0.5 mL IM ASDIR Follow Influenza Protocol Document administration in POE Order date: [**12-16**] @ 1109 500 mL NS Bolus 500 ml Over 60 mins Order date: [**12-16**] @ 0525 15. Ipratropium Bromide Neb 1 NEB IH Q6H Order date: [**12-12**] @ 2137 Acetaminophen 325-650 mg PO Q6H:PRN Order date: [**12-16**] @ 0836 LeVETiracetam 250 mg PO BID Order date: [**12-15**] @ 1754 Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Order date: [**12-12**] @ 2137 Metoprolol Tartrate 12.5 mg PO BID Start: In am hold hr<55 sbp<100 Order date: [**12-12**] @ 2248 Doxazosin 1 mg PO HS Order date: [**12-12**] @ 2137 Multivitamins 5 mL PO DAILY Order date: [**12-13**] @ 1210 Docusate Sodium (Liquid) 100 mg PO BID Order date: [**12-12**] @ 2137 Namenda *NF* 10 mg Oral [**Hospital1 **] Order date: [**12-12**] @ 2137 Donepezil 5 mg PO HS Order date: [**12-12**] @ 2137 Senna 1 TAB PO BID Order date: [**12-12**] @ 2137 Famotidine 20 mg PO BID Order date: [**12-12**] @ 2137 FoLIC Acid 1 mg PO DAILY Order date: [**12-12**] @ 2137 Thiamine 100 mg PO DAILY Order date: [**12-12**] @ 2137 Discharge Disposition: Expired Discharge Diagnosis: Pneumonia Discharge Condition: Expired [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2133-12-24**]

[ "995.92", "272.4", "V45.81", "585.2", "584.9", "996.64", "933.1", "038.9", "331.0", "V10.46", "518.81", "280.0", "276.0", "599.0", "507.0", "403.90", "V10.05", "453.41", "294.10" ]

icd9cm

[ [ [] ] ]

[ "88.51", "38.7", "38.93", "96.6", "99.04" ]

icd9pcs

[ [ [] ] ]

7980, 7989

4004, 6487

231, 237

8042, 8217

2658, 3981

2057, 2075

8010, 8021

6513, 7957

2090, 2639

188, 193

265, 1441

1463, 1932

1948, 2041

70,796

168,402

2142

Discharge summary

report

Admission Date: [**2181-10-30**] Discharge Date: [**2181-11-4**] Date of Birth: [**2126-7-29**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5119**] Chief Complaint: Loss of consciousness Major Surgical or Invasive Procedure: None History of Present Illness: Initial history and physical is as per the [**Hospital Unit Name 153**] resident. . 55-year-old man with history of EtOH abuse and likely withdrawal seizures, but on phenytoin in the past, presented with a witnessed seizure. The patient had a 2 minute-long tonic clonic seizure with loss of consciousness while walking down a street near his house. Denies any urine or stool incontinence. Woke up in the ambulance. Patient is not sure if he has had withdrawal seizures in the past. He last drank a few days ago. . On presentation to the ED, T 99.0, HR 100, SBP 185/120, RR 12, O2 sat 100% RA. Serum EtOH level was negative. He received a banana bag, lorazepam 1 mg IV x 1. . On arrival to the ICU, the patient was oriented x 3, with T now 101.1, SBP in the 180s, HR 80s. . ROS: The patient reports some nonproductive coughs since [**Month (only) 547**] with ?worsening for the past few days. Also some "diarrhea" but then reports that he has had bowel movements every few days recently. Denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, constipation, melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, lower extremity edema, urinary frequency, urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: EtOH abuse/Coccaine abuse Hepatitis C: genotype 1 DM Essential tremor HTN Peptic ulcers Hx of traumatic brain injury Social History: He is originally from [**Male First Name (un) 1056**] and has been in the United States for 32 years. He worked as a punch press operator; however, he has been on disability since [**2172**]. He is single, living with his brother. [**Name (NI) **] smokes half a pack of cigarettes a day for many decades. Stopped using heroin years ago. Last cocaine was months ago. Reports heavy drinking in the past but a "small" drink of vodka every few days now. Family History: His family history is noted for a mother who had diabetes. His father also had shaking, which he attributes to excessive alcohol use Physical Exam: Vitals: T:100.7 BP: 156-98 HR:88 RR: 95 rA GEN: NAD HEENT: EOMI, PERRL, sclera anicteric, abrasion L cheeck w some blood in mouth, resolved after rinsing, no active bleed noted NECK: No JVD, no cervical lymphadenopathy, COR: RRR, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: alert, oriented to hospital and year, initially thought it wa [**Month (only) **] but corrected himself and said [**Month (only) **]. CN II ?????? XII grossly intact. motor/sensation non-focal. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [**2181-10-30**] 05:00PM BLOOD WBC-3.0*# RBC-4.13* Hgb-14.2 Hct-40.3 MCV-98 MCH-34.2* MCHC-35.1* RDW-13.5 [**2181-10-30**] 05:00PM BLOOD Neuts-78.9* Lymphs-15.8* Monos-3.8 Eos-1.2 Baso-0.4 [**2181-10-30**] 05:00PM BLOOD PT-15.1* PTT-28.8 INR(PT)-1.3* [**2181-10-30**] 05:00PM BLOOD Glucose-127* UreaN-16 Creat-1.0 Na-134 K-3.9 Cl-97 HCO3-24 AnGap-17 [**2181-10-30**] 05:00PM BLOOD ALT-134* AST-126* AlkPhos-87 TotBili-2.5* [**2181-10-30**] 05:00PM BLOOD Albumin-4.2 Calcium-9.5 Phos-2.5*# Mg-1.6 [**2181-10-30**] 05:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . Chest X-ray: Prelim - No acute cardiopulmonary abnormalities . CT Head: There is no intracranial hemorrhage, mass effect, or shift of normally midline structures. The patient is status post left craniectomy. An area of hypodensity involving the left posterior frontal lobe is chronic in appearance. The visualized paranasal sinuses and mastoid air cells are well aerated. There is no hydrocephalus. IMPRESSION: No acute intracranial process. Post-surgical changes of the left craniectomy. Please correlate with [**Hospital 228**] medical and surgical history. Brief Hospital Course: Assessment: 55-year-old man with history of EtOH abuse, withdrawal seizures, hepatitis C presented with witnessed generalized tonic clonic seizure, likely a withdrawal seizure given that his last alcoholic drink was a few days ago. . Summary by problem: # Alcohol withdrawal seizures: The timing of the patient's seizure was consistent with alcohol withdrawal. Pt reports that over 10yrs ago, he had head injury and was on dilantin but has not been on any anti-epleptics X10 yrs and has had no seizures until this episode. EtOH negative on admission. He was monitored in the intensive care unit overnight. He was also treated with thiamine, folate, and a MVI. He was then called out to the floor where he was agitated, tremulous, and hallucinating. He was placed on standing diazepam, placed on seizure and withdrawal precautions, and placed on telemetry. He also required prn diazepam. His mental status improved and he was weaned off of valium. Social work was consulted. Pt expressed a desire to stop drinking. Pt's plan is to return to church and to stop drinking on his own. Pt does not wish to attend AA or any other treatment programs. . # Hypertension: The patient initially has an SBP 180s. He was placed on lisinopril 40 mg daily and his SBP came down into the 110s. He was given a prescription for lisinopril and instructed to follow up with his PCP. . # Seasonal allergies: The pateint complained of rhinitis, sinus congestion and itchy eyes during his hospitaliaztion. He was started on fexofenadine which helped his symptoms. He was given a prescription at discharge. . # Hepatitis C: was seen by Dr. [**Last Name (STitle) **] in clinic a few years back but lost to follow-up. If pt is compliant and follows up with pcp then he should be referred back to hepatology. . # Essential tremor: with resting tremor in both hands. Saw neurologist several years ago. Unchanged per patient. . # Leukopenia/thrombocytopenia - noted on admission. Likely [**2-10**] alcoholism. Platelet counts improved over the hospitalization without intervention. . #Dispo - Pt [**First Name9 (NamePattern2) 11483**] [**Last Name (un) **] ein dtable condition. He was instructed to follow up with his PCP. Medications on Admission: None Discharge Medications: 1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: ETOH withdrawal seizure Discharge Condition: Good Discharge Instructions: -Take Lisinopril for high blood pressure. -Take fexofenadine for seasonal allergies. -Follow up with at the [**Hospital **] Community Health Center in [**1-10**] weeks regrarding this hospitalization and to establish routine care. They should follow up on you high blood pressure and your liver care. They should call you Monday with an appointment. If you do not hear from them by midweek please call [**Telephone/Fax (1) 3581**], x1255 to establish an appointment -Do not drink alcohol. -Return to ED if you have another seizure, worsening tremor, nausea/vomiting or any other worrisome signs/symptoms. Followup Instructions: -Follow up with at the [**Hospital **] Community Health Center in [**1-10**] weeks regrarding this hospitalization and to establish routine care. They should call you Monday with an appointment. If you do not hear from them by midweek please call [**Telephone/Fax (1) 3581**], x1255 to establish an appointment [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**] Completed by:[**2181-11-4**]

[ "287.4", "070.70", "571.2", "401.9", "303.01", "291.81", "304.21", "780.39" ]

icd9cm

[ [ [] ] ]

[ "94.62" ]

icd9pcs

[ [ [] ] ]

6842, 6848

4292, 6497

338, 345

6916, 6923

3110, 3770

7578, 8064

2307, 2441

6552, 6819

6869, 6895

6523, 6529

6947, 7555

2456, 3091

277, 300

373, 1683

3779, 4269

1705, 1824

1840, 2291

6,823

142,535

47370

Discharge summary

report

Admission Date: [**2140-7-11**] Discharge Date: [**2140-7-16**] Date of Birth: [**2077-9-28**] Sex: F Service: MICU HISTORY OF PRESENT ILLNESS: This is a 62-year-old woman with vulvar cancer originally diagnosed in [**2131**], status post surgical resection, radiation therapy and chemotherapy, coronary artery disease, and severe dilated cardiomyopathy, who presented to the hospital on [**7-11**] with perineal pain and was noted to have genital, perineal, and sacral decubitus ulcers. She was evaluated by Plastic Service, General Surgery, and Gynecology and was planned for in no acute distress with diverting colostomy. The patient was noted to have signs and symptoms of congestive heart failure on admission; however, diuresis was deferred secondary to a question of dehydration. The patient was placed on antibiotic coverage for a possible skin infection as well as urinary tract infection. Further studies revealed a large right-sided pleural effusion, hepatic congestion, as well as a left hip incision draining sinus from a previous total hip replacement. There was evidence of periosteal elevation on pelvic plain films concerning for osteomyelitis and potential septic hip joint. On the morning of [**7-14**], the patient was noted to become acutely short of breath. She was placed on a nonrebreather, and systolic blood pressures were in the 90s. An arterial blood gas revealed a pH of 7.3, PCO2 was 23, and PO2 was 67. The patient was given 20 mg of intravenous Lasix without effect and was subsequently transferred to the Intensive Care Unit. PAST MEDICAL HISTORY: 1. Vulvar cancer. 2. Coronary artery disease; status post cardiac catheterization in [**2135**], status post percutaneous transluminal coronary angioplasty and stent of the left anterior descending artery. 3. Cardiomyopathy; echocardiogram in [**2135**] revealed severe global left ventricular dysfunction with an ejection fraction of less than 20%, severe mitral regurgitation, and moderate pulmonary hypertension. 4. Bilateral total hip replacements. 5. Seizure disorder. 6. Upper gastrointestinal bleed in [**2134**]. 7. Splenic artery aneurysm, status post embolization. SOCIAL HISTORY: The patient reportedly lived at home alone with a home health aide. She was relatively immobile secondary to severe degenerative arthritis. FAMILY HISTORY: Family history was noncontributory. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission to the Intensive Care Unit revealed an alert, elderly, tachypneic woman on 100 nonrebreather. Temperature was 95.5, heart rate was 100, blood pressure was 90/70, SpO2 was 91% to 93% on 100% nonrebreather. Head, eyes, ears, nose, and throat revealed sclerae were anicteric. Pupils were 3 mm and symmetric. Chest revealed bilateral rales three quarters of the way up bilaterally. Heart was regular, tachycardic. Jugular venous pulsations to the angle of the jaw. Heart sounds were distant. The abdomen was mildly distended, nontender. Extremities revealed 3+ pitting edema, cool. No cyanosis. Perineum revealed extensive excoriation, erythema, and ulcerations on the labia bilaterally. The posterior vulva by skin folds extending medially, perianally, and in the sacral regions. Neurologically, tarda dyskinesia was present. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on admission to the Intensive Care Unit revealed white blood cell count was 12.6, hematocrit was 31.6, platelets were 398. PT was 15.6, PTT was 28.8, INR was 1.2. Sodium was 126, potassium was 5.2, chloride was 98, bicarbonate was 16, blood urea nitrogen was 22, creatinine was 0.9, blood glucose was 86. Albumin was 2.5, phosphate was 2.6, calcium was 7.8, magnesium was 1.6. ALT was 219, AST was 469, alkaline phosphatase was 137, total bilirubin was 0.6. Arterial blood gas revealed a pH of 7.3, PCO2 was 23, PO2 was 67. RADIOLOGY/IMAGING: A chest x-ray revealed a dilated heart, pulmonary edema. Electrocardiogram showed sinus tachycardia, a left bundle-branch block, with more prominent T waves precordially and increased ST depressions in V6. HOSPITAL COURSE: This is a 62-year-old woman with coronary artery disease, and severe dilated cardiomyopathy, and a history of vulvar cancer who presented to the hospital with a perineal ulcer. She was noted to be in mild congestive heart failure on presentation. She was treated with ciprofloxacin for a urinary tract infection and covered with cefazolin for possible infection in the perineum. She was seen by General Surgery, Plastic Service, and Gynecology and was planned for surgical intervention with incision and drainage and a diverting colostomy. The patient was transferred to the Medical Intensive Care Unit on [**7-14**] for acute shortness of breath with a primary metabolic acidosis and secondary respiratory alkalosis. Examination and chest x-ray were consistent with congestive heart failure. The patient was diuresed with Lasix and placed on nitrates. She was placed on supplemental oxygen and received a trial of BiPAP which she was unable to tolerate. She was diuresed over 1100 cc over the first day in the Intensive Care Unit; though this was limited by concomitant hypotension. She was evaluated by the Cardiology Service given her severe dilated cardiomyopathy with congestive heart failure and hypotension. They recommended placement of a Swan-Ganz catheter prior to initiation of tailored therapy. The patient continued to be markedly short of breath and desaturated with increased FIO2 requirements. She was electively intubated. Following intubation, and mechanical ventilation, the patient continued to do poorly. Her FIO2 requirements continued to increase, and she became hypotensive to the 70s. The patient was initiated on a Levophed drip. A left subclavian line was attempted to be placed with a PA catheter. This was no successful. A follow-up chest x-ray revealed the patient had developed a large left-sided tension pneumothorax. A needle decompression was performed. The patient's family was kept informed of the ensuing events and decided to make the patient comfort measures only given her overall clinical status and declining quality of life over the past several years. A thoracostomy tube was declined. The patient's epinephrine drip was weaned to off. The patient subsequently became hypotensive. The patient died on [**2140-7-16**] at 12:50 p.m. Her son, [**Name (NI) 122**], was present at the bedside at the time of her death. The family declined a postmortem examination. DISCHARGE DIAGNOSES: 1. Vulvar cancer. 2. Perineal ulcer. 3. Congestive heart failure. 4. Coronary artery disease. 5. Severe dilated cardiomyopathy. 6. Urinary tract infection. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**] Dictated By:[**Last Name (NamePattern1) 23338**] MEDQUIST36 D: [**2140-7-16**] 14:28 T: [**2140-7-21**] 11:56 JOB#: [**Job Number **]

[ "707.0", "276.5", "425.4", "428.0", "682.2", "112.1", "511.9", "276.1" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

2367, 4131

6601, 7050

4150, 6580

162, 1585

1607, 2190

2207, 2349

28,052

123,016

32826

Discharge summary

report

Admission Date: [**2104-2-9**] Discharge Date: [**2104-2-18**] Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2518**] Chief Complaint: intraparenchymal hemorrhage Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a [**Age over 90 **] yo man with apparently no PMH who was doing yardwork with his son today when he slumped over slowly. Limited history as patient poor historian and no family available. He was kneeling on the ground raking and slowly slumped over onto his left buttock. There was no head trauma and no LOC. He denies any pain, but was immediately noted to have left sided weaknes. Initially refused to allow son to call EMS. Also was noted to have left facial droop. At OSH was noted to have right gaze preference and left hemi sensory and pareisis. At [**Hospital1 **], was noted as having RUE 4-5/5, RLE 4-5/5, LUE 0-1/5, LLE 2-3/5. CT showed a large right IPH in the internal capsule measuring 4.2 by 2.1 x 3.5 cm. EMS transferred him to [**Hospital1 **] and then later transfered to [**Hospital1 **]. They noted that the left sided weakness seemed to be worse on the transfer. The patient denies any pain, headache, nausea or deficit. Denies any vision changes. ROS: The patient denies any pain, headache, nausea or deficit. Denies any vision changes. Denies chest pain, SOB. Cough some times. Past Medical History: None Social History: Quit smoking and drinking years ago. Lives with his son. Is widowed and used to work in sales. Family History: son had MI. No strokes or bleeds. Physical Exam: T- 97.2 BP- 181/61 (up to SBP 230s later) HR- 52 RR- 18 O2Sat 99 2L Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid or vertebral bruit Back: No point tenderness or erythema CV: Distant RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally aBd: +BS soft, nontender ext: no edema Neurologic examination: Mental status: Awake and slow but alert, cooperative with exam on right side and neglects left persistently in arm and intermittently in leg. Closes eyes at baseline but opens to voice and maintains. Flattened. affect. Left visual neglect. Oriented to person, and date but says [**Hospital1 **] for place. Able to [**First Name8 (NamePattern2) **] [**Doctor Last Name 1841**] backwards. Speech is fluent with normal comprehension and repetition; naming intact. Moderate dysarthria. Unable to read, but unclear if he wears glasses or reads at baseline. Left hemineglect. Cranial Nerves: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Blinks to threat right only. Tracks to right only, not past midline to left. Left facial droop. Hearing intact to grossly. Palate elevation symmetrical. Tongue midline, movements intact Motor: Normal bulk bilaterally. Tone flacid left arm > leg. No observed myoclonus or tremor Dense hemiplegia of left arm with no movement or withdrawl to nox stim. Left leg has antigravity breifly and [**4-19**] HS and DF. RUE and RLE full at Triceps, IP, HS and DF otherwise could not cooperate. Sensation: Intact to light touch, pinprick, vibration and proprioception throughout. No extinction to DSS Reflexes: +2 and symmetric throughout. Toes up bilaterally Coordination: cannot do FNF left ( secondary to visual )and plegic right. Heel shin intact right, but cannot left due to weakness. Gait: NA. Romberg: NA Pertinent Results: [**2104-2-11**] 02:20AM BLOOD WBC-11.2* RBC-4.91 Hgb-15.0 Hct-43.5 MCV-89 MCH-30.5 MCHC-34.4 RDW-14.0 Plt Ct-191 [**2104-2-9**] 04:40PM BLOOD Neuts-84.8* Lymphs-9.7* Monos-4.8 Eos-0.2 Baso-0.5 [**2104-2-9**] 04:40PM BLOOD PT-13.5* PTT-31.6 INR(PT)-1.2* [**2104-2-9**] 04:40PM BLOOD Glucose-97 UreaN-20 Creat-1.3* Na-143 K-4.0 Cl-107 HCO3-28 AnGap-12 [**2104-2-11**] 02:20AM BLOOD Glucose-117* UreaN-24* Creat-1.3* Na-138 K-3.9 Cl-104 HCO3-27 AnGap-11 [**2104-2-9**] 04:40PM BLOOD cTropnT-0.01 [**2104-2-10**] 03:13AM BLOOD CK-MB-NotDone cTropnT-0.01 [**2104-2-9**] 04:40PM BLOOD CK(CPK)-59 [**2104-2-10**] 03:13AM BLOOD CK(CPK)-72 CXR: Increased density in the left lower lung which may represent parenchymal consolidation. Head CT: 5.7 x 2.3 cm intraparenchymal hemorrhage centered within the right basal ganglia, most likely hypertensive. VIDEO OROPHARYNGEAL SWALLOW [**2104-2-13**] 1:06 PM VIDEO OROPHARYNGEAL STUDY: This study was performed in collaboration with speech pathology department. Barium of various consistencies was administered orally to the patient under fluoroscopy. ORAL PHASE: There was moderate-to-severe impairment of bolus formation and control. Significant premature spillover occurred prior to swallow. There is a small amount of residue left after the swallow secondary to lingual weakness. Tongue pumping was necessary to transport bolus, and the base of the tongue retraction was mildly reduced. PHARYNGEAL PHASE: There is mild-to-moderate delay in swallowing initiation. Although palatal elevation was normal, laryngeal elevation was mildly reduced. Pharyngeal transit time was normal, and pharyngeal constriction was normal. A mild coating of residue is seen in the valleculae after the swallow. Pharyngeal esophageal sphincter opening was within normal limits at the height of the swallow. ASPIRATION/PENETRATION: There was intermittent penetration of nectar thick liquids, with one episode of aspiration prior to swallow. This is apparently a result of premature spillover and delay in swallow initiation. A delayed spontaneous cough was effective in clearing the majority of the aspirated material. IMPRESSION: 1. Pharyngeal dysphasia with loss of bolus control and delay in initiation of pharyngeal swallow. 2. Multiple episodes of penetration, and one episode of aspiration. 3. No aspiration of honey-thick liquids today. CHEST (PORTABLE AP) [**2104-2-14**] 11:57 AM FINDINGS: In comparison with the study of [**2-12**], the opacification at the left base appears to be somewhat less, suggesting some resolution of atelectatic or infiltrate of change. Dobbhoff tube again extends to the upper stomach. Brief Hospital Course: Mr. [**Known lastname 76430**] was admitted to the ICU for closer monitoring. His hospital course by problem is as follows: 1) Right Internal Capsule Hemorrhage: This was felt to be likely secondary to hypertension given its location. He was initially admitted to the Neurology ICU. His BP was maintained at 140-170 and a MAP of less than 130. His Head of the bed was kept elevated above 30 degress. He was not intubated. He was transferred to the neurology floor for further care. Initial speech and swallow revealed ? aspiration. Video swallow evaluation cleared pt for modified consistency diet. He was monitored for a full three day calorie count to ensure adequate nutritional intake. The patient is able to take adequate calories with 1:1 assisted meals. His left hemiparesis showed some signs of slight improvement with 1/5 strength at FF, WE and biceps prior to discharge. Left leg remains plegic. Pt's mental status is normal. He was titrated on lisinopril for BP control. The patient will follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in the Stroke neurology center at [**Hospital1 18**]. A MRI with and without contrast could be considered in [**3-18**] weeks to rule out underlying lesion. 2) 1st degree AV block: He was monitored on tele and he was ruled out for an MI with 2 sets of CE. 3) Renal- Noted to have chronic renal insufficiency. Likely HTN related. ACE was started for renoprotection without Cr elevation. Cr at discharge was 1.1 Medications on Admission: None Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 3. Lisinopril 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Right Internal Capsule Hemorrhage (intracranial hemorrhage) Hypertension Discharge Condition: Stable. Examination notable for left hemiparesis. Discharge Instructions: Please continue all medications as prescribed. Please attend all follow-up appointments. If you experience difficulty with vision, speech, weakness, numbness or other concerning symptoms, please call your primary care doctor or report to the emergency department for evaluation. Followup Instructions: Please follow-up with your primary care doctor 7-10 days after discharge from rehab. Neurology: Please call [**Telephone/Fax (1) 1694**] prior to the appointment so that we may get demographic information from you. Tuesday [**4-22**] at 1:30PM. Shapairo 8 Clinical Center, [**Hospital1 18**].Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**] Date/Time:[**2104-4-22**] 1:30 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2533**]

[ "401.9", "781.94", "593.9", "426.11", "507.0", "431", "342.90", "787.23" ]

icd9cm

[ [ [] ] ]

[ "96.6" ]

icd9pcs

[ [ [] ] ]

8061, 8158

6239, 7726

292, 298

8275, 8327

3567, 4293

8654, 9206

1612, 1649

7781, 8038

8179, 8254

7752, 7758

8351, 8631

1664, 2047

223, 254

326, 1453

2665, 3548

4302, 6216

2086, 2649

2071, 2071

1475, 1481

1497, 1596

52,011

163,900

36601+58103

Discharge summary

report+addendum

Admission Date: [**2120-8-24**] Discharge Date: [**2120-8-30**] Date of Birth: [**2033-7-5**] Sex: F Service: SURGERY Allergies: morphine Attending:[**First Name3 (LF) 4691**] Chief Complaint: Abdominal pain, nausea, right leg pain. Major Surgical or Invasive Procedure: [**2120-8-24**] laparotomy, small bowel resection, R obturator herniorrhaphy, right inguinal herniorrhaphy and umbilical herniorrhaphy. History of Present Illness: 87F history of hypertension complains of right-sided abdominal pain and vomiting. Per EMS, the pain has been going on for about a week. Patient called EMS because she ate this evening and then started vomiting. Has not been able to eat since last sunday night because she vomits everything. No BM for a few days. Unreliable historian; denied abd pain initially in MICU saying it was more of a soreness in her thigh and radiating down her leg. When asked if she had N/V she also denied that initially, then asked if she was sure, said she did. C/o dry mouth. In the ED, VS 98.8 112 148/76 18 97% ra. CBC WNL but diff with 28% bands. INR 1.0, PTT 23.6, Cr 2.1 (baseline 1.1 one year ago), BUN 75, lytes normal, LFTs WNL, lipase 36, trop 0.05, lactate 2.5. Blood cultures drawn and pending. CXR Mild to moderate pulmonary edema with bibasilar lower lobe opacities that could represent atelectasis or pneumonia on prelim. Started on CTX/azithro. EKG with st depressions in V4-V6. tachypnea to 30 so sent to unit despite satting 98% RA prior to transfer. On arrival to the MICU, VS 99.3, 113/63, 107, 27, 93% 2L NC. She denies fevers, chills, chest pain, shortness of breath. No cough, no dysuria, no weakness, no numbness, no incontinence, no change in back pain. No recent trauma. No history of abdominal surgeries. Past Medical History: Hypertension Breast CA s/p masectomy 30 yrs ago LBP Social History: Paient quit smoking 30 yrs ago, smoked 1 ppd x 20 years, social alcohol use, no illicit drug use. Family History: Non-contributory Physical Exam: On admission: Vitals: 99.3, 113/63, 107, 27, 93% 2L NC General: Alert, oriented, no acute distress, cachectic HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL, palatal petechiae, erythematous OP Neck: supple, JVP not elevated, left anterior cervical nontender LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: LLL crackles Abdomen: soft, mildly TTP in RLQ, normoactive bowel sounds Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema On discharge: VS T 98.8, HR 79,BP 153/70, RR 18, sat 94% on room air. Neuro: Lethargic, arousable, pleasant. Oriented to self. Unable to express place or time unless given two options (correct option always selected). Card: S1, S2. RRR. No m/r/g appreciated. Pulm: Anterior clear bilaterally. Diminished in bases bilaterally. GI: Active BS. Non-distended, non-tender. Mid-line incision closed with surgical staples. CDI. GU: Voiding without issue. Extrem: Warm, dry, well-perfused. Pertinent Results: [**2120-8-24**] 02:40AM BLOOD WBC-6.1 RBC-4.32# Hgb-14.0# Hct-41.7# MCV-97 MCH-32.3* MCHC-33.5 RDW-12.7 Plt Ct-361# [**2120-8-24**] 02:40AM BLOOD Neuts-61 Bands-28* Lymphs-5* Monos-5 Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 [**2120-8-24**] 02:40AM BLOOD PT-11.0 PTT-23.6* INR(PT)-1.0 [**2120-8-24**] 04:05PM BLOOD Fibrino-386 [**2120-8-24**] 02:40AM BLOOD Glucose-166* UreaN-75* Creat-2.1* Na-136 K-5.0 Cl-93* HCO3-29 AnGap-19 [**2120-8-24**] 02:53AM BLOOD Lactate-2.5* CT Abdomen without contrast ([**2120-8-24**]) 1. Bibasilar opacifications is concerning for aspiration/pneumonia versus atelectasis in the correct clinical setting. 2. Small pericardial effusion. 3. Distended loops of small bowel measuring up to 4.2 cm with transition point in a right obturator hernia and with completely collapsed large bowel loops concerning for high-grade small-bowel obstruction. 4. Fat-containing umbilical hernia. 5. Right inguinal hernia containing decompressed loops of small bowel. 6. Right kidney demonstrates mild fullness of the collecting system and the proximal ureter without evidence of obstructive calculus. 7. Severe degenerative changes within the thoracolumbar spine. [**2120-8-24**] ECG Sinus tachycardia. Early precordial R wave progression suggestive of prior posterior myocardial infarction. Non-specific ST-T wave abnormalities. Compared to the previous tracing T wave inversions in the anteroseptal leads are less prominent. [**2120-8-26**] ECG Sinus rhythm and slowing of the rate as compared with previous tracing of [**2120-8-24**]. The anterolateral ST-T wave abnormalities have improved, although there is continued ST segment depression and T wave inversion in leads V1-V3 which may represent anterior ischemia. Followup and clinical correlation are suggested [**2120-8-27**] CXR Patient's condition did not permit PA and lateral chest technique, but had to convert it to sitting examination using AP frontal and left lateral views. Enlarged heart, as before. High-positioned diaphragms conceal major portion of the heart shadow and diaphragmatic contours obscured by bilateral pleural densities that blunt the lateral and posterior pleural sinuses. Mostly linear densities on the bases indicate crowded pulmonary vasculature most likely related to the bilateral pleural effusions. Pulmonary vasculature again shows perivascular haze on the bases consistent with marked pulmonary congestion. As before, the patient has a marked S-shaped scoliosis in the thoracolumbar spine with advanced degenerative changes. Comparison with the next previous examination demonstrates that the patient is still in left-sided heart failure with dilated heart shadow and bilateral pleural effusions. No new discrete parenchymal infiltrates can be identified, but the possibility of some processes in the lung bases with the crowded pulmonary vasculature and partial atelectasis cannot be excluded. Brief Hospital Course: 87 year old female with one week history of abdominal pain, nausea and vomiting who was admitted to MICU with [**Last Name (un) **] and noted to have incarcerated hernia. She was taken to the OR on [**2120-8-24**] for repair of her hernia. She was admitted to the TSICU post-op for close hemodynamic monitoring. N: Her pain was controlled w/ dilaudid and tylenol prn. She was intermittently agitated/delirius and was given haldol low dose prn CV: She was initially on pressors intraoperatively (neo) but was able to be weaned off. Her hypotension responded to fluid boluses. She had some St segment depression, though likely due to demand ischmia, and she was put on metoprolol. Cardiac enzymes were sent and returned negative. Pulm: She was extubated after the OR and did well on NC then eventually room air. GI: She was kept NPO and on IV fluids, awaiting return of bowel frunction. GU: She had an elevated Cr on admission, thought likely due to dehydration, and she was given fluids for resuscitation. Her creatinine continued to improve daily. ID: She was placed on zosyn for a day for ischemic bowel. Mrs. [**Known lastname 82823**] was transferred to the surgical floor under the ACS service on [**2120-8-26**]. Her pain continued to be managed with parenteral analgesics. As her diet was advanced, oral non-narcotic and narcotic analgesics were administered. Her NGT was discontinued. Physical and occupational therapy were consulted. Both felt that, due to deconditioning, Mrs. [**Known lastname 82823**] would benefit with discharge to a rehabilitation facility. Post-operatively, the patient became agitated during the evening, requiring PRN doses of olanzapine. She was started on the regimen twice daily. As the patient became somnolent during the day, the anti-psychotic was written on an as-needed basis. Mrs.[**Last Name (un) 82824**] initial CT scan of the chest showed areas of questionable pneumonia or atelectasis. She was afebrile, but had a consistent leukocytosis of approximately 13. A follow-up chest radiograph showed bilateral pleural effusions. She exhibited no issus of shortness of breath, hypoxia or dyspnea. Aggressive pulmonary toileting was achieved through the use of an incentive spirometer and ambulation. The patient's foley catheter was discontinued on POD 1 and she had not issues voiding thereafter. The tolerated an oral diet well, but has not had a bowel movement. A bowel regimen of colace and senna was initated. At the time of discharge, Mrs. [**Known lastname 82823**] was hemodynamically stable and afebrile. Medications on Admission: Atenolol 25', MVI. Discharge Medications: 1. Acetaminophen 650 mg PO TID 2. Atenolol 25 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Senna 2 TAB PO HS 5. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain 6. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain hold for increased sedation, resp. rate <10 7. OLANZapine (Disintegrating Tablet) 2.5 mg PO BID:PRN agitation Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: 1. Small bowel obstruction due to incarcerated obturator hernia with necrotic small bowel. 2. Right inguinal direct hernia and umbilical hernia, both incarcerated. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to [**Hospital1 69**] due to complaints of abdominal pain, vomiting and right leg pain. Imaging showed you have a small bowel obstruction secondary to a hernia. You were taken to the operating room on [**8-24**] where you underwent a hernia repair and small bowel resection. Your bowel function has returned and you have resumed a regular diet. Please follow up in [**Hospital 2536**] clinic at the appointment scheduled for you below. Your staples will be removed at this appointment. ACTIVITY: o Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. o You may climb stairs. o You may go outside, but avoid traveling long distances until you see your [**Hospital 5059**] at your next visit. o Don't lift more than 20-25 lbs for 4-6 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. o You may start some light exercise when you feel comfortable. o You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. o Heavy exercise may be started after 6 weeks, but use common sense and go slowly at first. HOW YOU [**Month (only) **] FEEL: o You may feel weak or "washed out" for 6 weeks. You might want to nap often. Simple tasks may exhaust you. o You may have a sore throat because of a tube that was in your throat during surgery. o You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. o You could have a poor appetite for a while. Food may seem unappealing. 0 All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your [**Month (only) 5059**]. YOUR INCISION: o Your incision may be slightly red around the staples. This is normal. o You may gently wash away dried material around your incision. It is normal to feel a firm ridge along the incision. This will go away. o Avoid direct sun exposure to the incision area. o Do not use any ointments on the incision unless you were told otherwise. o You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your [**Month (only) 5059**]. o You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. o Over the next 6-12 months, your incision will fade and become less prominent. YOUR BOWELS: Constipation is a common side effect of medicine such as Percocet or codeine. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. If you go 48 hours without a bowel movement, or have pain moving the bowels, call your [**Month (only) 5059**]. PAIN MANAGEMENT: It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your [**Name2 (NI) 5059**]. o Your pain medicine will work better if you take it before your pain gets too severe. o Talk with your [**Name2 (NI) 5059**] about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your [**Name2 (NI) 5059**] has said its okay. o If you are experiencing no pain, it is okay to skip a dose of pain medicine. o Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. If you have any questions about what medicine to take or not to take, please call your [**Name2 (NI) 5059**]. Followup Instructions: Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] When: TUESDAY [**2120-9-17**] at 2:00 PM With: ACUTE CARE CLINIC/ Dr.[**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 600**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2120-8-29**] Name: [**Known lastname 13247**],[**Known firstname 3485**] Unit No: [**Numeric Identifier 13248**] Admission Date: [**2120-8-24**] Discharge Date: [**2120-8-30**] Date of Birth: [**2033-7-5**] Sex: F Service: SURGERY Allergies: morphine Attending:[**First Name3 (LF) 9036**] Addendum: Mrs. [**Known lastname **] was preparing for discharge at approximately 1300 on [**8-31**]. The bedside RN informed the ACS team that the patient vomited twice after eating lunch. As a result, the patient's discharge was held. She was kept NPO and IV fluids were initiated. As of this morning, [**2120-8-31**], Mrs. [**Known lastname **] tolerated an oral diet and had a bowel movement (after receiving a dulcolax suppository). She reports no nausea or GI upset. At this time, the patient is stable and will be discharged to [**Hospital6 609**]. She is in no acute distress, hemodynamically stable, and afebrile. Discharge Disposition: Extended Care Facility: [**Hospital6 609**] for the Aged - MACU [**First Name11 (Name Pattern1) 1332**] [**Last Name (NamePattern1) 9039**] MD [**MD Number(2) 9040**] Completed by:[**2120-8-30**]

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Discharge summary

report

Admission Date: [**2197-11-23**] Discharge Date: [**2197-12-5**] Date of Birth: [**2150-12-12**] Sex: M Service: MEDICINE Allergies: Codeine / Demerol / Biaxin Attending:[**First Name3 (LF) 11552**] Chief Complaint: Altered mental status and hyperglycemia Major Surgical or Invasive Procedure: None History of Present Illness: 46 M with T1DM, s/p DD Renal Tx ([**2178**]), s/p R MCA CVA [**12/2196**] (L weakness), Blindness, presents from [**Hospital1 3597**] MICU for management of ARF. . Mr. [**Known lastname **] was found unresponsive by family after 24 hours of noncontact. EMS found GCS 3, VSS (100.4, 139/68, 109, 100%on2L), BS 601. Taken to ED at 10pm on [**2197-11-22**] where he was obtunded. Labs were notable for had Glucose 601 with an elevated AG (20), K of 3.0 WBC of 16 (87% P, 3.3%L, 5% bands) amd a Cr of 3.3 from Baseline 1.9 ([**2197-10-10**]) and a bilirubin of 5.1 (baseline 0.9). A tox screen was negative. HCT was 40.4. Cortisol was 21.7. A head CT was negative; a chest CT showed LLL PNA vs atelectasis and A/P CT showed only gall bladder sludge. His mental status "improved with fluid resuscitation by 22:41." . The patient was admitted to the ICU for an Insulin Drip. Several things happened: 1. AG Closed and sugar slowly normalized at 4U per hour drip with NPH 12u on [**11-23**] in the AM and 6 U before transfer in the PM. His OSM went fro 332-326, his serum ketones were 80.He received 3L of NS in the ED and D51/2NS at 200cc in the ICU 2. LP was performed with WBC 0 and 7 RBC (No polys, negative GS); Protein 127 and Glucose 164. 3. Troponin at 10pm on [**11-22**] was 0.06, 2.0 at 7A on [**11-23**] and 1.6 at 2pm on [**11-23**]. He had serial EKGs with "STE in Anterior leads" that were considered part of his baseline. Cardiology was consulted and performed a TTE where there were no WMA and an EF of 75%. He never received an Aspirin. 4. Infectious Disease was consulted an reccomended Ceftriaxone, Vancomycin and Acyclovir for PNA vs Meningitis. He also received one dose of Zosyn. He never had any neck stiffness or fever. ABG 7.36/37/84/21, lactate 0.8 5. Renal insufficiency improved to 2.3 . At the time of transfer, his insulin at 4 U/Hr. He was received D5/1/2NS at 100 cc/hr through two PIV. His HR was 80-100's, BP 113-147/62-76, Sp02 98-100%. An NGT in place (for PO contrast), clamped. Foley draining at 45-120/hr. He was occasionally crying, rubbing his legs. Past Medical History: 1. IDDM. C/b nephropathy, retinopathy 2. Kidney transplant [**2178**] in Michicago. He had good graft function without significant proteinuria as of [**10-8**]. 3. Hypertension. 4. Recent CVA - now on full dose ASA but does not want to take pravachol. Social History: sister denied t/e/d "very independent", lives alone with frequent contact with sisters. His apartment is "immaculate". Has involved sisters, though he has verbal fights with one sister. Family History: DM and Asthma Physical Exam: On Admission: VS: Temp: afebrile BP: 156/73/ HR: 90-110 RR:16 O2sa: 98 GEN: Dishevelled, malodorous;Eyes closed, interactive, nonverbal, two crying spells. Ketotic breath HEENT: anicteric, severe cataract, equally round, unreactive pupils, Dry MM, Poor dentitition, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: CTA b/l with good air movement throughout CV: Tachy with RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly. RLQ scar. EXT: no c/c/e. SKIN: Severely Dry scales, several excoriations without obvious infection over arms, legs. Abrasions over backside covered with bandage NEURO: No obvious posturing. Antalgic smile, will not protrude tongue, 5/5 strength on right, 1-2/5 hand strength on left, [**4-3**] arm strength. Can move both legs with 4/5 strength on left. 2+DTR's-patellar and biceps On Discharge: Objective:Tm:98.5 P:91-93 BP:131-142/90-94 RR:18 O2sat:98-100%RA CBG: 140/227/100/132 General: Male in no acute distress HEENT: PERRLA. Supple neck Chest: Clear to auscultation anteriorly. No crackles or wheezing noted Heart: Regular rate and rhythm. No murmurs or gallops appreciated Abdomen: Soft, nontender and nondistended. Normoactive bowel sounds. External: No edema. No rash. Neuro: CN 2-12 intact. Alert and oriented to person, place and time. No expressive or receptive aphasia. [**5-3**] motor strength @ UE and LE. Mild stuttering of his speech which is at baseline according to sister. Legally [**Name2 (NI) 11345**]. Pertinent Results: [**2197-11-23**] 08:24PM GLUCOSE-109* UREA N-40* CREAT-1.7* SODIUM-141 POTASSIUM-3.5 CHLORIDE-109* TOTAL CO2-21* ANION GAP-15 [**2197-11-23**] 08:24PM LD(LDH)-215 CK(CPK)-1011* TOT BILI-2.4* [**2197-11-23**] 08:24PM CK-MB-5 cTropnT-0.10* [**2197-11-23**] 08:24PM CK-MB-5 cTropnT-0.10* [**2197-11-23**] 08:24PM CALCIUM-8.7 PHOSPHATE-1.9* MAGNESIUM-1.8 [**2197-11-23**] 08:24PM CALCIUM-8.7 PHOSPHATE-1.9* MAGNESIUM-1.8 [**2197-11-23**] 08:24PM HAPTOGLOB-175 [**2197-11-23**] 08:24PM TSH-2.3 [**2197-11-23**] 08:24PM WBC-10.4 RBC-3.58* HGB-11.8* HCT-34.5* MCV-97 MCH-32.9* MCHC-34.0 RDW-12.9 Discharge Labs: [**2197-12-3**] 06:00AM BLOOD WBC-10.3 RBC-3.52* Hgb-11.7* Hct-34.7* MCV-99* MCH-33.2* MCHC-33.7 RDW-13.2 Plt Ct-311 [**2197-11-29**] 05:10AM BLOOD Neuts-75.1* Lymphs-18.7 Monos-4.1 Eos-1.5 Baso-0.5 [**2197-12-5**] 04:55AM BLOOD Glucose-129* UreaN-29* Creat-1.6* Na-139 K-4.2 Cl-102 HCO3-26 AnGap-15 [**2197-12-1**] 04:40AM BLOOD ALT-34 AST-55* AlkPhos-89 TotBili-0.5 [**2197-12-3**] 08:55AM BLOOD Calcium-9.7 Phos-3.2 Mg-1.7 [**2197-11-24**] 03:21AM BLOOD VitB12-GREATER TH [**2197-11-23**] 08:24PM BLOOD TSH-2.3 [**2197-12-5**] 04:55AM BLOOD tacroFK-5.1 . Pertinent Imaging EEG ([**2197-11-24**]): ABNORMALITY #1: Throughout the recording the background rhythm was often suppressed in voltage and also it was usually of slower frequencies, typically in the [**4-4**] Hz range. There were runs of faster activity with a generalized distribution. Toward the end of the recording, background frequencies improved significantly, and the recording began to resemble drowsiness and sleep. ABNORMALITY #2: There were additional bursts of generalized delta slowing, sometimes followed by the generalized faster activity. HYPERVENTILATION: Could not be performed. INTERMITTENT PHOTIC STIMULATION: Could not be performed. SLEEP: No normal waking or sleeping patterns were evident early in the recording, but drowsiness or early sleep emerged toward the end. CARDIAC MONITOR: Showed a generally regular rhythm. IMPRESSION: Abnormal portable EEG due to the substantial suppression of the background with slower frequencies throughout and occasional bursts of generalized slowing. These findings suggest a widespread encephalopathy, with medications among the most common causes. Metabolic disturbances and infection are other possibilities. There were no prominent focal abnormalities, but encephalopathies may obscure focal findings. Later in the record, the background included faster frequencies and suggested the presence of drowsiness or early sleep. This could be the manifestation of a milder encephalopathy. There were no clearly epileptiform features. . MRI Head without contrast ([**2197-11-25**]): 1. No acute infarction. Dystrophic right globe- correlate clinically. . EEG ([**2197-12-3**]): No pushbutton for seizure symptoms occurred. The recording, however, continues to show frequent bursts of frontal central synchronous rhythmic theta and occasional delta frequency activity suggesting a projected abnormality although there are some independent- appearing runs over the right central region. No clear epileptic activity was identified . EKG ([**2197-11-23**]): Sinus rhythm. Non-specific ST-T wave changes. No previous tracing available for comparison. . LP records from OSH showed no WBC, few RBC. Gram stain did not show anything. . Brief Hospital Course: This is a 46 year old male with IDDM, s/p DD Renal Tx ([**2178**]), s/p R MCA CVA [**12/2196**] (L weakness), Blindness, presenting from [**Hospital1 3597**] MICU for further management of DKA, [**Last Name (un) **], and minimal responsiveness after being found down by family. 1. Altered Mental Status - The patient's mental status on admission was minimally responsive but cooperating with commands; he did not speak or open his eyes. The differential included tacrolimus toxicity, meningitis, cerebrovascular accident, seizures or psychotic disorder. . An LP was performed at the OSH prior to transfer and the CSF was sent for culture, Tb, HSV PCR, CMV, cryptococcus, and West [**Doctor First Name **] antibody. Once the records were obtained the latter stuides were found to be negative. Empiric antiobiotics were started on admission (Vancomycin, ceftriaxone) but were discontinued when outside hospital records showed no source of infection. . His mental status improved to baseline over next few days. Unsure of the etiology. CT/MRI head negative for acute intracranial process. 24 EEG did not show epileptiform etiology. Psychology did not think he has selective mutism. Mental status improved spontaneously to baseline by time of discharge (confirmed with his sister [**Location (un) 19904**]. . 2. Diabetic ketoacidosis - Unclear precipitant. Non-adherence was considered; however, we also were concerned with underlying infection. He was initially on an insulin drip while in the unit, as well as on the floor due to poor glucose control with sliding scale insulin. Endocronolgy was consulted and his glucose were well controlled with their help. His final insulin regimen on discharge was lantus 22 units in the morning with humalog 6, 3 and 4 fixed dose units with meals 9breakfast, lunch and dinner respectively) and sliding scale humalog insulin. . 3. [**Last Name (un) **] - not likely tacrolimus toxicity. Renal transplant team was following him while he was on the floor and in the ICU. His renal function improved and he was restarted on tacrolimus, Imuran and Prednisone daily for immunosuppression. His discharge tacrolimus dose was 4 mg po BID. He was started on Bactrim SS daily for PCP [**Name Initial (PRE) 1102**]. . 4. Elevated cardiac enzymes. He has an elevated CK to 1011 with troponin up to 0.10 here, likely due to being found down on the floor. EKG has baseline STE in V1-V3. Started aspirin and cardiac enzymes have trended downward. He had no events on telemetry while in the hospital. . #. Hyperbilirubinemia - Peaked at 5.1, now down to 2.4 on admission here which is mostly indirect. Unclear source with schistocytes on peripheral smear but haptoglobin and LDH negative. Prior to discharge his Bili was within normal ranges. . # Hx of CVA: Aspirin 325 mg po qdaily was continued for secondary prophylaxis. MRI and CT head did not show new cerebrovascular accident. . #. Hyperlipidemia - Patient is not on a statin. This can be initiate when he sees his primary care or follow-up care at rehab. . #. Communication: [**Name (NI) 19904**] [**Name (NI) **], Sister and HCP. [**Telephone/Fax (1) 26629**] . #. Full Code . . PENDING ISSUES: (1) Monitoring tacrolimus levels. Please send tacrolimus trough levels to [**Telephone/Fax (1) 673**] on [**2197-12-6**] and [**2197-12-7**]. Send to Dr. [**Last Name (STitle) **] in Nephrology. Please ask for [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7749**]. Medications on Admission: HOME MEDICATIONS: 1. AZATHIOPRINE [IMURAN] - 50 mg t once a day 2. PREDNISONE 5 mg once a day 3. TACROLIMUS [PROGRAF] - 0.5 mg Capsule twice a day 4. TACROLIMUS [PROGRAF] - 1 mg Capsule - 3 Capsule(s) by mouth twice a day 5. INSULIN REGULAR HUMAN - am scale is 1 more unit than hs scale as directed 6. MULTIVITAMIN once a day 7. NPH INSULIN HUMAN RECOMB 24unit in am 6 units in pm OTCs: 5. ASPIRIN-CAFFEINE [ANALGESIC] 325 mg Tablet daily 6. ERGOCALCIFEROL 5,000 unit Tablet - 1 Tablet(s) by mouth daily . MEDS IN MICU: 1. KCl 20meq D5 [**12-31**]. 2. Aspirin 325 3. Azathioprine 50 PO/NG Daily 4. Ceftriaxone 1g IV/day Day1 = [**11-23**] 5. Heparin SC 5000 TID 6. Sliding Scale Insulin 7. Prednisone 5 Daily 8. Tacrolimus 2mg PO BID 9. Vancomycin 1000 IV Q12Hrs D1=[**11-23**] Discharge Medications: 1. azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. tacrolimus 0.5 mg Capsule Sig: Eight (8) Capsule PO BID (2 times a day): Total of 4 mg by mouth twice a day. 4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. insulin glargine 100 unit/mL Solution Sig: Twenty Two (22) units Subcutaneous QAM (mornings). 7. Insulin Humalog Fixed doses with meals. 6 units with breakfast 3 units with lunch 4 units with dinner 8. Insulin Humalog Sliding scale doses based on fingersticks: Please see attached sliding scale 9. Blood work Please send tacrolimus trough levels to [**Telephone/Fax (1) 673**] on [**2197-12-6**] and [**2197-12-7**]. Send to Dr. [**Last Name (STitle) **] in Nephrology. Please ask for [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7749**]. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] [**Location (un) 86**] Discharge Diagnosis: Primary Diagnosis 1. Altered mental status of unknown etiology 2. Diabetic ketoacidosis . Secondary Diagnosis 1. Type I diabetes mellitus 2. s/p kidney transplant in [**2178**] 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 transferred to our hospital from an outside facility, where you were brought because you were found to be unresponsive by your family members. Imaging of your head with MRI and CT did not show any pathology to expalin your symptoms. Your records from outside hospital did not show infection in your brain, blood or urine. EEG of your brain by neurology did not show any seizure activity. You returned to your baseline over the next few days. You were discharged to [**Hospital3 **]. . Followup Instructions: Department: TRANSPLANT CENTER When: TUESDAY [**2198-4-17**] at 11:00 AM With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

[ "729.89", "401.9", "250.43", "272.4", "784.3", "362.01", "369.4", "782.4", "438.89", "583.81", "250.13", "250.53", "790.7", "584.9", "V58.67", "349.82" ]

icd9cm

[ [ [] ] ]

[ "96.6" ]

icd9pcs

[ [ [] ] ]

13236, 13304

7948, 11423

330, 336

13525, 13525

4551, 5159

14229, 14538

2945, 2960

12255, 13213

13325, 13504

11449, 11449

13708, 14206

5175, 7925

2975, 2975

11467, 12232

3896, 4532

251, 292

364, 2449

2989, 3882

13540, 13684

2471, 2726

2742, 2929

69,805

109,255

40147+58353

Discharge summary

report+addendum

Admission Date: [**2183-12-24**] Discharge Date: [**2184-1-6**] Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: Generally asymptomatic, slight dyspnea with walking greater than 150 feet Major Surgical or Invasive Procedure: [**2183-12-24**] 1) Coronary artery bypass grafting x3, left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the marginal branch and ramus intermedius. 2) Aortic valve replacement, 23-mm Biocor Epic tissue valve. 3) Aortic endarterectomy. History of Present Illness: 85yo man with known aortic stenosis followed by serial echocardiograms over last 3 years. Presents for surgical evaluation. Cardiac Catheterization: [**2183-12-3**] [**Hospital3 20284**] Center, [**Hospital1 189**] 1. Critical AS [**Location (un) 109**] 0.7cm2 2. normal to hyperdynamic LV systolic function 3. mild pulmonary htn 4. systemic htn 5. cors: LM 50% distal RI 90% LAD 30% mid RCA near normal 6. calcified aortic arch [**2183-10-17**] Echocardiogram: LVEF 65%. Severe aortic stenosis with [**Location (un) 109**] 0.7cm2 with mean gradient of 76mmHg, mild aortic insufficiency. Trace MR. [**First Name (Titles) **] [**Last Name (Titles) **]. Mild pulmonary HTN(PASP 42mmHg). Normal aortic dimensions-root 3.0. Carotid Ultrasound: 40-59% bilaterally Past Medical History: Aortic Stenosis/aortic insufficiency s/p AVR/CABG [**2183-12-24**] Coronary artery disease Hypertension Paroxysmal atrial fibrillation Benign Prostatic Hypertrophy Chronic Renal Insufficiency(creatinine 1.6) with acute kidney injury this admission due to hypovolemia (Cr rose to 3.0) Past Surgical History: Inguinal hernia repair Social History: Race: Caucasian Last Dental Exam: [**2183-5-17**], will schedule exam before surgery Lives with: Son and daughter-in-law Occupation: Retired printer Tobacco: Quit 40 years ago ETOH: [**2-19**] glasses of wine/year Family History: Non contributory Physical Exam: Pulse:79 Resp: 18 O2 sat: 100%-RA B/P Right:138/53 Left: 131/50 Height: 5'8" Weight: 184lbs General: NADS Skin: Warm[x] Dry [x] intact [x] HEENT: NCAT[x] PERRLA [x] EOMI [x] MMM-normal oropharynx Neck: Supple [x] Full ROM [x] no JVD Chest: Lungs clear bilaterally [x] Heart: RRR [x] Murmur 4/6 SEM Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema: none Varicosities: None [x] Neuro: A&O x3, MAE, non focal exam Pulses: Femoral Right: 2+ Left: 2+ DP Right: - Left: - PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit -radiated murmur bilaterally Discharge Physical Exam: VS: General: 85 year-old male no apparent distress HEENT: normocephalic, mucus membranes moist Neck; supple no lymphadenopathy Card: RRR normal S1,S2 no murmur/gallop or rub GI: benign Extr: warm 3+ edema Incision: sternal clean, dry intact, bilateral extremities clean dry intact incision upper thigh area with scab Neuro: awake, alert, oriented. moves all extremities Pertinent Results: [**2184-1-3**] Hct-27.7 [**2184-1-2**] WBC-6.6 RBC-3.29* Hgb-9.9* Hct-29.8* MCV-91 MCH-30.0 MCHC-33.1 RDW-14.4 Plt Ct-178 [**2183-12-30**] WBC-6.9 RBC-3.26* Hgb-10.0* Hct-30.2* MCV-93 MCH-30.6 MCHC-33.0 RDW-14.6 Plt Ct-138* [**2184-1-4**] Glucose-95 UreaN-66* Creat-2.0* Na-139 K-4.1 Cl-107 HCO3-26 [**2184-1-3**] UreaN-79* Creat-2.2* Na-141 K-4.2 Cl-109* [**2184-1-2**] Glucose-93 UreaN-82* Creat-2.3* Na-141 K-4.2 Cl-109* HCO3-25 [**2183-12-30**] Glucose-103* UreaN-80* Creat-2.6* Na-145 K-3.7 Cl-109* HCO3-25 [**2183-12-29**] Glucose-95 UreaN-71* Creat-2.8* Na-142 K-3.8 Cl-109* HCO3-24 [**2183-12-29**] Glucose-85 UreaN-60* Creat-2.3* Na-144 K-3.2* Cl-116* HCO3-22 [**2183-12-28**] Glucose-112* UreaN-70* Creat-2.9* Na-141 K-3.7 Cl-109* HCO3-25 [**2183-12-28**] Glucose-101* UreaN-64* Creat-3.0* Na-139 K-3.6 Cl-107 HCO3-24 [**2183-12-24**] Echo Prebypass No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is mild valvular mitral stenosis (area 1.5-2.0cm2). Mild to moderate ([**1-18**]+) mitral regurgitation is seen. Post bypass Patient is AV paced and receiving an infusion of phenylephrine. Biventricular systolic function is unchanged. Bioprosthetic valve noted in the aortic position. The valve appears well seated. The leaflets are difficult to visualize. Mild mitral regurgitation present. Aorta is intact post decannulation CXR [**2183-12-31**]: IMPRESSION: Persistent patchy left lower lobe opacity, but probably somewhat improved, with a suspected tiny residual pleural effusion. [**2183-12-24**]: FINDINGS: In comparison with a preoperative study, there has been a CABG procedure performed. Endotracheal tube tip lies approximately 7 cm above the carina and is at the mid clavicular level. Right IJ Swan-Ganz catheter is in the right pulmonary artery. Nasogastric tube is coiled in the fundus of the stomach. Left chest tube is in place and there is no pneumothorax. Retrocardiac atelectasis is seen. IMPRESSION: Standard appearance following CABG. Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [**2183-12-24**] where the patient underwent coronary artery bypass grafting x3, left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the marginal branch and ramus intermedius and aortic valve replacement with 23-mm Biocor Epic tissue valve. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. He did have some post operative confusion requiring Haldol. At the time of discharge he was oriented x 3 and not requiring Haldol. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. He did have post operative ATN with a peak crea to 3.0 and peak BUN to 85. Lasix was decreased and his renal function was stable at the time of discharge with BUN 66, CRE 2.0. He was hypertensive amlodipine was started the ACE held secondary to his renal function. While working with PT his systolic blood pressure was 190. He was started on hydralazine with good effect. His Foley catheter had to be reinserted on POD4 for urinary retention. He was restarted on his home dose of Terazosin and Foley was removed again on POD6 and he did void successfully. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 12 the patient was ambulating independently the wound was healing and pain was controlled with Tylenol. The patient was discharged to home with VNA and PT. He will have his renal function checked on [**2184-1-6**]. He will follow-up with his nephrologist Dr. [**Last Name (STitle) 88186**] in 2 weeks and Dr. [**Last Name (STitle) **] and his PCP in one month. Medications on Admission: Amiodarone 200 QD Hydrochlorthiazide 25 QS Lisinopril 40 QD Lovastatin 20 QD Terazosin 2 WQD MVI Allergies:NKDA Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 6. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 7. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 8. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**1-18**] puff Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*qs inhaler* Refills:*1* 9. amlodipine 10 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 10. Outpatient Lab Work Chem 7 BUN & CRE. Please call [**Doctor First Name **] at Dr.[**Name (NI) 5572**] office [**Telephone/Fax (1) 170**] with results. 11. lovastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 12. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 14. hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:*120 Tablet(s)* Refills:*2* Discharge Disposition: Home with Service Facility: Palm [**Hospital 731**] Nursing Home - [**Location (un) 15749**] Discharge Diagnosis: Aortic Stenosis/aortic insufficiency s/p AVR/CABG [**2183-12-24**] Coronary artery disease Hypertension Paroxysmal atrial fibrillation Benign Prostatic Hypertrophy Chronic Renal Insufficiency(creatinine 1.6) with acute kidney injury this admission due to hypovolemia (Cr rose to 3.0) Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Tylenol Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. [**2-19**]+ Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [**Last Name (STitle) **] [**2183-1-29**] at 2:15 PM Cardiologist: Dr [**Last Name (STitle) 5655**] on [**2183-2-13**] at 9:00 AM Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 1169**] [**Last Name (NamePattern1) 79**] in [**4-21**] weeks Please call Dr.[**Name (NI) 88187**] office (nephrologist) [**Telephone/Fax (1) 24335**] for an appointment within 2 weeks Blood draw on Tuesday with VNA Electrolytes BUN/CRE. Please call results to [**Doctor First Name **] at Dr.[**Name (NI) 5572**] office [**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** Completed by:[**2184-1-5**] Name: [**Known lastname 13986**],[**Known firstname 140**] Unit No: [**Numeric Identifier 13987**] Admission Date: [**2183-12-24**] Discharge Date: [**2184-1-6**] Date of Birth: [**2098-1-8**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 741**] Addendum: Mr. [**Known lastname **] developed rapid atrial fibrillation which was treated with amiodarone, beta blocker and coumadin was initiated. He stayed inpatient one extra day for this. He was discharged to home with VNA on POD 13 with all follow-up appointments advised. Coumadin will be followed by Dr. [**Name (NI) 10738**] office until the patient is accepted in to the VA coumadin clinic. Discharge Disposition: Home With Service Facility: [**Last Name (LF) 1066**], [**First Name3 (LF) **] [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2184-1-6**]

[ "600.01", "424.1", "427.31", "276.52", "293.9", "403.90", "584.5", "V58.61", "414.01", "788.21", "585.3" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

