ChanBeDu/relevant_section_length · Datasets at Hugging Face

5,743

187,525

16191+56739

Discharge summary

report+addendum

Admission Date: [**2159-11-25**] Discharge Date: [**2159-11-27**] Service: CCU Medicine [**Hospital Ward Name 517**] CHIEF COMPLAINT: AICD firing. HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **]-year-old gentleman with an AICD placed in outside hospital in [**2158-12-17**] for atrial flutter, ventricular tachycardia with DDI placed at [**Hospital3 **]. Patient has also had two visits to the [**Hospital1 1444**] one ED visit, one outpatient, Electrophysiology clinic visit for adjustments of a threshold setting as the patient's atrial flutter was inappropriately setting off the firing of the AICD. The threshold had been ....................< to 170 beats per minute at time of admission. Patient had at least two episodes of AICD firing on the day prior to admission. Was brought in from [**Hospital6 46219**] For the Age resident and arrived in the ED heart rate of 160, blood pressure 120/90. ECG at that point was initially interpreted as atrial fibrillation with ventricular rate of 170. Patient was given 5 mg of intravenous Lopressor and 60 mg of IV adenosine. Heart rate decreased to 140s and 150s. Patient was given an additional of 5 mg of Lopressor. Heart rate decreased into the 140s. Blood pressure fell to 79/56. Patient was given normal saline bolus 500 cc and shocked cardioversion 200 joules with 2 mg of Versed. The patient was given additional 200 joule shock and intubated at that point, also given 300 mg of IV amiodarone transcutaneous pacing ....................< at that time as well as right IJ central line transcutaneous pacing was then stopped at the recommendation of the Electrophysiology service. Dopamine drip was started for blood pressure at that point to 70/44 and bumped back up to 140-160 systolic blood pressure. Total fluids received in the Emergency [**Apartment Address(1) 46220**].5 liters of normal saline. Patient arrived in the CCU intubated requiring Versed and propofol for agitation and sedation. PAST MEDICAL HISTORY: 1. CABG in [**2145**]. 2. AICD placed in [**2158**] as mentioned above. 3. Chronic renal insufficiency with a baseline creatinine of 1.9. 4. Left lower lobe granuloma. 5. MI in [**2158**]. 6. CHF with EF of 30%. 7. Depression. 8. GERD. 9. Right CEA. 10. Renal stones. 11. Cholelithiasis. 12. Pneumonia in [**Month (only) 216**] of this year. ALLERGIES: No known allergies, but there is a noted GI intolerance to amiodarone. OUTPATIENT MEDICATIONS: 1. Aspirin 81. 2. Calcium carbonate b.i.d. 3. Imdur 30. 4. Lansoprazole 30. 5. Lopressor 12.5 in a.m. and 25 in p.m. 6. Multivitamin. 7. Senna. SOCIAL HISTORY: The patient is a retired salesman, widowed. Requiring assistance with many of his activities of daily living, a resident of [**Hospital6 459**] for the Age. He has a son, who is his proxy involved in his care. LABORATORIES: Initial laboratories were unremarkable. Initial CK was 30. PHYSICAL EXAMINATION: General physical exam was notable for a very thin emaciated elderly gentleman with noted temporal wasting. Chest wall is very thin with all ribs prominent. Lungs are extremely clear on examination. Palpable AICD was palpable in the left upper quadrant of the chest. The abdomen is benign, no evidence of lower extremity edema. HOSPITAL COURSE: The patient was the input of Electrophysiology had his AICD threshold lowered ....................< appropriate firing for V-tach. Patient, in review of the ECGs, had actually in ventricular tachycardia. Patient had approximately 17 episodes of AICD firing including overdrive pacing during his initial course in the CCU. Patient was started on amiodarone drip at 1 mg/minute as well as lidocaine drip 1 mg/minute. The lidocaine was subsequently discontinued during the following morning. Sedation was maintained with propofol and dopamine was gradually weaned off. Patient was successfully extubated, and was transferred to the floor on the [**12-26**]. Plan was to discharge the patient back to [**Hospital6 459**] for the Age with initial outpatient medications and with the addition of amiodarone ....................< p.o. b.i.d. The drip has since been discontinued. Pacer threshold has been readjusted. DISCHARGE DIAGNOSIS: Ventricular tachycardia with AICD firing. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2057**] Dictated By:[**Last Name (NamePattern1) 8442**] MEDQUIST36 D: [**2159-11-27**] 08:05 T: [**2159-11-27**] 08:15 JOB#: [**Job Number 46221**] Name: [**Known lastname 8499**], [**Known firstname 2381**] Unit No: [**Numeric Identifier 8500**] Admission Date: [**2159-11-25**] Discharge Date: [**2159-11-27**] Date of Birth: [**2067-10-1**] Sex: M Service: ADDENDUM: The original discharge summary stands as dictated on [**11-27**], with the addition of the following notes: DISCHARGE DIAGNOSES: 1. Ventricular tachycardia with AICD firing. CONDITION AT DISCHARGE: The patient is stable. DISCHARGE MEDICATIONS: 1. Aspirin 325 p.o. q. day. 2. Amiodarone 200 mg p.o. twice a day to be taken until follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], in one month. 3. Imdur 30 mg sustained release q. day. 4. Lansoprazole 30 p.o. q. day. 5. Lopressor 12.5 mg q. a.m. and then 25 mg q. p.m. 6. Calcium carbonate, one capsule twice a day. 7. Senna, one tablet a day. 8. Multivitamin, one tablet a day. DISCHARGE INSTRUCTIONS: 1. The patient's diet will be two gram sodium, low fat. 2. The patient will have a Swish and Swallow evaluation at [**Hospital3 643**]. [**First Name8 (NamePattern2) 77**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 715**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2159-11-27**] 14:59 T: [**2159-11-27**] 16:53 JOB#: [**Job Number 8501**]

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icd9cm

[ [ [] ] ]

[ "99.62", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

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61,519

197,609

54674

Discharge summary

report

Admission Date: [**2148-9-17**] Discharge Date: [**2148-9-23**] Date of Birth: [**2092-1-10**] Sex: F Service: NEUROSURGERY Allergies: Sulfa(Sulfonamide Antibiotics) / eggs Attending:[**First Name3 (LF) 78**] Chief Complaint: Elective aortic valvuloplasty; Right cranial defect. Major Surgical or Invasive Procedure: [**2148-9-17**]: Aortic valvuloplasty [**2148-9-19**]: Right cranioplasty on [**2148-9-19**]. History of Present Illness: Ms. [**Known lastname 52932**] is a 56F with h/o critical aortic stenosis ([**Location (un) 109**] 0.5cm2 on [**2148-7-17**]), possible congestive heart failure (LVEF 64% on [**2148-7-17**]), atrial fibrillation (not on anticoagulation), resolved mitral valve prolapse, and recent admission for right intracranial hemorrhage status post right hemicraniectomy and embolization of right MCA aneurysm who is admitted from an extended care facility following aortic valvuloplasty. In brief, she initially presented to [**Hospital6 19155**] with palpitations on [**2148-7-13**], when she was found to be in rapid atrial fibrillation (HR 120s), with EKG at that time also notable for STD in association with mildly elevated Tn and CK-MB, ultimately attributed to demand ischemia by the OSH. She received aspirin/clopidogrel, enoxaparin, and IV diltiazem, with subsequent conversion to sinus rhythm, and was discharged on aspirin 325mg daily with or without enoxaparin (reportedly likely without) for thromboprophylaxis. After developing headache and left facial droop with flaccid paralysis on [**7-16**], she returned to [**Hospital6 19155**], where noncontrast head CT revealed right intraparenchymal hemorrhage, and she was found to be in rapid atrial fibrillation (HR 160s), prompting transfer to [**Hospital1 18**] for further management. On arrival to [**Hospital1 18**] [**7-16**], cardiology was consulted for persistent rapid atrial fibrillation with hemodynamic instability in the setting of angiogram, and diltiazem drip was initiated, with subsequent transition to oral diltiazem. Following right decompressive hemicraniectomy on [**7-17**], TEE revealed critical aortic stenosis ([**Location (un) 109**] 0.5cm2) with preserved LVEF (64%). When she developed recurrent atrial fibrillation with hemodynamic instability on [**7-17**] in the setting of repeat angiogram, transient pressors and amiodarone were initiated, with subsequent conversion to sinus rhythm on [**7-18**] before planned cardioversion; third attempt at angiogram with right MCA coiling was successful on [**7-18**]. Hospital course also was complicated by presumed ventilator-associated pneumonia, for which she was treated with vancomycin/Zosyn, and right MCA vasospasm, for which she received intraarterial verapamil. Diltiazem and nimodipine ultimately were discontinued and amiodarone decreased to 200mg daily due to soft pressures on 400mg daily. She was discharged on [**8-1**] to an extended care facility, with subsequent cranioplasty cancelled pending correction of critical aortic stenosis. She was evaluated by cardiac surgery on [**9-3**], with valvuloplasty advised in place of operative intervention, given high-risk surgical candidate. On transfer to [**Hospital1 18**], she underwent successful aortic valvuloplasty without complications. Cardiac catheterization reportedly demonstrated no significant coronary disease. On arrival to the floor, she reports sharp frontal headaches in the setting of the procedure, now resolved, as well as nonradiating chest pressure that she attributes to anxiety. Past Medical History: Critical aortic stenosis ([**Location (un) 109**] 0.5cm2 on [**2148-7-17**]) Atrial fibrillation with rapid ventricular response Mitral valve prolapse (resolved as of [**2148-7-17**]) Congestive heart failure (LVEF 64% on [**2148-7-17**]) Hyperlipidemia Right intracerebral hemorrhage complicated by left hemiparesis and vasospasm status post right hemicraniectomy and embolization of right MCA aneurysm Migraine headaches Remote history of lung abscess Ventilator-associated pneumonia Status post sinus surgery Social History: Prior to recent cerebrovascular accident, patient was completely independent and worked in a group home for adults with developmental disabilities. -Tobacco history: 1 ppd x >30 years. -ETOH: Denies. -Illicit drugs: Denies. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: On admission: VS: 98.5, 124/63, 56, 18, 98% RA GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: Status post right hemicraniectomy. Sclerae anicteric. PERRL, EOMI. Conjunctivae pink, no pallor or cyanosis of the oral mucosa. No xanthelasma. NECK: Supple with no JVD. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR. SEM throughout precordium. No thrills, lifts. No S3 or S4. LUNGS: Respirations unlabored, no accessory muscle use. CTAB anteriorly. ABDOMEN: Soft, NT/ND. No HSM or tenderness. EXTREMITIES: No c/c/e. R groin access site without ecchymosis, hematoma, nonTTP. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. NEURO: Detailed exam deferred. Physical Examination on Discharge: Alert and oriented x3. Awake, pleasant with occasional perservation and hallucinations. PERRL. Pupils 5-2mm bilaterally. Left hemiparesis unchanged, left UE greater than left LE. Right upper and lower extremity strength unchanged. Incision is clean, dry and intact with sutures and staples in place. Pertinent Results: On admission: [**2148-9-17**] 05:08PM BLOOD WBC-7.6 RBC-3.84* Hgb-11.5* Hct-34.6* MCV-90 MCH-30.0 MCHC-33.3 RDW-14.9 Plt Ct-203 [**2148-9-17**] 05:08PM BLOOD PT-11.5 PTT-30.3 INR(PT)-1.1 [**2148-9-17**] 05:08PM BLOOD Glucose-94 UreaN-12 Creat-0.6 Na-137 K-4.4 Cl-102 HCO3-25 AnGap-14 [**2148-9-17**] 05:08PM BLOOD Calcium-8.6 Phos-5.0*# Mg-1.9 [**2148-9-17**] 10:56AM BLOOD Type-ART FiO2-20 pO2-74* pCO2-49* pH-7.36 calTCO2-29 Base XS-0 Intubat-NOT INTUBA [**2148-9-17**] 07:20PM BLOOD CK(CPK)-67 [**2148-9-18**] 07:10AM BLOOD CK(CPK)-75 [**2148-9-17**] 07:20PM BLOOD CK-MB-8 cTropnT-0.11* [**2148-9-18**] 07:10AM BLOOD CK-MB-9 cTropnT-0.21* . Cardiac catheterization ([**2148-9-17**]): FINAL DIAGNOSIS: 1. No significant coronary artery disease. 2. Critical aortic stenosis. 3. Successful balloon aortic valvuloplasty. Head CT without Contrast ([**2148-9-21**]): IMPRESSION: Increased edema surrounding the right temporal hematoma. No other significant change in appearance of intraparenchymal hemorrhage after cranioplasty. TTE ([**2148-9-17**]): There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is normal (LVEF>55%). The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Mild (1+) aortic regurgitation is seen. There is no pericardial effusion. IMPRESSION: Focused transthoracic examination following aortic valvuloplasty shows residual moderate to severe aortic stenosis (mean gradient 40 mmHg) with mild aortic regurgitation. There is no pericardial effusion. Portable CXR ([**2148-9-17**]): In comparison with study of [**7-25**], the cardiac silhouette remains prominent and there is tortuosity of the aorta. However, no evidence of acute focal pneumonia or vascular congestion or pleural effusion. There may be mild atelectatic changes in the retrocardiac region. Labs on Discharge: [**2148-9-23**] 05:55AM BLOOD WBC-4.9 RBC-3.12* Hgb-9.5* Hct-28.2* MCV-90 MCH-30.5 MCHC-33.7 RDW-15.3 Plt Ct-180 [**2148-9-23**] 05:55AM BLOOD Plt Ct-180 [**2148-9-23**] 05:55AM BLOOD Glucose-90 UreaN-14 Creat-0.6 Na-140 K-3.7 Cl-107 HCO3-29 AnGap-8 [**2148-9-23**] 05:55AM BLOOD Calcium-7.9* Phos-2.7 Mg-1.9 Brief Hospital Course: Ms. [**Known lastname 52932**] is a 56F with h/o critical aortic stenosis ([**Location (un) 109**] 0.5cm2 on [**2148-7-17**]), congestive heart failure (LVEF 64% on [**2148-7-17**]), atrial fibrillation (not on anticoagulation), resolved mitral valve prolapse, and recent admission for R intracranial hemorrhage s/p R hemicraniectomy and embolization of R MCA aneurysm who was admitted from an extended care facility for aortic valvuloplasty and R cranioplasty. Active Issues: # Critical aortic stenosis: Patient with incidentally noted critical aortic stenosis ([**Location (un) 109**] 0.5cm2, peak gradient 125mmHg on [**2148-7-17**]) underwent aortic valvuloplasty on hospital day 1. Postprocedural TTE demonstrated [**Location (un) 109**] 0.8-1cm2 and peak gradient 63mmHg consistent with residual moderate to severe aortic stenosis; mild aortic regurgitation also was noted. # Chest pain/troponinemia: Patient reportedly experienced central chest pain periprocedurally, with recurrence, less severe in intensity, following arrival to the cardiology floor. EKG demonstrated ST-T wave abnormalities unchanged from priors [**2148-7-29**]. Mild troponinemia (0.11 -> 0.21) was felt to be attributable to myocardial stretch in the setting of aortic valvuloplasty, particularly given reportedly normal cardiac catheterization earlier in the day. Chest pain resolved with sleep and did not recur the following day. # Atrial fibrillation: Patient remained in sinus rhythm on amiodarone 200mg daily, but off aspirin in anticipation of right cranioplasty. # R intracranial hemorrhage s/p R hemicraniectomy and embolization of R MCA aneurysm: Levetiracetam 500mg [**Hospital1 **], gabapentin 400mg qid, and modafinil 100mg daily were continued. Inactive Issues: # Depression/Anxiety: Home sertraline 100mg daily, trazodone 75mg qhs, and Ativan 0.5mg q4h prn anxiety were continued throughout admission. # Hyperlipidemia: Home atorvastatin 20mg daily was continued throughout admission. # Gastroesophageal reflux disease: Home omeprazole 20mg [**Hospital1 **] was continued throughout admission. Patient was transferred to Neurosurgery on [**2148-9-18**]. The patient was made NPO at midnight for a planned right cranioplasty on [**9-19**]. Post-operatively, her hematocrit was low and she received 2 units of pRBCs. Post-op head CT showed a new right temporal IPH. She received 2 units of FFP and was transferred to the ICU for work-up of decrease in hematocrit. Her troponins were mildly elevated which was thought to be secondary to the valvuloplasty. On [**9-20**], she received 2 additional units pRBCs. EKG changes were noted and the troponins were cycled. She complained of a headache, nausea and began vomiting. She was started on Mannitol 12.5mg Q6H. The subgaleal drain was removed and four staples were placed. On [**9-21**], the Mannitol was discontinued. The repeat non-contrast head CT was stable. She received Toradol 15mg x two doses for headaches. A prednisone taper was added for headache. Subcutaneous Heparin was started for DVT prophylaxis. Intravenous pain medication was discontinued. Physical therapy was consulted. On [**9-23**], the prednisone was discontinued secondary to hallucinations and she was started on Zyprexa. She was evaluated by physical therapy and recommended rehabilitation. She is set for discharge to rehabilitation. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Amiodarone 200 mg PO DAILY 2. Atorvastatin 20 mg PO DAILY 3. BusPIRone 15 mg PO TID 4. Docusate Sodium 100 mg PO BID 5. Gabapentin 400 mg PO QID 6. LeVETiracetam 500 mg PO BID 7. modafinil *NF* 100 mg Oral qam 8. Omeprazole 20 mg PO BID 9. Sertraline 100 mg PO DAILY 10. traZODONE 75 mg PO HS 11. Lorazepam 0.5 mg PO Q4H:PRN anxiety Hold for sedation, RR<10 Discharge Medications: 1. Amiodarone 200 mg PO DAILY 2. Atorvastatin 20 mg PO DAILY 3. BusPIRone 5 mg PO TID 4. Docusate Sodium 100 mg PO DAILY:PRN constipation 5. Gabapentin 400 mg PO QID 6. LeVETiracetam 500 mg PO BID 7. traZODONE 75 mg PO HS 8. Lorazepam 0.5 mg PO Q4H:PRN anxiety Hold for sedation, RR<10 9. modafinil *NF* 100 mg Oral qam 10. Sertraline 100 mg PO DAILY 11. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain 12. Ondansetron 4 mg IV Q6H:PRN nausea 13. Heparin 5000 UNIT SC TID 14. Acetaminophen-Caff-Butalbital [**12-11**] TAB PO Q6H:PRN headache 15. Bisacodyl 10 mg PO DAILY:PRN constipation 16. OLANZapine 5 mg PO DAILY 17. Omeprazole 20 mg PO BID Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Cranial defect Urinary tract infection 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: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Your wound was closed with sutures and staples. You may wash your hair only after sutures and staples have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. Followup Instructions: Please follow-up with Dr [**First Name (STitle) **] in 4 weeks with a CT head. Please call [**Telephone/Fax (1) 4296**] to make this appointment. Completed by:[**2148-9-23**]

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icd9cm

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[ "37.23", "02.03", "88.55", "35.96" ]