12799, 13002

5781, 7917

332, 635

10080, 10305

3166, 5758

11145, 12776

2029, 2048

8081, 9634

9773, 10059

7943, 8058

10329, 11122

1756, 1781

2063, 2750

218, 294

663, 1427

1449, 1733

1797, 2013

2775, 3147

43,927

110,958

34660

Discharge summary

report

Admission Date: [**2175-10-2**] Discharge Date: [**2175-10-6**] Date of Birth: [**2104-2-12**] Sex: F Service: CARDIOTHORACIC Allergies: Codeine / Protamine Sulfate Attending:[**First Name3 (LF) 1505**] Chief Complaint: Exertional chest pain Major Surgical or Invasive Procedure: [**2175-10-2**] Three Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary artery to left anterior descending artery with vein grafts to diagonal and obtuse marginal. History of Present Illness: Mrs. [**Known lastname **] is a 71 yo female with history of CAD s/p angioplasty of LAD in [**2175-6-14**], diabetes, and carotid disease with chest discomfort over the past month with mild exertion who was referred for catheterization. A complex restensosis of her intramyocardial LAD was found in addition to diagonal artery disease. Based on her significant LAD disease she is referred to Dr. [**Last Name (STitle) **] for surgical evaluation. Past Medical History: Hypertension Hyperlipidemia Diabetes type II Carotid artery disease Asthma Sinusitis Pancreatisis [**2172**] Colon polyp removed [**2174**] Mild arthritis in the winter Kidney stones 35 years ago s/p tonsillectomy Bilateral cataract surgery s/p PPM for presyncope Social History: Lives alone. Occasional wine. 10 pack year history of tobacco, quit over 35 years ago. Denies recreational drug use. Does not use any assistive devices to ambulate. Daughter helps pt make medical decisions and is her HCP. Family History: Mother died of breath cancer age 54; brother had brain cancer Physical Exam: Pulse: 80 SR Resp: 18 O2 sat: 98% RA B/P Right: 169/78 Left: 173/74 Height:4'[**76**]" Weight:61.2 kg (135 lbs) General: WDWN female in NAD Skin: Warm, dry and intact. NO C/C/E HEENT: NCAT, PERRLA, EOMI< Sclera anicteric, OP benign Neck: Supple [X] Full ROM [X] No JVD Chest: Lungs clear bilaterally [X] Heart: RRR [X] No M/R/G Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] No Edema Varicosities: Spider veins present (B). Mild anterior varicosities below knee but GSV appears suitable. Neuro: Grossly intact Pulses: Femoral Right: 2 Left: 2 DP Right: 1 Left: 1 PT [**Name (NI) 167**]: 1 Left: 1 Radial Right: 2 Left: 1 Carotid Bruit Right: Mild bruit Left: None Pertinent Results: [**2175-10-2**] Intraop TEE -- Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. 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. Trivial mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: Patient is AV-Paced, on NTG infusion. Preserved biventricular systolic fxn. Trace MR. [**First Name (Titles) **] [**Last Name (Titles) **]. Aorta intact. Other parameters as pre-bypass. [**2175-10-5**] 05:50AM BLOOD WBC-11.7* RBC-3.00* Hgb-9.0* Hct-27.1* MCV-90 MCH-29.9 MCHC-33.2 RDW-14.3 Plt Ct-182 [**2175-10-5**] 05:50AM BLOOD Plt Ct-182 [**2175-10-5**] 05:50AM BLOOD Glucose-84 UreaN-27* Creat-0.6 Na-140 K-3.8 Cl-104 HCO3-31 AnGap-9 Brief Hospital Course: On [**10-2**] Ms. [**Known lastname **] was admitted and taken to the operating room where she underwent coronary artery bypass grafting x 3 (left internal mammary artery to left anterior descending artery with vein grafts to diagonal and obtuse marginal) with Dr.[**Last Name (STitle) **]. Cross clamp time was 46 minutes. Cardiopulmonary Bypass time was 62 minutes. Please refer to Dr.[**Name (NI) 5572**] operative note for further surgical details. She was intubated and sedated, transferred to the CVICU in critical but stable condition. Within 24 hours, she awoke neurologically intact and was extubated without incident. All lines and drains were discontinued in a timely fashion. Beta-blocker/Statin/ASA/Plavix and diuresis was initiated. She continued to progress and was transferred to the step down unit for further monitoring. Physical therapy was consulted for evaluation. The remainder of her postoperative course was essentially uneventful. She was cleared by Dr.[**Last Name (STitle) **] for discharge to rehab on POD# four. All follow up appointments were advised. Medications on Admission: Lipitor 40mg daily Advair Disk 250 mcg/50mcg 1 inhalation each day Metformin 500mg one tablet once daily Toprol XL 25mg two tablets in am and two tablets in pm Singular 10mg once a day Ambien 10mg daily at hs Aspirin 325mg daily Calcium with vitamin D 600mg/400IU daily Plavix 75mg daily - last dose [**2175-9-26**] Claritin 10mg daily Quinapril Hcl 40mg daily Fish oil 1000mg daily Vitamin A, C, E twice daily Albuterol inhalation PRN Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Disp:*20 Tablet(s)* Refills:*2* 5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10 days. Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* 6. Metformin 500 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*60 Disk with Device(s)* Refills:*2* 9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 11. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:*qs * Refills:*0* 13. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-16**] Drops Ophthalmic PRN (as needed) as needed for itching/redness. Disp:*qs * Refills:*0* 14. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. Disp:*30 ML(s)* Refills:*0* 15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. Disp:*30 Suppository(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: Coronary Artery Disease, s/p CABG Hypertension Hyperlipidemia Diabetes mellitus type II Carotid Disease Prior PPM(for presyncope) Discharge Condition: Good Discharge Instructions: 1)No driving for one month 2)No lifting more than 10 lbs for at least 10 weeks from the date of surgery 3)Please shower daily. Wash surgical incisions with soap and water only. 4)Do not apply lotions, creams or ointments to any surgical incision. 5)Please call cardiac surgeon immediately if you experience fever, excessive weight gain and/or signs of a wound infection(erythema, drainage, etc...). Office number is [**Telephone/Fax (1) 170**]. 6)Call with any additional questions or concerns. Followup Instructions: Dr. [**Last Name (STitle) **] in [**3-19**] weeks, call for appt [**Telephone/Fax (1) 170**] Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**1-17**] weeks, call for appt Dr. [**Last Name (STitle) 6924**] in [**1-17**] weeks, call for appt ([**Telephone/Fax (2) 79498**] Wound check on [**Hospital Ward Name 121**] 6 as directed Completed by:[**2175-10-6**]

[ "414.2", "250.00", "401.9", "V45.82", "433.10", "414.01", "V12.72", "V13.01", "493.90", "413.9", "272.4" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

7073, 7146

3423, 4508

316, 507

7320, 7327

2412, 3400

7871, 8258

1528, 1591

4995, 7050

7167, 7299

4534, 4972

7351, 7848

1606, 2393

255, 278

535, 984

1006, 1272

1288, 1512

71,062

153,191

39965

Discharge summary

report

Admission Date: [**2120-11-11**] Discharge Date: [**2120-11-13**] Date of Birth: [**2065-2-28**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor Last Name 15044**] Chief Complaint: seziure Major Surgical or Invasive Procedure: None. History of Present Illness: HPI: 55 year old female, previously healthy, presents with two episodes concerning for seizure today. The patient was feeling well this morning but did not eat or drink in the morning because she had to take her mother to the doctor's office. While she was at lunch, she stood up, felt lightheaded, and fell down, hitting the left part of her forehead. The patient's mother was present and reported no shaking during the episode (though, of note, the patient's mother's doctor appointment was for a workup of dementia). The patient had loss of consciousness for 4-5 minutes. She did not bite her tongue, but by EMS report had urinary incontinence (though patient denies this). Although the patient reports she was alert and oriented in the ambulance and "just didn't want to go to the hospital," by EMS report she was confused and combative. Neurology was consulted given concern for seizure. When neurology asked how much alcohol the patient drinks, she was slow to answer and said she had to "think about it" because she "wanted to get it right." After a prolonged period of thinking, the patient's eyes and head deviated to the right and all extremities became stiff, with the left arm extended and the right arm bent. The patient also had lip smacking movements and bit her tongue. She was foaming at the mouth. There was tachycardia to the 160s with perioral cyanosis; O2 saturation unknown as the tracing was lost during the episode. She remained this way, without significant clonic movements, for approximately 4 minutes. After the episode, she awoke but was confused and combative. Lorazepam 1mg IV was given after the episode ended. ROS: Has a cough at baseline. No recent problems with fever, headache, vision, hearing, eating, swallowing, vomiting, diarrhea, constipation, urination, weakness, or paresthesias. Past Medical History: Otherwise Healthy Social History: Smokes cigarettes, 1ppd. Amount of alcohol use unclear; nursing was told that patient drinks "a lot," but after the seizure reported she drinks 2-3 drinks 2-3 times per week, and last drank last night for Halloween. Family History: Mom with dementia; remainder of family history unknown. Physical Exam: Exam: (Limited due to recent seizure as above) T- BP- HR- RR- O2Sat Gen: Lying in bed, NAD HEENT: There is a hematoma on the left forehead, and blood in the mouth where the patient bit her tongue during the seizure in the ED. Neck: Supple CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally Abd: +BS soft, nontender Ext: no edema Neurologic examination: Mental status: Initially alert, awake, with normal affect and able to relay history. After the seizure patient was confused, combative, asked the examiner how she could know she had a seizure if she didn't take a picture of it. Cranial Nerves: II: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. VII: Facial movement symmetric. VIII: Hearing grossly intact. IX & X: Palate elevation symmetric. Uvula is midline. Gives a good cough. [**Doctor First Name 81**]: Not tested (patient uncooperative after seizure) XII: Good bulk. No fasciculations. Tongue midline, movements intact. Motor: Moves all extremities antigravity with good strength. Not able to cooperate with more detailed testing. Deep tendon Reflexes: . Biceps: Tric: Brachial: Patellar: Achilles Toes: Right 2 2 2 2 2 WITHDRAWS Left 2 2 2 2 2 WITHDRAWS . Sensation: Withdraws to light touch in all extremities Coordination: Not tested Gait: Not tested Pertinent Results: [**2120-11-13**] 05:35AM BLOOD WBC-6.9 RBC-3.41* Hgb-11.6* Hct-35.4* MCV-104* MCH-34.0* MCHC-32.7 RDW-14.3 Plt Ct-263 [**2120-11-13**] 05:35AM BLOOD Glucose-82 UreaN-6 Creat-0.5 Na-140 K-4.3 Cl-107 HCO3-25 AnGap-12 [**2120-11-13**] 05:35AM BLOOD ALT-11 AST-23 AlkPhos-90 TotBili-0.4 [**2120-11-13**] 05:35AM BLOOD Albumin-3.6 Calcium-9.1 Phos-3.6 Mg-1.9 [**2120-11-11**] 04:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2120-11-12**] 06:20PM BLOOD Lactate-1.1 [**2120-11-13**] 05:35AM BLOOD Triglyc-129 HDL-54 CHOL/HD-4.0 LDLcalc-135* [**2120-11-13**] 05:35AM BLOOD TSH-0.69 [**2120-11-13**] 05:35AM BLOOD %HbA1c-PND Head CT ([**11-11**]) IMPRESSION: 1. Left frontal subgaleal hematoma. 2. Right mastoid air cells opacifications without fracture noted. If the temporal bone fracture is a clinical concern, then consider dedicated temporal bone CT for further evaluation. If not post-traumatic, may be post-inflammatory. Brief Hospital Course: Ms. [**Known lastname **] was admitted to the hospital after having a 2nd witnessed seizure in the emergency department. She was given ativan and then diazepam which stopped the seizure activity, but because of continued confusion, agitation and unclear degree of alcohol use, she was admitted to the intensive care unit. She was started on Keppra, monitored overnight in the ICU and then transferred to the general neurology floor. She had no further seizures during the hospitalization. Her EEG was normal. Her brain MRI showed evidence of vascular disease and her LDL cholesterol was 135. She was started on a statin, advised to stop smoking, maintain a heart healthy diet and exercise to minimize her risk of strokes. An incidental thyroid hypodensity was identified on her CT scan and she was advised to follow up with her primary care physician for further workup including an ultrasound. Her TSH was within normal limits. Because Ms. [**Known lastname **] did not have a PCP, [**Name10 (NameIs) **] arranged for her to follow up with the [**Hospital 18**] [**Hospital3 **] in the next several weeks. She was advised to immediately return to the hospital if she had any discharge from her nose, as she was at risk for a skull fracture given her periorbital hematomas from her fall (although all imaging was negative for fracture). She was also started on multivitamin, folate and thiamine prior to discharge, given her alcohol use. Medications on Admission: None. Discharge Medications: 1. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Tablet, Chewable(s) 3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: seizure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [**Known lastname **] you were admitted to the neurology service after having 2 seizures. We started you on a medication to prevent future seizures. This medication is Keppra and you should continue to take it when you are discharged from the hospital. Some small changes were noted on you brain MRI suggesting that you are at risk for strokes. It is important that you take a baby aspirin (81mg) everyday, take the cholesterol lowering medication (simvastatin), have close monitoring of your cholesterol by your primary care doctor, stop smoking and eat a heart-healthy diet with regular exercise to minimize your risk for strokes. There was also a small hypodensity found in your thyroid gland and you will need to have a thyroid ultrasound for follow up. Your primary care doctor will help to arrange this test. You will also need to follow up with the neurology doctors [**First Name (Titles) **] [**Last Name (Titles) **] of your seizures. Followup Instructions: Primary Care Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 54892**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2120-11-26**] 1:45 Neurology Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name 6596**] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2121-2-6**] 4:00 Will need thyroid ultrasound outpatient. Will need follow up of HgbA1C-pending at discharge.

[ "345.90", "873.42", "780.09", "E917.4", "272.4" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7214, 7220

5062, 6512

327, 334

7272, 7272

4080, 5039

8402, 8835

2496, 2553

6568, 7191

7241, 7251

6538, 6545

7423, 8379

2569, 2936

280, 289

362, 2204

3206, 4061

7287, 7399

2960, 2960

2226, 2245

2261, 2480

59,141

108,103

7013

Discharge summary

report

Admission Date: [**2181-2-8**] Discharge Date: [**2181-2-9**] Date of Birth: [**2118-5-23**] Sex: M Service: MEDICINE Allergies: Penicillins / Ace Inhibitors / Acebutolol / Atenolol / Betaxolol / Bisoprolol / Carvedilol / Labetalol / Metoprolol / Nadolol / Penbutolol / Pindolol / Propranolol / Timolol Attending:[**First Name3 (LF) 425**] Chief Complaint: Infected [**Hospital1 **]-V ICD leads and device Major Surgical or Invasive Procedure: s/p ICD lead and device extraction on [**2181-2-8**] History of Present Illness: 62 year old male patient of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 26237**], Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5051**], and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] who has an extensive past medical history including non-ischemic cardiomyopathy with an EF 15-20%, s/p initial implantation of an ICD in [**2175**] and a BiV lead upgrade in [**2179-8-21**]. Following the lead upgrade, the patient developed an erosion of the overlying skin which was complicated by an infection in the device pocket. The pocket was debrided on [**2180-8-18**]. Since that time, the patient has required multiple courses of antibiotics, both intravenous and oral. He is currently taking a 3-week course of oral cephalexin. He was referred for extraction of the ICD leads and device. Past Medical History: Past Medical History: 1. Nonischemic cardiomyopathy, chronic systolic heart failure. 2. Mitral regurgitation with pulmonary hypertension. 3. Ventricular tachycardia s/p ICD implantation [**2175**] 4. COPD. 5. Morbid obesity. 6. Spinal stenosis. 7. Right malignant renal tumor, s/p right nephrectomy 8. Stage 4 chronic renal failure. 9. Hypertension. 10. Leg ulcers. 11. Gout Other Past Surgeries: laparoscopic cholecystectomy in [**2174**], mini thoracotomy [**8-27**], hernia repair. Social History: The patient is a disabled former truck driver who currently helps run a home daycare center. He is married with adult children and lives with his wife. [**Name (NI) **] quit smoking at age 35. No alcohol,no drugs. Family History: No family history of premature CAD, sudden cardiac death, or arryhtmias. His father has a history of a cerebral hemmorhage. Physical Exam: General: Obese white male in no acute distress lying in bed. Neuro: Alert and oriented to person, place, and time. Cardiac: Regular rate and rhythm. Normal S1,S2. No murmurs/rubs/gallops. Resp: Lungs are diminished throughout. GI: Abdomen is large and softly distended. Bowel sounds are present. GU: Voids concentrated yellow urine. Integ: Left chest incision is covered with dry sterile dressing. Surrounding skin is reddened. No drainage noted. Periph vasc: Right femoral vein access site is intact. No hematoma or bruit. Distal pulses are present. Bilateral lower extremities are scaly, dusky, and dry. Feet are warm with decreased sensation. Right ankle ulcer is approximately [**12-22**] inch and no drainage is noted. Pertinent Results: [**2181-2-9**] 05:20AM BLOOD WBC-9.0 RBC-4.05* Hgb-11.2* Hct-34.8* MCV-86 MCH-27.7 MCHC-32.2 RDW-15.6* Plt Ct-203 [**2181-2-9**] 05:20AM BLOOD Plt Ct-203 [**2181-2-9**] 05:20AM BLOOD UreaN-54* Creat-3.1* Brief Hospital Course: ICD site infection: Patient was admitted to [**Hospital1 **] on [**2181-2-8**] and underwent extraction of ICD lead and device. He was admitted to the inpatient cardiac unit for observation and continuous cardiac monitoring. He was continued on all of his home medications. Oral cephalexin was continued as part of 3-week outpatient course. The patient remained afebrile with all vital signs stable during his hospitalization. Stage 4 chronic renal failure: Patient has a history of a malignant right renal tumor and a right nephrectomy [**2180-3-21**]. Creatinine at admission was 3.4 and on [**2-9**] was 3.1. Right foot ulcer: Patient has history of right ankle skin graft [**2180-2-19**] for a non-healing ulcer. An open area that remains is approximately [**12-22**] inch and was evaluated by a wound/ostomy nurse. Dressing changes were recommended and should be continued after transfer. Medications on Admission: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation [**Hospital1 **] (2 times a day). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Lasix 80 mg Tablet Sig: one and a half Tablet PO twice a day. 4. Imdur 30 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. 5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Quinidine Gluconate 324 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO QAM (once a day (in the morning)). 7. Quinidine Gluconate 324 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day): one tablet in afternoon and one tablet in evening, in addition to two tablets in the morning . 8. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 9. Mexiletine 200 mg Capsule Sig: Two (2) Capsule PO QAM (once a day (in the morning)). 10. Mexiletine 200 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): one capsule in the afternoon and one capsule in the evening in addition to two capsules every morning. 11. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily). 13. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation [**Hospital1 **] (2 times a day). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Lasix 80 mg Tablet Sig: one and a half Tablet PO twice a day. 4. Imdur 30 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. 5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Quinidine Gluconate 324 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO QAM (once a day (in the morning)). 7. Quinidine Gluconate 324 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day): one tablet in afternoon and one tablet in evening, in addition to two tablets in the morning . 8. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 9. Mexiletine 200 mg Capsule Sig: Two (2) Capsule PO QAM (once a day (in the morning)). 10. Mexiletine 200 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): one capsule in the afternoon and one capsule in the evening in addition to two capsules every morning. 11. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily). 13. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 1110**] Discharge Diagnosis: s/p ICD lead and device extraction secondary to infected pocket Discharge Condition: Vitals: 97.3 - 93/48 - 76 - 20 - 95% on room air Labs: BUN 54 Cre 3.1 WBC 9.0 Hgb 11.2 Hct 34.8 Plt 203 Neuro: Alert and oriented X 3. Cardiac: Regular rate and rhythm. Normal S1,S2. No murmurs appreciated. Respiratory: Lungs are diminished throughout. Peripheral vascular: Right femoral vein access site intact. No bleeding, hematoma, or bruit. Distal pulses are present. Skin: Left chest wall incision is intact and covered with a dry, sterile dressing. Surrounding skin has considerable erythema, but scant drainage. Discharge Instructions: Continue your current medications as prescribed. It is important that you complete your 3-week course of Cephalexin. Keep your chest dressing dry. The nurses at the rehabilitation facility will change the dressing daily. If you develop a fever, chills, or signs of worsening infection at the incision site, notify your doctor. Followup Instructions: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on Friday, [**2181-2-23**] at 3:40 p.m. ***Patient should be transported by ACLS ambluance to this appointment to maintain continuous cardiac monitoring.*** Completed by:[**2181-2-9**]

[ "707.14", "496", "425.4", "416.0", "428.22", "585.4", "996.61", "428.0", "403.90", "278.01" ]

icd9cm

[ [ [] ] ]

[ "37.77", "37.79" ]

icd9pcs

[ [ [] ] ]

7255, 7338

3314, 4217

480, 535

7445, 7975

3086, 3291

8354, 8611

2191, 2318

5749, 7232

7359, 7424

4243, 5726

7999, 8331

2333, 3067

392, 442

563, 1421

1465, 1941

1957, 2175

6,188

109,517

21635+21636

Discharge summary

report+report

Admission Date: [**2110-8-29**] Dictation Date: [**2110-9-25**] Date of Birth: [**2110-8-29**] Sex: M Service: NEONATOLOGY This is an interim dictation covering the period from birth to [**2110-9-25**]. HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname 56934**] is the former 1.41 kg product of a 33-2/7 weeks gestation pregnancy born to a 32-year-old G1 P0 woman. Prenatal screens: Blood type B positive, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, rubella immune, group B Strep status unknown. The pregnancy was complicated by pregnancy- induced hypertension. The mother presented on the day prior to delivery with increasing symptoms of evolving preeclampsia manifested by headaches and visual changes. Fetal ultrasound showed poor fetal growth. She was admitted to [**Hospital1 **] on [**2110-8-26**]. Estimated fetal weight was less than the third percentile and low amniotic fluid was noted. Elective induction of labor was undertaken, but the mother was taken to cesarean section due to intolerance of labor. The infant emerged with good tone and cry. Apgars were 8 at 1 minute and 8 at 5 minutes. He was admitted to the Neonatal Intensive Care Unit for treatment of prematurity. PHYSICAL EXAM UPON ADMISSION TO THE NEONATAL INTENSIVE CARE UNIT: Weight 1.41 kg, 10th percentile. Length 40 cm, 10th percentile. Head circumference 30.5 cm, 25th-50th percentile. General: Nondysmorphic preterm male, good activity and tone. Skin: Pink, no rashes. Head, eyes, ears, nose, and throat: Anterior fontanel is soft and flat. Positive red reflex bilaterally. Palate intact. Neck is supple without masses. Chest: No grunting, flaring, and retracting. Breath sounds clear and equal. Cardiovascular: Regular rate and rhythm without murmur. Normal S1, S2. Femoral pulses plus 2. Abdomen: Three-vessel cord, no masses, no hepatosplenomegaly, positive bowel sounds. GU: Preterm male, normal phallus. Testes descending. Anus: Patent. Spine: Straight, normal sacrum. Hips: Stable. Positive grasp. Positive morrow. Symmetric tone. HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY DATA: Respiratory: [**Known lastname **] was in room air for his entire Neonatal Intensive Care Unit admission. He did not have any episodes of spontaneous apnea or bradycardia until [**2110-9-20**] when he underwent a car seat test and had an episode of apnea and bradycardia. He was observed for an additional five days without any further episodes. Cardiovascular: [**Known lastname **] has remained normotensive with normal heart rates. A soft intermittent murmur was heard on day of life number 25. A chest x-ray, four limb blood pressures, and EKG were obtained with all results within normal limits. He passed an oxygen challenge test. At the time of dictation, the murmur was thought to be benign in nature. Fluid, electrolytes, and nutrition: [**Known lastname **] was initially nothing by mouth and started on intravenous fluids. He had intermittent episodes of hypoglycemia during the first week of life, which resolved with feedings and intravenous fluids. Enteral feeds were started on day of life number one and advanced to full volume. At the time of dictation, he is breast feeding or bottle feeding expressed breast milk fortified to 26 calories/ounce 4 calories by NeoSure powder and 2 calories by corn oil. Weight on the day of dictation is 2.195 kg, which is 4 pounds 13 ounces. Head circumference is 32 cm and length is 44 cm. Infectious disease: There were no infectious disease issues. Gastrointestinal: [**Known lastname **] required treatment for unconjugated hyperbilirubinemia with phototherapy. Peak serum bilirubin occurred on day of life two, total of 7.89 mg/dl/0.5 mg/dl. He received approximately six days of phototherapy. Rebound bilirubin on day of life eight was a total of 2.6 mg/dl/0.5 mg/dl. Hematological: Hematocrit was checked on day of life number six and was 53 percent. [**Known lastname **] did not receive any transfusions of blood products. He is being treated with supplemental iron. Neurology: [**Known lastname **] has maintained a normal neurological examination during admission. There are no neurological concerns at the time of discharge. Sensory: Audiology: Hearing screening was performed with automated auditory brain stem responses. [**Known lastname **] passed in both ears. Ophthalmology: Eyes were most recently examined on [**2110-9-22**]. Retinas were found to be immature to zone three with a recommended followup in three weeks. Appointment has been scheduled with Dr.[**First Name9 (NamePattern2) **] [**Name (STitle) **] for [**2110-10-23**] at 9 a.m. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Home with the parents. PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 56935**], M.D., [**Street Address(2) 56936**], [**Location (un) **], [**Numeric Identifier 56937**]. Phone number is ([**Telephone/Fax (1) 56938**]. Fax number is ([**Telephone/Fax (1) 56939**]. CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: FEEDING: Breast feeding or bottle feeding expressed mother's milk fortified to 26 calories/ounce 4 calories by NeoSure powder and 2 calories by corn oil. The NeoSure powder is recommended until 6-9 months corrected age. MEDICATIONS: Ferrous sulfate 25 mg/mL dilution 0.2 mL by mouth once daily. Vi-Daylin 1 mL by mouth once daily. CAR SEAT POSITION SCREENING: As previously mentioned. The initial car seat screening performed on [**2110-9-20**] had [**Known lastname **] failing. A repeat was performed on [**2110-9-24**], and [**Known lastname **] was observed for 90 minutes in his car seat without any episodes of oxygen desaturation or bradycardia. STATE NEWBORN SCREENS: Sent on [**9-2**] and [**2110-9-13**] with no notification of abnormal results to date. IMMUNIZATIONS RECEIVED: Hepatitis B vaccine was administered on [**2110-9-20**]. IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet any of the three criteria: 1. Born at less than 32 weeks, 2. Born between 32 and 35 weeks with two of three of the following: daycare during the RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, or school-age siblings, or 3. With chronic lung disease. Influenza immunization is recommended annually in the fall for all infants once they reach six months of age. Before this age and for the first 24 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers. FOLLOW-UP APPOINTMENTS SCHEDULED: Appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 56935**] within three days of discharge. Dr.[**First Name9 (NamePattern2) **] [**Name (STitle) **], Pediatric ophthalmologist for [**2110-10-23**] at 9 a.m. Phone number is ([**Telephone/Fax (1) 56940**]. DISCHARGE DIAGNOSES: Prematurity at 33-2/7 weeks gestation. Intrauterine growth restriction. Unconjugated hyperbilirubinemia . Apnea of prematurity. Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**] Dictated By:[**Last Name (NamePattern1) 43348**] MEDQUIST36 D: [**2110-9-25**] 02:53:58 T: [**2110-9-25**] 04:21:04 Job#: [**Job Number 56941**] Admission Date: [**2110-8-29**] Discharge Date: [**2110-10-5**] Date of Birth: [**2110-8-29**] Sex: M Service: NB ADDENDUM: This is an addendum discharge summary for Conner [**Known lastname 56934**] who is now a 37 day old, former 33 2/7 weeks infant who is ready for discharge home, continuing from the last summary dated [**2110-9-25**]. HOSPITAL COURSE: Respiratory status - On [**2110-9-25**], Conner had an episode of significant bradycardia and desaturations associated with feeding. His last episode occurred on [**2110-9-28**]. On examination his respirations are comfortable. Lung sounds are clear and equal. Cardiovascular status - In light of the infant's episodes of bradycardia, desaturation, murmur (and a family history of a sudden death of a paternal aunt at age 26 who had had a childhood of syncope), a Cardiology evaluation was prompted. The electrocardiogram of the infant from [**2110-9-24**] showed a prolonged QTC segment of 0.49. A 2nd electrocardiogram on [**2110-9-25**] showed a borderline prolonged QTC of 0.45. A 3rd electrocardiogram on [**2110-10-2**], showed a normal QTC segment. Conner should be followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43836**] of [**Hospital3 1810**] Cardiology Service one month after discharge. Telephone number for Ped Cardiology appointment is [**Telephone/Fax (1) 46235**]. On examination he had a Grade I/VI systolic ejection murmur on the left sternal border. He is pink and well perfused and he has remained normotensive. Fluids, electrolytes and nutrition status - At the time of discharge his weight is 2,705 gm. His length is 45.5 cm and head circumference is 33 cm. He is breastfeeding or taking supplemental breast milk or formula made with NeoSure powder. Hematological status - On [**2110-9-30**], his hematocrit was 31.4, and his reticulocyte count was 3.6 percent. ADDITIONAL DISCHARGE DIAGNOSIS: Status post transient prolonged QTC syndrome. Anemia of prematurity. [**First Name8 (NamePattern2) 1154**] [**Last Name (NamePattern1) **], MD [**MD Number(2) 56585**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2110-10-5**] 03:25:10 T: [**2110-10-5**] 07:16:23 Job#: [**Job Number 56942**]

[ "794.31", "779.3", "V05.3", "691.0", "771.6", "V30.01", "774.2", "765.15", "775.6", "V72.1", "770.81", "764.95", "779.81", "765.27" ]

icd9cm

[ [ [] ] ]

[ "99.83", "96.6", "99.55", "96.35" ]

icd9pcs

[ [ [] ] ]

4799, 6016

7080, 7841

9422, 9762

7859, 9400

6044, 7058

253, 4743

4768, 4775

24,617

192,762

24084

Discharge summary

report

Admission Date: [**2165-3-3**] Discharge Date: [**2165-3-14**] Date of Birth: [**2087-9-14**] Sex: F Service: NSU HISTORY OF PRESENT ILLNESS: The patient is a 77 year old woman with a past medical history significant for hypertension who awoke the morning of admission feeling "funny" while doing her morning routine. Per report from an outside hospital the patient then called a neighbor who noted the patient had slurred speech and left facial droop. The patient was also unable to ambulate, was still awake and alert. The patient was taken to an outside hospital where on CT she was noted to have a cerebellar hemorrhage extending into the ventricles. The patient was transferred to [**Hospital6 1760**] for further management. PAST MEDICAL HISTORY: Hypertension and hypercholesterolemia. MEDICATIONS: Zestril 20 q. day, Lipitor 10 q. day, hydrochlorothiazide 20 q. day, Toprol 50 q. day. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: Temperature was 96.5, 142/43 blood pressure, 60 heart rate, 12 respiratory rate, saturations 100% on nonrebreather. ICP was 7. The patient was sleepy but easily arousable, oriented x3, attending examiner. Speech was slurred but appropriate. Pupils equal, round and reactive to light. Eye movements, the patient had no voluntary eye movements, just torsional movements. The patient had a left facial droop. Her tongue was midline. Motor strength, she was 5 out of 5 in all muscles groups. Her reflexes were 2+ throughout. She has positive dysmetria bilaterally. Her toes were equivocal. Her gait was not tested. CT scan shows a 2.8 by 2 cm midline cerebellar hemorrhage with extension into the fourth and third ventricles. HOSPITAL COURSE: The patient was admitted to the ICU for close neurologic observation on [**3-3**]. After admission to the ICU the patient had a ventriculostomy drain placed. MRI showed left paramedian parenchymal-based pontine mid brain hemorrhage with mild ventricular enlargement, open cistern, no contrast enhancement, no signs of restricted diffusion, consistent with acute stroke. SVT from [**2165-3-4**], is stable. Due to the findings from the MRI scan neurology recommended doing conventional angiography. The patient did undergo this angiogram and it showed a basilar chip aneurysm. On [**2165-3-7**], the patient's centering was raised to 20 cm above the tragus. On exam the patient was following commands, wiggled her toes bilaterally, squeezed bilaterally. Her EOMs moved in all directions but were not full. [**2165-3-8**], the patient had a white-out of the left lung and required reintubation. Bronchoscopy showed left main stem bronchus and segmental bronchi with thick mucus and secretion plugging. [**2165-3-9**], the patient's ventriculostomy drain was clamped. The patient had a head CT which was stable with no change in the size of the ventricles. The patient was lethargic but still squeezing bilateral upper extremities and wiggling toes, opens eyes to voice. Blood pressure remains stable. [**2165-3-11**], the ventriculoscopy drain was discontinued. The patient's neurologic status remained stable. Cardiology was consulted regarding intermittent episodes of atrial fibrillation. The patient was started on amiodarone and had baseline TSH and liver function tests checked. EP saw the patient and felt the patient should just be observed, not loaded with amiodarone. The patient has not had any further episodes with AS. The patient had trach and PEG done on [**2165-3-12**], without complications. She remains on the ventilator but awake and alert following commands. She still has less facial droop and still has difficulty with her eye movements. DISCHARGE MEDICATIONS: 1. Heparin 5000 units subcutaneously t.i.d. 2. Insulin sliding scale. 3. Pantoprazole 40 p.o. q. day. 4. Lansoprazole 30 p.o. q. day. 5. Amiodarone 6. Hydralazine 60 mg p.o. q.6h., hold for SBP less than 110. CONDITION ON DISCHARGE: The patient's condition was stable at the time of discharge. FOLLOW UP: She will follow up with Dr. [**First Name (STitle) **] with a repeat head CT in one month. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 8632**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2165-3-13**] 16:22:41 T: [**2165-3-13**] 17:04:22 Job#: [**Job Number 61242**]

[ "E915", "431", "437.3", "272.0", "427.31", "934.1", "518.84", "305.1", "401.9", "331.4" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.6", "96.72", "43.11", "38.91", "33.22", "38.93", "02.39", "31.1" ]

icd9pcs

[ [ [] ] ]

3705, 3916

1722, 3682

4016, 4371

980, 1704

164, 754

777, 957

3941, 4004

31,054

119,104

26845

Discharge summary

report

Admission Date: [**2134-8-9**] Discharge Date: [**2134-8-26**] Date of Birth: [**2093-11-27**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Ethyl Alcohol / Erythromycin Base / Latex Gloves / Bactrim / Dilaudid Attending:[**First Name3 (LF) 922**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [**2134-8-11**] - Repair of thoracoabdominal aortic aneurysm with a 28-mm Vascutek (Cosselli) graft with multiple side branches to the visceral vessels and partial right heart bypass. History of Present Illness: 40 year old female who has undergone repair of type a dissection that represented abdominal pain with plan for intervention on thoracic aneurysm dilitation. However during that admission in [**2134-6-22**] she had sternal wire removal and was discharged for readmission now for treatment and heparin bridge prior to surgery. She continues with abdominal pain [**1-23**] times a week sharp lasting less than 30 minutes, continues on oxycodone. Admiited now for surgical management of her thoracoabdominal aortic aneurysm. Past Medical History: HTN Marfan's syndrome - first evaluated at the [**Hospital1 18**] on [**3-/2132**] for evaluation of a Type B aortic dissection - emergent repair of her type A dissection in [**1-/2134**] with ascending aorta replacement and CABG x 1 Asthma Hashimoto's thyroiditis Hyperprolactinemia Arthritis Loss of vision in the right eye Borderline ovarian cancer s/p LSO - Recent pelvic ultrasound returned normal Endometriosis - Controlled with Implanon Depression . Past Surgical History: Bentall procedure with CABG x 1 - Total arch replacement grafts to the LCCA and the innominate artery and Coronary artery bypass grafting w/ reverse saphenous vein graft from the neo ascending aorta to the LAD D&C with left salpingo-oophorectomy Polypectomy - HSC polypectomy - [**Hospital 8**] Hospital - Abd MMY - [**Hospital1 756**] - Laparoscopic lysis of adhesions of adhesionOA and Left Salpingo Oophorectomy for Borderline Ovarian Tumor - aortic dissection repair [**1-/2134**] Social History: Patient lives with husband in [**Name (NI) 577**]. She is not employed. She denies tobacco or ETOH or illicits. Family History: Cousin with Marfans, Ao dissection, and MI. Uncles with [**Name2 (NI) **]. No family hx of ovarian or breast cancer. Physical Exam: Pulse: 72 Resp: 18 O2 sat: 100% RA B/P Right: 122/70 Left: Height: Weight: 78.2 kgs 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 Crisp valve sounds Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: no Left: no Pertinent Results: [**2134-8-10**] ECHO Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF 60%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The descending thoracic aorta is mildly dilated. A bileaflet aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. Mild (1+) aortic regurgitation is seen. [The amount of regurgitation present is normal for this prosthetic aortic valve.] The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. [**2134-8-13**] Abdominal Ultrasound No evidence for biliary ductal dilation or hepatic arterial compromise. Given the technically limited nature of this examination, there is high concern for compromised hepatic arterial flow, cross-sectional (CTA) imaging is recommended. [**2134-8-14**] Abdominal MRA 1. Status post thoracoabdominal aortic graft placement with grafting of the celiac artery, SMA, and renal arteries. There is slight mural irregularity at the sites of the anastomoses, however, all of these vessels remain patent. 2. Slight heterogeneous perfusion on the left lateral segment of the liver, of uncertain significance. 3. Left-sided pleural effusion/seroma with associated atelectasis. 4. Slightly decreased enhancement of the medial left kidney, which may be due to ischemia. 5. Proteinaceous or hemorrhagic left renal cysts. [**2134-8-19**] Gallbladder Ultrasound: 1. Limited study, without evidence for biliary ductal dilatation. 2. Main hepatic artery and main portal vein appear grossly patent. Slight blunting of the systolic peak and notching of the waveform at early diastole are of uncertain significance, and may relate to the altered anatomy from aortic aneurysm repair and graft placement. [**2134-8-26**] WBC-13.5* RBC-3.40* Hgb-9.8* Hct-29.5* RDW-15.0 Plt Ct-623* [**2134-8-25**] WBC-14.0* RBC-3.60* Hgb-10.3* Hct-31.5* RDW-15.3 Plt Ct-636* [**2134-8-24**] WBC-16.0* RBC-3.74* Hgb-10.7* Hct-32.3* RDW-15.2 Plt Ct-500* [**2134-8-23**] WBC-19.2* RBC-4.04* Hgb-11.5* Hct-35.1* RDW-15.3 Plt Ct-457* [**2134-8-22**] WBC-17.6* RBC-3.94* Hgb-11.6* Hct-34.6* RDW-15.5 Plt Ct-385 [**2134-8-21**] WBC-13.7* RBC-3.87* Hgb-11.2* Hct-33.4* RDW-15.6* Plt Ct-266 [**2134-8-20**] WBC-12.4* RBC-4.15* Hgb-11.7* Hct-36.2 RDW-15.5 Plt Ct-237 [**2134-8-26**] PT-33.0* PTT-49.3* INR(PT)-3.3* [**2134-8-25**] PT-39.9* PTT-50.0* INR(PT)-4.2* [**2134-8-24**] PT-35.4* PTT-48.6* INR(PT)-3.6* [**2134-8-24**] PT-51.8* PTT-51.3* INR(PT)-5.7* [**2134-8-24**] PT-49.2* INR(PT)-5.4* [**2134-8-23**] PT-27.9* INR(PT)-2.7* [**2134-8-22**] PT-22.3* INR(PT)-2.1* [**2134-8-21**] PT-27.7* PTT-44.2* INR(PT)-2.7* [**2134-8-20**] PT-42.3* PTT-51.2* INR(PT)-4.5* [**2134-8-19**] PT-45.1* INR(PT)-4.8* [**2134-8-18**] PT-43.8* PTT-43.9* INR(PT)-4.7* [**2134-8-17**] PT-38.2* PTT-39.3* INR(PT)-4.0* [**2134-8-26**] Glucose-121* UreaN-8 Creat-0.5 Na-134 K-4.2 Cl-100 HCO3-25 [**2134-8-25**] Glucose-99 UreaN-9 Creat-0.6 Na-136 K-4.0 Cl-100 HCO3-26 AnGap-14 [**2134-8-24**] Glucose-91 UreaN-9 Creat-0.6 Na-136 K-3.8 Cl-102 HCO3-25 AnGap-13 [**2134-8-23**] Glucose-89 UreaN-7 Creat-0.6 Na-134 K-4.0 Cl-98 HCO3-27 AnGap-13 [**2134-8-22**] Glucose-87 UreaN-9 Creat-0.6 Na-135 K-4.2 Cl-99 HCO3-27 AnGap-13 [**2134-8-21**] Glucose-105* UreaN-9 Creat-0.7 Na-134 K-3.9 Cl-101 HCO3-27 [**2134-8-20**] Glucose-96 UreaN-10 Creat-0.9 Na-135 K-3.6 Cl-99 HCO3-28 AnGap-12 [**2134-8-26**] ALT-91* AST-49* LD(LDH)-420* AlkPhos-152* Amylase-143* TotBili-2.6* [**2134-8-25**] ALT-106* AST-50* LD(LDH)-473* AlkPhos-159* Amylase-121* TotBili-2.8* [**2134-8-23**] ALT-174* AST-50* LD(LDH)-470* AlkPhos-186* Amylase-109* TotBili-3.9* [**2134-8-22**] ALT-211* AST-58* LD(LDH)-467* AlkPhos-197* Amylase-103* TotBili-4.4* [**2134-8-21**] ALT-260* AST-79* LD(LDH)-452* AlkPhos-199* Amylase-105* TotBili-5.9* [**2134-8-20**] ALT-357* AST-98* LD(LDH)-492* AlkPhos-188* Amylase-112* TotBili-5.6* [**2134-8-19**] ALT-481* AST-130* LD(LDH)-609* AlkPhos-138* Amylase-143* TotBili-7.1* DirBili-4.4* IndBili-2.7 [**2134-8-17**] ALT-932* AST-312* LD(LDH)-576* AlkPhos-127* Amylase-158* TotBili-5.7* DirBili-3.7* IndBili-2.0 [**2134-8-26**] Lipase-166* [**2134-8-25**] Lipase-179* [**2134-8-23**] Lipase-145* [**2134-8-22**] Lipase-119* [**2134-8-21**] Lipase-125* [**2134-8-20**] Lipase-125* [**2134-8-26**] Albumin-2.8* Calcium-8.1* Phos-3.3 Mg-1.9 [**2134-8-25**] Albumin-3.1* Calcium-8.3* Phos-3.4 Mg-2.0 [**2134-8-21**] Albumin-2.5* Calcium-8.2* Phos-3.1# Mg-1.9 [**2134-8-20**] Albumin-2.7* Calcium-8.1* Phos-5.0* Mg-1.8 [**2134-8-17**] Albumin-2.7* Phos-2.5* Mg-2.2 Brief Hospital Course: Mrs. [**Known lastname 15785**] was admitted to the [**Hospital1 18**] on [**2134-8-9**] for surgical management of her thoracoabdominal aneurysm. Heparin was started as she had been off coumadin for several days in preparation for surgery. On [**2134-8-11**], Mrs. [**Known lastname 15785**] was taken to the operating room where she underwent repair of a thoracoabdominal aneurysm. Please see operative note for details. Following surgery, she was taken to the intensive care unit for monitoring. On postoperative day one, Mrs. [**Known lastname 15785**] awoke neurologically intact and was extubated. She had a transient period of delirium and hallucinatins which resolved over several days. Thrombocytopenia was noted but there was no issues with active bleeding. A heparin induced assay (HIT Panel) was sent which was negative. By discharge, thrombocytopenia resolved. Due to perisistent nausea and elevated liver enzymes, a right upper quadrant ultrasound was obtained which was unremarkable. An MRA was also performed which showed no evidence of vascular compromise to her abdominal organs. Her nausea gradually improved and her diet was advanced as tolerated. LFT's gradually improved. Warfarin was resumed for her mechanical aortic valve and titrated for a goal INR between 2.0 - 3.0. INR flucuated and she appeared to be very sensitive to Warfarin. She required two units of fresh frozen plasma on [**2134-8-24**] for an INR of 5.4. Prior to discharge, her INR improved and low dose Warfarin was resumed. She experienced significant epistaxis for which ENT was consulted. Successful nasal packing was performed on [**2134-8-24**] and she will followup with ENT on [**2134-8-30**] as an outpatient for a pack pull. Clindamycin was started for nasal packing which should continue until pack removed. Also started on Ciprofloxacin for postoperative urinary tract infection(gram negative bacteria). She was discharged to home in stable condition on POD#15. She will follow up with ENT on Mon. [**8-30**] to have her nasal packing removed and her coumadin will be followed by Dr. [**Last Name (STitle) 23903**] at the [**Hospital3 33953**] Health Center. Medications on Admission: Aspirin 81 mg daily - states not on but was discharged on Levothyroxine 75 mcg daily Oxycodone-Acetaminophen 5-325 mg Tablet prn 1-2 times a week Atorvastatin 40 mg daily Disp:*30 Tablet(s)* Refills:*0* Fluoxetine 20 mg daily Losartan 50 mg daily Docusate Sodium 100 twice a day Prilosec 40 mg daily Magnesium Oxide 400 mg daily Triamterene-Hydrochlorothiazide 37.5-25 mg daily Metoprolol Tartrate 12.5 mg twice a day Amlodipine 5 mg daily Albuterol inhaler 2-4 puffs prn asthma attack ~ 1 month Coumadin stopped [**8-6**] - 7.5 mg daily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*90 Tablet(s)* Refills:*2* 5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*60 Capsule(s)* Refills:*2* 8. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 10. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: Take as directed by Dr. [**Last Name (STitle) 23903**]. Daily dose may vary according to INR. Goal INR between 2.0 - 3.0. Disp:*60 Tablet(s)* Refills:*2* 11. Sodium Chloride 0.65 % Aerosol, Spray Sig: Three (3) Spray Nasal TID (3 times a day). Disp:*1 month supply* Refills:*0* 12. Oxymetazoline 0.05 % Aerosol, Spray Sig: Two (2) Spray Nasal [**Hospital1 **] (2 times a day). Disp:*1 month supply* Refills:*0* 13. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 4 days: 5 day course will be completed on [**2134-8-29**]. Disp:*32 Capsule(s)* Refills:*0* 14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 doses: total of 6 doses -last dose on [**2134-8-27**]. Disp:*2 Tablet(s)* Refills:*0* 15. Outpatient Lab Work Please check INR every Mon, Wed and Friday for several weeks until INR stabilizes. Dr. [**Last Name (STitle) 23903**] will monitor INR as outpatient and titrate frequency accordingly. Goal INR between 2.0 - 3.0. Dr. [**Last Name (STitle) 23903**] phone number is ([**Telephone/Fax (1) **]. Please call cardiac surgery office at [**Telephone/Fax (1) 170**] with any questions or concerns. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Repair of Thoracoabdominal aortic aneurysm s/p Bental (mechanical AVR) total arch replacement, and CABG [**2134**]. s/p Sternal wire removal [**2134-7-7**] Hypertension Postop Epistaxis, s/p packing Postop Delirium Postop Nausua with Elevated Liver Function Tests - improved Postop Urinary Tract Infection Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Discharge Instructions: 1) 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 2) Please NO lotions, cream, powder, or ointments to incisions 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart 4) No driving for approximately one month until follow up with surgeon 5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns [**Telephone/Fax (1) 170**] *Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Surgeon: Dr. [**Last Name (STitle) 914**] Tuesday [**2134-9-14**] 3:30PM ([**Telephone/Fax (1) 4044**] ENT: Dr. [**Last Name (STitle) 38669**] on [**2134-8-30**] @ 1045 AM. Address is [**Location 66073**]in [**Location (un) 55**]. Instructed to arrive at least 30 minutes prior to appt [**Telephone/Fax (1) 2349**] Please call to schedule appointments with your: Primary Care Dr. [**Last Name (STitle) 23903**] in [**1-23**] weeks [**Telephone/Fax (1) 17826**] Cardiologist Dr. [**Last Name (STitle) **] in [**1-23**] weeks Vascular Dr. [**Last Name (STitle) **] in 4 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 AVR Goal INR: 2.0 - 3.0 First draw: [**2134-8-27**] Results to: Dr. [**Last Name (STitle) 23903**], phone([**Telephone/Fax (1) 66074**] Completed by:[**2134-8-26**]

[ "759.82", "287.5", "441.03", "293.0", "784.7", "998.0", "599.0", "V45.81", "253.1", "E878.2", "V58.61", "787.02", "401.9", "245.2", "369.60", "285.9", "493.90", "V43.3" ]

icd9cm

[ [ [] ] ]

[ "39.99", "38.45", "38.44", "88.72", "39.61", "21.02" ]

icd9pcs

[ [ [] ] ]

13188, 13246

8060, 10231

364, 551

13596, 13818

3031, 8037

14675, 15688

2240, 2359

10836, 13165

13267, 13575

10257, 10813

13842, 14652

1606, 2093

2374, 3012

310, 326

579, 1104

1126, 1583

2109, 2224

8,668

115,180

4177

Discharge summary

report

Admission Date: [**2146-1-22**] Discharge Date: [**2146-2-7**] Date of Birth: [**2067-7-11**] Sex: F Service: SURGERY Allergies: Penicillins / Percodan / Percocet / Codeine / Talwin / Demerol / Valium / Aspirin Attending:[**First Name3 (LF) 2836**] Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: Exploratory laparotomy with lysis of adhesions. History of Present Illness: This is a 78 y/o female admitted on after 1 1/2 days of abdominal pain, right groin pain, and N/V. EMS was called for respiratory distress and hypotension and she was intubated in the ED. On arrival, she was volue resuscitated and started on pressors. Her initial physical exam revealed focal peritoneal signs in the RLQ. A CT was done showing complete small-bowel obstruction, with transition point at the level of the ileocecal valve. Past Medical History: # Aortic stenosis - valve area 1.1 on [**2144-4-3**] # CHF (EF of 60%) # atrial fibrillation - on warfarin # s/p femur fx [**8-17**] # s/p R BKD [**2144-10-28**] # COPD # Rheumatoid arthritis - on prednisone # RA/SLE/positive [**Doctor First Name **] antibody - in remission # osteoporosis # venous stasis # peripheral neuropathy # h/o Clostridium difficile in the past # spinal stenosis # SBO Social History: lives alone in home, able to do ADL's, has [**Name (NI) 269**], PT, home aid at home. +tob hx, quit 40 years ago, no ETOH, no drugs Family History: arthritis, mother - liver cancer, father - CVA Physical Exam: Intubated, awake, in moderate distess CV: irregularly irregular, tachycaardic Chest: breath sounds course bilat and diminished at left Abd: soft, obese, minimally distended and tympanitis. Localized tenderness to the RLQ with guarding, no rebound. Ext: mild cyanosisof left toes, +edema Pertinent Results: [**2146-1-22**] 02:50PM BLOOD WBC-23.4*# RBC-3.84* Hgb-12.6 Hct-37.6 MCV-98 MCH-32.9* MCHC-33.6 RDW-14.1 Plt Ct-338 [**2146-1-25**] 03:48AM BLOOD WBC-18.0* RBC-3.25* Hgb-10.5* Hct-31.9* MCV-98 MCH-32.2* MCHC-32.8 RDW-14.1 Plt Ct-302 [**2146-1-31**] 07:20AM BLOOD WBC-15.3* RBC-3.23* Hgb-10.6* Hct-31.7* MCV-98 MCH-32.7* MCHC-33.3 RDW-14.2 Plt Ct-369 [**2146-1-31**] 07:20AM BLOOD PT-15.1* PTT-41.5* INR(PT)-1.3* [**2146-1-31**] 07:20AM BLOOD Glucose-74 UreaN-25* Creat-0.8 Na-138 K-3.6 Cl-99 HCO3-31 AnGap-12 [**2146-1-22**] 02:50PM BLOOD ALT-14 AST-23 AlkPhos-47 Amylase-80 TotBili-0.9 [**2146-1-25**] 03:48AM BLOOD ALT-15 AST-21 LD(LDH)-242 AlkPhos-44 Amylase-98 TotBili-0.6 [**2146-1-25**] 03:48AM BLOOD Lipase-47 [**2146-1-31**] 07:20AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.1 . CT PELVIS W/CONTRAST [**2146-1-22**] 3:48 PM IMPRESSION: 1. Complete small-bowel obstruction, with transition point at the level of the ileocecal valve. Taking into account the recent hernia reduction, it is unclear whether these findings could represent slow passage of fecalized small bowel contents into the cecum following the hernia reduction. 2. No sign of incarcerated hernia. Fluid-filled hernia sac seen in the right inguinal region. This may be related to recent reduction of the inguinal hernia. 3. Right lower lobe atelectasis, and a few nodular areas of right lower lobe opacity which could represent aspiration, less likely an infectious process. 4. Extensive thoracolumbar spine degenerative change, and multiple vertebral body compression fractures as described above. . Cardiology Report ECG Study Date of [**2146-1-22**] 2:43:36 PM Atrial fibrillation with a rapid ventricular response. Extensive ST-T wave changes which are likely due to rate or myocardial ischemia. Compared to the previous tracing of [**2145-12-22**] the rate has increased significantly and there are now diffuse ST-T wave changes. Clinical correlation is suggested. Intervals Axes Rate PR QRS QT/QTc P QRS T 113 0 76 360/452 0 47 -155 . CHEST (PORTABLE AP) [**2146-1-30**] 4:15 AM [**Hospital 93**] MEDICAL CONDITION: 78 year old woman s/p LOA for obstruction w/ elevated WBC COMPARISON: [**2146-1-26**]. FINDINGS: The NGT, left CVL and ETT have been removed. Large retrocardiac density with air-fluid level was consistent with hiatal hernia. Adjacent atelectasis is seen. There are no new focal consolidations and the pulmonary [**Month/Day/Year 1106**] markings appear normal. There is stable cardiomegaly. IMPRESSION: No new consolidations. Brief Hospital Course: This is a 78 year old female with 1 1/2 days of abdominal pain, right groin pain, and N/V. EMS was called for respiratory distress and she was intubated in the ED. She had peritoneal signs on exam and a SBO was found on CT and the pt went to the OR for ex-lap + LOA. CV: She received beta blockers when appropriate for rate control. She continued in A-fib. When appropriate, her Coumadin was restarted. Her cardiologist recommended IV Lasix for 24-48 hours to assist with diuresis and then to resume her home PO dose. She responded well to the IV Lasix. Resp: She was intubated and comfortable. As she improved clinically, she was weaned to extubate. She was extubated on [**2146-1-26**]. She had CXR at time of discharge to assess volume status and she was not fluid overloaded. Abd/GI: She was NPO with IVF and a NGT. She had a Dobhoff placed, but it remained in the stomach. She was started on trophic tubefeeds. She was seen by speech and swallow and cleared for a PO diet. Her NGT was removed, Dobhoff removed, and her diet was advanced along. Her incision was C/D/I, with a small amount of redness along the incision. Renal: Her BUN/Cr were monitored and stable. She had good urine output and her volume status was watched closely. She received occasional fluid bolus for hypovolemia. As she continued to improved, she was started back on Lasix for diuresis due to her CHF. ID: She was started on broad coverage ABX, including Vanco, Zosyn, and Flagyl. Her antibiotics were tailored and she grew E.coli from her urine and completed a 7 day course of Meropenum. The patient's daughter was concerned about recurrent [**Name (NI) 14870**] and was requesting prophylactic ABX. Atrial Fibrillation: She continued in A-fib with a controlled rate. She was started back on her Coumadin. PT: It was recommended that she be discharged to a rehab facility for further strength and stability training. Medications on Admission: Prednisone 10', warfarin 3', gabapentin 400''', lisinopril 10', lasix 40''', metop 50'SR, ibandronate 150 q month, morphine 15q6h prn, omeprazole 20' Discharge Medications: 1. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 4. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime): 1 DROP RIGHT EYE HS . 6. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours): DROP RIGHT EYE Q8H . 7. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day): 1 DROP RIGHT EYE [**Hospital1 **] . 8. Warfarin 3 mg Tablet Sig: One (1) Tablet PO ONCE (Once): Monitor INR. 9. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Warfarin 6 mg Tablet Sig: One (1) Tablet PO ONCE (Once): Please dose daily and adjust accordingly. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Right groin pain, Palpable hernia (nonreducible) Small Bowel Obstruction Respiratory distress CHF Sepsis 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: Incision Care: Keep clean and dry. -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. . Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. . * Please resume all regular home medications and take any new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to increase activity daily and work towards daily ambulation. * No heavy lifting (>[**10-26**] lbs) until your follow up appointment. Followup Instructions: Please follow-up with Dr. [**First Name (STitle) **] in 2 weeks. Call ([**Telephone/Fax (1) 6347**] to schedule an appointment. Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3512**] Date/Time:[**2146-3-15**] 1:00 Provider: [**Name10 (NameIs) 2352**] ECHO Phone:[**Telephone/Fax (1) 15347**] Date/Time:[**2146-4-8**] 2:30 Completed by:[**2146-2-7**]

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icd9cm

[ [ [] ] ]

[ "38.91", "96.6", "96.04", "96.71", "54.59", "99.15" ]

icd9pcs

[ [ [] ] ]

7552, 7631

4367, 6273

355, 405

7780, 7787

1825, 3878

9671, 10107

1455, 1503

6473, 7529

3915, 4344

7652, 7759

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7811, 7931

7946, 9648

1518, 1806

301, 317

433, 872

894, 1290

1306, 1439

8,369

139,165

27759+27760

Discharge summary

report+report

Admission Date: [**2103-2-7**] Discharge Date: [**2103-2-13**] Date of Birth: [**2039-11-15**] Sex: M Service: MEDICINE Allergies: Hydralazine Attending:[**First Name3 (LF) 477**] Chief Complaint: Dysphagia/inability to swallow liquids or solids Major Surgical or Invasive Procedure: EGD with stent placement History of Present Illness: Pt is a 63 YO M with progressive esophageal cancer on 3rd line chemo, xeloda, presenting with 4 day hx of progressive difficulty swollowing first solids, now liquids. Pt denies nausea, and states that his vomitting complain it actually food or pills that "get stuck" coming back up. He denies substernal pain, has not experienced reflux. He also has had some peri-umbilical pain. Bowel movements have been normal. He states he was recently found to had an umbilical hernia by CT but has never noticed any outward bulging. Pain is dull, [**4-12**], adn constant. He was receiving some response with oral pain medications. He denies other pain, diarrhea, melena or hematochezia, jaundice. His other complaint is that his mouth feels exceptionally dry lately. . ROS: Denies fevers, chills, HA, change in vision/hearing, neck stiffness, CP, SOB, cough, dysuria, hematuria, focal weakness/numbness/tingling. . Onc Hx: Dx with esophageal cancer [**5-9**]. Advanced unresectable stage IVB. Started Irenotecan/Cisplatin [**6-8**] now on cycle 4. Last dose [**11-30**]. Now on xeloda. Past Medical History: Dx with esophageal cancer [**5-9**]. Advanced unresectable stage IVB. Started Irenotecan/Cisplatin [**6-8**] for 4 cycles. Last dose 12/28. Now on xeloda. . PMH: hypercholesterolemia depression anxiety BPH Social History: lives with wife, daughter, former [**Name2 (NI) **], rare etoh, no drugs. Family History: N/C Physical Exam: vs - T 98.5 BP 155/86 HR 78 RR 22 94%RA gen- a+ox3, nad heent - eomi, perrl, mmm, no oral lesions or thrush neck - supple, no LAD cor - rrr, no murmurs chest - cta b abd - mild tend to deep palpation at periumbilical area, otherwise pain free, no palpated hernia, non-distended ext - w/wp, no edema Pertinent Results: Initial labs: [**2103-2-7**] 06:30PM PT-14.2* PTT-27.1 INR(PT)-1.3* [**2103-2-7**] 06:30PM PLT COUNT-124* [**2103-2-7**] 06:30PM ANISOCYT-2+ MACROCYT-3+ [**2103-2-7**] 06:30PM NEUTS-79.9* LYMPHS-14.0* MONOS-5.5 EOS-0.4 BASOS-0.1 [**2103-2-7**] 06:30PM WBC-5.4 RBC-2.96* HGB-10.8* HCT-31.2* MCV-105* MCH-36.4* MCHC-34.5 RDW-21.0* [**2103-2-7**] 06:30PM CALCIUM-9.3 PHOSPHATE-3.5 MAGNESIUM-1.7 [**2103-2-7**] 06:30PM LIPASE-164* [**2103-2-7**] 06:30PM ALT(SGPT)-16 AST(SGOT)-21 ALK PHOS-92 AMYLASE-110* TOT BILI-0.8 [**2103-2-7**] 06:30PM GLUCOSE-101 UREA N-12 CREAT-1.1 SODIUM-140 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-27 ANION GAP-13 Discharge labs: [**2103-2-13**] 12:00AM BLOOD WBC-6.3 RBC-2.56* Hgb-9.5* Hct-27.2* MCV-106* MCH-37.1* MCHC-34.8 RDW-18.7* Plt Ct-106* [**2103-2-9**] 12:00AM BLOOD Neuts-67.3 Lymphs-21.5 Monos-8.4 Eos-2.5 Baso-0.2 [**2103-2-13**] 12:00AM BLOOD Plt Ct-106* [**2103-2-13**] 12:00AM BLOOD Glucose-101 UreaN-11 Creat-1.1 Na-132* K-3.8 Cl-99 HCO3-24 AnGap-13 [**2103-2-13**] 12:00AM BLOOD ALT-38 AST-50* LD(LDH)-215 AlkPhos-144* Amylase-51 TotBili-1.0 [**2103-2-13**] 12:00AM BLOOD Calcium-8.4 Phos-3.7 Mg-1.8 [**2103-2-12**] 12:00AM BLOOD TSH-3.0 Imaging: [**2-7**] CXR negative [**2-8**] CT abd/pelvis: 1. Mildly swollen ill-defined body and tail of the pancreas consistent with acute pancreatitis. Low-attenuation enlarged periportal lymph nodes consistent with metastatic involvement which appear to produce mass effect upon the pancreas. No pancreatic duct dilatation or ductal calcified stone identified. 2. Large heterogeneously enhancing lesion within the distal esophagus with luminal narrowing consistent with patient's known esophageal cancer. 3. Noncalcified pulmonary nodule within the right lung base measuring 1.1 cm, worrisome for metastatic disease. 4. Distended gallbladder without wall thickening or edema consistent with fasting state. 5. Small amount of free intrapelvic fluid. 6. Pathologically enlarged paraaortic and periportal lymph nodes identified on recent PET-CT to show increased FDG avidity consistent with pathologic involvement. [**2-12**] CT head 1. No evidence of intracranial hemorrhage or enhancing intracranial lesions. 2. Asymmetrically positioned odontoid process, incompletely evaluated on current study. This is likely positional but may be further evaluated with dedicated CT cervical spine if clinically indicated. Brief Hospital Course: 63 yo M with metastatic esophageal ca pw dysphagia, abdominal pain, and elevated lipase. . #Abdominal pain with (mildly) elevated lipase: The patient has known metastatic disease to pancreas seen on PET scan in [**Month (only) **]. Ct abdomen shows no pancreatic duct dilation and amylase and lipase trended down. ERCP felt not to be necessary as there was no pancreatic duct dilation. Patient treated with oxycodone and oxycontin for pain control. He did not have nausea and tolerated soft diet. . #Dysphagia - Patient initially had difficulty swallowing solids and this progressed to liquids. As he has known esophageal cancer, GI was consulted for stent which was placed on [**2103-2-9**]. The day after the procedure, pt tolerated liquids and soft diet which he should continue. The patient had sscp after the procedure worse with movement. It was not clear if this pain was present prior to the procedure and just worsened by it. He was controlled with miracle mouth wash, oxycontin and oxycodone. We also continued protonix. . #Pruritis- patient had rash on chest and back and this was thought to be due to hydralazine which was started and stopped that day. Rash improved and wa sgone by discharge. Another possible culprit could have been fluconazole which the patient was started on admission for possible fungal esophagitis causing dysphagia. We treated patient with sarna lotion and benadryl. . #Dizziness-patient has had this symptom since starting chemotherapy. On admission, patient was orthostatic and responded to fluid bolus both blood pressure wise and symptomatically. This was likely due to poor po intake. Patient had a normal neuro exam including cerebellar exam. Patient not on any medications that cause orthostasis. [**Month (only) 116**] also be a component of peripheral neuropathy as well as deconditioning. PT consulted and patient was sent home with home safety eval and PT as well as a walker. We encouraged patient to take in plenty of liquids at home. . #Mental status- patient very slow to respond. Wife notes this has been happening for the last month or so. He often "spaces out". Poor attention on mini-mental status exam which supports depression as possible cause. TSH and b12 were normal. Patient was continued on celexa, alprazolam and risperdal. [**Month (only) 116**] be compounded here by pain medication. Normal neuro exam. Head CT with contrast was negative for mets. . # esophageal cancer - metastatic to liver and pancreas. Currently on xeloda. Will f/u w/ Dr. [**Last Name (STitle) **] in one week to discuss further treatment. . # anemia/thrombocytopenia - patient at his baseline. This is likely chemo-related. . # depression/anxiety - Will treat with risperdal, alprazalom, celexa. . # hypercholesterolemia - lipitor . # BPH - proscar Medications on Admission: lipitor 20 mg QD celexa 40 mg QD xanax prn risperidal 1 mg QHS proscar 5 mg QHS oxycodone prn Discharge Medications: 1. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*0* 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) tablet PO BID (2 times a day). Disp:*60 tablet* Refills:*2* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 6. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*30 Tablet(s)* Refills:*2* 7. Risperidone 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 8. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 9. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO QDAY (). Disp:*90 Tablet(s)* Refills:*2* 10. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 11. OxyContin 20 mg Tablet Sustained Release 12HR Sig: One (1) Tablet Sustained Release 12HR PO twice a day. Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNA of Greater [**Location (un) 5871**]/[**Location (un) 6159**] Discharge Diagnosis: Esophageal cancer Dysphagia Discharge Condition: HD stable and afebrile. Discharge Instructions: You were admitted for difficulty swallowing and had a stent place by GI. Please take all medications as directed. Please follow-up with all outpatient appointments. Please call your oncologist or return to the ED if you experience any fever > 101, worsening chest pain, shortness of breath, abdominal pain, vomiting, diarrhea or any other concerning symptoms. Followup Instructions: Please follow-up with Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 877**] on Tuesday [**2-20**] at 11:30 am. [**Name6 (MD) **] [**Name8 (MD) 490**] MD, [**MD Number(3) 491**] Admission Date: [**2103-2-14**] Discharge Date: [**2103-2-28**] Date of Birth: [**2039-11-15**] Sex: M Service: MEDICINE Allergies: Hydralazine Attending:[**First Name3 (LF) 477**] Chief Complaint: coffee ground emesis Major Surgical or Invasive Procedure: EGD with stent removal and placement of two new esophageal stents History of Present Illness: Pt is a 63 YO M with progressive esophageal cancer on xeloda who was admitted to [**Hospital1 18**] from [**Date range (1) 17912**] for dysphagia w/course notable for distal esophageal stent placement by the ERCP team. On the day of discharge, he developed nausea with emesis, and vomited twice with dark blood. His wife called the floor and was told to call 911 and come to [**Hospital1 18**], but he initially went to an OSH and was found to have a HCT of 27. He vomited a third time, very small amount when there, which was considered coffee grounds. He was transferred to [**Hospital1 18**] and had a hct of 22 on presentation. He was admitted to the MICU for concern for an upper GI bleed from his cancer. . In the ED, he was given Protonix 40 IV once and crossmatched for blood. GI was contact[**Name (NI) **] and suggested probably scope in the AM. He was admitted to the MICU for possible scope tomorrow. . ROS: He complains of some abdominal pain which is persistent for months. He has some shortness of breath at rest. He denies chest pain. He had vomiting but no nausea currently. He has not vomited since admission. He is not a forthcoming historian. Past Medical History: 1. Esophageal cancer, diagnsoed [**5-9**]. Advanced unresectable stage. Started Irenotecan/Cisplatin [**6-8**] now on cycle 4. Last dose 12/28. 2. Hypercholesterolemia 3. Depression 4. Anxiety 5. BPH Social History: lives with wife. Former [**Name2 (NI) **], rare etoh, no drugs. Family History: N/C Physical Exam: V: 98.8 P84 BP 142/82 R20 97% 2L NC Gen: No apparent distress, with long pauses between questions and answers HEENT: PERRLA, OP clear, MMM Resp: CTA bilaterally CV: RRR nl s1s2 no MGR Abd: soft, slight TTP diffusely across abdomen, no rebound/guarding Ext: no edema Neuro: A+O to [**Hospital1 18**], [**2103-2-1**] (but not date), with slow responses Pertinent Results: CXR on [**2103-2-7**]: IMPRESSION: No acute cardiopulmonary disease. CT Abdomen/Pelvis on [**2103-2-8**]: IMPRESSION: 1. Mildly swollen ill-defined body and tail of the pancreas consistent with acute pancreatitis. Low-attenuation enlarged periportal lymph nodes consistent with metastatic involvement which appear to produce mass effect upon the pancreas. No pancreatic duct dilatation or ductal calcified stone identified. 2. Large heterogeneously enhancing lesion within the distal esophagus with luminal narrowing consistent with patient's known esophageal cancer. 3. Noncalcified pulmonary nodule within the right lung base measuring 1.1 cm, worrisome for metastatic disease. 4. Distended gallbladder without wall thickening or edema consistent with fasting state. 5. Small amount of free intrapelvic fluid. 6. Pathologically enlarged paraaortic and periportal lymph nodes identified on recent PET-CT to show increased FDG avidity consistent with pathologic involvement. CT Head on [**2103-2-8**]: IMPRESSION: 1. No evidence of hemorrhage or mass. 2. Asymmetrically positioned odontoid process, incompletely evaluated on current study. This is likely positional but may be further evaluated with dedicated CT cervical spine if clinically indicated. EGD on [**2103-2-14**]: Impression: Blood in the lower third of the esophagus Mass in the lower third of the esophagus Food in the stomach body Otherwise normal EGD to stomach body [**2103-2-13**] 12:00AM BLOOD WBC-6.3 RBC-2.56* Hgb-9.5* Hct-27.2* MCV-106* MCH-37.1* MCHC-34.8 RDW-18.7* Plt Ct-106* [**2103-2-14**] 01:45AM BLOOD WBC-3.9* RBC-2.14* Hgb-8.0* Hct-22.7* MCV-106* MCH-37.3* MCHC-35.2* RDW-18.9* Plt Ct-115* [**2103-2-14**] 09:19AM BLOOD WBC-3.6* RBC-3.10*# Hgb-10.7*# Hct-31.1*# MCV-100* MCH-34.4* MCHC-34.3 RDW-20.7* Plt Ct-101* [**2103-2-14**] 08:37PM BLOOD Hct-29.6* [**2103-2-15**] 04:16AM BLOOD WBC-2.8* RBC-2.95* Hgb-10.3* Hct-30.5* MCV-103* MCH-34.8* MCHC-33.7 RDW-20.3* Plt Ct-100* [**2103-2-15**] 12:01PM BLOOD Hct-29.8* [**2103-2-15**] 04:16AM BLOOD PT-14.0* PTT-28.2 INR(PT)-1.2* [**2103-2-15**] 04:16AM BLOOD Glucose-125* UreaN-11 Creat-0.8 Na-135 K-3.7 Cl-101 HCO3-24 AnGap-14 [**2103-2-15**] 04:16AM BLOOD ALT-91* AST-85* LD(LDH)-214 AlkPhos-317* Amylase-33 TotBili-5.0* DirBili-3.9* IndBili-1.1 Brief Hospital Course: 1. Esophageal cancer: Metastatic to liver and pancreas. Patient initially presented with dysphagia and required a stent. He initially had a lot of pain, but was eating well and was sent home. Patient returned to the hospital with coffee ground emesis and KUB showed that the stent migrated to his stomach. He required several units of blood and underwent second EGD and stent was retrieved and two additional esoph stents were placed. Unfortunately, 5 days after the last two stents were placed, the patient again started to vomit. CXR was obtained and again both stents migrated to the stomach. Given patient's condition, Dr. [**Last Name (STitle) **] and his family agreed that he should not under go another EGD for stent removal. He was placed on CMO and expired 4 am [**2103-3-1**]. 2. Cholangitis: Patient had elevated total bilirubin. This was thought to be due to progressive cancer and he was not thought to be candidate for stent. 3. Mental status changes: This was likely a combination of narcotics, elevated total bilirubin, anxiolytics. CT head negative. 4. depression/anxiety/agitation: Initially we continued celexa and risperidal. As the patient developed toxic metabolic confusion and was agitated and combative, we increased risperdal to 1 mg [**Hospital1 **] and used haldol. 5. Hypercholesterolemia: Discontinued lipitor when patient was made CMO. 6. BPH: Given initially and then discontinued when patient made CMO. Medications on Admission: Senna 8.8 mg/5 mL PO BID Docusate Sodium 50 mg/5 mL PO BID Pantoprazole 40 mg PO Q24H Finasteride 5 mg PO DAILY Atorvastatin 20 mg PO DAILY Alprazolam 0.25 mg PO TID Risperidone 1 mg PO HS Citalopram 40 mg PO DAILY Fexofenadine 60 mg PO QDAY Oxycodone 10 mg PO Q4H:PRN pain OxyContin 20 mg PO twice a day Discharge Medications: None. Discharge Disposition: Home With Service Facility: [**First Name5 (NamePattern1) 5871**] [**Last Name (NamePattern1) 269**] Discharge Diagnosis: Esophageal cancer Discharge Condition: Expired. Discharge Instructions: None. Followup Instructions: None. [**Name6 (MD) **] [**Name8 (MD) 490**] MD, [**MD Number(3) 491**]

[ "578.0", "285.1", "600.00", "197.8", "V66.7", "300.4", "272.0", "197.7", "150.5", "996.59", "570" ]

icd9cm

[ [ [] ] ]

[ "99.04", "45.13", "97.59", "42.81" ]

icd9pcs

[ [ [] ] ]

16057, 16160

14220, 15671

9929, 9996

16221, 16231

11905, 14197

16285, 16388

11513, 11518

16027, 16034

16181, 16200

15697, 16004

16255, 16262

2805, 4553

11533, 11886

9869, 9891

10025, 11190

11212, 11415

11431, 11497

46,078

189,859

47145

Discharge summary

report

Admission Date: [**2154-4-4**] Discharge Date: [**2154-4-8**] Date of Birth: [**2075-11-15**] Sex: F Service: MEDICINE Allergies: Tetracycline / Erythromycin / Polysonic Attending:[**First Name3 (LF) 5810**] Chief Complaint: [**Last Name (LF) **],[**First Name3 (LF) **] E. PCP: [**Name Initial (NameIs) 69975**]: [**Hospital1 **] HEALTHCARE - [**Location (un) **] Address: [**Location (un) **], [**Apartment Address(1) 6850**], [**Location (un) **],[**Numeric Identifier 1700**] Phone: [**Telephone/Fax (1) 3329**] Fax: [**Telephone/Fax (1) 16236**] Confirmed with pt on admission. Last saw her on [**2154-4-3**] . Admitted [**2154-4-4**] at 2350 Coughing and weakness x 8 days. Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a 78 year old highly functioning community dwelling female with h/o osteoperosis, hypercholesterolemia who presents with cough X 8 days. Prior to developing the cough she visited her ill cousin who was sick with fever and a cough. She was started on aumgentin on [**2154-4-1**],and then switched to bactrim 1 day PTP since she developed emesis on augmentin. She continued to feel worse and very weak. She vomited after supper and this prompted her to come into the ED. Her Na was found to be 111. Her CXR was clear. K was 2.8 on presentation and 3.8 on re-check. She has been unable to keep down pos including chicken soup secondary to emesis. No foreign travel.[**9-10**] HA currently. She does not usually get HAx 3 days. No sinus tenderness. No slurred speech or other neuro sx. . + 17:09 0 98 62 164/80 12 95 . Given levaquin prior to presentation out of concern for possible PNA. Also given 1L NS with 40 meq K. . ROS Constitutional: []WNL [-]Weight loss [+]Fatigue/Malaise [-]Fever [-]Chills/Rigors []Nightweats [+]Anorexia- markedly decreased appetite -Eyes: []WNL [+]Blurry Vision- now resolved [+]Diplopia- now resolved []Loss of Vision []Photophobia -ENT: []WNL [+]Dry Mouth []Oral ulcers []Bleeding gums/nose []Tinnitus []Sinus pain []Sore throat -Cardiac: []WNL [-]Chest pain []Palpitations []LE edema []Orthopnea/PND []DOE -Respiratory: []WNL [-]SOB []Pleuritic pain []Hemoptysis [+]Cough- productive but unable to cough up phlegm -Gastrointestinal: []WNL [+]Nausea [+]Vomiting [-]Abdominal pain []Abdominal Swelling [-]Diarrhea [-]Constipation []Hematemesis []Hematochezia []Melena -Heme/Lymph: [X]WNL []Bleeding []Bruising []Lymphadenopathy -GU: [X]WNL []Incontinence/Retention []Dysuria []Hematuria []Discharge []Menorrhagia -Skin: [X]WNL []Rash []Pruritus -Endocrine: [X]WNL []Change in skin/hair []Loss of energy []Heat/Cold intolerance -Musculoskeletal: [X]WNL []Myalgias []Arthralgias []Back pain -Neurological: [ ]WNL []Numbness of extremities []Weakness of extremities []Parasthesias [+]Dizziness/Lightheaded with standing []Vertigo []Confusion [+]Headache -Psychiatric: [X]WNL []Depression []Suicidal Ideation -Allergy/Immunological: [X] WNL []Seasonal Allergies All other ROS negative Past Medical History: CONSTIPATION (ICD-564.0) IMPACTED CERUMEN (ICD-380.4) LOSS, HEARING NOS (ICD-389.9) HYPERCHOLESTEROLEMIA (ICD-272.0) INSECT BITE, HEAD W/O INFECTION (ICD-910.4) CONJUNCTIVITIS NOS (ICD-372.30) HYPERPARATHYROIDISM (ICD-252.0) HYPERTENSION (ICD-401.9) BURSITIS, HIP (ICD-726.5) OSTEOPOROSIS (ICD-733.0) Social History: widowed since [**2138**], live alone, takes care of self, lots of friends but they have moved to [**Name (NI) 108**], active, going to Europe in the fall with a bunch of friends, financially comfortable, 3 daughters all live away- [**Name (NI) 18317**], [**Name (NI) 92191**] and [**State 4260**], 4 grandchildren [**Telephone/Fax (1) 99910**]- [**Doctor First Name 22969**] HCP Independent of [**Doctor Last Name **] ADLS [**Name (NI) 55343**] of accounting, medications, shopping, drving exercise 4 times a week but she has not since she has been ill Does not walk with walker/cane/wheelchair No recent falls - dentures - + visual aides - - hearing adies etoh Family History: sister with MS. Mother with heart disease and cancer. Physical Exam: Admission: GENERAL:Middle aged female who appears younger than her stated age. Vitals: 96.5, 188/92, 64, 18, 99% on RA L am 180/90 Nourishment: good Grooming: good Mentation: Alert,good historian. Eyes:NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted Fundi: Poorly visualized but no obvious papiladema. Ears/Nose/Mouth/Throat: dry MM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Respiratory: Lungs CTA bilaterally without R/R/W Cardiovascular: RRR, nl. S1S2, no M/R/G noted Gastrointestinal: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Rectal: guiac negative brown stool. Not impacted Genitourinary: WNL Skin: no rashes or lesions noted. No pressure ulcer Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Lymphatics/Heme/Immun: No cervical, supraclavicular, axillary or inguinal lymphadenopathy noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. -cranial nerves: II-XII intact -motor: normal bulk, strength and tone throughout. No abnormal movements noted. -DTRs: 2+ patellar reflexes bilaterally. No foley catheter/tracheostomy/PEG/ventilator support/chest tube/colostomy Psychiatric: WNL- full appropriate affect. She just appears exhausted. Pertinent Results: Admission: [**2154-4-4**] 07:47PM PH-7.52* COMMENTS-LYTES,FREE [**2154-4-4**] 07:47PM GLUCOSE-128* LACTATE-1.9 NA+-111* K+-3.8 CL--65* TCO2-33* [**2154-4-4**] 07:47PM freeCa-0.90* [**2154-4-4**] 06:34PM GLUCOSE-128* UREA N-10 CREAT-0.7 SODIUM-110* POTASSIUM-2.8* CHLORIDE-61* TOTAL CO2-31 ANION GAP-21* [**2154-4-4**] 06:34PM estGFR-Using this [**2154-4-4**] 06:34PM WBC-4.6 RBC-4.41 HGB-13.7 HCT-37.2 MCV-84# MCH-31.1 MCHC-36.9*# RDW-12.0 [**2154-4-4**] 06:34PM NEUTS-69.3 LYMPHS-18.3 MONOS-11.5* EOS-0.7 BASOS-0.3 [**2154-4-4**] 06:34PM PLT COUNT-233 . Admission CXR: No consolidation or edema. Chronic compression fx of T12- stable. . ECG: SR 68 bpm, prolonged QTC. No old for comparison. . [**2154-4-7**] 06:35AM BLOOD Glucose-84 UreaN-7 Creat-0.7 Na-132* K-4.1 Cl-96 HCO3-27 AnGap-13 [**2154-4-7**] 06:35AM BLOOD Calcium-8.1* Phos-2.6* Mg-1.9 [**2154-4-5**] 07:07AM BLOOD freeCa-0.97* [**2154-4-5**] 02:08AM URINE Eos-NEGATIVE [**2154-4-5**] 05:58PM URINE Hours-RANDOM UreaN-88 Creat-11 Na-34 Uric Ac-5.7 [**2154-4-5**] 05:58PM URINE Osmolal-154 [**2154-4-5**] 02:08AM URINE Osmolal-530 [**2154-4-5**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT negative [**2154-4-4**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] [**2154-4-4**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] CT HEAD W/O CONTRAST: There is no intracranial hemorrhage, mass, shift of normally midline structures, or evidence of acute major vascular territorial infarct. Bifrontal atrophy is noted. Minimal periventricular hypodensity is consistent with age-related small vessel ischemic changes. The surrounding osseous structures are unremarkable. Bilateral ethmoid sinus mucosal thickening is observed. Brief Hospital Course: 78 year old female with h/o hypercholesterolemia, hyperparathyrodism and HTN who presented with cough, n/v and was found to have a sodium of 110 on admission. . # Hyponatremia, symptomatic Renal was consulted, and given the patient's history of poor po intake, GI losses from emesis, and dehydration, it was felt that the patient's hyponatremia was due to hypovolemia in the setting of continued HCTZ use (started in late [**9-9**]), combined with decreased solid food intake, while continuing to drink signif water. Her HCTZ was discontinued, she was hydrated with 3+L of NS and was admitted to the medical floor. She was subsequently transferred to the ICU to initiate 3% saline gtt, as her sodium only improved slightly to 112. With 3% saline, her sodium levels gradually improved, and she returned to the medical floor for ongoing care. At the time of discharge her sodium level was 130 and she was allowed to drink to thirst, not forcing excess water intake. She will no longer take HCTZ and will need a follow-up Na check later this week with her pcp. [**Name10 (NameIs) **] her case with renal at the time of discharge. She does not require renal follow-up at this time, but if has persistent/recurrent hyponatremia, this referral may be made as an outpatient #HYPERTENSION: - discontinued her home HCTZ - started on Lisinopril 10 mg po q day She is tolerating this well., bp in 120s/70s at the time of discharge. #SECONDARY HYPERPARATHYROIDISM: Etiology of this is unclear, possibly secondary to hypocalcemia. She also was found to have a very low vitamin D level in the past (25 OH vit D <4 in [**3-12**]). We will continue her home Calcium and vitamin D and request endocrinology follow-up for this issue and her hyperparathyroidism (had been scheduled for [**4-8**], but was still inpatient at that time) #HYPERCHOLESTEROLEMIA - continued statin. . #BRONCHITIS: - CXR PA/L negative for PNA, afebrile without leukocytosis - Antibiotics were discontinued on admission given her nausea/vomiting and intolerance to bactrim and augmentin. - tessalon perles and nebulizer treatments prn Her cough was much improved at the time of discharge. . #HEADACHE: Given elevated BP and headache, there was initial concern for possible hypertensive emergency. Absence of papilladema on exam. Pt's HA improved with tylenol and resolved with improvement of her hyponatremia. Head Ct unremarkable, as above. . # Deconditioning: She was evaluated by physical therapy and felt to be safe to go home from this standpoint. She is independent in her ADLs. We did request an evaluation for elder services for some additional help, to be initiated by social worker. . . Code Status: DNR/DNI. . NEXT OF [**Doctor First Name **]: [**Known lastname 43918**],[**First Name3 (LF) **] PHONE: [**Telephone/Fax (1) 99911**] PCP [**Name (NI) 653**] on admission. Medications on Admission: FOSAMAX PLUS D 70-2800 MG-UNIT TABS (ALENDRONATE-CHOLECALCIFEROL) 1 po q week- q Sunday morning HYDROCHLOROT TAB 25MG (HYDROCHLOROTHIAZIDE) ONE PO QD ZOCOR 20 MG TABS (SIMVASTATIN) 1 po qd AUGMENTIN TAB 875MG (AMOXICILLIN-POT CLAVULANATE) one tab po BID- d/c'ed [**3-5**] nausea and vomiting . BACTRIM DS TAB 800-160 one po bid [**2154-4-3**] ROBITUSSIN SYP A-C SF [**2-2**] tsp hs [**2154-4-3**] TESSALON PER CAP 100MG one capsule tid prn cough [**2154-4-3**] Discharge Disposition: Home Discharge Diagnosis: # Severe hyponatremia, symptomatic # Hypertension, benign # Bronchitis, acute # Secodary hyperparathyroidism Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You were admitted with severely low sodium levels in your blood, which was likely due to a combination of your hydrochlorothiazide, not eating well, and drinking a lot of water. You have been taken off of your hydrochlorothiazide (HCTZ). You are encouraged to improve your diet, by eating nutritious meals, and supplement drinks as needed (such as Ensure Plus). Followup Instructions: Department: MEDICAL SPECIALTIES When: MONDAY [**2154-4-8**] at 9:00 AM With: BONE DENSITY TESTING [**Telephone/Fax (1) 4586**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: MONDAY [**2154-4-8**] at 10:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10545**], M.D. [**Telephone/Fax (1) 4586**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage These two appointments will need to be rescheduled.

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39892

Discharge summary

report

Admission Date: [**2106-12-6**] Discharge Date: [**2106-12-15**] Date of Birth: [**2022-6-10**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2751**] Chief Complaint: hypotension, AMS Major Surgical or Invasive Procedure: PEG tube placement History of Present Illness: 84F, h/o IDDM, dens fx in [**2106-9-27**] after fall w/ delayed spinal cord injury (upper extremity weakness) in [**Month (only) 1096**], s/p halo placement, presents from rehab facility with altered mental status and hypotension. At baseline, per records, she is oriented x2, speaks in full sentences. On admission she was oriented x1 and was not speaking coherently. Her systolic blood pressure at rehabilitation was 74, and she wsa started on Cipro (Day 1 [**2106-12-3**]) for a UTI from an indwelling Foley. . In the ED, initial vs were: 100.9 103 99/66 18 97%. Exam showed no focal neurologic deficits. She received 3L IVF with blood pressure increase to the 100's. Dipped down again to 70s, responded to fluids. Baseline reportedly around 90-100s. She was noted to have a WBC 14.6, febrile to 100.9. Got vanc, zosyn. CT head showed no acute process. Creat noted to be 1.7, up from baseline 0.6. Had poor urine output in the ED (~100 cc over the last few hours). Also noted to have trop 0.17, without chest pain or EKG changes. Aspirin given. Guiaic negative. Heparin drip ok'd by neurosurgery, however ultimately cards decided not to start in the setting of no EKG changes, no chest pain, and flat CK-MB. VS on transfer: 95 96/50 16 98% RA . On admission to the the ICU, the patient received a CT chest/spine which showed a non-displaced fracture of the anterior and posterior arches of C1, and showed a Type II fracture of the odontoid process that had improved alightment and healing. Her blood cultures came back as gram positive cocci in pairs and clusters, but this was felt to be a contaminent since she did not have any leukocytosis or fever. Ortho was consluted for left knee pain, and indicated that they did not feel it was septic arthritis; joint not tapped. Renal was consulted as the patient was anuric in the setting of a normal renal U/S. TTE showed overall left ventricular systolic function is normal, inconclusive for endocarditis, but did have some mitral regurgitation. Renal recommended diuresing with Metolazone and IV Lasix. G-tube placement complicated by the fact that patient is in Halo, and wil lneed anesthia, but is a difficult intubation. Family in meeting is ok to rescind DNR/DNI one time if needed to place PEG tube. They would also be ok with dialysis for short time if needed. Recently patient has been even in I/Os. The patient has never had leukocytosis and fever, and a source for infection was never locatlized. There was concern from renal for ATN after hypotension from ischemia. Past Medical History: RA GERD HTN DM 2 Depression Social History: married, lives with husband. no tobacco, occas etoh, no drugs. ambulates with walker at baseline. Family History: N/C Physical Exam: General: Alert, no acute distress, oriented x 1. Unable to answer most questions HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: tachycardic, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: moving all extremities, CN intact Pertinent Results: Admission Labs [**2106-12-6**] 04:45PM BLOOD WBC-14.6* RBC-3.96* Hgb-11.8* Hct-35.0* MCV-89 MCH-29.8 MCHC-33.7 RDW-14.8 Plt Ct-356 [**2106-12-7**] 05:00AM BLOOD Glucose-90 UreaN-23* Creat-1.9* Na-142 K-3.7 Cl-115* HCO3-18* AnGap-13 . Pertinent Labs [**2106-12-7**] 05:00AM BLOOD Glucose-90 UreaN-23* Creat-1.9* Na-142 K-3.7 Cl-115* HCO3-18* AnGap-13 [**2106-12-7**] 04:21PM BLOOD Glucose-68* UreaN-28* Creat-2.5* Na-144 K-4.3 Cl-118* HCO3-15* AnGap-15 [**2106-12-8**] 07:58AM BLOOD Glucose-160* UreaN-32* Creat-3.1* Na-142 K-3.9 Cl-112* HCO3-20* AnGap-14 [**2106-12-8**] 06:18PM BLOOD Glucose-166* UreaN-32* Creat-3.4* Na-141 K-3.8 Cl-110* HCO3-21* AnGap-14 [**2106-12-9**] 03:34AM BLOOD Glucose-107* UreaN-34* Creat-3.7* Na-141 K-4.0 Cl-109* HCO3-21* AnGap-15 [**2106-12-9**] 05:19PM BLOOD Glucose-91 UreaN-36* Creat-4.2* Na-142 K-4.1 Cl-110* HCO3-21* AnGap-15 [**2106-12-10**] 03:09AM BLOOD Glucose-90 UreaN-38* Creat-4.5* Na-141 K-3.7 Cl-108 HCO3-23 AnGap-14 [**2106-12-10**] 04:43PM BLOOD Glucose-225* UreaN-42* Creat-4.7* Na-142 K-3.9 Cl-107 HCO3-22 AnGap-17 [**2106-12-11**] 03:43AM BLOOD Glucose-122* UreaN-43* Creat-4.7* Na-145 K-3.6 Cl-109* HCO3-23 AnGap-17 . [**2106-12-6**] 04:45PM BLOOD cTropnT-0.17* [**2106-12-6**] 11:50PM BLOOD cTropnT-0.18* [**2106-12-7**] 05:00AM BLOOD CK-MB-9 cTropnT-0.21* [**2106-12-7**] 04:21PM BLOOD CK-MB-8 cTropnT-0.22* [**2106-12-9**] 05:19PM BLOOD CK-MB-4 cTropnT-0.16* [**2106-12-10**] 03:09AM BLOOD CK-MB-4 cTropnT-0.14* . [**2106-12-7**] 05:00AM BLOOD CRP-125.1* . Labs on Discharge: Lactate:1.4 141 103 35 -------------<64 4.2 23 2.6 Ca: 8.5 Mg: 2.0 P: 4.3 10.4 9.6 >----<399 32.4 PT: 13.7 PTT: 23.1 INR: 1.2 Microbiology: [**2106-12-6**] BLOOD CULTURE - GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS [**2106-12-6**] URINE Culture - Negative, NGTD FINAL 1/10,14,14,15/11 BLOOD CULTURE - PENDING Pertinent Reports - CHEST (PA & LAT) Study Date of [**2106-12-6**] 6:11 PM IMPRESSION: Low lung volumes, which accentuate the bronchovascular markings, particularly at the lung bases. Given this, patchy left base opacity may relate to atelectasis and overlying soft tissue, although focal consolidation is not excluded. Mild blunting of the posterior costophrenic angles on the lateral view could be due to pleural thickening or very trace effusions. . - KNEE (AP, LAT & OBLIQUE) LEFT Study Date of [**2106-12-6**] 8:03 PM IMPRESSION: 1. Depression of the lateral tibial plateau in the absence of a joint effusion or overlying soft tissue swelling. Recommend clinical correlation for age of fracture, it may be subacute to chronic. Recommend clinical correlation for point tenderness to further assess acuity and consider cross section imaging as clinically warranted. . - CT HEAD W/O CONTRAST Study Date of [**2106-12-6**] 9:00 PM IMPRESSION: Severely limited examination secondary to the Halo device. No evidence of gross acute intracranial hemorrhage. . - CHEST (PORTABLE AP) Study Date of [**2106-12-7**] 2:58 AM FINDINGS: As compared to the previous radiograph, there is a newly appeared retrocardiac and platelike left basal atelectasis. No evidence of focal parenchymal opacity suggesting pneumonia, with all limitations given positioning of the patient. Borderline size of the cardiac silhouette. No evidence of larger pleural effusions. . - RENAL U.S. Study Date of [**2106-12-7**] 1:59 PM IMPRESSION: Grossly normal renal ultrasound. . - CT C-SPINE W/O CONTRAST Study Date of [**2106-12-7**] 2:34 PM IMPRESSION: 1. Non-displaced fracture of the anterior and posterior arches of C1. Possible mild interim healing along the left posterior fracture line. 2. Type II fracture of the odontoid process demonstrates improved alignment of the fracture fragments and possible partial interval healing across the fracture line. . - CT CHEST W/O CONTRAST Study Date of [**2106-12-7**] 2:35 PM IMPRESSION: 1. Kyphosis. Compression fracture of T12. 2. Bilateral pleural effusions and associated atelectasis with very low likelihood of infectious process. 3. Extensive degenerative changes of the thoracic spine. 4. Coronary calcifications, hemodynamic significance is unclear. . - TTE (Focused views) Done [**2106-12-8**] at 9:35:42 AM FINAL Overall left ventricular systolic function is normal (LVEF>55%). The aortic valve is not well seen. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. The mitral valve leaflets are mildly thickened. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. Mild to moderate ([**11-28**]+) mitral regurgitation is seen. No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. IMPRESSION: Suboptimal image quality. Extremely limited views. Study inconclusive for endocarditis. Mild to moderate mitral regurgitation. If clinically indicated, a TEE may be helpful in evaluating for vegetations. . - CHEST (PORTABLE AP) Study Date of [**2106-12-11**] 2:55 AM HISTORY: Volume overload, evaluate for change. One limited AP view. Lung volumes are low and there is motion artifact. An external stabilization device overlies the patient. There is no definite focal consolidation. The retrocardiac area is not well penetrated. Mediastinal structures appear stable. IMPRESSION: Very limited study demonstrating no definite interval change. . EKG: low voltage. sinus tach @ 110. LAD, normal intervals. TWI III, aVF - PERC G/G-J TUBE PLMT Study Date of [**2106-12-14**] 3:19 PM Final Study Read Pending - C-SPINE (PORTABLE) Study Date of [**2106-12-15**] 8:12 AM Final Study Read Pending - C-SPINE (PORTABLE) Study Date of [**2106-12-15**] Final Study Read Pending Brief Hospital Course: 84F with h/o IDDM, s/p dens fracture noted to have altered mental status and hypotension, who was found to have acute renal failure and elevated troponins, requiring admission to the MICU for hypotension. # Altered mental status: The patient at baseline is believed to be alert and oriented x 2. Upon admission, vascular sources of AMS were ruled out with a negative head CT, infectious sources were ultimately ruled out with negative blood cultures, urine cultures, a chest x-ray, as well as a surface Echo. Toxic-metabolic favors certainly could have played a role, with the patient's elevated troponin and cardiac injury leading to poor perfusion of her kidneys, causing an elevation in renal toxins. Her mental status improved to baseline during her last few days in the ICU, as well as on the floor. The patient is AAOx3, but apparently is AAOx2 at baseline, and she speaks in full sentences upon her discharge from the hospital. # NSTEMI - The patient is believed to have undergone an NSTEMI, based on several factors. One, the patient's troponin rose throughout her admission, peaking on [**2106-12-7**], but subsequently tending down. We ended our tending of troponins as troponin level was 0.17 in the setting of known appropriate medical management of NSTEMI, in addition to lack of symptomatology of ACS in the setting of renal injury which can elevate troponins. Medical management was started with ASA, Statin, and BB. The patient's ECHO on [**2106-12-8**] showed a normal EF, without any obvious wall motion abnormalities or valvular vegetations. Mild to moderate ([**11-28**]+) mitral regurgitation was seen. She was discharged on medical management for an NSTEMI with ASA, Statin, and BB. . # Acute renal failure/ATN: On presentation, Cr 1.7 from baseline 0.6. Cr trended upwards to a zenith of 4.7, but afterwards began to trend down, such that on the day of her discharge, Cr was 2.6. The etiology was felt to be ATN secondary to kidney injury from hypotension in the context of a presumed NSTEMI. The renal team was involved in her care, and was diuresed in the ICU with metolazone and furosemide. The patient and family were okay with CVVH or HD should renal deem it necessary, but over the course of her admission she auto diuresed, and her creatinine continued to trend down. She will need close follow-up of her kidney injury upon DC; per renal, she will follow-up in 2 week's time with one of their physicians. Additionally, her ACE-inhibitor can likely be restarted in 2 weeks time, per our renal physicians as well. # Hypotension: The patient was noted on presentation in the nursing home to have SBPs in the 70s, with a baseline around 90s-100s. Upon arrival to our ICU, she again dripped into the 70s, but was fluid responsive. She initially received Vanc/Zosyn as broad coverage for sepsis, but her blood cultures came back positive x 1 for STAPHYLOCOCCUS, COAGULASE NEGATIVE in [**11-30**] bottles, leading the infectious disease team to believe this was a contaminant; antibiotics were DC'ed, and the patient maintained her blood pressure well. Upon transfer to the floor, the patient maintained her blood pressures in the 110s-130s. # Nutrition: Per S&S, patient is not taking in adequate POs to maintain nutrition, and they've recommended a PEG tube placement. Family is in agreement. PEG was placed via IR on [**2106-12-14**]. The patient tolerated the procedure well. Speech and swallow also recommended a diet consisting of thin liquids, soft solids. The patient recieved her PEG placement without issues, and nutrition made recommendations which are included in the patient's discharge instruction as to what her tube feeds should be. Neurosurgery came by to cut out parts of the plastic HALO such that her G-tube would be able to be visualized and assessed. # Dens fracture s/p halo placement: Patient remained in a HALO per neurosurgery guidelines. They evaluated the patient and signed off, given no neurosurgical intervention required. The patient was recommended to have an appointment in 1 month's time with Dr. [**Last Name (STitle) 739**]. Neurosurgery also came back to tighten the screws on the HALO on the day of the patient's discharge, after finding that her HALO was slightly loose. # DM: Continue insulin sliding scale per in-house sliding scale, may need to be adjusted at rehab post-tube feeds. # HTN: Home lisinopril and hydralazine were held in the setting of hypotension/acute renal failure. These medications can be restarted by the PCP if clinically indicated once acute renal failure has resolved. # GERD: The patient was started on famotidine in house, but was discharged on her home dose of ranitidine. # Rheumatoid arthritis: Pain control with Tylenol PRN and oxycodone PRN. # Depression: The patient was continued on her home medication regimen. # Left knee pain: The patient has bilateral knee pain, which was felt to be consistent with arthritis; we controlled this pain in-house using Tylenol and oxycodone. # Pending results [**2106-12-11**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2106-12-10**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2106-12-10**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT - C-SPINE (PORTABLE) Study Date of [**2106-12-15**] 8:12 AM : Final read pending - PERC G/G-J TUBE PLMT Study Date of [**2106-12-14**] 3:19 PM : Final read pending - C-SPINE (PORTABLE) [**2106-12-15**] Final read pending # PCP [**Name9 (PRE) 702**] Issues - STRESS MIBI. The patient will require a STRESS MIBI as an outpatient to ascertain if she has underwent an NSTEMI - Follow Cr, and restart Lisinopril/Hydralazine if patient is hypertensive, in the setting of a resolved ARF - Please ensure patient goes to [**Hospital 4695**] clinic in 1 month's time (appointment has been made) - Please sure that patient goes to her Nephrology appointment as well - Closely monitor insulin requirements as the patient is starting a new tube feeding regimen, described in the discharge instruction. Medications on Admission: bisacodyl 10 daily ciprofoxacin 500 [**Hospital1 **] colace 100 mg po bid heparin sq / currently on hold for peg placement lisinopril 2.5 mg po daily ranitidine 150 mg po bid senna 10ml daily at bedtime trazodone 12.5mg at hs mvi hydralazine 20mg po q 6 hrs prn snp >160 Discharge Medications: 1. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day. 2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 3. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) U Injection three times a day. 4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day. 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime. 6. trazodone 50 mg Tablet Sig: 0.25 Tablet PO at bedtime. 7. multivitamin Tablet Sig: One (1) Tablet PO once a day. 8. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 9. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 11. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*0* 12. clotrimazole 1 % Cream Sig: One (1) application Topical once a day: apply to affected areas. Disp:*1 bottle* Refills:*0* 13. insulin regular human 100 unit/mL Solution Sig: One (1) injection Injection ASDIR (AS DIRECTED): Per Insulin Sliding Scale Attached. Disp:*10 ml* Refills:*0* 14. oxycodone 5 mg Capsule Sig: 0.5 Capsule PO every four (4) hours as needed for pain. Disp:*15 Capsule(s)* Refills:*0* 15. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 16. multivitamin Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Primary Diagnosis: - Non-ST elevation myocardial infarction - Acute Tubular Necrosis Secondary Diagnosis: - Rheumatoid Arthritis - GERD 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: Ms. [**Known lastname 7188**], it was a pleasure taking care of you. You were admitted to the hospital because you were found to have very low blood pressure; you were in fact so ill that you needed to be in the intensive care unit. While you were there, the doctors noticed that some markers of damage to the heart were elevated, and our concern was that your heart damage led to the heart not pumping blood very well to the kidneys, which subsequently damaged the kidneys. Because of this damage we started you on several new medications to help to protect your heart. Our speech and swallow specialists also looked at you, and while they thought it was okay for you to continue swallowing the foods that you normally have been, their concern was that you are not taking enough nutrition by mouth. Because of this concern, we placed a tube that goes from your skin directly into your stomach, so that we can feed you even if you aren't able to take food through your mouth. Our nutritions made recommendations for the type of feeding that should go through your G-tube. . When you leave the hospital - STOP hydralazine 20 mg Daily every 6 (six) hours as needed for SBP >160 (ask your physician about restarting this if your blood pressure starts to become high) - STOP lisinopril 2.5 mg Daily (You can consider restarting this medication in 2 weeks) - START Aspirin 81 mg Daily - START Atorvastatin 80 mg Daily - START Metoprolol Tartrate 25 mg twice a day - START Insulin Sliding Scale (see attached, will need to be adjusted as patient starting tube feedings) - START oxycodone 2.5 mg every 4 hours as needed for pain - START Tylenol 650 mg every 6 hours as needed for pain - START a Multivitamin Capsule: Take One (1) Capsule once a day - START Clotrimazole 1 % Cream: Use one (1) application Topical once a day to affected areas We did not make any other changes to you medications, so please continue to take them as you normally have. - When you leave the hospital, you will need a STRESS MIBI (stress test) Your primary care doctor can order this for you. Followup Instructions: You have an appointment to see your primary care doctor, Dr. [**Last Name (STitle) 41076**]. He is currently on vacation, but his earliest available appointment is [**2106-12-27**] at 2:45 PM, please meet him at this time. You have an appointment to see a nephrologist (kidney doctor), on Monday [**2106-12-20**] at 3 PM with Dr. [**Last Name (STitle) 13219**] located in the [**Hospital Ward Name 121**] Building on the [**Location (un) 453**]. Department: SPINE CENTER When: THURSDAY [**2107-1-27**] at 10:40 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3736**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: RADIOLOGY When: THURSDAY [**2107-1-27**] at 9:45 AM With: CAT SCAN [**Telephone/Fax (1) 327**] Building: [**Hospital6 29**] [**Location (un) 861**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

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icd9pcs

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Discharge summary

report

Admission Date: [**2155-10-28**] Discharge Date: [**2155-11-11**] Date of Birth: [**2098-5-26**] Sex: M Service: [**Hospital1 **] CHIEF COMPLAINT: Change in mental status. HISTORY OF PRESENT ILLNESS: This is a 57-year-old gentleman with a complicated past medical history including end-stage renal disease on hemodialysis, insulin-dependent diabetes mellitus, chronic MRSA infection of an aorto-aortic graft, aortic dissection status post repair in [**2143**], coronary artery disease status post coronary artery bypass grafting, who presented with a three-week history of increased confusion and somnolence. According to the patient's family, the patient had a slowly declining mental status over the past three months; however, during the three weeks prior to this admission, decline in mental status was much more rapid. One week prior to admission, the patient had increased mumbling and has been speaking to people who were not present. On the night prior to admission, the patient's wife reported that his head and eyes started twitching. During this time, the patient was intermittently communicative versus nonsensical mumbling. He had no history of bowel or bladder incontinence. No history of seizures or tongue biting. On the day of admission, the twitching resolved following hemodialysis; however, at hemodialysis, the patient continued to be agitated and was sent to the Emergency Department. In the Emergency Department, the patient's blood pressure was increased to 230/120. At that time, he was given 100 mg IV Labetalol and 1 in Nitropaste with a decrease in his blood pressure to the systolic 170s. On further review of systems, the patient's wife reported that he was "hot" last night but denied any chills, cough, abdominal pain, diarrhea, constipation, bright red blood per rectum, melena, chest pain or shortness of breath. The patient had decreased p.o. intake one week prior to admission. The patient also complained of feeling heavy times one week. PAST MEDICAL HISTORY: 1. End-stage renal disease on hemodialysis Tuesday, Thursday and Saturday since [**2151**]. 2. History of chronic MRSA infection of his aortic graft. 3. History of aortic dissection with repair in [**2143**]. 4. Hypertension. 5. Adult onset diabetes mellitus. 6. Status post cardiac arrest in [**2151**] in the setting of hyperkalemia. 7. History of gastrointestinal bleed in [**2151**]. 8. History of endocarditis of the mitral leaflets in [**2152**]. 9. Coronary artery disease status post coronary artery bypass grafting in [**2148**]. 10. Left rotator cuff tear. 11. Sleep apnea. 12. History of multiple cerebrovascular accidents. 13. Gastroesophageal reflux disease. ALLERGIES: NO KNOWN DRUG ALLERGIES. MEDICATIONS ON ADMISSION: Nephrocaps 1 cap p.o. q.d., Labetalol 200 mg p.o. t.i.d., Zantac 150 mg p.o. q.p.m., Lentes 8 U q.h.s., Epogen 8000 U three times per week, Seroquel 25 mg p.o. q.h.s., Lisinopril 10 mg p.o. b.i.d., Ativan 0.5 mg p.o. b.i.d., Vancomycin dosed at hemodialysis. SOCIAL HISTORY: The patient is a retired school principal who lives with his wife. [**Name (NI) **] is an immigrant from [**Country 2045**]. He is former smoker. No intravenous drug use. The patient is DNR/DNI. PHYSICAL EXAMINATION: Vital signs: Temperature 98.7??????, blood pressure 177/87, pulse 86, respirations 15, oxygen saturation 90% on room air. General: The patient was an elderly man lying comfortably in bed, mumbling incoherently. HEENT: Pupils equal, round and reactive to light. Sclera muddy. Semi-dry mucous membranes. Fundus not visualized. Neck: Supple. No lymphadenopathy. Cardiovascular: Regular, rate and rhythm. S1 and S2. No murmurs, rubs, or gallops. Pulmonary: Clear to auscultation bilaterally. Abdomen: Soft. Positive bowel sounds. Nontender, nondistended. Extremities: No clubbing, cyanosis, or edema. Right femoral groin line in place. Right AV fistula thrill. Neurological: The patient was alert and oriented times three. LABORATORY DATA: On admission white count was 6.8, hematocrit 38.7, platelet count 239; INR 1.1; sodium 140, potassium 4.8, chloride 97, bicarb 33, BUN 20, creatinine 5.7, glucose 126, iron 44, total iron binding capacity 240, ferratin 792, hemoglobin A1C 7.7, CK 54. CT of the head showed no evidence of acute intracranial hemorrhage, no shift of normally midline structures or mass affect. There was a stable appearance of low attenuation area within the right frontal lobe. There was chronic bilateral microvascular infarctions in the periventricular white matter. There was a stable appearing bilateral lacunar infarct. There was moderate brain atrophy. Chest x-ray showed stable moderate cardiomegaly. Aorta >................... There was no pulmonary vascular congestion, pleural effusion, local infiltrate or pneumothorax. There were degenerative changes in the left shoulder. Electrocardiogram was normal sinus rhythm at 84 beats per minute. Left anterior descending. Normal intervals. T-wave inversion in I, AVL, V5-V6, unchanged from previous studies. HOSPITAL COURSE: 1. Hypertension: The patient was admitted with hypertensive urgency. On admission he had no electrocardiogram changes and a poorly visualized .................. exam. Initially the patient's blood pressure decreased with Labetalol and an ACE inhibitor. Initially the patient was admitted to the Medical Intensive Care Unit where he was started on a Labetalol drip for blood pressure control. At that time, he was also continued on his home ACE inhibitor. By [**2155-11-1**], the patient was able to be transferred to the floor with oral control of his blood pressure. Hypertension continued to be an active issue throughout the hospitalization with the patient having frequent systolic blood pressures in the 200s. A final medication regimen of Labetalol 400 mg p.o. b.i.d., Amlodipine 5 mg p.o. q.d., Lisinopril 40 mg p.o. q.d. has provided the best blood pressure control in this patient. In addition, fluid is being removed in hemodialysis to decrease the patient's dry weight in hopes of improving his hypertension. His blood pressure has been fairly well controlled over the past 3-4 days with systolic blood pressures most commonly in the 160-170s. 2. Altered mental status: In speaking with the patient's family, he has had a declining mental status over the three months prior to admission; however, this decline was occurring more sharply in the three weeks prior to admission. In addition, he had acute changes including mumbling and hallucinations in the one week prior to admission. During this admission, an extensive work-up was done to evaluate the patient's mental status. In addition to the CT obtained on admission, the patient had an MRI of his head on [**2155-10-29**]. This revealed no evidence of abnormal diffusion on diffusion weighted imaging to suggest a major or minor vascular territorial infarct. The exam was unchanged when compared to a previous exam from [**2155-10-15**], with diffuse abnormal signal in the periventricular white matter and pons consistent with chronic microvascular infarct, diffuse atrophy, and scattered tiny foci of abnormal signal on ................. imaging suggestive of remote hemorrhagic infarct and amyloid angiopathy. In addition, the patient had an EEG on [**2155-10-30**], which showed slow rhythm throughout along with generalized .................. delta slowing superimposed. During this study, the patient would talk "nonsense," and there were no correlating EEG abnormalities to indicate seizure activity. No focal or epileptiform features were seen. The EEG was considered most consistent with encephalopathy. In addition, the patient had a negative toxicology screen, normal TSH, normal Vitamin B12, and normal folic acid during this admission. Although there was a very low suspicion, a lumbar puncture was attempted on [**2155-11-7**]. This was unsuccessful. Throughout the admission, the patient's mental status continued to wax and wane. It is most likely multifactorial due to his TIAs, CVAs, hypercalcemia, chronic infection, and end-stage renal disease. The patient's hyperkalemia is being corrected at hemodialysis. He is receiving Vancomycin for his chronic aortic graft infection. 3. End-stage renal disease: The patient was continued on his schedule of Saturday, Tuesday, Thursday hemodialysis throughout the admission. The patient was dosed with Vancomycin at hemodialysis. He was also continued on his Nephrocaps 1 cap p.o. q.d. throughout the admission. 4. Infectious disease: The patient has a chronic infection of his aortic graft with intermittent bacteremia. His last positive blood culture, which grew Methicillin resistant Staphylococcus aureus, was from [**2155-11-2**]. Throughout the admission, he continued to receive Vancomycin at hemodialysis. 5. Diabetes mellitus: The patient was continued on Glargine and sliding scale Insulin throughout the admission and q.i.d. fingersticks. Overall the patient had good blood sugar control, although he did have multiple sugars in the low 200s. 6. Gastrointestinal: The patient was continued on Zantac throughout the admission for symptoms of gastroesophageal reflux disease. 7. Fluids, electrolytes and nutrition: The patient continued on the Americana Diabetic Association, 2 g sodium, cardiac diet throughout the admission. On [**2155-11-8**], the patient had an episode of choking while taking his medications. Following this episode, the patient was made NPO. His risk of aspiration due to his waxing and [**Doctor Last Name 688**] mental status was discussed with the family at a family meeting on [**2155-10-21**]. They have decided that he would wish to be fed despite the risk of aspiration. They are in agreement with this. On [**2155-11-10**], the patient had a swallowing study, which he passed without difficulty while alert. At this time, the patient will be continued on a regular diet with the family understanding the possible risk of aspiration. He should maintained on aspiration precautions. The patient has made previously known his desire to not have a feeding tube. 8. Prophylaxis: The patient continued on subcue Heparin for DVT prophylaxis throughout the admission. He continued on a bowel regimen. 9. Code status: The patient is DNR/DNI. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient will be discharged to [**Hospital **] Health Center for further care. DISCHARGE DIAGNOSIS: 1. End-stage renal disease on chronic hemodialysis. 2. Hypertension. 3. Transient ischemic attack. 4. Cerebrovascular accident. 5. Chronically infected aortic graft on Vancomycin. 6. Dementia. 7. Delirium. 8. Hypercalcemia. 9. Diabetes mellitus. 10. Coronary artery disease status post coronary artery bypass grafting in [**2148**]. 11. History of gastrointestinal bleed in [**2151**]. DISCHARGE MEDICATIONS: Nephrocaps 1 cap p.o. q.d., Docusate Sodium 100 mg p.o. b.i.d., Senna 1 tab b.i.d. p.r.n., Pantoprazole 40 mg p.o. q.d., Labetalol 400 mg p.o. b.i.d., Amlodipine 5 mg p.o. q.d., Lisinopril 40 mg p.o. q.d., Vancomycin 1000 mg IV to be dosed at hemodialysis, sliding scale Insulin, Glargine 8 U subcutaneous q.h.s., subcue Heparin 5000 U q.12 hours. FOLLOW-UP: 1. The patient will follow-up for hemodialysis at .................. [**Location (un) **] on Tuesday, Thursday, Saturday. 2. The patient will be seen by physicians at [**Hospital3 4262**] Group while the patient is at [**Hospital **] Healthcare. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4263**] Dictated By:[**Name8 (MD) 315**] MEDQUIST36 D: [**2155-11-11**] 13:28 T: [**2155-11-11**] 13:42 JOB#: [**Job Number 4264**]

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icd9cm

[ [ [] ] ]

[ "39.95", "38.91" ]

icd9pcs

[ [ [] ] ]

10966, 11836

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Discharge summary

report+addendum

Admission Date: [**2189-5-11**] Discharge Date: [**2189-5-18**] Date of Birth: [**2133-11-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1042**] Chief Complaint: fever and lethargy at outpatient HD Major Surgical or Invasive Procedure: 1) removal of right internal jugular dialysis line 2) placement of left internal jugular temporary HD line 3) conversion of temporary HD line to left internal jugular tunneled catheter 4) hemodialysis History of Present Illness: 55 year-old male with a history of ESRD on [**Hospital 58910**] transferred from outpatient HD for fever to 102 and lethargy. Prior to transfer, blood cultures were drawn and he was given a dose of Vancomycin and ceftazidime. Of note, he was recently admitted in [**Month (only) 404**] and [**Month (only) 956**] of this year also with fevers. In [**Month (only) 404**], he was treated empirically for a line infection, although cultures were negative, and completed a 14-day course of Vancomycin. During the admission in [**Month (only) 956**], patient found to have pneumonia and was treated with 14-days of levofloxacin . In the ED, his initial vitals were T:102.9 BP:176/81 HR:78 RR:16 O2Sat:96% on 3L. He was subsquently found to be markedly hypertensive (199/106) and hypoxic (86% on 4 litres), feeling lethargic. He was started on a nitroglycerin gtt at 16:50 and placed on non-rebreather. By 18:55, patient's blood pressure had come down to 133/65. Given the hypoxia, there was concern for pneumonia so he was empirically given 1 dose of levofloxacin 750mg IV after blood cultures were again drawn. He received a chest CT-A for hypoxia that demonstrated pulmonary oedema with embolism. He also received a head CT given mental status changes and this was unremarkable. Patient's oxygenation improved with blood prsesure control, and supplemental oxygenation was down-titrated to 3 litres nasal cannula, with a saturation of 95%. He was admitted for further workup. . With his wife providing interpretation this AM, he denies any feeling any fevers, chills, pain, or SOB. No cough or new sputum production. No worsening peripheral edema. He endorses a higher salt diet intake recently, but states he has taken all of his medications as prescribed without fail and has attended all HD sessions as usual. Past Medical History: -- HTN: difficult to control, multiple agents used -- DM: with retinopathy, nephropathy -- ESRD due to IgA nephropathy/DM -- diabetic retinopathy- Blindness -- R subclavian Thrombus [**2187**] - stopped anticoagulation in [**2187**] -- Anemia of chronic disease -- Hyperlipidemia -- CAD - not an intervetional or CABG candidate. Cardiac catheterization from [**2188-2-4**] showed 3VD with a 30% left main, a diffusely diseased LAD with 80% mid stenosis, 90% diagonal, 60% second diagonal, and 90% OM1. None suitable for PCI or CABG. EF 60-70% TTE [**2188-10-14**] Social History: Cantonese/Mandarin speaking, limited English, immigrated to the US 10 yrs ago, currently lives with wife and 3 children, has been blind for approx 3 years, has not worked recently; No history of tobacco use, alcohol, or illicit drug use. Wife injects insulin. Family History: No family history of DM, CAD, Stroke, HTN, or Renal Disease Physical Exam: Vitals: T:99.9 BP: 136/66 HR: 69 RR: 22 O2Sat: 96% on 3L GEN: thin and chronically ill appearing but NAD HEENT: NC/AT, sclera anicteric, no epistaxis or rhinorrhea, poor dentition, MMM NECK: markedly elevated JVP to level of ear. RIJ tunneled line erythematous and warm, no fluctuance appreciated, non-tender to palpation COR: RR, normal rate, no M/G/R, no S3 or S4 PULM: Bibasilar inspiratory crackles ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, WWP, 2+ distal pulses at DP NEURO: alert, pleasant. CN II ?????? XII grossly intact. Moves all 4 extremities equally: SKIN: see nck. otherwise without erythema or rash. Pertinent Results: CBC: [**2189-5-11**] WBC-16.1*# RBC-4.29* Hgb-13.3* Hct-37.8* MCV-88 MCH-30.9 MCHC-35.1* RDW-15.8* Plt Ct-209 Neuts-92.3* Bands-0 Lymphs-3.3* Monos-4.1 Eos-0.2 Baso-0.1 [**2189-5-16**] WBC-5.2 RBC-3.40* Hgb-10.5* Hct-30.4* MCV-89 MCH-30.9 MCHC-34.6 RDW-15.2 Plt Ct-178 . COAGs: [**2189-5-11**] PT-13.4 PTT-79.7* INR(PT)-1.1 . CHEM: [**2189-5-11**] Glucose-46* UreaN-21* Creat-4.5* Na-140 K-4.1 Cl-98 HCO3-29 AnGap-17 Calcium-9.4 Phos-1.6*# Mg-1.7 [**2189-5-16**] Glucose-115* UreaN-34* Creat-6.6*# Na-134 K-5.9* Cl-97 HCO3-22 AnGap-21* Calcium-8.2* Phos-4.0# Mg-1.7 . CE's: [**2189-5-12**] 07:30AM BLOOD CK(CPK)-119 CK-MB-4 cTropnT-0.33* . [**2189-5-11**] 05:25PM BLOOD Lactate-1.2 . [**2189-5-13**] [**Doctor First Name **]-NEGATIVE . [**2189-5-13**] TSH-2.1 . [**5-11**] outpt HD blood cultures: reoprted back as [**5-8**]+ for GPCs in pairs, clusters [**5-11**] BCx: [**3-9**] + MRSA [**5-12**] Cath tip: + Staph aureus [**5-12**] BCX: NGTD at d/c [**5-13**] BCX: NGTD at d/c [**5-14**] BCx: NGTD at d/c [**2189-5-11**] CXR: IMPRESSION: 1. CHF, with small bilateral pleural effusions, new since [**3-13**]. 2. Pericardial effusion, likely related both to hemodialysis status as well as CHF. . [**2189-5-11**] CTA CHEST IMPRESSION: 1. No central or proximal segmental pulmonary embolism. Respiratory motion limits more distal assessment. 2. Mild interstitial pulmonary edema and bilateral pleural effusions with associated lower lobe atelectasis. Borderline mediastinal lymphadenopathy may be reactive. 3. Moderate size pericardial effusion, which is larger than on [**2188-10-15**]. . [**2189-5-11**] CT HEAD W/O CONTRAST IMPRESSION: 1. No acute intracranial process. 2. High attenuation within the left ocular globe with areas of low attenuation suggestive of evolving vitreal hemorrhage . [**2189-5-12**] UNILAT UP EXT VEINS US RIGHT IMPRESSION: Thickened edematous tissue surrounding the right hemodialysis port as it travels through the subcutaneous tissues. The appearance of this tissue is worrisome for an infectious site. . [**5-13**] Transthoracic Echo: IMPRESSION: No echo evidence of endocarditis or abscess seen. There is a Chiari network/prominent Eustachian valve seen which, at least theoretically, could [**Hospital1 **] a vegetation. There is a moderate to large pericardial effusion mostly located behind the infero-lateral wall which is 2cm at its maximum width in diastole. No echo evidence of tamponade. Mild pulmonary artery systoli hypertension. . [**5-14**] Temporary Line PLacement Successful placement of temporary double-lumen hemodialysis catheter via the left internal jugular vein, with the catheter tip located in the proximal right atrium. The line is ready to use. . [**2189-5-15**] TUNNELLED CATH PLACEMENT IMPRESSION: Successful placement of a 15.5 French, 27-cm tip-to-cuff double- lumen hemodialysis catheter via the left internal jugular vein with the tip in the right atrium. Bleeding in the access site was felt to reflect the effect of aspirin and Plavix therapy and was successfully controlled with manual pressure and Gelfoam embolization of the tunnel. Brief Hospital Course: 55 year-old male with ESRD on HD, labile hypertension, and h/o recent line infection now p/w fever and lethargy, found to have high grade MRSA bacteremia likely to due to line infection. Infection likely responsible for sympathetic discharge leading to hypertensive urgency, which in turn led to pulmonary oedema on presentation. Hospital course by problem: . #. MRSA Line Sepsis - blood cultures (in house and from outpt HD) grew MRSA, line also grew MRSA. Had been started on vanc at HD prior to admission, continued qHD while in-house. Will need 4 weeks of vancomycin from last positive blood culture ([**2189-5-12**]), neding with HD on [**2189-6-8**]. Transplant surgery removed right IJ line on [**5-12**], IR placed temporary left IJ line on [**5-14**], and converted to left IJ tunneled catheter on [**2189-5-15**]. Pt was afebrile after admission. Had a TTE without e/o endocarditis, therefore a TEE was not needed. . #. ESRD - was markedly volume overloaded on presentation, improved with HD. Was serially dialyzed with improvement in volume status, electrolytes, and hypertension. . #. Flash pulmonary oedema - resolved in ED with improved blood pressure control via nitro gtt. This was quickly weaned off, and pt did not have any significant O2 requirement while on the floor. Maintained strict blood pressure control (SBP < 160) to avoid any subsequent pulmonary edema. . #. Hypertensive urgency - Resolved in ED on nitroglycerin gtt. Has extrmeely refractory HTN, on multi-drug regimen at home. Nitro gtt was not needed after admission. Beta blocker changed to labetalol (from metoprolol) for adidtional alpha blockade, and was uptitrated fro brief elevationin BP to SBP 170's, quickly resolved. Continued home amlodipine, lisinopril, losartan, minoxidil, clonidine, and ISMN. . #. Non-revascularizable CAD - Given that he is not a candidate for PCI or CABG, any further management would be limited to medical therapy (eg heparin gtt). Serial CE's were not c/w ACS despite questionable ST elevations on admission EKG. Pt had on chest pain. Continued ASA, atorvastatin, clopidogrel, ACE-I, [**Last Name (un) **], BB, ISMN, and CCB for secondary prevention and angina treatment. . #. Pericardial Effusion - pt noted to have moderate to large pericardial effusion, increased in size from previsouly, on TTE. Presumed due to uremia. Other w/u ([**Doctor First Name **], TSH) was negative. No signs of tamponade on echo or clinically (non-elevated pulsus). contact[**Name (NI) **] PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] for followup echo in 4 weeks to evaluate effusion. . #. Mixed Acid-Base disturbance from end-stage renal disease and chronic hemodialysis. . # Chronic diastolic CHF - stable. Continued medical management with beta blocker, ACE/[**Last Name (un) **]. . #. DM - continued home NPH 8 units qAM, 6 units qPM . #. GERD - Continued pantoprazole . #. Left vitreous hemorrhage - evaluated during last admission without need for intervention. Eye was painful, red on this admission. Ophtho was consulted but could not see pt during inpatient timeframe. Outpatient followup. Continued erythormycin gtt's. . #. FEN - ate a renal, diabetic, cardiac diet. lyte correction at HD and prn . #. Code - Full code . #. Comm: Was with patient and wife [**Name (NI) **], (c) [**Telephone/Fax (1) 58903**] -- Primary Care Physician: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 8236**] Medications on Admission: #. Aspirin 325mg daily #. Clopidogrel 75mg daily #. Metoprolol Tartrate 150mg TID #. Amlodipine 10mg daily #. Lisinopril 40mg daily #. Clonidine 0.3mg/24hr Patch QSunday #. Losartan 100mg daily #. Minoxidil 2.5mg [**Hospital1 **] #. Isosorbide Mononitrate 30mg SR daily #. Atorvastatin 40mg daily #. Insulin NPH 8 units qAM, 6 units qPM #. Pantoprazole 40mg daily #. Erythromycin 5mg/g Ointment OU QID #. Nephrocaps daily Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 5 mg Tablet Sig: Eight (8) Tablet PO DAILY (Daily). 5. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 6. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 9. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSUN (every Sunday). 10. Minoxidil 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous HD PROTOCOL (HD Protochol): last dose will be at dialysis on [**2189-6-8**]. 12. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 13. Erythromycin 5 mg/g Ointment Sig: One (1) gtt Ophthalmic QID (4 times a day). 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 15. insulin Please continue to take your insulin NPH 8 units qAM, 6 units qPM as before Discharge Disposition: Home Discharge Diagnosis: Primary: MRSA Line Sepsis Hypertensive Urgency Flash Pulmonary Oedema . Secondary: # HTN: difficult to control, multiple agents used # DM: with retinopathy, nephropathy # ESRD due to IgA nephropathy/DM # diabetic retinopathy- Blindness # R subclavian Thrombus [**2187**] - stopped anticoagulation in [**2187**] # Anemia of chronic disease # Hyperlipidemia # CAD - not an intervetional or CABG candidate # HD line infection Discharge Condition: stable, improved, serial blood cultures negative since [**5-12**] Discharge Instructions: You were admitted to the hospital with an infected hemodialysis line. This likely caused your blood pressure to elevate, which in turn caused you to become short of breath. . We controlled your high blood pressure with additional medications. We performed hemodialysis to remove extra fluid from your lungs, which improved your shortness of breath. We treated you with antibiotics for your line infection, and removed the infected line. We placed a new dialysis line after your infection cleared up. . The following changes were made to your medications: 1) Your metoprolol was changed to labetalol 600mg [**Hospital1 **] 2) You will be receiving an antibiotic called vancomycin at hemodialysis until [**2189-6-8**] . Please keep the new line site clean and dry and only allow the staff at the dialysis center to perform dressing changes. . Please take all medications as prescribed. Please keep all outpatient appointments. If you experience any further fevers/chills, weakness or unusual fatigue, passing out, or other symptoms which concern you, please call your doctor [**First Name (Titles) **] [**Last Name (Titles) 10046**]d to the ED. Followup Instructions: 1) PRIMARY CARE Please follow up with Dr. [**Last Name (STitle) **] on Thursday [**5-21**] at 3:15 PM. It is very important that you come to this visit. If you need to change or reschedule this appointment, please call [**Telephone/Fax (1) 8236**]. You will need a repeat echocardiogram of your heart in [**4-7**] weeks to make sure the fluid around your heart is not increasing. Dr.[**Doctor Last Name 55497**] office was informed of this and they will arrange for this for you. . 2) CARDIOLOGY: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2189-6-30**] 10:00 . 3) Please make an appointment to see an ophthalmologist at ([**Telephone/Fax (1) 7572**]. Dr. [**Last Name (STitle) **] can also facilitate this for you. Name: [**Known lastname **],[**Known firstname 10852**] Unit No: [**Numeric Identifier 10853**] Admission Date: [**2189-5-11**] Discharge Date: [**2189-5-18**] Date of Birth: [**2133-11-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4226**] Addendum: Pt's stay was extended to [**2189-5-18**] by non-hemodynamically significant oozing at site of new tunneled HD catheter site. This was treated with gelfoam, thrombin spray, and pressure dressings. IR had already stitched the line quite tightly so no surgical revision was performed. DDAVP was considered but not given due to patient refusing to have peripheral IV replaced. . All bleeding had resolved by [**5-18**], and pt was released after HD. Of note, labetalol was uptitrated to 800mg tid for persistently elevated systolic blood pressures. Discharge Disposition: Home [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4228**] Completed by:[**2189-5-18**]