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53846

Discharge summary

report

Admission Date: [**2153-5-11**] Discharge Date: [**2153-5-13**] Date of Birth: [**2066-11-9**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 69838**] Chief Complaint: Pneumothorax and hypotension post pleurex cath placement Major Surgical or Invasive Procedure: Right pleuroscopy, pleural biopsies and PleurX catheter placement Left thoracentesis - 1200cc out History of Present Illness: 86 year old man with h/o mantle cell lymphoma who came for an elective procedure for pleuroscopy with pleurex catheter placement on [**2153-5-11**]. In preparation for the procedure he developed right pneumothorax in an attempt by anesthesia to do a paravertebral block to decrease pain during the procedure. An apical catheter was placed and patient looked better and the procedure went ahead. He did well except being tachycardic to 120s-130s sinus (though has h/o afib). He got esmolol during procedure and with low blood pressures, (SBPs upto 80s) he was placed on neo for rest of procedure. After procedure, Blood pressures in the PACU were low and he was continued on neo. Patient was uncooperating and confused but able to move extremities. He was eventually stabilized with 500cc of IVF in the PACU after receiving 500cc during the procedure. After evaluation by ICU team, he was deemed stable for the floor given stable BPs and improved mental status.(he does have confusion/poor memory at baseline). His BPs awake were SBPs 110-120s. On ROS, he denied any recent fevers, chills, nausea, vomiting, chest pain, shortness of breath, abdominal pain, constipation, diarrhea or dysura. Past Medical History: afib mantle cell lymphoma CAD s/p stent in [**2147**] hypothyroidism hx. of [**5-10**] years of amiodarone therapy s/p CEA [**2150**] with resultant facial droop osteoarthritis of the knees s/p partial gastrectomy 50 years prior Social History: Patient lives in [**Location (un) 37452**] but stays with his son in Fla in the winter. He is a widower of 4 years. He smoked 2ppd for many years but quit 20 years ago. He drinks a glass of scotch nightly and used to drink a glass of scotch and a beer nightly at a younger age. Family History: dementia in his mother, colon CA, stroke, MI in his father Physical Exam: Physical exam on transfer: Temp: 97.6 BP 108/60 HR 91 RR 22 O2sat 97% on RA Ins 420 PO, 2450 IV Output 100V 65 CT apical 400 CT pleurex General: NAD, comfortable and friendly [**Name (NI) 4459**]: EOMI, [**Name (NI) 22031**], oral mucosa moist. Neck: Supple, no JVD, no LAD Heart: Difficulty to assess S1 and S2 due to inspiratory gruntle patient makes Lungs: CTAB, shallow respirations. Chest tubes in place - CT Apical and CT Pleurex - currently on water seal. Abdomen: Soft, NT, ND, NO hepatosplenomegaly Extremities: 2+ pulse, no edema. Neuro: Awake, AxOx2 (person and time). Knows he's in a hospital but confused between [**Hospital1 112**] and [**Hospital1 18**]. Able to list days of week backwards, able to do calculation accurately. Good strength in all extremities ([**5-5**]). No focal lesions. CN II-XII intact. Physical exam on discharge: Temp: 97.3 BP 109/71 HR 113 RR 18 O2sat 97% on RA General: NAD, comfortable and friendly [**Name (NI) 4459**]: EOMI, [**Name (NI) 22031**], oral mucosa moist. Neck: Supple, no JVD, no LAD Heart: Difficulty to assess S1 and S2 due to inspiratory gruntle patient makes Lungs: CTAB, CT Pleurex - currently on water seal. Abdomen: Soft, NT, ND, No hepatosplenomegaly Extremities: 2+ pulse, no edema. Neuro: Awake, AxOx3. Good strength in all extremities ([**5-5**]). No focal lesions. CN II-XII intact. Pertinent Results: Labs on admission [**2153-5-11**] 08:04PM PLEURAL WBC-1225* RBC-[**2090**]* POLYS-41* LYMPHS-56* MONOS-1* OTHER-2* [**2153-5-11**] 08:04PM PLEURAL TOT PROT-2.2 LD(LDH)-268 CHOLEST-9 [**2153-5-11**] 08:15PM PLT COUNT-185 [**2153-5-11**] 08:15PM WBC-11.2*# RBC-3.51* HGB-11.2* HCT-36.9* MCV-105* MCH-31.9 MCHC-30.3* RDW-14.6 [**2153-5-11**] 08:15PM GLUCOSE-94 UREA N-34* CREAT-1.6* SODIUM-136 POTASSIUM-5.0 CHLORIDE-103 TOTAL CO2-22 ANION GAP-16 [**2153-5-11**] 10:08PM PT-13.6* PTT-31.7 INR(PT)-1.3* Imaging CHEST XRAY - [**2153-5-12**] HISTORY: History of mantle cell lymphoma, pleural effusion, pneumothorax. CHEST, SINGLE AP PORTABLE VIEW. Compared with [**2153-5-12**] at 7:37 a.m., there has been interval clearing of opacities at the right base. The right apical pneumothorax is again seen, possibly minimally smaller. The right-sided catheter is grossly unchanged. Cardiomegaly and increased retrocardiac density with additional opacity in the left midzone is unchanged. Upper zone redistribution is again seen. Doubt overt CHF. A catheter is again seen overlying the right upper quadrant or right lower lung. IMPRESSION: 1. Right apical pneumothorax, minimally smaller. 2. Interval clearing of opacities at the right base COMPARISON: [**2153-5-12**] chest radiograph. FINDINGS: Following removal of a right pleural catheter, a small right apical pneumothorax is essentially unchanged in size. Small right pleural effusion also appears similar. Diffuse mediastinal and hilar lymphadenopathy are unchanged. Left retrocardiac opacity also appears similar to the prior study and may reflect atelectasis and/or infectious consolidation. Adjacent moderate left pleural effusion is unchanged. Micro PLEURAL FLUID RIGHT PLEURAL FLUID. GRAM STAIN (Final [**2153-5-11**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ACID FAST SMEAR (Final [**2153-5-12**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): Labs on discharge [**2153-5-12**] 07:55AM BLOOD WBC-8.0 RBC-3.36* Hgb-10.8* Hct-35.3* MCV-105* MCH-32.2* MCHC-30.6* RDW-15.0 Plt Ct-176 [**2153-5-12**] 07:55AM BLOOD Glucose-80 UreaN-35* Creat-1.4* Na-134 K-4.3 Cl-101 HCO3-22 AnGap-15 [**2153-5-12**] 07:55AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.9 [**2153-5-12**] 07:55AM BLOOD cTropnT-0.01 Results pending: - Tissue biopsy - Pleural fluid Brief Hospital Course: 86 yo M with h/o mantle cell lymphoma and recent pleural effusions concerning for malignant effusions who presented for elective pleurex placement and developed pneumothorax and hypotension # Effusions/pleurex placement: Likely malignant effusions (as it is exudate) due to mantle cell lymphoma. Currently awaiting pathology results and biopsy to make final diagnosis. This was an elective procedure for the right pleural effusion to be drained and a pleurex cathether placed. Procedure led to a pneumothorax which resolved with placement of a chest tube. On second day of hospitalization, chest tube was removed. Patient had the left sided pleural effusion drained as well. After subsequent xrays to monitor progression of right sided pleural effusion and to ensure there wasn't a new pneumothorax on the left side, patient was discharged. Daughter was present throughout and will be monitoring his pressures at home. Plan is to follow up wtih IP service. Levofloxacin was intially started for concern of pneumonia however was discontinued prior to discharge. # Hypotension: Patient had borderline low normal pressures and was on neo in PACU. Etiology of hypotension is likely due to anesthesia and poor PO intake for NPO for procedure. Patient was given a total of 1500cc and at 150cc/hr. He was given another 500cc on night prior to discharge to avoid low pressures. He was stable with pressures in the 90s-110s/60s-70s. Patient currently normotensive and further fluids were held to prevent lung collection. # Pneumothorax: Occured in the setting of paravertebral block on right side. Patient was stable enough to go through with right pleurex cath placement. Chest tube was put in place and removed day prior to discharge. Serial Chest Xrays showed improvement of pneumothorax. Final chest xray hours prior to discharge and after left pleural fluid tap showed no pneumothorax on left side. # Hypothyroidism - Patient was stable while in patient and on levothyroxine # Atrial fibrillation: Warfarin was briefly stopped due to procedures, however it was restarted on discharge. # CKD: At baseline. Patient initially had reduced urine output on admission, but with good PO intake and hydration his urine output increased and his creatinine was at his baseline of 1.4-1.6 # CAD: No active issues. Serial troponins were negative. # Psych: Patient was continued on mirtazapine Medications on Admission: - Levothyroxine 112 mcg PO daily - ASA 81 mg PO daily - Zantac 75 mg PO daily - Metoprolol 12.5 mg PO bid - Mirtazapine 15 mg PO DAILY - Simvastatin 40 mg PO daily - Ambien 5 mg PO QHS - Warfarin 0.5 mg PO daily - Tylenol 650 mg prn arthritis - Phytonadione 5 mg PO 2 tablet by mouth Thursday night and 1 tablet on Friday morning (pre-procedure) Discharge Medications: 1. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 5. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 8. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 9. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary Diagnosis Pneumothorax Unspecified pleural effusion Mantle cell lymphoma Secondary Diagnosis Atrial Fibrillation Chronic Kidney Disease Coronary Artery Disease Discharge Condition: confused at times, but appropriate. ambulatory with some unsteadiness to gait at baseline Discharge Instructions: You were admitted to the hospital because you developed a pneumothorax when the interventional pulmonologists were draining the fluid from your right lung. A chest tube was placed and you were admitted to the medicine service for monitoring. The pneumothorax improved the following day and your chest tube was removed. A pleurex catheter was placed as well which was functioning properly. This will remain in place and will be managed by home nursing. You also were noted to have low blood pressures. You briefly required medicines to maintain an adequate blood pressure. Your blood pressure was monitored during your admission. You required some IV fluids however your blood pressure normalized prior to discharge. The left lung was evaluated by the interventional pulmonolgists and more fluid was drained the day of your discharge. Approximately 1.2L of fluid was removed. Medication Changes None Followup Instructions: Follow up in interventional pulmonary clinic with Dr. [**Last Name (STitle) **] in 2 weeks, their clinic coordinator will contact you. [**Telephone/Fax (1) 7769**] for any questions or concerns. Please make a follow up appointment with your PCP [**Name9 (PRE) **],[**Name9 (PRE) **] MD, [**Telephone/Fax (1) 3530**] within one week of discharge. You have an appointment with your oncologist this upcoming week. Please proceed with this scheduled appointment. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 69841**]

[ "V49.86", "427.31", "511.81", "512.1", "V45.82", "200.40", "715.36", "414.01", "E938.3", "785.0", "458.29", "V15.82", "585.9", "E938.6", "244.9" ]

icd9cm

[ [ [] ] ]

[ "34.91", "34.20", "34.04", "34.06", "34.09" ]

icd9pcs

[ [ [] ] ]

9878, 9927

6404, 8790

362, 462

10140, 10233

3698, 5737

11184, 11772

2245, 2305

9186, 9855

9948, 10119

8816, 9163

10257, 11161

2320, 3148

5962, 5962

5993, 6381

3176, 3679

266, 324

490, 1681

5819, 5926

1703, 1933

1949, 2229

5769, 5783

64,887

112,914

37318

Discharge summary

report

Admission Date: [**2117-2-6**] Discharge Date: [**2117-2-17**] Date of Birth: [**2035-9-12**] Sex: F Service: MEDICINE Allergies: Lisinopril Attending:[**First Name3 (LF) 2009**] Chief Complaint: Rectal bleeding Major Surgical or Invasive Procedure: None History of Present Illness: 81F with atrial fibrillation on coumadin, Hep B without ESLD, s/p colonoscopy 8 days PTA, presenting with 7 days of mild rectal bleeding with 2 days of heavier bleeding and finding of low hematocrit as an outpatient. She had routine outpatient colonoscopy at [**Hospital1 112**] on [**2116-1-30**]. Daughter reports polyps removed, but report not yet available. She had stopped coumadin prior to procedure, and resumed use the day following her procedure. Since the procedure she has noted small amounts of red blood in her stools. Then two day ago she had a large bowel movement which was basically all red blood. Since then she has had 5 similar bowel movements. No abdominal pain, but notes a gassy feeling. Has felt fatigued with activity and daughter notes she slept in today. Has had decreased PO intake and little interest in food since colonoscopy, but most notably in past 2 days since larger bleeding started. Also notes a feeling of her heart pounding earlier today. No chest pain or dyspnea. No fever. No lightheadedness or presyncope. She presented to her PCP today, thought ?related to colonoscopy vs. viral. Prescribed lomotil and took one dose today. Labs returned with hematocrit of 24.1. She was therefore referred to the ED. . In the ED, initial vs were: T98.1 P71 123/34 16 100% on RA. Vital signs remained stable throughout ED course. BRB on rectal exam. Hct 21.9 and INR 2.4. Given 5 mg IV vitamin K, ordered for FFP and typed and crossed for 2 units PRBCs. GI paged but have not yet called back. Admitted to MICU given severity of anemia, age, unclear how fast she is bleeding. . On the floor, patient reports feeling well, just fatigued. No abdominal pain. Past Medical History: - Atrial fibrillation, most recently in sinus. On beta blocker and coumadin. - Hepatitis B. No evidence of cirrhosis ever. Recent labs ([**1-30**]) with viral load of 431 and normal LFTs. - Hypertension - ?Past CVA or TIA (had weakness of fingers of one hand, which resolved) - Hyperlipidemia - Osteopenia/osteoporosis - ?Elevated fasting glucose - "being watched" per daughter. - s/p cataract surgery [**11/2116**], no complications. Social History: Lives with daughter and granddaughter. [**Name (NI) **] works full time. - Tobacco: remote history of occasional smoking, quit > 45 years ago. - Alcohol: none - Illicits: none Family History: Daughter with kidney stones. Physical Exam: Admission exam: General: Appears younger than stated age, alert, oriented, no distress. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVD 2-3 cm ASA, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi, some decrease at bases. CV: Regular rate and rhythm, normal S1 + S2, soft SM at RUSB and at apex. No significant radiation to carotids. 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: CN II-XII intact. Strength 5/5 in UEs and LEs. Pertinent Results: Admission labs: [**2117-2-6**] 08:55PM BLOOD WBC-6.7 RBC-2.36* Hgb-7.4* Hct-21.9* MCV-93 MCH-31.3 MCHC-33.7 RDW-13.6 Plt Ct-216 [**2117-2-6**] 08:55PM BLOOD Neuts-53.0 Lymphs-40.0 Monos-4.7 Eos-1.3 Baso-1.1 [**2117-2-6**] 08:55PM BLOOD PT-25.4* PTT-34.1 INR(PT)-2.4* [**2117-2-6**] 08:55PM BLOOD Glucose-132* UreaN-24* Creat-0.8 Na-139 K-3.8 Cl-107 HCO3-23 AnGap-13 [**2117-2-6**] 08:55PM BLOOD ALT-11 AST-20 LD(LDH)-182 AlkPhos-32* TotBili-0.2 [**2117-2-8**] 06:48AM BLOOD CK-MB-4 cTropnT-0.02* (subsequent .01) [**2117-2-7**] 06:43AM BLOOD Calcium-7.8* Phos-3.1 Mg-2.1 [**2117-2-6**] 08:55PM BLOOD Albumin-3.4* [**2117-2-6**] 10:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.008 [**2117-2-6**] 10:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG Discharge and other labs: [**2117-2-12**] 07:05AM BLOOD TSH-0.59 [**2117-2-17**] 06:10AM BLOOD WBC-7.3 RBC-4.26 Hgb-12.2 Hct-36.8 MCV-86 MCH-28.7 MCHC-33.2 RDW-17.0* Plt Ct-264 [**2117-2-17**] 06:10AM BLOOD PT-17.5* INR(PT)-1.6* [**2117-2-17**] 06:10AM BLOOD Glucose-92 UreaN-17 Creat-0.8 Na-143 K-3.9 Cl-108 HCO3-25 AnGap-14 [**2117-2-11**] 07:00AM BLOOD CK(CPK)-140 [**2117-2-17**] 06:10AM BLOOD Calcium-8.6 Phos-3.2# Mg-2.1 Studies: [**2-10**] R ankle x-ray Five total images of the right foot and lower leg are submitted. The bones are osteopenic. There is a small ankle joint effusion. There are mild degenerative changes at the tibiotalar joint and talonavicular joint. No acute abnormality is noted. Five total images of the right foot and lower leg are submitted. The bones are osteopenic. There is a small ankle joint effusion. There are mild degenerative changes at the tibiotalar joint and talonavicular joint. No acute abnormality is noted. [**2-16**] CXR Transvenous right atrial and right ventricular pacer leads follow their expected courses from the left axillary pacemaker. No pneumothorax or mediastinal widening is present. Lateral view shows a very small pleural effusion collected posteriorly. Heart size normal, probable small pericardial effusion projects to the left of the cardiac apex, but there is no mediastinal vascular engorgement to suggest that this is hemodynamically significant. Vascular deficiency in the right upper lobe is probably due to emphysema. No focal pulmonary abnormality is seen elsewhere. Brief Hospital Course: 81 yo F with atrial fibrillation on Coumadin, chronic HBV without ESLD, presenting with BRBPR s/p colonoscopy one week ago. . # BRBPR. Presenting with 2 days of painless rectal bleeding, in the setting of having a colonoscopy one week ago - high suspicion for post-polypectomy bleed in the setting of re-starting Coumadin as an outpatient, particularly since pt had been having smaller amounts of bleeding since the procedure. No evidence of ischemic colitis. Patient was admitted overnight to the MICU and made NPO while trending her hematocrit. Her INR was reversed with vitamin K and FFP. GI saw her and recommended continued supportive management at this time. We obtained OSH records that confirmed polypectomy x3 in the cecum. Patient was stable throughout the day in the MICU and transferred to the floor. Patient had one additional episode of bloody BM on the general medicine floor in the setting of PTT >150 while on Heparin drip bridging to Coumadin, and this resolved when Heparin was discontinued. Hct was stable and patient did not require any transfusions. She did not have any additional BRBPR during her hospital stay. . # Atrial fibrillation. On coumadin. Patient's anticoagulation was initially held in the setting of acute bleed, but then restarted by the time of patient's discharge from the MICU. She was started on Metoprolol 25mg [**Hospital1 **] (increased from home dose of Metoprolol 25mg daily) and was paroxysmally in and out of a fib/flutter throughout her stay on the medicine wards. Patient's HR was in the 140's during episodes of a fib/flutter. Heart rate responded to IV Metoprolol and IV Diltiazem, but the patient was seen to have [**3-28**] second pauses on telemetry with IV nodal agents. She was seen by her outpatient cardiologist and was scheduled to have a pacemaker placed which was done on [**2-15**]. Given the patient was only symptomatic from her a fib/flutter was during the initial episode on the floor, and remained asymptomatic with stable BPs during her subsequent episodes of a fib/flutter, it was decided to hold off on attempt to rate control prior to placement of pacemaker. After the pacemaker was placed she continued to have afib with RVR without a good response to Metoprolol. Diltiazem was started with good response. Amiodarone loading with 400mg [**Hospital1 **] was also started on day of discharge. Her INR was not therapeutic at discharge however there was concern of bleeding into the pacemaker pocket if she were bridged with Heparin. . # Hypertension. Normotensive in the MICU. BP meds were held in the setting of acute bleed. . # Osteoporosis versus osteopenia. Fosamax was held while patient was in-house and started at discharge. . #Next of [**Doctor First Name **]: [**Known lastname **],[**First Name3 (LF) **] Relationship: DAUGHTER Phone: [**Telephone/Fax (1) 83954**] Other Phone: [**Telephone/Fax (1) 83955**] # Code: Full Medications on Admission: - Coumadin 2.5 mg Tue/Fri, 2 mg other days - Avapro 150 mg daily - Metoprolol 25 mg daily - Fosamax 70 mg weekly - Simvastatin 20 mg daily - Multivitamin daily - vitamin D 1000 units daily - Fish oil 1000 mg daily Discharge Disposition: Home With Service Facility: Americare at Home Inc Discharge Diagnosis: Bright red blood per rectum Atrial fibrillation/flutter . Secondary Diagnosis: - Hypertension - Diet controlled Diabetes Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You presented to the hospital for bloody bowel movements after having a colonoscopy with removal of polyps. You were on blood thinners during this time, which were held initially while you were in the hospital. You were monitored in the intensive care unit and transfused 4 units of blood to bring your blood counts back up. After your blood count stabilized and you did not have any further bleeds, you were transferred to the floor. While on the general medicine floor, you went into atrial fibrillation/flutter, and were given medications to control your heart rate. Your blood thinners were re-started. A pacemaker was placed in your chest on [**2-15**] since the medications for the atrial fibrillation were causing your heart to beat too slowly. You heart is now beating normally. While you were here some of your home medications were changed. You should CONTINUE taking: Avapro 150 mg daily Fosamax 70 mg weekly Simvastatin 20mg daily multivitamin daily Vitamin D 1000U daily Fish oil 1000U daily You should CHANGE: Coumadin should now be 2mg every day and NOT 2.5mg. You should follow the coumadin dosing as prescribed by your coumadin clinic. You should START: -Cephalexin, an antibiotic which is given to prevent infection after a procedure. Finish the pills in the prescription. -Diltiazem 120mg daily -Amiodarone 400mg twice a day. Take this pill until told to stop by Dr. [**First Name (STitle) **]. -Tylenol as needed for pain. If that doesn't work you can take Oxycodone as prescribed, however do not drive when using this medication. If you have any palpitations or feel your heart is beating funny you should call you Dr. [**First Name (STitle) **] at the number below. Followup Instructions: An appointment has been scheduled for you with your cardiologist, Dr. [**Last Name (STitle) 83956**] [**Name (STitle) **], on [**2-22**] at 2pm. Your pacemaker will be checked at that time. Telephone number [**Telephone/Fax (1) 2258**]. You should have your INR checked your lab or PCP's office on Friday [**2-19**]. You should follow-up with your primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 644**]) on [**2-22**] at 11am.