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icd9cm

[ [ [] ] ]

[ "38.95", "39.95" ]

icd9pcs

[ [ [] ] ]

15942, 16069

7123, 7453

352, 555

12887, 12955

3999, 7100

14146, 15919

3274, 3335

11056, 12384

12434, 12866

10610, 11033

12979, 14123

3350, 3980

277, 314

7481, 10584

583, 2393

2415, 2980

2996, 3258

1,165

151,872

23932

Discharge summary

report

Admission Date: [**2103-10-3**] Discharge Date: [**2103-10-22**] Date of Birth: [**2034-8-31**] Sex: M Service: CARDIOTHORACIC Allergies: Cephalosporins Attending:[**Last Name (NamePattern1) 1561**] Chief Complaint: transfer from OSH Major Surgical or Invasive Procedure: tracheoplasty [**2103-10-19**] tracheostomy [**2103-10-22**] History of Present Illness: 69M with severe tracheobronchial malacia transferred from OSH for evaluation for possible surgical intervention for definitive tracheal modification. Patient was initially admitted from home to OSH ([**Location (un) 8117**], NH) [**2103-9-19**] for fatigue, dehydration and several week h/o daily diarrhea and transferred to [**Hospital1 18**] [**2103-10-3**]. Prior to his admission on [**2103-9-19**], the patient was at a rehab facility from early [**8-22**] to [**2103-9-6**] where he was being treated for a PNA with Vancomycin and for a UTI with Ciprofloxacin. Given recent courses of antibiotics, patient was treated empirically with flagyl for possible c.diff, but this was later d/c'd when stool cultures returned negative for c. diff x1. Diarrhea resolved during most of his hospitalization in [**Location (un) 8117**], but restarted one day prior to transfer. Patient reports that he has been having a non-productive cough at home associated with worsening shortness of breath. He denied fevers and chills. No associated CP/palpitations/N/V/diaphoresis. CXR and Chest CT at OSH revealed new R pleural effusion, but no evidence of infiltrate suggestive of PNA. Patient was s/p diagnostic thoracentesis [**2103-10-1**]. Preliminiary results: Glucose 68, LDH 1106, TProt 5.4. Thoracentesis was complicated by AFib with RVR that was rate controlled with Diltiazem. Patient later spontaneously converted to sinus rhythm. On transfer to [**Hospital1 18**], patient with no specific complaints. Reported that respiratory status was close to baseline, but perhaps a little worse. He felt comfortable, denied chest pain/abdominal pain and baseline appetite. He noted 1 episode of diarrhea one day prior to transfer. Past Medical History: 1. Tracheobroncheal malacia, dx [**11-22**]; s/p Y stent placement [**2-20**] and removal [**7-23**] 2. CAD 3. Hypercholesterolemia 4. HTN 5. AFib 6. Pulm HTN 7. LLE DVT -> PE '[**99**] 8. OSA, intolerant to CPAP 9. h/o MRSA PNA 10. BPH (foley changed [**2-26**], needs to be changed q month- will have laser surgery once resp issues resolved.) 11. CVA x3 -> L hemiparesis. 12. Recurrent bronchitis 13. Home O2 (3L at baseline) Social History: He has worked as a technical writer, a desk job, Lives w/ wife in southern [**Name (NI) **], 3 children, daughter [**Name (NI) **] involved/supportive. 6 grandchildren lifelong non-smoker no etoh Family History: Father died at age [**Age over 90 **], and a history of TIAs. Mother died at age 75 and a history pneumonias, hypertension, and stroke. Brother died of an embolic stroke to the brainstem. Aunt died of colon cancer. Three children, six grandchildren, and one of his daughters has been recently diagnosed with incurable pancreatic cancer. Physical Exam: T98.9 BP104/60 HR92 RR18 94%3L Gen: sitting in bed, NAD HEENT: PERRL, EOMI, OP-clear, MMM Neck supple, no LAD Resp: loud, upper airway sounds. +ronchi throughout, no wheezes, no crackles CV: RR no murmurs/rubs/gallops Abd: NT/ND, +BS ext: no edema. TEDS in place Neuro: AOx3, grossly normal. Pertinent Results: [**2103-10-3**] 09:20PM WBC-11.0 HGB-11.5* HCT-32.8* MCV-85 PLT COUNT-368 SODIUM-143 POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-27 UREA N-23* CREAT-1.4* GLUCOSE-148* CALCIUM-8.9 PHOSPHATE-3.0 MAGNESIUM-2.0 UA pending EKG: Sinus rhythm at 91 with frequent atrial and ventricular ectopy. No ST-T changes. No significant change from prior ([**2-20**]). . STUDIES: [**2103-10-5**] P-MIBI: CONCLUSION: Normal myocardial perfusion study, no evidence for ischemia, normalwall motion with a 65% ejection fraction. . [**2103-10-5**] STRESS: IMPRESSION: No anginal type symptoms or ischemic EKG changes. Nuclear report sent separately. . [**2103-10-5**] CXR: PORTABLE AP CHEST RADIOGRAPH: There are poor inspiratory lung volumes, with pulmonary vascular crowding. The cardiac and mediastinal contours are stable. There is a tortuous aorta. No pneumothorax is seen. There is slight elevation of the right hemidiaphragm which is unchanged from the prior study. Additionally, there may be minimal blunting of the right costophrenic angle. There is limited evaluation of the trachea and bronchus, likely due to technical factors. A stent can be seen within the main trachea, however, the distal extent of this into the bronchi is not visualized on this exam. . [**2103-10-8**] VIDEO SWALLOW: IMPRESSION: Mild residue which cleared with repeated swallows. Trace penetration with no aspiration. . [**2103-10-9**] CHEST CT: IMPRESSION: 1. Tracheal stent extending from the thoracic inlet down into the left main stem bronchus. 2. Right lower lobe atelectasis. . [**2103-10-9**] PLEURAL FLUID: 10cc Bloody fluid collected, NEGATIVE FOR MALIGNANT CELLS. Histiocytes and blood. . [**2103-10-11**] CXR: Since the previous exam, the tracheobronchial stent has been removed. The trachea above the carina shows narrowing. There are bilateral small pleural effusions. There is also pleural thickening along the lateral chest wall. The lungs are clear. There is slight asymmetric aeration of the lungs, which may be due to air-trapping. IMPRESSION: Bilateral small pleural effusions, right greater, and narrowing of the distal trachea. . Brief Hospital Course: 69M with severe tracheobronchial malacia here for surgical evaluation. #. Tracheobronchial malacia- Awaiting eval and input from Dr. [**Last Name (STitle) 952**] and Dr. [**Last Name (STitle) **]. Per IP 2 tracheobronchial metal stents were placed on [**10-5**], initially thought stents would improve breathing. Stents were followed with serial CXR and chest CT which showed no migration or stents. However, pt had persistent cough without releif with atrovent nebs, lidocaine IH, and guafenesin. On [**10-10**] metal stents were removed per IP for symptomatic relief of persistent cough. CT [**Doctor First Name **] followed pt throughout course of hospitalization. Atrovent nebs qid, ativan qhs, guaifenesin prn, and lidocaine nebs PRN per respiratory were continued. [**2103-10-19**]: Patient was transferred to the thoracic surgery service and underwent a tracheoplasty for his tracheobronchial malacia. Postoperatively, he was transferred to the ICU intubated. He was restarted on his heparin drip immediately postoperatively. He remained stable overnight and was given intermittent fluid for low blood pressures. Pain was controlled using an epidural. POD #1-Bronchoscopy was performed on POD #1 and the patient was extubated. On the evening of POD #1, patient became less alert with desaturations despite supplemental oxygen. His creatinine also increased despite gentle fluid resuscitation. Anesthesia was called for increasing desaturations and the patient was reintubated at the bedside without complication. POD #2-Patient maintained on mechanical ventilation, remained stable throughout the day. POD #3-Patient stable on a low neosynephrine drip. He went back to the operating room for an uncomplicated tracheostomy. Postoperatively, patient was noted to be unresponsive despite weaning of his anesthetics as well as hypoxic to the low 80's despite mechanical ventilation via his tracheostomy. He experienced episodes of ventricular tachycardia treated with amiodarone and lidocaine. Laboratory values at this time demonstrated the patient to be severely acidemic with a bicarbonate of 16 as well as an arterial pH of 7.12. The patient was given bicarbonate supplementation and aggressively ventilated. At this time, the patient remained unresponsive with unequal pupils on exam. He continued to deteriorate with decreasing urine output, continuing acidemia, and elevated transaminases to >1000. A Swan Ganz catheter was placed at the bedside and the patient's pulmonary artery pressures were noted to be markedly elevated. A stat echocardiogram was performed at the bedside for a presumed pulmonary embolism which demonstrated a dilated, hypokinetic RV. A lactate performed at this time reached it's peak at 9.5. General surgery was consulted for question of ischemic bowel as well as renal for a decreasing urine output. Neurology was also consulted for questionable seizure activity. The patient did eventually stabilize hemodynamically and underwent a head, chest and abdominal CT scan. A preliminary read demonstrated a large R sided pulmonary embolism. The patient was started on TPA and managed supportively for his low blood pressure and acidosis. He was maintained on maximal pressor support as well as mechanical ventilation with continuing acidemia. In discussion with the patient's family, the patient was withdrawn from mechanical ventilation as well as pressor support on the evening of POD #3. The patient expired with his family at the bedside. #. ID: Pt had initially been started on Vanc for preop empiric treatment on [**10-7**]. Of note, Urine culture was positive for MRSA at OSH. Given lack of leukocytosis and fever, patient was thought to be colonized and was not initially treated. However, on [**10-7**] UA was +for UTI, UCulture w/Enterobacter and staph Aureus, so Vanc was continued for Enterobacter UTI. Levo/flagyl was started on [**10-9**] for empiric treatment of Asp PNA. Although video swallow study was neg for Aspiration, pt aspirated x2 and was continued on levo/flagyl. On [**10-10**] pt spiked to 102.7 in setting of Levo/Flagyl/Vanc already on board, repeat CXR did not show consolidation, UA [**10-11**] improved from previous UA. ID was consulted for further evaluation of persistent fevers in setting of ABX coverage. On [**10-12**] USensitivities came back for VRE UTI, vanc was d/c'd, started on Linezolid. Levo/Flagyl were d/c'd on [**10-12**] as no clear evidence of Asp PNA/no consolidation noted on imaging studies CXR/CT. Recommended IP to rebronch thich mucous secretions to r/o pulmonary infectious process prior to CT [**Doctor First Name **]. #. Atrial Fibrillation-rate controlled with BB. On [**10-9**] had an episode of RVR, HR up to 140s and responded to Metoprolol 5mg IV x1 which converted back to NSR. Throughout hospitalization continued to convert in and out of AF/SR. In setting of continual cough and poor PO intake, coumadin was discontinued and started on hep gtt for anticoagulation. . #. Pleural Effusion- OSH reported moderate sized pleural effusion with question of underlying infiltrate. Patient was evaluated by the pulmonary service, who thought that PNA was not likely and thus antibiotic treatment was initially not initiated. Patient is s/p diagnostic thoracentesis at OSH. Follow-up pleural fluid results showed histiocytes and blood, no malignant cells. . #. ARF- Baseline Cr 1.0. Likely pre-renal; Sent urine lytes. Cr slowly trended up from 1.1--1.6--2.0 in setting of continual diuretic use, clots noted in foley c/w post renal/obstruction. FEna 0.6% and FEun 33% c/w prerenal etiology and diuretic use. Diuretics were d/c'd [**10-11**]. Patient with chronic indwelling foley and prolonged hospitalization. Hydrated with IVF o/n. Clots resolved w/continuous bladder irrigation per Urology. Pt Cr. started to trend down on [**10-13**] to 1.7 from 2.0. . #. GU/Foley trauma-pt was noted to have clots in foley bag on [**10-9**], urology was consulted, pt with chronic indwelling foley for BPH changed qmonth per urologist. During this admission foley was changed on [**10-10**] with Continuous Bladder Irrigation. Hep gtt off for 2 days for bleeding. Bleeding stopped, urine clear. . #. ?CAD- continue BB, statin. Echo at OSH [**9-22**] EF 45-50%. During this admission stress test and p-MIBI were normal, therefore ? if true CAD. Pt has no h/o MI. . #. Diarrhea- Stool cx neg for c.diff at OSH. Will re-send stool cultures for c.diff x3. Pt did not have diarrhea during this admission. Medications on Admission: Home Medications: Ativan 0.5mg po qhs Zocor 40mg po daily Atrovent nebs QID Coumadin 7.5mg T,Sa; Coumadin 5mg other days Flomax 0.4mg po qhs Metoprolol 75mg po bid Proscar 5mg po qam Protonix 40mg po daily Lasix 40mg po qam, 20mg po qpm Guafenisin 600mg po bid Medications on transfer: Ativan 0.5mg po qhs Zocor 40mg po daily Atrovent nebs QID Coumadin 3mg po daily Flomax 0.4mg po qhs Metoprolol 75mg po bid Proscar 5mg po qam Protonix 40mg po daily Lasix 20mg po bid Guafenisin 600mg po bid Discharge Disposition: Expired Facility: [**Hospital1 18**] Discharge Diagnosis: tracheomalacia Discharge Condition: deceased

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icd9cm

[ [ [] ] ]

[ "96.72", "34.91", "00.14", "31.1", "00.17", "99.04", "96.04", "99.10", "03.90", "96.05", "33.48", "98.15", "34.51", "31.79", "33.22" ]

icd9pcs

[ [ [] ] ]

12681, 12720

5631, 12136

308, 370

12778, 12789

3496, 5608

2824, 3163

12741, 12757

12162, 12162

3178, 3477

12180, 12424

251, 270

398, 2134

12449, 12658

2156, 2594

2610, 2808

30,576

149,889

3252

Discharge summary

report

Admission Date: [**2188-4-16**] Discharge Date: [**2188-4-17**] Date of Birth: [**2107-4-11**] Sex: F Service: MEDICINE Allergies: Levaquin Attending:[**First Name3 (LF) 1711**] Chief Complaint: shortness of breath at NH Major Surgical or Invasive Procedure: none History of Present Illness: 81 yo woman with HTN, CAD, afib, ESRD on HD with recent admission to [**Hospital **] hospital with likely aspiration PNA and sepsis with enterococcal and yeast UTI tx. with broad spectrum abx., presents from [**Location (un) 582**] NH with SOB, found to have ST elevations (BL LBBB) V1-4 on EKG in the field. Brought in as code STEMI. Pt. reports new unproductive cough without fever, chills over last few days. + increased PND, DOE with mild exertion. denies dysuria. Last dialyzed monday, with plan for dialyis today. Per pt., also recent change in her dialysis center. . In field and [**Name (NI) **], pt. received 4x81mg ASA, 600mg plavix, started on heparin/integrillin gtt, given 500cc, BNP >50,000, HR 112 in afib, BP 140/79, O2 sat 98% NRB. Pt is DNR/DNI, declined catheterization. . On review of symptoms, she denies prior history of stroke, TIA, bleeding at the time of surgery, myalgias, joint pains, hemoptysis, black or red stools. She also denies any recent fevers, chills or rigors. She denies any increased LE edema, exertional buttock or calf pain. She does have h/o deep venous thrombosis, + unproductive cough X 3-4 days. 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, abscence of ankle edema, palpitations, syncope or presyncope. Past Medical History: - h/o CAD with EF 35-40%, LBBB - Afib, not on anticoagulation - HTN - DVT s/p IVC filter - DM2 - ESRD on HD [**3-1**] cholesterol emboli s/p PCI in [**2187**], AV fistula L antecubitus, R SCL tunneled tessio - Hypercholesterolemia - OA - h/o GI bleed - h/o mild dementia - Bilateral hip surgery - dry gangrene [**3-1**] cholesterol emboli - h/o gastric ulcers. received protonix [**Hospital1 **] X months Social History: Social history is significant for the absence of current tobacco use. Quit in [**2140**]. There is no history of alcohol abuse. . Family History: negative for early CAD Physical Exam: VS: T 96.0, BP 121/106, HR 102, RR 27, O2 97% on NRB Gen: elderly woman, mildly tachypneic, soft spoken, able to speak full sentences on NRB, Oriented x 2. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pale, +pallor or cyanosis of the oral mucosa. Neck: Supple with JVD to ear CV: PMI located in 5th intercostal space, midclavicular line. sl. tachy, irregularly irregular, soft S1, S2. No S4, no S3 noted Chest: No chest wall deformities, scoliosis or kyphosis. Resp were mildly labored, with decreased BS in R>L base, rales above, occ. inspiratory wheeze on L. R SCL tessio line C/D/I, no TTP Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. dry eschar of lateral 1st and 2nd toes bilaterally. mild thrill over L antecubitum Skin: No stasis dermatitis, ulcers, scars, or xanthomas. mild skin breakdown over coccyx Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP guaiac negative Pertinent Results: Admission labs: [**2188-4-16**] 11:20PM HCT-30.9* [**2188-4-16**] 05:24PM CK(CPK)-8* [**2188-4-16**] 05:24PM CK-MB-NotDone cTropnT-0.12* [**2188-4-16**] 05:24PM IRON-27* [**2188-4-16**] 05:24PM calTIBC-140* VIT B12-903* FOLATE-GREATER TH FERRITIN-1797* TRF-108* [**2188-4-16**] 11:20AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.018 [**2188-4-16**] 11:20AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2188-4-16**] 11:20AM URINE RBC-0 WBC->50 BACTERIA-0 YEAST-NONE EPI-0 [**2188-4-16**] 10:40AM GLUCOSE-135* UREA N-29* CREAT-3.2* SODIUM-134 POTASSIUM-5.0 CHLORIDE-92* TOTAL CO2-29 ANION GAP-18 [**2188-4-16**] 10:40AM estGFR-Using this [**2188-4-16**] 10:40AM CK(CPK)-24* [**2188-4-16**] 10:40AM cTropnT-0.13* [**2188-4-16**] 10:40AM CK-MB-NotDone proBNP-[**Numeric Identifier 15160**]* [**2188-4-16**] 10:40AM WBC-11.0 RBC-2.66* HGB-8.2* HCT-27.2* MCV-102* MCH-30.7 MCHC-30.0* RDW-19.9* [**2188-4-16**] 10:40AM NEUTS-82.4* LYMPHS-13.5* MONOS-2.9 EOS-0.8 BASOS-0.3 [**2188-4-16**] 10:40AM PLT COUNT-526* [**2188-4-16**] 10:40AM PT-13.2 PTT-31.1 INR(PT)-1.1 D/C labs [**2188-4-17**] 02:44AM BLOOD WBC-10.7 RBC-3.06* Hgb-9.4* Hct-30.4* MCV-99* MCH-30.7 MCHC-31.0 RDW-21.3* Plt Ct-486* [**2188-4-17**] 02:44AM BLOOD Glucose-89 UreaN-21* Creat-2.5* Na-139 K-4.8 Cl-102 HCO3-32 AnGap-10 [**2188-4-17**] 02:44AM BLOOD CK-MB-NotDone cTropnT-0.14* [**2188-4-16**] 05:24PM BLOOD calTIBC-140* VitB12-903* Folate-GREATER TH Ferritn-1797* TRF-108* [**2188-4-17**] 02:44AM BLOOD Triglyc-108 HDL-41 CHOL/HD-2.8 LDLcalc-53 [**2188-4-17**] 02:44AM BLOOD Digoxin-1.5 ECHO: LEFT ATRIUM: Elongated LA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild-moderate global left ventricular hypokinesis. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Paradoxic septal motion consistent with conduction abnormality/ventricular pacing. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. Mild (1+) AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Moderate thickening of mitral valve chordae. Mild functional MS due to MAC. Mild to moderate ([**1-30**]+) MR. [Due to acoustic shadowing, the severity of MR may be significantly UNDERestimated.] TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR. Mild PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. Conclusions The left atrium is elongated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild to moderate global left ventricular hypokinesis (LVEF = 35-40%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is moderate thickening of the mitral valve chordae. There is mild functional mitral stenosis (mean gradient 3mmHg) due to mitral annular calcification. Mild to moderate ([**1-30**]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: # CAD/Ischemia: s/p stent placement in [**2187**]. EKG non-diagnostic in setting of LBBB. troponin leak 0.13, CK, CK-MB negative on first set. No intervention, per pt. preference anyway, though this likely represents subendocardial ischemia from CHF exacerbation. CK-MBs low though troponins chronically positive, partially [**3-1**] renal dz. though to have a component of ischemia [**3-1**] stretch from CHF exacerbation. - asa, plavix loaded in ED. will continue asa 325 and restart Plavix as she had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] in [**Month (only) **], unclear why patient off plavix. - on lopressor, unclear why not on [**Name (NI) **] consider adding as an outpatient - continue statin - lipid panel, A1c show good lipid control, though HDL low . # Pump: likely combination of acute on chronic systolic and diastolic congestive heart failure. Last EF 35-40%. BNP [**Numeric Identifier 15160**]. Unclear why having acute exacerbation, though may relate to either poor BP control, Afib, infection. h/o hypertension-mediated acute pulmonary edema, though no HTN here. repeat CXR shows improved pulm. edema - ECHO showed EF 35%-40% with mild global HK - renal consulted for dialysis for fluid removal, dialyzed 2.2 L on wednesday, as well as 3 liters on day of discharge. - pt. likely should be on ACE-I, as no allergy or known contraindication. Can be started as an outpatient. . # Rhythm: in afib with rapid ventricular response initially. Her home metoprolol and diltiazem were restarted with better rate control. BPs during HD tolerated these medications, so likely should be given on day of dialysis. - continued digoxin post dialysis - no anticoagulation in past, likely [**3-1**] previous GI bleed, but could not obtain documentation of this. . # ESRD: renal consulted, dialyzed X 2. Should restart her dialysis on previous schedule. on MWF schedule. Needs a lower dry weight (goal per outpt. dialysis 62 kg), here was 70kilos post 1st day 2.2 L dialysis. Weight at discharge was 68kg. Continued nephrocaps and sevelamer. . # UTI: pyuria on U/A, started cefpodoxime, with plans to treat for 7d, first day [**4-16**], to be dosed after dialysis, urine cx pending on discharge and needs to be followed up as an outpatient to ensure appropriate antibiotic coverage. . # HTN: Continued diltiazem, lopressor, add low dose ACE added as tolerated . # Anemia: h/o GI bleed [**3-1**] ulcers, unclear if she had f/u EGD to ensure healing of ulcers - PPI - B12, folate, wnl, Fe studies c/w anemia of chronic disease due to renal dysfunction - unclear if she ever had repeat EGD. Should have one as outpatient if not. . # Dx/AMS: continue buproprion, risperidone (recently initiated) - stopped provigil . # FEN: restarted TFs; has h/o aspiration, but per NH, had been transitioning to some solids. Would have oupt. speech and swallow consult, when out of acute HF exacerbation . # Prophylaxis: hep SC, home PPI, bowel regimen . # Code: DNR/DNI confirmed . # Communication: HCP is [**Name (NI) 15161**] [**Name (NI) 15162**]([**Telephone/Fax (1) 15163**] (c) [**Telephone/Fax (1) 15164**] (h); daughter [**Name (NI) 15165**] [**Name (NI) 4702**] ([**Telephone/Fax (1) 15166**]; Medications on Admission: - digoxin .125 qdaily - provigil 50 qdaily - lansoprazole - ASA 81mg - diltiazem 60mg q6h - hep 5000bid - simvastatin 20mg qdaily metoprolol 75 tid - epogen - colace, senna, bisacodyl, miralax, PRN - duoderm over sacral area - nepro feeds 40cc/h x 12h with 200cc flushes tid Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet [**Telephone/Fax (1) **]: 1.5 Tablets PO TID (3 times a day). 2. Cefpodoxime 100 mg Tablet [**Telephone/Fax (1) **]: Two (2) Tablet PO HD PROTOCOL (HD Protochol) for 3 doses: Give three times/week post HD. 3. Lanthanum 500 mg Tablet, Chewable [**Telephone/Fax (1) **]: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Digoxin 125 mcg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily). 5. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Telephone/Fax (1) **]: One (1) Cap PO DAILY (Daily). 6. Simvastatin 10 mg Tablet [**Telephone/Fax (1) **]: Two (2) Tablet PO DAILY (Daily). 7. Bupropion 75 mg Tablet [**Telephone/Fax (1) **]: Two (2) Tablet PO DAILY (Daily). 8. Risperidone 0.5 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO BID (2 times a day). 9. Diltiazem HCl 60 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO QID (4 times a day). 10. Heparin (Porcine) 5,000 unit/mL Solution [**Telephone/Fax (1) **]: One (1) Injection twice a day. 11. Clopidogrel 75 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily). 12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 13. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: Four (4) Tablet, Chewable PO DAILY (Daily). 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 15. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day) as needed. 16. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg PO BID (2 times a day). 17. Epogen 10,000 unit/mL Solution [**Last Name (STitle) **]: One (1) Injection once a week. 18. Miralax 17 gram (100 %) Powder in Packet [**Last Name (STitle) **]: One (1) PO once a day as needed. Discharge Disposition: Extended Care Facility: [**Location (un) 582**] Of [**Location (un) 620**] Discharge Diagnosis: End stage renal disease on hemodialysis Coronary artery disease Hypertension atrial fibrillation Discharge Condition: All vitals signs stable, afebrile, off oxygen Discharge Instructions: You were admitted with shortness of breath. This was from fluid build up in your lungs. This occured from a combination of incomplete dialysis and a rapid heart rate. You were dialyzed twice to get this fluid off and you were given more medications to slow your heart rate. You did not have a heart attack although initially your EKG was concerning. However, lab tests showed no damage to your heart. Please take all your medications as prescribed and make all your follow up appointments. Please call your doctor or return to the emergency room if you experience chest pain, shortness of breath, nausea, vomitting, fevers, chills or any other symptoms that concern you. Followup Instructions: Please call Dr.[**Name (NI) 15167**] office to make a follow up appointment in the next 1-2 weeks.

[ "715.90", "599.0", "428.43", "414.01", "428.0", "426.3", "585.6", "272.0", "V45.1", "427.31", "403.91", "285.21", "V44.1" ]

icd9cm

[ [ [] ] ]

[ "99.20", "96.6", "39.95" ]

icd9pcs

[ [ [] ] ]

12616, 12693

7090, 10340

295, 301

12834, 12882

3434, 3434

13603, 13705

2310, 2334

10666, 12593

12714, 12813

10366, 10643

12906, 13580

2349, 3415

230, 257

329, 1717

3451, 7067

1739, 2146

2162, 2294

30,799

100,338

50098

Discharge summary

report

Admission Date: [**2182-9-7**] Discharge Date: [**2182-9-18**] Service: MEDICINE Allergies: Aspirin / Adhesive Tape Attending:[**First Name3 (LF) 1436**] Chief Complaint: Tachycardia Major Surgical or Invasive Procedure: -Cardiopulmonary resuscitation -Endotracheal intubation History of Present Illness: 89F CAD, Afib, DM2 felt "strange" around 9pm last night with malaise. Denies CP or SOB. Presented to [**Hospital3 4107**] ED, where her HR was in 150s with question of SVT. She was given IV dilt and HR came back to SR 60/min. Patient reported feeling much better. She denied any CP this time. She uses a walker to ambulate but denied DOE. No N/V. Her ECG in at OSH showed ST elevations in V2-V5 and III, w/ Q waves V2-V4,inferior. She was transferred to [**Hospital1 18**] for further management. Past Medical History: Coronary Artery Disease s/p MI 15y ago s/p angioplasty Afib on coumadin Hypertension Hypercholesterolemia Upper GI [**Last Name (un) **] 10y ago Osteoarthritis (primarily affecting knees) Social History: Lives on her own in [**Hospital1 **], has family nearby, mostly independent & takes care of herself, no tobacco, occ EtOH Family History: non-contributory Physical Exam: VS: T97.1 , BP 114/66 , P86 , SaO298%2L at RR22 GENERAL: No apparent distress HEENT: PERRLA, MMM NECK: no JVD CHEST: CTAB CVS: irreg, 1/6 SEM ABD: +BS. soft, NT/ND. EXT: Warm, without edema. SKIN: no rash NEURO: AO3, moving all spontaneously Pertinent Results: Admission Labs: [**2182-9-7**] 07:50AM WBC-6.2 RBC-3.73* HGB-11.4* HCT-35.7* MCV-96 MCH-30.6 MCHC-32.0 RDW-14.6 PLT COUNT-156 [**2182-9-7**] TSH-1.9 [**2182-9-7**] CK-MB-24* MB INDX-15.7* cTropnT-1.23* [**2182-9-7**] CK(CPK)-153* [**2182-9-7**] GLUCOSE-146* UREA N-33* CREAT-1.3* SODIUM-142 POTASSIUM-5.1 CHLORIDE-110* TOTAL CO2-23 ANION GAP-14 . Discharge Labs: [**2182-9-18**] WBC-6.2 RBC-3.26* Hgb-9.8* Hct-31.2* MCV-96 MCH-30.1 MCHC-31.4 RDW-15.2 Plt Ct-269 [**2182-9-18**] PT-20.5* INR(PT)-2.0* [**2182-9-18**] Glucose-99 UreaN-22* Creat-1.2* Na-140 K-4.8 Cl-106 HCO3-27 AnGap-12 [**2182-9-12**] -32 AST-40 LD(LDH)-199 AlkPhos-122* TotBili-0.9 [**2182-9-12**] CK-MB-NotDone cTropnT-0.37* [**2182-9-17**] Calcium-8.4 Phos-3.0 Mg-2.2 Imaging: [**2182-9-18**] CXR - FINDINGS: In comparison with the study of [**9-12**], there is again acute enlargement of the cardiac silhouette. Although the retrocardiac area is poorly seen, there does appear to be some increased opacification that would be consistent with atelectatic change. Mild prominence of the right hilar vessels, though no definite increase in pulmonary venous pressure is appreciated. . [**2182-9-9**] TTE: EF 30%. The left atrium is mildly dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is severe regional left ventricular systolic dysfunction with septal, anterior and distal LV akinesis. No masses or thrombi are seen in the left ventricle. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. Right ventricular chamber size is normal. Right ventricular systolic function is 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 moderate thickening of the mitral valve chordae. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small to moderate sized pericardial effusion. There are no echocardiographic signs of tamponade. Brief Hospital Course: 89yo F w/ CAD s/p MI, Afib, DM2, transferred to [**Hospital1 18**] here w/ wide complex tachycardia and elevated CEs. * Wide complex tachycardia: On admission, pt was thought to have supraventricular tachycardia with right bundle branch block. She was given adenosine; however, the adenosine did not break rhythm. The rhythm lasted for a few hours and broke spontaneously. The pt was hemodynamically stable during the event. She noted only a mild discomfort in her interscapular area. Approximately 24hr after the rhythm broke she went into it again, w/o hemodynamic compromise or symptoms. Again, the rhythm broke spontaneously after a few hours--metoprolol was given during the event without apparent effect. EP was consulted (Dr. [**Last Name (STitle) **] was initially EP attending, then Dr. [**Last Name (STitle) **]. They determined that the rhythm was actually a narrow, monomorphic ventricular tachycadia with RBBB and an inferior axis, likely arising in/near the septum. (Of note, the official EKG readings in OMR do not describe the rhythm as VT--see EKG from [**2182-9-7**] at 4:23 for an example of the VT.) Pt had a third episode of VT, during which she was given lidocaine with good response. Discussion was had between the team, the pt, and the pt's family about whether the pt should undergo an EP study or start amiodarone empirically without an EP study. Given the patient's overall clinic picture and wishes, amiodarone was started, no EP study was done. She was loaded with approximately 6grams of amiodarone. She was then continued on 200mg daily for maintenance. The patient had no further episodes of ventricular tachycardia after starting the amiodarone. Of note the patient had normal thyroid & liver function prior to starting amiodarone. She is scheduled to follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at his [**Hospital1 **] office on [**2182-10-15**] at 2:40pm. She will likely need baseline pulmonary function tests, ophthomalogic exam, and repeat thyroid & liver function tests. * PEA arrest: After the patient's third episode of VT broke, she had a severe coughing fit, and became hypoxic with 02 into the 70s. She then went into PEA arrest, presumably from hypoxia, as no other cause was found. CPR was performed for less than 5 minutes before a spontaneous rhythm was achieved. However, the patient was intubated given concern over her ability to proctect her airway. The patient was intubated for less than 48hr. * Coronary artery disease: Pt has a remote history of an MI approximately 15yr, at which time she underwent angioplasty. Prior to transfer to [**Hospital1 18**], she had diffuse ST elevations on EKG at OSH. These had resolved by time of admission here. Pt was without chest pain. CE were elevated on admission & trended down. Her EKGs from OSH were reviewed and it was questioned whether the ST elevations were from ischemia vs. repolarization change or pericarditis. Given her lack of CP and overall clinical picture, it was felt that she did not need to go for cardiac catheterization. She was continued on her statin. Her b-blocker (coreg) was given until she was started on amiodarone, at which time it was stopped due to bradycardia occasionally into the 40s (without symptoms). She is being discharged off of coreg. Caution should be used with b-blockers given she has first degree AV block and is on amiodarone. The pt refuses aspirin due to prior bleeding with it. * Atrial fibrillation: Rate controlled with amiodarone. Coreg discontinued due to bradycardia (hr 40-50s on amio). Coumadin dose decreased to 1.5mg daily (from 2.5mg) after starting amiodarone. INR on day of discharge was 2. This should be rechecked on [**2182-9-20**] and coumadin adjusted as necessary. * Congestive heart failure: acute on chronic systolic heart failure. Echo during this stay showed an EF of 30% with moderate mitral regurgitation moderate to severe tricuspid regurgitation. She was diuresed with IV lasix as necessary and continued on home dose of lasix 20mg daily. On day of discharge, pt received a dose of 20mg IV lasix for slight volume overload. Her aldactone (25mg daily) was also restarted on [**2182-9-18**]. An ACEi or [**Last Name (un) **] was not started during this hospital stay due to relatively low BP (90-100); though pt would likely benefit from one of these agents in future. * Cough: Pt had a dry cough on admission, which ecame more severe during hospital stay. No clear pneumonia on imaging. Pt thought to likely have viral lower respiratory tract infection. She was treated with standing anti-tussives and ipratropium nebulizer (avoided albuterol because of arrythmias). If cough persists, consider further evaluation with her primary care doctor. * Acute renal failure: pt had episode of pre-renal failure early in her hospital stay that was thought to be from dehydration. Baseline crt unknown, though was as low as 1.2 and peaked at 1.5. Discharge crt 1.2. * LE ulcers: stable & appear to healing slowly. Pt received 7d course of abx for possible infection of LE ulcer. Pt has two ulcers, one on left leg & the other on the R leg. Left lower leg is a traumatic ulcer approx 1.5 x 1 cm. The wound bed is 80% pink, 20% yellow. The wound edges are irregular. The periwound tissue is intact with resolving cellulitis. Right lower extremity full thickness ulcer is present on anterior tibialis, approx 7 x 5.5 cm, and the wound bed is 60% yellow, 20% black, 20% pink. There is a moderate amount of serosanguinos yellow drainage with no odor. The periwound tissue is discolored, dark purple. Pt seen by wound care nurse and plastic surgery. * DM: type II, on low dose glipizide at home. Was treated with insulin sliding scale. Sugars well controlled. [**Month (only) 116**] continue insulin sliding scale at rehab; however, pt can likely resume home regimen in near future. * PPx: Therapeutic INR * Code: Full Medications on Admission: lasix 20 daily aldactone 25 daily lipitor 10 daily MV protonix 40 daily coreg 25 [**Hospital1 **] detrol 2 [**Hospital1 **] coumadin 2.5 daily glipizide 5 daily cranberry caps daily keflex q6h start [**9-2**] for 7 days Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) for 7 days: Con't for 1 week or until cough resolves. 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 5. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day): [**Month (only) 116**] stop when cough resolves. 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 11. Warfarin 1 mg Tablet Sig: 1.5 Tablets PO DAILY16 (Once Daily at 16). 12. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: Ten (10) ML PO Q4H (every 4 hours) as needed for cough: pt may refuse; discontinue once cough resolves. 13. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Insulin Regular Human 100 unit/mL Solution Sig: Per sliding scale Injection ASDIR (AS DIRECTED). 15. Aldactone 25mg daily (restarted on [**2182-9-18**]) Discharge Disposition: Extended Care Facility: [**Hospital **] health care center Discharge Diagnosis: Primary: - Monomorphic ventricular tachycardia with right bundle branch block - Cardiac arrest from pulseless electrical activity (in setting of hypoxia) - Bronchitis - Lower extremity ulcers Secondary: Coronary artery disease s/p MI 15years ago s/p angioplasty Atrial fibrillation on coumadin Hypertension Hypercholesterolemia UGIB 10y ago Osteoarthritis (primarily affecting knees) Discharge Condition: Good, ambulating with assistance, 02 saturation 97% on 2L NC. Afebrile, BP 110-120/50-60s, HR 50-80s in atrial fibrillation. No BM for 4 days--got suppository today ([**2182-10-18**]) Discharge Instructions: You were admitted with ventricular tachycardia. You were started on a new medication for this called amiodarone. You will need to have pulmonary function tests and an eye exam now that you are on a new medication called amiodarone. Additionally, you will need to have your liver function tests followed from time to time. Please discuss this with your cardiologist and, or your primary care doctor. Your dose of warfarin was decreased to 1.5mg. Your new medication amiodarone may cause your coumadin level to increase, so your blood should be monitored closely and your coumadin dose adjusted as needed. Please call your doctor or 911 if you develop fever, chills, shortness of breath, chest pain, lightheadedness, or any other concerning change in your condition. Followup Instructions: Please call your PCP [**Name9 (PRE) 61898**],[**Name9 (PRE) 278**] [**Name Initial (PRE) **]. at [**Telephone/Fax (1) 61899**] to schedule appointment . You have an appointment scheduled with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], cardiologist and electrophysiologist, on [**2182-10-15**] at 2:40pm at his [**Hospital1 **] office. See address below. [**Hospital3 **] Internal Medicine Address: [**Street Address(2) **]. # 300 [**Hospital1 **], [**Numeric Identifier 4474**] Phone: ([**Telephone/Fax (1) 24747**]

[ "397.0", "272.0", "715.90", "412", "424.0", "427.5", "416.8", "707.19", "428.0", "414.01", "799.02", "427.31", "V58.61", "272.4", "426.4", "427.1", "428.23", "584.9", "276.51", "466.0", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

11577, 11638

3850, 9830

242, 300

12067, 12253

1490, 1490

13072, 13620

1194, 1212

10101, 11554

11659, 12046

9856, 10078

12277, 13049

1856, 3827

1227, 1471

191, 204

328, 827

1506, 1840

849, 1039

1055, 1178

64,008

156,207

492

Discharge summary

report

Admission Date: [**2166-4-11**] Discharge Date: [**2166-4-18**] Date of Birth: [**2119-11-6**] Sex: F Service: NEUROSURGERY Allergies: Penicillins / Egg / Sulfa(Sulfonamide Antibiotics) / Sulfa(Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 78**] Chief Complaint: Headache Major Surgical or Invasive Procedure: cerebral angiogram History of Present Illness: This is a 46 year old woman who was a passenger on a motorcycle this evening when she developed severe headache at the vertex that she describes as the worst headache of her life. She was taken to OSH and CT showed SAH. She was transferred to [**Hospital1 18**] for further management Past Medical History: AIDS (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4109**] [**Hospital 1559**] Medical Center), Hepatitis C, CD4 in 20's, viral load 190,000, thrombocytopenia, recently seen by Hem/Onc at OSH, depression, hypertension, ureteral implants, colposcopy, IV drug use, rotator cuff injury, gallstones Social History: She formally used IV drugs, reports no current ETOH. Reports 3 cigarettes for 1 year. She lives in a sober house. She is on disability. Family History: No aneurysms Physical Exam: On Admission: : T:98.7 BP: 145/99 HR: 70 R 24 O2Sats 100% 2L NC Gen: WD/WN, uncomfortable, photophobic. HEENT: Pupils: [**2-19**] EOMs intact Extrem: Warm and well-perfused. No C/C/E. Neuro: Mental status: Awake but lethargic, somewhat uncooperative with exam. Yelling at examiner. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2 to 1 mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to finger rub bilaterally. 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. Patient not cooperative with exam due to HA, moving symmetrically. No pronator drift Sensation: Intact to light touch Toes downgoing bilaterally on the day of discharge: [**2166-5-19**]- deceased Pertinent Results: CTA head [**2166-4-11**] CT angiography of the head demonstrates an approximately 3.5 mm aneurysm arising from the anterior communicating artery at the junction of the right A1 and A2 segments and pointing to the left side. No other definite aneurysms are identified in the arteries of anterior and posterior circulation. IMPRESSION: 1. CT head demonstrates subarachnoid and intraventricular blood and signs of early obstructive hydrocephalus. 2. CT angiography of the head demonstrates a 3.5 mm aneurysm from the anterior communicating artery at the junction of the right A1 and A2 segment and pointing to the left side. No other aneurysms are seen in the head. 3. CT angiography of the neck demonstrates no vascular occlusion or stenosis. CT Head [**2166-4-12**]: IMPRESSION: 1. Status post coiling of ACOM aneurysm. Stable amount of subarachnoid hemorrhage with interval redistribution. Minimal interval increase in the left lateral ventricle IVH. 2. Diffuse sulcal effacement, as before, likely secondary to mild global edema. 3. No new hemorrhage. ECHO [**2166-4-14**]: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. 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 mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. CTA Head [**2166-4-15**]: IMPRESSION: 1. Status post coiling of anterior communicating artery aneurysm with decreased subarachnoid and intraventricular hemorrhage since the prior exam. No new hemorrhage or obvious infarction. Cerebral edema has improved since the prior exam. A small hypodense focus in the right frontal lobe laterally may relate to volume averaging or less likely a focus of ischemic change and needs attention on f/u. 2. No flow limiting stenosis or obvious vasospasm or new large aneurysm. 3. Right distal cervical ICA is tortuous, of uncertain significance. Given young age and lack of atherosclerotic disease, clinical correlation for connective tissue/ vascular disorders is suggested. ABDOMEN U.S. (COMPLETE STUDY) PORT Study Date of [**2166-4-16**] 7:36 AM IMPRESSION: 1. Moderate ascites within the abdomen. 2. No focal liver lesion and no biliary dilatation. 3. Splenomegaly. CHEST (PORTABLE AP) Study Date of [**2166-4-17**] 3:31 AM FINDINGS: As compared to the previous radiograph, there is unchanged position of the right PICC line. Unchanged moderate cardiomegaly. However, the increased vascular diameter and slightly increased diameter of the right paramediastinal vessels suggest newly appeared moderate pulmonary edema. The observation was made at the time of dictation, 8:34 a.m., on [**2166-4-17**]. At that time, the referring physician was paged for notification. Findings were subsequently discussed over the telephone. [**2166-4-17**] 01:57AM BLOOD WBC-6.4 RBC-2.81* Hgb-9.3* Hct-29.7* MCV-106* MCH-33.0* MCHC-31.3 RDW-17.0* Plt Ct-102* [**2166-4-11**] 10:30PM BLOOD Neuts-74.8* Bands-0 Lymphs-16.1* Monos-5.6 Eos-3.1 Baso-0.4 [**2166-4-17**] 01:57AM BLOOD Plt Ct-102* [**2166-4-15**] 09:43AM BLOOD Fibrino-164* [**2166-4-17**] 06:20PM BLOOD Glucose-114* UreaN-42* Creat-2.5* Na-138 K-6.0* Cl-110* HCO3-17* AnGap-17 [**2166-4-17**] 01:57AM BLOOD ALT-55* AST-102* LD(LDH)-375* AlkPhos-147* TotBili-1.9* [**2166-4-17**] 06:20PM BLOOD Calcium-8.9 Phos-4.1 Mg-2.6 [**2166-4-17**] 06:25PM BLOOD Type-ART pO2-92 pCO2-25* pH-7.44 calTCO2-18* Base XS--4 [**2166-4-17**] 06:25PM BLOOD K-6.1* [**2166-4-13**] 06:26AM BLOOD freeCa-0.98* Brief Hospital Course: Ms. [**Known lastname 4110**] was admitted to the NICU. CTA was done that redemonstrated SAH and suggested R ACOMM aneurysm. She was started on nimodipine and Keppra with Q1 hr neuro checks while in the ICU. She underwent an angio with coiling. She remained intubated post-op secondary to delayed reversal. She was angiosealed to the R side. She was extubated Saturday evening but then required reintubation for hypoxia on [**4-12**]. On [**4-13**] she was hypotensive and Nimodipine was held. TCDs on [**4-14**] were normal and her SBP normalized and she restarted Nimodipine. Patient expressed her wishes and declared herself DNI. On [**4-15**], she appeared more confused in the AM. A CTA head was done which showed no vasospasm. No changes were made to her management. A UA/UC was sent, UA was negative. We also checked her liver enzymes which appeared improved since admission. On [**4-16**], Transcranial dopplers revealed no vasospasm. She continued to be observed. Hepatology saw her for moderate acites on US. They recommended lactulose, aldactone and lasix. The patient continues to exerience to have tachypnea. [**4-17**]: Hepatology performed diagnostic paracentesis (40cc) which the patient refused half way through the procedure that was negative for infection, given 100g albumin. Pt made Care and comfort measures only per her and family wishes TCD showed no overt spasm. Hepatology reccommende starting lactulose, lasix and aldactone; increasing abdominal distention overnight, pancultured complained of SOB and was given lasix for a urine output of 50-60ml/hr. The patients hyperkalemia worsened and so insulin/D50 was given along with kayexylate. nephrology consulted and recommended giving 80mg lasix and patient did not respond, so an additional 160mg of lasix was given. Dialysis not an option as informed by mother (health care proxy) that patient would never want to be dialyzed. Ultimately, family decided for CMO for patient. The patient experienced respiratory ditress overnight, tachypnea and was on a morphine gtt for comfort. Due to respiratory distress the patient wxpired at 0941 on [**4-18**]. Medications on Admission: lopressor, fluconazole 200mg QD, Truvada, Trazodone 0.5 QHS, DApsone 100mg po QD, Kaletra, Acyclovir 400 QD, Azithromycin 600mg 2 tabs weekly, Triamcinolone Discharge Medications: none- deceased Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: none- patient deceased Discharge Instructions: none - pt deceased Followup Instructions: pt deceased Completed by:[**2166-4-18**]

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icd9cm

[ [ [] ] ]

[ "88.41", "39.75", "54.91", "96.71", "96.04", "38.97" ]

icd9pcs

[ [ [] ] ]

8730, 8739

6343, 8483

355, 375

8791, 8815

2418, 6320

8882, 8924

1198, 1213

8691, 8707

8760, 8770

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307, 317

403, 689

1695, 2399

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1437, 1679

711, 1028

1044, 1182

2,238

120,286

31005

Discharge summary

report

Admission Date: [**2136-3-30**] Discharge Date: [**2136-4-9**] Date of Birth: [**2109-1-4**] Sex: M Service: NEUROSURGERY Allergies: Vancomycin / Gentamicin Attending:[**First Name3 (LF) 1854**] Chief Complaint: Intracranial Hemmorrhage s/p Transfer [**Location (un) 47**] [**Hospital1 1281**]/[**Hospital1 **] Major Surgical or Invasive Procedure: Bilateral external ventricular drain placement [**2136-3-30**] History of Present Illness: HPI:27 M last seen normal [**3-29**] PM was found by mother @ 1800 with EMS in bed per [**Location (un) **]. Found c 7 fentanyl patches in various stages on patient. No signs of trauma per team. Pt was able to be aroused, was agitated, nonpurposeful, was combative, no comment on motor exam, deteriorated to GCS 6, was intubated, BP 180-200/120-130 initially. Patient received total 550mcg fentanyl, ativan 8, then propofol up to 100mcg/kg. Apparently, seizing at osh c tremors and enroute - stopped with propofol. Past Medical History: PMHx: Crohn's colitis s/p mult abd surgeries, sacral osteomyel- itis s/p drainage (tx @ [**Hospital1 112**] but not able to tx [**12-30**] no beds), chronic pain issues, fentanyl abuse, depression. All: NKDA Social History: Social Hx: drug abuse, ? alc/tob Family History: noncontributory Physical Exam: PHYSICAL EXAM: O: T: 96.4 BP: 112/66 HR: 62 R 12 O2Sats 100% vent Gen: WD/WN, comfortable, NAD. intubated. NGT in place. Foley in. HEENT: Pupils: pinpoint fixed EOMs [**Last Name (un) **] Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. intubated Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: GCS 5 Recall:[**Last Name (un) **] Language: [**Last Name (un) **] Cranial Nerves: I: Not tested II: Pupils pinpoint III, IV, VI: [**Last Name (un) **] V, VII: [**Last Name (un) **] +corneal Bilat VIII: [**Last Name (un) **] IX, X: [**Last Name (un) **]. + gag/cough [**Doctor First Name 81**]: [**Last Name (un) **]. XII: [**Last Name (un) **]. Motor: LUE: +contractions/flailing localizing to pain. RUE/BLE: +contractions/nonpurposeful to pain Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right none-----------> (unable to elicit) Left none-----------> (unable to elicit) Toes equivocal bilaterally Coordination: [**Last Name (un) **] Pertinent Results: [**2136-4-9**] Na 144 Cl109 BUN 7 Gluc 115 AGap=14 K 3.6 CO225 Cr 0.7 Ca: 9.0 Mg: 2.2 P: 3.0 Phenytoin: 8.2 WC 14.5 Hg11.4 Hct33.4 Plt clumped (Plt 449 on [**2136-4-8**]) N:77 Band:3 L:15 M:5 E:0 Bas:0 Anisocy: 2+ Polychr: 1+ PT: 12.5 PTT: 25.2 INR: 1.1 CSF [**4-5**] WC 205 (3 polys, 30 lymphs, 46 monos, 21 macrophages) RC 4950 Prot 18 Gluc 118 Negative garm stain and culture. [**2136-4-7**] ESR 25 CRP 192.2 C.diff in stool EIA negative on [**5-13**] and [**4-3**]. CTA Head: NO OBVIOUS AVM IS SEEN. BILATERAL FRONTAL HEMMORHAGE WITH ASSOCIATED SUBFALCINE AND UNCAL HERNIATION .IVH is seen as extension of of parenchymal hemmorhage. CT Head without contrast: Massive R (7.8x4.5cm)>L (2.8x1.8cm) with R parietal/frontal SDH and small L frontal SDH, small R falx SAH, +10mm midline shift with subfalcine and subuncal herniation on the right. +Effacement of suprasellar cistern. NCHCT [**2136-4-7**] Biventricular catheters have been removed with small air present within the ventricles and pneumocephalus along the catheter tracts. The large bifrontal intracranial hemorrhages (right greater than left) are stable in appearance. Mass effect including a leftward subfalcine herniation and small uncal herniation is unchanged. The visualized paranasal sinuses are clear. The osseous structures are unremarkable aside from bifrontal burr holes and overlying skin staples. IMPRESSION: Stable appearance of the brain with large bifrontal intracranial hemorrhages, subfalcine and uncal herniation. Bilateral ventricular catheters removed. CT [**Last Name (un) 103**]/Pelvis [**2136-4-8**] 1. Marked inflammatory changes in the pelvis, with a linear tract leading from the presacral coccygeal space to the skin surface, may represent a perianal sinus tract. No drainable fluid collection. Linear tract in the right lower abdominal wall may also represent a fistula, however the assessment is difficult due to lack of the contrast in the underlying bowel loops. 2. Abnormal appearance of the sacrum and L5 vertebral body, consistent with given history of osteomyelitis. MR could be obtained to evaluate for evidence of active process. 3. Moderately dilated loops of small bowel, consistent with ileus. CXR [**2136-4-6**] Low lung volumes. No evidence of failure or worsening infection. BILAT HIPS (AP,LAT & AP PELVIS) [**2136-4-9**] 27 year old man with frontal hemorrhage and [**Last Name (un) 73258**] disease fell out of bed c/o left hip pain REASON FOR THIS EXAMINATION:R/o fracture HISTORY: Left hip pain. Five radiographs of the pelvis and bilateral hips demonstrate no fracture. Femoral head contours are smooth. Bilateral sacroiliac joint spaces are normal. Pubic symphysis is normal. Regional soft tissues are unremarkable. IMPRESSION:No fracture. Brief Hospital Course: This is a 27 y old man with large R>L frontal atraumatic ICH with intraventricular extension and hydrocephalus in the setting of known cocaine use. ICH: Bilateral external ventricular drains were placed on [**2136-3-30**]. He was admitted to the ICU for close monitoring. He was treated with dilantin for seizure prophylaxis. Serial CT scans showed stable appearances of hemorrhage. EVD was clamped and removed on [**2136-4-5**]. He was transferred to the floor on [**2136-4-5**]. His mental status improved. He consistently thought he was at the [**Hospital6 1708**]. Oriented to time and person. There was no focal motor deficit, normal coordination. He has L>R action tremor. He was observed for 24 hours was found to be neurologically intact with the exception of short term memory difficulties, slightly disinhibited/emotional. The patient is being treated with dilantin for seizure prophylaxis. Please continue to monitor levels. Goal dilantin 15-20. Additional 300mg given on [**2136-4-9**]. The patient was seen by PT and OT and will be discharged to rehabilitation facility for further recovery. Please arrange follow up with Dr [**Last Name (STitle) **] in 4 weeks with CT head. Pneumonia: CXR showed LLL opacity concerning for penumonia and on [**2136-4-2**] he was commenced on levofloxacin. This was ceased on [**2136-4-6**] as he was covered for meningitis (see below). Repeat CXR on [**2136-4-6**] showed stable to improved. Sacral osteomyelitis/Crohn's disease: Crohn's disease with sacral osteomyelitis and sacral drain. General surgical team discussed with [**Hospital1 112**] surgeon regarding drain and directed to leave drain in situ, he is should be treated prophylactically with Amoxicillin. Amoxicillin ceased on [**2136-4-6**] while covered with ceftriaxone and linezolid. Amoxycillin should be restarted after other antibiotic course completed. Drain pulled out on [**2136-4-8**]. CT abdomen revealed no abcess or fluid collection. Discussed with general surgery team. Not for replacement of drain at this stage. Monitor clinically for pain, signs of inflammation and monitor inflammatory markers. Repeat imaging studies if indicated. The patient needs follow up with the Gastroenterology and General Surgical teams at [**Hospital1 112**]. There is a small draining sinus/fistula on the anterior abdomen (draining small serous fluid) and a small sinus on the left buttock (site of sacral drain). A further GI operation has been recommended by the surgical team for treatment of Crohn's disease. The patient had failed to attend follow up. Please arrange follow up appointment and facilitate attendance. He currently has a rectal tube in situ. [**4-6**] Pt's WBC increased to 23, on further evaluation of his CSF from [**4-5**] he had 205 WBC 4950 RBC and 118 glucose gram stain negative. He was not systemically unwell, had only background headache and no neck stiffness. A chest xray showed: stable right pneumonia and urine analysis: [**1-30**] WBC [**1-30**] RBC and few bacteria. Given his CSF analysis we decided to treat with ceftriaxone and linezolid for 10 days (final day [**2136-4-15**]). WCC on day of discharge was 14. His white cell count/inflammatory markers should be followed. Quetiapine was ceased while on treatment with linezolid due to concern for Serotonin Syndrome. Quetiapine should be restarted when linezolid ceased ([**2136-4-15**]). The patient had a fall from bed on [**2136-4-8**] and was complaining of left hip pain. No evidence of fracture on plain films. No other injuries. Medications on Admission: Medications prior to admission: Levoquin, Seroquel, Clonopin, Fentanyl, Vicodin Discharge Medications: 1. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 2. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed for fever. 4. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) Injection Q4H (every 4 hours) as needed. 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 7. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 9. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): (Hold medication until linezolid stopped due to concern regarding serotonin syndrome). 10. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 11. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours): (10 days treatment ends on [**2136-4-15**]). 12. Ceftriaxone-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: Two (2) g Intravenous Q12H (every 12 hours): (10 days treatment ends on [**2136-4-15**]). 13. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Bilateral frontal intraparenchymal hemorrhage with intraventricular extension Hydrocephalus Meningitis Pneumonia Crohn's Disease Discharge Condition: Improved level of consciousness. No focal motor deficit. Discharge Instructions: You have been treated for bilateral intracranial hemorrhage likely related to cocaine use. Dilantin has been started to decrease the risk of seizures. Please taken medication as prescribed and keep follow up appointments. Seek further medical opinion for changes in level of consciousness, focal weakness or sensory change, speech difficulty, seizure activity or any other concerns. Watch incisions for any redness, drainage, and bleeding. R/O staples on [**2136-4-12**] Followup Instructions: Follow up with Dr [**Last Name (STitle) **] in 1 month with a head CT call [**Telephone/Fax (1) 3231**] for an appointment. Have staples removed on [**4-12**] at rehab facility. . Please see your PCP [**Name Initial (PRE) 176**] 1-2 weeks Dr [**First Name8 (NamePattern2) 2092**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ph [**Numeric Identifier 73259**]. . Please arrange gastroenterology follow up at [**Hospital1 112**] with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8494**] ph[**Telephone/Fax (5) 73260**] and general surgery follow up at [**Hospital1 112**] with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ph[**Telephone/Fax (5) 73260**] within 1-2 weeks for further evaluation of your fistula and your chronic osteomyelitis.

[ "E884.4", "555.9", "305.90", "431", "730.28", "569.81", "348.4", "780.39", "331.4", "719.45", "322.9", "486" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.72", "02.2", "93.90", "99.07" ]

icd9pcs

[ [ [] ] ]

10218, 10315

5222, 8775

386, 451

10488, 10547

2416, 4887

11068, 11876

1309, 1326

8906, 10195

10336, 10467

8801, 8801

10571, 11045

1356, 1670

8833, 8883

247, 348

4915, 5199

479, 999

1769, 2397

1685, 1753

1021, 1242

1258, 1293

7,671

127,375

10087

Discharge summary

report

Admission Date: [**2197-10-5**] Discharge Date: [**2197-10-14**] Date of Birth: [**2148-4-6**] Sex: F Service: CCU PRESENT ILLNESS: The patient is a 49-year-old woman with a longstanding vascular disease including coronary artery disease status post MI, status post CABG, who was recently admitted to [**Hospital6 256**] from [**Date range (1) 33695**], at which time she was admitted for a non-ST elevation myocardial infarction. At that admission, the patient had a cardiac catheterization which revealed a fresh thrombus in her saphenous vein graft to D-1, and it was decided that no intervention was undertaken at that time. During this admission, her peak CK's rose to 910 and her troponin was noted to be greater than 50. Upon discharge, she had been chest pain free for 48 hours and was ambulatory at the time of discharge. A follow-up echo at this time revealed a relatively preserved left ventricular ejection fraction of approximately 50% with 2+ mitral regurgitation. The following evening, at approximately 8 p.m., the patient developed a sudden onset of [**9-9**] substernal chest pain. The pain was described as crushing pressure radiating to the neck. It was associated with nausea, though the patient denied vomiting, palpitations or shortness of breath. The pain was unrelieved by sublingual nitroglycerin times three. The patient called the EMS and was brought to the Emergency Room where initial vital signs were stable. The patient was started on morphine p.r.n. with a nitroglycerin drip. Her EKG at presentation had no changes from her baseline. With these medications, her chest pain was reduced to [**2205-3-6**] and the patient was started on hirudin. The emergency course was remarkable for the sudden resurgence of chest pain while on nitroglycerin and hirudin. Subsequently, her blood pressure dropped to 60/30 for about 10 minutes and the patient was intubated secondary to impending respiratory arrest. Her blood pressure increased with 1.5 liters of IV fluid and peripheral dopamine at 15 mcg/kg per minute. The Emergency Room course was also notable for spontaneous extubation for which she was reintubated. A right IJ was placed for access. Her blood pressure stabilized at 130/70 with a heart rate of 80 on 15 mcg/kg per minute of dopamine. The patient did experience another slight decrease in her blood pressure to 90's/60's with administration of 100 mcg of fentanyl. The patient was then taken to the catheterization laboratory for emergent cardiac catheterization. Catheterization revealed a left main coronary artery of 40% ostial lesion, left anterior descending with 70% ulcerated stenosis proximally, and left circumflex with mild luminal irregularities. Interventional Cardiology and Cardiothoracic Surgery reviewed these films and decision was made to perform PTCA stenting of the left anterior lesion with 3.0 velocity at 18 mm, and 2.5 velocity 8 mm. PAST MEDICAL HISTORY: 1. Coronary artery disease status post MI [**5-31**], [**10-31**], [**2-1**], [**9-1**], status post CABG [**2193**] with saphenous vein graft to RCA, saphenous vein graft to D-1, status post cardiac catheterization with RCA stent in [**2192**], left circumflex PTCA in [**2192**], RCA stent in 11/00, and [**3-3**]. 2. Peripheral vascular disease status post bilateral aorto-femoral bypass in 2/00, status post axillo-femoral bypass in 5/00, status post left brachial stent in [**10-31**] which was complicated by an aneurysm that required surgical repair. 3. Heparin induced thrombocytopenia. 4. Hypothyroidism. 5. Status post SDH with evacuation in [**4-1**]. 6. Seizures. PAST SURGICAL HISTORY: As above. OUTPATIENT MEDICATIONS: 1. Dilantin, 500 mg PO q d. 2. Levoxyl, 125 mg PO q d. 3. Folate, 1 gram PO q d. 4. Pepcid, 20 mg PO b.i.d.. 5. Flexeril, 10 mg PO t.i.d.. 6. Metoprolol, 50 mg PO b.i.d.. 7. Aspirin, 325 mg PO q d. 8. Accupril, 5 mg PO q d. 9. Isordil, 10 mg PO t.i.d.. 10. Tricor, 108 mg PO q d. 11. Zocor, 80 mg PO q d. 12. Senokot, two tabs q h.s.. 13. Colace, 100 mg PO b.i.d.. ALLERGIES: 1. Heparin, induced thrombocytopenia. 2. Codeine. 3. Sulfa. 4. Ceclor. SOCIAL HISTORY: Lives at home with husband in [**Name (NI) 3844**], reformed tobacco smoker of one-and-a-half packs per day times 20 years. FAMILY HISTORY: Significant for coronary artery and peripheral vascular disease. PHYSICAL EXAMINATION: Upon arrival to the unit, general exam: The patient was intubated and sedated on 30 of dopamine. Vital signs: Blood pressure 125/77, pulse of 122 and regular, temperature of 102 rectally. The patient was on a ventilator, FIMB at 814, 5, and 5. HEENT: Pupils were equally round and reacted to light and accommodation. Cardiovascular exam: S1, S2, tachycardiac, no murmurs, rubs or gallops. There is a carotid bruit on the left side. Chest: Clear to auscultation bilaterally. Abdomen: Soft, nontender, nondistended. Positive bowel sounds in all four quadrants. Extremities: No dopplerable pulses, radial, DP, PT, no edema, extremities cool to touch. Neuro: Patient was sedated. LABORATORIES IN THE EMERGENCY ROOM: Sodium 142, potassium 4.2, chloride 103, bicarbonate 24, BUN 16, creatinine 0.7, glucose of 106. White blood cell count of 9.1, hematocrit 29.8, platelets of 341, MCV of 92. Differential: Neutrophils 54.3, lymphs 35.7, monos 5, eos 3, basos 0.1. PT of 13.1, INR of 1.2, PTT of 30. Creatine kinase of 113 initially and with repeat to 1381, with troponin unable to be interpreted given previous troponin at discharge was greater than 50. Calcium 9.1, phosphorus 5.8, magnesium 1.5. TSH of 0.1. ALT 29, AST 19, alkaline phosphatase 67, total bilirubin 0.3. An ABG on admission was 7.44, 27, 350. EKG one at baseline revealed normal rate, rhythm, axis, and intervals, first in the Emergency Room revealed ST depressions in V3 through V5. EKG number three corresponding with hypotensive episode revealed 2 mm elevations in V2, 3 mm elevation in V3, and 1 mm elevations in V4 and V5. Chest x-ray revealed patchy opacities which may represent developing pulmonary edema. HOSPITAL COURSE: 1. Coronary vascular system: 1. Coronary artery disease: The patient was transferred to the CCU status post cardiac catheterization with LAD stent times two. The patient was continued on aspirin and Integrilin with initial holding of her beta blocker and ACE inhibitor secondary to pressor. Plavix was initially held for possible upcoming CAB. The patient was continued on antihyperlipidemia medication. Cardiac Thoracic Surgery was consulted and was aware of this patient for determination of future need for CABG. The patient was weaned off dopamine and metoprolol and Captopril were added as the patient tolerated. The patient remained chest pain free until hospital day number seven when the patient began to experience [**4-9**] chest and jaw pressure after she got up to go to the bathroom. The pain was described as [**6-9**] chest pressure with mild sternal and radiation to the jaw, and patient states that this pain is similar to her angina pain. The patient received sublingual nitroglycerin times three with decrease in the pain from [**6-9**] to [**2205-3-6**]. Vital signs remained stable, at this time. An EKG revealed nonspecific ST and T wave changes. Nitro drip was started and IV Lopressor was started for heart rate control, and CK's were cycled. The patient experienced pain episodic throughout the day and, again, had no EKG changes, patient had no increase in her creatine kinase enzyme. Lopressor was given as needed to control heart rate. C-Surgery was contact[**Name (NI) **] and the patient underwent pain MIBI to assess for ischemia of anterior left ventricle. MIBI revealed moderate to severe perfusion defects anteriorly, inferiorly, and at the apex, mild global hypokinesis, decreased ejection fraction of 44%. CT Surgery did not feel that this patient is a candidate for surgical intervention at this time, given risk-benefit ratio. The goal for this patient was to medically optimize cardiac risk factors and anti-anginal medications prior to discharge. Prior to discharge, the patient was weaned off the nitro drip and started on Imdur 90 mg PO q d, and patient was started on Plavix prior to discharge. Integrilin was also DC'd at this time. Please see discharge medications for outpatient medications. 2. Cardiovascular system: An echocardiogram on [**10-3**] revealed an ejection fraction of 55%. A repeat echo revealed a decrease in the ejection fraction to 35% following this ischemic insult. The patient was optimized on ACE inhibitor and beta blockers prior to discharge. 3. Cardiovascular system: Rhythm: The patient has no history of arrhythmias, and patient remained arrhythmia free throughout the hospital stay. 4. Pulmonary: Patient was ventilated for impending respiratory arrest and was continued on ventilatory support through hospital day number three. Extubation was notable in that, 15 minutes after extubation, the patient became stridorous and was given racemic epinephrine and nebulizer with resolution. ENT was consulted to evaluate air rate. ENT reports not evidence of airway obstruction, and felt episode was possibly due to laryngospasm. There was no recurrence of the symptoms. Patient remained extubated, saturating well throughout the remainder of hospital stay. 5. Infectious Disease: On day of the admission, the patient was noted to have high fevers which continued throughout the first three days of hospital stay, and the patient's gram stain was notable for gram positive cocci in pairs. The patient was started empirically on megalomicin and Levaquin and treated for a 14 day course of antibiotics. The patient defervesced on hospital day number six and continued to remain afebrile with a stable white blood cell count throughout remainder of hospital stay. 6. Musculoskeletal: Given high fevers and increased creatine kinase of greater than [**Numeric Identifier 389**] with an MB index of less than 0.3, it was believed that the patient developed muscle damage perhaps secondary to seizure experienced in the Emergency Room or possible rhabdomyolysis given history of peripheral vascular disease and hypotensive episode. The patient was hydrated during this time and enzymes continued to down trend throughout the remainder of hospital stay. 7. Neurology: It is notable that the patient, while in the Emergency Room, had an episode of shaking that was perhaps consistent with seizure that had been controlled with Ativan. Patient again had another shaking episode upon arriving to the CCU that was also treated with Ativan and patient experienced no other episode of seizure-like activity throughout the remainder of the hospital stay. The patient was continued on Dilantin for her history of seizures. 8. Endocrine: The patient was continued on Synthroid for history of hypothyroidism. 9. Code status: The patient signed a DNR-DNI prior to discharge, as discussed with the attending. CONDITION ON DISCHARGE: Fair. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSES: 1. ST elevation myocardial infarction. 2. Cardiogenic shock. 3. Seizure. 4. Hypothyroidism. 5. Bacteremia. DISCHARGE MEDICATIONS: 1. Aspirin, 325 mg PO q d. 2. Imdur, 90 mg PO q d. 3. Lipitor, 10 mg PO q d. 4. Captopril, 25 mg PO t.i.d.. 5. Metoprolol, 50 mg PO b.i.d.. 6. Vancomycin, 1 gram q 12 hours times five days. 7. Levaquin, 500 mg PO times six days. 8. Levoxyl. 9. Depakote, 500 mg PO q d. 10. Plavix, 75 mg PO q d. 11. Percocet, 5 mg/125 mg, one tab PO q 6 p.r.n. for pain. FOLLOW-UP PLANS: 1. Patient to follow-up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], patient's PCP, [**Name10 (NameIs) **] two weeks. 2. Vancomycin is to be continued via PICC line with home nursing times five days after discharge. 3. Patient to follow with ENT appointment to reassess posterior vocal cords in one to two months after trauma has resolved. Follow-up with Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 41**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**] Dictated By:[**Last Name (NamePattern1) 33696**] MEDQUIST36 D: [**2197-11-6**] 15:01 T: [**2197-11-9**] 11:05 JOB#: [**Job Number 33697**]

[ "410.71", "780.39", "785.51", "287.4", "790.7", "V45.81", "401.9", "244.9", "414.01" ]

icd9cm

[ [ [] ] ]

[ "36.01", "38.93", "37.22", "36.06", "99.20", "88.57", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

4320, 4385

11117, 11230

11253, 11617

6122, 11035

3664, 3675

3699, 4161

4408, 6105

11634, 12363

2957, 3640

4178, 4303

11060, 11096

11,985

128,923

10647

Discharge summary

report

Admission Date: [**2173-2-6**] Discharge Date: Date of Birth: [**2137-8-16**] Sex: M Service: MEDICINE HISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname 34937**] is a 35-year-old male with a history of HIV positivity with a CD4 count in the 200s recently and a viral load of 10,000, who is followed by [**First Name8 (NamePattern2) 34938**] [**Last Name (NamePattern1) 2916**] in this hospital. The patient was transferred to the [**Hospital1 69**] Intensive Care Unit from [**Hospital6 3105**] for hyperosmolar-hyperglycemic, nonketonic coma. The patient was brought to [**Hospital6 3105**] on [**2173-2-5**], when he was found nonarousable in bed by his wife with urinary incontinence. He was intubated at the [**Hospital6 23267**] for airway protection. On admission to [**Hospital6 3105**] his serum glucose was 1060. At this time he was febrile to 103.5 degrees rectally. The heart rate was tachycardiac at 161 per minute. Blood pressure was 140s to 160s/90s. He was breathing at 28 times a minute and saturating to 99% to 100% on a nonrebreather mask when he arrived at the [**Hospital6 3105**]. At the [**Hospital6 3105**] the patient received five liters of normal saline total and IV insulin for correction of his hyperglycemia. Over the next day, the patient's glucose was corrected down to the 200s, but his serum sodium started to rise up to a 167. At this point, he was transferred to the [**Hospital1 69**] for further medical care. Upon retrospective history, the patient's wife reported that he was not in his usual state of health a week prior to his admission to [**Hospital6 3105**]. She noted that he was confused at times and noted him to be "walking crooked." She also noticed that he was urinating constantly and drank six gallons of water a day. He continued to deteriorate until the morning of [**2-5**], when his wife found him in bed and nonarousable with urinary incontinence and called an ambulance. After extubation, the patient was questioned regarding his symptoms prior to the onset of his polyuria and polydipsia. The patient reported that he had had two to three days of bloody diarrhea six to seven times a day prior to the onset of his polyuria and polydipsia, which he in fact, does not recollect. He denied any cough, fevers, chills, headaches, photophobia. He denied any abdominal pain, vomiting or nausea. He denied any chest pain. He denied any sick contacts or any travel history. He did not eat anything unusual in the recent past. The patient was at this time on 60 mg of Prednisone a day for his mononeuritis multiplex. Because of his peripheral neuropathy he does walk with a cane and he has hyperesthesias, which are controlled by Neurontin. The patient denied any history of elevated blood sugars in the past. Recent laboratory data was reviewed. The glucose was normal, as recently as [**2172-11-26**], when it was 106. PAST MEDICAL HISTORY: 1. HIV diagnosed in the year [**2171**], followed by Dr. [**First Name8 (NamePattern2) 34938**] [**Last Name (NamePattern1) 2916**]. The most recent CD4 count was 287 and the viral load was 9,830, done on [**2172-12-15**]. 2. Mononeuritis multiplex status post two sural-nerve biopsies. 3. Sickle-cell trait. 4. Hypertension. 5. Bilateral cataracts in childhood requiring surgery. 6. G6PD trait positive. 7. Status post liver biopsy for questionable hepatitis. 8. Question of meningitis with chronic CNS pleocytosis followed by the Neurology. MEDICATIONS ON ADMISSION: (on admission to the [**Hospital1 346**]) 1. Prednisone 50 mg a day. 2. Insulin drip. 3. Ceftriaxone 1 gram IV q.12h. 4. Heparin subcutaneously 5000 units b.i.d. FAMILY HISTORY: The patient denied any family history of diabetes mellitus. The patient reports that his mother has arthritis. SOCIAL HISTORY: The patient is married and has two children. The patient works as a collections officer for the City of [**Location (un) 86**]. He had contracted his HIV from his previous marriage. His previous wife had died of cervical cancer. The patient was originally from the [**Country 13622**] Republic. He is bilingual in English and Spanish. His children are HIV negative. The only person who is aware of his HIV status is his current wire. The patient denied any tobacco use, alcohol, or drug use. PHYSICAL EXAMINATION: Examination on admission to the hospital revealed the following: The patient was intubated and sedated. VITAL SIGNS: Temperature 102.8, blood pressure 136/73, pulse 119, respiratory rate 12, oxygen saturation 100%. The patient had post surgical pupils. HEENT: Patient's pupils are post surgical with right-side esotropia. He was intubated and sedated. He had normal dentition, no thrush. NECK: Neck was supple. CARDIOVASCULAR: Examination revealed normal S1 and S2, sinus tachycardia and regular rate and rhythm with no murmurs and no friction rubs. RESPIRATORY: Clear to auscultation bilaterally. ABDOMEN: The abdomen is obese, protruding, which was soft, and did not appear to be tender. There was hypoactive bowel sounds ausculted. EXTREMITIES: Examination revealed normal extremities with no focal swelling. The distal pulses were all intact. The skin was dry and warm. NEUROLOGICAL: Examination revealed intubated and sedated patient, who responds to noxious stimuli. Studies on admission revealed sodium of 165, potassium of 4.4, chloride 129, bicarbonate 28, BUN 42, creatinine 1.7, sugar 140. Serum calculated osmolality was 352. The patient's hematocrit was 38.9, white count was 8.6 and the platelet count was 107. The PT was 14.3, PTT 21.2. The albumin was 3.9, calcium 9.3, magnesium 2.4, phosphate 4.2, total bilirubin 0.5, AST of 79, ALT 94. Per report from the outside hospital, the patient has a normal CT of his head. HOSPITAL COURSE: The patient was transferred from [**Hospital6 23267**] to the Medical Intensive Care Unit at [**Hospital1 1444**]. On admission he was hyponatremia and hyperosmolar. He was placed on insulin drip, given D5 and volume resuscitated with saline boluses. Blood, urine, and spinal fluid cultures were also obtained for workup of his fever. The patient was empirically covered with acyclovir, 2 grams Ceftriaxone q.12h., Ampicillin, Flagyl, and Levofloxacin in the Intensive Care Unit. Chest x-ray done on admission revealed possible left lower lobe infiltrate in the retrocardiac window. The patient also received MRI of his head with gadolinium for careful look at his pituitary for question of diabetes mellitus insipidus. No structural abnormalities were noted in this MRI. With repletion involving resuscitation, the patient's sodium began to decrease. His mental status also improved upon weaning of his sedatives. He was extubated successfully on [**2173-2-8**]. At this time he remained febrile to a temperature of 101.4. On [**2-10**], the patient's sodium was corrected to a normal level of 142. He remained on an insulin drip at around 10 units an hour. He was converted to long-acting insulin with NPH 60 units twice a day and transferred out to the floor. Upon arrival to the floor, the patient, on examination, was found to have mild right lower quadrant tenderness on palpation. By [**2173-2-11**], AM labs had indicated that the hematocrit was dropping from a baseline of 39 on admission to the outside hospital to a hematocrit of 27 on [**2173-2-11**]. This was complicated by the fact that the patient is a Jehovah witness. He was also noted to have guaiac-positive stool. Given his history of bloody diarrhea, prior to his presentation to the [**Hospital6 3105**], guaiac-positive stool and dropping hematocrit, a CT scan of his abdomen was done, which revealed severe cecal inflammation. The patient was made NPO and placed on IV Ampicillin, Levofloxacin, and Flagyl. He was getting Ceftriaxone at this time at 2 grams every 12 hours for meningitic coverage. Surgery Service was consulted to follow the patient. The patient did very well clinically over the next few days. His diet was advanced as tolerated. On [**2173-2-14**], he developed a low-grade temperature overnight at 100.8 to 100.9 without clear source. He was continued on Ampicillin, Levofloxacin, Flagyl, and Ceftriaxone at this time. Right arm small pustule was noted at an old IV site. There was no pustule and no fluctuance and the lesion appeared superficial. The lesion proceeded to heal itself with no further complications. The patient's low-grade temperature, however, did not resolve. On [**2173-2-16**], with worsening spiking, the CT of the abdomen was obtained. On this repeat CT scan, there was no change in the cecal thickening, which was observed. There was no evidence of intra-abdominal abscesses or perforations. Incidentally noted on the CT scan was worsening of the patient's left lower lobe infiltrate as a questionable source of his fever. The Vancomycin was added at this time. Upon the start of Vancomycin, the patient's fever spikes resolved to a mild low-grade temperature at 99.9 for two days. During this time, he still received regular blood/urine cultures with viral cultures including CMV antigenemia, which was sent. The patient was feeling very well clinically with no abdominal pain on examination. The patient had no cough, no crackles on lung examination, and the patient wanted to go home. Between [**2-19**] and 26th, the patient was noted to start to have tachycardia of unclear etiology. On [**2-21**], he started spiking temperature again overnight. He has finished his two-week course of meningitic doses of Ceftriaxone at this time. Decision was made to stop all previous antibiotics and change his antibiotic regimen to piperacillin/Tazobactam for Pseudomonal coverage. The patient was also noted to have worsening of his neuropathy symptoms. Between [**2-11**] and [**2-21**], the patient was on a rapid tapering of his Prednisone dose. His Prednisone was completely off by [**2-21**]. On [**2-21**], the patient again had right lower quadrant tenderness on examination. Repeat CAT scan of his abdomen and chest was done on [**2-22**]. There was still underfilling of his cecum, but the cecal inflammation was felt to be unchanged. There was interim evidence of improvement of the left lower lobe pneumonia. At that time it was felt that an infectious nidus may be his cecal inflammation and the Department of Gastroenterology was consulted to perform a colonoscopy. The patient received his colonoscopy on [**2173-2-24**], which revealed a completely normal examination with a completely normal cecum. Biopsies were taken for pathology, as well as culture. The patient's temperature meanwhile had been escalating and on [**2-24**], upon returning from his colonoscopy, his temperature was up to 105.8. He required cooling blankets, ice pats, as well as around-the-clock Tylenol. On [**2-25**], the patient remained febrile at 104 to 105 degrees requiring cooling blankets. Other than chills which he feels when his temperature is up to 104 to 105, the patient, otherwise, felt well. He had a good appetite. He had no headaches, no back pains, no nausea, vomiting, or shortness of breath. Vital signs remained very stable, except for a tachycardia in the 110s to 130s with his temperature. His sugar remained well controlled and his multiple blood and urine cultures had been negative. At this point, it was felt that a bacterial cause for his persistent spike was unlikely. A CMV-PCR was sent. The HIV viral load and repeat CD4 count was also sent. All antibiotics were stopped on [**2173-2-25**] to observe the patient's fever curve off antibiotics in case this is a drug fever. SUMMARY OF PROBLEMS BY SYSTEM: 1. INFECTIOUS: The patient has persistent fever of unclear origin. Multiple scans of his chest and abdomen did not reveal any possible infectious source. At this time the differential diagnosis includes the following: viral syndrome, possible etiologies included CMV, EBV, or HIV itself. The patient may still have a resolving infectious diarrhea per the history he has given us. Another possibility is drug fever and for this the antibiotics were all stopped. Finally, this fever may be associated with vasculitis and connective tissue disease, which the patient has some evidence on his nerve biopsy, as well as his liver biopsy. This fever may have been masked by PO Prednisone, which he was taking. Further investigations at this time include the following: awaiting viral cultures and hematology/oncology consultation, potential bone narrow biopsy for workup of fever of unknown origin. Gallium scan is another possibility. 2. ENDOCRINOLOGY: The patient has been receiving 60 of NPH twice a day with good control of his blood sugar. 3. HIV: The patient is currently off all antiretroviral medicines. He is not to restart on any antiretroviral medicines until his current acute illness has resolved. 4. HEMATOLOGIC: The patient's hematocrit had been stable since [**2173-2-11**]. However, over [**2-21**] to 30th, [**2173**], it was noted that the patient has been decreasing his white blood cell count, as well as the percentage of his neutrophils. This has been followed daily and the Hematology/Oncology Service has been consulted. 5. NEUROLOGICAL: The patient has some peripheral neuropathy presumed to be mononeuritis multiplex. On sural-nerve biopsy there was a suggestion of HSV1 inclusion bodies in the nerve cells, as well as evidence of vasculitis, question of HIV vasculopathy. The Neurology Service is following the patient with agreement of tapering of his Prednisone. The patient remains on 1200 mg Neurontin three times a day to control his neuropathy. The patient also has a history of CNS pleocytosis with elevated white counts and lymphocytic predominance in his lumbar punctures. Differential diagnosis of this finding includes a slow HIV related meningitis, CNS sarcoid, or carcinomatous meningitis. The Department of Neurology is following the patient and the patient will need to followup lumbar punctures in two to four weeks time after discharge with the [**Hospital 878**] Clinic. 6. HYPERTENSION: The patient is on 100 mg of Atenolol per day with good control of his blood pressure. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**] Dictated By:[**Name8 (MD) 9921**] MEDQUIST36 D: [**2173-2-26**] 09:13 T: [**2173-2-26**] 09:42 JOB#: [**Job Number **]

[ "V08", "401.9", "282.5", "486", "276.1", "250.20", "355.9", "047.8" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

3709, 3822

3525, 3692

5838, 14545

4361, 5820

2944, 3498

3839, 4338

49,565

171,674

43959

Discharge summary

report

Admission Date: [**2124-5-30**] Discharge Date: [**2124-6-14**] Date of Birth: [**2051-1-8**] Sex: F Service: MEDICINE Allergies: Penicillins / Codeine / Percocet / Darvocet A500 / Cefepime Attending:[**First Name3 (LF) 759**] Chief Complaint: Elective laminectomy Major Surgical or Invasive Procedure: Endotracheal intubation Central Venous Line Arterial Line History of Present Illness: Ortho HPI: 73 yo F admitted for elective laminectomy. MICU HPI: This is a 73 year old female with a history of CVA on recently on plavix (d/c'd 1wk ago) admit for electave posterior fusion. Her operation was complicated by needing to be re-intubated immediatly post op for respiratory distress and O2 sats in the 70s-80s. She was then succesfully extubated and called out to the floor. On [**2124-6-1**] she developed hypoxia. She desatted to the high 70s on 5L NC. With a face mask she improved to 91%; finally 97% on NRB. She was never tachycardic (70-80's). BP a little lower than baseline, sbp 110's for past couple days, and decrease to 90-100. She was given narcan on the floor and became very agitated. It is unclear it neb treatement were given on the floor. She had a CXR that was consistent with atalectasis and she was transferred to the ICU for respiratory distress. In the ICU she was hypoxic, but not tachypneic. She was feeling short of breath. No chest pain, N/V/D, has not had bowel mvmt yet, no flatus, no ab distention, no fevers, chills or cough. Past Medical History: cLBP, spinal stenosis w/ radiculopathy HLD Polymyalgia rheumatica (6 months pred in [**2119**]) CVA NASH Kidney stones appy CCY hysterectomy mastoidectomy knee surgery R vertebral stent Social History: tob: 1ppd x 50 years EtOH 1 pint vidka per day No recreational drugs Family History: Diabetes Physical Exam: PHYSICAL EXAM UPON ADMISSION: . Vitals: 97.2, 83, 80/54, 61, 18, 93% RA General: Alert, oriented, mild respiratory distress. HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP flat, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi. Back with dressing on over incision site CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . PHYSICAL EXAM UPON DISCHARGE: . Vitals: General: Alert, oriented x2, non-labored breathing, hoarse voice. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP flat, no LAD Lungs: Crackles at bases bilaterally, L>R. No wheezes/rhonchi. Back with dressing on over incision site CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, obese, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley with streaks of blood present Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis 1+ LE edema, pneumoboots on. Pertinent Results: LABS UPON ADMISSION: . [**2124-5-30**] 11:35AM BLOOD Hct-26.7*# [**2124-5-30**] 04:40PM BLOOD Hct-34.5*# [**2124-5-30**] 09:25PM BLOOD Hct-34.0* [**2124-5-31**] 05:40AM BLOOD WBC-6.2 RBC-3.62* Hgb-11.4*# Hct-34.2* MCV-95 MCH- 31.4 MCHC-33.2 RDW-18.3* Plt Ct-118* [**2124-6-1**] 04:48PM BLOOD Neuts-79.3* Lymphs-14.0* Monos-4.6 Eos-1.9 Baso-0.2 [**2124-6-1**] 10:35PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Ovalocy-2+ [**2124-5-30**] 10:22AM BLOOD PT-12.5 PTT-26.3 INR(PT)-1.1 [**2124-5-30**] 10:22AM BLOOD Fibrino-295 [**2124-6-1**] 10:35PM BLOOD Fibrino-630*# [**2124-6-1**] 10:35PM BLOOD FDP-10-40* [**2124-5-31**] 05:40AM BLOOD Glucose-113* UreaN-12 Creat-0.7 Na-142 K-3.9 Cl-107 HCO3-27 AnGap-12 [**2124-6-1**] 04:48PM BLOOD ALT-102* AST-160* LD(LDH)-221 AlkPhos-106* TotBili-3.1* [**2124-6-1**] 10:35PM BLOOD LD(LDH)-258* CK(CPK)-3666* [**2124-6-1**] 10:35PM BLOOD CK-MB-29* MB Indx-0.8 cTropnT-<0.01 [**2124-6-2**] 04:15AM BLOOD CK-MB-25* MB Indx-0.8 cTropnT-<0.01 [**2124-5-31**] 05:40AM BLOOD Calcium-7.4* Phos-3.2 Mg-1.2* [**2124-6-1**] 10:35PM BLOOD Hapto-196 [**2124-6-4**] 04:14AM BLOOD Hapto-233* [**2124-6-2**] 04:15AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2124-6-2**] 04:15AM BLOOD HCV Ab-NEGATIVE [**2124-5-30**] 08:48AM BLOOD Type-ART pO2-234* pCO2-43 pH-7.42 calTCO2-29 Base XS-3 Intubat-INTUBATED [**2124-5-30**] 08:48AM BLOOD Glucose-106* Lactate-1.7 Na-140 K-3.6 Cl-100 [**2124-5-30**] 08:48AM BLOOD freeCa-1.12 . LABS UPON DISCHARGE: . [**2124-6-14**]: WBC: 7.3 Hb: 8.8 HCT: 26.7 Plt: 517 [**2124-6-13**]: AST 41 ALT 62 ALK PO4 241 T. Bili: 1.0 [**2124-6-13**]: BG: 96 BUN 10 CR 0.8 Na 140 K 4.0 CL 107 HCO3 24 [**2124-6-14**]: Vanco trough: . L-SPINE X-RAY [**2124-5-30**]: Single lateral view of the lumbar spine obtained portably in the OR, labeled #1. It shows pedicle screws at the presumptive L3, L4, and L5 levels, in nominal alignment on the single lateral view, with additional instrumentation and materials posteriorly. Incidental note is made of calcification at the T12-S1 disc space and of aortic calcification. . CT-A CHEST: [**2124-6-1**] 1. No pulmonary embolism. 2. Moderately large bilateral pleural effusions explain severe bibasilar atelectasis. 3. Probable right pneumonia, likely secondary to aspiration. 4. 60% stenosis of the origin of the right common carotid artery. . ECHOCARDIOGRAM [**2124-6-2**] The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. There 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. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . IMPRESSION: Normal global and regional biventricular systolic function. Mild mitral regurgitaiton. Mild pulmonary hypertension. . CXR: [**2124-6-11**]: The cardiomediastinal silhouette is unchanged. Again seen is right perihilar upper lung zone opacity which is similar in appearance. There are small bilateral pleural effusions as well as opacity in the lower lobes. This is also not appreciably changed. Biapical pleural thickening is noted. No pneumothorax is appreciated. IMPRESSION: Persistent multifocal opacities consistent with history of pneumonia. . CT head without contrast: [**2124-6-11**]: The cardiomediastinal silhouette is unchanged. Again seen is right perihilar upper lung zone opacity which is similar in appearance. There are small bilateral pleural effusions as well as opacity in the lower lobes. This is also not appreciably changed. Biapical pleural thickening is noted. No pneumothorax is appreciated. IMPRESSION: Persistent multifocal opacities consistent with history of pneumonia. . CXR [**2124-6-8**]: The patient was extubated on the current study. The left central line tip is at the level of mid SVC. The NG tube has been removed as well. There is interval improvement of the left basal aeration. The right perihilar upper lung opacity is slightly improved in the interim. There is no appreciable pleural effusion or pneumothorax demonstrated on the current study. . CXR [**2124-6-2**]: Comparison is made to the prior study from [**2124-6-2**]. The endotracheal tube terminates at the thoracic inlet. Nasogastric tube courses below the diaphragm but the tip is not seen. Left subclavian catheter terminates at the brachiocephalic SVC junction. There is interstitial prominence not appreciably changed since the prior study. This probably represents mild central pulmonary vascular congestion. There is also mild atelectasis at the right lung base with a probable small right-sided pleural effusion. There is also a small left-sided pleural effusion. . CXR [**2124-5-31**]: Lung volumes are appreciably lower primarily due to moderately severe new postoperative basal atelectasis which could explain hypoxia. Upper lungs clear. Pleural effusions are small. Heart size normal. . RUQ US: [**2124-6-2**]: Limited study. Echogenic liver consistent with fatty infiltration. Superimposed fibrosis and/or cirrhosis cannot be excluded. Brief Hospital Course: MICU Course: [**Date range (1) 79435**] 73 yo F admitted for elective laminectomy with PMH of CVA (Plavix held 5 days prior to admission and not yet restarted), NASH, and hyperlipidemia. Post operative course complicated by hypoxia and respiratory distress requiring intubation and MICU transfer. Her hypoxia was thought to be due to significant atlectatsis in setting of post-operative pain, large abdomen and possible hospital acquired pneumonia. She was difficult to wean off the vent and required high PEEP initially. She was treated for HAP with vancomycin and initally cefepime but developed a rash so cefepime was changed to cipro. She will complete her 8 day course on [**2124-6-9**]. While on the vent she was intermittently agitated with hypertension and tachycardic and there was concern for alcohol withdrawal as she has had signifcnat EtOH history of 1 point vodka/day. She was treated with midazolam gtt while intubated. Her liver enzymes were found to be elevated and RUQ u/s was c/w with known diagnosis of NASH. She may also have a component of alcoholic hepatitis. Hep serologies were negative. Her statin was held in light of her elevated transaminases. Her vent was slowly weaned down and she was successfully extubated on [**6-7**] and called out to the floor. By the time of extubation, she was felt to be out of the window of withdrawal. . MEDICINE course: [**Date range (1) 94414**]: [**Known firstname **] arrived on the medicine floor oriented x3, but with some mild confusion. Several hours later, her confusion subsided and was likely attributed to lingering sedating medications s/p extubation. She was continued on 4 L of oxygen by nasal canula and maintained sats 94-97%. Her hospital acquired pneumonia was treated with Vancomycin and Ciprofloxacin, which was given for an 8 day course, finishing [**2124-6-9**]. She was treated with albuterol and ipratropium nebulizer treatments for likely COPD secondary to her smoking history. She was also started on an inhaled steroid daily. Her aspirin was restarted as she has a history of vertebral stent and prior CVAs. Plavix was held until discharge (due to bleeding risk of wound) and can be resumed [**2124-6-16**]. She was seen by social work for her history of alcohol abuse and was given counseling regarding cessation. She was seen by occupational and physical therapy and was able to move with assistance from bed to chair and commode. She was stable for discharge to a rehabilitation facility for further OT and PT and weaning of her oxygen requirement to room air. . During the weekend of [**7-28**], the patient developed delerium with paranoid delusions and an elevated WBC count. Full workup was completed with negative UA, urine cultures and blood cultures negative thus far and no interval change on her CXR. CT head without contrast did not reveal any acute intracranial process, although she does have evidence of small vessel disease. She had clear serosanguinous drainage from her lower back wound which may have been the cause of a temp of 100.1 on [**2124-6-12**], this drainage is minimal upon discharge. She was empirically started on Vancomycin for a seroma on [**2124-6-10**] which should be continued until [**2124-6-17**] for a 7 day total course and her PICC can be removed upon completion of antibiotics. Her mental status improved to baseline [**2124-6-12**]. . It is recommended that upon discharge from the rehabilitation center that the patient call her primary care physician to [**Month/Day/Year **] [**Name Initial (PRE) **] follow up visit regarding her hospital admission. She would likely benefit from pulmonary function testing and will need long term management of newly started inhaled steroids and continuation of her nebulizer treatments. She will also need an outpatient sleep study for possible sleep apnea. She will also need follow up regarding retesting her liver function tests to monitor possible fatty liver verses alcoholic hepatitis. Her statin can be resumed if liver function tests are stable and clinically warranted based on her current lipid levels. She will continue on daily multivitamin, thiamine and folate. She will need outpatient monitoring of her anemia as well, likely post-op anemia and anemia of chronic disease. . The patient will follow up with her spinal surgeon Dr. [**Last Name (STitle) 363**] within a week, his office will call her husband with an appointment today. She already received post-op L-spine x-rays which have been reviewed by Dr. [**Last Name (STitle) 363**]. Her dressings can be changed daily. She will continue on Tylenol as needed for pain. . We also recommend follow up with Dr. [**Last Name (STitle) 94415**] regarding monitoring carotid stenosis, history of verterbral stenting and management of her anti-platelet medications once she leaves the rehabilitation facility. . We recommend continuation of social work counseling and support as an outpatient regarding her alcohol abuse. . The patient was full code for this admission. Medications on Admission: ASA Combivent Lipitor Plavix (stopped 5 days prior to admit) Simvistatin Discharge Medications: 1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 5. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours). 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 12. Vancomycin 750 mg Recon Soln Sig: One (1) Intravenous Q 12H (Every 12 Hours) for 3 days: To stop [**2124-6-17**]. Discharge Disposition: Extended Care Facility: [**Hospital6 **] Discharge Diagnosis: Primary Diagnosis: Low back pain, status post Laminectomy Hypoxia Respiratory Failure Transaminitis/Hyperbilirubemia Alcohol Abuse Hyperlipidemia Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You came to the hospital for an elective laminectomy for your back pain. After the surgery, you had touble breathing and were transferred to the ICU where you were intubated. Your trouble breathing was most likely due to limited breath volume due to pain, a new pneumonia and possibly lung disease secondary to your history of smoking. You were extubated on [**2124-6-7**] and your breathing improved. You received 8 days worth of treatment for a hospital acquired pneumonia. You still require oxygen supplementation, but the goal will be to wean this off slowly in the upcoming days at the rehabilitation center. . Please stop drinking alcohol. It is imperative to both your physical and mental health to change your habits. Please seek support in this endeavor from your family and/or from a social work counselor. . We made the following changes to your medications: -Start Multivitamin One (1) Tablet DAILY. -Start Folic Acid 1 mg Tablet DAILY. -Start Thiamine HCl 100 mg One (1) Tablet DAILY. -Start Gabapentin 100 mg Capsule One (1) Capsule 3 times a day. -Start Acetaminophen 650 mg 1 Tablet as needed every 6 hours as needed for pain. - Start Colace 100 mg Capsule 1 tab twice daily as needed for constipation. - Start Senna 8.6mg 1 tablet twice daily as needed for constipation. - Start Albuterol Sulfate 2.5 mg /3 mL (0.083 %) One nebulizer treatment every 6 hours. - Start Ipratropium Bromide 0.02 % Solution 1 nebulizer treatment every 6 hours - Continue Aspirin 325 mg 1 Tablet daily -Stop simvistatin until your liver enzymes have been rechecked and your doctor feels it is safe to resume this medication. -Start Fluticasone 110 mcg/Actuation Aerosol 2 puffs twice daily -Restart Plavix 75mg daily starting [**2124-6-16**]. -Start Vancomycin 75omg every 12 hours for 3 more days (total 7 day course) [**Date range (3) 94416**]. . Please follow up with your physicians. When you leave the rehabilitation center, you will need to call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] a follow up visit. Dr.[**Name (NI) 12040**] office will call you with an appointment for next week, if you do not here from them in a few days, please call Dr.[**Name (NI) 12040**] office to confirm (number below). Followup Instructions: When you leave the rehabilitation center, you will need to call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] a follow up visit. Primary Care doctor: [**Last Name (LF) **],[**First Name3 (LF) **] A. [**Telephone/Fax (1) 24287**] . . With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] Location: [**Location (un) 830**] [**Hospital Ward Name 23**] Building [**Location (un) 551**], [**Location (un) 86**] [**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3573**] Appointment: Office will call you with an appointment for follow up next week - if you do not here from them in a few days, please call to confirm. Completed by:[**2124-6-14**]

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icd9cm

[ [ [] ] ]

[ "38.93", "33.24", "81.62", "38.91", "96.72", "81.08", "03.09", "96.04", "77.79" ]

icd9pcs

[ [ [] ] ]

14538, 14581

8339, 13377

339, 398

14771, 14888

3057, 3064

17204, 17912

1819, 1829

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1732, 1803

11,122

186,974

4749

Discharge summary

report

Admission Date: [**2191-5-31**] Discharge Date: [**2191-6-6**] Service: [**Hospital Unit Name 196**] CHIEF COMPLAINT: Unstable angina. HISTORY OF THE PRESENT ILLNESS: The patient is an 89-year-old female with coronary risk factors including known CAD, age, hypertension, and hyperlipidemia, who presents with a two week history of intermittent chest pain at rest with a particularly severe episode occurring on the night of admission at 7:30 p.m. while the patient was getting out of bed. She described the pain as [**10-7**] substernal "burning" in quality. No shortness of breath or diaphoresis. No nausea or radiation of the pain. No pleuritic component to the pain. In the past, the pain has not necessarily been exertionally related. EMS was contact[**Name (NI) **] and she was given oxygen, aspirin, nitroglycerin, and her pain relieved on arrival to the Emergency Department. On arrival to the Emergency Department, she was saturating 82% on room air which improved to 92% on 4 liters. She was given Lasix, started on intravenous heparin, and intravenous Integrelin. She became slightly hypotensive to the sublingual nitroglycerin. An EKG was performed which showed normal sinus rhythm without pacer spikes, however, showed [**Street Address(2) 4793**] elevation in V1 through V4. Therefore, she was taken directly to the Cardiac Catheterization Laboratory. REVIEW OF SYSTEMS: The patient complains of occasional dyspnea on exertion without any orthopnea or PND. She denied any lower extremity edema, or recent changes in weight. She has not had any fever, chills, nausea, or vomiting, cough, or nasal congestion. No change in bowel or bladder function. No bright red blood per rectum or melena. PAST MEDICAL HISTORY: 1. Coronary artery disease with transthoracic echocardiogram on [**2190-9-10**] showing moderately dilated left ventricle with anterior apical left ventricular aneurysm, moderate depressed LV function, EF 30-35%, anterior, septal, and apical akinesis. 2. Status post myocardial infarction times two. 3. Hyperlipidemia. 4. Status post pacemaker placement six years ago for syncope. 5. Hypertension. 6. Urinary incontinence. 7. Lower back pain. 8. Osteoporosis. ALLERGIES: The patient has no known drug allergies. ADMISSION MEDICATIONS: 1. Diovan 80 mg p.o. q.d. 2. Lipitor 10 mg p.o. q.d. 3. Aspirin. 4. Toprol XL 25 mg q.h.s. 5. Digoxin 0.125 mg q.d. 6. Vitamin D 400 mg q.d. 7. Calcium 600 mg p.o. q.d. 8. Oxybutynin one-half a tablet p.o. b.i.d. 9. Fosamax q. week on Sunday. SOCIAL HISTORY: The patient lives alone at an [**Hospital3 12272**] facility. She has a remote tobacco history, quit 50 years ago. No current alcohol use. Her daughter is [**Name (NI) 19948**] [**Name (NI) 19949**], phone number [**Telephone/Fax (1) 19950**]. FAMILY HISTORY: Mother with diabetes. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 97.9, blood pressure 133/57, heart rate 72, oxygen saturation 100% on nonrebreather. General: The patient was alert and oriented times three in no apparent distress lying flat in bed. HEENT: Normocephalic, atraumatic. Extraocular muscles were intact. The pupils were equal, round, and reactive. The oropharynx was clear. Neck: Jugular venous distention to approximately 10-12 cm. The neck was supple. No lymphadenopathy. Chest: Bibasilar crackles approximately one-third of the way up, scattered wheezes. Cardiovascular: Regular rate, II/VI systolic murmur at the left sternal border, no rubs or gallops. Abdomen: Soft, nontender, nondistended, no hepatosplenomegaly. Extremities: No clubbing, cyanosis or edema. Rectal: Guaiac negative per ED report. LABORATORY/RADIOLOGIC DATA: Sodium 134, potassium 5.0, chloride 102, bicarbonate 26, BUN 27, creatinine 1.0, glucose 157. White count 11.0, hematocrit 41.1, platelets 219,000, MCV 90. PT 12.9, PTT 28.4, INR 1.1. 1. Transthoracic echocardiogram on [**2191-6-3**]: EF 30-35%, no pericardial effusion, left atrium moderately dilated, left ventricular wall thickness normal, anterior apical left ventricular aneurysm, and apical, anterior, and septal akinesis. Mild 1+ MR. [**Name13 (STitle) **] findings were consistent with transthoracic echocardiogram performed in [**2191-8-29**]. 2. EKG on admission on [**2191-5-30**]: Q waves in leads V1 through V2, consistent with anteroseptal myocardial infarct, borderline first-degree AV conduction delay. 3. Portable chest x-ray on [**2191-5-30**]: Slight upper zone distribution indicative of mild CHF, bibasilar atelectatic changes, no pleural effusions. 4. CT angiogram of the chest: No evidence of pulmonary embolism, diffuse bilateral ground glass opacities consistent with mild pulmonary edema versus viral or eosinophilic pneumonia. HOSPITAL COURSE: 1. CORONARY ARTERY DISEASE: The patient was taken to the Cardiac Catheterization Laboratory on [**2191-5-31**] which showed left main coronary artery disease as well as three vessel disease. Left main coronary artery showed 70% distal occlusion, LAD showed 50% proximal, 90% mid, left circumflex showed 50% proximal, 80% major OM, and RCA showed ulcerated 90% mid lesion. Left ventriculography showed an EF of 35%. Given her findings of left main and three vessel disease, Cardiothoracic Surgery was consulted who felt that the patient was not an appropriate surgical candidate. Instead, in consultation with the interventional cardiologist, they felt that the main culprit lesion was her right coronary artery which was stented on repeat cardiac catheterization on [**2191-6-2**]. She did have a right dominant system. During repeat catheterization on [**2191-6-2**], the right coronary artery was initially balloon dilated and attempts were made to place a 3 by 23 mm cipher stent. She became hypotensive and bradycardiac which required one dose of Atropine and initiation of intravenous dopamine infusion. It was noted at that time that her peripheral IV was occluded and, therefore, heparin and Integrelin were not being infused at the time. Intravenous access was restored and she was administered the Atropine, dopamine, heparin and Integrelin. The RCA lesion was then stented with a 3 by 15 mm Zeta stent. The lesion was then postdilated with a 3 by 10 mm NC raptor. Final angiography demonstrated the vessel to be widely patent with no residual stenosis. A right heart catheterization was performed and an echocardiogram demonstrated no evidence of tamponade. The patient then left the Cardiac Catheterization Lab and was transferred to the Coronary Intensive Care Unit on dopamine. Her dopamine was continued for approximately 24 hours, at which time it was weaned off with stable hemodynamics. After the second cardiac catheterization, she had a bump in her cardiac enzymes with an MB index reaching as high as 17.6. Her CKs, however, were relatively mildly elevated at 194 with CK MBs reaching as high as 31. It was felt that she had a post catheterization myocardial infarct which was responsible for her transient hypotension. Integrelin was continued for 18 hours and then weaned off. Her heparin was discontinued while in the Cardiac Intensive Care Unit. She was continued on whole-dose aspirin and Plavix for which she should continue for nine months. Once blood pressure had stabilized and she had been off dopamine for greater than 24 hours, her antihypertensives were restarted slowly. At the time of this dictation, she is restarted on her Lopressor with hopes of restarting her Diovan just prior to discharge. Her blood pressure remained stable in the 110s to 120s after reinitiation of Lopressor. In addition, her cardiac enzymes were cycled after her post catheterization MI and were all found to be back to baseline at the time of dictation. 2. CONGESTIVE HEART FAILURE: On presentation to the Emergency Department, the patient had an oxygen requirement which was felt secondary to mild congestive heart failure. She was diuresed with mild intravenous Lasix 10-20 mg IV p.r.n. with good response. By hospital day number two, her oxygen saturations had returned to 100% on room air. A transthoracic echocardiogram and ventriculogram while in the Cardiac Catheterization Lab confirmed chronic CHF with ejection fraction of 30-35%. 3. HEMATOLOGY: Post catheterization, her hematocrit fell to as low as 28.4 and she was transfused 2 units of packed red blood cells. Her hematocrit responded appropriately and she remained stable at 33 throughout the remainder of her hospitalization. 4. INFECTIOUS DISEASE: She was found to have a urinary tract infection by urinalysis and urine culture for which she was treated for three days of ciprofloxacin. She was symptom-free by the time of discharge. DISPOSITION: She was evaluated by physical therapy after being discharged from the Intensive Care Unit who felt that she would benefit from a short inpatient rehabilitation stay secondary to deconditioning. Prior to admission, she was living at an [**Hospital3 **] facility; however, was independent in all of her ADLs. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Status post PCTA and stenting of the right coronary artery. 3. Transient bradycardia and hypotension. 4. Postcardiac catheterization myocardial infarct. 5. Status post pacemaker placement. 6. Hypertension. 7. Hyperlipidemia. 8. Urinary incontinence. 9. Osteoporosis. DISCHARGE MEDICATIONS: 1. Lipitor 10 mg p.o. q.d. 2. Enteric coated aspirin 325 mg p.o. q.d. 3. Plavix 75 mg p.o. q.d. times nine months. 4. Toprol XL 25 mg p.o. q.h.s. 5. Digoxin 0.125 mg p.o. q.d. 6. Vitamin D 400 mg p.o. q.d. 7. Calcium carbonate 1,000 mg p.o. q.d. 8. Fosamax 20 mg q. Sunday. 9. Oxybutynin 2.5 mg p.o. q.d. 10. Diovan 80 mg p.o. q.d., currently on hold until blood pressure stabilizes. DISCHARGE DISPOSITION: The patient will be discharged to acute inpatient rehabilitation stay for cardiac rehabilitation and strength training exercises. [**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**MD Number(1) 2144**] Dictated By:[**Last Name (NamePattern1) 6240**] MEDQUIST36 D: [**2191-6-5**] 04:10 T: [**2191-6-5**] 16:19 JOB#: [**Job Number 19951**]

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icd9cm

[ [ [] ] ]

[ "99.20", "88.53", "88.56", "36.07", "88.55", "36.01", "37.23" ]

icd9pcs

[ [ [] ] ]

9901, 10291

2838, 2882

9483, 9877

9139, 9460

4813, 9084

2303, 2556

1411, 1734

131, 1391

2897, 4795

1756, 2280

2573, 2821

9109, 9118

57,735

121,828

26930

Discharge summary

report

Admission Date: [**2109-3-25**] Discharge Date: [**2109-3-28**] Service: MEDICINE Allergies: Penicillins / Brimonidine Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: dehydration Major Surgical or Invasive Procedure: Central Venous Line Placement History of Present Illness: [**Age over 90 **] year old Russian-speaking female wtih dual chamber pacer for SSS/CHB, Afib on aspirin, distolic HF, h/o pericardial effusion presents from NH after not feeling well over last week. Per her daughters, she developed a cough and lower extremity swelling 10 days ago and her lasix was increased to 40mg [**Hospital1 **] and zaroxyln was added. She improved slowely and over the past 3 days was noted to be fatigued, nauseous, and stop eating and drinking. On the am of presentation, she was found to have systolics in 80s and presented to [**Hospital1 18**] with hypotension. At rehab over the past few days, labs were notable for creatinine increasing from 1.8 to 3.6, and sodium dropping to 130. . In ED, vitals were T 99.4 HR 103 BP 78/50 RR 18 POx 94. She reported only nausea. Unremarkable exam. Patient given Ondansetron, Piperacillin-Tazo, Vancomycin 1g, and started on Norepinephrine gtt. Blood cultures were sent. She received 2L NS with improvement in SBP to 80s. Right IJ TLC placed in ED without complication. CVP measured at 8 and an additional liter of NS was given. EKG showed paced rhythm. Cardiology performed bedside ECHO which domonstrated old left atrial myxoma and no pericardial effusion. A foley [**Last Name (un) **] was placed with 300cc clear urine output. Vital signs prior to transfer HR 84 BP 112/64 RR 24 POx 100% on 2L. Transferred on levophed 0.09. . On arrival to the [**Hospital Unit Name 153**], patient was without complaint. She denied chest pain, shortness of breath, lightheadedhess, nausea, abdominal pain. Past Medical History: CHF pacemaker (?symptomatic bradycardia) HTN CRI Aspiration pneumonia hypothyroidism falls atrial fibrillation DVT Alzheimer's right glaucoma Social History: Lives at [**Hospital 100**] Rehab for past year. Originally from [**Country 32045**], moved here 8.5 years ago. Daughter involved in her care. No h/o tobacco, EtOH or other drug use. Family History: Non-contributory Physical Exam: GENERAL - well-appearing elderly female in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMD, OP clear NECK - supple, no thyromegaly, right IJ TLC in place, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use, occasional dry cough HEART - PMI non-displaced, RRR, no MRG, nl S1-S2, no S3S4 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - left LE cool, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - stasis dermatitis on b/l shins LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&O to person and hospital, not time, CNs II-XII grossly intact, muscle strength 5/5 throughout, sensation grossly intact throughout, gait deferred Pertinent Results: [**2109-3-25**] 11:38PM GLUCOSE-117* UREA N-91* CREAT-3.1* SODIUM-134 POTASSIUM-3.0* CHLORIDE-90* TOTAL CO2-24 ANION GAP-23* [**2109-3-25**] 11:38PM CALCIUM-8.2* PHOSPHATE-4.1 MAGNESIUM-1.9 [**2109-3-25**] 11:38PM DIGOXIN-3.1* [**2109-3-25**] 11:38PM WBC-17.4* RBC-3.92* HGB-11.5* HCT-32.9* MCV-84 MCH-29.4 MCHC-35.0 RDW-14.4 [**2109-3-25**] 11:38PM PLT COUNT-193# [**2109-3-25**] 08:53PM TYPE-[**Last Name (un) **] PO2-49* PCO2-34* PH-7.39 TOTAL CO2-21 BASE XS--3 COMMENTS-GREENTOP [**2109-3-25**] 08:53PM LACTATE-1.3 [**2109-3-25**] 08:45PM URINE HOURS-RANDOM UREA N-292 CREAT-46 SODIUM-62 [**2109-3-25**] 08:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.007 [**2109-3-25**] 08:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2109-3-25**] 05:10PM GLUCOSE-109* UREA N-105* CREAT-3.7*# SODIUM-133 POTASSIUM-3.6 CHLORIDE-82* TOTAL CO2-26 ANION GAP-29* [**2109-3-25**] 05:10PM estGFR-Using this [**2109-3-25**] 05:10PM CK(CPK)-99 [**2109-3-25**] 05:10PM WBC-13.2*# RBC-4.75# HGB-13.6# HCT-40.0# MCV-84 MCH-28.7 MCHC-34.1 RDW-14.9 [**2109-3-25**] 05:10PM WBC-13.2*# RBC-4.75# HGB-13.6# HCT-40.0# MCV-84 MCH-28.7 MCHC-34.1 RDW-14.9 [**2109-3-25**] 05:10PM NEUTS-72.5* LYMPHS-22.5 MONOS-3.9 EOS-0.5 BASOS-0.6 [**2109-3-25**] 05:10PM PLT COUNT-122* [**2109-3-25**] 05:08PM GLUCOSE-110* LACTATE-2.1* NA+-132* K+-3.6 CL--78* TCO2-34* [**2109-3-25**] 05:08PM HGB-14.5 calcHCT-44 [**3-26**] Echo The left atrium is moderately dilated. A large (3.4 x 4.5 cm) mass seen in the body of the left atrium. The right atrium is dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. 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) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are structurally normal. Physiologic mitral regurgitation is seen (within normal limits). There is severe pulmonary artery systolic hypertension. Trivial/physiologic pericardial effusion. Brief Hospital Course: [**Age over 90 **] yo female with Afib, SSS/ CHB s/p dual chamber pacer, diastolic heart failure with recent exacerbation presents from NH with poor po intake, nausea and fatigue x 3 days with hypotension and acute on chronic renal failure. #. Chronic Diastolic Heart Failure - Patient had been admitted with hypotension. Patient had had shortness of breath one week prior to admission and had been diuretic regimen increased. Patient presented with SBP in 70s initially and did not repond to fluid boluses. Patient had mild elevation in cardiac enzymes, thought to be related to myocardial stress. Patient required levophed on admission and 6L NS boluses to get MAP > 55 to wean pressors. Patient Echocardiogram did not show any evidence for tamponade or [**Last Name (LF) **], [**First Name3 (LF) **] was preserved. Patient's echo showed newly elevated pulmonary pressures, which is new since her prior echocardiogram. It is unclear what the etiology of her elevated PA pressures are, whether related to known [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 16564**] . On discharge, patient's systolic BPs have been 100s-120. Patient was restarted on [**12-7**] of her dose of lopressor at 12.5mg [**Hospital1 **]. On day of discharge, patient was restarted on her lasix 40mg po and had small oxygen requirement at 2L NC. Plan is for patient to be diuresed to being euvolemic and then on maintanence dose of lasix. . Of note, on admission, patient was noted to be on Digoxin and had level of 3.1. Patient had no signs or symptoms of toxicity, but given her propensity to become dehydrated and digoxin toxic, this medication was discontinued and plan to be discontinued indefinitely. Plan was communicated with NP at [**Hospital1 100**]. - Continue Lopressor 12.5mg [**Hospital1 **], uptitrate as tolerated - Continue Lasix 40mg daily - Restart Imdur once patient's SBPs are stable. - Continue ASA 325mg daily - Discontinue digoxin indefinitely - Follow up with Dr. [**Last Name (STitle) 171**] #. Acute on Chronic Renal Failure ?????? Pre-renal etiology. On admission, patient's Cr was 3.7 and responded to fluid resusitation. Patient's Cr trended down to 2.4 on day prior to discharge. Her baseline Cr is 1.8. Patient's Creatinine was not checked on day of discharge. Will need to trend once patient discharged to rehab. - Check Chem 7 on [**2109-3-29**] - renally dose all meds, avoid nephrotoxins . # ID: Afebrile throughout admission. Patient??????s CXR is not concerning for PNA. Patient had been treated at her facility with levaquin but have decided to defer antibiotic as patient is clinically doing well as she is afebrile, WBC trending downward. #. Hypothyroidism - continue Synthroid 112mcgs . #. Code - DNR/DNI Medications on Admission: levofloxacin 500mg Q48 hours, started [**3-19**] x 14 days Vitamin D 1000 units daily Calciume carbonate 650mg [**Hospital1 **] Flonase 2 puffs [**Hospital1 **] Lasix 40 mg a day Toprol 50 mg daily Imdur 60 mg daily aspirin 325 mg daily Synthroid 112 mcg daily Latanoprost 0.005% 1 gtt QHS bilaterally Ferrous gulconate 324mg [**Hospital1 **] Digoxin 0.125mg daily Discharge Medications: 1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets PO DAILY (Daily). 2. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 6. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation every eight (8) hours. 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation every eight (8) hours as needed. 9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 12. Latanoprost 0.005 % Drops Sig: One (1) Ophthalmic at bedtime: Both eyes. 13. Flovent HFA 110 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation twice a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged 1- East Discharge Diagnosis: Primary - Hypotension - Chronic diastolic heart failure Secondary - Left Atrial Myxoma Discharge Condition: Afebrile, vitals stable Discharge Instructions: You were hospitalized because you had low blood pressure. After a thorough work up, it is likely that your low blood pressure was because you were dehydrated. We obtained an echocardiogram and your pulmonary artery pressures were noted to be elevated. After giving you several liters of fluids, your blood pressure was normalized. We were unable to completely wean you from oxygen, likely from fluid on your lungs. You were started on Lasix 40mg daily to help remove some of the fluid on your lungs. You were restarted on half of your dose of Metoprolol (12.5mg [**Hospital1 **]) Please discontinue Digoxin. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: Followup Instructions: Please follow up with the physician at your facility. Cardiology Please follow up with Dr. [**Last Name (STitle) 171**] on [**6-3**] at 3:40pm. His number is [**Telephone/Fax (1) 62**]. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2109-4-30**]

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icd9cm

[ [ [] ] ]

[ "38.93", "38.91" ]

icd9pcs

[ [ [] ] ]

9679, 9747

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252, 283

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5,592

164,835

44026+58678

Discharge summary

report+addendum

Admission Date: [**2166-6-27**] Discharge Date: [**2166-6-29**] Date of Birth: [**2118-3-4**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 4232**] Chief Complaint: positive RPR with [**First Name9 (NamePattern2) 26204**] [**Last Name (un) **] - admitted for [**Last Name (un) **] desensitization Major Surgical or Invasive Procedure: PICC placement Penicillin desensitization History of Present Illness: 48 yo man with HIV (per patient, last CD4 count 200; VL 3093) with a positive RPR and a rash presents for evaluation and treatment for presumed syphilis and r/o tertiary syphilis. The pt has a history of syphilis x 2 as teenager (17 and 19 yo - rx with [**Last Name (un) 26204**], had titer 1:64). Had edema and rash to [**Last Name (un) 26204**] on a third treatment (not for syphilis). He has had negative RPR multiple times in recent years per his PCP. [**Name10 (NameIs) **] was one year ago. In [**Month (only) **] he developed a positive RPR. At the time it was 1:2 titer and he had no symptoms. He was treated with doxycycline, which he was compliant with. He developed a rash over his forehead that worsened over a 1 month course. It was not itchy nor painful. It started at his forehead, respected the hairline, spread bilaterally, and then down onto his face and upper back. He had no other symptoms. At the end of a 1 month course, PCP checked RPR (1 week PTA). Results returned 1 day PTA with a RPR titer of 1:16. He is sent in for desensitization to [**Month (only) 26204**] and treatment for a 3 week course. Of note: the pt was seen in clinic in early [**Month (only) 116**] for R eye redness and swelling and pain thought to be due to viral conjunctivitis, but treated with erythro eye drops. Also seen in ED in [**Month (only) 116**] for R sided facial swelling that was thought to be due to salivary duct blockage by stone. Treated with clindamycin for a 7 day course and salt water gargles. . ROS: Rash as noted above, no f/c. No wt loss, n/v/d. No imbalance, no confusion, changes in sensation, no weakness. No falls. No LOC, no palpitations, no LH. No dysuria. . Past Medical History: # HIV dx [**2150**] on HAART since [**2155**] # Syphilis at ages 17 and 19 - treated with [**Year (4 digits) 26204**] - developed a reaction the second time with edema, hives - given epinephrine. Pt followed by Dr. [**Last Name (STitle) **] for years and has had neg RPR - in [**Month (only) 547**] developed 1:2 titer. Rx x 1 month with doxy - RPR increased to 1:16 titer. # Depression/Bipolar # Inactive gastritis and GERD dx'd on EGD biopsy in [**2165**] # Negative c'scope in [**2165**] # (Anal wart): Condyloma acummatum with low-grade squamous epithelial dysplasia in [**2156**] # gangrenous appendicitis s/p appy in [**2160**] . All: [**Year (4 digits) 26204**] - hives and swelling Social History: SH: Denies smoking, etoh. Tats from [**2140**]'s. No sexual partners x 1 year. No IVDU. . FH: NC Physical Exam: Vitals in ED: 98.2, 73, 134/76, 18 Gen: NAD HEENT: PERRL, EOMI, OP clear, Neck supple. No carotid bruits. No scleral injection. LN: Small node on R cervical chain, no axillary nodes. No inguinal nodes. CV: RRR, II/VI SEM at base. No radiation. No JVD nor HJR. Lung: Clear bilaterally Abd: Soft, NT, ND, +BS. No masses. No HSM. Ext: No clubbing, cyanosis, nor edema. Neuro: MS: Alert and oriented to city and date and person. Speech fluent without errors. Naming intact. Distant memory intact. No evidence of apraxia. CN: I not tested. II with full visual fields and reactive pupils. III, IV, VI with intact extraoccular muscles. V with intact sensation. VII with no droop; smile, brow elevate symmetrically. VIII with nml hearing. IX with symetric palate. X, [**Doctor First Name 81**] Shrug [**5-30**]. XII - tongue midline. Motor: [**5-30**] biceps, delts, grip, wrist extensors bilaterally. [**5-30**] hip flexors, dorsiflexion, and plantarflexion bilaterally. Coordination: FNF intact bilaterally. No pronator drift bilaterally. Reflexes: 2+ symmetric throughout. Toes downgoing. Sensation: Intact to LT throughout. No loss of proprioception in toes bilaterally. Gait: Intact (normal, heel walk, toe walk). Toes downgoing. Romberg negative. . SKIN: eruption over forehead bilaterally respecting hairline and covering to cheeks and nose, also sparsely over neck and entire back. made up of discrete small papules with very little erythema. Firm. Non-pruritic. Non vessicular. No palmar rash nor erythema. Sclera non-injected. Pertinent Results: ADMISSION LABS: [**2166-6-27**] 11:35AM BLOOD WBC-2.9* RBC-4.56* Hgb-14.5 Hct-40.4 MCV-89 MCH-31.8 MCHC-35.9* RDW-13.0 Plt Ct-162 [**2166-6-27**] 11:35AM BLOOD Glucose-117* UreaN-12 Creat-1.0 Na-138 K-4.6 Cl-103 HCO3-25 AnGap-15 [**2166-6-27**] 11:35AM BLOOD ALT-24 AST-33 AlkPhos-56 Amylase-137* TotBili-0.5 [**2166-6-27**] 11:35AM BLOOD Lipase-53 [**2166-6-27**] 11:35AM BLOOD Albumin-4.4 [**2166-6-28**] 04:42AM BLOOD Lithium-0.4* [**2166-6-27**] 12:15PM BLOOD Lactate-1.3 . DISCHARGE LABS: [**2166-6-28**] 04:42AM BLOOD WBC-3.2* RBC-4.73 Hgb-14.9 Hct-42.1 MCV-89 MCH-31.5 MCHC-35.5* RDW-13.1 Plt Ct-191 [**2166-6-28**] 04:42AM BLOOD Plt Ct-191 [**2166-6-27**] 11:55AM BLOOD PT-12.4 PTT-24.4 INR(PT)-1.1 [**2166-6-28**] 04:42AM BLOOD Glucose-115* UreaN-15 Creat-1.1 Na-137 K-4.1 Cl-102 HCO3-25 AnGap-14 [**2166-6-28**] 04:42AM BLOOD Amylase-155* [**2166-6-28**] 04:42AM BLOOD Lipase-54 . CXR (Post PICC Placement): Tip of the new left PIC catheter projects over the lowest third of the SVC. Lungs clear. Heart size normal. No pleural abnormalities. Brief Hospital Course: 48 yo M HIV (CD4 200, VL 3038) with multiple past episodes of syphilis in distant past rx'd with [**Month/Day/Year 26204**] but with [**Month/Day/Year 26204**] allergy and new RPR positive and new rash treated with doxy but with increasing titers of RPR here for treatment of syphilis with [**Month/Day/Year 26204**] desensitization prior. BRIEF HOSPITAL COURSE: The pt had been treated with [**Month/Day/Year 26204**] in past at ages 17 and 19, but then developed [**Month/Day/Year 26204**] reaction with edema/hives. Pt had had negative titers of RPR until [**Month (only) 547**] when it turned positive at 1:2. Pt was treated with doxycyclin x 1 month with repeat RPR at 1:16. Had not had LP. Neuro exam revealed no signs/symptoms of neurosyphilis. Pt recently had conjunctivitis R>L with a reactive R preauricular node and was seen multiple times at ophtho including at an HIV specialist - thought to be simple conjunctivitis. Cleared with antibiotic ophtho drops. . The pt was admitted for [**Month (only) 26204**] desensitization and possible LP for diagnosis of neurosyphilis. He was transfered to the MICU for [**Month (only) 26204**] desensitization overnight. In the MICU he refused LP (had a bad experience with post-LP headache in the past). It was explained that the LP would help to distinguish neural involvement from secondary syphilis and would be helpful in the future if he were to develop neurologic symptoms. He declined. The [**Month (only) 26204**] sensitization was successful. He had a PICC placed and [**Month (only) 26204**] was initiated at 4MU every 4 hours for a 2 week course with the plan for a repeat RPR after the treatment. All HAART therapy was continued (recent CD4 of 200 and VL of >3000 suggest HAART therapy change would be in order - this was discussed with PCP and [**Name Initial (PRE) **] change is planned in the near future.). Bactrim and acyclovir ppx doses were continued. . HIV: Essentially stable, though there is a trend downward in CD4 count over years. Now CD4 of 200. On HAART. On ppx for PCP and CMV. [**Month (only) 116**] need HAART changes in past. - continue HAART - cont Bactrim and acyclovir . Bipolar - on lithium, dexedrine, and klonipin. Maintained OP meds. . RASH: It was felt by dermatology and the ID service that the rash was not related to syphilis - rather, it was likely contact dermatitis or folliculitis. The pt was established with a follow up appointment with dermatology for Monday [**6-30**]. . The pt had home [**Month (only) 26204**] pump care established and was discharged in stable condition on [**Month (only) 26204**] for a planned 2 week course. Medications on Admission: Truvada Trazadone 50 hs Wellbutrin 200 [**Hospital1 **] Bactrim ds qd Acyclovir 800 qd Klonipin 0.5 at lunch, 1.5 hs Dexedrine 5 [**Hospital1 **] Lithobid 300 [**Hospital1 **] Crixovan Discharge Medications: 1. Lithium Carbonate 300 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 2. Bupropion 100 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO BID (2 times a day). 3. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Clonazepam 0.5 mg Tablet Sig: Three (3) Tablet PO QHS (once a day (at bedtime)). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Acyclovir 800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Dextroamphetamine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 10. Indinavir 400 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 11. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Penicillin G Potassium 20,000,000 unit Recon Soln Sig: 4,000,000 units Recon Solns Injection Q4H (every 4 hours) for 2 weeks. Disp:*qs units Recon Soln(s)* Refills:*0* 13. Truvada 200-300 mg Tablet Sig: One (1) Tablet PO once a day. 14. Heparin Flush 10 unit/mL Kit Sig: 5-10 cc flush Intravenous twice a day as needed: per protocol. Disp:*2 week supply* Refills:*0* 15. Normal Saline Flush 0.9 % Syringe Sig: 5-10 cc flush Injection as needed: per protocol. Disp:*2 week suppy* Refills:*0* Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Syphillis HIV Discharge Condition: Stable, afebrile. Discharge Instructions: Please seek medical attention for fevers > 101.4, shortness of breath, or anything concerning to you. You've been desensitized to penicillin. Please contact your PCP if you miss a dose of your penicillin because this may mean that you need to be desensitized again. Please take your medications as directed. Followup Instructions: Please see your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**1-27**] days for follow up. Dermatology will call you on Monday to arrange an outpatient appointment for evaluation of your rash. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 4236**] Completed by:[**2166-6-30**] Name: [**Known lastname 5251**],[**Known firstname 63**] Unit No: [**Numeric Identifier 14954**] Admission Date: [**2166-6-27**] Discharge Date: [**2166-6-29**] Date of Birth: [**2118-3-4**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 11538**] Addendum: Of note, the pt has a known elevated amylase and lipase at baseline. This was stable at this hospitalization. Discharge Disposition: Home With Service Facility: Critical Care Systems [**Name6 (MD) 634**] [**Name8 (MD) 635**] MD [**MD Number(1) 636**] Completed by:[**2166-6-30**]