[ "272.4", "578.1", "733.00", "V12.54", "427.31", "E878.8", "733.90", "427.32", "401.9", "998.11", "070.32", "274.9", "250.00", "285.1", "V58.61", "427.81" ]

icd9cm

[ [ [] ] ]

[ "37.83", "37.72" ]

icd9pcs

[ [ [] ] ]

8959, 9011

5769, 8695

286, 292

9176, 9176

3377, 3377

11047, 11546

2694, 2724

9032, 9090

8721, 8936

9321, 11024

2739, 3358

231, 248

320, 2023

9111, 9155

3393, 4218

9190, 9297

2045, 2484

2500, 2678

4230, 5746

13,993

180,704

1978

Discharge summary

report

Admission Date: [**2103-10-10**] Discharge Date: [**2103-11-16**] Date of Birth: [**2039-8-30**] Sex: F Service: Thoracic Surgery HISTORY OF PRESENT ILLNESS: The patient is a 63-year-old woman with diabetes and a past history of lung cancer who is status post bilateral upper lobectomies. Over the past year, the patient has had problems with persistent pneumonia and an effusion on the right side that was thought to be due to a mechanical narrowing and kinking of her right middle lobe bronchi resulting in a right middle lobe syndrome. A video thoracoscopy had identified the right middle lobe as a small, and voluted, and chronically infected structure. After a long discussion with the patient, her family, and her primary care physician, [**Name10 (NameIs) **] was determined that the most reasonable course of action was surgical resection given that the only other alternative would be likely frequent readmissions for a persistent pneumonia and effusions on this right side. CONCISE SUMMARY OF HOSPITAL COURSE: Thus, on [**2103-10-10**], the patient was taken for a right middle lobectomy and a tracheobronchoplasty. Immediately postoperatively, the patient was able to be extubated but had some mucoid secretions that plugged her lower lube bronchi, resulting in respiratory distress. The patient had to be intubated again, and at bronchoscopy a mucous plug was evacuated, and the patient was able to be subsequently extubated. Unfortunately, this problem happened again, and the patient had to be reintubated, and again underwent a therapeutic bronchoscopy. At this point, the patient was transferred to the Cardiothoracic Intensive Care Unit where she was monitored very closely for evidence of a recurrent mucous plugging of her lower lobe bronchi. On postoperative day two, the patient had a bedside percutaneous tracheostomy placed by Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**] to facilitate aggressive pulmonary toilet. Over the next several days, we were able to wean her ventilatory support and progressed quite rapidly to having the patient on tracheostomy mask during the day with some ventilatory support at night. The patient had intermittent episodes of recurrent mucous plugging of her right lower lobe bronchi; at which point we performed expeditious therapeutic bronchoscopies to evacuate the mucous plugging and to reexpand her lower lobe. The patient initially improved and stabilized and was actually to progress toward using a Passy-Muir valve. However, approximately two weeks postoperatively she developed a methicillin-resistant Staphylococcus aureus pneumonia. Despite early and aggressive antibiotic therapy, as well as intermittent therapeutic bronchoscopies, the patient progressively deteriorated. We attempted to optimize her nutrition by feeding her through her previously placed gastrostomy tube and having her work with the physical therapist as much as possible; which included taking daily walks around the Intensive Care Unit. However, over the next three weeks, this pneumonia settled into the basilar segments of her right lower lobe and she became progressively depressed and physically fatigued. Early in her hospitalization, we requested the assistance of the Psychiatry Service in managing her depressed mood as well as her anxiety. They were very helpful in getting her on an appropriate medication regimen including Remeron and Seroquel with as needed Ativan. Over the ensuing weeks, the patient began to express a dissatisfaction with her continued tube feeds and positive pressure ventilation at night. After an extensive discussion with her husband, her daughters (including one daughter who is a clinical psychologist), and the patient; it was felt that the situation with her limited pulmonary reserve in the face of this unremitting pneumonia would not likely allow her to be off life support in the near future. Consequently, she requested that the life saving measures be discontinued and that she be allowed to expire comfortably. Thus, on [**2103-11-16**], in the presence of her family, we placed the patient on a tracheostomy mask. She was able to say her final good byes, and we initiated a low-dose morphine drip to eliminate any air hunger, after which she expired. CONDITION AT DISCHARGE: Condition on discharge was deceased. DISCHARGE DIAGNOSES: 1. Status post right middle lobectomy and tracheobronchoplasty on [**2103-10-10**]. 2. Methicillin-resistant Staphylococcus aureus pneumonia. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**] Dictated By:[**Dictator Info 10891**] MEDQUIST36 D: [**2103-11-16**] 20:50 T: [**2103-11-17**] 05:56 JOB#: [**Job Number 10892**]

[ "496", "E849.7", "518.0", "508.1", "934.1", "428.0", "482.41", "V44.1", "E912" ]

icd9cm

[ [ [] ] ]

[ "96.72", "33.48", "31.79", "32.4", "33.22", "31.1", "96.05", "96.6", "33.21" ]

icd9pcs

[ [ [] ] ]

4392, 4809

1043, 4318

4333, 4371

176, 1014

65,236

141,639

50225

Discharge summary

report

Admission Date: [**2169-7-25**] Discharge Date: [**2169-7-28**] Date of Birth: [**2114-8-2**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1943**] Chief Complaint: Medication overdose, somnolence Major Surgical or Invasive Procedure: Intubation History of Present Illness: 54yo woman with a history of major depressive disorder with prior suicidal ideations found unresponsive by husband with time of ingestion at approx 1500. Per husband, patient was distressed with multiple stressors and they had gotten into an argument. She went to the bathroom and took a number of pills (unclear which and how many) and was subsequently found to be speaking nonsensical sentences. Her husband promptly called EMS. She was found to be unresponsive in field with a saturation of 50% on RA with good pleth but hemodynamically stable. Narcan was reportedly tried without success. She was emergently intubated in the field and given versed 5mg IV and fentanyl 100mcg IV for sedation. After intubation the patient awoke and they were unable to successfully sedate patient with this regimen despite an additional bolus of versed 2mg IV ONCE. In the ED, she had the following intial vital signs: 96.9 97 100/61 20 99% on 500/14, FIO2 100%/PEEP 5. Propofol started at 30mcg/kg/hr instead of fent/midaz with increased sedation. The patient was subsequently noted to be increasingly bradycardiac to the 50s, then high 40s thought to be secondary to propofol. Toxicology was consulted who recommended serial cardiac and neurologic monitoring. The patient had 2 18 gauge IVs in place and given a total of 1.2L of NS. Last set of vitals were 97.2 53 110/70 14 100% on same settings as above. Past Medical History: 1) L Bradyalgia 2) Cervical spondylosis 3) Myelopathy 4) Esophageal ulcer 5) Bladder prolapse s/p repair 6) Depression 7) Gastroesophageal reflux 8) Esophageal ulcer 9) Melanoma s/p excision Social History: Former nurse, currently retired. - Tobacco: Nonsmoker - Alcohol: Rarely drinks (confirmed with husband) - [**Name (NI) 3264**]: None per husband Family History: Unknown Physical Exam: On admission: 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 GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Constricted pupils bilaterally but PERRL, rousable to voice and vigorous stimulation barely opens eyes, follows commands in all four extremities, nods head in affirmative when asked if in pain On discharge: pt is awake and alert and oriented x3. Very tearful. No other abnormal findings on physical exam. Pertinent Results: Labs on admission: [**2169-7-25**] 04:37PM BLOOD WBC-10.1 RBC-3.74* Hgb-12.7 Hct-38.1 MCV-102* MCH-34.0* MCHC-33.3 RDW-13.5 Plt Ct-305 [**2169-7-25**] 04:37PM BLOOD Fibrino-519* [**2169-7-25**] 06:55PM BLOOD Glucose-94 Na-143 K-4.1 Cl-107 HCO3-23 AnGap-17 [**2169-7-25**] 04:37PM BLOOD ALT-20 AST-37 LD(LDH)-356* AlkPhos-75 TotBili-0.3 [**2169-7-25**] 06:55PM BLOOD Calcium-8.2* Phos-2.7 Mg-2.1 [**2169-7-25**] 04:37PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2169-7-25**] 06:55PM BLOOD Acetmnp-NEG [**2169-7-25**] 06:46PM BLOOD Type-ART Tidal V-500 FiO2-100 pO2-356* pCO2-31* pH-7.54* calTCO2-27 Base XS-5 AADO2-341 REQ O2-61 -ASSIST/CON Intubat-INTUBATED [**2169-7-25**] 04:45PM BLOOD Glucose-153* Lactate-2.9* Na-142 K-4.7 Cl-100 calHCO3-28 [**2169-7-25**] 04:45PM BLOOD freeCa-1.04* Labs on discharge: [**2169-7-28**] 07:50AM BLOOD WBC-7.8 RBC-3.89* Hgb-13.0 Hct-37.3 MCV-96 MCH-33.5* MCHC-34.9 RDW-13.2 Plt Ct-266 [**2169-7-28**] 07:50AM BLOOD Glucose-87 UreaN-9 Creat-0.7 Na-142 K-3.8 Cl-103 HCO3-29 AnGap-14 CXR [**7-25**]:Endotracheal tube is seen with tip at the level of the carina. Lungs are well aerated with the exception of linear atelectasis in the left base. Cardiomediastinal silhouette is unremarkable. CXR [**7-26**] n comparison with the study of [**7-25**], the tip of the endotracheal tube measures approximately 4.2 cm above the carina. Minimal atelectatic changes are seen at the left base and there is mild elevation of the right hemidiaphragmatic contour. No evidence of vascular congestion or acute focal pneumonia Brief Hospital Course: 54F with h/o MDD with prior suicidal ideations who presents with polysubstance overdose, leading to respiratory faiulre, with concerns for benzo, SSRI, and/or antipsychotic drug toxicity. # Overdose: The patient may have potentially ingested vilazodone, fluoxetine, clonazepam, lorazepam, aripiprazole, and Percocet per report. Her negative tox screen seems to make opiate, TCA, or tylenol overdose less likely. Unclear if this was suicide attempt versus accidental ingestion per husband. She was intubated on admission for airway protection and hypoxia and admitted to the ICU where she was treated with supportive care and seen by toxicology who recommended supportive care as QTc normalized. She initially had QT prolongation however this was monitored and improved. She was evaluated by psychiatry who recommended inpatient psychiatric admission. Pt was transferred to psychiatric facility. # Respiratory failure: Secondary to oversedation [**2-15**] benzo toxicity with hypoventilation and inability to protect airway. She was extubated on [**7-26**] without event. Did not have further respiratory problems once extubated. # Hypotension: Very transient and likely [**2-15**] propofol dose versus dehdration. We were not concerned for sepsis as clear CXR, negative U/A, no fever, white count or focal signs/symptoms. Resolved with small fluid boluses. # Bradycardia: Likely [**2-15**] propofol since it correlated with timing of the dose vs persistent benzodiazepem toxicity. This improved during the admission with supportive care only. # Depression: Fair to poor control per husband with chronic SI for years, no prior attempts. Psych was consulted and recommended inpatient psychiatric admission. # UTI: pt developed dysuria after transferred from ICU to the floor with urine positive for WBC and few bacteria. Treated with 3 days of cipro. Medications on Admission: 1) Aripiprazole 5mg PO daily 2) Vibryd 40mg PO daily 3) Clonazepam 5mg HS 4) Lorazepam 5mg HS PRN insomnia 5) Benadryl 1 tab HS PRN insomnia 6) Clonazepam PRN anxiety Discharge Medications: 1. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days. Discharge Disposition: Extended Care Facility: [**Hospital1 69**] - [**Location (un) 86**] Discharge Diagnosis: Drug overdose Urinary tract infection Depression Anxiety Insomnia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [**Known lastname **], It was a pleasure caring for you during your recent hospitalization. You came in with a drug overdose and low breathing rate and some abnormalities in your heart rhythm. Because of your trouble breathing we had to intubate you and keep you in the intensive care unit. After several days your status improved and we were able to extubate you. You are being transfered to a psychiatric facility for futher care. Followup Instructions: Per psychiatry.

[ "518.81", "969.03", "427.89", "969.4", "E938.3", "E950.3", "300.4", "969.3", "599.0", "458.29", "296.90" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

7043, 7113

4591, 6450

335, 347

7222, 7222

2984, 2989

7833, 7851

2164, 2173

6667, 7020

7134, 7201

6476, 6644

7372, 7810

2188, 2188

2866, 2965

264, 297

3827, 4568

375, 1772

3003, 3808

7237, 7348

1794, 1986

2002, 2148

49,037

137,569

52872

Discharge summary

report

Admission Date: [**2178-10-12**] Discharge Date: [**2178-10-20**] Date of Birth: [**2121-1-31**] Sex: F Service: MEDICINE Allergies: Sulfisoxazole Attending:[**First Name3 (LF) 2485**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: History of Present Illness: Ms. [**Known lastname 61295**] is a 57 year old female with HCV cirrhosis, s/p failed liver transplant, admitted with altered mental status. [**Name (NI) **] husband reports over the past few days, she has had increasing become more somnolent. She has been taking lactulose 4x daily, but is having only 2 BMs/day. Denies fevers, chills, dysuria, diarrhea, melena, hematemasis. He did report occasional BRBPR that is longstanding and of note patient had normal colonoscopy with grade 1 varices noted on EGD. She had some complaints of abdominal pain per husband, but he was unable to further clarify these symptoms. . In th ED, vitals were T 98.3, HR 93, BP 113/54, RR 14, O2 Sat 93% on RA. An NGT was placed and she was given lactulose. She was given vanco/cipro/zosyn for conern of SBP. She was given 4L IVF. Labs were notable for an ammonia of 266. She was found to have an INR of 3.6 and a lactate of 6.3. Stox was negative. CT Head was negative. Abdominal ultrasound showed patent portal vein and not enough ascites to safely tap. Abdominal CT showed moderate ascites but no acute process (though oral contrast was not given). Past Medical History: - Cirrhosis [**1-3**] Hep C; s/p OLT [**2172**] with recurrent hep C and autoimmune hepatitis (seen on biopsy); s/p IFN/ribavirin in past. Complicated by recurrent hepatic encephalopathy, SBP prior to transplant per husband, GI bleeding (both BRBPR and melena, last 3-4 months ago per husband, but per husband does not seem that she has ever required blood transfusions etc). - recurrent facial cellulitis of cheeks - asthma - DM - HTN - osteoporosis - nephrolithiasis - h/o C.diff - zoster Social History: Lives with husband. [**Name (NI) 4906**] denies etoh, smoking, drug use. Family History: Noncontributory Physical Exam: VS: HR 95, BP 112/66, RR 14, 100% on RA Gen: moaning, eyes closed HEENT: PERRL CV: +2/6 systolic murmur Pulm: clear to ausculatation Abd: distended, NT, bowel sounds present, no difinitive ascites Ext: 2+ bilateral pitting edema Neuro: unable to cooperate, moving all extremities . Pertinent Results: 139 | 106 | 26 / ---------------- 90 4.3 | 26 | 0.9 \ . CK 59 . .. \ 9.5 / 5.1 ----- 77 .. / 29.9 \ . PT 34.4 PTT 54.5 INR 3.6 . Ammonia 266 . ALT 60 AST 96 AP 88 T. bili 7.2 D. bili 4.2 Alb 2.3 . Stox - negative. . Micro: Bl Cx x 2 - NGTD Urine culture - pending . Lactate 6.3 . Imaging: CXR: no acute process . Liver ultrasound: Patent portal vein with hepatopetal flow CT pelvis. IMPRESSION: 1. Cirrhotic transplant liver with moderate amount of ascites and prominent varices. Portal vein is patent. 2. Small right-sided pleural effusion. 3. Gastric and bowel wall thickening, most likely due to liver disease/hypoalbuminemia. Evaluation is limited, as there was no oral contrast. 4. Multiple vertebral compression fractures, age indeterminate. . Brief Hospital Course: On [**10-20**], house officer was called for increasing O2 requirement. On exam, patient complained of new abdominal pain. On exam, 02 sats low 90s on non-rebreather, other vital signs stable. She was found to have BRBPR. ABG was done, showing pO2 65. CBC and CXR performed. CXR showed no acute process. Transfer to the MICU was arragned. Blood pressure became inaudible, so she was taken emergently to the MICU. In the MICU, patient began to have hematemesis followed shortly by PEA arrest. ACLS protocol was begun. She was transfused multiple units pRBC via rapid infuser. Also given several units of FFP and platelets. Pulse was restored after 30 minutes following ACLS protocol. She continued to have hematemesis and [**Last Name (un) **] tube was placed by the liver attending and fellow. She again went into PEA arrest and ACLS protocol was initiated. During this time discussions were ongoing with the husband and sister regarding her poor prognosis. The patient expired that night from presumed massive gastrointestinal hemorrhage. Ms. [**Known lastname 61295**] is a 57 year old female with cirrhosis admitted for hepatic encephalopathy in setting of UTI. . Hepatic encephalopathy. Hepatic encephalopathy likely triggered by UTI. Patient treated with lactulose 30 q 2 hours for >24 hours until patient had significant improvement of mental status. She was given ceftriaxone for UTI. Not enough ascites to tap and there was low suspicion for SBP, so she did not get a paracentesis or SBP treatment. She was continued on rifaximin. . Cirrhosis S/p liver transplant. Patient has HCV cirrhosis, s/p transplant. She had subequent liver failure secondary to HCV verus autoimmune hepatitis. She was listed for a second transplant during this hospital stay. She was continued on mycophenolate and tacrolimus. Cellcept was held per liver team on hospital day 3. . UTI. Patient found to have pansensitive klebsiella UTI and was treated with 3 days of ceftriaxone, but was switched to cipro due to concern for pancotypenia. . Pancytopenia. Patient developed pancytopenia, requiring 4 units of PRBCs, 4 units FFP, and 1 unit of cryoprecipitate. She was evaluated by hematology who felt it was likely a medication effect (?dose of zosyn given in ED, ceftriaxone for UTI). She was monitored in the ICU. There was no evidence of bleeding or splenic vein thrombosis leading to splenic sequestration. EBV, Parvovirus, and CMV studies were sent for concern for an infectious etiology of pancytopenia. Coagulatopathy. INR 2.5- 3 at baseline but rose to >7 during hospitalization. She was given 4 units of FFP. Her INR stabilized at 2.9. Likely secondary to hepatic dysfunction. She received two days of vitamin K. Thrombocytopenia. Stable. Known to have splenomegaly. HIT was sent, but pending at present. . Renal failure. Cr rose from 1.1 to 1.7 in setting of aggressive Lactulose regimen and getting a dose of lasix 40 IV on hospital day 2. He renal function later imprved with albumin and holding lasix. Hypernatremia. Initially hypernatremic in setting of being NPO for two days due to AMS and dehydration secondary to significant diarrhea from Lactulose. This improved when her mental status improved and she was able to eat and drink. Medications on Admission: Mycophenolate mofetil 1000 mg qam, 500 mg qpm Metoprolol 25 mg [**Hospital1 **] Lactulose 60 TID Pantoprazole 40 mg daily Prednisone 10 mg daily Rifaximin 400 mg TID Tacrolimus 0.5 mg qpm Folic acid Insulin glargin 9 units qhs Lasix 20 mg daily MVI Vitamin D Lispro sliding scale Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased

[ "789.59", "427.5", "584.9", "453.8", "518.81", "996.82", "250.00", "070.54", "284.1", "287.5", "286.9", "578.9", "401.9", "285.1", "599.0", "571.5", "572.2", "276.0" ]

icd9cm

[ [ [] ] ]

[ "38.93", "38.91", "99.60" ]

icd9pcs

[ [ [] ] ]

6812, 6821

3205, 6482

300, 300

6873, 6883

2429, 3182

6940, 6951

2095, 2112

6842, 6852

6508, 6789

6907, 6917

2127, 2410

237, 260

328, 1474

1496, 1989

2005, 2079

23,858

151,226

7000

Discharge summary

report

Admission Date: [**2149-6-17**] Discharge Date: [**2149-7-2**] Date of Birth: [**2077-10-10**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Heparin Agents Attending:[**First Name3 (LF) 1283**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2149-6-17**] Redo Sternotomy, Aortic valve replacement(21mm Pericardial), Mitral valve replacement(27mm Porcine), and Aortic Endarterectomy. [**2149-6-27**] Implantation of Permanent Pacemaker([**Company 1543**]) History of Present Illness: Ms. [**Known lastname 26213**] is a 71 yo F who has had previous bypass grafts x3 and also a mitral valve repair in [**2142**], presented with increasing symptoms of dyspnea on exertion and fatigue. On further investigation with echocardiogram and coronary angiogram it was discovered that she had patent coronary grafts with no significant disease, but she did have severe aortic stenosis with a valve area of 4.8. Intraoperative transesophageal echocardiography also demonstrated severe mitral stenosis. The mitral valve repair previously has been with an annuloplasty band. Left ventricular ejection fraction was about 50% and she was electively admitted for redo aortic as well as mitral valve replacement. Past Medical History: Mitral stenosis Aortic stenosis CAD, s/p CABG and MV repair in [**2142**] HTN DMII Hypercholesterolemia b/l carotid stenosis rectal ca, s/p resection and chemo/XRT s/p TAH in [**2134**] s/p cavernous malformation in the R. parietal region pulmonary HTN Social History: Patient is widowed. Her daughter lives in an apartment above her home. She has four adult children and a daughter in law who is a nurse. Family History: No history of premature CAD Physical Exam: Vitals: BP 135/50, HR 72, RR 20 General: elderly female in no acute distress HEENT: oropharynx benign, PERRL Neck: supple, no JVD, bilateral carotid bruits noted Heart: regular rate, normal s1s2, 4/6 SEM Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds, well healed scar Ext: warm, 1+ edema, Pulses: 2+ distally Neuro: alert and oriented, CN 2-12 intact, nonfocal Pertinent Results: [**2149-7-1**] 07:10AM BLOOD Hct-30.1* Plt Ct-264# [**2149-7-2**] 06:30AM BLOOD PT-28.8* INR(PT)-3.0* [**2149-7-1**] 04:10PM BLOOD PT-31.2* PTT-37.8* INR(PT)-3.3* [**2149-7-2**] 06:30AM BLOOD Creat-1.4* [**2149-7-2**] 06:30AM BLOOD Creat-1.4* [**2149-7-1**] 04:10PM BLOOD Creat-1.5* [**2149-7-1**] 07:10AM BLOOD Glucose-105 UreaN-27* Creat-1.5* Na-136 K-4.1 Cl-92* HCO3-32 AnGap-16 [**2149-6-29**] 04:57AM BLOOD K-4.8 [**2149-6-28**] 04:40AM BLOOD Glucose-74 UreaN-26* Creat-1.3* Na-140 K-3.6 Cl-96 HCO3-31 AnGap-17 [**Last Name (NamePattern4) 4125**]ospital Course: On [**2149-6-17**], Ms. [**Known lastname 26213**] was admitted to the cardiac surgery service under the care of Dr. [**Last Name (Prefixes) **]. That same day, she underwent a redo-sternotomy, mitral and aortic valve replacements, with an aortic endarterectomy. For details of the procedure please see Dr. [**Last Name (STitle) **] [**Last Name (Prefixes) 2546**] operative report. Following the operation, she was brought to the CSRU for invasive monitoring. Within 24 hours, she awoke neurologically intact and was extubated. She maintained stable hemodynamics and weaned from pressor support without difficulty. On postoperative day two, she transferred to the SDU. On postoperative day three, she converted to a rate controlled atrial fibrillation which was initially treated with Amiodarone. She went on to develop bradycardia/complete heart block with junctional escape rhythm which required ventricular pacing. All nodal agents were discontinued and the EP service was consulted for pacemaker evaluation. After several days of observation, it was decided to proceed with permanent pacemaker due to persistent complete heart block/atrial fibrillation with junctional escape and the need for beta blockade. On [**2149-6-27**], the EP service successfully implanted a dual chamber [**Company 1543**] pacemaker with settings DDD/AAI 60-120. Mrs. [**Known lastname 26213**] tolerated the procedure well and there were no complications. Her hospital course was also notable for the diagnosis of HIT which was confirmed by Heparin PF4 antibody by [**Doctor First Name **] . Her platelet count dropped as low as 110K. She was temporarily treated with intravenous Argatroban and slowly transitioned to Coumadin. Coumadin was dosed daily for a goal INR between [**12-27**]. Once her pacemaker was implanted, beta blockade was slowly advanced as tolerated. She otherwise continued to make clinical improvements with medical therapy and steady progress with physical therapy. Medications on Admission: Enalapril 20", Lasix 80', Klor-Con 10meq', Metoprolol 50", Metalozone 2.5 QOD, Actos 30', Lipitor 80', Protonix 40', Diovan 160", FA 1', ASA 81' Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 6. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*0* 9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours). Disp:*120 Capsule, Sustained Release(s)* Refills:*0* 10. Coumadin 1 mg Tablet Sig: Three (3) Tablet PO at bedtime: 3 mg x 2 days, check INR [**7-4**] with results to Dr. [**Last Name (STitle) 4783**] . Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: Severe aortic stenosis and prostheric mitral stenosis - s/p AVR, MVR, Postoperative Complete Heart Block, Postop Atrial Fibrillation, Heparin Induced Thrombocytopenia, Congestive Heart Failure, Coronary Artery Disease - prior CABG, Hypertension, Diabetes Mellitus, Hypercholesterolemia, Carotid Disease, History of Colon Cancer - s/p colectomy, Hyperhomocystenemia Discharge Condition: Good Discharge Instructions: Call with fever, redness or drainage from incisions, or weight gain more than 2 pounds in one day or five in one week, Shower, no bath, no lotions, creams or powders to incision. No driving or heavy lifting until follow up with surgeon. [**Last Name (NamePattern4) 2138**]p Instructions: Dr. [**Last Name (Prefixes) **] in 4 weeks - call for appt [**Telephone/Fax (1) 170**] Dr. [**Last Name (STitle) 5017**] in 2 weeks - call for appt [**Telephone/Fax (1) 5424**] and for coumadin follow up Device clinic early next week [**Telephone/Fax (1) 59**] Completed by:[**2149-7-2**]

[ "V10.05", "287.4", "250.00", "428.0", "414.00", "272.0", "427.31", "426.0", "V45.81", "401.9", "997.1", "E934.2", "396.0" ]

icd9cm

[ [ [] ] ]

[ "37.72", "39.61", "35.21", "37.83", "35.23" ]

icd9pcs

[ [ [] ] ]

6207, 6290

315, 533

6699, 6706

2176, 2693

1719, 1748

4912, 6184

6311, 6678

4743, 4889

6730, 6968

7019, 7310

1763, 2157

2744, 4717

256, 277

561, 1273

1295, 1549

1565, 1703

78,729

198,023

4775+55607

Discharge summary

report+addendum

Admission Date: [**2129-12-16**] Discharge Date: [**2129-12-21**] Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 618**] Chief Complaint: ICH Major Surgical or Invasive Procedure: none History of Present Illness: The pt is a 88 y/o man with a history of a-fib on Coumadin presented to an OSH after being found at home by family in a disheveled manner. OSH ordered a CT head and found ICH and subsequently sent him here for neuro-[**Doctor First Name **] evaluation. Per report he had a series of falls lately. Family not at bedside yet. I tried called emergency contact [**Name (NI) **] [**Name (NI) **] at [**Telephone/Fax (1) 20038**] and [**Telephone/Fax (1) 20039**], both of these numbers do not work. The patient himself states he has had falls but none today. He does not know exactly he is here, but states he is here " to get better", to "fix my medical needs". I told him he was here because of bleeding in his brain. He states that he had a headache earlier but not currently, he notes no weakness or numbness. Denies diplopia as well. Past Medical History: a-fib HTN, Hyperlipidemia, CKD Social History: lives alone. He denies bad habits. Family History: No history of head bleeds. Physical Exam: At admission: Vitals: T:97.4 P:122 R: 16 BP:115/61 SaO2:96 2lNC General: Awake, cooperative, NAD. HEENT: has a left frontal bruise, and a small lac on his forehead. Dry Mucus membranes. Neck: in a hard C-collar. Pulmonary: Lungs CTA bilaterally Cardiac: irregular, systolic murmur with displaced PMI. Abdomen: soft, NT/ND. Extremities: No edema, his right wrist has ulnar deviation. The right leg is externally rotated. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented to person, birth date, and hospital, not the name, states the year is [**2129**] and its [**Month (only) 404**] but thinks its the first. Unable to give me details of his history. He is dysarthric, and I believe he called the feather a letter? but it may have been feather. and he called the glove a fist. Able to repeat. Able to follow one step commands but not 3 step commands. Did not try 2 step commands. He has a grasp reflex b/l and he has motor perseveration and verbal perseveration as well (verbal only demonstrated twice). -Cranial Nerves: I: Olfaction not tested. II: PERRL 2mm, reactive. VFF to blink. III, IV, VI: limited upgaze, and unable to fully blurry the sclera b/l on lateral gaze. V: Facial sensation intact to light touch. VII: No facial droop, appreciated. VIII: Hearing intact to finger-rub bilaterally. IX, X: could not see palate. [**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: thin man. No pronator drift bilaterally but was not holding arms with palms up. No tremor, asterixis noted. Strength appreciated as normal in the delts, biceps, triceps, finger flexor, IP's, quads and hamstrings as well as TA and gastrocs. -Sensory: No deficits to light touch b/l. did not test other modalities. -DTRs: Only trace at the biceps. otherwise 0. Plantar response was extensor bilaterally. -Coordination: No dysmetria on FNF bilaterally. At discharge: Mental status remains to be an issue, but improved throughout hospitalization. Patient is able to state year and brother's name, but not oriented to place. CV: irregular rate Pulm: CTAB Ext: AVF in RUE, bruising in LUE Pertinent Results: [**2129-12-16**] 03:00PM WBC-7.9 RBC-3.10* HGB-10.6* HCT-31.0* MCV-100* MCH-34.3* MCHC-34.3 RDW-13.4 [**2129-12-16**] 03:00PM NEUTS-88.3* LYMPHS-4.9* MONOS-6.6 EOS-0.1 BASOS-0.1 [**2129-12-16**] 03:00PM PLT COUNT-195 [**2129-12-16**] 03:00PM PT-29.8* PTT-39.0* INR(PT)-2.9* [**2129-12-16**] 03:00PM CALCIUM-9.8 PHOSPHATE-3.1 MAGNESIUM-2.0 [**2129-12-16**] 03:00PM GLUCOSE-120* UREA N-36* CREAT-2.0* SODIUM-140 POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-24 ANION GAP-20 [**2129-12-16**] 03:18PM URINE MUCOUS-RARE [**2129-12-16**] 03:18PM URINE RBC-4* WBC-5 BACTERIA-NONE YEAST-NONE EPI-0 RENAL EPI-9 [**2129-12-16**] 03:18PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2129-12-16**] 03:18PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.012 [**2129-12-21**] 09:00AM BLOOD WBC-9.6 RBC-3.36* Hgb-11.3* Hct-34.5* MCV-103* MCH-33.8* MCHC-32.8 RDW-13.6 Plt Ct-173 [**2129-12-18**] 08:40AM BLOOD PT-11.9 INR(PT)-1.1 [**2129-12-21**] 09:00AM BLOOD Plt Ct-173 [**2129-12-21**] 09:00AM BLOOD Glucose-93 UreaN-41* Creat-1.4* Na-155* K-3.3 Cl-117* HCO3-25 AnGap-16 [**2129-12-21**] 09:00AM BLOOD Calcium-8.8 Phos-2.3* Mg-2.2 [**2129-12-17**] 01:31AM BLOOD Triglyc-64 HDL-82 CHOL/HD-1.8 LDLcalc-56 [**2129-12-17**] 01:31AM BLOOD TSH-2.0 [**2129-12-17**] 01:31AM BLOOD Phenyto-14.7 [**2129-12-17**] 01:31AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ECG: Atrial fibrillation with moderately rapid ventricular response. Diffuse non-specific ST segment abnormality. Possible left ventricular hypertrophy. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 94 0 82 364/423 0 33 51 CXR 1 view: SUPINE AP VIEW OF THE CHEST: The heart size is mildly enlarged. The aorta is slightly tortuous. There is fullness of the hila bilaterally and there is mild pulmonary vascular congestion. Linear opacities within the right upper lobe may reflect scarring and chronic changes. There is likely mild streaky opacity in left lung base, reflective of atelectasis. No focal consolidation, pleural effusion, or pneumothorax is visualized. No definite displaced rib fractures are seen; however, the left lateral ribs are not completely included in the field of view. IMPRESSION: Mild pulmonary vascular congestion. Probable left basilar atelectasis and chronic changes within the right upper lobe. Pelvis Xray - 1 view: AP VIEW OF THE PELVIS, TWO VIEWS OF THE RIGHT FEMUR: No definite fracture or dislocation is present. There is diffuse demineralization of the osseous structures which limits the detection for subtle fractures. The right leg is rotated, though no distinct fracture line is visible. There are mild degenerative changes in both hips with joint space narrowing. No diastasis of the pubic symphysis or sacroiliac joints is seen. There are diffuse vascular calcifications. Extensive degenerative changes are noted within the imaged aspect of the right knee with joint space narrowing, subchondral sclerosis and osteophyte formation. A moderate-sized suprapatellar joint effusion is also noted. IMPRESSION: Rotation of the right femur, but no definite fracture or dislocation. If there is continued clinical concern for an occult fracture, a CT is recommended for further evaluation. Femur Xray - 2view: AP VIEW OF THE PELVIS, TWO VIEWS OF THE RIGHT FEMUR: No definite fracture or dislocation is present. There is diffuse demineralization of the osseous structures which limits the detection for subtle fractures. The right leg is rotated, though no distinct fracture line is visible. There are mild degenerative changes in both hips with joint space narrowing. No diastasis of the pubic symphysis or sacroiliac joints is seen. There are diffuse vascular calcifications. Extensive degenerative changes are noted within the imaged aspect of the right knee with joint space narrowing, subchondral sclerosis and osteophyte formation. A moderate-sized suprapatellar joint effusion is also noted. IMPRESSION: Rotation of the right femur, but no definite fracture or dislocation. If there is continued clinical concern for an occult fracture, a CT is recommended for further evaluation. Hip Xray: 2 view AP VIEW OF THE PELVIS, TWO VIEWS OF THE RIGHT FEMUR: No definite fracture or dislocation is present. There is diffuse demineralization of the osseous structures which limits the detection for subtle fractures. The right leg is rotated, though no distinct fracture line is visible. There are mild degenerative changes in both hips with joint space narrowing. No diastasis of the pubic symphysis or sacroiliac joints is seen. There are diffuse vascular calcifications. Extensive degenerative changes are noted within the imaged aspect of the right knee with joint space narrowing, subchondral sclerosis and osteophyte formation. A moderate-sized suprapatellar joint effusion is also noted. IMPRESSION: Rotation of the right femur, but no definite fracture or dislocation. If there is continued clinical concern for an occult fracture, a CT is recommended for further evaluation. CT C-spine without contrast: FINDINGS: Non-displaced fractures are present at the left transverse processes of T1 and T2 (601B:32). No acute vertebral body fractures are seen. There is a chronic wedge compression deformity of T2 (602B:36). Severe multilevel degenerative changes are seen throughout the cervical spine, worst at C3/4 and the C6/7, there is loss of intervertebral disc space with endplate sclerosis and subchondral cystic changes. Subluxation of multiple facets are compatible with severe osteoarthropathy. Included views of the lung apices demonstrate scarring and pleural calcifications, as seen on the prior chest radiograph (5:61). IMPRESSION: 1. Non-displaced fractures of the left T1 and T2 transverse processes. 2. Chronic wedge compression deformity at T2. 3. Severe multilevel degenerative changes throughout the cervical spine. CT Head noncontrast [**12-16**]: IMPRESSION: 1. Numerous bifrontal and left temporal intraparenchymal hematomas, unchanged in appearance since the 1:01 p.m. study, with new trace intraventricular extension. Findings are most compatible with traumatic contusion injuries. If the diagnosis is in doubt and amyloid angiopathy is being entertained as a potential diagnosis, then MR may be of potential value in further assessment. 2. Very small subdural hygromas, not significantly changed and also supporting the probability of a traumatic etiology. Head Ct noncontrast [**12-17**]: IMPRESSION: 1. Bifrontal and left temporal [**Doctor Last Name 534**] parenchymal hemorrhage, largely unchanged in distribution compared to the prior with some likely evolution- i.e. slightly increased focus of hemorrhage at left frontal lobe (2,20) and slightly less prominent foci at the left frontal lobe at the vertex (2, 23)when compared to the comparable level and allowing for differences in technique. 2. Small subdural hygromas stable. 3. Minimally increased vasogenic edema particularly at the level of the the left frontal lobe at the vertex (2, 23). 4. Stable layering blood in the occipital horns bilaterally. MRI Head without contrast: FINDINGS: Multiple foci of blood products are seen in both frontal lobes, left temporal lobe and intraventricular blood is also identified. There are bilateral small subdural collections seen extending from frontal to the occipital region with a maximum width of approximately 6 mm on the left and 5 mm on the right side. There is mild indentation on the adjacent sulci seen. On the susceptibility images, the areas of blood products corresponding to the CT abnormality are identified. There are no additional foci seen to indicate underlying microhemorrhages. There is no mass effect or midline shift seen. Mild changes of small vessel disease are noted. IMPRESSION: Blood products in both frontal and left temporal region likely due to hemorrhagic contusions, although the locations of the abnormalities are somewhat atypical. No evidence of chronic microhemorrhages seen in other parts of the brain to suggest underlying abnormality. Small bilateral subdural collections are seen. Brief Hospital Course: The patient was admitted to the Neurology Service at [**Hospital1 18**] on [**2129-12-16**] after sustaining multiple falls with confusion. Imaging of his head showed several areas of hemorrhage in bifrontal and left temporal areas. . The patient was kept in the ICU for several days for close observation and then transferred to the floor. He was cleared from his c-collar medically while in the ICU. His coumadin was held during his stay and his goal SBP was <160. Hydralazine was given as necessary to keep within these parameters, although the patient autoregulated well during his stay. He was started on Keppra for seizure prophylaxis. . The patient also had an issue with hypernatremia and was started on normal saline at 70 cc/hr for treatment. He should get labs daily at rehab, and may need further treamtent for his hypernatremia. . One of the major issues during his stay was his mental status. The majority of his stay he was not oriented to person, place, or time. On discharge he is oriented to place and year. . He was not able to pass a speech and swallow evaluation until [**12-21**] as he would not swallow, but was cleared for pureed solids and thin liquids with meds given crushed in puree. The patient should be under observation when eating. This should be re-evaluated at rehab to see if diet can be advanced. . Once leaving rehab, the patient will need to followup with his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 20040**] in reference to restarting warfarin. He was stopped due to intracranial hemorrhages. Having atrial fibrillation puts him at risk for embolic strokes. Since he has a history of falls, his primary care physician should assess him as an outpatient to evaluate the risks and benefits of restarting coumadin. His simvastatin and lopressor doses were not known, and he will not go to rehab on either medication. He should followup with his PCP about restarting these medications after rehab. . He will need followup with Dr. [**Last Name (STitle) **] on [**2130-2-7**] and get a head CT one week before this appointment. He will need followup with his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 20040**], within one week of leaving rehab. Medications on Admission: Coumadin Lopressor simvastatin (unknown dosage) Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 5. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 6. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea. 7. dextrose 50% in water (D50W) Syringe Sig: One (1) Intravenous PRN (as needed) as needed for hypoglycemia protocol. 8. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day. 9. hydralazine 20 mg/mL Solution Sig: 0.5 Injection Q6H (every 6 hours) as needed for PRN SBP >160. Discharge Disposition: Extended Care Facility: [**Hospital **] [**Hospital **] Hospital Discharge Diagnosis: bifrontal and left temporal hemorrhages 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 Mr. [**Known lastname **], You were admitted to the Neurology Service at [**Hospital1 18**] on [**2129-12-16**] after sustaining multiple falls with confusion. Imaging of your head showed several areas of hemorrhage in your brain. . You were taking coumadin for your atrial fibrillation. This medication was held during your stay as it can increase hemorrhages in your brain. Your blood pressure was also kept below a certain level for treatment. . You were initially in the ICU for close monitoring, and then transferred to the floor once stable. . You were started on keppra for seizure prophylaxis which you will go to rehab on and continue until your appointment with Dr. [**Last Name (STitle) **] on [**2130-2-7**]. Once leaving rehab, you will need to followup with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 20040**] in reference to restarting your warfarin. You were stopped due to the hemorrhages in your brain. Having atrial fibrillation puts you at risk for blood clots which can cause strokes. Since you have a history of falls, your primary care physician should assess you as an outpatient to evaluate the risks and benefits of restarting coumadin. Your simvastatin and lopressor doses were not known, and you will not go to rehab on either medication. You should followup with your PCP about restarting these medications after rehab. . You were not able to pass a speech and swallow evaluation until [**12-21**], and they then cleared you for pureed solids and thin liquids. . Please followup with Dr. [**Last Name (STitle) **] on [**2130-2-7**] and get a CT scan of your head one week before this appointment. Please followup with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 20040**], within one week of leaving rehab. Followup Instructions: You will need to schedule at CT scan of your head one week before your appointment with Dr. [**Last Name (STitle) **] Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2130-2-7**] 3:00 [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Name: [**Known lastname **],[**Known firstname 1178**] Unit No: [**Numeric Identifier 3333**] Admission Date: [**2129-12-16**] Discharge Date: [**2129-12-21**] Date of Birth: [**2041-4-8**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 608**] Addendum: There was minimal cerebral edema on the Head CT from [**12-17**]. The patient??????s creatinine rose to 1.6 later in the day and remained at 1.4 the day after till discharge. This was likely related to dehydration. Discharge Disposition: Extended Care Facility: [**Hospital **] [**Hospital **] Hospital [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 610**] Completed by:[**2130-1-24**]

[ "276.0", "785.0", "V49.87", "E888.9", "793.7", "853.01", "585.9", "272.4", "V58.61", "427.31", "784.51", "403.90" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