[ "V58.83", "272.6", "042", "V14.0", "692.9", "790.5", "097.0", "530.81", "296.80" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

11291, 11469

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404, 448

10096, 10116

4556, 4556

10475, 11268

8509, 9963

10059, 10075

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10140, 10452

5050, 5609

3006, 4537

232, 366

476, 2162

4572, 5034

2184, 2876

2892, 2991

76,975

141,118

36763

Discharge summary

report

Admission Date: [**2161-11-5**] Discharge Date: [**2161-11-13**] Date of Birth: [**2107-11-24**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2736**] Chief Complaint: Ventricular fibrillation arrest Major Surgical or Invasive Procedure: Arctic sun cooling protocol. History of Present Illness: 53-year-old woman with history of atrial fibrillation presented after having v-fib arrest. At her nursing home this morning she was found down. EMS was called, finding her to be in v-fib. She received shocks x 3, 6 mg total of epinephrine, 300 mg loading dose of amiodarone then drip. Intubated in the field. She was transported to [**First Name4 (NamePattern1) 46**] [**Last Name (NamePattern1) **], where she was given 1 unit of pRBCs. Guaiac reportedly negative. Got a total of 2.5 L of NS. Started on Artic Sun before med flight to [**Hospital1 18**]. . On arrival to the [**Hospital1 18**] ED, she was found cold with 8mm fixed pupils bilaterally and no response to stimuli. SBP was in the 140s-160s without pressor, HR 50s-60s. ECG showed... She got a head CT and chest CTA. Transferred to CCU for further management. . Of note, patient was admitted to [**Hospital1 18**] from [**2161-8-12**] to [**2161-8-17**] for syncope and runs of VT. Prior to this admission, OSH ETT had shown possible mild basal inferior ischemia vs. attenuation artifact with overall normal systolic function. She underwent cardiac catheterization, which showed a 90% distal RCA stenosis, and a DES was placed in the RCA. TTE and TEE showed a large (21 mm) secundum atrial septal defect with LVEF>55%. Review of her strip rhythm suggested that her arrhythmia may be atrial in origin rather than ventricular tachycardia. For that reason, she underwent an EP study on [**2161-8-14**], which included ventricular stimulation as well as assessment for atrial arrhythmias. She was found to have inducible atrial flutter, that was typical counter clockwise flutter and she had a successful isthmus ablation. She had no sustained ventricular tachycardia with ventricular stimulation protocol. She was evaluated by the cardiac surgeons as well as the interventional cardiologists for percutaneous surgical closure of her large secundum ASD, and it was deemed that this should be done as an outpatient. In addition, with her history of significant atrial arrhythmias and atrial fibrillation, it was thought that a pulmonary vein isolation procedure would be beneficial prior to any closure of her secundum ASD. Past Medical History: 1. CAD RISK FACTORS: Hypertension 2. CARDIAC HISTORY: -CABG: NONE -PERCUTANEOUS CORONARY INTERVENTIONS: NONE -PACING/ICD: NONE 3. OTHER PAST MEDICAL HISTORY: Atrial Fibrillation COPD ASD TAH-BSO Hypothyroidism Hypertension GERD S/P left knee replacement Bipolar disorder Social History: Lives independently, smokes few cigarettes daily - average 1-1/2 pack a day for 37 years. No alcohol. Family History: Premature coronary disease: Father died of MI in 40s. Brother MI in 50's s/p bypass or stent. Physical Exam: On admission: GENERAL: Elderly woman intubated HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: JVP of *** cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Coarse breath sounds bilaterally from anterior. ABDOMEN: Soft, nondistended, no HSM. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [**2161-11-12**] 04:47AM BLOOD WBC-14.0* RBC-3.69* Hgb-11.4* Hct-32.8* MCV-89 MCH-30.9 MCHC-34.7 RDW-14.6 Plt Ct-297 [**2161-11-5**] 03:30PM BLOOD Neuts-87.5* Lymphs-6.9* Monos-5.1 Eos-0.1 Baso-0.3 [**2161-11-12**] 04:47AM BLOOD PT-17.9* PTT-70.9* INR(PT)-1.6* [**2161-11-12**] 04:47AM BLOOD Glucose-126* UreaN-25* Creat-0.7 Na-142 K-4.2 Cl-106 HCO3-27 AnGap-13 [**2161-11-9**] 04:23AM BLOOD ALT-46* AST-127* AlkPhos-64 TotBili-0.3 [**2161-11-12**] 04:47AM BLOOD Calcium-9.0 Phos-3.1 Mg-1.9 [**2161-11-12**] 05:50AM BLOOD Type-ART Temp-36.8 pO2-89 pCO2-38 pH-7.50* calTCO2-31* Base XS-5 . ECHO [**11-6**] The left atrium is normal in size. The right atrium is moderately dilated. A large secundum atrial septal defect is present. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. 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 a normal left ventricular filling pressure (PCWP<12mmHg). The right ventricular cavity is dilated with borderline normal free wall function. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. 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. There is at least mild pulmonary artery systolic hypertension. There is no pericardial effusion. . [**11-7**] CXR: New right IJ catheter tip is in the lower SVC. ET tube is in standard position. NG tube tip is in the stomach. Mild-to-moderate cardiomegaly is stable. The main pulmonary arteries are dilated. Multifocal consolidations in the upper and lower lobes have improved. There is no pneumothorax or pleural effusion. . [**11-8**] MRI head: FINDINGS: Increased FLAIR-T2 signal in the entire cerebral cortex, medial temporal lobe (hippocampus) and basal ganglia and thalamus correspond to areas of decreased diffusion. There is no intracranial hemorrhage or mass effect. The ventricles and extra-axial spaces are within normal limits. Flow void in visualized intracranial arteries is consistent with their patency. Mucosal thickening with probable air-fluid levels in the bilateral sphenoid sinuses are noted. Visualized orbits are unremarkable. IMPRESSION: Diffuse cerebral anoxic injury. No intracranial hemorrhage. . [**11-12**] CXR: FINDINGS: As compared to the previous examination, the monitoring and support devices are in unchanged position. The ventilation of the lung parenchyma is improved. However, a pre-existing small retrocardiac atelectasis is slightly increased in extent. Minimal areas of atelectasis are also seen at the medial basal right aspect of the hemithorax. Focal parenchymal opacities suggesting pneumonia are not present. Marked cardiomegaly with signs of mild overhydration and increase of the carinal angle, most likely caused by increasing diameter of the left atrium. No evidence of pneumothorax, no larger pleural effusions. . EEG [**11-6**]: This is an abnormal video EEG study due to a burst suppression pattern with initial frequent electrographic seizures consisting of persistent eye opening and upward deviation that improved in frequency and duration over the course of this recording. Compared to the first half of this recording when rare electrographic seizures were occurring every five to ten minutes and lasting up to eight seconds in duration, there were no seizures in the latter half of this record. Electrographic seizures increased in duration with increase in midazolam doses, then abated and were replaced by a burst-suppression pattern after propofol was started. These findings are indicative of severe diffuse cerebral dysfunction and nonconvulsive status epilepticus, both of which portend a poor neurologic outcome in this patient with anoxic brain injury. . [**11-10**] EEG: This is an abnormal video EEG study due to burst suppression in background activity with intermittent 1 Hz generalized sharp and slow wave discharges with bifrontal predominance consistent with generalized periodic epileptiform discharges (GPEDs). These findings suggest a severe encephalopathy consistent with the patient's history of anoxic brain injury. There were no electrographic seizures seen during this recording. This telemetry captured no pushbutton activations. Compared to the prior 24 hours, this EEG is unchanged. . [**11-12**] EP: After stimulation of either median nerve there were well-formed evoked potential peaks and at the P/N13 waveform position, but there were no discernible peaks (or even modest deflections) at the N19 waveform position. These studies suggest a normal peripheral large fiber somatosensory conduction through the brachioplexus and medulla, but there was absence of any signal from thalama cortical areas. Assuming the absence of medication effect, this is a poor prognostic sign in coma. Brief Hospital Course: The patient was admitted for v-fib arrest and treated with arctic sun protocol and medical management of her MI. She required pressor support and remained intubated on propofol. She was monitored on EEG and showed increasing EEG activity when propofol was weaned. She was started on anti-seizure medications with some improvement in her EEG tracings, however evoked potential testing was performed and showed no conduction beyond the medulla and therefore it was determined that her potential for meaningful recovery was extremely low, therefore patient made comfort-measures-only (CMO) following a discussion between the patient's HCP (her brother [**Name (NI) 4468**] [**Name (NI) 83106**]) and the CCU team. Palliative care and social work were involved as was the chaplain's office. Patient was extubated, and approximately 24 hours later she died. Death was pronounced, the patient's brother [**Name (NI) 382**] was notified, autopsy was declined, attending notified, death paperwork completed. Medications on Admission: warfarin 5 mg PO DAILY MVI Ipratropium-Albuterol prn Nicotine 7 mg/24 hr Clopidogrel 75 mg PO DAILY Lamotrigine 200 mg PO QAM and 300 mg PO QHS Simvastatin 80 mg PO at bedtime Aripiprazole 15 mg PO DAILY Alendronate 70 mg PO QSUN Levothyroxine 50 mcg PO DAILY Ranitidine 150 mg PO BID Vitamin D 1.25 mg PO weekly Alprazolam 1 mg PO QHS as needed for anxiety Acetaminophen 325 mg prn Aspirin 325 mg PO once a day Fluticasone 2 puffs [**Hospital1 **] Discharge Medications: n/a, patient expired. Discharge Disposition: Expired Discharge Diagnosis: ventricular fibrillation arrest seizure activity death Discharge Condition: deceased Discharge Instructions: n/a Followup Instructions: n/a Completed by:[**2161-11-16**]

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icd9cm

[ [ [] ] ]

[ "38.93", "38.91", "96.6", "96.72", "99.81" ]

icd9pcs

[ [ [] ] ]

10460, 10469

8911, 9914

349, 379

10567, 10577

3846, 8888

10629, 10664

3023, 3118

10414, 10437

10490, 10546

9940, 10391

10601, 10606

3133, 3133

2669, 2742

278, 311

407, 2593

3147, 3827

2773, 2887

2615, 2649

2903, 3007

24,803

148,478

7716+55872

Discharge summary

report+addendum

Unit No: [**Numeric Identifier 28016**] Admission Date: [**2155-7-22**] Discharge Date: [**2155-8-7**] Date of Birth: [**2075-5-5**] Sex: M Service: VSU CHIEF COMPLAINT: Right leg gangrene. HISTORY OF PRESENT ILLNESS: This is an 80 year-old gentleman with right first toe ischemic gangrenous changes post trauma for duration of 5 to 6 months. Initially saw his podiatrist who did a nail clipping and since then the wound has progressed. The patient has been on antibiotics po regimen. Medication and length of therapy he does not remember. Patient denies right calf hip claudication. He does admit to right first toe pain with walking. Patient underwent an arteriogram at [**Hospital6 3105**] where they felt that the patient was not a surgical candidate. Patient was referred to Dr. [**Last Name (STitle) 1391**] for a second opinion. Patient now is admitted for elective surgery. Last dose of Coumadin was [**2155-7-20**]. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Lantus 20 units every a.m., renal vit every day, Lopid 600 mg b.i.d., Coreg 25 mg b.i.d., Prevacid 30 mg every day, Diovan 320 mg every day, Lasix 80 mg every day hold on dialysis days. Renagel 2400 mg t.i.d., Zoloft 50 mg every day, lisinopril 20 mg b.i.d., aspirin 81 mg every day, albuterol puffs multidose inhaler 2 q.i.d., Spiriva puff 1 every day, Advair discus 100/50 puff 1 b.i.d., Digitek 0.125 mg every day, Norvasc 5 mg every p.m., Coumadin 2 mg every p.m., Procrit at dialysis, Lasix 160 mg every a.m. Wednesday, Thursday, Saturday, Sunday and 80 mg of Lasix every p.m., which is to be held on hemodialysis days. SOCIAL HISTORY: Patient is widowed for the last 5 years. Lives with his daughter. [**Name (NI) **] is retired. Had been self employed. He is a former 3 pack per day smoker for 20 years. Has not smoked for 10 years. Does admit to alcohol use, but has discontinued alcohol for the last 15 years. PAST MEDICAL HISTORY: Coronary artery disease with history of myocardial infarction in [**2148**]. Denies any congestive heart failure, type 2 diabetes with neuropathy and nephropathy insulin dependent for the last 10 to 12 years, history of hypercholesterolemia, history of aortic valvular disease, history of carotid disease, history of C diff in [**Month (only) 958**] of 99, pneumonia in [**Month (only) 216**] of 99. Echo [**7-/2149**] showed an AVR prosthesis with ejection fraction of 45%, left ventricular hypertrophy and MR with mitral valve prolapse. Patient has a history of hematochezia, which was worked up at [**Hospital3 **], which was negative. PAST SURGICAL HISTORY: He is status post AVR and CABG in [**2139**] in [**Location (un) 5450**], [**Location (un) 3844**]. Left AV fistula in [**2151**]. Bilateral carotid endarterectomies in 97. Hemodialysis is at Marymac Dialysis Center [**Telephone/Fax (1) 28017**]. PHYSICAL EXAMINATION: General appearance, alert white male in no acute distress. HEENT exam shows bilateral transmitted murmurs versus bruits. Carotid pulses are 1+ bilaterally. There is no JVD. There is no thyromegaly. Lungs are clear to auscultation. Heart is a regular rate and rhythm with 2/6 systolic ejection murmur at the base, which radiates to the apex and carotids. Abdominal exam is soft, nontender, nondistended. Bowel sounds x 4. No masses. Epigastric and iliac bruits. Peripheral vascular exam shows right first toe with ischemic color changes and the nail tip gangrene. Patient has bilateral femoral bruits. He has underwent a left greater saphenous vein harvest. Pulses are on the right radial 2+, femoral 1+, popliteal, DP and PT absent. On the left the radial pulse is 1+, femoral 1+, absent popliteal, dopplerable DP and absent PT. Left AV fistula in the upper arm has a thrill and neurological exam patient is oriented x 3, nonfocal. HOSPITAL COURSE: Patient was admitted to the vascular service. Renal was consulted for hemodialysis needs. The patient was continued on Augmentin renal dosing and he was placed on bed rest in the vascular position. IV heparinization was instituted once the patient's INR was less then 2.0. Patient's echocardiogram demonstrated moderate left atrial enlargement, right atrium and interatrial septum was moderately dilated and with an aneurysmal interatrial septum. The left ventricular showed symmetrical left ventricular hypertrophy mild, the left ventricular cavity size was normal. The suboptimal technical quality of focal wall motion abnormality could not be fully excluded. Overall ejection was greater then 55%. There is a false LV tendon, which is (normal variant). The aortic valve was by a prosthetic aortic valve. There is thickened AVR leaflets and increased AVR gradient with a mild aortic insufficiency of 1+. The mitral valve showed moderate mitral anular calcification with mild thickening of the mitral valve cordae and calcifications at the tips of the papillary muscles. There was no mitral stenosis. The mitral regurg is 1+. Due to the acoustic shadowing the severity of the mitral regurg may be significantly underestimated. The tricuspid valve was not well visualized. It was indeterminate PA systolic pressure. The pulmonic valve was not well seen. There was no pericardial effusion. Admitting chest x-ray showed cardiomegaly without acute cardiopulmonary process and left pleural thickening. Ultrasounds of the carotids were obtained for a history of carotid endarterectomy, which demonstrated less then 40% right internal and left internal carotid artery stenosis. Patient was evaluated by renal who felt that patient would require more then just twice a week hemodialysis. He was begun on a Monday, Tuesday, Thursday, Saturday schedule. [**Last Name (un) **] also followed the patient for his diabetes care. The patient underwent on [**2155-7-24**] a right axillary bifemoral bypass. He tolerated the procedure well. He was transferred to the PACU in stable condition. Postoperatively he remained hemodynamically stable and was transferred to the VICU for continued monitoring and care. Postoperative day one he did require fluid boluses overnight for low urinary output. Heparin drip was begun. He complained of right shoulder pain. An ultrasound was obtained, which showed a right subclavian DVT. His feet were warm and well perfuse. His medications were converted to po pain medications. He was restarted on his preoperative medications. Ambulation to chair was begun. Patient was transferred to the ICU, required a need for neo- synephrine support. Postoperative day 2 his neo was slowly weaned. He remained afebrile. Blood gas 7.31, 38, 126, 21, - 6. The graft was dopplerable. Anticipated to transfer patient to the VICU once weaned off of his neo. Postoperative day 3 the patient continued on triple antibiotic therapy. He continued on neo-synephrine. He was extubated and the neo was weaned and he was transferred to the VICU for continued care. Because the patient remained on the neo-synephrine the patient required to be transferred to the SICU for continued care. Dialysis was continued by the renal service. By postoperative day 5 the neo was weaned. Hematocrit was stable at 29.4. BUN 40, creatinine 2.5. Patient was adequate control with Dilaudid for pain. He continued on his preoperative medications. His Swan was discontinued. Ambulation was begun. His diet was advanced as tolerated. Patient was transferred to the VICU for continued monitoring and care. Patient continued to do well and was transferred to the regular floor on [**2155-7-30**]. Heparin drip was continued with a goal PTT of 60 to 70. Vancomycin was continued. MRSA screen was negative. VRE screen was negative. Patient had blood cultures done, which were negative. His hematocrit drifted to 26.9. They felt this was related to volume and he required aggressive hemodialysis over the next 72 hours on a daily basis for volume overload. Vancomycin was discontinued on [**2155-7-31**]. His central line was converted to a peripheral line. He is beginning screening and physical therapy assessed the patient for discharge planning. Patient was dialyzed on [**2155-8-5**]. There was difficulty with accessing the AV fistula. It was noted on physical exam only the proximal 1 mm of the AV fistula had a good thrill. An AV fistulogram was recommended. At the time of dictation this was ordered and pending scheduling. The remaining hospital course prior to discharge will be dictated at the time of patient's discharge. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**] Dictated By:[**Last Name (NamePattern1) 2382**] MEDQUIST36 D: [**2155-8-5**] 14:05:27 T: [**2155-8-5**] 14:56:26 Job#: [**Job Number 28018**] Name: [**Known lastname 4895**],[**Known firstname 4896**] J. Unit No: [**Numeric Identifier 4897**] Admission Date: [**2155-7-22**] Discharge Date: [**2155-8-7**] Date of Birth: [**2075-5-5**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 231**] Addendum: [**2155-8-6**] s/p a-v fistulogram and dilitation.Will hemodialize [**2155-8-7**] before sending to rehab. Major Surgical or Invasive Procedure: Brief Hospital Course: . Medications on Admission: see d/c summary part 1 Discharge Disposition: Extended Care Facility: [**Location (un) 2785**] House Nursing Home - [**Location 2786**] Discharge Diagnosis: Ischemic right leg gangrene postoperative blood loss anemia,corrected arterio-venous fistula stenosis postoperative hypotension, requiring vasopressor support,resolved End stage renal disease on hemodialysis Tue/Fri@home, Monday wed. fri in hospital diabetes type 2, insulin dependant with neuropathy and nephropathy history of hypercholestremia history of coronary artery disease, MI [**2139**], S/p CABG's [**2139**] @ [**Location (un) 4898**] N.H. history of aortic valvular disease s/p AVR history of carotid disease s/p bilateral carotid endartectomies history of pneumonia [**7-/2149**] history of c. difficle [**2-/2149**] s/p Arterio-venous fistula Discharge Condition: stable Discharge Instructions: Please take medications as prescribed. please return to emergency room if signs of infections occur such as temperatures greater than 100.4, increasing pain, redness or drainage from incision site. Patient recieved last dialysis Thursday [**2155-8-7**]. Please have patient dialyzed Monday [**2155-8-11**] then Friday [**8-15**]. From that point please have patient resume normal Tuesday, Friday dialysis schedule Followup Instructions: 2 weeks Dr. [**Last Name (STitle) **]. call for appointment [**Telephone/Fax (1) 236**] [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**] Completed by:[**2155-8-7**]

[ "V45.81", "996.73", "250.60", "403.91", "250.40", "V43.3", "357.2", "440.24", "396.3", "285.1", "272.0" ]

icd9cm

[ [ [] ] ]

[ "39.50", "39.95", "38.93", "39.29", "99.04" ]

icd9pcs

[ [ [] ] ]

9345, 9437

9269, 9272

9246, 9246

10138, 10147

10609, 10855

9458, 10117

9298, 9322

3831, 9207

10171, 10586

2609, 2857

2880, 3813

177, 198

227, 973

1945, 2585

1643, 1922

109

189,332

14865

Discharge summary

report

Admission Date: [**2142-8-28**] Discharge Date: [**2142-8-30**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 2145**] Chief Complaint: Dyspnea, weakness Major Surgical or Invasive Procedure: none History of Present Illness: 25F with SLE since age 16, ESRD on HD, malignant HTN, and h/o PRES, admitted with HTN urgency. Last dialyzed on Saturday [**8-25**]. Pt has had multiple recent admission over past 1 month, most recently 2 wks ago for HTN urgency and dyspnea. During that time, she was started on labetalol gtt, with improvement overnight, and dialyzed on schedule. TTE showed normal EF but severe LVH, small to mod pericardial effusion w/o tamponade. . Pt was feeling well until yesterday AM, when she began c/o gen weakness and fatigue, w/ worsening DOE, orthopnea. No chest pain, [**Location (un) **], sacral edema, fevers, cough, n/v/d, or other sx. She was feeling so unwell that she missed her HD session yesterday and came to the ED. Says she took all of her BP meds yesterday. . In ED, BP was 150s/120 with normal oxygenation on RA. CXR showed mild pulmonary edema w/o infiltrate; she received levaquin and vancomycin x1 dose, with labetalol 20 mg IV x1. Then transferred to MICU. . Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD 3. Malignant hypertension with baseline SBP's 180's-220's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 17. Gastric ulcer 18. PRES Social History: Home: lives with mother Occupation: on disability, previously employed with various temp jobs EtOH: Denies Drugs: Denies Tobacco: Denies Family History: No history of autoimmune disease Physical Exam: Vitals: 97.9 90 172/128 29 100%RA General: Age appropriate female in NAD HEENT: Pupil reactive on right, enucleated eye on left; OP clear without lesions, exudate, or erythema. Neck supple, no LAD. Lungs: Minimal bibasilar rales CV: Nl S1+S2, no m/r/g Abd: S/ND +bs, TTP throughout. No rebound or guarding. Ext: No c/c/e. 1+ dp/pt bilaterally Neuro: AAOx3. CN 2-12 intact. Strength 4/5 bilaterally upper and lower Pertinent Results: [**2142-8-28**] 05:50PM PT-14.1* PTT-37.9* INR(PT)-1.2* [**2142-8-28**] 05:47PM GLUCOSE-95 LACTATE-1.1 NA+-134* K+-5.4* CL--102 TCO2-21 [**2142-8-28**] 05:30PM WBC-4.3 RBC-2.73* HGB-7.6* HCT-24.6* MCV-90 MCH-27.9 MCHC-31.0 RDW-18.0* [**2142-8-28**] 05:30PM NEUTS-81.1* LYMPHS-15.2* MONOS-2.2 EOS-1.3 BASOS-0.1 [**2142-8-28**] 05:30PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL [**2142-8-28**] 05:30PM PLT COUNT-93* [**2142-8-29**] 03:48AM BLOOD WBC-4.1 RBC-2.49* Hgb-6.9* Hct-22.5* MCV-90 MCH-27.6 MCHC-30.6* RDW-18.7* Plt Ct-101* [**2142-8-29**] 03:48AM BLOOD Plt Ct-101* [**2142-8-29**] 03:48AM BLOOD Glucose-91 UreaN-55* Creat-7.6* Na-132* K-6.0* Cl-102 HCO3-22 AnGap-14 [**2142-8-29**] 03:48AM BLOOD Calcium-8.8 Phos-5.4* Mg-2.2 . CXR: [**2142-8-28**] AP VIEW OF THE CHEST: Severe cardiomegaly is stable. There are bilateral hazy perihilar opacities with mild upper zone vascular redistribution compatible with mild pulmonary edema, worse in the interval. Small left pleural effusion is stable. There is a retrocardiac opacity, likely representing atelectasis. No pneumothorax is visualized. The osseous structures are unchanged. IMPRESSION: Mild pulmonary edema, slightly worse compared to prior. . ECHO [**2142-8-29**]: The left atrium is elongated. The estimated right atrial pressure is 0-5 mmHg. There is severe symmetric left ventricular hypertrophy with normal cavity size and regiona/global systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The right ventricular free wall is hypertrophied. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is moderate pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is a small circumferential pericardial effusion without evidence for hemodynamic compromise. Compared with the prior study (images reviewed) of [**2142-8-13**], the estimated pulmonary artery systolic pressure is higher and the pericardial effusion is minimally larger. . Brief Hospital Course: 25F with SLE since age 16, ESRD on HD, malignant HTN, and h/o PRES, admitted with HTN urgency and dyspnea, probable volume overload. # Dyspnea: On admission was thought secondary to volume overload given exam and CXR consistent with increased pulmonary vascular congestion. Less likely to be infiltrate lack of radiographic infiltrate, leukocytosis, or increased sputum production, so antibiotics were not continued. Pt has small cardiac effusion likely chronic serositis?????? may be contributing to dyspnea and resulting in a restrictive physiology. She received a repeat ECHO showed only a mild enlargement of this effusion (no tamponade) and there were no concerning EKG changes. She was treated with [**Year (4 digits) 2286**] and was transferred to the floor in stable condition. Unfortunately on [**2142-8-30**] while in the [**Date Range 2286**] unit pt became hypotensive with SBP in 60s. Pt was given 2L NS boluses without significant improvement in SBP. She was drowsy but able to converse. EKG showed sinus rhythm. During the 3rd L of fluid, pt became unresponsive and appeared to be having respiratory distress. A Code Blue was called at that point and when a pulse was checked, it was absent. Resuscitation efforts for PEA arrest were initiated. She underwent a prolonged code with appropriate interventions for PEA arrest; due to concern for possible PE (she had known SVC thrombosis and had not been anticoag due to noncompliance), she even received TPA. Unfortunately, all efforts to resuscitate the patient were unsuccessful. Her mother who is a [**Hospital1 18**] employee was contact[**Name (NI) **] in the beginning of the code and was able to be present with her several times during the resuscitation. She received emotional support from our social worker, several [**Name (NI) 10945**] nurses, as well as her work colleagues. Her mother did agree to an autopsy evaluation, results pending. Her nephrologist Dr. [**Last Name (STitle) 4883**] was notified of her death by one of his colleagues. Medications on Admission: Protonix 40 mg po bid Clonidine 0.4 mg mg/24hr patch Nifedipine SR 90 mg Daily Aliskiren 150 mg po bid Citalopram 20 mg daily Prednisone 4 mg daily Lidocaine patch daily - 12 hours on 12 hours off Sevelamer 400 mg po tid with meals Gabapentin 100 mg QHD Labetalol 1000 mg po tid Hydralazine 100 mg po Q8H Hydromorphone 2 mg tabs, 1-2 tabs Q4H prn Levetiracetam 1000 mg po QT,R,Sa Senna 1 tab po bid prn Colace 100 mg po bid Alprazolam 0.25 po bid prn Acetaminophen 325 mg, 1-2 tabs Q6H prn Hydralazine 100 mg po prn for SBP>100 Discharge Medications: none - pt deceased Discharge Disposition: Expired Discharge Diagnosis: Cardiopulmonary arrest, respiratory failure Dyspnea Hypertensive urgency Secondary Diagnoses: - Systemic lupus erythematosus - End Stage Renal Disease on [**Last Name (STitle) 2286**] - Malignant hypertension - Thrombocytopenia - SVC thrombosis - HOCM - Anemia - History of left eye enucleation [**2139-4-20**] for fungal infection - h/o vaginal bleeding [**2139**] s/p DepoProvera injection - Coag neg Staph bacteremia and HD line infections [**6-16**], [**5-17**] - Thrombotic microangiopathy - Obstructive sleep apnea on CPAP - Left abdominal wall hematoma - MSSA bacteremia associated with HD line [**Month (only) 956**]-[**2142-3-11**]. Discharge Condition: Pt expired Discharge Instructions: Pt expired Followup Instructions: Pt expired [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**] Completed by:[**2142-9-6**]

[ "789.59", "427.5", "710.0", "284.1", "345.90", "287.5", "622.11", "423.2", "338.29", "789.00", "443.89", "531.90", "276.6", "276.7", "585.6", "V58.61", "425.4", "327.23", "V12.51", "582.81", "403.01", "V15.81", "459.2", "530.81", "285.21" ]

icd9cm

[ [ [] ] ]

[ "39.95", "99.04", "99.60", "38.93", "99.10", "96.04" ]

icd9pcs

[ [ [] ] ]

8480, 8489

5826, 7858

311, 317

9176, 9188

3458, 5803

9247, 9379

2974, 3008

8437, 8457

8510, 8584

7884, 8414

9212, 9224

3023, 3439

8605, 9155

254, 273

345, 1321

1343, 2803

2819, 2958

8,231

161,551

49374

Discharge summary

report

Admission Date: [**2120-7-4**] Discharge Date: [**2120-7-10**] Date of Birth: [**2043-2-2**] Sex: F Service: MEDICINE Allergies: Penicillins / Codeine / Heparin Agents / Levofloxacin Attending:[**First Name3 (LF) 2160**] Chief Complaint: rectal bleeding Major Surgical or Invasive Procedure: colonoscopy egd GI bleeding study History of Present Illness: Patient is a 77 year old female with a past medical history significant for GI bleeding secondary to arteriovenous malformations, who presents with maroon stool and a hematocrit drop. Three days ago began to develop black stools. There was no clear blood in the toilet bowl. In addition, she developed nausea and decreased PO intake. She had a cough productive of white sputum and felt warm, although she did not record her temperature. At dialysis on day of admission, she related these symptoms for the first time and had a bloody bowel movement. Concerned, the staff sent her directly to the [**Hospital1 18**]. In the ED, her temperature was 96.5, HR 51, BP 112/60, RR 18, and oxygen saturation was 98% on ambient air. Her hematocrit was measured at 23.5, while her baseline hematocrit is in the low 30s. An NG lavage was performed and there was bilious return. Rectal examination was notable for guiaiac positive maroon stool. She was type and crossed and transfused two units of packed red blood cells. IV PPI was given and the GI team was consulted and she was scheduled for colonoscopy and EGD on the morning of [**7-5**]. She was transferred to the MICU for observation. Past Medical History: DM2 on insulin CRI [**3-1**] HTN and DM nephropathy, with baseline creatinine 4-4.5 Chronic GI bleeding: documented AVMs Anemia w/baseline hct 27-30 Thrombocytopenia Coagulopathy, HIT in [**2116**] Cardiomyopathy MRSA endocardiitis ([**12-30**]) CAD; status post coronary artery bypass graft times two and status post myocardial infarction in [**2103**] and [**2113**]. Asthma Hypothyroidism Osteoarthritis Paroxysmal atrial fibrillation PUD, Barrett's Esophagus CHF EF 50% 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: T:97.2 BP:127/57 HR:68 RR:11 O2saturation: 97% on ambient air Gen: Pleasant, well appearing heavy set woman laying in bed. HEENT: Slight conjunctival pallor. No scleral icterus. Slightly dry mucous membranes. NECK: Supple. No JVD. CV: RRR. Systolic murmur in right upper sternal border. Normal S1 and S2. No rubs or [**Last Name (un) 549**] appreciated. LUNGS: Crackles in lower lung fields. No wheezes or rhonci appreciated. ABD: Slightly hyperactive bowel sounds throughout. Soft. Nontender and nondistended. No guarding or rebound. Liver edge not palpated. No splenomegaly appreciated. Guaiac positive maroon stool in ED. EXT: Warm and well perfused. No clubbing or cyanosis. No lower extremity edema, bilaterally. 2+ dorsalis pedis and radial pulse on left. No radial pulse on right. AV fistula on right. Pertinent Results: [**2120-7-9**] 12:56AM BLOOD WBC-4.0 RBC-3.54* Hgb-11.6* Hct-32.9* MCV-93 MCH-32.8* MCHC-35.2* RDW-18.5* Plt Ct-65* [**2120-7-4**] 12:29PM BLOOD Hct-23.5*# [**2120-7-4**] 04:40PM BLOOD WBC-3.2* RBC-2.49*# Hgb-8.4*# Hct-24.5*# MCV-98 MCH-33.7* MCHC-34.3 RDW-18.5* Plt Ct-69* [**2120-7-8**] 04:52AM BLOOD PT-14.7* PTT-28.9 INR(PT)-1.3* [**2120-7-9**] 12:56AM BLOOD UreaN-27* Creat-4.1* Na-130* K-3.7 Cl-94* HCO3-27 AnGap-13 [**2120-7-8**] 04:52AM BLOOD Glucose-129* UreaN-24* Creat-3.4* Na-134 K-3.2* Cl-96 HCO3-29 AnGap-12 [**2120-7-4**] 04:40PM BLOOD Glucose-187* UreaN-21* Creat-2.0*# Na-139 K-3.2* Cl-96 HCO3-35* AnGap-11 [**2120-7-9**] 12:56AM BLOOD Calcium-8.0* Phos-3.5 Mg-1.8 Cardiology Report ECG Study Date of [**2120-7-4**] 5:40:48 PM Sinus bradycardia with markedly prolonged P-R interval and Wenckebach type atrio-ventricular conduction delay. Right bundle-branch block. Indeterminate frontal plane QRS axis. Compared to the previous tracing of [**2119-9-14**] multiple abnormalities as previously noted persist without major change. Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**] Intervals Axes Rate PR QRS QT/QTc P QRS T 57 0 154 [**Telephone/Fax (2) 103412**]6 -37 [**2120-7-5**] 5:40 pm SEROLOGY/BLOOD Source: Line-central. **FINAL REPORT [**2120-7-8**]** HELICOBACTER PYLORI ANTIBODY TEST (Final [**2120-7-8**]): NEGATIVE BY EIA. (Reference Range-Negative). GI bleed study - IMPRESSION: Active radiotracer activity in the right lower quadrant in a serpingneous f fashion suggestive of distal small bowel. EGD - Impression: Angioectasias in the fundus Angioectasias in the antrum Angioectasias in the proximal jejunum and mid jejunum Angioectasia in the duodenum Otherwise normal small bowel enteroscopy to mid jejunum Recommendations: No site of active bleeding was seen. The fundal AVMs are a potential site of bleeding although do not explain the extent of bleeding. Consider endoscopic argon plasma therapy Proceed with colonoscopy. Colonoscopy - Impression: Blood in the colon Grade 1 external hemorrhoids Angioectasia in the colon Diverticulosis of the colon Otherwise normal colonoscopy to cecum Brief Hospital Course: Blood loss anemia from GI bleeding - the bleeding was likely from an AVM. EGD, colonoscopy and tagged scan results as above. eventhough uptake was noted in the rt LQ, no clear site of bleeding was noticed on colonoscopy. hence, no intervention was performed. she was transfused with 5 units of PRBC in the ICU andsent to the [**Hospital1 **]. Her hematocrit remained stable for 4 days prior to discharge. No further bleeding noted. GI consult team followed pt in hospital. On discussion with Dr [**Last Name (STitle) 10689**] and Dr [**Last Name (STitle) 3708**] from GI - they recommended that she follow with Dr. [**Last Name (STitle) **] for consideration of argon photocoagulation as out-patient. Given the innumerable number of AVM's, it is diffcult to assess which the culprit lesion is and GI may start APL from the fundus of stomach. Patient to get CBC checked with PCP this week as below. ASA was held and may be restarted if Hct stable in clinic at the PCP's discretion. Chronic thrombocytopenia was noted, however the patient did not require platelet transfusions. Has a h/o HIT. The metoprolol was held during acute bleeding phase and restarted prior to discharge as her BP stabilized. Other medical problems stable. Dialysis was continued 3/week. I personally talked with Dr [**Last Name (STitle) 20670**] at the time of discharge to update him with the hospital events. Medications on Admission: -Atorvastatin 80 mg QD -Hydroxyzine HCl 25 mg Tablet PO Q4-6H PRN for itching -Levothyroxine 175 mcg PO qd -Albuterol 90 mcg 1-2 Puffs INH q6hr PRN -Nitroglycerin 0.3 mg Tablet PRN -Metoprolol Tartrate 12.5 mg [**Hospital1 **] -B Complex-Vitamin C-Folic Acid 1 mg Capsule QD -Insulin NPH 75-25 20units qAM and humalog sliding scale Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 3. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 5. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Menthol-Cetylpyridinium Cl 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual as needed as needed for chest pain. 9. Insulin Continue to take the insulin as you were taking prior to the hospital visit 10. Outpatient Lab Work CBC (to be checked by Dr [**Last Name (STitle) 20670**] [**Telephone/Fax (1) 21993**] on [**2120-7-12**]) 11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Acute blood loss anemia from rectal bleeding Thrombocytopenia - chronic Secondary diagnosis - HTN DM type 1 CKD stage 5 Hypothyroidism Asthma Coronary artery disease Discharge Condition: stable. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Do not take the aspirin unless you see Dr [**Last Name (STitle) 20670**]. Continue to take the insulin as you were taking prior to hospital visit. Keep your appointments. Please see your doctor (Dr [**Last Name (STitle) 20670**] on [**Last Name (STitle) 2974**] [**2120-7-12**] for a blood test (cbc). He has asked you call the clinic [**Month/Day/Year 2974**] morning for a same day appointment. Continue the dialysis three times a week. Return to the hospital if you notice bleeding or any other symptoms of concern to you. Followup Instructions: Provider: [**Name10 (NameIs) 23679**] Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2120-7-19**] 9:30 Gastroenterology - [**Last Name (LF) **], [**First Name3 (LF) 452**] Rose - [**Location (un) 453**]. Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2120-7-16**] 8:20 Primary doctor - Dr [**Last Name (STitle) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 21993**] - please see your doctor [**First Name (Titles) **] [**Last Name (Titles) 2974**] [**2120-7-12**] for a blood test (cbc). Dialysis as scheduled.

[ "285.1", "427.31", "250.00", "414.00", "428.0", "V45.81", "244.9", "537.83", "403.90", "286.9", "493.90", "425.4", "287.5", "562.10", "585.5", "455.3" ]

icd9cm

[ [ [] ] ]

[ "45.13", "99.04", "38.93", "45.23", "99.05", "39.95", "88.47" ]

icd9pcs

[ [ [] ] ]

8249, 8306

5432, 6822

328, 364

8517, 8527

3173, 5409

9206, 9807

2315, 2328

7205, 8226

8327, 8496

6848, 7182

8551, 9183

2343, 3154

273, 290

392, 1574

1596, 2072

2088, 2299

77,301

110,550

16618+56781+56784

Discharge summary

report+addendum+addendum

Admission Date: [**2135-2-3**] Discharge Date: [**2135-2-12**] Date of Birth: [**2060-8-28**] Sex: F Service: MEDICINE Allergies: Penicillins / Codeine / Morphine Attending:[**First Name3 (LF) 2901**] Chief Complaint: hypotension s/p surgical ASD closure Major Surgical or Invasive Procedure: ASD repair [**2135-2-3**] History of Present Illness: Ms. [**Known lastname 47091**] is a 74 yo F with h/o AF, IPF (on 4L home O2), cardiomyopathy with EF 35%, and diabetes who was admitted today for ASD closure with Dr. [**Last Name (STitle) 911**]. Plan was for her to be admitted to the NP service post-procedure, repeat echo tomorrow AM and discharge home. ASD closure was successful, but during the procedure patient became bradycardic to 40s and hypotensive to 70s systolic. Received 500cc IVF with little improvement. She was then was started on dopamine and neosynephrine gtt (now weaned to only dopamine), and bolused with atropine 0.5mg IV x2. In the PACU she was given another 1L IVF with little hemodynamic improvement. Of note, midazolam, fentanyl, rocuronium and etomidate were used for sedation and paralysis during the case. Patient is now being admitted to the CCU for pressors and monitoring overnight. . During ASD closure, patient was noted to have left to right shunting at the level of the left brachiocephalic artery. She was also found to have right to left shunting at the level of the right atrium, causing hypoxemia (see below for blood oximetry data). Filling pressures were found to be WNL: RAmean 9, RVEDP 8, PAP 54/24, PCWP 11. Ratio of pulmonary blood flow to systemic blood flow (Qp/Qs) was 1.4. ASD was successfully closed. Given her h/o IPF and right heart failure, selective catheter placement in each of the 4 pulmonary arteries was performed and angiography demonstrated no stenosis. Plan is for patient to start ASA and Warfarin anticoagulation and f/u with Dr. [**Last Name (STitle) 911**] in 1 month. . Patient has h/o cardiomyopathy with EF 35% and IPF diagnosed in [**2131**]. Over the past 6 months she has become progressively more short of breath, now becoming extremely dyspneic on minimal exertion (e.g. walking to bathroom). She is on 2-4L O2 per NC at home, normally satting in high 70s to low 80s on room air and low 90s on 4L O2. . On arrival to the CCU, patient is hemodynamically stable (SBP 110s, HR 60s), satting 88-93% on 4L. She is awake and responding to questions. Denies pain, dyspnea, chest pain, palpitations, nausea, leg pain. Past Medical History: 1. Atrial fibrillation, currently rate controlled with Toprol-XL and Warfarin for thromboembolic prophylaxis. 2. Interstitial pulmonary fibrosis on 2L (4 liters with exertion) home O2 initiated spring of [**2133**] only at night and requiring oxygen around the clock at present. 3. Hospitalization last year for decompensated heart failure. 4. Cardiomyopathy, most recent LVEF of 35% in addition to RV dysfunction and severe TR on a recent echo. NYHA III-IV. 5. Secundum ASD noted on recent echocardiogram with left-to-right shunting. 6. Diabetes. 7. Chronic right hip pain due to hip fracture requiring the use of a crutch for ambulation. 8. Tonsillectomy Social History: patient worked previously as a nurse. She never smoked cigarettes. Family History: Mother - DM, liver cancer, died at 70. Father - hypertension, stroke, died at 70. No family history of cardiac disease. Physical Exam: ADMISSION PHYSICAL EXAM: GENERAL: elderly asian F in NAD. AAOx3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 8 cm. Positive Kussmaul sign. CARDIAC: PMI located in 5th intercostal space, midclavicular line. Irregularly irregular. +RV heave. Split S1, loud S2. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Fine inspiratory crackles throughout both lung fields. No wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: Cool, no c/c/e. No femoral bruits. SKIN: Right groin bandage C/D/I, no hematoma. No stasis dermatitis, ulcers, scars, or xanthomas. NEURO: AAOx3, CNII-XII grossly intact, 5/5 strength biceps, triceps, wrist, knee/hip flexors/extensors, 2+ reflexes biceps, brachioradialis, patellar, ankle. PULSES: DP/PT 1+ bilaterally . DISCHARGE PHYSICAL EXAM: unchanged. Pertinent Results: LABS ON ADMISSION: [**2135-2-3**] 04:15PM BLOOD WBC-6.0 RBC-3.84* Hgb-9.2* Hct-31.1* MCV-81* MCH-24.0* MCHC-29.6* RDW-17.0* Plt Ct-370 [**2135-2-3**] 07:26AM BLOOD PT-21.3* INR(PT)-2.0* [**2135-2-3**] 04:15PM BLOOD Glucose-104* UreaN-15 Creat-0.6 Na-138 K-3.5 Cl-100 HCO3-31 AnGap-11 [**2135-2-3**] 04:15PM BLOOD ALT-11 AST-18 LD(LDH)-207 AlkPhos-60 TotBili-0.4 [**2135-2-3**] 04:15PM BLOOD Calcium-8.6 Phos-4.6* Mg-1.6 [**2135-2-4**] 03:46AM BLOOD Digoxin-0.8* IRON STUDIES: [**2135-2-5**] 06:00AM BLOOD calTIBC-382 Ferritn-17 TRF-294 TTE [**2135-2-3**]: Pre-device deployment: No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). A patent foramen ovale is present. A right-to-left shunt across the interatrial septum is seen at rest. Overall left ventricular systolic function is mildly depressed (LVEF= 45-50 %). The right ventricular free wall is hypertrophied. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. Severe [4+] tricuspid regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person of the results at time of procedure. TTE [**2135-2-4**]: The left atrium is mildly dilated. The right atrium is moderately dilated. A septal occluder device is seen across the interatrial septum. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is no ventricular septal defect. The right ventricular free wall is hypertrophied. The right ventricular cavity is moderately dilated with mild global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic root is mildly dilated at the sinus level. 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. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: PRIMARY REASON FOR HOSPITALIZATION: Ms. [**Known lastname 47091**] is a 74 yo F with h/o AF, secundum ASD, IPF (on 4L home O2), cardiomyopathy with EF 35%, and diabetes who was admitted today for ASD closure, procedure c/b bradycardia and hypotension. . #.HYPOXEMIA: Ms. [**Known lastname 47091**] was satting 88-93% on 4L O2 per NC on arrival to CCU. With her end stage IPF, she reports home O2 sats of high 70s-low 80s on room air, and 90-94% on her usual 4L. CXR inconsistent with fluid overload. Worsening of PAH may also be contributing to worsening hypoxemia/dyspnea. On the floor, she would desaturate to the 70s on 4L NC with ambulation. With preoxygenation with 100% NRB prior to and with ambulation, these desaturations were avoided. Per most recent pulm notes, her pulmonary and overall functional status has significantly worsened over the past 6 months, now with dyspnea on minimal exertion and requiring 4L home O2 at all times. Unfortunately there is no effective therapy for IPF. Baseline CXR showed interval worsening of IPF. Ms. [**Known lastname 47092**] outpatient pulmonary provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] recommended diuresis, and Ms. [**Known lastname 47091**] was 2L negative length of stay with 20mg PO daily furosemide. Unfortunately, diuresis did not appear to cause a improvement in dyspnea, and her SpO2 would still decrease to the low 90s on 4L NC with minimal ambulation. In addition, her blood pressure dropped to the high 70s after diuresis with pt reporting subjective fatigue, prompting discontinuation of all standing Lasix. On [**2-9**] per pulm recs patient underwent inhaled NO trial with serial targeted echos assessing tricuspid regurgitation jet before/after NO. After receiving NO, her pulmonary hypertension improved moderately, with decrease in pulmonary artery systolic pressure from 37-79mmHg to 39-54mm Hg. She did not report subjective improvement in symptoms with NO (trial performed at rest), and her O2 sats were 97-100% throughout. She will be followed up as outpatient with pulmonology, where she may be candidate for either pulmonary vasodilator (sildenafil) or inhaled prostacyclin therapy. On discharge she is satting between 90-100% on 4L NC, also requiring pre-oxygenation with 8L by high-flow facemask prior to exertion (e.g. chair to bed) in order to prevent dropping her O2 sats. Per her request, she is discharged to home rather than pulmonary rehab. . #.BRADYCARDIA, HYPOTENSION: patient became bradycardic and hypotensive during ASD closure, requiring both neosynephrine and dopamine and atropine and IVF. She was weaned off dopamine over the next day with stable BPs and HR. Most likely etiology was slow clearance of sedative/paralytic anesthesia during the case, as well as possible oversuppression of heart rate with home digoxin and beta blocker. Patient was hypotensive to high 70s-low 80s multiple times throughout CCU stay, so her home medications were tapered down: metoprolol was stopped, and lasix was also stopped as she remained euvolemic without diuretics . Her home digoxin was not changed, with goal of improving rate control without sacrificing blood pressure, and she was continued on 0.125mg daily . #.s/p SECUNDUM ASD CLOSURE: Procedure was successful, with repeat echo showing well-seated septal occluder device. Patient also noted to have right-to-left interatrial shunting (Eisenmenger syndrome) as well as severe (3+) TR during procedure, secondary to her chronically elevated right heart pressures (which themselves are likely secondary to pulmonary hypertension from IPF as well as earlier left-to-right shunting across ASD). She became bradycardic and hypotensive in the OR, which required dopamine drip which was maintained for 24 hours. She was hemodynamically stable and off of pressors 24 hours following the procedure and did not have a pressor requirement at any later time this admission. Repeat TTE on [**2-4**] showed improved LVEF (55%), but also worsening RV pressure overload and worsening TR (4+). Another TTE on [**2-8**] demonstrated small left-to-right shunt across the septal occluder device, and slight improvement in pulmonary pressures. Home Warfarin and ASA were continued for anticoagulation following the procedure. Home digoxin and metoprolol were also continued. . #.ANEMIA: Ms. [**Known lastname 47091**] became anemic to HCT 26.8 this admission with MCV 80; HCT 31 on arrival and drifting down since then. Her baseline HCT is 37. Worsening microcytic anemia does suggest likely iron deficiency, and iron studies were consistent. Stools guaiac negative. Iron supplementation was initiated, with slow improvement in her HCT. She would likely benefit from outpatient colonoscopy to rule out occult malignancy if her life expectancy improves from the current poor (<6 month) prognosis. . #.AFib: Ms. [**Known lastname 47091**] was well rate-controlled on Metoprolol and Digoxin and is on home Warfarin for thromboembolic prophylaxis. Given bradycardia, her metoprolol was decreased from 50 to 25mg PO daily, and she remained under good rate control. She is also on home digoxin. Warfarin dose was also decreased from 3mg to 2mg PO daily as her INR was supratherapeutic. . #.CARDIOMYOPATHY: patient has h/o NYHA class III-IV cardiomyopathy with echo from [**7-30**] showing LVEF 35%, RV dysfunction and severe TR. Echo post-procedure showed LVEF 45-50%. Etiology of her heart failure could be IPF causing pulmonary hypertension and increased right heart afterload, as well as chronically increased right heart filling pressures [**1-20**] ASD. In addition, her left-to-right brachiocephalic trunk may have further increased right heart preload, further exacerbating right overload. Right heart failure likely then led to left heart failure. After an initial diuresis of 2L LOS, her standing lasix dose was decreased to 20mg daily PO to keep her euvolemic, and then discontinued altogether as it was suspected to be contributing to her hypotension. . #.CODE STATUS: per conversation with pt's outpatient pulmonologist [**First Name4 (NamePattern1) 2048**] [**Last Name (NamePattern1) **], patient and her husband decided that she would like to be made DNR/DNI. Code status was updated in her medical record. Patient refused inpatient pulmonary rehab despite urging by her inpatient team, and will therefore be discharged home with hospice (as well as continuation of all her current medical therapies). . # NIDDM: Metformin was initially held, and SSI was started. Metformin was restarted 3 days prior to discharge, but given low-normal blood sugars 90s-100s in the morning and likely short life expectancy, metformin was held upon discharge. . ==================== TRANSITIONAL ISSUES: 1. Needs colonoscopy to f/u iron deficiency anemia 2. Patient needs to pre-oxygenate with 8L per facemask before any movement/ambulation. She is on 4L per NC at rest, satting 90-100%. 3. Inhaled NO improved [**MD Number(3) 47093**]-invasive TTE studies, will need to consider inhaled prostacyclin therapy as an outpatient. 4. Consider discontinuing beta blocker if appropriate rate control is achieved with digoxin as the beta blocker may be contributing to dyspnea. Medications on Admission: -Digoxin 125 mcg PO daily -Warfarin 3.5mg PO qHS (instructed to take 1mg on [**2-1**] and resume usual dose on [**2-2**]) -Furosemide 40mg PO BID -Metoprolol succinate 50mg PO daily -Metformin 1000mg PO BID -Oxygen: 2L/min continuously 2lpm cont via pulse dose, 4L/min with exertion via pulse dose. O2 sat 77% at rest. Dx=515. Please provide appropriate oxygen conserving device. -Ergocalciferol (Vitamin D2) 50,000 mg PO qmonth -Calcium carbonate (Vitamin D3) 600mg Ca (1500mg)-400 unit tab PO daily Discharge Medications: 1. digoxin 125 mcg Tablet Sig: One (1) Tablet PO daily. Disp:*30 Tablet(s)* Refills:*2* 2. warfarin 1 mg 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. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever, pain. 6. oxycodone 5 mg/5 mL Solution Sig: 4-16 mg PO q1h PRN as needed for pain. Disp:*100 mg* Refills:*0* 7. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for anxiety. Disp:*20 Tablet(s)* Refills:*0* 8. haloperidol 1 mg Tablet Sig: One (1) Tablet PO q6h PRN as needed for agitation. Disp:*16 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Season's Hospice Discharge Diagnosis: Atrial fibrillation Cardiomyopathy, EF 35% Interstitail pulmonary fibrosis Diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 47091**], You were admitted to the hospital following a catheterization and ASD repair. Following the procedure, your oxygen levels increased and you were found to have a low oxygen saturation with minimal activity. This improved a little with getting a little fluid off of you, and also improved with giving you oxygen by facemask before you exerted yourself. We felt you were a bit weak and would benefit from some rehabilitation from a pulmonary perspective. Therefore, we transferred you to [**Hospital 100**] Rehab where rehab with a focus on the lungs would take place. Also while you were here we discovered that you had iron deficiency anemia. We started you on iron supplementation. We also found that your heart rates was rather low, therefore we decreased the doses of your metoprolol and digoxin which can both lower your heart rate. We made the following changes to your medications: 1. Stop Metoprolol 2. DECREASE Warfarin (blood thinner) from 3.5mg daily to 2 mg daily 3. STOP taking furosemide (Lasix) 5. START Ferrous Sulfate 1 pill by mouth daily for iron-deficiency anemia 6. STOP Metformin as your blood sugars have been normal Please take Aspirin daily and continue Coumadin and Digoxin. Weigh yourself every morning, and call your doctor if weight goes up more than 3 lbs. If you need to speak with Dr. [**Last Name (STitle) 911**], you can reach him on his cell phone: [**Telephone/Fax (1) 47094**]. Followup Instructions: Department: CARDIAC SERVICES When: WEDNESDAY [**2135-3-9**] at 3:00 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: MEDICAL SPECIALTIES When: THURSDAY [**2135-2-24**] at 3:30 PM With: DRS. [**Name5 (PTitle) 4013**] & [**Doctor Last Name **] [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PULMONARY FUNCTION LAB When: THURSDAY [**2135-2-24**] at 3:10 PM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PFT When: THURSDAY [**2135-2-24**] at 3:30 PM [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**] Name: [**Known lastname 8684**],[**Known firstname 8685**] Unit No: [**Numeric Identifier 8686**] Admission Date: [**2135-2-3**] Discharge Date: [**2135-2-12**] Date of Birth: [**2060-8-28**] Sex: F Service: MEDICINE Allergies: Penicillins / Codeine / Morphine Attending:[**First Name3 (LF) 949**] Addendum: Also of note, the right sided congestive heart failure was systolic. Discharge Disposition: Home With Service Facility: Season's Hospice [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 950**] MD, [**MD Number(3) 951**] Completed by:[**2135-4-1**] Name: [**Known lastname 8684**],[**Known firstname 8685**] Unit No: [**Numeric Identifier 8686**] Admission Date: [**2135-2-3**] Discharge Date: [**2135-2-12**] Date of Birth: [**2060-8-28**] Sex: F Service: MEDICINE Allergies: Penicillins / Codeine / Morphine Attending:[**First Name3 (LF) 949**] Addendum: To clarify, Ms. [**Known lastname **] had acute on chronic right sided congestive heart failure. This was treated with oxygen, beta blockers, and diuretics as needed. Discharge Disposition: Home With Service Facility: Season's Hospice [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 950**] MD, [**MD Number(3) 951**] Completed by:[**2135-4-1**]