18062, 18250

11716, 13937

257, 264

15090, 15090

3487, 11693

17076, 18039

1254, 1283

14036, 14916

15027, 15069

13963, 14013

15268, 17053

2354, 3234

1298, 1770

3248, 3468

214, 219

292, 1130

15105, 15244

1152, 1185

1201, 1238

17,751

117,145

10100

Discharge summary

report

Admission Date: [**2179-2-11**] Discharge Date: [**2179-2-21**] Date of Birth: [**2115-5-24**] Sex: F Service: SURGERY Allergies: Penicillins / Meperidine / Codeine / Percocet Attending:[**First Name3 (LF) 148**] Chief Complaint: melena, hypotension Major Surgical or Invasive Procedure: paracentesis [**2179-2-11**] central line placement [**2179-2-11**] ERCP, stent removal [**2179-2-12**] endotracheal intubation [**2179-2-12**] exploratory laparotomy, Roux-en-Y hepaticojejunostomy, duodenostomy, G and J tube placement, cholecystectomy [**2179-2-13**] History of Present Illness: 63yo F with prior diagnosis of pancreatic cancer that was unresectable and is s/p chemo/XRT. A CBD stent had been placed in [**5-7**] to relieve biliary obstruction. Pt was recently receiving chemotherapy whose treatment was halted due to progressive fatigue/weakness. 2d prior to [**Hospital1 18**] admission she presented to [**Hospital3 **] hospital for hematemesis where an EGD demonstrated the CBD stent had slipped distally into the duodenum and was causing erosion against the duodenal wall. She was transfused 2u PRBC, hemodynamically stable, and transferred for [**Hospital1 18**] for further management and resumption of her prior care that was performed here. Past Medical History: pancreatic carcinoma, locally advanced, s/p chemo and XRT renal cell carcinoma ulcerative colitis hypercholesterolemia depression diverticulosis Social History: no Tob or EtOH lives on [**Hospital3 635**], married, many close children Family History: Mother died of cholangiocarcinoma at 80yo Maternal aunt died of pancreatic carcinoma at 60's yo Maternal grandfather died of pancreatic carcinoma Physical Exam: on presentation to the [**Hospital Unit Name 153**]: 100.5, HR 148, BP 130/67, R 23, sat 98% on 4L NC lethargic but oriented x3 and responsive dry mucous membranes supple tachy, regular, no M/R/G CTAB soft, NT, slightly distended. fluid wave no c/c/e, 2+ pulses, WWP moves all extremities x4, CN 2-12 intact Pertinent Results: [**2179-2-11**] 08:30PM BLOOD WBC-2.6* RBC-4.03* Hgb-12.6 Hct-37.5 MCV-93 MCH-31.3 MCHC-33.6 RDW-18.0* Plt Ct-263 [**2179-2-12**] 04:17AM BLOOD WBC-23.6*# RBC-3.71* Hgb-11.5* Hct-33.3* MCV-90 MCH-30.9 MCHC-34.4 RDW-18.1* Plt Ct-134* [**2179-2-12**] 04:17AM BLOOD Neuts-91* Bands-2 Lymphs-2* Monos-3 Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2179-2-12**] 03:08PM BLOOD WBC-46.3*# RBC-4.41 Hgb-13.4 Hct-39.7 MCV-90 MCH-30.5 MCHC-33.8 RDW-17.3* Plt Ct-166 [**2179-2-11**] 08:30PM BLOOD Plt Ct-263 [**2179-2-11**] 08:30PM BLOOD PT-14.7* PTT-25.5 INR(PT)-1.3* [**2179-2-11**] 08:30PM BLOOD Glucose-58* UreaN-20 Creat-0.7 Na-138 K-4.5 Cl-108 HCO3-18* AnGap-17 [**2179-2-12**] 04:17AM BLOOD Glucose-82 UreaN-19 Creat-0.7 Na-140 K-3.2* Cl-111* HCO3-16* AnGap-16 [**2179-2-11**] 08:30PM BLOOD ALT-23 AST-50* LD(LDH)-212 AlkPhos-387* Amylase-15 TotBili-1.1 [**2179-2-11**] 08:30PM BLOOD Albumin-2.6* Calcium-9.0 Phos-2.8 Mg-1.6 [**2179-2-20**] 12:36PM BLOOD Hapto-<20* TRF-<10* [**2179-2-11**] 09:07PM BLOOD Type-ART Temp-38.9 pO2-187* pCO2-24* pH-7.48* calHCO3-18* Base XS--2 Intubat-NOT INTUBA Comment-INTERPRET [**2179-2-11**] 09:07PM BLOOD Lactate-3.5* [**2179-2-21**] 01:22AM BLOOD Lactate-6.3* [**2179-2-11**] 11:35PM ASCITES WBC-89* RBC-124* Polys-4* Lymphs-13* Monos-23* Mesothe-3* Macroph-32* Other-25* [**2179-2-11**] 11:35PM ASCITES TotPro-0.3 Glucose-83 LD(LDH)-39 Albumin-<1.0 Blood CX [**2-11**]: EColi, pan-sensitive. Klebsiella, pan-sensitive. Blood Cx [**2-11**]: EColi, same sensitivities. Strep Milleri, [**Last Name (un) 36**] to PCN, Vanco. Brief Hospital Course: Pt was initially admitted to the floor but subsequently had an episode of large melena associated with hypotension and non-responsiveness. 2L IVF were bolused and she was transferred to the [**Hospital Unit Name 153**]. CVL lines placed and paracentesis performed for ascites, transfused 2u PRBC, and begun empiric antibiotics. GI consulted and ERCP performed the following morning, finding the CBD stent in the duodenal lumen which was removed. That afternoon, respiratory distress ensued with hypoxia, and the patient was intubated in the ERCP-PACU. The abdomen was distended and tympanitic, a KUB was concerning for localized air but no free air. Surgical consult from Dr. [**Last Name (STitle) **] and the Gold (hepatobiliary) service was obtained and, after extensive discussion with the family, decision was reached for exploratory laparotomy for duodenal perforatoin from wall stent erosion, which was performed on [**3-22**] with a biliary bypass, repair of duodenal perforation. She continued to require aggressive IVF resuscitation in SICU on the [**Hospital Ward Name 517**] but overall was hemodynamically improved on moderate dose levophed. The evening of POD 1 ([**2-14**]) was notable for an acute desaturation into the 30's associated with hypotension into the 50's. Max'd pressors with large-scale IVF resuscitation. ABG showed worsening acidosis. SVT into 200's ensued which converted into sinus tachycardia in 120's. A swan-ganz catheter was utilized to guide management. Clinical picture highly suspicious and consistent with massive pulmonary embolus, but was too unstable for radiographic confirmation. Heparin drip was begun empirically. No further events ensued that evening as pressors remained at high levels, broad-spectrum antibiotics were continued, and net positive IVF resuscitation was required. cc per cc replacement of high JP (ascites) output commenced. Over the next few days, ventilatory pressures were high and vent changed to pressure-control ventilation. Thrombocytopenia ensued, a HIT was negative and heparin maintained throughout. Hematocrits were stable. An echocardiogram on [**2-15**] demonstrated no pericardial effusion. With results from admission cultures, antibiotics were adjusted. Trophic tube feeds begun. With rising bilirubin, ultrasound revealed complete thrombosis of the portal vein. A family meeting was held on POD 5 and she was made DNR. With worsening thrombocytopenia to 7, a hematology consult was obtained, and she was transfused platelets. On the morning on POD 9, she became hypotensive with falling hematocrit and worsening pressor and IVF requirement. Some mucosal bleeding was noted. After a lengthy discussion with the family, decision was reached to move to CMO care. Morphine gtt was titrated, pressors withdrawn, and eventually she was extubated and passed away in the presence of her family. Medications on Admission: ritalin [**5-12**] [**Hospital1 **] prn avastin, last dose 2/6 procrit qMon zofran prn prevacid 20qday compazine 10 prn wellbutrin 200mg [**Hospital1 **] xanax prn Discharge Disposition: Expired Discharge Diagnosis: advanced pancreatic carcinoma duodenal perforation d/t displaced CBD stent pulmonary embolus portal vein thrombosis Discharge Condition: expired

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icd9cm

[ [ [] ] ]

[ "96.6", "99.15", "51.59", "96.04", "89.64", "99.04", "51.37", "51.22", "46.39", "51.10", "96.72", "46.71", "54.91", "97.55", "38.93" ]

icd9pcs

[ [ [] ] ]

6750, 6759

3641, 6536

324, 594

6918, 6928

2063, 3618

1573, 1720

6780, 6897

6562, 6727

1735, 2044

265, 286

622, 1298

1320, 1466

1482, 1557

60,842

115,305

40049

Discharge summary

report

Admission Date: [**2119-1-9**] Discharge Date: [**2119-1-14**] Date of Birth: [**2087-4-22**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1406**] Chief Complaint: Type A dissection Major Surgical or Invasive Procedure: [**2119-1-9**] Replacement of Ascending aorta with 28mm Gelweave graft History of Present Illness: This 31 year old male awoke on [**1-9**] with substernal chest pain radiating to his back and then legs with shortness of breath. A CTA elsewhere revealed a Type A dissection, extending to the renal, without visualization of the right kidney. He was Life Flighted here after diversion from [**Hospital1 2025**]. Past Medical History: Remote stroke after rodding, no residual Left deep vein thrombophlebitis Chronic low back pain Obstructive sleep apnea Sinusitis- completed course antibiotics/prednisone s/p Lumbar laminectomies s/p femoral rodding h/o tympanic membrane surgeries Social History: 15pk year history (active smoker) heavy ETOH until 2years ago disabled from back pain Family History: noncontributory Physical Exam: admission: Pulse: 88 Resp: O2 sat: B/P Right: 116/60 Left: Height: Weight: 95 kg 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] Edema Varicosities: None [] Neuro: Grossly intact Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: dop PT [**Name (NI) 167**]: dop Left: dop Radial Right: 2+ Left: 2+ Carotid Bruit Right: no Left: Pertinent Results: [**2119-1-9**] Echo: PRE-CPB:1. The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is mildly depressed (LVEF= 50 %). 3. Right ventricular chamber size and free wall motion are normal. 4. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The descending thoracic aorta is mildly dilated. A mobile density is seen in the ascending aorta consistent with an intimal flap/aortic dissection. The aortic wall is thickened consistent with an intramural hematoma, which extends into the descending aorta. 5. There are three aortic valve leaflets. There is no aortic valve stenosis. Mild to moderate ([**1-8**]+) aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. 6. There is a small left pleural effusion. 7. There is a trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results. POST-CPB: On infusion of phenylephrine. A pacing for slow sinus. Repaired ascending aorta with synthetic material seen. No residual dissection flap seen. Preserved biventricular systolic function. No AI seen. MR remains 1+. The descending aortic contour is unchanged post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. [**2119-1-10**] Kidney U/S: 1. No normal arterial venous waveforms noted within the right kidney with an abnormal-appearing pulsatile flow only seen within the right renal hilum likely representing collateral flow from lumbar vessels. 2. More normal-appearing arterial and venous waveforms within the left kidney. Although, this also appears slightly hypoperfused as demonstrated by the lack of significant vascularity extending out into the cortex on the color images. [**2119-1-13**] CXR: The heart size is stable. Post-sternotomy wires are unremarkable. The aortic contour is still enlarged which might be related to recent surgery and the presence of known dissection. There is no pneumothorax. There is small amount of left pleural effusion but overall the aeration at the lung bases has improved in the interim. [**2119-1-9**] 07:20PM BLOOD WBC-13.4* RBC-3.79* Hgb-11.0* Hct-33.1* MCV-88 MCH-29.0 MCHC-33.2 RDW-12.9 Plt Ct-297 [**2119-1-11**] 01:51AM BLOOD WBC-25.1*# RBC-3.44* Hgb-10.3* Hct-29.8* MCV-87 MCH-30.1 MCHC-34.7 RDW-13.4 Plt Ct-238 [**2119-1-14**] 05:50AM BLOOD WBC-14.4* RBC-3.21* Hgb-9.4* Hct-28.3* MCV-88 MCH-29.4 MCHC-33.4 RDW-14.2 Plt Ct-316 [**2119-1-9**] 07:20PM BLOOD PT-16.3* PTT-27.4 INR(PT)-1.4* [**2119-1-11**] 01:51AM BLOOD PT-17.7* PTT-28.8 INR(PT)-1.6* [**2119-1-9**] 07:20PM BLOOD UreaN-15 Creat-1.5* [**2119-1-10**] 04:56AM BLOOD Glucose-112* UreaN-15 Creat-1.5* Na-137 K-4.6 Cl-108 HCO3-23 AnGap-11 [**2119-1-14**] 05:50AM BLOOD Glucose-94 UreaN-20 Creat-1.5* Na-134 K-4.0 Cl-100 HCO3-26 AnGap-12 Brief Hospital Course: Following admission he was taken in stable condition emergently to the Operating Room where the ascending aorta was replace. Please see operative report for surgical details. He tolerated the procedure well and weaned from bypass on Neo-Synephrine and Propofol and transferred to the CVICU for invasive monitoring in stable condition. He remained stable, weaned from sedation, awoke neurologically intact and extubated with 24 hours. During surgery, the aorta appeared abnormal and aortitis was considered. Biopsy was sent from the Operating Room. Rheumatology and Infectious Disease were consulted for assistance in elucidation of this. Blood cultures were sent. He was transferred to the floor on post-op day #2 to begin increasing his activity level. He was gently diuresed toward his preop weight. His pathology report suggested a differential diagnosis that included Ehlers-Danlos Type IV. As such he was referred to see the genetic counselling service at [**Hospital1 11900**] of [**Location (un) 86**] as an outpatient. As mentioned earlier Infectious disease was consulted to evaluate for an infectious cause of his dissection or aortitis but it was felt that there was not evidence for either. He continued to make good progress and by post-operative day five he was ready for discharge to home with VNA services, appropriate medications and follow-up appointments. Medications on Admission: Naprosyn PRN Amoxicillin 500 mg PO TID-just completed 10 day course for sinusitis Cipro 500 mg PO BID for 14 days-just completed 14 day course Prednisone taper just completed 5 days ago for sinusitis Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 5. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 6. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. Disp:*3 Tablet(s)* Refills:*0* 7. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 3 days. Disp:*3 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: Type A Aortic dissection s/p Replacement of ascending aorta Postop UTI Past medical history: Remote stroke Chronic low back pain Obstructive sleep apnea s/p Lumbar laminectomies s/p femoral rodding h/o tympanic membrane surgeries 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 Edema: trace Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on Wednesday [**2-1**] at 1:00 ([**Hospital Ward Name **] 2A) *** Cardiologist: Please ask Dr. [**Last Name (STitle) **] for a referral to a cardiologist and make appt for 4 weeks Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office from genetic testing at [**Hospital1 11900**] of [**Location (un) 86**] will be calling you on Monday to arrange an appointment. His office phone is ([**Telephone/Fax (1) 77621**]. Please call to schedule appointments with your Primary Care Dr.[**Last Name (STitle) **] in [**4-11**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2119-1-14**]

[ "396.3", "599.0", "303.93", "447.6", "441.03", "593.2", "V12.54", "756.83" ]

icd9cm

[ [ [] ] ]

[ "39.61", "38.45" ]

icd9pcs

[ [ [] ] ]

7371, 7427

4788, 6164

327, 399

7701, 7879

1794, 4765

8802, 9664

1129, 1146

6414, 7348

7448, 7520

6190, 6391

7903, 8779

1161, 1775

270, 289

427, 740

7542, 7680

1026, 1113

11,618

167,056

24232

Discharge summary

report

Admission Date: [**2162-6-2**] Discharge Date: [**2162-6-4**] Date of Birth: [**2096-2-23**] Sex: F Service: VSU CHIEF COMPLAINT: Patient with known peripheral vascular disease and bilateral claudication who is admitted postoperatively for continued postoperative care. HISTORY: ABIs done on [**2161-7-28**] demonstrate on the right 0.48, on the left 0.44. Patient with severe bilateral possibly tandem aortoiliac inflow popliteal and distal runoff atherosclerotic disease. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Benicar 40 mg daily, atenolol 25 mg daily, Caduet 5/80 mg capsule daily, aspirin 325 mg daily, Spiriva puffs 2 q.a.m. PAST MEDICAL HISTORY: Significant for non-ST-endocardial myocardial infarction, status post CABG on [**2161-4-27**]: A LIMA to the LAD, saphenous vein graft to the obtuse marginal/diagonal was not grafted. Most recent ETT in [**2161-10-27**] showed a small fixed apical perfusion defect with an ejection fraction of 56% with septal hypokinesis. Other medical problems include cardiomyopathy, hyperlipidemia, peripheral vascular disease, postoperative atrial fibrillation, history of nonsustained ventricular tachycardia, history of carotid disease by ultrasound, history of COPD, history of recurrent pneumonia, former smoker, type 2 diabetes. PAST SURGICAL HISTORY: Right 2nd toe amputation 20 years ago. SOCIAL HISTORY: Patient is married who lives with 4 living children, 1 deceased. Husband and daughter will accompany patient to procedure. REVIEW OF SYSTEMS: Negative. PHYSICAL EXAM: General appearance is well, but anxious female. Heart is a regular rate and rhythm with a normal S1 and 2. Lungs are clear to auscultation. Abdominal exam is unremarkable. Neurological exam is intact. HOSPITAL COURSE: Patient was admitted to the preoperative holding area. On [**2162-6-2**], she underwent bilateral femoral endarterectomies with Bovine patch angioplasties, bilateral common iliac stenting, external iliac stenting. Patient tolerated the procedure well and was transferred to the PACU for continued monitoring and care. Patient was transfused 2 units of packed red blood cells intraoperatively. Postoperatively, patient remained hemodynamically stable, continued to do well, and was transferred to the VICU for continued monitoring and care. Electrolytes were repleted. On postoperative day 1, there were no overnight events. She remained hemodynamically stable. Exam remained unchanged. Her diet was advanced as tolerated. Ambulation was instituted, and the patient was transferred to the regular nursing floor. Patient was followed postoperatively by her cardiologist, Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**]. Patient did well from a cardiac standpoint. The remaining hospital course was unremarkable, and patient was discharged on postoperative day 2 in stable condition to home. Wounds were clean, dry, and intact. She had palpable pulses. Patient would be discharged on preadmission medications and additional Plavix 75 mg for total of 1 month, aspirin 325 mg indefinitely. DISCHARGE DIAGNOSES: Arterial insufficiency with bilateral buttocks claudication, history of coronary artery disease with history of myocardial infarction, status post coronary artery bypass graft, left internal mammary artery to the left anterior descending artery, saphenous vein graft to obtuse marginal, history of nonsustained ventricular tachycardia, history of atrial fibrillation, history of hypercholesterolemia, history of congestive heart failure, history of chronic obstructive pulmonary disease with recurrent pneumonia, history of smoking, new pulmonary nodule on admitting x-ray on [**2162-5-27**]. FOLLOW UP: Recommended followup with Dr. [**Last Name (STitle) **] in 2 weeks' time. She should call his office for an appointment. DISCHARGE MEDICATIONS: Olmesartan 40 mg daily, atenolol 25 mg daily, Caduet 5/80 mg tablets daily, aspirin 325 mg daily, tiotropium bromide inhaled device daily, Plavix 75 mg daily. MAJOR INVASIVE PROCEDURES: Bilateral femoral endarterectomies with common iliac and external iliac stenting and Bovine patches to the femoral arteries. Patient's primary care physician will be notified of new chest x-ray findings and the need for the patient to undergo an outpatient CT followup. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3186**] Dictated By:[**Last Name (NamePattern1) 2382**] MEDQUIST36 D: [**2162-6-4**] 10:12:19 T: [**2162-6-4**] 10:46:29 Job#: [**Job Number 61514**]

[ "272.0", "397.0", "424.0", "428.0", "V45.81", "250.00", "425.4", "496", "440.21" ]

icd9cm

[ [ [] ] ]

[ "00.43", "00.47", "39.90", "99.04", "38.18", "39.50" ]

icd9pcs

[ [ [] ] ]

3139, 3733

3891, 4619

564, 683

1801, 3117

1353, 1393

1581, 1783

3745, 3867

1554, 1565

152, 537

706, 1329

1410, 1534

14,830

196,186

26226

Discharge summary

report

Admission Date: [**2193-10-31**] Discharge Date: [**2193-11-9**] Date of Birth: [**2143-2-18**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1481**] Chief Complaint: Paraganglioma Major Surgical or Invasive Procedure: Paraganglioma resection, repair of duodenotomy, G-J tube placement [**10-31**] History of Present Illness: 50-year-old woman who noted some fullness in her abdomen and some "pangs" of pain. A CT scan showed a 9-cm retroperitoneal mass. There is no adenopathy. She denies any fevers, chills, night sweats, or weight loss. She has had no change in her bowel habits. A CT guided needle biopsy of this mass did not show any evidence of lymphoma. There were some areas of vascular spaces and endothelial markers, which may suggest a vascular process. She has had a PET scan, which shows that this area is PET avid. There are no other areas of abnormality. Past Medical History: Hypertension Physical Exam: GEN: WDWN, NAD HEENT: NCAT Neck: supple, no masses/nodules, no thyromegaly CV: RRR, no m/r/g Resp: CTAB Abd: soft, NT, palpable mass on right Lymph: no LAD in neck, supraclavicular regions, axilla, or groin Ext: no C/C/E Neuro: no focal deficits Pertinent Results: [**2193-10-31**] 07:45PM BLOOD WBC-11.6* RBC-3.47* Hgb-10.8* Hct-31.7* MCV-91 MCH-31.0 MCHC-34.0 RDW-17.2* Plt Ct-230 [**2193-11-7**] 07:00AM BLOOD WBC-6.4 RBC-3.30* Hgb-10.4* Hct-29.8* MCV-90 MCH-31.6 MCHC-35.0 RDW-15.7* Plt Ct-446* [**2193-11-5**] 09:21PM BLOOD Neuts-85.9* Lymphs-8.6* Monos-4.5 Eos-0.8 Baso-0.2 [**2193-10-31**] 07:45PM BLOOD PT-13.1 PTT-24.8 INR(PT)-1.1 [**2193-11-7**] 07:00AM BLOOD Plt Ct-446* [**2193-10-31**] 10:19PM BLOOD Fibrino-284 [**2193-11-1**] 04:34AM BLOOD Fibrino-363 [**2193-11-7**] 07:00AM BLOOD estGFR-Using this [**2193-10-31**] 10:19PM BLOOD Calcium-8.4 Phos-4.4 Mg-1.5* [**2193-11-7**] 07:00AM BLOOD Calcium-8.2* Phos-3.8 Mg-1.8 [**2193-11-8**] 11:00AM BLOOD Vanco-5.0* [**2193-10-31**] 03:11PM BLOOD Type-ART pO2-118* pCO2-34* pH-7.45 calTCO2-24 Base XS-0 Intubat-INTUBATED [**2193-11-1**] 04:53AM BLOOD Type-ART pO2-162* pCO2-37 pH-7.36 calTCO2-22 Base XS--3 [**2193-10-31**] 06:33PM BLOOD Lactate-1.6 [**2193-11-1**] 04:53AM BLOOD Glucose-113* Lactate-0.9 [**2193-10-31**] 03:11PM BLOOD Hgb-10.5* calcHCT-32 [**2193-10-31**] 06:33PM BLOOD freeCa-1.02* [**2193-11-1**] 04:53AM BLOOD freeCa-1.12 Brief Hospital Course: The patient presented for pre-operative care and was taken to the OR on [**2193-10-31**]. She underwent resection of the paraganglioma, repair of duodenotomy, and G-J tube placement without intraoperative complications. She was transferred to the ICU and was extubated without incident on POD 1. She continued to do well and was transferred to the floor on POD 3. On POD 4 a gastrograffin swallow study showed no evidence of leak, but did show an ileus, so the patient was kept NPO. On POD 5, she ambulated well with well-controlled pain, but became tachycardic to the 140's for 15 minutes. ECG was normal. She also had a Tmax of 101.1 and blood and urine cultures were sent. Her blood cultures were positive for MRSA and she was started on vancomycin IV. She remained afebrile for the rest of her course, however, on POD 7, she had a 7 beat run of V tach, which resolved spontaneously without intervention. ECG was again normal. Her lopressor was increased to 10 mg IV Q6H from 5q6. Her GJ tube was clamped on POD 7. She tolerated clears well and was slowly advanced to regular. She is currently tolerating a regular diet. She will be discharged today on POD 9, with one week of linezolid. Medications on Admission: phenoxybenzamine 10BID ([**10-22**]); propanolol 10QID ([**10-28**]); SSKI 3gtt daily; venlafaxine 75QD Discharge Medications: 1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 days. Disp:*4 Tablet(s)* Refills:*0* 2. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed: Stop taking and call the office if your experience fevers, increased sedation, or dizziness. 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:*2* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Paraganglioma Discharge Condition: Stable Discharge Instructions: What to expect when you go home: 1. It is normal to feel weak and tired, this will last for [**5-23**] weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? You may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have incisional swelling: ?????? Wear loose fitting pants/clothing (this will be less irritating to incision) 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving while taking narcotic pain medications (such as percocet or vicodin; tylenol and ibuprofen are ok) ?????? You should get up every day, get dressed and walk, gradually increasing your activity ?????? You may go up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (let the soapy water run over incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 101.5F for 24 hours ?????? Bleeding from incision ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? New or increased abdominal distension and/or nausea, palpitations, chest pain, or any other concern Followup Instructions: Please call ([**Telephone/Fax (1) 1483**] to schedule a follow up appointment with Dr. [**Last Name (STitle) **]. You should see him sometime within the next 1-2 weeks.

[ "599.0", "401.9", "790.7", "560.1", "537.89", "V13.01", "459.2", "237.3" ]

icd9cm

[ [ [] ] ]

[ "45.31", "96.6", "00.17", "46.32", "38.93", "54.4", "39.91" ]

icd9pcs

[ [ [] ] ]

4579, 4585

2463, 3669

329, 410

4643, 4652

1302, 2440

7012, 7185

3824, 4556

4606, 4622

3695, 3801

4676, 6452

6478, 6989

1036, 1283

276, 291

438, 985

1007, 1021

8,427

166,934

51537+59356

Discharge summary

report+addendum

Admission Date: [**2146-12-13**] Discharge Date: [**2147-1-6**] Date of Birth: [**2078-1-10**] Sex: M Service: CARDIOTHORACIC Allergies: Seroquel / Fentanyl / Flagyl Attending:[**First Name3 (LF) 1406**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Incision and drainage of sternal wound [**2146-12-19**] History of Present Illness: Mr. [**Name13 (STitle) 106855**] is a 68-year-old man who was discharged to rehab after a coronary artery bypass grafting on [**2146-11-11**], he now presents with chest pain and a supertherapeutic INR. Past Medical History: - h/o atrial Fibrillation - s/p Pacer ([**Company 1543**] DDD) - COPD - Hypertension - PVD s/p Aortobifemoral bypass - Hyperlipidemia - Chronic liver disease [**2-22**] EtOH (sober now) - Anemia: h/o maroon stools; colonoscopy in [**2146**] with hemorrhoids, colon polyps, adenoma - h/o epistaxis - history of AAA that was repaired in 07 - h/o PE ~2-3 months ago per pt. Notes from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] mention PE and imaging from today mentions stable PE. However, no records at [**Hospital1 18**] mention PE. - Wedge fractures - Noted in lumbar region on CT scan - prolonged hospitalization at [**Hospital1 18**] in [**8-30**] for epiglottitis requiring cric/trach, with hospital course complicated by GI bleeding and pseudonomas bacteremia Social History: Mr. [**Name13 (STitle) 106855**] is unemployed and live alone. He smoked 1.5 packs per day for about 50 years, but quit 3 months ago. He has a history of heavy alcohol use, but quit 9 months ago. Family History: father and mother both died of CAD, dad died after age >50 Physical Exam: Pulse: 70 Resp: 18 O2 sat: 98% B/P Right: 126/78 Height: 6'0" Weight: 84.8 kg General: Pleasant, no acute distress laying in bed Skin: Dry [x] * sternal incision w redness at upper and lower [**1-23**]- outlined, sensitive to touch mid line abdomen, left groin, midline neck surgical scars HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur no Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Cool Edema none Varicosities: None [x] Neuro: Alert and oriented x3 residual right upper nad lower extremity weakness Pulses: Femoral Right: +1 Left: +1 DP Right: +1 Left: +1 PT [**Name (NI) 167**]: +1 Left: +1 Radial Right: +1 Left: +1 Carotid Bruit Right: bruit Left: no bruit Pertinent Results: [**2146-12-14**] Echo: Conclusions The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricular cavity is dilated with depressed free wall contractility. The aortic root is mildly dilated at the sinus level. The descending thoracic aorta is mildly dilated. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is a small to moderate sized circumferential pericardial effusion without echocardiographic signs of tamponade. IMPRESSION: Suboptimal image quality. Normal left ventricular cavity sizes with preserved global systolic function. Right ventricular cavity enlargement with free wall hypokinesis. Compared with the report of the prior study (images unavailable for review) of [**2146-11-8**], a small-moderate circumferential pericardial effusion is now present. The severity of tricuspid regurgitation and the estimated pulmonary artery systolic pressure are now reduced. [**2147-1-6**] 09:35AM BLOOD WBC-14.8* RBC-2.79* Hgb-7.8* Hct-23.8* MCV-85 MCH-28.0 MCHC-32.8 RDW-16.8* Plt Ct-335 [**2147-1-6**] 09:35AM BLOOD PT-19.2* PTT-37.2* INR(PT)-1.8* [**2147-1-6**] 09:35AM BLOOD Glucose-119* UreaN-25* Creat-0.6 Na-140 K-4.0 Cl-98 HCO3-35* AnGap-11 Brief Hospital Course: Mr. [**Known lastname 63108**] was admitted and given Vitamin K for an INR 6.7. He remained on bed-rest until INR came below 5. His echo revealed a small, 1.2 cm circumferential pericardial effusion without evidence of tamponade. Sternal erythema was noted and IV vancomycin and oral cipro were started. Additionally, he developed small, fluctuant collections of the sternal incision. These were incised and drained to reveal blood and serous fluid. There was no pus or evidence of infection. He remained on antibiotics and wound was the packed. His INR continued to drift down. The erythema continued to progress on antibiotics and the sternum became unstable. The patient was brought to the operating room on [**2146-12-20**] for sternal exploration and debridement with a vacuum dressing placement. He underwent a subsequent debridement on [**12-23**] with the plastic surgery service. On [**12-29**] he had a third debridement with a vacuum dressing placement. On [**1-2**] he had a fourth debridement with pec and omental flap. Please see the operative notes for details. He was seen in consultation by the ID service for an OR culture that grew pseudomonas and for c.diff (PCR positive) diarrhea. He was placed on oral Vancomycin and ceftazapine. He was started on TPN due to poor oral intake. He was started on wellbutrin to help with smoking cessation and any depression that may be inhibiting his poor oral intake. Coumadin was started for atrial fibrillation and history of pulmonary embolism, but due to his extreme sensitivity toward coumadin, only low doses were used and INR was checked daily. His permanaent pacemaker was interrogated secondary to what appeared to be oversensing, but the electrophysiology service felt that it was pacing appropriately to APCs. He complained of a painful abdomen but was given maalox with resolution of his symptoms. By post-operative day 25 he was ready for discharge to rehab. All follow-up appointments were advised. Medications on Admission: clonazepam .5mg [**Hospital1 **], sildenafil 10 mg [**Hospital1 **],fluticasone-salmeterol 250-50 mcg [**Hospital1 **] digoxin 125 mcg DAILY,nicotine 7 mg/24 hr Patch, Calcium 600 + D(3) 600-400 mg-unit daily, simvastatin 80 mg daily, multivitamin DAILY, folic acid 1 mg DAILY, famotidine 20 mg DAILY, aspirin 81 mg DAILY, pantoprazole 40 mg daily, midodrine 10 mg TID, tamsulosin 0.4 mg hs,oxycodone 5mg prn, amiodarone 200 mg daily ,ipratropium-albuterol 2Puffs Q6H, furosemide 40 mg Tablet DAILY, potassium chloride 20 mEq DAILY , Coumadin 2.5 mg as directed for AFIB/PE Discharge Medications: 1. Outpatient Lab Work laboratory monitoring required - cbc diff bun cr lfts frequency - weekly Creat bun T bili Alt Ast Alk ph wbc Hct/Hgb Dose Drug peak Drug trough All laboratory results should be faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**] All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**] 2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 4. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2* 5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): plan for 14 days treatment, unless otherwise directed by the infectious disease service . Disp:*120 Capsule(s)* Refills:*2* 8. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) as needed for anxiety. Disp:*60 Tablet(s)* Refills:*0* 9. ceftazidime 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q8H (every 8 hours): plan for 6-8 weeks total treatment after final debridement unless otherwise directed by the infectious disease service. Disp:*2 Recon Soln(s)* Refills:*2* 10. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:*40 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:*2* 12. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 13. warfarin 1 mg Tablet Sig: 0.5 Tablet PO ONCE (Once) for 1 doses: total of 0.5mg daily for 2 weeks, INR goal [**2-23**] for afib/PE (patient very sensitive to coumadin). Disp:*30 Tablet(s)* Refills:*2* 14. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days: then taper to home dose of 40mg daily. Disp:*20 Tablet(s)* Refills:*2* 15. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for gas pain. Disp:*30 ML(s)* Refills:*0* 16. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: [**1-22**] puff Inhalation twice a day. Disp:*qs * Refills:*2* 17. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* 18. Wellbutrin SR 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day: 150mg daily for 3 days, then increase to [**Hospital1 **] for smoking cessation . Disp:*30 Tablet Sustained Release(s)* Refills:*2* 19. ipratropium bromide 0.02 % Solution Sig: Two (2) puffs Inhalation Q6H (every 6 hours) as needed for wheeze. Disp:*qs puffs* Refills:*0* 20. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours). Disp:*qs * Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**] Discharge Diagnosis: supratherapeutic INR PMH: coronary artery disease s/p cabg Hypertension Peripheral vascular disease Atrial fibrillation Chronic obstructive pulmonary disease Upper GI bleed [**8-30**] d/t gastritis esophagitis ischemic esophagus pulmonary embolism liver disease Pulmonary hypertension on viagra Anemia Epitaxis Right side paralysis at age 1 Bacteremia - pseudomonas [**8-/2146**] Past Surgical History Emergent Cricothyroidotomy with tracheostomy [**8-/2146**] d/t epiglottic bleeding Right leg fracture repair at age 6 Aortobifem Permanent pacemaker AAA repair [**2143**] Discharge Condition: Alert and oriented x3 nonfocal Deconditioned Incisional pain managed with Oxycodone Incisions: Sternal - clean, dry, intact Leg Left - healing well, no erythema or drainage. 1+ lower extremity 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. Maintain tegaderm dressing placed in OR by plastic surgery service. It will be removed during their follow-up appointment. 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**] Follow INR daily until therapeutic INR 2.5 for afib and histroy of PE in [**2146-8-21**]. **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 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2146-12-28**] 1:45, will need an [**Month/Day/Year 461**] before the appointment. Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2147-1-11**] 9:00 Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2147-1-24**] 10:40 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name12 (NameIs) **] ID WEST (SB) Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2147-1-10**] 10:50 Please see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (plastic surgery) in 2 weeks. ([**Telephone/Fax (1) 14596**] Please call to schedule appointments with your Primary Care Dr.[**Last Name (STitle) 84032**] [**Telephone/Fax (1) 28612**] in [**4-25**] weeks Schedule a follow up appointment with your hematologist in 2 weeks. **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** INR goal [**2-23**] for a-fib with history of PE First draw on [**2147-1-7**] Please arrange for INR follow-up at discharge Completed by:[**2147-1-6**] Name: [**Known lastname 17447**],[**Known firstname **] Unit No: [**Numeric Identifier 17448**] Admission Date: [**2146-12-13**] Discharge Date: [**2147-1-6**] Date of Birth: [**2078-1-10**] Sex: M Service: CARDIOTHORACIC Allergies: Seroquel / Fentanyl / Flagyl Attending:[**First Name3 (LF) 135**] Addendum: Mr. [**Name13 (STitle) 17449**] was discharged to [**Hospital **] [**Hospital 4534**] rehab. Discharge Disposition: Extended Care Facility: [**Hospital3 2215**] - [**Location (un) 95**] - [**Location (un) 4534**] [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**] Completed by:[**2147-1-6**]

[ "401.9", "421.0", "998.31", "416.2", "E878.2", "V02.9", "491.21", "427.31", "V53.31", "041.7", "V58.61", "730.08", "429.5", "416.8", "272.4", "571.2", "790.92", "008.45", "423.0", "998.59" ]

icd9cm

[ [ [] ] ]

[ "33.24", "34.91", "77.61", "83.82", "34.01", "86.74", "99.15", "86.04" ]

icd9pcs

[ [ [] ] ]

13915, 14170

4182, 6170

306, 364

10807, 11008

2572, 4159

12065, 13892

1639, 1699

6798, 10067

10211, 10786

6196, 6775

11032, 12042

1714, 2553

256, 268

392, 596

618, 1408

1424, 1623

19,095

131,302

8623

Discharge summary

report

Admission Date: [**2143-11-4**] Discharge Date: [**2143-12-6**] Service: CARDIOTHORACIC Allergies: Strawberry Attending:[**First Name3 (LF) 1505**] Chief Complaint: 84F with chest pain. Major Surgical or Invasive Procedure: s/p Cardiac Catheterization on [**2143-11-4**] s/p Coronary Artery Bypass Graft x 3 (Lima to LAD, SVG to OM, Diag), MAZE procedure, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1916**] ligation, Tricuspid Valve Repair w/ 28mm CE annuloplasty ring, Patch with pericardium to LV wall on [**2143-11-12**] s/p bilateral thoracentesis s/p Dobbhoff feeding tube placement History of Present Illness: 84 year old woman with known 3 vessel disease and RCA stenting in [**2138**] (NQWMI in [**2138**]) with sudden onset of chest pain. Chest pain onset was 1 week before hospital admission and recurrence occurred 3 days later at rest. Pt. was told from cardiologist to come to ED. In [**Name (NI) **] pt was still experiencing angina and had new ST-T wave changes. Past Medical History: Coronary Artery Disease s/p Myocardial Infarction (NQWMI) and RCA stenting [**2138**] Hypertension Hyperlipidemia Transient Ischemia Attack/Cerebral Vascular Accident [**2139**] Paroxysmal Atrial Fibrillation on Coumadin Mild carotid disease Congestive Heart Failure Gout s/p Cholecystectomy s/p Appendectomy s/p Hysterectomy Shingles Social History: She lives alone at home. She is widowed. She has family in the area. Independent ADLs. She does have a past tobacco history but quit 30 years ago (one pack per day times 30 years). She drinks alcohol socially about two drinks per night. She never had cocaine use. Family History: Mother with cerebrovascular accidents, with a stroke in the 60s, diabetes mellitus. There is a family history of hypertension and coronary artery disease. She has 10 brothers all with CAD. Oldest brother had first MI at age 33, other brothers had their MIs in their 50s. Father passed at age 59 of an MI. Physical Exam: VS: 80-100 AF 150/70 GEN: NAD, lying comfortably in bed HEENT: MMM, EOMI, PERRL RESP: CTAB, -w/r/r CV: Irreg rhythm, Nml S1, S2, no murmur appreciated ABD: soft ND/NT, +BS EXT: Trace edema, warm feet, 2+ DP pulses B/L Pertinent Results: [**2143-12-6**] 04:00AM BLOOD WBC-14.2* RBC-3.73* Hgb-10.5* Hct-31.6* MCV-85 MCH-28.3 MCHC-33.4 RDW-19.0* Plt Ct-277 [**2143-12-5**] 03:30AM BLOOD Glucose-103 UreaN-57* Creat-1.3* Na-148* K-3.6 Cl-110* HCO3-28 AnGap-14 [**2143-12-6**] 04:00AM BLOOD PT-16.5* INR(PT)-1.9 Date: [**2143-12-5**] Signed by [**First Name8 (NamePattern2) 2620**] [**Last Name (NamePattern1) 2621**] on [**2143-12-5**] Affiliation: [**Hospital1 18**] Cosigned by [**Name (NI) **] [**Name2 (NI) **], CCC,SLP on [**2143-12-5**] Title: REPEAT BEDSIDE SWALLOW EVALUATION REPEAT BEDSIDE SWALLOWING EVALUATION: HISTORY: Thank you for consulting on this 84 y/o female who was admitted [**2143-11-4**] after chest pain s/p cadiac cath which found 2 vessel disease. Pt is now s/p CABG x 3, MAZE and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 30221**] ligation [**11-12**]. Pt was extubated [**2143-11-15**] and was seen for a bedside swallow on [**2143-11-18**], followed by a video on [**2143-11-19**]. Pt was made NPO after the video swallow due to fatigue and aspiration combined with overall medical status. Followed up on [**11-25**] but pt was reintubated at that time. we were reconsulted after extubation on [**11-28**] but at that point pt had excess secretions and was noted to aspirate during oral care. We returned today to see if pt was ready for a repeat evaluation. PMH includes NQWMI, known 3VD and RCA stenting [**2138**], HTN, hyperlipidemia, TIA/CVA, sig family hx of CAD/MI, PAF on coumadin, mild carotid dz in [**2139**], shingles, gout, ccy, appy, hysterectomy EVALUATION: The examination was performed while the patient was seated upright in the bed. Cognition, language, speech, voice: Pt was A&O x 3 with fluent language. MS and overall status much improved compared to previous evaluations. Speech was wfl, but vocal quality was hoarse with low volume. Pt could increase volume slightly on command, but not to normal volume, concerning for vocal cord damage. Able to follow all basic commands Secretions: mild dried secretions in the posterior oral cavity, could not clear given strong gag reflex ORAL MOTOR EXAM: Pt presented with symmetrical facial appearance with adequate lip seal and buccal tongue. Tongue was at midline with mildly reduced strength, adequate ROM. Palatal elevation mildly reduced but gag reflex intact. SWALLOWING ASSESSMENT: Pt was given nectar thick liquis (tsp, cup) and purees at the bedside. Oral transit was wfl without oral residue. Pt did not have overt coughing or throat clearing after the tsps of nectar thick liquid, then delayed throat clear after the 2nd cup sip of nectar thick liquid. Pt did not have any signs of aspiration after purees. Did not give further POs at the bedside. Laryngeal elevation timely but mildly reduced. SUMMARY / IMPRESSION: Pt's swallow function and overall medical status and MS is much improved compared to previous evaluations. It was recommended pt been seen for a repeat video swallow, as pt would likely be able to use compensatory techniques given improved status if needed to resume PO intake, whether trials or meals, however per discussion with team, pt is scheduled for d/c early tomorrow. If pt is still here, would be happy to perform the video swallow prior to d/c to rehab, but if not would suggest pt receive the video swallow at rehab to see if she can be advanced to POs. RECOMMENDATIONS: 1. Suggest pt remain NPO until video swallow can be completed. 2. Pt may take ice chips for pleasure if strict oral care is maintained. 3. Video swallow either here tomorrow prior to d/c or upon arrival to rehab. These recommendations were shared with the patient, nurse and medical team. ____________________________________ [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MS, Clinical Fellow Pager#[**Serial Number 2622**] ____________________________________ [**First Name4 (NamePattern1) 1154**] [**Last Name (NamePattern1) 19916**] [**Doctor Last Name 3748**], M.S., CCC-SLP Pager #[**Numeric Identifier 22568**] Face time: 10:30-10:50 Total time: 60 minutes RADIOLOGY Final Report CHEST (SINGLE VIEW) [**2143-12-5**] 8:26 AM CHEST (SINGLE VIEW) Reason: r/o inf, eff [**Hospital 93**] MEDICAL CONDITION: 84 year old woman with REASON FOR THIS EXAMINATION: r/o inf, eff AP CHEST, 8:43 A.M. ON [**12-5**]: HISTORY: Infiltrate and effusions. IMPRESSION: AP chest compared to [**12-1**], [**12-3**] and [**12-4**]. Moderate-sized right pleural effusion has not changed while a small left pleural effusion has increased in volume since [**12-3**]. Severe cardiomegaly is stable as is mild interstitial edema. Nasogastric tube passes below the diaphragm and out of view. Left subclavian catheter tip projects over the mid portion of the right atrium. The patient has had median sternotomy, coronary bypass grafting, and tricuspid valve replacement. Thoracic aorta is heavily calcified, but not focally dilated. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] Approved: [**Doctor First Name **] [**2143-12-5**] 2:50 PM Brief Hospital Course: As mentioned in the HPI, pt presented to the ED with Chest pain. After stabilization in the ED with appropriate meds and lab work-up, pt was brought for a cardiac catheterization. Cath revealed a hazy LMCA, 90% LAD, serial 90% lesion in the OMs, and no obstructive dz in the RCA except for collaterals to the AM. Pt. was admitted and received medical management under cardiology service and consulted cardiac surgery for surgical revascularization. Prior to surgery pt was started on a Heparin gtt to keep pt. therapeutic for her A. Fib. Pre-operative labs were done and an Echo and Carotid u/s were completed. Echo revealed an EF>55% w/ [**2-3**]+ MR, 2+ TR, and mild pulm. HTN. Carotid U/S showed less than 40% bilateral ICA stenosis. Pt's surgery was delayed several days secondary to elevated INR and was awaiting her INR to decrease less than 1.3 prior to surgery. On [**2143-11-12**] pt was brought to the operating room where she underwent a Coronary Artery Bypass Graft x 3 (Lima to LAD, SVG to OM, Diag), MAZE procedure, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1916**] ligation, Tricuspid Valve Repair w/ 28mm CE Annuloplasty ring, and patch with pericardium to LV wall. Pt. tolerated the procedure well with total bypass time of 117 minutes and cross-clamp time of 77 minutes. She was transferred to the CSRU in stable condition on the following gtts: Milrinone, Epinephrine, Levophed, Amiodarone, and Propofol. Diuretics were initiated on POD #1 and Inotropes were continued for BP control. Pt. remained on mechanical ventilation until POD #3 and aggressive pulm. toilet was initiated following extubation. Also on POD #3 pt had a run of rapid A. Fib (Amiodarone was continued). Her chest tubes were removed and post chest tube pull revealed no pneumothorax. By POD #4 pt was weaned off of all gtts, except for Amiodarone and Milrinone. Coumadin was restarted and Amiodarone was switched to PO. On POD #6, a swallow study was performed b/c pt was noted to aspirate thin liquids. Video swallow study revealed aspiration of liquids and swallow delay and a post-pyloric Dobbhoff feeding tube was place by IR. Renal was consulted on POD #9 to eval for acidosis/renal failure. Pt. had slowly worsening respiratory distress/acidosis/oxygenation and despite PT, diuretics, inhalers, oxygen she was reintubated on POD #11. CXR revealed b/l pleural effusion and significant interstitial pulmonary congestion (bilat. aspiration pneumonia). Pt. had to be restarted on Inotropes at this time for pressure support. She was restarted on Vanco and remained intubated until POD #16 (aggressive PT initiated) . Chest CT [**11-25**] revealed bilat pleural effusions, adjacent atelectasis, pulmonary edema w/ patchy peripheral opacities, moderate pericardial effusion, and retrosternal fluid collection. She eventually had bilat thoracentesis on POD#13,14. Along with re-intubation complication, pt. continued to have elevated WBC, along with fevers post-operatively. Antibiotics were given and many cultures were taken (C.diff negative). Also, pt. had to be transfused red cells multiple times d/t low HCT. She eventually was found to have BRBPR. General surgery was consulted and recommended anoscopy/colonoscopy. She continued to have AFib and will be discharged with Amiodarone and Coumadin. During post-op course pt was continuously followed by PT with appropriate treatment. Nutrition also saw pt and assisted in care. Pt remained NPO at time of d/c and repeat speech swallow performed. Feed tubes were continued and had improved swallowing. Pt. was slowly improving and hemodyanimcally stable. She was discharged to rehab facility on POD #24 in stable condition. Medications on Admission: 1. Xanax .25mg 2. ASA 325 3. Cozaar 100 4. Plavix 75 5. Lopressor 75 6. Digoxin 7. Lipitor 8. Heparin gtt 700u/hour Discharge Medications: 1. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily). 7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 8. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 9. Potassium Chloride 20 mEq/50 mL Piggyback Sig: One (1) Intravenous PRN (as needed) as needed for K<4.4 and CR<2.0. 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. 11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. ML(s) 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for temperature >38.0. 13. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. 14. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO once a day. 16. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day: INR goal 2-2.5. 17. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day. 18. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Coronary Artery Disease/PAF/TR s/p Coronary Artery Bypass Graft x 3 (Lima to LAD, SVG to OM, Diag), MAZE procedure, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1916**] ligation, Tricuspid Valve Repair w/ 28mm CE annuloplasty ring, Patch with pericardium to LV wall on [**2143-11-12**] Hypertension Hyperlipidemia Transient Ischemia Attack/Cerebral Vascular Accident [**2139**] Paroxysmal Atrial Fibrillation on Coumadin Mild carotid disease Congestive Heart Failure Gout Discharge Condition: Good Discharge Instructions: Can not drive for 1 month Do not lift great than 10# for 2 months Call our office for sternal drainage, temp>101.5 Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks. Make an appointment with Dr. [**Last Name (STitle) **] for 2-3 weeks. Make an appointment with Dr. [**Last Name (STitle) 1016**] for 3-4 weeks. Completed by:[**2143-12-6**]