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26115

Discharge summary

report

Admission Date: [**2151-6-22**] Discharge Date: [**2151-7-16**] Date of Birth: [**2090-3-24**] Sex: M Service: CARDIOTHORACIC Allergies: Heparin Agents Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain when lying flat, dyspnea on exertion Major Surgical or Invasive Procedure: [**2151-6-28**] redo/redo sternotomy/Coronary Artery Bypass Graft x3 (Left internal mammary artery to left anterior descending, Saphenous vein graft to obtuse marginal, Saphenous vein graft to posterior descending artery)/ Aortic Valve Replacement ([**Street Address(2) 64790**]. [**Male First Name (un) 923**] mechanical)/Mitral Valve repair (28 mm [**Company 1543**] CG Future ring) [**2151-6-30**] mediastinal washout and closure History of Present Illness: 61 yoF w/ a h/o Aortic stenosis and CAD s/p AVR x 2 (initially bioprosthetic valve which was replaced with mechanical valve, on coumadin) and CABG x 2 (SVG to OM, SVG to RCA, re-do with SVG to PDA) was recently admitted to the [**Hospital1 18**] with prosthetic valve endocarditis returns with dyspnea on exertion and chest pain. The patient states over the past 1 week he has noticed worsening dyspnea on exertion. He states that especially in the afternoon just ambulating across the room causes dyspnea. The dyspnea is associated with palpitations. He has non exertional chest pain also at night when he lies down to go to bed, it is a dull L chest sensation and radiates to his L arm. No orthopnea or PND. Minimal LE swelling which is "baseline." He has a [**2-24**] lb weight gain. He stopped taking his lasix 6 days ago as his LE edema was improving. (although he states his symptoms preceeded his lasix discontinuation) . The patient had been on 6 weeks of antibiotics for his strep viridans bactermia / endocarditis which had finished on [**2151-6-13**]. No F/C, no sweats. Minimal non productive cough. No other symptoms. Referred for surgical eval. Past Medical History: Hypertension Dyslipidemia Coronary Artery Disease s/p NSTEMI [**5-31**] s/p 2.5x8mm Cypher DES to LCx proximally and four (4)overlapping 2.5x12mm Promus [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 22595**] Rheumatic fever Atrial Fibrillation Past Surgical History: s/p Aortic Valve Replacement (25 mm CE pericardial valve)/Coronary Artery Bypass Graft x 2 (SVG->OM, SVG->RCA)@ [**Hospital1 112**] [**2139**] s/p Aortic Valve Replacement (St. [**Male First Name (un) 923**] 21mm mechanical)/Coronary Artery Bypass Graft x 1 (SVG->PDA) [**2147**] with Dr. [**Last Name (STitle) **] s/p left elbow [**Doctor First Name **] w/2 screws still in place s/p right ankle surgery Social History: lives alone previously worked as a truck driver smoked 1+ ppd x 40 years no ETOH or recreational drugs Family History: CAD and s/p CABG in mother and CVA in father (died of CVA at 49) Physical Exam: Temp 98.0 Pulse:116 Resp:20 O2 sat:97%RA B/P 110/79 Height: 6'1" Weight: 210 (pre-op) General:NAD, sitting up, appears comfortable Skin: Dry [x] intact [x] HEENT: PERRLA [x EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally []crackles at bases Heart: RRR [] tachycardic Irregular [] I-II/VI SEM Murmur Valve Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Has endoscopic vein harvest sites on BLE Neuro: grossly normal Pulses: Femoral Right: +2 Left: +2 DP Right: +2 Left: +2 PT [**Name (NI) 167**]: +2 Left: +2 Radial Right: +2 Left: +2 Carotid Bruit Right: ? soft bruit Left: none Pertinent Results: [**2151-6-28**] Echo: Prebypass: Very poor images of the ascending aorta. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). with mild global RV free wall hypokinesis. The aortic root is moderately dilated at the sinus level. A mechanical aortic valve prosthesis is present. Motion of the aortic valve prosthesis leaflets/discs is abnormal. There is dehiscence noted of the prosthetic aortic valve.Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The leaflets are tethered. No obvious vegetatiion seen on the mitral valve. Severe (4+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2151-6-28**] at 930am. Post bypass: Patient is AV paced and receiving an infusion of levophed, milrinone, vasopressin and epinephrine. LVEF= 40%. RV mildly hypokinetic. Mechanical valve seen in the aortic position. With limited views it appears well seated and the leaflets move well. Annuloplasty ring seen in the mitral position. It appears well seated but there is 2+ mitral regurgitation. The moderate to severe tricuspid regurgitation persists. Unable to visualize the aorta completely post decannulation. [**2151-7-7**] Liver U/S: Cholelithiasis without evidence of acute cholecystitis. Small right pleural effusion. Limited exam. [**2151-7-9**] Abd MRI: 1. Gallstone within the gallbladder, without evidence of acute cholecystitis. 2. The common bile duct and intrahepatic bile ducts are of normal caliber with no evidence of obstruction. 3. Significant subcutaneous emphysema (which has been present on recent chest radiographs. [**2151-7-16**] 04:39AM BLOOD WBC-8.2 RBC-3.74* Hgb-10.7* Hct-33.2* MCV-89 MCH-28.5 MCHC-32.1 RDW-17.4* Plt Ct-281 [**2151-7-15**] 05:46AM BLOOD WBC-8.4 RBC-3.78* Hgb-11.3* Hct-34.1* MCV-90 MCH-30.0 MCHC-33.2 RDW-17.1* Plt Ct-275 [**2151-7-14**] 05:23AM BLOOD WBC-10.4 RBC-4.11* Hgb-11.2* Hct-36.6* MCV-89 MCH-27.3 MCHC-30.7* RDW-17.2* Plt Ct-294 [**2151-7-13**] 04:39AM BLOOD WBC-12.1* RBC-4.03* Hgb-11.7* Hct-36.1* MCV-90 MCH-29.1 MCHC-32.4 RDW-16.9* Plt Ct-264 [**2151-7-16**] 04:39AM BLOOD PT-22.6* PTT-34.8 INR(PT)-2.1* [**2151-7-15**] 05:46AM BLOOD PT-25.3* PTT-35.6* INR(PT)-2.4* [**2151-7-14**] 05:23AM BLOOD PT-27.5* PTT-35.6* INR(PT)-2.7* [**2151-7-13**] 04:39AM BLOOD PT-21.9* PTT-33.1 INR(PT)-2.0* [**2151-7-12**] 05:40AM BLOOD PT-27.8* INR(PT)-2.7* [**2151-7-11**] 05:10AM BLOOD PT-34.0* PTT-37.3* INR(PT)-3.5* [**2151-7-10**] 05:53AM BLOOD PT-36.5* PTT-38.4* INR(PT)-3.8* [**2151-7-16**] 04:39AM BLOOD Glucose-88 UreaN-30* Creat-0.6 Na-134 K-4.4 Cl-98 HCO3-28 AnGap-12 [**2151-7-15**] 05:46AM BLOOD Glucose-85 UreaN-29* Creat-0.9 Na-134 K-4.2 Cl-98 HCO3-29 AnGap-11 [**2151-7-14**] 05:23AM BLOOD Glucose-89 UreaN-28* Creat-0.8 Na-136 K-4.2 Cl-99 HCO3-29 AnGap-12 [**2151-7-13**] 04:39AM BLOOD Glucose-99 UreaN-31* Creat-0.9 Na-134 K-4.8 Cl-98 HCO3-27 AnGap-14 [**2151-7-12**] 05:40AM BLOOD Glucose-100 UreaN-37* Creat-1.0 Na-134 K-3.9 Cl-99 HCO3-28 AnGap-11 [**2151-7-11**] 05:10AM BLOOD Glucose-106* UreaN-36* Creat-0.6 Na-137 K-4.1 Cl-101 HCO3-27 AnGap-13 [**2151-7-16**] 04:39AM BLOOD ALT-68* AST-86* LD(LDH)-406* AlkPhos-165* Amylase-65 TotBili-14.4* [**2151-7-15**] 05:46AM BLOOD ALT-70* AST-92* LD(LDH)-480* AlkPhos-179* Amylase-70 TotBili-16.0* DirBili-14.4* IndBili-1.6 [**2151-7-14**] 05:23AM BLOOD ALT-62* AST-87* LD(LDH)-523* AlkPhos-178* TotBili-17.7* [**2151-7-13**] 04:39AM BLOOD ALT-66* AST-90* LD(LDH)-582* AlkPhos-186* Amylase-78 TotBili-21.5* [**2151-7-12**] 05:40AM BLOOD ALT-70* AST-98* LD(LDH)-614* AlkPhos-188* Amylase-104* TotBili-21.1* [**2151-7-11**] 05:10AM BLOOD ALT-72* AST-104* AlkPhos-167* Amylase-123* TotBili-21.2* DirBili-17.1* IndBili-4.1 [**2151-7-10**] 05:53AM BLOOD ALT-72* AST-105* AlkPhos-159* Amylase-154* TotBili-20.2* [**2151-7-9**] 05:42AM BLOOD ALT-77* AST-120* LD(LDH)-645* AlkPhos-165* Amylase-233* TotBili-19.4* DirBili-15.0* IndBili-4.4 [**2151-7-8**] 03:00AM BLOOD ALT-84* AST-138* AlkPhos-152* Amylase-246* TotBili-19.3* [**2151-7-7**] 02:12AM BLOOD ALT-89* AST-151* AlkPhos-136* Amylase-198* TotBili-18.1* [**2151-7-6**] 02:13AM BLOOD ALT-93* AST-162* AlkPhos-119 Amylase-137* TotBili-17.6* [**2151-7-16**] 04:39AM BLOOD Albumin-3.1* Calcium-8.8 Phos-3.4 Mg-2.0 [**2151-7-15**] 05:46AM BLOOD Albumin-2.6* Calcium-8.4 Phos-3.0 Mg-2.1 [**2151-6-24**] 08:10AM BLOOD %HbA1c-6.1* eAG-128* [**2151-6-23**] 07:50AM BLOOD TSH-3.4 [**2151-7-13**] 04:39AM BLOOD AMA-NEGATIVE [**2151-7-9**] 09:14PM BLOOD AMA-NEGATIVE Smooth-POSITIVE [**2151-7-13**] 04:39AM BLOOD [**Doctor First Name **]-NEGATIVE [**2151-7-13**] 04:39AM BLOOD IgG-1270 IgM-726* [**2151-7-16**] 04:39AM BLOOD Vanco-13.8 Brief Hospital Course: 61 yoM w/ a h/o AS s/p mechanical valve, CAD s/p CABG and recent admission for prosthetic valve endocarditis presents with dyspnea on exertion and chest pain. . # ? of Aortic valve dehiscence on ECHO. Concern for persistent endocarditis with valve destruction. Appreciate input: 1) CSurg - CTA chest + TEE 2) ID - Vanc + CTX, TEE 3) referred for surgery . # Dyspnea on exertion: Possibly from above.. NYHA III heart failure symptoms. Given exam, weight gain, discontinuation of lasix most suggestive of heart failure, possibly triggered by cessation of lasix in setting of continued tachycardia (causing tachymyopathy). . # Atrial arrhythmia: While inpatient [**Date range (1) 64791**], the patient had atrial fibrillation as well as possible atrial flutter vs. atrial tachycardia. He was never cardioverted and had no history of atrial arrhythmias prior to admission. He was initiated on amiodarone and has finished a load, currently on 200mg po daily. Currently on physical exam and telemetry, has been atrial tachycardic. - Patient has been intolerant of beta blockers in the past given his COPD (significant bronchospasms) - Continue Diltiazem 30mg four times daily for now and uptitrate as HR and BP tolerates (patient unsure if taking, discharged on 120mg CR daily) . # Chronic shoulder pain: Continue oxycontin 10mg po qhs as patient still unsure of dose - will start low. Pre-op workup completed and underwent surgery with Dr. [**Last Name (STitle) **] on [**6-28**]. Transferred to the CVICU in fair condition with a packed open chest on levophed, vasopressin, epinephrine, and milrinone drips. Returned to OR on [**6-30**] for washout,closure and DCCV and then back to ICU on same 4 drips plus titrated propofol. ID was further [**Month/Day (4) 4221**] for abx mgmt. Seen by gen. [**Doctor First Name **] for elevated LFTs. Coumadin started for mechanical valve. Extubated on POD #5. Deep tissue injury noted to sacral area and treatment continued with recs from wound care nurse. [**First Name (Titles) 3585**] [**Last Name (Titles) 4221**] [**7-9**] for continuing elevated LFTs.Scan showed gallstones without obstruction of ducts. He was pan-cultured. Transfered to the floor on POD #11 to begin increasing his activity level. Also followed by clinical nutrition team. EP consult done for further A Fib mgmt. Digoxin and eplenerone started. Vancomycin and cefepime started per [**Month/Year (2) **] for liver dz. Abx will continue through [**7-21**]. He is cleared for discharge to rehab by Dr. [**Last Name (STitle) **] on [**2151-7-16**]. Appropriate follow up is advised. Medications on Admission: Plavix 75mg daily ASA 325mg daily Lisniopril 5mg daily Amiodarone 200mg po daily Coumadin 2.5mg daily Lipitor 40mg daily Flexeril prn Discharge Medications: 1. dressing Leg Right groin with small 1 cm opening due to not well approximated when staples removed for MRI - no drainage or odor, continue with wet to dry dressing changes TID 2. Outpatient Lab Work Labs CBC, SMA 7, PT/PTT, LFT with total and direct Bilirubin on [**7-22**] - please fax results to Dr [**Name (STitle) 23173**] Liver Center Fax [**Telephone/Fax (1) 4400**] 3. Outpatient Lab Work Daily INR until off antibiotics and LFT normalized then three times a week for coumadin dosing Goal INR 2.5-3.0 for coumadin dosing mechanical AVR 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. PICC line Per protocol - heparin free due to allergy - flush with saline 7. Warfarin 1 mg Tablet Sig: Goal INR 2.5-3.0 Tablets PO once a 8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Eplerenone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed for insomnia. 14. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for pain. 15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 16. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 17. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 18. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily). 19. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 20. Cefepime 2 gram Recon Soln Sig: Two (2) gram Intravenous Q12H (every 12 hours): 7 day course per liver attending completes [**7-22**] after pm dose . 21. Vancomycin 1,000 mg Recon Soln Sig: 1250 (1250) mg Intravenous Q 12H (Every 12 Hours): 7 day course per liver attending completes [**7-22**] after pm dose please check trough [**7-18**] before am dose goal 15-20. 22. Statin Due to liver dysfunction - statin stopped - will need to resume when [**Month/Year (2) **] clears to restart - please re evaluate after labs draw in 1 week Discharge Disposition: Extended Care Facility: [**Hospital6 19504**] of [**Location (un) 1514**] - [**Location (un) 1514**], NH Discharge Diagnosis: Endocarditis/?dehiscence of prior prosthetic Aortic Valve [**5-1**] cholelithiasis Past Medical History: Hypertension Dyslipidemia Coronary Artery Disease s/p NSTEMI [**5-31**] s/p 2.5x8mm Cypher DES to LCx proximally and four (4)overlapping 2.5x12mm Promus [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 22595**] Rheumatic fever Atrial Fibrillation Past Surgical History: s/p Aortic Valve Replacement (25 mm CE pericardial valve)/Coronary Artery Bypass Graft x 2 (SVG->OM, SVG->RCA)@ [**Hospital1 112**] [**2139**] s/p Aortic Valve Replacement (St. [**Male First Name (un) 923**] 21mm mechanical)/Coronary Artery Bypass Graft x 1 (SVG->PDA) [**2147**] with Dr. [**Last Name (STitle) **] s/p left elbow [**Doctor First Name **] w/2 screws still in place s/p right ankle surgery Discharge Condition: Alert and oriented x3 nonfocal Does not ambulate; requires 2 person assist deconditioned Incisional pain managed with oxycodone/cyclobenzaprine Incisions: Sternal - healing well, no erythema or drainage Leg Right - healing well, no erythema or drainage, ecchymosis Edema :2+ 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 until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] 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: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2151-8-19**] 1:45 pm Liver: [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2151-8-2**] 10:30 Please call to schedule appointments with your Primary Care/Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 64792**] in [**1-23**] 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 ?????? Mechanical Valve/Atrial Fibrillation Goal INR : 2.5-3.0 (mechanical aortic valve and A Fib) First draw [**2151-7-17**] Please check INR daily and dose coumadin based on results due to changing liver function dosing is progressively going up - When LFT stable and off antibiotics - please check three times a week INR Coumadin [**2151-7-16**] 04:39 2.1* - 5 mg Source: Line-pic [**2151-7-15**] 05:46 2.4* - 2 mg Source: Line-PICC [**2151-7-14**] 05:23 2.7* - 1 mg Source: Line-PICC [**2151-7-13**] 04:39 2.0* - 2.5mg Source: Line-picc [**2151-7-12**] 05:40 2.7* - 2.5 mg Source: Line-Right PICC [**2151-7-11**] 05:10 3.5* - 1 mg Source: Line-right PICC [**2151-7-10**] 05:53 3.8* - 1 mg Source: Line-PICC [**2151-7-9**] 05:42 4.4* - none [**2151-7-8**] 03:00 5.7*1 - none [**2151-7-7**] 02:12 4.4* - none Source: Line-RIJ [**2151-7-6**] 02:13 5.7*2 - none Source: Line-arterial [**2151-7-5**] 11:54 5.7*3 - none Source: Line-aline [**2151-7-5**] 03:10 5.1*4 - none Source: Line-aline [**2151-7-4**] 02:42 3.6* - none Source: Line-a-line [**2151-7-3**] 03:10 2.3* - 2.5 mg Source: Line-aline [**2151-7-2**] 14:00 1.9* - 2 mg Source: Line-aline [**2151-7-2**] 05:16 1.8* ---- Source: Line-art [**2151-7-1**] 22:07 1.7*5 - 2 mg Source: Line-art; heparin dose: 700 [**2151-7-1**] 01:40 1.6* - 2 mg Source: Line-a-line [**2151-6-30**] 10:06 1.6* Source: Line-A line [**2151-6-30**] 01:31 1.4* Labs CBC, SMA 7, PT/PTT, LFT with total and direct Bilirubin on [**7-22**] - please fax results to Dr [**Name (STitle) 23173**] Liver Center Fax [**Telephone/Fax (1) 4400**] Completed by:[**2151-7-16**]

[ "421.0", "410.72", "V58.41", "996.61", "574.20", "041.09", "707.05", "441.2", "745.5", "427.31", "458.29", "427.32", "790.29", "719.41", "287.5", "349.82", "707.25", "397.0", "573.8", "394.1", "338.29", "996.02", "414.02", "V45.82", "300.00", "493.20", "272.4", "V43.3", "285.9", "414.01", "276.6", "E878.1", "429.89", "401.9" ]

icd9cm

[ [ [] ] ]

[ "88.72", "96.72", "35.22", "88.56", "35.33", "38.93", "99.62", "37.22", "99.69", "34.79", "36.12", "36.15", "39.61" ]

icd9pcs

[ [ [] ] ]

13700, 13807

8508, 11102

329, 763

14636, 14917

3649, 8485

15756, 18107

2792, 2859

11286, 13677

13828, 13911

11128, 11263

14941, 15733

14208, 14615

2874, 3630

242, 291

791, 1952

13933, 14185

2672, 2776

77,336

121,307

5467

Discharge summary

report

Admission Date: [**2101-11-16**] Discharge Date: [**2101-11-18**] Date of Birth: [**2033-7-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 398**] Chief Complaint: Unresponsiveness Major Surgical or Invasive Procedure: none History of Present Illness: 68M with metastatic colon cancer, CAD and prior CVA presenting with massive intracranial hemorrhage. Family reports that the patient had sudden onset of nausea at dinner. He vomited and went to bed and was subsequently discovered to be unresponsive. An attempt to intubate was made in the field that was unsuccessful. Pt was intitially taken to [**Hospital1 **] where he was intubated without sedation. Head CT showed a large intracranial hemorrhage. Pupils were notes to be fixed. The patient was not responsive. . In the ED, initial vitals 97.4 57 169/90 14 100% vented. Pt was seen by neurosurgery who felt that his was a terminal bleed. Pt was given 10mg deacdron IV. Head CT was read as massive intraventricular hemorrhage filling lateral, third, and 4th ventricles, with hydrocephalus and transependymal migration of CSF. Large hemorrhage within left centrum semiovale. EKG sinus bradycardia with QT prolongation. Pt's family that he be full code overnight so that family could be at bedside tomorrow for terminal extubation. . On arrival to the floor, vitals 95.1 54 175/81 14 100% vented. Past Medical History: Metastatic Colon Cancer Coronary Artery Disease s/p CABG x2 Diabetes Mellitus Hypertension Stroke Social History: Lives with sons. Recently moved to [**Location (un) 86**] from [**State 108**]. Family History: Noncontributory Physical Exam: General Appearance: Well nourished, No acute distress, Thin Eyes / Conjunctiva: No(t) PERRL, No(t) Pupils dilated, No(t) Sclera edema, Pupils 4mm, fixed Head, Ears, Nose, Throat: Normocephalic, NG tube Cardiovascular: (S1: Normal), (S2: Normal) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Rhonchorous: ) Abdominal: Soft, Non-tender, No(t) Bowel sounds present Extremities: Right lower extremity edema: Absent, Left lower extremity edema: Absent, No(t) Cyanosis Skin: Warm, No(t) Rash: , No(t) Jaundice Neurologic: No(t) Follows simple commands, Responds to: Unresponsive, Movement: No spontaneous movement, Tone: Decreased Pertinent Results: [**2101-11-16**] CT HEAD W/O CONTRAST FINDINGS: There is a large intraparenchymal hemorrhage, likely originating from a parenchymal hemorrhage in the left centrum semiovale. There is a large amount of hemorrhage filling bilateral lateral ventricles, temporal horns, third and fourth ventricles. Associated ventriculomegaly is compatible with obstructive hydrocephalus, with periventricular white matter low attenuation suggestive of transependymal flow of CSF. There is associated edema related to the left centrum semiovale intraparenchymal hemorrhage. However, no significant shift of normally midline structures or central herniation is identified. The overall findings are not significantly change from the study performed at [**Hospital3 **] at 7:32 p.m. There is patchy opacification of the ethmoid air cells, with air- fluid levels in bilateral maxillary sinuses. No fractures are identified. IMPRESSION: 1. No significant interval change in a large intraparenchymal hemorrhage likely originating within the left centrum semiovale, with massive hemorrhage extension within the ventricular system. 2. Obstructive hydrocephalus, without herniation. Brief Hospital Course: Evaluated by neurosurgery in the ED and it was determined that given the extent of intracranial hemorrhage that there was little chance of a meaningful recovery, and operative therapy was deferred. Patient had evidence of [**Location (un) **] response with progressive neurologic deterioration. The family decided to make the patient comfort measures only and he ultimately expired on [**2101-11-18**] at 2:37 AM. Autopsy was deferred. Medications on Admission: Dutasteride 0.5 mg po Famotidine 20mg po daily Simvastatin 80mg po daily Ibuprofen 600mg po prn Glipizide 5mg po bid Terazosin 5mg po daily Lisinopril 5mg po daily Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Cardiopulmonary collapse Intracranial hemorrhage Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A Completed by:[**2101-11-18**]

[ "431", "V12.54", "401.9", "348.4", "331.4", "250.00", "348.5", "V10.05" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

4398, 4407

3718, 4155

333, 339

4499, 4508

2538, 3695

4560, 4595

1701, 1718

4370, 4375

4428, 4478

4181, 4347

4532, 4537

1733, 2519

277, 295

367, 1466

1488, 1588

1604, 1685

49,395

169,700

39002

Discharge summary

report

Admission Date: [**2197-1-8**] Discharge Date: [**2197-1-10**] Date of Birth: [**2114-4-20**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2485**] Chief Complaint: G tube bleeding / concern for infection Major Surgical or Invasive Procedure: PEG tube removal [**2197-1-9**] History of Present Illness: 82 year-old female with a history of metestatic uterine cancer s/p hysterectomy as well as DM, HTN, left MCA stroke with subsequent hemorrhagic transformation, bilateral segmental and subsegmental pulmonary emboli, nonverbal at baseline, completely dependant of ADLs, PEG placed [**2196-5-1**], who presents from her nursing home with bleeding from her G tube and concern for infection for the past 3 days. Per discussion with her son her G tube has been oozing over the past few days and they are wondering if it is infected. They sent her to the hospital with the hope of having her G tube removed and any infection present surgically treated. . Of note she was discharged two days ago to home with hospice care after being hospitalized for labial induration as well as peritoneal metastases with abdominal ascietes and RLE/pelvic thrombus found on CT scans. She was also incidentally noted to have proctitis on her CT and was treated with 7 days of cipro/flagyl. . On arrival in the ED her initial VS were temp 97.3 heart rate 105 blood pressure 169/100 respiratory rate of 18 and O2 sats of 92% on room air. Urinalysis showed moderate bacteria and a chest x-ray showed a right pleural effusion. A CT abdomen showed no evidence of active extravasation but showed multiple peritoneal and omental implants, ascietes, a right iliac [**Last Name (LF) 86508**], [**First Name3 (LF) **] occluded left common femoral artery (with patent nearby collaterals), a stable right renal infarct and a narrowed celiac oriigin as well as a left atrial filling defect which was not present on prior CTA and was felt to be consistent with a clot. The patient's G tube was in place. She was started on vanc and zosyn. She received 3L of NS. She also received 5mg IV metoprolol and 4mg morphine. Per report the ED staff spoke with the patient's family and confirmed that she was a full code. Her venous access at the time of arrival was 1 EJ line. Vital signs prior to admission were temp of 97.9 heart rate 119 SBPs in the 120s and breathing 98% on 2L NC. . On arrival in the ICU she was nonverbal consistent with her baseline and did not appear to be in no acute distress. . ROS: Unable to obtain. Past Medical History: - DM II - HTN - Hx of uterine cancer s/p hysterectomy - Afib, on Coumadin - s/p large left MCA stroke, now completely dependant of ADLs with G-tube for feeding and non-verbal at baseline - s/p PEG placed [**2196-5-1**] Social History: Haitian Creole. From [**Hospital **] rehab. Bed bound, completely dependant of all ADLs. No EtOH, no smoking, no illicits. Family History: No known family history of stroke Physical Exam: Vitals: T: 97.9 BP: 115/69 HR: 143 RR: 19 O2Sat: 95%/2L GEN: non-responsive, ill-appearing, elderly woman HEENT: Pupils slightly unequal, R>L, reactive to light NECK: unable to appreciate JVD COR: irregularly irregular, faint murmur PULM: coarse anteriorly with rhonchi bilaterally ABD: firm, mildly distended, + hypoactive BS, G tube site with surrounding brownish discharge, G tube flushes well EXT: right thigh firm and significantly larger than left, distal pulses dopplerable NEURO: unalert, unable to respond to questions, witnessed to move left sided extremities spontaneously, withdraws to pain Pertinent Results: Admission labs: [**2197-1-8**] 04:50PM BLOOD WBC-26.1*# RBC-4.15* Hgb-11.2* Hct-34.8* MCV-84 MCH-27.1 MCHC-32.3 RDW-18.4* Plt Ct-63*# [**2197-1-8**] 04:50PM BLOOD Neuts-91.6* Lymphs-5.1* Monos-2.8 Eos-0.4 Baso-0.2 [**2197-1-8**] 04:50PM BLOOD PT-34.4* PTT-37.0* INR(PT)-3.5* [**2197-1-9**] 10:26AM BLOOD PT-38.3* PTT-33.8 INR(PT)-4.0* [**2197-1-8**] 04:50PM BLOOD Glucose-180* UreaN-32* Creat-1.4* Na-144 K-3.7 Cl-107 HCO3-24 AnGap-17 [**2197-1-8**] 04:50PM BLOOD Calcium-9.2 Phos-3.6 Mg-1.7 . Other labs: [**2197-1-9**] 10:26AM BLOOD PT-38.3* PTT-33.8 INR(PT)-4.0* [**2197-1-9**] 02:56AM BLOOD Glucose-151* UreaN-32* Creat-1.6* Na-145 K-5.7* Cl-113* HCO3-17* AnGap-21* [**2197-1-9**] 10:26AM BLOOD Glucose-212* UreaN-30* Creat-1.5* Na-144 K-3.6 Cl-108 HCO3-22 AnGap-18 [**2197-1-9**] 02:56AM BLOOD Calcium-8.6 Phos-4.4 Mg-1.8 [**2197-1-9**] 10:26AM BLOOD Albumin-3.4* Calcium-8.5 Phos-7.1*# Mg-8.1* Iron-30 [**2197-1-9**] 10:26AM BLOOD calTIBC-199* Hapto-264* Ferritn-192* TRF-153* [**2197-1-8**] 05:01PM BLOOD Lactate-2.2* . . Urine: [**2197-1-8**] 06:05PM URINE Color-Amber Appear-Hazy Sp [**Last Name (un) **]-1.035 [**2197-1-8**] 06:05PM URINE Blood-LG Nitrite-NEG Protein-75 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR [**2197-1-8**] 06:05PM URINE RBC-[**2-25**]* WBC-0-2 Bacteri-MOD Yeast-NONE Epi-0-2 [**2197-1-9**] 06:09AM URINE Osmolal-417 [**2197-1-9**] 06:09AM URINE Hours-RANDOM UreaN-146 Creat-191 Na-LESS THAN K-43 Cl-LESS THAN [**2197-1-9**] 06:09AM URINE Eos-NEGATIVE [**2197-1-9**] 06:09AM URINE Color-Red Appear-Hazy Sp [**Last Name (un) **]-1.050* [**2197-1-9**] 06:09AM URINE Blood-LG Nitrite-NEG Protein-100 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM [**2197-1-9**] 06:09AM URINE RBC-487* WBC-67* Bacteri-OCC Yeast-NONE Epi-1 . . Microbiology: BC [**1-8**] x2 pending at time of writing UCx [**1-8**] negative MRSA screen [**1-9**] negative . . Radiology: XR CHEST (PA & LAT) Study Date of [**2197-1-8**] 6:48 PM UPRIGHT AP AND LATERAL VIEWS OF THE CHEST: There are low inspiratory lung volumes. The heart size remains mildly enlarged. The mediastinal and hilar contours are unchanged with tortuosity of the thoracic aorta redemonstrated. Redemonstrated within the right infrahilar region is a patchy airspace opacity which is stable, and likely represents an area of atelectasis. The left lung remains clear. There is a small right pleural effusion. No pneumothorax is seen. There are multilevel degenerative changes in the thoracic spine. IMPRESSION: Right infrahilar opacity likely reflects atelectasis. Small right pleural effusion. . CTA ABDOMEN/PELVIS W&W/O C & RECONS Study Date of [**2197-1-8**] 9:11 PM FINDINGS: ABDOMEN: 3-cm round filling defect is noted within the left atrium, compatible with thrombus. The lung bases demonstrate moderate pleural effusion on the right with associated atelectasis. The liver is unremarkable without focal lesions. There is no intrahepatic biliary dilatation. The gallbladder is unremarkable without stones or wall edema. The spleen is normal in size and appearance. The pancreas and adrenal glands are unremarkable. The kidneys enhance with and excrete contrast symmetrically. In the lower pole of the right kidney is a 2 cm in diameter hypoenhancing area, unchanged from prior, and likely represents a renal infarct. A percutaneous G-tube is seen within the stomach. There is no evidence of active extravasation within the stomach or bowel. The small and large intestine show no signs of obstruction. The peritoneum demonstrates multiple enhancing nodular implants consistent with peritoneal carcinomatosis, particularly subdiaphragmatically. Additionally, omental implants are seen, the largest of which measures 4 x 4.5 cm (4A; 91) within the right lower quadrant, unchanged. Large amount of intra-abdominal ascites is seen. There is no organized fluid collection or free air. Prominent retroperitoneal lymph nodes are seen, most prominent of which are in the left para-aortic region and measure 15 mm in the short axis (4; 239). Anasarca is noted diffusely. PELVIS: The bladder and rectum appear normal. The patient is status post hysterectomy and bilateral salpingo-oophorectomy. A single locule of gas is seen within the bladder, consistent with recent catheterization. Small amount of free fluid is seen in the pelvis, contiguous with the aforementioned intra-abdominal ascites. A right inguinal lymph node is seen measuring 14 mm in short axis (4B; 339). CTA: The aorta is of normal caliber along its course with moderate atherosclerotic calcification. The celiac artery is noted to be severely stenotic at its origin. The renal arteries, SMA and [**Female First Name (un) 899**] are patent. There is aneurysmal dilatation of the right common iliac artery measuring 28 x 25 mm (4A; 49) with mural thrombus. The right internal iliac artery also demonstrates ectasia with mural thrombus. Additionally, the left common femoral and proximal superficial femoral artery is occluded, but a nearby collateral vessel is noted (4A; 154). Portal vein, SMV, and splenic vein are patent but markedly attenuated. BONES: Mild degenerative changes are seen in the thoracolumbar spine, most prominent at L4-L5 with endplate sclerosis and anterior osteophytes. IMPRESSION: 1. G-tube place without evidence of active contrast extravasation within the stomach or bowel. 2. Moderate right-sided pleural effusion with atelectasis. 3. Left atrial thrombus. 4. Numerous peritoneal and omental implants with intra-abdominal ascites compatible with peritoneal carcinomatosis. 5. Stable right inferior pole hypoattenuating area in the kidney, likely a renal infarct. 6. Severly stenotic celiac artery at its origin. 7. 3 cm aneurysm of the right common iliac artery with mural thrombus. 8. Occluded left common femoral artery and proximal superficial femoral artery. . . Cardiology: ECG Study Date of [**2197-1-8**] 6:00:30 PM Atrial fibrillation with rapid ventricular response and occasional ventricular premature beats. Cannot rule out septal myocardial infarction. Low QRS in the precordial leads and extensive non-specific ST-T wave changes. Compared to the previous tracing of [**2196-12-27**] the rate is a little slower and the ventricular premature beats are new. Otherwise, no significant diagnostic change. Read by: [**Last Name (LF) **],[**First Name3 (LF) **] Intervals Axes Rate PR QRS QT/QTc P QRS T 129 0 70 302/422 0 -7 90 Brief Hospital Course: 82 year year-old female with metastatic uterine cancer, multiple comorbidities, nonverbal at baseline presented with concern for G tube bleeding and infection and found to be septic with likely UTI and likely DIC. She was critically ill and was deemed to have an overall very poor prognosis. She was initially actively treated as per the wishes of her relatives and latterly after further iscussion with her family, she was made CMO. As a palliative procedure, her PEG tube was removed by surgery on [**1-9**] and she was symptomatically treated with a morphine IV infusion. She died at 0315 on [**2197-1-10**]. . . # Sepsis: Patient had a very poor baseline with significant functional disability following metastatic cancer and left MCA stroke with hemorrhagic ransformation which left her completely dependent for all ADLs. She presented following bleeding from her PEG tube with concern for infection. On arrival in the ED she met SIRS criteria with leukocytosis (WBC 26.1) and tachycardia (105) with no hypotension. She had a CT-A abdomen showed no evidence of active extravasation but showed multiple peritoneal and omental implants, ascietes, a right iliac [**Last Name (LF) 86508**], [**First Name3 (LF) **] occluded left common femoral artery (with patent nearby collaterals), a stable right renal infarct and a narrowed celiac oriigin as well as a left atrial filling defect which was not present on prior CTA and was felt to be consistent with a clot. The patient's G tube was in place with no associated fluid collection or abscess along its track. She was treated with vancomycin and Piperacillin/Tazobactam and received 3L of NS. She also received IV metoprolol for rate control. She was transferred from the ED to the ICU on [**1-9**] with concern that she was peri-arrest given that after discussion with family she was felt to be full code. Likely source was felt to be possible UTI (given mildly positive UA - culture was ultimattely negative) versus cellulitis or other soft tissue infection surrounding G-tube. She was given IV fluids and antibiotics were continued. She was noted to be thrombocytopenic secondary to DIC versus HIT (had recent heparin on last admission) given falling platelets which had fallen from 354 on [**12-30**] to 63 on [**1-8**] and a low fibrinogen of 8.5 and already high INR 3.5 given concomitant warfarin therapy. Goals of care were discussed with her family and they made the decision to make her CMO on [**1-9**] and she was reviewed by palliative care. She was treated symptomatically. On teh request of her family, her PEG tube was removed by the general surgeons on [**1-9**]. She died at 0315 on [**2197-1-10**]. . # [**Last Name (un) **]: Cr was 1.6 on admission vs 0.7 baseline (as recently as 1 week prior to admission). This was felt to be likely pre-renal in the setting of sepsis, hypovolemia, or poor forward flow secondary to new onset CHF. She was made CMO and died as above. . # Anemia/G Tube Bleeding: oozing in setting of high INR and low platelets. Warfarin was held and teher was no further significant bleeding noted. PEG tube was removed by general surgery on [**1-9**] per the wishes of her family as a palliative procedure. . # Fast Atrial Fibrilation: Noted on prior admissions and patient was treated with metoprolol and diltiazem at baseline and on this admission was tachycardic to 140s in setting of having not received medications for most of the day in teh context of sepsis as above. She was initially treated with IV metoprolol and latterly made CMO on [**1-9**] and died on [**1-10**]. . # DVTs and Pelvic Thrombus: Recently subtherapeutic and now supertherapeutic on warfarin on this admission. Results were being forwarded to Dr. [**Last Name (STitle) 4149**] from palliative care since patient has not recently had a PCP. [**Name10 (NameIs) 3003**] imaging showed occluded L common femoral artery w/ patent nearby collaterals. Current exam was concerning for right leg clot. We held warfarin in setting of supratherapeutic INR and patient was made CMO as above and died on [**1-10**]. . # Right Lower Extremity Swelling: Known right iliac 3 cm aneurysm as previously imaged. Coagulopathic with multiple known clots. Anticoagulation as above. . # Uterine Cancer: s/p resection in [**2194**], now with metasteses. Goals of care previously discussed with family and initially they had wanted full code. Palliative care were involved early and reviewed. After discussion with her family she was made CMO on [**1-9**] and died on [**1-10**]. . # Goals of Care: Patient was critically ill with advanced metastatic disease and multiple comorbidities. Her overall prognosis was considered extremely poor. Palliative care has been involved in discussions with the patient's family in the past and reviewed on this admission. Per discussion with son they had been actively considering changing patient's code status but initially did not due to difficulties accepting this decision. After discussion with her family she was made CMO on [**1-9**] and died on [**1-10**]. Medications on Admission: lisinopril 20 mg daily metoprolol tartrate 100 mg [**Hospital1 **] diltiazem HCl 90 mg TID warfarin 3 mg daily magnesium hydroxide 400 mg/5 mL q8H bisacodyl 10 mg rectal daily prn constipation Tylenol Ex Str Arthritis Pain 500 mg tab 2 PO BID senna 8.8 mg/5 mL Syrup Sig: 2 teaspoons daily ipratropium bromide 0.02 % Solution Q6H morphine concentrate 20 mg/mL Solution Sig: 5-15 mg PO Q2H (every 2 hours) as needed for pain. Discharge Medications: Patient died Discharge Disposition: Expired Discharge Diagnosis: Sepsis Acute renal failure Thrombocytopenia ? cause Discharge Condition: Deceased Discharge Instructions: Deceased Followup Instructions: Deceased

[ "442.2", "584.9", "E879.8", "285.9", "995.91", "E849.8", "288.60", "536.49", "250.00", "287.5", "569.61", "427.31", "038.9", "V58.61", "V10.42", "197.6", "511.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

15703, 15712

10142, 15191

343, 376

15807, 15817

3664, 3664

15874, 15885

2989, 3025

15666, 15680

15733, 15786

15217, 15643

15841, 15851

3040, 3645

264, 305

404, 2588

3680, 4158

2610, 2831

2847, 2973

4170, 10119

13,033

144,122

43034

Discharge summary

report

Admission Date: [**2186-7-18**] Discharge Date: [**2186-7-21**] Date of Birth: [**2148-4-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 9240**] Chief Complaint: abdominal pain, n/v, "usual" symptoms Major Surgical or Invasive Procedure: None History of Present Illness: 38 man, extremely well known to Medicine, with DM1 complicated by severe gastroparesis, hypertension, [**Name6 (MD) 2091**] on RRT (o/p HD tiw) admitted 2-3 times per month with either abdominal pain crises with n/v, resulting in uncontrolled HTN, or uncontrollable HTN [**3-17**] poor medication compliance. He was admitted on [**2186-7-18**] with his usual abdominal pain with vomiting, presented to the ED, and was found to have BP in the 200-220 over 100 to 120 range mostly with high of 240/180. Plain film of abd neg for free air, Patient was treated with labetolol gtt, zofran, ativan, dilaudid without effect. He was treated with a new clonidine patch and nitro gtt with better control and admitted to the ICU. His blood pressure stabilized and nitro gtt was stopped. Past Medical History: 1. Diabetes mellitus type I 2. End-stage renal disease on hemodialysis started [**2-/2184**] TuThSa 3. Severe autonomic dysfunction with multiple hospitalizations for hypertensive emergency, gastroparesis, and orthostatic hypotension 5. History of esophageal erosion, [**Doctor First Name **]-[**Doctor Last Name **] tear 6. Coronary artery disease with 1-vessel disease (50% stenosis D1) - Fixed, small, moderate severity perfusion defect involving the LAD (diagonal) territory by MIBI on [**2186-6-7**] 7. History of foot ulcer - 2 months, healing slowly 8. History of clot in AV fistula clot on coumadin - [**Month (only) 958**]/[**Month (only) 205**] of [**2185**] s/p multiple attempts to remove clot 9. History of coagulase negative Staphylococcus bacteremia Social History: Denies alcohol or tobacco use. Endorses occassional marijuana use. Family History: His father died of ESRD and diabetes. His mother is in her 50s and has hypertension. He has two sisters, one with diabetes, and six brothers, one with diabetes. Physical Exam: VS: 97.8 110/69 87 16 HEENT: OP clear, MMM, neck supple COR: RRR no MRG PULM: CTAB ABD: soft. NT, ND, +BS EXT: No edema NEURO: Alert, oriented. Face symmetric. Moves all four extremities. Brief Hospital Course: Patient was admitted on [**2186-7-18**] with his usual abdominal pain with vomiting, presented to the ED, and was found to have BP in the 200-220 over 100 to 120 range mostly with high of 240/180. Plain film of abd neg for free air, Patient was treated with labetolol gtt, zofran, ativan, dilaudid without effect. He was treated with a new clonidine patch and nitro gtt with better control and admitted to the ICU. His blood pressure stabilized and nitro gtt was stopped. He was called out to the floor. He remained stable overnight, but was again noted to have high blood pressures in the morning prior to receiving his usual PO medications. His blood pressure normalized after receiving his medications and was relatively hypotensive. Patient eloped prior to re-check, and before we were we able to give him his scripts or discharge paperwork. He eloped with his port still accessed for hemodialysis. He was called at home at [**Telephone/Fax (1) 92670**] (no answer - left a message) and [**Telephone/Fax (1) 92671**]. Spoke to his brother [**Name (NI) **], and advised patient to return to the ED immediately to have his port de-accessed. Warned that leaving the port accessed was extremely dangerous and could serve as a nidus for severe infection requiring re-hospitalization. His brother said he would give Ms. [**Known lastname **] the message. Medications on Admission: 1. Aspirin 81 mg Tablet, 1 PO DAILY (Daily). 2. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every Monday). 4. Lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Metoclopramide 5 mg Tablet Sig: Two (2) Tablet PO QIDACHS 6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Three (3) units Subcutaneous twice a day. 8. Insulin Regular Human 100 unit/mL Solution Sig: One (1) sliding scale Injection four times a day. 9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID 10. B Complex-Vitamin C-Folic Acid 1 mg Capsule 1 PO DAILY (Daily). 11. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). 12. FOSRENOL 1,000 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day. 13. Phenergan 25 mg Suppository Sig: [**2-14**] Rectal every six (6) hours as needed for nausea. 14. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. 15. Dilaudid-5 1 mg/mL Liquid Sig: [**3-19**] ml PO every six (6) hours as needed for pain: 16. Ativan 1 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain: Can also be dissolved under your tongue. Do not take anymore when you are sleepy or breathing slowly. Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Transdermal QTUE. Disp:*8 patches* Refills:*2* 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 6. Lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day). 7. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. 11. Heparin Lock Flush (Porcine) 10 unit/mL Solution Sig: One (1) ML Intravenous DAILY (Daily) as needed. 12. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Three (3) units Subcutaneous twice a day. 13. Insulin Regular Human 100 unit/mL Cartridge Sig: ASDIR Injection ASDIR. 14. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO once a day. Disp:*60 Tablet Sustained Release(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Diabetes Mellitus Diabetic Gastroparesis Hypertension Discharge Condition: Stable Patient eloped prior to receiving discharge instructions or prescriptions. He eloped with his port still accessed. He was called at home at [**Telephone/Fax (1) 92670**] (Left a message) and [**Telephone/Fax (1) 92671**]. Spoke to his brother [**Name (NI) **], and advised patient to return to the ED immediately to have his port de-accessed. His brother said he would give Ms. [**Known lastname **] the message. Discharge Instructions: Patient eloped prior to receiving discharge instructions or prescriptions. He eloped with his port still accessed. He was called at home at [**Telephone/Fax (1) 92670**] (Left a message) and [**Telephone/Fax (1) 92671**]. Spoke to his brother [**Name (NI) **], and advised patient to return to the ED immediately to have his port de-accessed. His brother said he would give Ms. [**Known lastname **] the message. Take all medications as prescribed. They are all important! Do not stop taking your medications for any reason. If you have any questions or problems with your medications, call your physician [**Name Initial (PRE) 2227**]. If you have chest pain, shortness of breath, dizziness, palpitations, nausea, vomitting, adiarrhea, pain in abdomen please call your primary care docotor or go to the emergency room Followup Instructions: Patient eloped prior to receiving discharge instructions or prescriptions. He eloped with his port still accessed. He was called at home at [**Telephone/Fax (1) 92670**] (Left a message) and [**Telephone/Fax (1) 92671**]. Spoke to his brother [**Name (NI) **], and advised patient to return to the ED immediately to have his port de-accessed. His brother said he would give Ms. [**Known lastname **] the message. 1. Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2186-8-15**] 1:30 Please make a follow up appointment with your primary care provider Dr [**Last Name (STitle) 9006**] ([**Telephone/Fax (1) 1247**]) within 2 weeks of discharge.

[ "403.91", "V45.1", "536.3", "250.61", "414.01", "585.6" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6577, 6583

2444, 3807

353, 359

6681, 7106

7981, 8698

2054, 2216

5273, 6554

6604, 6660

3833, 5250

7130, 7958

2231, 2421

276, 315

387, 1165

1187, 1954

1970, 2038

21,447

148,466

4668

Discharge summary

report

Admission Date: [**2200-5-25**] Discharge Date: [**2200-5-27**] Date of Birth: [**2158-11-18**] Sex: F Service: [**Location (un) 259**] CHIEF COMPLAINT: Unresponsiveness and hyperkalemia. HISTORY OF THE PRESENT ILLNESS: This is a 41-year-old woman with a history of diabetes mellitus type I, end-stage renal disease on hemodialysis, who presented from [**Hospital1 1319**] unresponsive. The patient further reports increasing confusion times three days. She was found with slow breathing and decreased level of consciousness. She awoke with stimulation. She was sent to the emergency department for evaluation. In the ED, the patient had an oxygen saturation in the 70s on room air, which increased to 100% on 100% nonrebreather. She had an elevated white blood count awoke with stimulation. She was also noted to have left bundle branch block on the EKG, which was new, but which she had had occasionally in the past. She had recently been started on Cefuroxime for question of right lower extremity cellulitis, which has improved. The patient has had no fevers, chills, cough, or chest pain. PAST MEDICAL HISTORY: 1. Diabetes mellitus type 1 since the age of 23. 2. H/O recurrent DKA 3. End-stage renal disease on hemodialysis. History of peritoneal dialysis in the past. 5. Hypertension. 6. Upper GI bleed secondary to gastritis. 7. History of atrial flutter. 8. Barrett's esophagus. 9. Pelvic fracture. 10. History of right atrial thrombus. 11. History of syncope. 12. Coronary artery disease, status post MI in [**2199-3-31**], ejection fraction 61%, T+ TR, 1+ MR. 13. chronic recurrent hyperkalemia 14. Peritonitis-just finished course of ceftaz +cefazolin via PD catheter daily for 1 week. MEDICATIONS ON ADMISSION: 1. Lantus insulin 14 units. subcutaneously q.h.s. 2. Amiodarone 400 mg q.d. 3. Reglan 5 q.a.c. and q.h.s. 4. Renagel 1600 t.i.d. 5. Nortriptyline 15 q.h.s. 6. Neurontin 100 t.i.d. 7. Nephrocaps one q.d. 8. Protonix 40 b.i.d. 9. Epogen 23,000 with hemodialysis, Ativan prior to hemodialysis. 10. Coumadin 1 mg q.d. 11. Humalog sliding scale. 12. Cefuroxime 500 q.d. times seven days. 13. Calcium acetate 4 tabs t.i.d. 14. Florinef 0.2 q.d. 15. ativan 2 mg po prn ALLERGIES: The patient is allergic to ERYTHROMYCIN, WHICH CAUSES GI UPSET. ACE-I aggarvates hyperkalemia FAMILY HISTORY: History is unable to be obtained. SOCIAL HISTORY: The patient lives with her parents. There is no tobacco, occasional alcohol use. She had recently been at [**Hospital 1319**] Hospital since her most recent discharge on [**2200-5-17**]. PHYSICAL EXAMINATION: Examination on admission revealed the following: Temperature 97.7, blood pressure 101/45, pulse 82, respiratory rate 14, oxygen saturation 100% on 100% nonrebreather, 75% on room air. GENERAL: The patient is somnolent, responsive to voice, no distress. HEENT: Bilateral surgical pupils, reactive and icteric sclerae. Mucous membranes moist. NECK: No JVD, no lymphadenopathy, supple. LUNGS: Lungs revealed bilateral basilar rales. HEART: Regular rate and rhythm with a [**4-5**] holosystolic murmur at the left upper sternal border. ABDOMEN: Peritoneal dialysis catheter was clean, dry, and intact. Soft and nontender abdomen with normoactive bowel sounds. EXTREMITIES: No edema, decreased pulses bilateral lower extremities, no open wounds.several cm area of focal erythema dorsum right foot. NEUROLOGICAL: The patient is oriented times two, no date, moves all extremities, normal tone, 1+ DTRs in the bilateral lower extremities. LABORATORY DATA: Labs on admission are notable for the following: White blood count of 13.2, hematocrit 38.8, potassium 6.6, bicarbonate 19, glucose 269, BUN 59, creatinine 7.4, chloride 96, sodium 131, anion gap 16, INR 2.1. The ABG on admission was 7.22, 52 and 118. EKG: Normal sinus rhythm at 86, left axis deviation, PR prolongation, peaked T waves in V3 and V4. No change from [**2200-4-8**]. Chest x-ray: Cardiomegaly; bilateral hilar fullness, which is old; right basilar streaky atelectasis versus infiltrate. HOSPITAL COURSE: The patient was admitted to the medical Intensive Care Unit. The next day, the patient was transferred to the General Medicine Team. BY SYSTEM: INFECTIOUS DISEASE: There was a question of infection. She had an elevated white blood cell count, nothing localizing on examination. Cultures remained negative. She was switched to Ceftriaxone and Flagyl in the emergency department and Levofloxacin, Flagyl, and Vancomycin in the Intensive Care Unit. She came to the floor and the Levofloxacin and Flagyl were continued. The Vancomycin was discontinued. Cultures remained negative. She was afebrile on the date of discharge. PULMONARY: The patient presented withrespiratory depression and ABG concerning for respiratory acidosis. This was believed to be secondary to Ativan in her system. The plan was made to decrease her Ativan dosing and not offer her p.r.n. doses. Oxygen saturation remained stable throughout the hospital course. Pt has no pulmonary sxs and repeat ABG on the day prior to discahrge was normal on room air. CARDIOVASCULAR: INitially hypotensive. This was felt most likely due to hypovolemia vs sepsis. All cxs remain neg. She reportedly had peritoneal fulid sent for culture late last week whcih was neg but cell counts are not known to us. Cell count of peritoneal fluid needs to be repeated if not done to verify that peritonitis ahs resolved. pt has no sxs of peritonitis but she also had no sxs when diagnosed recently. The course was not concerning for new myocardial ischemia. She had an initial troponin and two CKs, which were negative. Because of her history of recent arrhythmia, she was started on Amiodarone during her previous hospitalization. Echocardiogram was done at an outside hospital and the plan was to repeat that here before discharge. ENDOCRINE: She presented with concern for diabetic ketoacidosis. Acetone level was initially small in the blood and later negative. Anion gap on admission was 16 and that decreased to normal on the second day of admission. Insulin drip was weaned and she was put back on her home regimen of Glargine 14 units subcutaneously q.h.s. and Humalog sliding scale. RENAL: The patient received hemodialysis per renal team. DISCHARGE PLAN: The patient is to be transferred back to [**Hospital3 4419**] on the following medications: 1. Lantus 14 mg subcutaneously q.h.s. 2. Amiodarone 400 mg p.o.q.d.Should decrase to 200 mg qd approx [**2200-6-5**] 3. Reglan 5 mg p.o.q.a.c.and q.h.s. 4. Renagel 1600 mg p.o.t.i.d. 5. Nortriptyline 15 mg p.o.q.h.s. 6. Neurontin 100 mg p.o.t.i.d. 7. Nephrocaps 1 tablet p.o.q.d. 8. Protonix 40 mg p.o.b.i.d. 9. EPO 23,000 units subcutaneously with dialysis 10. Ativan prior to hemodialysis 1.0 mg to be titrated up as needed. 11. Coumadin 1 mg p.o.q.h.s. 12. Humalog sliding scale to be given with meals. 13. Florinef 0.2 q.d. 14. Levofloxacin 250 mg p.o.q.48h.for 7 days 15. Flagyl 500 mg p.o.q.d.,for a total of seven days. 16. Ultram 50 mg p.o.q.4h. to 6h.p.r.n. The patient will continue to followup for hemodialysis and with the primary care physician- [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) 19512**] in [**Hospital3 1301**] at [**Hospital1 18**]. Needs f/u wtih Dr. [**Last Name (STitle) **] of cardiolgy at [**Hospital1 18**] in few weeks to address issue of cardiac cath. If no evidence of atrial clot on repeat echo her coumadin may be d/c'd. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3022**], M.D. [**MD Number(1) 3023**] Dictated By:[**Name8 (MD) 6069**] MEDQUIST36 D: [**2200-5-27**] 14:01 T: [**2200-5-27**] 14:12 JOB#: [**Job Number 19739**] cc:[**Hospital3 19740**]

[ "250.41", "250.11", "424.0", "276.7", "585", "583.81", "276.2", "397.0", "414.01" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

2358, 2393

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2623, 4094

174, 1127

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2410, 2600

9,253

115,671

412

Discharge summary

report

Admission Date: [**2147-9-25**] Discharge Date: [**2147-9-29**] Service: MEDICINE Allergies: Valium Attending:[**First Name3 (LF) 594**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **]M h/o HTN, osteoperosis, and chronic resp failure [**1-5**] to parkinson's disease, trached and peged d/t multiple aspiration events, recent pneumonia and SIADH, who was brought to the ED from his NH with concern for AMS. Per my discussion with his wife, over the last 10 days he has been less interactive, and today has been moaning. At baseline the patient requires extensive pulmonary toilet, and today was noted to have worsening secretions. No fevers documented in the rehab facility. Additionally, she reports that he has new abdominal distension. In the ED, initial VS were: 62, 129/55, 20, 100%. He underwent CT head and CT abdomen. CT head did not show any acute process. CT abdomen shows a likely infectious process in the right lower lobe, concerning for necrotizine pneumonia. He also had a UA with 129 WBC's, few bacteria, and large leukesterase. In the ED he was started on vancomycin, cefepime, and flagyl. He was noted to be hypotensive, but was not responsive to IVF resusitation. As a result, he was placed on norepinepherine. Prior to transfer to the floor, his SBP was in the 120s. On arrival to the MICU, the patient was unresponsive, on ventilator. Additional history or review of systems were unobtainable. Past Medical History: 1. h/o aspiration PNA - Tx with levo, unasyn, vanco/zosyn in the past 2. h/o aspiration s/p swallow eval with swallowing difficulty, s/p [**Month/Day (2) 282**] placement on [**10-10**] - pt continues to feed for pleasure at HebReb 3. Parkinson disease 4. Osteoporosis 5. T11/12 compression fx 6. LLE osteomyelelitis as a child/Chronic osteomyelitis, quiescent. 7. granulomatous liver disease 8. LUE rotator cuff tear 9. Prostate cancer s/p orchiectomy in [**2126**] 10. s/p laminectomy L4-5 11. Cataracts s/p surgery [**46**]. Glaucoma 13. Hypertension 14. h/o of treatment for pseudomonas and aspiration PNA at heb reb 15. s/p Trach with night ventilator support. 16. s/p wrist fx 17. chronic constipation 18. Chronic abd pain- per Heb Reb notes 19. Recent admission following vasovagal event at heb/reb s/p chest compressions complicated by PTX s/p chest tube 20. L ant pubic rami fracture, L ant iliac fracture Social History: The patient has a sixty-pack-year history of tobacco. He quit in [**12/2098**]. He lives at [**Hospital **] rehab MACU for last 3 hrs. He is a retired history professor. [**First Name (Titles) **] [**Last Name (Titles) **], no alcohol intake. - Tobacco: none currently - Alcohol: none currently - Illicits: none Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM General: unresponsive, trached, on ventilator HEENT: Sclera anicteric, MMM, left pupil 4mm, right pupul 2mm Neck: supple CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: diffuse wheezes and ronchi throughout the bilateral lung fields Abdomen: + BS, firm, distended, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing or cyanosis, 2+ non-pitting edema in the left arm Neuro: unresponsive Pertinent Results: ADMISSION LABS [**2147-9-25**] 04:50PM BLOOD WBC-26.1* RBC-3.23* Hgb-9.6* Hct-30.6* MCV-95 MCH-29.8 MCHC-31.5 RDW-15.5 Plt Ct-360 [**2147-9-25**] 04:50PM BLOOD Neuts-82* Bands-4 Lymphs-5* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-4* [**2147-9-25**] 04:50PM BLOOD Hypochr-1+ Anisocy-OCCASIONAL Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-NORMAL Polychr-1+ Stipple-1+ [**2147-9-25**] 04:50PM BLOOD Plt Ct-360 [**2147-9-26**] 01:45AM BLOOD PT-11.8 PTT-31.6 INR(PT)-1.1 [**2147-9-25**] 04:50PM BLOOD Glucose-157* UreaN-77* Creat-1.5* Na-115* K-5.0 Cl-73* HCO3-33* AnGap-14 [**2147-9-25**] 04:50PM BLOOD cTropnT-0.09* [**2147-9-26**] 01:45AM BLOOD Calcium-7.2* Phos-5.1*# Mg-2.6 [**2147-9-25**] 04:50PM BLOOD Osmolal-274* [**2147-9-25**] 05:18PM BLOOD Type-ART pO2-232* pCO2-90* pH-7.18* calTCO2-35* Base XS-2 [**2147-9-26**] 12:31AM BLOOD freeCa-1.01* [**2147-9-26**] 01:45AM BLOOD Glucose-164* UreaN-74* Creat-1.5* Na-117* K-4.6 Cl-83* HCO3-29 AnGap-10 [**2147-9-26**] 02:42PM BLOOD Na-118* K-4.6 Cl-86* [**2147-9-27**] 02:15AM BLOOD Glucose-102* UreaN-77* Creat-1.9* Na-116* K-5.0 Cl-87* HCO3-17* AnGap-17 [**2147-9-27**] 08:44AM BLOOD Na-122* K-4.8 Cl-87* [**2147-9-27**] 09:00PM BLOOD Na-119* K-5.1 Cl-86* [**2147-9-28**] 03:55AM BLOOD Glucose-104* UreaN-84* Creat-2.4* Na-119* K-5.1 Cl-86* HCO3-21* AnGap-17 [**2147-9-28**] 04:06PM BLOOD Glucose-125* UreaN-84* Creat-2.6* Na-121* K-5.2* Cl-89* HCO3-20* AnGap-17 [**2147-9-29**] 03:03AM BLOOD Glucose-148* UreaN-98* Creat-2.9* Na-121* K-5.6* Cl-88* HCO3-20* AnGap-19 [**2147-9-25**] 05:21PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.015 [**2147-9-25**] 05:21PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG [**2147-9-25**] 05:21PM URINE RBC-68* WBC-129* Bacteri-FEW Yeast-NONE Epi-0 [**2147-9-25**] 06:14PM URINE Hours-RANDOM UreaN-416 Creat-66 Na-11 K-29 Cl-LESS THAN [**2147-9-27**] 06:40AM URINE Hours-RANDOM UreaN-450 Creat-42 Na-<10 K-22 Cl-<10 [**2147-9-28**] 11:48AM URINE Hours-RANDOM UreaN-245 Creat-37 Na-26 K-34 Cl-53 [**2147-9-27**] 06:40AM URINE Osmolal-318 [**2147-9-28**] 11:48AM URINE Osmolal-290 MICRO: [**2147-9-25**] 6:09 pm SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. **FINAL REPORT [**2147-9-27**]** GRAM STAIN (Final [**2147-9-25**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [**2147-9-27**]): SPARSE GROWTH Commensal Respiratory Flora. ESCHERICHIA COLI. SPARSE 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 _________________________________________________________ ESCHERICHIA COLI | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- =>16 R [**2147-9-25**] Blood cultures: No growth [**2147-9-25**] NCHCT; IMPRESSION: No acute intracranial process. Mastoid air cell and paranasal sinus opacification is likely related to tracheostomy. [**2147-9-25**] CT abd/pelvis: IMPRESSION: 1. Right lower lobe opacification with areas of non-enhancing pulmonary parenchyma concerning for necrotizing pneumonia. Bilateral moderate pleural effusions. 2. Evidence of right heart failure with congested liver, periportal edema, trace ascites, and gallbladder edema (no evidence to suggest cholecystitis). 3. Age-indeterminate T12 compression fracture [**2147-9-27**] CXR: CONCLUSION: New right PICC in standard position, terminating in the low SVC. Improved aeration of both upper lungs and improvement in previously seen right mid lung opacity. Otherwise, unchanged since the prior study. Brief Hospital Course: [**Age over 90 **] yo M h/o parkinson's disease, chronic respiratory failure (s/p trach, ventilator dependent) admitted to the ICU with acute encephalopathy, UTI and pneumonia. # Oliguria / acute renal failure: The patient experienced progressive renal failure and oliguria throughout his ICU course. Despite large volume IVF resuscitation and urine electrolytes showing a pre-renal picture, the patient's creatinine continued to worsen. His urine output remained low despite high doses of furosemide, and he wa equally unresponsive to a furosemide drip. His potassium continued to worsen in light of this as well. A family meeting was held on HD#4 with the patient's wife, [**Name (NI) **], to discuss the patient's poor overall clinical status as well as his progressive, likely irrevocable, renal failure and the decision was made to pursue comfort care options at that time in concert with his wife's understanding of his wishes given the clinical circumstances. The patient became progressively bradycardic during HD #3, and by 19:35 he progressed to asystole on telemetry monitoring. The patient's pupils were fixed and dilated, and he was noted to be without spontaneous respirations. All cranial and brainstem reflexes were non-reactive and the patient was pronounced dead and his wife was notified. # Respiratory acidosis: On admission the patient appeared to be retaining carbon dioxide in the setting of increased secretions and penumonia seen on CT. His exam was diffusely wheezy and ronchorus. His ventilator settings were optimized by increasing TV and PEEP in an effort to assist him with clearing his acidemia. RT was unable to titrate up RR based on auto-peep and further retention. Repeat ABG's are showed worsening of his acid-base status on HD#1, despite these interventions. Due to his extensive wheezing on examination, he was started on albuterol and ipratropium MDIs through the ventilator to aid with bronchidilation, as well as methylprednisolone to help reduce airway inflammation. His respiratory exam improved throughout his ICU course on this regimen, and his ventilator settings were weaned back to his baseline. # Hypotension: Initially in the ED he was responsive to IVF, but subsequently required the initiation of norepinephrine. Initially on transfer to the ICU he had SBP??????s in the 110-130 range. Norepinephrine was titrated to maintain MAPs > 60, and the patient recieved IVF boluses for BP support as well. # Pneumonia: CT abdomen on admission showed possible necrotizing pneumonia in the right lung bases, likely consistent with aspiration-associated pneumonia, given the presents of debris in the left bronchi. The patient was started initially on vancomycin, cefepime and flagyl for broad spectrum empiric coverage, which was titrated down to ceftriaxone in the setting of his sputum culture results. # Bacteriuria: UA concerning for UTI, with the culture pending. The patient is unable to communicate any symptoms of UTI. He was maintained on the antibiotic regimen stated above, and final urine cultures were negative. # Acute encephalopathy: Multifactorial etiology, with contributions from CO2 retention, hyponatremia, and infection. These various medical issues were managed as mentioned previously. # Hyponatremia: Likely from hypovolemic hyponatremia; although he appears volume up on exam, his circulating volume was likely low. In this setting, it was felt he would likely benefit from additional NS IVF. Just with IVF given in the ED his serum sodium began to slowly correct, although he subsequently deteriorated while in the ICU. Salt tabs were used in conjunction with volume resuscitation, however his hyponatremia did not improve on this regimen. After goals of care were discussed with the family, the patient was made CMO as mentioned previously. # Glaucoma: The patient was continued on his home regimen of Latanoprost, Artificial Tears # Parkinson's Disease: The patient was continued on his home regimen of sinemet, entacapone, mirapex Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Comtan *NF* (entacapone) 200 mg GT 7x/day 0500, 0800, 1100, 1400, 1700, [**2134**], 2300 2. Mirapex *NF* (pramipexole) 0.5 mg GT QHS 3. Artificial Tears Preserv. Free 2 DROP BOTH EYES QID 4. Acetylcysteine 20% Dose is Unknown NEB [**Hospital1 **] 5. Calmoseptine *NF* (menthol-zinc oxide) 0.44-20.625 % Topical [**Hospital1 **] 6. Albuterol-Ipratropium 2 PUFF IH Q6H 7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 8. Mirapex *NF* (pramipexole) 0.125 mg Oral QID @ 0500, 0800, 1100, 1400 9. Ferrous Sulfate 325 mg PO DAILY 10. Miconazole 2% Cream 1 Appl TP [**Hospital1 **] 11. Levothyroxine Sodium 50 mcg PO DAILY 12. Acetaminophen (Liquid) 650 mg PO Q4H:PRN pain 13. Racepinephrine 0.5 mL IH Q2H:PRN hemoptysis 14. Tobramycin-Dexamethasone Ophth Oint 1 Appl BOTH EYES QHS 15. Acetaminophen (Liquid) 650 mg PO Frequency is Unknown 16. Carbidopa-Levodopa (25-100) 1 TAB PO TID @0500, 0800, 1100 17. Carbidopa-Levodopa (25-100) 1 TAB PO QID @1400, 1700, [**2134**], 2300 18. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL TID swab 19. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES [**Hospital1 **] 20. Simethicone 80 mg PO TID:PRN distension, gas 21. Omeprazole 20 mg PO DAILY 22. Vitamin D 1000 UNIT PO DAILY 23. Lorazepam 0.5 mg PO Q6H:PRN anxiety 24. OxycoDONE Liquid 5 mg PO Q3H:PRN severe pain 25. Sorbitol 15 mL GT [**Hospital1 **] 26. Tobramycin-Dexamethasone Ophth Oint 1 Appl BOTH EYES QID 27. Sodium Chloride 1 gm PO BID Discharge Medications: Patient expired Discharge Disposition: Expired Discharge Diagnosis: Renal failure Respiratory failure Discharge Condition: Expired