[ "414.01", "790.92", "285.1", "578.1", "V17.3", "511.9", "427.31", "707.8", "998.11", "507.0", "518.81", "584.9", "428.0", "274.9", "585.3", "397.0", "411.1" ]

icd9cm

[ [ [] ] ]

[ "99.06", "88.56", "35.14", "96.72", "36.15", "96.6", "33.22", "00.13", "34.03", "34.91", "37.33", "36.12", "88.72", "39.61", "37.99", "96.04" ]

icd9pcs

[ [ [] ] ]

12782, 12879

7393, 11070

245, 621

13403, 13409

2233, 6455

13573, 13816

1672, 1980

11244, 12759

6492, 6515

12900, 13382

11096, 11221

13433, 13550

1995, 2214

185, 207

6544, 7370

649, 1012

1034, 1370

1386, 1656

29,601

133,895

34683

Discharge summary

report

Admission Date: [**2135-11-27**] Discharge Date: [**2135-12-7**] Date of Birth: [**2062-2-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 458**] Chief Complaint: ICD Firing Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: Mr. [**Known lastname 66402**] is a 73 y/o man with a history of diabetes, coronary artery disease s/p CABG >20 years ago, h/o VT s/p abdominal ICD and admission in [**9-2**] for VT storm w/exchange of ICD, Ischemic dilated cardiomyopathy with an EF 25-30%, severe mitral and tricuspid regurgitation, Chronic renal failure, hypertension, who is admitted to the CCU after presenting to [**Hospital3 **] in [**Location (un) 47**] when his ICD fired several times in succession this morning. . Approximetly 1 week prior to this episode, he was admitted to [**Hospital1 **] with a similar presentation. During that admission he was apparently loaded with IV amiodarone and discharged on amiodarone 200mg po qday. Full discharge summary pending. . He did well until sunday [**11-27**], the morning of his admission here. He was getting dressed for the morning when his ICD began firing. He believes that it went off 5 or 6 times. He presented to [**Hospital1 **] where he was started on an amiodarone drip as well as given a bolus of lidocaine 50mg IV. He was not started on a lido drip. He was subsequently transfered to [**Hospital1 18**] for consideration of further EP study. . On review of systems he denies increased dyspnea, denies angina or resting chest pain (outside of ICD shocks), and denies syncope or pre-syncope. He has not had orthopnea or lower extremity edema. He denies fevers or chills. He does note that he had nausea when amiodarone was tried in the past, and that he seems to be developing that again with recently restarting amio earlier this week. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: > 20 years ago @ [**Hospital1 2025**] -PERCUTANEOUS CORONARY INTERVENTIONS: none per patient reports -PACING/ICD: Abdominal ICD placed in [**2116**]. Admitted to BIDin [**2135-8-26**] with VT and multiple shocks had removal of abdominal ICD and placement of Pacer/ICD in left upper shoulder. Had EP study in [**2135-8-26**] with multiple areas of enhanced automaticity, s/p attempted ablation 3. OTHER PAST MEDICAL HISTORY: # Systolic Congestive Heart Failure, EF 25-30% # Diabetes Mellitus type II # Hypercholesterolemia (intolerant of statins) # Probably depression/anxiety due to recent experiences with VT storm # Atrial fibrillation, anticoagulated on coumadin # s/p AICD in abdomen with residual hematoma # Renal insufficiency # Severe TR & MR # Cardiomyopathy # s/p MV reconstruction # CAD s/p CABG # s/p AAA repair # Hypertension Social History: -Tobacco history: none -ETOH: minimal -Illicit drugs: none Family History: No family history of early MI, otherwise non-contributory. Physical Exam: 98.7 70 128/70 20 965RA GEN: not in acute distress, but appears chronically ill and fatigued HEENT: MMM, JVP not elevated while patient sitting up in bed CV: rrr, s1 is obscurred by a III/VI holosystolic murmur heard best at LLSB and over mitral area that does not radiate to carotids RESP: crackles bilaterally @ bases of lungs ABD: soft, NT, palpaple mass over site of previous abdominal ICD site EXT: 2+ pulses bilaterally, right toe noted to be blue, but with good capillary refill and intact sensation, no pain. (patient states happens when feet get cold) Pertinent Results: LABS: From [**Hospital **] hospital drawn on day of admission to [**Hospital1 18**] ([**11-27**]) were notable for Cr 2.2, CO2 21, Troponin T 0.34, Hct 37, WBC 10, PLT 179 . EKG: atrial pacing @ 70bpm, QRS 130 with LBBB pattern. nl axis. . TELEMETRY: frequent runs of NSVT . 2D-ECHOCARDIOGRAM [**2135-9-22**]: EF 25-30%, inferior hypokinesis, 3+MR, 4+TR . [**2135-11-29**] 12:20 pm BLOOD CULTURE STAPH AUREUS COAG + ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- =>4 R PENICILLIN G---------- =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S CARDIAC ECHO [**11-5**]: No distinct vegetations are seen. However, there appears to be a para-mitral annular ring leak at the base of the anterior leaflet. Marked left atrial dilation. Complex atheromas. Moderate mitral regurgitation. Moderate tricuspid regurgitation. CT HEAD: In comparison with the prior study, no significant changes are demonstrated. Persistent areas of low attenuation in the subcortical white matter and left frontal lobe consistent with a chronic ischemic event and small vessel disease. Dense atherosclerotic calcifications noted in the carotid siphons and left vertebral artery. If there is any clinical concern related with an acute/subacute ischemic event, correlation with MRI is recommended if clinically warranted. Brief Hospital Course: 73 y/o man with CAD, CHF, admitted for refractory ventricular tachycardia . # Ventricular Tachycardia: He has failed several drug regemins, largely due to GI intolerence, as well as the multiple foci of excitable ventricular myocardium. He was recently on quinidine/mexilitine, but quinidine was discontinued due to GI intolerance. Had breakthrough VT on mexilitine on presentation to [**Hospital1 **]. There he was loaded on amiodarone IV and continued on mexilitine on discharge along with 200mg amiodarone, but continued to have VT, apparently refractory to his anti-tachycardic pacing. EP evaluation considered him unlikely to respond well to further ablation. He was loaded with amiodorone IV and transitioned to PO, as well as mixilitine TID. He has some significant apprehesive nausea and was given omeprazole and zofran for nausea. He was monitored on telemetry and had no episodes. EP had recommended lidocaine 50-100mg bolus then [**1-26**]/min gtt in the event of an episode. . # MRSA Bacteremia: On [**11-29**], he became febrile to 102 PO (104 rectal) and developed dyspnea. He was started on Levaquin and Vancomycin [**11-29**]. Blood cultures eventually grew [**4-29**] MRSA. Pt also noted to have purulent drainage from left IV site started at OSH (culture now growing Staph Aureus). Subsequent LUE Ultrasound positive for DVT. Pt hads been HD stable afebrile since [**11-29**] however o/n he became hypotensive o/n requiring transient pressors. A right IJ central line was placed for HD monitoring and was subsequently removed. A TTE showed a small vegitation which was not seen on TTE, but TTE showed para-mitral annular ring leak at the base of the anterior leaflet. He will need to complete 6 weeks of IV vancomycin from [**11-30**]. He has a chronic abdominal hematoma. Ultrasound showed 6.8 cm complex cystic mass, without sign of infection, thus it was not drained. . # UE DVT: Patient had a UE thrombophlebitis that was was confirmed by US. He will remain on anticoagulation with lovenox bridge to Coumadin and 6 weeks of IV antibiotics [**2135-11-30**]- [**2136-1-4**]. . # Cardiac asthma: He was noted to have positional expiratory wheezing that worsened in the setting of volume overload and appeared to improve with diuresis. A neck CT to r/o subglottic lesion was considered but deferred given his improvement with diuresis. . # Acute on Chronic Renal Failure: Cr peaked at 3.5 from baseline of 2.3 in setting of hypoperfusion during sepsis. He returned to baseline prior to discharge. . # CAD: He was continued on aspirin and ezetimibe (intolerant of statins). Pt's BB and ACE were held given sepsis, and restarted slowly based on BP and renal function. Prior to discharge ACEi was returned to home dose and BB dose adjusted. . # DM: Outpatient glyburide was held and he was maintainted on a regular insulin sliding scale. Medications on Admission: ASA 81mg Zetia 10mg po Qday Mexilitine 150mg po BID Metoprolol Succinate 100mg po Qday Glyburide 2.5mg po Qday Furosimide 80mg po BID Prevacid 30mg po BID Amiodarone 200mg po Qday Lisinopril 2.5mg po QPM Coumadin 5mg Qday, 2.5mg QTues/Fri Fish Oil QHS Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable [**Month/Day/Year **]: One (1) Tablet, Chewable PO DAILY (Daily). 2. Omega-3 Fatty Acids Capsule [**Month/Day/Year **]: 1000 (1000) mg PO HS (at bedtime). 3. Ezetimibe 10 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily). 4. Ipratropium Bromide 0.02 % Solution [**Month/Day/Year **]: One (1) vial Inhalation Q6H (every 6 hours) as needed for Wheezing. 5. Amiodarone 200 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO twice a day: take until [**12-11**]. . 6. Menthol-Cetylpyridinium 3 mg Lozenge [**Month/Year (2) **]: One (1) Lozenge Mucous membrane PRN (as needed) as needed for sore throat. 7. Furosemide 80 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a day). 8. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Month/Year (2) **]: One (1) gram Intravenous Q48H (every 48 hours): for 5 weeks. Last dose [**2136-1-10**]. 9. Heparin, Porcine (PF) 10 unit/mL Syringe [**Month/Day/Year **]: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 10. Saline Flush 0.9 % Syringe [**Month/Day/Year **]: Ten (10) cc Injection prn for flush. 11. Lorazepam 0.5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 12. Amiodarone 400 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day: Start [**2135-12-12**]. 13. Mexiletine 150 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO Q8H (every 8 hours). 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Month/Day/Year **]: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 15. Enoxaparin 60 mg/0.6 mL Syringe [**Month/Day/Year **]: One (1) syringe Subcutaneous DAILY (Daily): use daily until INR> 2.0. then d/c. . 16. Glyburide 2.5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO twice a day. 17. Outpatient Lab Work Please check weekly random vanco trough, CBC, BUN, creatinine, K and call results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8496**] at BIDMD fax: [**Telephone/Fax (1) 432**] phone:[**Telephone/Fax (1) 457**]. Also fax results to pt's PMD Dr. [**Last Name (STitle) **]: [**Telephone/Fax (1) 79532**]. 18. Lisinopril 5 mg Tablet [**Telephone/Fax (1) **]: 0.5 Tablet PO DAILY (Daily). 19. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr [**Telephone/Fax (1) **]: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily). 20. Senna 8.6 mg Tablet [**Telephone/Fax (1) **]: 1-2 Tablets PO at bedtime as needed for constipation. 21. Warfarin 2.5 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO Once Daily at 4 PM. 22. Outpatient Lab Work Please check INR on friday [**2135-12-9**], call results to provider Discharge Disposition: Extended Care Facility: [**Doctor First Name 3548**] [**Doctor Last Name 3549**] Nursing & Rehabilitation Center - [**Location (un) 1110**] Discharge Diagnosis: Ventricular Tachycardia Methcillin Resistant Staph Endocarditis Chronic Systolic congestive Heart Failure Left Arm Thrombophlebitis Acute on Chronic Renal Failure Hypertension Diabetes Post Traumatic Stress Disorder Discharge Condition: stable BUN=70, creat=2.3 hct=29.9 wbc=7.3 Discharge Instructions: You had an infection in your blood, likely from your abdominal pacer pocket, and thisinfected one of your heart valves. We did not see any infection on your pacer or ICD. You will need intravenous vancomycin for 6 weeks to treat this infection. You will also need Lovenox injections until your INR is > 2.0. We started you on admiodarone to prevent your ICD from firing. You will need pulmonary function tests in [**Month (only) 404**] and some additional labs at that time to check to see if you are tolerating the amiodarone. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day or 6 pounds in 3 days. Adhere to 2 gm sodium diet Fluid Restriction: 1.5 liters/day. New Medicines: Furosemide increased Metoprolol succinate decreased Lovenox: to prevent blood clots until after INR> 2.0 Vancomycin: antibiotic to treat the bacteria in your blood Amiodarone increased to 400 mg daily . Followup Instructions: Pt will need PFT's, TFT's in [**2136-1-26**] Infectious Disease: Provider: [**First Name4 (NamePattern1) 8495**] [**Last Name (NamePattern1) 8496**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2136-2-2**] 9:30. [**Last Name (NamePattern1) **]. [**Hospital Unit Name **], Suite GB (basement) Cardiology: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] Phone: [**Telephone/Fax (1) 6256**] Date/time: please make appt for patient to see in 2 weeks. Completed by:[**2135-12-7**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

10979, 11121

5107, 7986

326, 348

11381, 11425

3646, 4605

12386, 12898

2988, 3049

8289, 10956

11142, 11360

8012, 8266

11449, 12363

3064, 3627

2050, 2450

276, 288

376, 1946

4614, 5084

2481, 2896

1968, 2030

2912, 2972

24,101

199,571

27069

Discharge summary

report

Admission Date: [**2195-1-12**] Discharge Date: [**2195-2-7**] Date of Birth: [**2153-6-5**] Sex: M Service: PLASTIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 10416**] Chief Complaint: LLE necrotizing fasciitis Major Surgical or Invasive Procedure: LLE fasciotomy STSG from b/l thighs to LLE History of Present Illness: This is a 41-year-old morbidly obese gentleman who presented to an outside hospital approximately a week prior with progressing infection of his left lower extremity with bilateral heel ulcers. He underwent radical debridement there of his lower extremity including the skin and soft tissue below the knee, and extending up the posterior thigh behind the knee. He was transferred to our facility for further management. Past Medical History: morbid obesity (360lbs), OSA, hyperglycemia, gout, ?COPD vs restrictive lung dz, asthma, heel ulcers Social History: [**12-8**] PPD smoker Family History: n/c Physical Exam: 99.2 105st 105/55 MAP 71 100% CMV Intubated, sedated, obese Lungs clear to auscultation b/l with distant bs at bases Regular rate/rhythm, no m/g/r Abd: B/l inguinal erythema with skin breakdown, right abdomial pannus erythematours with sinus tract openings, no induration Obese, +NABS, soft R leg w/ chronic venous stasis skin changes, rt heel ulcer L leg debrided to mid thigh Palpaple DPs/PTs b/l Pertinent Results: [**2195-1-12**] 01:36AM BLOOD WBC-30.2* RBC-4.16* Hgb-11.7* Hct-33.4* MCV-80* MCH-28.3 MCHC-35.2* RDW-15.2 Plt Ct-331 [**2195-1-13**] 02:34AM BLOOD WBC-9.9 RBC-3.45* Hgb-9.5* Hct-28.5* MCV-83 MCH-27.4 MCHC-33.2 RDW-16.0* Plt Ct-341 [**2195-1-15**] 02:58AM BLOOD WBC-12.7* RBC-3.93* Hgb-10.3* Hct-32.5* MCV-83 MCH-26.2* MCHC-31.7 RDW-15.6* Plt Ct-365 [**2195-1-19**] 04:23AM BLOOD WBC-7.8 RBC-3.97* Hgb-11.1* Hct-32.9* MCV-83 MCH-28.0 MCHC-33.8 RDW-16.6* Plt Ct-400 [**2195-1-23**] 07:00AM BLOOD WBC-7.9 RBC-4.05* Hgb-10.9* Hct-33.3* MCV-82 MCH-26.9* MCHC-32.6 RDW-16.1* Plt Ct-471* [**2195-1-12**] 01:36AM BLOOD PT-13.7* PTT-28.6 INR(PT)-1.2* [**2195-1-12**] 01:36AM BLOOD Glucose-112* UreaN-13 Creat-0.8 Na-133 K-3.7 Cl-90* HCO3-39* AnGap-8 [**2195-1-14**] 04:23AM BLOOD Glucose-105 UreaN-13 Creat-0.8 Na-139 K-4.0 Cl-99 HCO3-38* AnGap-6* [**2195-1-17**] 12:35PM BLOOD Glucose-104 UreaN-9 Creat-0.6 Na-139 K-5.7* Cl-101 HCO3-31 AnGap-13 [**2195-1-20**] 02:49AM BLOOD Glucose-372* UreaN-5* Creat-0.7 Na-130* K-3.9 Cl-91* HCO3-33* AnGap-10 [**2195-1-23**] 07:00AM BLOOD Glucose-92 UreaN-5* Creat-0.7 Na-135 K-4.8 Cl-96 HCO3-34* AnGap-10 LEFT FOOT, TWO VIEWS [**2195-1-13**] There is a large skin defect overlying the posteroinferior calcaneus. However, the calcaneus is within normal limits, without evidence of osteomyelitis. A small inferior calcaneal spur is noted. Probable diffuse osteopenia, but no focal bone destruction. ANKLE (AP, MORTISE & LAT) RIGHT [**2195-1-13**] Considerable periosteal new bone formation along the mid and distal fibula and tibia, with some surrounding soft tissue edema. Differential diagnosis includes reactive changes, hypertrophic osteoarthropathy, and osteomyelitis. Osteomyelitis is considered somewhat less likely given the diffuse nature of the abnormality, but should be correlated with clinical findings. BIOPSY RESULTS Fascia, left thigh, biopsy [**2195-1-17**] Fibrous and adipose tissue with perivascular chronic inflammation Culture STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: The patient was admitted to the SICU on [**1-12**] after transfer from OSH for rapidly worsening infection of LLE. He was started on broad spectrum triple antibiotic therapy and maintained on the ventilator. His vent was able to be weaned and he was extubated on [**1-13**]. Plastic surgery and podiatric surgery were consulted for further management of extensive wounds. His antibiotics were narrowed on [**1-16**] to clindamycin and oxacillin for outside hospital culture data showing staph aureus (MSSA). Incision and wash-out of left lower extremity was performed on [**1-17**]. A tissue biopsy was sent to pathology and for culture at that time. Culture results were positive for stenotrophomonas maltophilia sensitive to bactrim. This [**Doctor Last Name 360**] was added to his antibiotic regimen on [**1-23**]. A vac was placed on [**1-20**] and continued with changes every 2-3days. On [**1-26**] plastic surgery performed a split thickness skin graft from left and right thigh to the LLE. A vac dressing was in place for 5 days post-op. On POD5 the vac was taken down and the graft noted to have taken well with good granulation. Twice daily dressing changes were performed with iodoform covering new graft, then kerlex wrapping, then an ACE bandage wrapped. The donor sites also had iodoform but these sites were left open to air and the edges have been trimmed as they loosen. Please do not remove iodoform from thighs but continue to trim edges as they curl away from skin. Patient also has an area of superficial denuded tissue at right upper gluteal approx 1.5 cm x 1.5 cm with yellow base. Wound care followed the patient and recommended turning side to side q 1-2 hours; [**Hospital1 **] & prn bowel movement cleanse pt gluteals with foam cleanser and pat dry applying double guard ointment then aloe vesta barrier cream. Medications on Admission: theophylline 600", lisinopril 20', HCTZ 25', Advair [**Hospital1 **], Flovent Discharge Medications: 1. Clindamycin Phosphate 900 mg/6 mL Solution [**Hospital1 **]: One (1) Intravenous Q8H (every 8 hours). Disp:*42 0* Refills:*0* 2. Oxacillin 2 g Recon Soln [**Hospital1 **]: One (1) Intravenous Q6H (every 6 hours). Disp:*56 0* Refills:*0* 3. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff Inhalation QID (4 times a day). Disp:*qs qs* Refills:*2* 4. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) Injection TID (3 times a day). Disp:*qs qs* Refills:*0* 5. Ascorbic Acid 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 6. Oxycodone-Acetaminophen 5-325 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for Breakthrough pain. 7. Gabapentin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q8H (every 8 hours). 8. Dolasetron 12.5 mg/0.625 mL Solution [**Hospital1 **]: One (1) Intravenous Q8H (every 8 hours) as needed. 9. Oxycodone 40 mg Tablet Sustained Release 12HR [**Hospital1 **]: One (1) Tablet Sustained Release 12HR PO Q8H (every 8 hours). 10. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 11. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 12. Zinc Sulfate 220 mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY (Daily). 13. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: Six (6) Puff Inhalation Q4H (every 4 hours) as needed. 14. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 15. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day) as needed. 16. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Hospital Discharge Diagnosis: LLE necrotizing fasciitis Discharge Condition: Good Discharge Instructions: [**Name8 (MD) **] M.D. for fevers, chills, worsening of symptoms, breakdown of wounds, drainage from wounds, questions or concerns. Do no drive while taking narcotic pain medications. Daily dressing changes with layer of iodoform covering skin graft areas on LLE, followed by dry kerlex wrap and Ace bandage (not tight). Donor sites on thighs bilaterally with dry iodoform on them...may be left open to air. Trim edges as they curl away Daily dressing changes with layer of iodoform covering skin graft areas on LLE, followed by dry kerlex wrap and Ace bandage (not tight). Donor sites on thighs bilaterally with dry iodoform on them...may be left open to air. Trim edges as they curl away from skin...do not pull off. [**Month (only) 116**] dangle legs over edge of bed ad lib. Minimum of 4-5xper day, increasing as tolerated. NWB on left leg. Will advance weight bearing status with follow-up. Followup Instructions: Follow-up with plastic surgery clinic in [**12-8**] weeks. Please call clinic to schedule [**Telephone/Fax (1) 5343**]. Follow-up with podiatric clinic for management of feet wounds in [**12-8**] weeks, please call clinic to schedule [**Telephone/Fax (1) 543**]. Completed by:[**2195-2-6**]