[ "491.21", "338.29", "276.52", "V46.11", "V15.82", "V44.1", "038.9", "787.91", "276.7", "733.00", "997.31", "V49.86", "995.92", "276.69", "785.52", "V70.7", "787.3", "E879.8", "276.2", "791.9", "518.84", "V10.46", "584.9", "789.00", "V44.0", "332.0", "253.6", "365.9", "401.9", "349.82", "564.00" ]

icd9cm

[ [ [] ] ]

[ "38.97", "38.93", "96.6", "96.71" ]

icd9pcs

[ [ [] ] ]

13223, 13232

7587, 11601

235, 241

13309, 13319

3315, 7564

2808, 2826

13183, 13200

13253, 13288

11627, 13160

2841, 3296

174, 197

269, 1520

1542, 2460

2476, 2792

1,199

151,187

9123

Discharge summary

report

Admission Date: [**2180-11-23**] Discharge Date: [**2180-11-28**] Date of Birth: [**2139-7-1**] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamides) / Tetracycline Attending:[**First Name3 (LF) 465**] Chief Complaint: Abdominal pain, N/V Major Surgical or Invasive Procedure: EGD History of Present Illness: Ms. [**Known lastname **] is a 41 year-old female with a history of abdominal pain, status post ERCP on [**11-21**] with biliary sphincterotomy for biliary sludge noted on a prior EUS, now presenting with abdominal pain and N/V since this morning. * She initially did well following the procedure, and returned home. She describes only residual abdominal doscomfort initially. This morning, she woke up with worsening abdominal discomfort, epigastric in location, not radiating to the back. She notes that lying down makes it better, and sitting up makes it worse. She then had 1 episode of N/V, with coffee-grounds hematemesis. She also reports one episode of melena. No chest pain, shortness of breath or palpitations. No fever or chills at home. She now endorses dizziness with standing. * In ED, Tm 100.3, BP 96/68, HR 115, RR 16, Sat 100% on RA. Hct down to 30 from 35, then down to 22 after 3L on NS. CXR negative for pneumoperitoneum. CT abdomen performed, report pending. She was seen by the ERCP fellow, with impression of likely bleed from the sphincterotomy site, and will need repeat scope in the morning. Transfusion initiated. Past Medical History: 1. Abdominal pain, status post EGD [**10-20**], s/p ERCP on [**11-21**] as above for biliary sludge noted on prior EUS. 2. Status post TAH-BSO in [**2177**] complicated by excessive bleeding. 3. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] deficiency, was told in setting of TAH, (likley quantitative) Social History: Married, 2children, unemployed, previous remote tob (<3pyrs), occ ETOH 3drinks/week, no IVDA. Family History: Father died from CAD, no bleeding disorders or GI malignancies in family. Physical Exam: Tm 100.3, Tc 100.1, 103/42, 62, 17, 98% RA GEN:Pale, A&O x3, NAD HEENT:anicteric, OP clear, MMM, PERRL NECK: no JVD, supple CV: reg tachycardia, no MRG PULM: CTAB ABD: soft, mild diff tenderness, no HSM, distenstion, or guarding. NABS EXT: no CCE, no CVAT. Rectal: guaiac positive black stool in ED. Access: 2Lge peripherals Pertinent Results: Admission labs [**2180-11-23**] 05:10PM BLOOD WBC-9.5# RBC-3.82* Hgb-11.3* Hct-30.4* MCV-80* MCH-29.6 MCHC-37.2* RDW-12.2 Plt Ct-264 PT-13.2 PTT-23.6 INR(PT)-1.2 Glucose-167* UreaN-32* Creat-0.9 Na-141 K-4.5 Cl-101 HCO3-26 AnGap-19 ALT-12 AST-17 AlkPhos-43 Amylase-114* TotBili-0.5 Lipase-30 Albumin-4.3 Calcium-9.6 Phos-2.8 Mg-1.5* . After bleeding [**2180-11-23**] 08:26PM BLOOD Hct-22.8* . Discharge labs [**2180-11-28**] 04:21AM BLOOD WBC-6.2 RBC-3.50* Hgb-10.4* Hct-29.5* MCV-84 MCH-29.7 MCHC-35.2* RDW-13.5 Plt Ct-153 [**2180-11-28**] 04:21AM BLOOD Glucose-111* UreaN-12 Creat-0.8 Na-143 K-4.2 Cl-108 HCO3-27 Calcium-9.0 Phos-4.3 Mg-1.8 [**2180-11-28**] 04:45PM BLOOD Hct-32.8* . EGD [**2180-11-24**] 1. Bile was seen in the stomach and was suctioned. 2. The major papilla was seen in a diverticulum. 3. No bleeding was seen from the sphincterotomy site. . CT Abd/Pelvis [**2180-11-23**] Status post ERCP with pneumobilia. No evidence for extraluminal air within the peritoneum or retroperitoneum. Small line of air along the lesser curvature of the stomach which may be along the wall or within the wall, not uncommon after ERCP. Brief Hospital Course: Ms. [**Known lastname **] was admitted on [**2180-11-23**] for an upper GI bleed in the setting of an ERCP done 2 days prior to presentation. Given her hematemesis, melena with a Hct of 21, s/p recent ERCP with sphincterotomy, this was a bleed most likely from the sphincterotomy site. She was given a total of 3 units of PRBCs on admission, with an appropriate response in her Hct to 27-28. She was started on IV Protonix [**Hospital1 **]. She had an EGD on [**2180-11-24**] which did not show any active bleeding, as the bleed most likely tamponed itself. She did require any more units of PRBCs during her course, as her Hct remained stable, which was checked every 6-8 hours. Her coags, platelets were normal. Given her questionable history of vWF deficiency, she was given a dose of dDAVP prior to the EGD. She was also given Dilaudid prn abdominal pain. While the patient was in-house, she developed sinus tachycardia upon any movements with HR into the 140's-160's. The tachycardia was accompanied by symptoms of lightheadedness and palpitations, and resolved once the patient was back in bed and resting. EKG's and telemetry strips just showed sinus tachycardia w/o evidence of any cardiac arrhythmias. Orthostatics done also showed a 10-15 mm Hg drop in systolic BP upon standing and movement. Her symptoms and findings were most likely [**1-26**] hypovolemia as she had not eaten for days and had started to autodiurese all the fluid and blood products she received on admission. She was aggressively fluid-resuscitated with IVF and encouragement of po intake, with resolution of her tachycardia episodes. She will follow-up with Dr. [**Last Name (STitle) 31431**] from ERCP after discharge and her PCP [**Last Name (NamePattern4) **] [**2-25**] days, and was discharged on Protonix, Maalox, and Oxycodone prn pain. Medications on Admission: Creon (stopped [**2180-11-20**]), Protonix started [**11-23**] Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 5. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. Discharge Disposition: Home Discharge Diagnosis: Upper GIB Discharge Condition: Hct stable, BP and HR stable. Discharge Instructions: If you experience any lightheadedness, hematemesis, bloody stools, dark tarry stools, passing out, abdominal pain, nasuea, vomiting, heart palpitations please seek medical attention immediately. Please follow up with your PCP in the in the next 3-4 days. Followup Instructions: Follow up with your PCP [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]

[ "998.11", "286.4", "E878.8", "285.1" ]

icd9cm

[ [ [] ] ]

[ "99.04", "45.13" ]

icd9pcs

[ [ [] ] ]

6099, 6105

3582, 5410

330, 336

6159, 6191

2417, 3559

6495, 6643

1981, 2056

5523, 6076

6126, 6138

5436, 5500

6215, 6472

2071, 2398

271, 292

364, 1507

1529, 1854

1870, 1965

3,588

189,487

13404

Discharge summary

report

Admission Date: [**2151-7-4**] Discharge Date: [**2151-7-21**] Service: Medical Intensive Care Unit HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] was an 84-year-old gentleman involved in an auto vs pedestrian accident on [**2151-4-25**]. He was sent to [**Hospital **] Rehabilitation facility where he experienced sudden onset of hypoxia. He was brought into [**Hospital1 69**] Emergency Room where he was noted to have oxygen saturations in the 70's and hypotension. HOSPITAL COURSE: He was admitted to the medical Intensive Care Unit following intubation. He subsequently developed dependence on the ventilator for oxygenation and respiration. He also developed hypotension requiring multiple pressors. In addition, Mr. [**Known lastname **] suffered from renal failure during his hospitalization that was attributed to his hypotension following several weeks of ventilation, cardiovascular support and transfusions for decreased hematocrit. Mr. [**Known lastname **] showed no signs of improvement in either his respiratory or cardiovascular status. A family meeting was held and decision was made by the family to withdraw all support excluding the mechanical ventilator. Two days later, Mr. [**Known lastname **] [**Last Name (Titles) **] from hypoperfusion to his organs with blood pressure 20/palp. Because Mr. [**Known lastname 40686**] initial injury related to the motor vehicle accident, the medical examiner accepted him for post mortem examination. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**] Dictated By:[**Last Name (NamePattern1) 17270**] MEDQUIST36 D: [**2151-7-26**] 15:15 T: [**2151-8-2**] 22:30 JOB#: [**Job Number 40687**]

[ "572.4", "571.5", "518.81", "789.5", "038.9", "785.59", "599.0", "276.2", "584.9" ]

icd9cm

[ [ [] ] ]

[ "34.91", "96.72", "96.6", "54.91", "89.64", "38.93", "89.68" ]

icd9pcs

[ [ [] ] ]

508, 1733

139, 490

71,286

157,761

6809

Discharge summary

report

Admission Date: [**2118-2-17**] Discharge Date: [**2118-2-28**] Date of Birth: [**2052-4-2**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor First Name 1402**] Chief Complaint: s/p VFib arrest, for pacemaker placement Major Surgical or Invasive Procedure: Defibrillator/Pacemaker placement History of Present Illness: 65 yo F w/ h/o dilated, non-ischemic cardiomyopathy, transferred from [**Hospital6 17183**] s/p VF arrest [**2-8**] thought [**1-4**] aspiration in setting of an EF of 20-25% and mod-severe MR [**First Name (Titles) **] [**Last Name (Titles) 25783**]D placement. Review of OSH reveals pt was at ENT office for management otitis externa, suffered witnessed arrest, CPR initiated with EMS giving 3 shocks, epi, atropine, and lido gtt followed by amiodarone gtt. Admitted to OSH ICU, intubated, treated for pulmonary edema and aspiration PNA w/zosyn (course completed). Echo showed EF 20%, no AICD. Neurology was consulted for hypoxic brain injury and she required NG tube placement for feeds [**1-4**] mental status but was able to tolerate honey thickend liquids/pureed diet at time of transfer. Pt was transfered to [**Hospital1 18**] for [**Hospital1 **]-V pacemaker/ICD placement. . On admission to the [**Hospital1 18**] cardiology floor, the patient was unable to recall the details of the events leading to her hospital course. She was continued on metoprolol, lasix 40mg p.o to prevent volume overload in setting of low EF and dilated cardiomyopathy. Her outpatient cardiologist and PCP were [**Name (NI) 653**] to attempt to obtain her most recent catheterization records, but none were able to be located. She received a cardiac MR [**First Name (Titles) **] [**Last Name (Titles) **] for scar, which showed effective LVEF of 28%. Echo showed LVEF severely depressed (LVEF= 25 %). . Of note, she had been receiving oral ciprofloxacin for management of otitis externa, which were started prior to [**2-8**] although exact date unclear. She was switched to topical cipro on admission to [**Hospital1 18**] as was having continued drainage. There is some concern for QTc prolongation in the setting of prolonged use of ciprofloxacin. In order to determine whether patient suffered drug induced torsades de pointes which deteriorated into VF, she was transferred to the CCU for ciprofloxacin challenge. . The patient was given Ciprofloxacin in the CCU with a prolongation of her QT but without reucrrence of VF. QT prolongation resolved by the following morning. She underwent electrical mapping in the EP lab on [**2-24**], where they were unable to induce VT, and was transferred back to the floor to await her ICD placement on [**2-25**]. . On arrival to the floor, the patient denied chest pain, shortness of breath, or any other complaints. . REVIEW OF SYSTEMS: The patient reports significant left ear and left facial pain for the last several days associated with drainage and worse with movement of the external ear. Denies fevers/chills. Pt also reports becoming "thinner" and losing weight in the past several months but cannot quantify the amount of weight loss. She denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: - s/u cardiac catheterization in [**Location (un) 701**] - Dilated, non-ischemic cardiomyopathy - per pt etiology unknown, EF 20% - Dyslipidemia Social History: -Tobacco history: remote tobacco x6yrs, quit many years ago -ETOH: occasional -Illicit drugs: denies Lives at home with her husband. [**Name (NI) 1403**] as a certified nurse assistant. Family History: Mother with cardiomyopathy, ? MI, deceased but age not known. Denies cardiac h/o in father. Further details unknown. Physical Exam: Admission VS: T= 98 BP=123/46 HR=88 RR=16 O2 sat= 98% on RA VS on transfer from CCU: T98.7 BP 126/60 P85 R18 PO2 98%RA GENERAL: WDWN female in NAD. Alert, A&Ox2. HEENT: right temple hematoma. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 5 cm. CARDIAC: PMI displaced inferiolaterally. RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ On discharge: VS: 97.9/97.9, 101/50 (94-123/50-59), 59 (59-69), 100%RA GENERAL: WDWN female in NAD. AAOx3. HEENT: PERRL, EOMI, MMM, neck supple, JVP of ~5 cm. CARDIAC: PMI displaced inferiolaterally. RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: At the OSH Labs on [**2-16**] significant for: WBC 18.3 (down trending from 35.6 on [**2-9**]) HCT 35.4 (stable) PLTs 369 PTT 45.5/INR 1.09/PT 13.5 144 103 41 ------------<149 3.4 31 0.8 Ca 9.4 Phos 3.4 TP 7.8 Alb 3.2 Tbili 0.3 AST 48 ALT 109 AP 116 Trop I 0.98 CK 1164 (peak on [**2-8**]) . Admission Labs: [**2118-2-17**] . 141 100 35 ------------ 99 3.8 33 0.7 . CK: 25 MB: Notdone Trop-T: <0.01 . Ca: 9.8 Mg: 2.5 P: 3.7 Dig: 0.8 . ......11.6 14.7 ------ 578 ......34.4 . PT: 13.2 PTT: 40.8 INR: 1.1 . CXR ([**2118-2-17**]): Negative for acute cardiopulmonary process . TTE ([**2118-2-18**]): The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular ejection fraction is severely depressed (LVEF= 25 %). The left ventricle appears to contract dyssynchronously. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. 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. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. . Cardiac MRI ([**2118-2-18**]): 1. Mildly increased left ventricular cavity size with abnormal left ventricular function. Severe hypokinesis in the basal to mid interventricular septum with paradoxical motion and mild hypokinesis in the remaining LV segments. The LVEF was moderately decreased at 32%. The effective forward LVEF was severely decreased at 28%. Resting myocardial perfusion images suggestive of delayed perfusion in the inferior and inferoseptal walls. There was a questionable focal area of hyper-enhancement in the basal lateral wall consistent with myocardial fibrosis. 2. Normal right ventricular cavity size and systolic function. The RVEF was normal at 59%. 3. Moderate mitral regurgitation and moderate tricuspid regurgitation. 4. The indexed diameters of the ascending and descending thoracic aorta were normal. The main pulmonary artery diameter index was normal. 5. Aortic atheroma. . Cardiac Catheterization ([**2118-2-24**]): COMMENTS: 1. Coronary angiography in this left dominant system revealed no angiographically apparent flow limiting stenoses. The LMCA, LAD, LCx, and RCA were patent. 2. No resting hemodynamics reported as case performed concurrently with Electrophysiology study. . FINAL DIAGNOSIS: 1. No angiographically apparent flow limiting CAD. . . CXR ([**2118-2-26**]): ICD in place. Brief Hospital Course: 65 yo F w/ dilated cardiomyopathy, EF 20% s/p Vfib arrest, pulmonary edema, aspiration PNA, being transferred from OSH for ICD placement. . # CORONARIES: No known history of CAD, no records of ETT, cath, ECHO. Cardiac MR did not show significant scar to account for patient's VF arrest. Cardiac catheterization [**2-24**] did not show any apparent flow limiting lesions. The patient was transferred on ACS medications, but these were discontinued prior to discharge given there was no evidence of ischemia precipitating her VF arrest. She was continued on aspirin 81 mg daily for primary prevention. . # PUMP: Pt with h/o non-ischemic cardiomyopathy, found to have EF 20% at OSH, no clinical evidence of decompenstated heart failure. TTE showed normal valvular function, EF 25%. The patient was started on Lasix at the OSH prior to transfer, presumaband was continued on a daily po dose of Lasix during her hospital stay. She became hyponatremic, however, and the patient was encouraged to increase her po water intake. She had transient hyponatremia that resolved with normal PO intake. She was discharged on Toprol XL 100mg daily, ACEinhibitor, Digoxin, and Lasix 40mg daily. . # RHYTHM: VFib arrest [**2-8**], unclear precipitant but possibly [**1-4**] aspiration in the setting of dilated cardiomyopathy with low EF. Cardiac MR showed no significant scar as cause of VF, and cardiac catheterization showed no flow limiting disease. There was also a question of whether ciprofloxacin had precipitated VT by prolonging the patient's QT interval. The patient was transferred to the CCU to receive a trial of ciprofloxacin and assess the effects on her QTc. The patient was given ciprofloxacin 500 mg PO on [**2118-2-23**]. Her QTc was 418 pre-cipro and 447 4-hours post-cipro. She was not given any additional doses of cipro (which she had taken for 24 hours prior to her event) and her QTc resolved the following morning. The patient was taken to the EP lab on [**2118-2-24**], where she was not found to have any inducible VT. The decision was made to place an ICD on [**2118-2-25**]. The patient underwent ICD/pacemaker placement without complications and was discharged on Toprol XL 100mg daily. . # Left Ear Pain: Patient was seeing ENT on day of VF arrest for left ear pain since before [**2-8**]. Appears to be otitis externa, presented with antibiotic ear drops. Patient with continued yellow drainage and worsening pain. ENT was consulted and suspects otitis externa vs. otitis media with perforated tympanic membrane, and suggested increasing dose of Cipro/Dexamethasone ear drops and initiating po Bactrim. Patient's ear pain and drainage improved, she completed a seven day course of Bactrim. Pain was controlled with Tylenol & Tramadol prn. Beta-2-transferrin was sent to r/o CSF leak, though it was thought low likelihood and was still pending on discharge. Patient will be discharged on ciprodex ear drops through [**3-22**] and will follow up with ENT as an outpatient. . # Aspiration PNA: Patient was found to have aspiration PNA at OSH and completed a full course of Zosyn on [**2-16**] at OSH. No evidence of active infection in-house following transfer given negative CXR, afebrile. Speech and swallow was consulted and performed video swallow study, cleared the patient without caution to advance slowly. . # Anoxic Brain Injury - evaluated by OSH neurology, no notes in transfer paperwork. Initially alert, oriented x 1.5. However, mental status improved during the hospitalization and pt is now A&Ox3 with impaired memory and recall. . # Elevated LFTs - This was thought most likely [**1-4**] shocked liver in the setting of VF arrest. They steadily trended down and resolved during hospital stay. . . CODE: full COMMUNICATION: Daughter, [**First Name4 (NamePattern1) 1439**] [**Known lastname 25784**] (cell) [**Telephone/Fax (1) 25785**] Medications on Admission: (Pt reports she has not been compliant with medications) At home: Simvastatin 20mg po daily Carvedilol 12.5mg [**Hospital1 **] Digoxin 0.25mg daily Enalapril 10mg po BID Motrin 800mg tid Prempro 0.625-2.5mg po daily x90 days Tramadol 50mg po tid prn pain . On transfer from OSH: Acetaminophen 650 mg PO/NG Q6H:PRN Aspirin 325 mg PO/NG DAILY CIPRODEX *NF* 0.3-0.1 % AS 5x day otitis externa Digoxin 0.25 mg PO/NG DAILY Docusate Sodium (Liquid) 100 mg PO/NG DAILY Enalapril Maleate 10 mg PO/NG [**Hospital1 **] Furosemide 40 mg IV BID Heparin IV per Weight-Based Dosing Metoprolol Tartrate 5 mg IV Q4H Milk of Magnesia 30 mL PO/NG Q6H:PRN Ondansetron 4 mg IV Q8H:PRN nausea Oxazepam 10 mg PO HS:PRN insomnia Pantoprazole 40 mg IV Q12H Amiodarone prn lorazepam 1-2mg prn agitation Mg/[**Doctor Last Name **]/Simthicone Q4H prn Morphine 2mg IV prn Chest pain Nitro prn chest pain Discharge Medications: 1. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 2. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Prempro 0.625-2.5 mg Tablet Sig: One (1) Tablet PO once a day for 90 days: as directed for 90 days total. 5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. 6. Ciprofloxacin 0.3 % Drops Sig: Five (5) Drop Ophthalmic TID (3 times a day) as needed for otitis externa : continue until [**3-22**] and appointment with ENT. Disp:*qs small bottle* Refills:*0* 7. Dexamethasone 0.1 % Drops, Suspension Sig: Five (5) Drop Ophthalmic TID (3 times a day) as needed for otitis externa : continue until [**3-22**] and appointment with ENT. Disp:*qs small bottle* Refills:*0* 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 10. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital 5503**] Rehab Hospital Discharge Diagnosis: Ventricular Tachycardia, Ventricular Fibrillation Dilated Cardiomyopathy (non-ischemic) 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 presented to an outside hospital after having an arrhythmia and cardiac arrest. You were successfully recussitated with CPR and shocks to your heart. It is believed that the Ciprofloxacin you took may have caused you to enter into an irregular heart rhythm, precipitating this event. While at the other hospital, you were also treated for pneumonia with antibiotics. You were transferred to [**Hospital3 **] for placement of a defibrillator/pacemaker to prevent your heart from entering into an irregular rhythm in the future. You tolerated this procedure well without complications. While in the hospital, an ear, nose, and throat specialist saw you for your ear pain and yellow drainage. Your ear drop dose was changed, and you were started on an oral antibiotic with improvement of your pain and drainage. Your medications have change, please make note of the changes as listed below: - new medication: Ciprofloxacin 0.3 % Drops, 5 drops to your ear three times a day - new medication: Dexamethasone 0.1 % Drops, 5 drops to your ear three times a day - new medication: Aspirin 81 mg Tablet, 1 tablet daily - new medication: Furosemide 40 mg, 1 tablet daily - STOP taking Carvedilol - start taking Toprol XL 100mg daily Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: You have the following appointments scheduled: Primary Care Physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 25786**] [**2118-3-4**] 11:15am Dr. [**Last Name (STitle) 3878**] (Ear, Nose, Throat) [**2118-3-24**] at 8:15AM [**Apartment Address(1) 17722**], [**Location (un) 55**], [**Numeric Identifier 25787**] ([**Telephone/Fax (1) 7767**] Provider: [**Name Initial (NameIs) 2963**] (ST-4) GI ROOMS Date/Time:[**2118-2-22**] 12:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2118-2-22**] 12:30

[ "427.41", "425.4", "794.31", "E930.8", "303.93", "348.1", "428.0", "382.4", "424.0", "570", "276.1" ]

icd9cm

[ [ [] ] ]

[ "00.51", "37.22", "37.26", "99.10", "88.56" ]

icd9pcs

[ [ [] ] ]

14467, 14528

8539, 12429

356, 392

14660, 14660

5799, 6091

16190, 16836

4105, 4223

13355, 14444

14549, 14639

12455, 13332

8423, 8516

14840, 16167

4238, 5106

5120, 5780

2898, 3716

276, 318

420, 2879

6107, 8406

14675, 14816

3738, 3884

3900, 4089

27,069

121,301

29201

Discharge summary

report

Admission Date: [**2187-12-1**] Discharge Date: [**2187-12-6**] Date of Birth: [**2122-12-23**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Latex Attending:[**First Name3 (LF) 3326**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Intubation Paracentesis and removal of 3L of fluid History of Present Illness: Mrs. [**Known lastname 70235**] is a 64 yo woman with metastatic uterine cancer, obesity, hypertension and hyperlipidemia who presented to the emergency department with dyspnea. . She was seen by her gynecologist-oncologist 2 days prior to admission, at which time she discussed with him recent CT findings of a large new abdominal mass. At that visit, she was complaining of worsening shortness of breath. Per report, she has had about a month of increasing abdominal girth and increasing peripheral edema. . In the emergency department, her initial VSs were 97.7, 114, 104/40, 24, 98% RA. She received 4L NS without much change in her blood pressure (lowest 88/58). She was intubated semi-electively for central line placement. She was then started on norepinephrine for mild hypotension. She also received levofloxacin for presumed pneumonia prior to her chest CTA. . ROS was unobtainable as the pt was sedated and intuabted. She denied pain in general and chest and abdominal pain in particular. Past Medical History: Uterine carcinosarcoma - Stage IC, Grade 3 Hypertension Hyperlipidemia Degenerative joint disease Asthma Melanoma (9 years ago) Excision of melanoma of the lower extremity C-section x1 TAH-BSO Wound revision, complicated by MRSA infection Knee surgery Social History: Per OMR, the pt does not smoke or drink. Family History: mother with cervical cancer. Physical Exam: Vitals: T: 98.6 BP: 105/69 P: 99 R: 36 SaO2: 100% General: sedated, intubated, responds to verbal stimuli, responds appropriately to questions HEENT: PERRL, no scleral icterus, MM dry Pulmonary: Lungs CTA bilaterally anteriorly, no wheezes, ronchi or rales Cardiac: borderline tachy, distant S1 S2, no murmurs, rubs or gallops appreciated Abdomen: soft, ND, normoactive bowel sounds, ? of large mass in center of abdomen, but not incredibly obvious Extremities: 2+ pitting edema to knees bilaterally, 1+ DP pulses bilaterally Neurologic: Sedated, intubated, squeezes hands on command, wiggles toes Pertinent Results: [**2187-12-2**] Renal U/S - No evidence of hydronephrosis [**2187-12-3**] Paracentesis - Successful therapeutic and diagnostic paracentesis with aspiration of 3 L of clear amber yellow fluid. Samples were sent for cytology and microbiology. [**2187-12-3**] Peritoneal fluid - Atypical epithelioid cells, reactive mesothelial cells and numerous inflammatory cells. See note. Negative for malignant cells. Reactive mesothelial cells and inflammatory cells. [**2187-12-4**] CXR - Free air in the abdomen, which is new. This was discussed with Dr. [**Last Name (STitle) 4312**] at the time of dictation. No other interval change [**2187-12-5**] Abd xray - 1. No radiographic evidence for obstruction. 2. Persistent pneumoperitoneum. Brief Hospital Course: Mrs. [**Known lastname 70235**] is a 64 yo woman with h/o uterine CA who was admitted with recurrent disease (large intrabdominal mass), new ascites, dyspnea and hypotension. Her course was complicated by likely bowel perforation due to tumor infiltration of adherant bowel. In setting of presumed bowel perforation she developed increased tachypnea, tachycardia and respiratory distress. Given her underlying malignancy, she decided not to be intubated and chose to be comfort measures only. She died overnight due to respiratory failure from underlying bowel perforation and increased abdominal free air. . 1) Respiratory distress: On admission, her symptoms of dyspnea were most likely [**12-22**] ascites and increased intra-abdominal pressure. She was intubated in the emergency department for respiratory distress and inability to tolerate lying flat. She had ultrasound guided paracentesis and removal of 3L of ascitic fluid. She was extubated the following day without problem however she continued to be tachypnic. The following day her respiratory status worsening in setting of suspected bowel perforation. She chose not to be intubated and died over night due to respiratory distress likely from increasing abdominal free air, abdominal mass, ascites and bowel perforation. She was treated with a morphine drip for symptoms of respiratory distress. She died overnight. . 2)Intra-abdominal free air - visible on CXR and KUB most likely due to bowel perforation most likely caused by tumor erosion into adherant bowel. Surgery consulted and after discussion with GYN-ONC and given patients underlying malignancy it was decided that she is not a good operative candidate. This was discussed at length with the patient and she chose to be comfort measures only at this point. She was treated with vancomycin and zosyn for bowel perforation. . 3)Ascites: Likely related to large intrabdominal mass/recurrent CA. She had bedside US guided paracentesis, with the removal of 3 liters. Cell counts show 9700 WBC (89% polys), and 1+ Budding yeast, concerning for SBP. She was treated with zosyn and fluconazole. . 4)Uterine CA: Recurrent disease, per oncology palliative treatment at this time. . 5) LE edema: Most likely due to IVC compression by large volume ascites. No evidence of PE on CTA. Medications on Admission: Hydrochlorothiazide-bisoprolol Atorvastatin Fluticasone-salmeterol Meloxicam Aspirin Furosemide Discharge Medications: patient expired Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired

[ "198.89", "V10.42", "276.50", "401.9", "272.4", "569.83", "789.59", "197.2", "V10.82", "518.81", "584.9", "567.9", "493.90" ]

icd9cm

[ [ [] ] ]

[ "54.91", "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

5662, 5671

3164, 5476

310, 362

5722, 5731

2404, 3141

5787, 5797

1741, 1771

5622, 5639

5692, 5701

5502, 5599

5755, 5764

1786, 2385

251, 272

390, 1392

1414, 1667

1683, 1725

12,935

161,822

156

Discharge summary

report

Admission Date: [**2148-1-22**] Discharge Date: [**2148-2-16**] Date of Birth: [**2089-6-30**] Sex: M Service: HEPATOBILIARY SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 58 year old male with a past medical history remarkable for pericarditis, diverticulosis, status post colostomy and take-down, obstructive sleep apnea, who was evaluated for painless jaundice in [**2147-12-6**]. The patient's CT scan revealed 1.6 by 2.0 centimeter Klatskin tumor with no evidence of liver mass nor encasement of vessels. The patient underwent an endoscopic retrograde cholangiopancreatography which showed normal pancreatic duct but biliary stricture, consistent with cholangiocarcinoma. A stent was placed in the upper third of the common bile duct. An MRCT in [**2147-12-6**], revealed a 2 centimeter mass in the porta hepatis consistent with cholangiocarcinoma, with extensive periportal lymphadenopathy. After a long discussion with the patient and family members, the patient was taken to the Operating Room on [**2148-1-22**]. PAST MEDICAL HISTORY: As noted above. MEDICATIONS: None. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Positive tobacco smoker for 25 years. PHYSICAL EXAMINATION: At the time of discharge the patient was well developed and well nourished in no apparent distress. HEENT: Sclerae was icteric with evidence of jaundice. Cranial nerves II through XII intact. Mucous membranes were moist; no evidence or oral ulcers. no cervical lymphadenopathy noted. Chest was clear to auscultation bilaterally. Cardiac is regular rhythm and rate. No murmurs. Abdomen is soft, nondistended, nontender, with lateral [**Location (un) 1661**]-[**Location (un) 1662**] intact and T-tube capped. Extremities had two plus edema, significantly decreased since discharge from the Surgical Intensive Care Unit; no evidence of rash noted. LABORATORY: On [**2148-2-15**], white blood cell count 8.0, hematocrit 29.9, platelets 204. PT 14.6, PTT 51.7, INR 1.4. Sodium 135, potassium 3.5, chloride 101, bicarbonate 24, BUN 14, creatinine 1.0 and glucose 78. AST 102, alkaline phosphatase 213, amylase 144/168. Total bilirubin 7.9, albumin 2.5, calcium 8.0, magnesium 1.8 and phosphate 3.2. Bio-cultures from [**2-5**], Enterococcus species in yeast and [**Location (un) 1661**]-[**Location (un) 1662**] cultures revealed Vancomycin sensitive enterococcus. Blood cultures from [**2-5**] showed no growth. IMAGING: [**2-5**], cholangiogram: Patent anastomosis with irregular left hepatic duct with multi-filling defects. Leakage of contrast material from left hepatic duct leading to a 5 centimeter fluid collection. [**2-6**] fistulogram: Drainage of right subhepatic collection after manual suction of 45 cc. fluid. [**2-6**] CT scan of abdomen: Complete resolution of right subhepatic collection. SUMMARY OF HOSPITAL COURSE: The patient is a 58 year old male who underwent an uncomplicated right hepatic lobectomy, common bile duct excision, cholecystectomy, Roux-en-Y hepaticojejunostomy for a Klatskin's tumor. The patient was admitted to the Surgical Intensive Care Unit intubated for close observation following surgery due to prolonged surgical time and estimated blood loss of 1200 cc.. The patient was extubated the following morning without difficulty and the epidural was discontinued secondary to induction of hypertension. The patient was placed on p.r.n. morphine with stable blood pressure achieved after additional fluid boluses. However, later on during the day, the patient's hypoxemia worsened secondary to fluid overload and required re-intubation. During this period, the patient's white blood cell count began to rise to 12.8, although the patient remained afebrile. Vancomycin and Zosyn were restarted. A [**1-24**] culture revealed coagulase negative Staphylococcus from blood, one out of four bottles and enterococcus fro peritoneal drain culture. On [**1-27**], the patient's peritoneal culture revealed [**Female First Name (un) 564**] and Fluconazole was added. By [**1-31**], the patient was doing well and the patient was extubated. With signs of bowel function, the patient's nasogastric tube was removed and he started on clears. By [**2-2**], the patient was transferred to the floor on Vancomycin after having discontinued Zosyn and Fluconazole. The patient had multiple fluid boluses from the Surgical Intensive Care Unit stay resulting in three plus peripheral edea. Net fluid gain was noted to be greater than ten liters at the time of transfer to the floor. A Lasix regimen was therefore added to target daily fluid losses to two liters. Interestingly, the patient's total bilirubin began to rise along with white blood cell counts. Zosyn and Fluconazole were added after consulting with Infectious Disease Service. A cholangiogram was also performed on [**2-5**] and because of the 5 centimeter fluid collection noted, Interventional Radiology was consulted to remove the collection for culture. With drain directly in proximity to the collection, aggressive suctioning lead to complete evacuation of this collection. No additional drain was required for removal of this collection. White blood cell count began to decrease the following day along with total bilirubin. By post-op day number 24, the patient was doing well, tolerating a regular diet and weaned off of total parenteral nutrition. The decision was made to discharge the patient on [**2-16**]. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To home with Visiting Nurse Service for help administering Zosyn. DISCHARGE INSTRUCTIONS: 1. The patient was reminded to continue on the twice a day Lasix regimen until Dr.[**Name (NI) 1369**] office visit in one week. At that time, the patient was to be re-evaluated on whether the Lasix should be continued. 2. The patient was also reminded to discontinue Zosyn and Fluconazole on [**3-15**]. 3. The patient at that time was instructed to start taking Ciprofloxacin 500 mg twice daily for prophylaxis. DISCHARGE MEDICATIONS: 1. Percocet 5/325, one to two tablets p.o. q. four to six hours p.r.n. pain. 2. Colace 100 mg p.o. three times a day. 3. Diphenhydramine 25 mg q. h.s. p.r.n. insomnia. 4. Reglan 10 mg, two tablets q. six hours. 5. Lasix 40 mg p.o. twice a day. 6. Metoprazole 40 mg p.o. q. day. 7. Fluconazole 400 mg two tablets p.o. q. day. 8. Zosyn 4.5 grams q. eight hours for 28 days. 9. Ciprofloxacin 500 mg p.o. twice a day starting [**3-15**]. FOLLOW-UP INSTRUCTIONS: 1. The patient was instructed to follow-up with Dr. [**Last Name (STitle) **] in seven days. 2. The patient was also instructed to call Infectious Disease Clinic for follow-up with Dr. [**First Name4 (NamePattern1) 1663**] [**Last Name (NamePattern1) 1005**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366 Dictated By:[**Name8 (MD) 1664**] MEDQUIST36 D: [**2148-2-25**] 14:58 T: [**2148-2-25**] 16:30 JOB#: [**Job Number 1665**]

[ "156.0", "428.0", "790.7", "276.2", "995.90", "197.8", "574.20", "518.5" ]

icd9cm

[ [ [] ] ]

[ "96.04", "51.69", "51.37", "99.15", "38.91", "50.3", "96.72", "51.22" ]

icd9pcs

[ [ [] ] ]

6073, 6517

5631, 6050

2896, 5487

1239, 2865

184, 1057

6541, 7054

1080, 1158

1176, 1215

5513, 5607

61,377

111,738

37154

Discharge summary

report

Admission Date: [**2166-11-6**] Discharge Date: [**2166-11-10**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7055**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catheterization with bare metal stent to Left anterior descending artery. History of Present Illness: 88 yo M with PMH significant for HTN, h/o stroke [**2156**] and DVT on coumadin, dementia presents with chest pain. The patient is a poor historian due to his dementia and thus history of taken with the help of his wife. The patient was in his normal state of health until last night when he complainted of chest discomfort to his wife. The episode resolved until the AM when he woke up and complainted of severe chest tightness to his wife. [**Name (NI) **] also was slightly diaphoretic, but denied SOB, nausea or vomiting. The wife called 911 and he was taken to [**Hospital1 18**]. . In the ED VS: 96.4 76 154/87 16 98% RA. The patient had ECG changes consistent with anterior STEMI and Code STEMI was called. He got ASA, plavix 600mg, heparin gtt and integralin bolus (no gtt). He was also given IV metoprolol 5mg x2 for BP and 1 SL nitro followed by a nitro gtt. CXR showed early interstitial pulmonary edema. Labs were remarkable for a trop 0..09, CK 65 and MB: not done, Cr:1.3 and potassium 5.6 (not-hemolyzed). He was taken to the cath lab. . The cath revealed 80% thrombotic mid-LAD lesion that was stented with a 3.0x15mm BMS, post with 3.0mm NC balloon. He also had 80% lesions in ramus and mid RCA and a 90% stenosis in a small distal LCx. Those lesions were not intervened upon. He remained hemodynamically stable throughout and without complications. . The patient denied any chest pain, SOB, nausea, vomiting. . On review of systems, he denies any prior history of pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Hypertension 2. CARDIAC HISTORY: None 3. OTHER PAST MEDICAL HISTORY: --h/o stroke [**2156**] with r sided weakness. --Multiple DVT in the leg and upper ext. Last DVT was [**2161**]. On life-long coumadin --Dementia --h/o melanoma on his back s/p removal Social History: Retired sales engineer. Lives with his wife. [**Name (NI) **] [**Name2 (NI) 269**] services -Tobacco history: none -ETOH: rare -Illicit drugs: none Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: T=97.8...BP=125/63...HR=67...RR=19...O2 sat=94% 2L GENERAL: NAD. Oriented x2. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 8 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. mild crackles at the bases no wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No venoous stasis changes ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: EKG: sinus at 65 bpm, NI, [**Last Name (LF) **], [**First Name3 (LF) **]-elevations in v1-v4. No prior for comparison . Cath Report [**11-6**]: LAD: 80% hazy mid LCx: 80% large ramus, 90% mid small distal circumflex RCA: 80% mid Bare metal stent to LAD, perclose right groin. CXR [**11-6**] IMPRESSION: Minimal increased interstitial linear markings in the right lung base suggestive of early interstitial pulmonary edema. ECHO [**11-7**]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with akinesis of the mid- and distal anterior wall and septum, apex and distal inferior segment (mid-LAD territory). The remaining segments contract normally (LVEF = 35%). The LV apex is not visualized sufficiently for a thrombus to be definitely excluded, although one is not seen. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Moderate regional left ventricular systolic dysfunction, c/w CAD. Mild mitral regurgitation. Mild pulmonary hypertension. Mildly dilated ascending aorta. [**2166-11-6**] 01:30PM BLOOD CK(CPK)-65 [**2166-11-6**] 01:30PM BLOOD CK-MB-NotDone [**2166-11-6**] 08:26PM BLOOD CK(CPK)-175* [**2166-11-6**] 08:26PM BLOOD CK-MB-16* MB Indx-9.1* cTropnT-0.09* [**2166-11-7**] 03:24AM BLOOD CK(CPK)-247* [**2166-11-7**] 03:24AM BLOOD CK-MB-17* MB Indx-6.9* cTropnT-1.00* [**2166-11-7**] 01:30PM BLOOD CK(CPK)-1147* [**2166-11-7**] 01:30PM BLOOD CK-MB-113* MB Indx-9.9* [**2166-11-7**] 10:05PM BLOOD CK(CPK)-951* [**2166-11-7**] 10:05PM BLOOD CK-MB-71* MB Indx-7.5* [**2166-11-8**] 05:20AM BLOOD CK(CPK)-731* [**2166-11-8**] 05:20AM BLOOD CK-MB-44* MB Indx-6.0 cTropnT-2.81* [**2166-11-9**] 06:20AM BLOOD CK(CPK)-410* [**2166-11-9**] 06:20AM BLOOD CK-MB-11* MB Indx-2.7 [**2166-11-7**] 03:24AM BLOOD Triglyc-112 HDL-41 CHOL/HD-4.1 LDLcalc-105 On discharge: [**2166-11-9**] Glucose-101 UreaN-19 Creat-1.2 Na-140 K-4.8 Cl-104 HCO3-26 AnGap-15 WBC-10.8 RBC-4.24* Hgb-12.5* Hct-36.3* Plt Ct-630* Brief Hospital Course: 88 yo M with PMH significant for HTN, h/o stroke [**2156**] and DVT on coumadin, dementia presents with STEMI s/p BMS to 80% thrombotic mid-LAD lesion. . # CORONARIES: Pt with anterior STEMI. He was taken to cath and s/p BMS to 80% mid LAD lesion without further complication. Patient with 80% lesions in ramus and mid RCA and a 90% stenosis in a small distal LCx that were not intervened as they were not likely the cause of his CP. TIMI risk score of 5 (12.4% mortality). Pt developed another episode of chest pain, back discomfort and shoulder pain the following morning with no significant ECG changes. CE peaked only once to CK 1147, CKMB 113, Trop 9.9. Delay in elevation was considered to be due to delayed washout. Pt was started on Plavix in addition to ASA 325, which should be continued for one year. Also maintained on lipitor 80mg, metoprolol 37.5mg tid, lisinopril 10mg. Imdur was uptitrated to prevent recurrance of anginal sx. Pt developed no complications of his MI. He had no evidence of heart failure. Follow up ECHO showed EF 35% with LV systolic dysfunction with akinesis of mid and distal anterior wall and septum, apex and distal inferior segment consistent with mid LAD infarct. No intervention given pt already therapeutic on coumadin for h/o DVT. Further intervention of mid RCA and ramus lesions should be considered as outpt. Medications on Admission: Atenolol 25 mg daily Lisinopril 10 mg daily Nemenda 10 mg daily Exelon 1.5 mg daily Coumadin 3 mg daily Supplement: Fibercon, Coenzyme Q10 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:*11* 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Metoprolol Succinate 100 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* 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Ranitidine HCl 75 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day. 8. Isosorbide Mononitrate 30 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* 9. Rivastigmine 1.5 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Memantine 10 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-29**] Drops Ophthalmic PRN (as needed) as needed for eye pain. Disp:*1 bottle* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Anterior ST Elevation Myocardial Infarction Hypertension Previous Stroke on coumadin Dementia Discharge Condition: Mental Status:Confused - always Level of Consciousness:Alert and interactive Activity Status:Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: You had a heart attack which caused your heart muscle to be weak. A cardiac catheterization showed 3 blockages in your coronary arteries. One of the blockages was fixed and a bare metal stent was inserted. this should keep the artery open. You will need to take aspirin and Plavix every day for at least one month and ideally one year to prevent the stent from clotting off and causing another heart attack. Medication changes: 1. Stop taking Atenolol 2. Start taking Metoprolol instead to slow the heart rate 3. Start taking Imdur, a long acting nitroglycerin to prevent chest pain and lower the blood pressure 4. Start taking aspirin and Plavix every day to prevent the stents from clotting off. Do not stop taking unless your cardiologist says it is OK to do so. 5. Start taking ranitidine to prevent stomach upset from the Plavix 6. Start taking Atorvastatin to lower your cholesterol and prevent another heart attack. 7. continue your warfarin and medicines for dementia 8. Continue the eye drops if your eyes are dry at home. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Primary Care: [**Last Name (LF) 8505**],[**First Name3 (LF) **] phone: [**Telephone/Fax (1) 8506**] Date/Time: Tuesday [**11-18**] at 11:00 am. . Cardiology: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Hospital1 **] Hospital [**Location (un) 83706**], [**Numeric Identifier 46003**] Phone: ([**Telephone/Fax (1) 11814**] Date/time: Wednesday [**12-3**] at 1:00pm. Please come to the hospital at 12:30pm to register and do new patient paperwork. Completed by:[**2166-11-10**]

[ "585.9", "V58.61", "403.90", "V12.51", "414.01", "414.2", "410.11", "294.8", "V12.54" ]

icd9cm

[ [ [] ] ]

[ "00.40", "00.66", "00.45", "37.22", "88.56", "36.07" ]

icd9pcs

[ [ [] ] ]

9025, 9083

6263, 7630

275, 359

9221, 9221

3808, 6090

10545, 11053

2791, 2906

7819, 9002

9104, 9200

7656, 7796

9397, 9805

2921, 3789

2385, 2390

6104, 6240

9825, 10522

225, 237

387, 2305

9235, 9373

2421, 2608

2327, 2365

2624, 2775

7,532

174,267

8994

Discharge summary

report

Admission Date: [**2182-12-3**] Discharge Date: [**2182-12-5**] Date of Birth: [**2145-8-29**] Sex: M Service: CAUSE OF DEATH: Cerebral hypoperfusion. HISTORY OF PRESENT ILLNESS: Patient is a 37-year-old male with morbid obesity, a BMI of approximately 50 with a weight of 350 pounds, who presents for laparoscopic adjustable gastric band. His comorbidities included obstructive-sleep apnea, hypertension, reflux, dyslipidemia, and backache, and depression. HOSPITAL COURSE: Patient was admitted on the morning of [**2182-12-3**] prior to the operation. He underwent an uncomplicated intubation, an uncomplicated laparoscopic adjustable gastric band. Extubation was notable for agitation and eventual tube removal followed by a respiratory arrest requiring reintubation. After the airway was established, the patient had cardiac arrest, which was treated with multiple medications and CPR. CPR was administered for over one hour. In the meantime, a transesophageal echo-probe was placed and there was found to be no evidence of an acute saddle embolus. Dr. [**Last Name (STitle) **] of Cardiac Surgery was contact[**Name (NI) **] for possible placement on cardiopulmonary bypass. This was achieved via the groin without difficulty with subsequent hemodynamic improvement. The patient was kept on cardiopulmonary bypass for several hours at which point, he was removed given his significant improvement. He was transferred to the ICU on multiple pressors for hemodynamic monitoring. He was noted to have a tense distended abdomen in the ICU with an abdominal compartment pressure in the 30s, therefore, an exploratory laparotomy and silo evacuation of abdominal fluid and placement of a silo were performed on the evening of [**2182-12-3**] with immediate resolution of respiratory compromise. The patient was then managed on multiple pressors. Started on CVVH for mobilization of fluid with hopes of improvement. He had to be paralyzed and sedated given his poor respiratory parameters. Therefore, neurologic exam was impossible. On [**2182-12-4**], the patient's hemodynamic parameters relatively stabilized despite multiple pressors. His lactic acid dropped down to the 6-7 range. Base access decreased and his oxygenation started to improve slightly. An intracranial bolt was placed given the lack of ability to follow a neurologic examination. The opening ICP pressure was 100. Therefore, the patient was started on mannitol and maximally supported. On the morning of [**2182-12-5**], nuclear medicine brain flow study was performed, which was found to be negative for blood flow. Upon transfer back to the Intensive Care Unit, the patient hemodynamically decompensated requiring multiple boluses of Epinephrine, bicarb, and calcium. The situation was discussed with the family in detail, and the patient ultimately expired from cerebral hypoperfusion and cardiac arrest. He was pronounced at 3:21 p.m. with his family at the bedside. ME office was consulted and refused the case, and the family is requesting an autopsy. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 23652**] Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2182-12-5**] 16:34 T: [**2182-12-6**] 07:44 JOB#: [**Job Number 31179**]

[ "427.5", "997.1", "997.5", "584.9", "997.3", "518.4", "997.09", "799.1", "278.01" ]

icd9cm

[ [ [] ] ]

[ "88.72", "01.18", "99.04", "39.61", "44.99", "34.04", "96.71", "96.04", "54.11" ]

icd9pcs

[ [ [] ] ]

497, 3332

198, 479

49,723

190,910

34728

Discharge summary

report

Admission Date: [**2142-10-17**] Discharge Date: [**2142-10-22**] Date of Birth: [**2064-7-20**] Sex: M Service: SURGERY Allergies: Penicillins / Bactrim / Shellfish Derived Attending:[**First Name3 (LF) 5569**] Chief Complaint: Liver cirrhosis, small bowel obstruction. Major Surgical or Invasive Procedure: [**2142-10-17**]: Exploratory laparotomy, small bowel resection. [**2142-10-21**]: Cardiac catheterization, coronary angiography, angioplasty of RCA History of Present Illness: 78M with a history of peripheral vascular disease, diabetes mellitus, and cryptogenic cirrhosis (suspected insulin resistance) with MELD 27 presents upon transfer from an OSH for concern of a small bowel obstruction. Mr [**Known lastname **] reports to be in his usual state of health until 2 days ago when he developed nausea with bilious emesis and abdominal pain over his chronic umbilical hernia. He presented to [**Hospital6 33**] where a CT abdomen/pelvis was reported to show a high-grade small bowel obstruction with a transition point at the umbilicial hernia. A nasogastric tube was placed, and he was transfered to [**Hospital1 18**] for further care. Upon interviewing Mr [**Known lastname **], who is accompanied by his sons that assist with providing history, he notes his last bowel movement to have been last evening. He denies flatus for the past 2 days. He notes his nausea to have resolved with placement of the NG tube. He reports his pain to have remained stable since onset. He denies fevers, chills, hematemesis, dirrhea, constipation, hematochezia, or melena. Of note, Mr [**Known lastname **] is cared for by Dr [**Last Name (STitle) 497**] and the Hepatology Team here at [**Hospital1 18**]. His ascites has been treated with diuretics and intermittent paracentesis. He was most recently seen [**7-/2142**] for increasing abdominal distension and associated umbilical hernia protrusion, for which his diuretic regimen was increased and paracentesis performed. At that time he had no encephalopathy or jaundice. His hernia was noted to be easily reducible at the time. Past Medical History: 1. Cryptogenic cirrhosis (suspected insulin resistance), MELD 27 2. Diabetes mellitus 3. Hypertension 4. Hx hip fracture requiring hospitalization, blood transfusion 5. Peripheral vascular disease s/p bilateral bypass procedures, details not known to patient 6. s/p facial trauma [**2111**], requiring multiple surgeries 7. GERD Social History: Lives at home with wife and son. Denies tobacco, EtOH, or illicit drug use. Family History: Non-contributory to obstruction. Physical Exam: Temp: 96, HR: 94, BP: 138/86, RR: 20, O2 Sat: 98% 2L GEN: Elderly male in NAD. NGT with bilious output. Somewhat lethargic. Oriented x2. HEENT: Sclerae icteric. Mucous membranes tachy. CV: RRR. PULM: Clear bilaterally. No w/r/r. ABD: Soft, protuberant abdomen, dull to percussion. Large umbilical hernia reducible after significant manipulation. Mild tenderness to deep palpation after reduction. No R/G. No HSM. EXT: LE with brawny skin changes, L > R. No edema. Feet slightly cool. Doppler DPs, PTs b/l. Pertinent Results: [**2142-10-16**] 08:45PM BLOOD WBC-3.6* RBC-2.95* Hgb-10.2* Hct-26.5* MCV-90 MCH-34.5*# MCHC-38.5*# RDW-16.6* Plt Ct-237 [**2142-10-16**] 08:45PM BLOOD PT-15.5* PTT-45.6* INR(PT)-1.3* [**2142-10-17**] 03:17AM BLOOD PT-15.2* PTT-46.4* INR(PT)-1.3* [**2142-10-17**] 09:29AM BLOOD PT-15.2* PTT-46.4* INR(PT)-1.3* [**2142-10-18**] 05:50AM BLOOD PT-17.7* PTT-52.4* INR(PT)-1.6* [**2142-10-18**] 04:45PM BLOOD PT-17.8* PTT-50.5* INR(PT)-1.6* [**2142-10-19**] 05:30AM BLOOD PT-17.1* PTT-49.5* INR(PT)-1.5* [**2142-10-20**] 05:00AM BLOOD PT-15.9* PTT-39.3* INR(PT)-1.4* [**2142-10-21**] 07:20AM BLOOD PT-17.8* PTT-39.8* INR(PT)-1.6* [**2142-10-21**] 07:45PM BLOOD PT-19.2* PTT-49.9* INR(PT)-1.7* [**2142-10-22**] 02:44AM BLOOD PT-39.7* PTT->150* INR(PT)-4.1* [**2142-10-16**] 08:45PM BLOOD Glucose-305* UreaN-84* Creat-2.3* Na-135 K-5.3* Cl-97 HCO3-22 AnGap-21* [**2142-10-17**] 03:17AM BLOOD Glucose-318* UreaN-89* Creat-2.6* Na-135 K-4.3 Cl-95* HCO3-27 AnGap-17 [**2142-10-17**] 09:29AM BLOOD Glucose-193* UreaN-92* Creat-2.5* Na-134 K-4.3 Cl-97 HCO3-25 AnGap-16 [**2142-10-18**] 05:50AM BLOOD Glucose-227* UreaN-105* Creat-3.0* Na-135 K-4.1 Cl-98 HCO3-25 AnGap-16 [**2142-10-18**] 04:45PM BLOOD Glucose-175* UreaN-107* Creat-2.9* Na-138 K-4.1 Cl-100 HCO3-27 AnGap-15 [**2142-10-19**] 05:30AM BLOOD Glucose-82 UreaN-106* Creat-2.7* Na-138 K-3.5 Cl-101 HCO3-24 AnGap-17 [**2142-10-20**] 05:00AM BLOOD Glucose-55* UreaN-121* Creat-2.4* Na-138 K-3.2* Cl-101 HCO3-19* AnGap-21* [**2142-10-21**] 07:20AM BLOOD Glucose-61* UreaN-134* Creat-3.0* Na-136 K-4.0 Cl-99 HCO3-17* AnGap-24* [**2142-10-21**] 07:45PM BLOOD Glucose-96 UreaN-149* Creat-3.9* Na-134 K-4.6 Cl-97 HCO3-13* AnGap-29* [**2142-10-22**] 02:44AM BLOOD Glucose-140* UreaN-158* Creat-3.6* Na-134 K-4.8 Cl-97 HCO3-14* AnGap-28* [**2142-10-16**] 08:45PM BLOOD ALT-21 AST-39 AlkPhos-88 TotBili-3.8* [**2142-10-17**] 03:17AM BLOOD ALT-20 AST-19 AlkPhos-84 TotBili-4.1* [**2142-10-17**] 09:29AM BLOOD ALT-17 AST-19 AlkPhos-73 TotBili-4.0* [**2142-10-18**] 05:50AM BLOOD ALT-14 AST-20 AlkPhos-57 TotBili-11.3* DirBili-5.7* IndBili-5.6 [**2142-10-18**] 04:45PM BLOOD ALT-14 AST-20 LD(LDH)-170 AlkPhos-57 TotBili-14.0* [**2142-10-18**] 04:45PM BLOOD TotBili-14.1* DirBili-8.6* IndBili-5.5 [**2142-10-19**] 05:30AM BLOOD ALT-10 AST-25 AlkPhos-46 TotBili-16.6* [**2142-10-20**] 05:00AM BLOOD ALT-11 AST-51* AlkPhos-44 TotBili-22.2* [**2142-10-21**] 07:20AM BLOOD ALT-15 AST-44* AlkPhos-41 TotBili-29.8* [**2142-10-21**] 07:45PM BLOOD ALT-34 AST-84* CK(CPK)-110 AlkPhos-39* TotBili-31.8* [**2142-10-22**] 02:44AM BLOOD ALT-69* AST-164* LD(LDH)-327* CK(CPK)-133 AlkPhos-39* TotBili-42.0* [**2142-10-21**] 07:45PM BLOOD CK-MB-15* MB Indx-13.6* cTropnT-1.11* [**2142-10-22**] 02:44AM BLOOD CK-MB-21* MB Indx-15.8* cTropnT-1.39* Brief Hospital Course: On [**2142-10-16**], the patient presented to the emergency department with small bowel obstruction, and on [**2142-10-17**], he underwent exploratory laparotomy with small bowel resection. Post-operatively, the patient recovered bowel function and tolerated regular diet. However, he developed acute renal failure with oliguria with progressive decline in synthetic liver function. On [**2142-10-21**], he developed chest pain with hypotension and hypoxia. ST segment changes were found on ECG. He was transferred to the TSICU and then to the CCU. He underwent cardiac catheterization with angioplasty of the RCA. Post-procedure, he was hypotensive requiring vasopressor but cleared by cardiology. Discussion with the patient and family resulted in agreeing on DNR/DNI code status for the patient. He was transferred to the SICU where later in the day he developed respiratory distress. The family rendered him CMO and he expired. Medications on Admission: Sucralfate 4', Aldactone 100', Pantoprazole 40'', Lasix 60'', Ferrous gluconate 648'', Neurontin 100 HS, Xafaxan 1100', Lantus 34u HS, Novolog sliding scale. Discharge Medications: None. Discharge Disposition: Expired Discharge Diagnosis: Respiratory failure. Hepatorenal syndrome. S/p small bowel resection for small bowel obstruction. Discharge Condition: Expired. Discharge Instructions: He who has gone, so we but cherish his memory. Followup Instructions: None. Completed by:[**2142-10-22**]

[ "571.5", "294.8", "250.00", "401.9", "285.9", "572.4", "789.59", "V49.86", "348.39", "551.1", "788.5", "414.01", "V66.7", "458.9", "518.81", "584.9", "410.41", "287.5", "276.2", "443.9" ]

icd9cm

[ [ [] ] ]

[ "53.49", "88.56", "38.91", "45.62", "54.91", "00.66", "00.40" ]

icd9pcs

[ [ [] ] ]

7131, 7140

5953, 6893

345, 496

7282, 7293

3161, 5930

7388, 7426

2582, 2616

7101, 7108

7161, 7261

6919, 7078

7317, 7365

2631, 3142

264, 307

524, 2121

2143, 2473

2489, 2566

30,877

126,193

30760

Discharge summary

report

Admission Date: [**2176-7-10**] Discharge Date: [**2176-7-16**] Date of Birth: [**2094-9-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1674**] Chief Complaint: right hip replacement Major Surgical or Invasive Procedure: [**7-10**] elective R hip replacement History of Present Illness: Patient is an 81 y/o male with a PMH of bilateral BKA, CAD s/p MI in [**2156**] followed by CABG, DM, s/p PPM for bradycardia, and LUE DVT on coumadin who was admitted on [**7-10**] for elective R hip replacement. Post surgical hospital course was complicated by orthostatic hypotension requiring overnight MICU stay with response to fluid boluses, and, after transfer back to floor, blood loss anemia in the setting of hematoma formation at the right hip surgical site during re-initiation of chronic anti-coagulation. Past Medical History: CAD s/p MI and CABG [**2156**] CHF EF 15-20% on TTE [**2172**] DM diagnosed 5 years ago LUE DVT [**2175-12-28**] on coumadin s/p b/l BKA [**12-29**] injury in WWII s/p cholecystectomy [**2136**] Hypercholesterolemia s/p Mohs surgery for squamous call CA on scalp s/p PPM [**2175**] for bradycardia Social History: Lives in [**State 531**]. Works part-time as a college Biology teacher. Served in WWII as a medic. Prior smoker while in service, quit [**2116**]. Rare EtOH. Family History: nc Physical Exam: VS: T 99 BP 107/45 P 72 RR 20 O2 sat 95% RA General: Obese, comfortable appearing elderly gentleman, alert and speaking in full sentences. HEENT: Op clear, MM dry, EOMI, PERRL Neck: supple, no LAD, JVP 8cm Heart: RRR, normal S1/S2, no murmurs, rubs or gallops Chest: Well-healed sternotomy scar. CTA Abdomen: obese, soft, NT, ND, normoactive BS Ext: b/l BKA, warm and well-perfused, R hip with clean pressure dressing, induration and ecchymosis surrounding the surgical incision. Other than focal area of induration, no tenseness to the right leg compared to left leg, mild swelling of r leg c/t left leg. Good ROM at b/l knees, full sensation. Neuro: AAO x3, CN II-XII intact, muscle strength 5/5 in upper ext and LLE, r leg strength difficult to assess [**12-29**] pain Pertinent Results: HIP FILMS: Two postoperative films are obtained. Surgical staples are present. Patient is status post total hip replacement. The films are technically limited by body habitus. The prosthesis appears to be within near anatomic alignment. No complication is grossly evident. On discharge hct is 28, wbc 12.3, plt 171, creat 0.6, inr 1.1. Brief Hospital Course: 1)Post op hypotension: Felt secondary to hypovolemia and narcotics. Responded to fluid bolus in ICU. Monitored overnight in ICU. No MI by cardiac enzymes and EKG. 2)Blood loss anemia: Pt has been on coumadin for 6 months for UE DVT. He has a defibrillator/PM and it is unclear as to whether the course for anti-coag should be the usual 6 months or longer given the threat of thrombus to the wire. He was started on heparin with a plan to bridge to coumadin on post op day 4 and developed a hematoma at the right surgical site with assoc blood drop from hct 28 to hct 20 over 36 hours. There was no evidence of compartment syndrome and orthopedic surgery team felt there was no need for evacuation of hematoma. His hct responded to 3 units of prbc and his past 2 hct checks on dc have been 26 and 28. The coumadin was not restarted but should be considered once at rehab. 3)CHF: Afer fluid resuscitation pt remained euvolemic. He was very concerned about restarting his chronic CHF meds after the hypotensive episode and refused throughout the hospital course. Home CHF meds include carvedilol 25 [**Hospital1 **], lasix 40 daily, captopril 50 qd. 4)Diabetes: Controlled on insulin sliding scale while inpatient, should restart home dose of metformin 500 daily. 5)CAD: patient is s/p MI and CABG [**2156**]. Currently CP free and no signs of active ischemia. Restart aspirin if hct remains stable. Titrate on beta blocker and ace-i as above (CHF). 6) Hyperlipidemia: cont. statin # Communication: Daughter [**Name (NI) **] [**Telephone/Fax (1) 72840**] (cell) [**Telephone/Fax (1) 72841**] (home) Medications on Admission: Coumadin dose, indeterminate treatment for a left upper extremity DVT. Digoxin 0.25 mg daily, metformin 500 mg daily, carvedilol 25 mg twice daily, Lasix 40 mg daily, captopril 50 mg three times a day, Lipitor 10 mg daily, nitroglycerin 0.4 mg one to four tablets sublingual p.r.n. as needed for chest pain. Discharge Medications: 1. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 11. Regular insulin sliding scale Please use the regular insulin sliding scale as [**First Name8 (NamePattern2) **] [**Hospital1 **] protocol 12. Metformin 500 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: hip replacement right thigh hematoma orthostatic hypotension after surgery Discharge Condition: stable Discharge Instructions: Please alert MD at rehab with chest pain, hip pain, or other concerning symptoms. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2176-7-22**] 9:50 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**] Completed by:[**2176-7-16**]

[ "V45.81", "998.12", "E878.4", "428.22", "V58.61", "V12.51", "V45.02", "V49.75", "285.1", "250.00", "412", "428.0", "715.35", "276.52" ]

icd9cm

[ [ [] ] ]

[ "99.04", "81.51" ]

icd9pcs

[ [ [] ] ]

5646, 5716

2615, 4230

337, 376

5835, 5844

2252, 2592

5974, 6280

1439, 1443

4590, 5623

5737, 5814

4256, 4567

5868, 5951

1458, 2233

276, 299

404, 926

948, 1248

1264, 1423