[ "274.9", "707.14", "728.86", "682.6", "327.23", "459.81", "707.8", "707.03", "305.1", "729.39", "041.01", "493.90", "518.5", "278.01", "250.00" ]

icd9cm

[ [ [] ] ]

[ "93.59", "83.09", "86.69", "96.71", "86.22", "38.93" ]

icd9pcs

[ [ [] ] ]

7379, 7435

3535, 5391

339, 383

7504, 7510

1454, 3512

8460, 8754

1011, 1016

5520, 7356

7456, 7483

5417, 5497

7534, 8437

1031, 1435

274, 301

411, 832

854, 956

972, 995

21,607

174,294

47504

Discharge summary

report

Admission Date: [**2140-3-8**] Discharge Date: [**2140-3-18**] Date of Birth: [**2083-9-13**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 1674**] Chief Complaint: hypothermia, hyperkalemia Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a 56 year old man with hx of schizoaffective disorder, CKD stage IV, OSA presenting hypothermia. Found by VNA to have stopped taking psych meds. On arrival, hypothermic to 90 degrees. In the ED his vitals were 32.7C 64 111/71 20 99%RA. He transiently dropped his sbp to 92 with responded to NS. Serum potassium was notable at 6.3. A EKG was unremarkable for peaked T waves. He received kayexalate, thiamine, bicarb 1amp, dextrose/insulin. He received vancomycin/ceftazadime. A CXR was improved from prior. Psychiatry was consulted who recommended re-introducing risperdal and would continue following. He denies pain, shortness of breath, chest pain, nausea, headache, visual changes, abdominal pain, diarrhea, dysuria, or other symptoms. Past Medical History: -Hypertension -stage V chronic kidney disease -Schizoaffective disorder -Morbid obesity -Gout -Chronic LE edema -Dyslipidemia -Severe OSA (prior Bipap settings [**8-30**] 2L O2) Social History: Pt was born and raised in [**State 9512**]. He attended college at [**University/College **] and reported that he went to medical school for a brief time at Duke. He later worked at [**University/College 25203**]as a librarian in the [**Doctor Last Name **] Science Library. Pt currently lives alone in [**Location (un) 100433**] [**Location (un) 34564**] (which was arranged through [**University/College **] Housing). Prior to this he had been living in a [**Last Name (un) **], which he was removed from due to poor hygiene. Pt is estranged from his family; reported to have a brother who lives in [**Name (NI) 622**] and rest of family in North or [**Doctor First Name 26692**]. Family History: Non-contributory Physical Exam: VS: HEENT: NCAT, PERRLl, MMM NECK: Unable to appreciate JVP 2/2 body habitus CV: RRR, no m/r/g PULM: Clear bilaterally, no rales or wheezes ABD: Obese, soft, NT, NABS EXT: Edema of bilateral extremities to knees, palpable distal pulses NEURO: AAOx3, pleasant and cooperative, follows commands Brief Hospital Course: A/P 56 year old man with hx of schizoaffective disorder, CKD, HTN and morbid obesity who is admitted after being found by his VNA hypothermic, in acute on chronic renal failure and with hyperkalemia to 6.3, off his psychiatric meds for 2 weeks. # Hypothermia: Etiology unclear. [**Name2 (NI) **] clear infection. Thyroid studies normal, cortisol normal, no evidence of infection. Rectal temp is always approximately 0.2 degrees higher than axillary or oral temp. Call medicine consult if trends to less than 92 for more than two days. # Acute on chronic kidney disease: Stage V CKD, followed by renal in hospital. Discussion of HD initiated with guardian and pt. Guardian agrees with HD if pt. will go along with it (as his agreement despite lack of capacity is still practical prerequisite to being able to sucessfully perform HD). Pt. stated he would do it if he had no other choice (if he would die without it). No urgent need for HD found during admission. Plan further outpatient monitoring and arrangement for HD as needed. Lasix started both for chronic edema and to help keep potassium down, was successful. Check chemistry 10 panel twice per week, if K > 5.8 and not hemolyzed specimen, call renal consult team. # Hyperkalemia: Patient has chronically elevated K in the setting of CKD. Acute elevation in the setting of acute on chronic renal failure. Insulin/dextrose, bicarb, kayexelate given in ED. He recieved Kayexalate in ICU. Lasix as above successful at medical management. # Schizoaffective disorder with psychosis: Patient is on risperidone and abilify as an outpatient, and it is unclear as to when he stopped taking these medications. At this time, the patient reports that the psychotropic medications make him tired, and since he does not feel psychotic, he does not want to take them. He has been unable to care for himself at home despite increased home health care arranged after his prior admission. Psychiatry was consulted from the ED who recommended he be started back on Risperdal 1mg qhs - but this did not control his disordered and delusional thoughts, so IV haldol was instituted with improvement. Later on medical floor, pt agreed to risperdal and refused haldol because he claimed it was causing blurry vision. Risperdal was restarted and increased to 2 mg qhs at recommendation of psychiatry team. # Obstructive sleep apnea: Patient was found to have sleep disordered breathing during his last admission. At that time, he was started on nightly BiPAP, though the patient has not been using this at home. He was continued on his prior settings for BiPAP (10/7/2L). # Hypertension: The patient has a long-standing history of hypertension and is on a number of medications at home including toprol XL, clonidine patch and norvasc. He has been normotensive since on clonidine and norvasc. Toprol was discontinued given concern that it could worsen hypothermia. # Dyslipidemia: Continued simvastatin 10mg daily # Gout: Continued allopurinol, renally dosed. Pt. has repeately failed to do well in an unsupervised/unassisted setting, therefore, after lengthy discussion with guardian and psychiatry and case management, permanent placement in an assisted setting was pursued. The general hope is that as pt's psychiatric state improves, he will consent to initiate hemodialysis. Gaurdian and pt willing at this point to initiate only if emergent, which renal team feels it is impending, but not currently urgent. Medications on Admission: Simvastatin 10 mg daily Senna 8.6 mg [**Hospital1 **] Lisinopril 20 mg daily Toprol XL 100 mg daily Toprol XL 50 mg Tablet Albuterol 90 mcg q6prn Allopurinol 100 mg qoday Amlodipine 10 mg daily Aripiprazole 5 mg Aspirin 325 mg daily Sodium Citrate-Citric Acid 500-300 mg/5 mL 60 mL TID Clonidine 0.1 mg/24 hr Patch qFriday Ferrous Sulfate 325 mg (65 mg Iron) daily B Complex-Vitamin C-Folic Acid 1 mg daily Psyllium 1.7 g [**Hospital1 **] Risperidone 2 mg qhs Sevelamer HCl 2400mg TID W/MEALS Ergocalciferol [**Numeric Identifier 1871**] qweek for 7 weeks Tums 500 mg TID W/MEALS Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) u Injection TID (3 times a day). 3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day) as needed. 9. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 11. Epoetin Alfa 2,000 unit/mL Solution Sig: [**2131**] ([**2131**]) u Injection QMOWEFR ([**Year (4 digits) 766**] -Wednesday-Friday). 12. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO QWED (every Wednesday). 13. Haloperidol Lactate 5 mg/mL Solution Sig: Two (2) mg Injection TID (3 times a day) as needed for agitation. 14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 16. Risperidone 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 18. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). Discharge Disposition: Extended Care Discharge Diagnosis: end stage kidney disease schizoaffective disorder benign hypertension Discharge Condition: stable Discharge Instructions: Please be sure to contact your doctor with increased edema in legs, difficulty breathing, ot other concerning symptoms. Followup Instructions: Follow up with your nephrologist within one month. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**] Completed by:[**2140-3-18**]

[ "780.99", "284.1", "585.6", "276.7", "295.70", "403.91", "327.23", "584.9", "272.4", "278.01", "274.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8132, 8147

2359, 5833

297, 304

8261, 8270

8438, 8642

2008, 2026

6464, 8109

8168, 8240

5859, 6441

8294, 8415

2041, 2336

232, 259

332, 1089

1111, 1291

1307, 1992

83,202

180,037

9398

Discharge summary

report

Admission Date: [**2152-10-26**] Discharge Date: [**2152-11-3**] Date of Birth: [**2113-6-14**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 613**] Chief Complaint: seizure Major Surgical or Invasive Procedure: Airway Intubation History of Present Illness: This is a 39 year-old female with a history of depression and PIH who presents from OSH per family request s/p seizure at 2 weeks postpartum. She presented to the OSH on [**2152-10-20**] after she was witnessed to have a tonic-clonic seizure by her partner with another seizure witnessed by EMS en route. She was admitted to [**Hospital1 2177**], with BP=250/105, and treated with magnesium sulfate for presumed eclampsia with subsequent intubation for airway protection in ED. Brain MRI at this time was consistent with Posterior Reversible Leukencephalopathy. . Patient was then extubated on Sunday (HD#2), but was reintubated after becoming agitated and hypertensive. CXR at this point showed new RUL infiltrate and pulmonary edema. Subsequent echo showed EF=55% with no valvular abnormalities or diastolic dysfunction. She was initially treated empirically with clindamycin and ceftriaxone. Sputum grew 4+ MSSA and urine grew Klebsiella. Patient was febrile with leukocytosis and copious secretions, switched to Levofloxacin. Hypertension/eclampsia was treated with labetalol and nifedipine. There was also a question of appendicitis on CT scan, but surgery and the MICU attending felt this was unlikely. . On transfer to the [**Hospital Unit Name 153**], intubated, vital signs were T=98.6, BP=151/87, P=83, RR=17, and she was complaining of headache. . ROS: Patient indicates headache. Denies abdominal discomfort. Patient is intubated and cannot indicate any other problems. Past Medical History: -Pregnancy induced hypertension -depression -migraine headaches -Uterine Fibroids -s/p laparoscopic tubal ligation -s/p inguinal hernia repair Social History: -History of domestic violence -No tobacco, EtOH, drug use Family History: -Hypertension -Diabetes -Sister with MS Physical Exam: Tmax: 37.9 ??????C (100.2 ??????F) Tcurrent: 37.2 ??????C (98.9 ??????F) HR: 91 (59 - 96) bpm BP: 141/66(81) {112/57(71) - 186/98(114)} mmHg RR: 15 (15 - 26) insp/min SpO2: 97% Gen: Sitting comfortably in bed HEENT: PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM with copious secretions. OG/ET tubes in place. Pt w/ low volume voice NECK: No JVD, trachea midline CV: RRR, normal S1/S2, no murmurs appreciated Pulm: Nonlabored work of breathing; coarse, turbulent breath sounds at upper airways; inspiratory wheezes on posterior auscultation Abd: Soft, nontender, not distended; normoactive bowel sounds. EXT: No C/C/E, no palpable cords. 2 PIVs in LUE, 1 PIV in RUE. NEURO: Initially responsive until propofol was given. Moves all 4 extremities with distal movements intact. Brachioradialis pulse present bilaterally. Patellar DTR +1 on Right, absent on Left. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [**2152-11-1**] 03:40AM BLOOD WBC-8.1 RBC-4.51 Hgb-12.6 Hct-37.1 MCV-82 MCH-27.9 MCHC-33.9 RDW-14.6 Plt Ct-278 [**2152-10-30**] 02:45AM BLOOD Neuts-70.0 Lymphs-20.3 Monos-4.9 Eos-4.5* Baso-0.3 [**2152-10-26**] 09:59PM BLOOD PT-13.5* PTT-24.9 INR(PT)-1.2* [**2152-11-1**] 03:40AM BLOOD Glucose-96 UreaN-10 Creat-0.6 Na-141 K-3.9 Cl-103 HCO3-27 AnGap-15 [**2152-10-26**] 09:59PM BLOOD ALT-34 AST-42* LD(LDH)-247 AlkPhos-132* TotBili-0.4 [**2152-11-1**] 03:40AM BLOOD Calcium-9.1 Phos-3.0 Mg-1.9 [**2152-10-27**] 05:14AM BLOOD HCG-<5 [**2152-10-26**] 10:08PM BLOOD Type-ART Temp-37.0 PEEP-5 FiO2-40 pO2-138* pCO2-43 pH-7.40 calTCO2-28 Base XS-1 Intubat-INTUBATED . EEG: [**2152-10-28**] IMPRESSION: This is a normal routine EEG mostly in the drowsy state. There were no lateralized or epileptiform features seen. . ECHO: The left atrium is elongated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. IMPRESSION: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. No valvular pathology or pathologic flow identified. . IMAGING: [**2152-10-27**] EXAM: MRI brain. CLINICAL INFORMATION: Patient with possible reversible encephalopathy. TECHNIQUE: T1 sagittal and FLAIR, T2 susceptibility and diffusion axial images of the brain were obtained. 3D time-of-flight MRA of the circle of [**Location (un) 431**] acquired. 2D time-of-flight MRA of the venous sinuses were obtained. FINDINGS: BRAIN MRI: There are no prior examinations for comparison. There is small focus of increased signal is seen in the left frontal subcortical white matter. Additionally, subtle increased signal is seen in both occipital subcortical white matter. No other foci with abnormalities seen within the brain. No acute infarcts are seen. There is no mass effect or hydrocephalus. Extensive soft tissue changes are seen in the sphenoid sinuses from retained secretions. Soft tissue changes are also seen in the left anterior ethmoid air cells and soft frontal sinus. IMPRESSION: Subtle T2 signal abnormalities in the left parietal and both occipital subcortical white matter could be due to early changes of reversible encephalopathy or due to resolving encephalopathy. Clinical correlation with history is recommended. If there are prior films, prior examinations, comparison would be helpful. Extensive soft tissue changes in the sphenoid sinus. No acute infarcts or mass effect. . MRA OF THE HEAD: Head MRA demonstrates normal flow signal within the arteries of anterior and posterior circulation. IMPRESSION: No significant abnormalities on MRA of the head. MRV OF THE HEAD: Head MRV demonstrates normal flow signal in the superior sagittal and transverse sinuses as well as in the deep venous system. The flow signal in the deep venous system in the left transverse sinus are not well seen on the projection images but are well visualized on the source images. IMPRESSION: Normal MRV of the head. No evidence of sinus thrombosis. Brief Hospital Course: Assesment: This is a 39 year-old female with a history of PIH, 3 weeks postpartum, who presents in transfer from [**Hospital3 9947**] with seizures, RUL infiltrate, and respiratory distress. . 1) Respiratory Distress/RUL Infiltrate: This likely represents an aspiration pneumonia secondary to seizure and intubation at the OSH. Sputum grew MSSA. Initially treated with clindamycin and ceftriaxone, overall 3 days. The patient was started on levofloxacin at [**Hospital1 2177**] on [**10-24**]. The patient's secretions were inhibiting the ability to wean off the ventilator. On [**10-27**] the patient failed extubation. She became stridorous, received heliox and racemic epinephrine. She was found to have erythematous vocal cords and was reintubated. On [**10-31**] the patient's vocal cords were visualized via bronchoscopy and the patient was sucessfully extubated. . 2) Hypertension/Eclampsia: Patient has past history of a pregnancy complicated by hypertension. The most recent pregnancy was induced for fetal distress. The patient developed tonic clonic seizures two weeks postpartum, and her overall clinical picture suggested late-onset post-partum eclampsia. The patient's blood pressures were controlled with labetalol 700mg TID and nifedipine 20mg TID with a goal BP <160/90. Neurology was consulted and recommended a Keppra load and lorazepam if seizures recur. She did not have any further seizure activity. The patient had an MRI that did not show any abnormalities and EEG did not show any seizure activity. She was transferred to the Hospital Medicine Service on [**11-2**], where she remained clinically stable and without any further seizure activity. Her labetolol was decreased as tolerated. . 3) Urinary Tract Infection: Urine culture at [**Hospital1 2177**] grew Klebsiella. This was treated with levofloxacin for a total of 7 days. . 4) FEN: The patient had an OG tube in place and was started on tube feeds [**10-28**]. After extubation the patient tolerated a regular diet, though her appetite was poor. . 5) lactation: The patient expressed interest in resuming breastfeeding, and a Lactation Consultation was called. A hospital-strength breast pump was provided, and her milk supply was maintained. We reviewed all her medications on Lactmed.org and confirmed that she may safely give her breastmilk to her baby. . 6) possible post-partum depression: Patient was quite emotional and overwhelmed by the events of the last few weeks, which is expected, but her tearfulness also raised the possibility of post-partum depression. I recommended an SSRI which is safe to take while breastfeeding (Zoloft), but she preferred to wait to discuss this further at her next OB appointment. When her fiance and oldest son came to visit her in the hospital, and discharge plans were being coordinated, she was in much better spirits. . 7) Communication: [**Name (NI) 32086**] [**Name (NI) 32087**] (Sister): [**Telephone/Fax (1) 32088**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4135**] (fiance): [**Telephone/Fax (1) 32089**] Medications on Admission: Home Meds: OTC Ca and Fe supplements [**Hospital1 2177**] Meds: Labetalol 600mg POGT q8hr, Nifedipine 10mg POGT q4hr, Enoxaparin 40mg SC q24hr, Levofloxacin 750mg PO q24hr, Ranitidine 150mg POGT [**Hospital1 **], Propofol infusion, Multivitamin 1 POGT qDay Discharge Medications: 1. Therapeutic Multivitamin Liquid Sig: One (1) Tablet PO DAILY (Daily). 2. Nifedipine 10 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). Disp:*180 Capsule(s)* Refills:*0* 3. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: 1. late-onset post-partum eclampsia 2. posterior reversible encephalopathy syndrome (PRES) 3. pregnancy-induced hypertension 4. aspiration pneumonia, treated 5. urinary tract infection, treated 6. probable post-partum depression Discharge Condition: Asymptomatic, tolerating po, ambulating with assistance. Discharge Instructions: You were admitted with seizures and severe high blood pressure two weeks after you delivered your baby. This has been diagnosed as late onset post-partum eclampsia. You were initially in our Intensive Care Unit, where you were intubated and supported with a ventilator. You were followed closely by Neurology. An MRI of your brain showed some abnormalities in the back portion of your brain which are sometimes seen with severe hypertension. These are usually reversible changes, and we have scheduled you for a follow-up MRI to confirm that your MRI returns to normal. You also developed an aspiration pneumonia in the setting of the seizure and intubation, as well as a urinary tract infection, and you were treated with antibiotics. Since you were transferred out the the regular medical floor, your blood pressure has been much better, and we have been adjusting your blood pressure medications. You were also seen by our Lactation Consultant and started successfully pumping your breast milk so that you can return to breastfeeding your newborn baby when you return home. We discussed the probability of some component of post-partum depression, and we recommended starting a medication called Zoloft, which would be safe with breastfeeding. You have decided to discuss this further with your doctor [**First Name (Titles) **] [**Last Name (Titles) **] next week. Followup Instructions: MATERNAL FETAL MEDICINE: Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] D. [**2152-11-8**] at 01:15p [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] MRI of the BRAIN: Thurs [**11-23**] at 1pm, [**Hospital Ward Name 517**] Clinical Center, [**Location (un) 470**] Radiology NEUROLOGY: [**Doctor Last Name 18530**]/[**Doctor Last Name **] Wed [**1-10**] at 4pm [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2152-11-8**]

[ "646.64", "348.5", "507.0", "518.81", "642.64", "041.3", "311", "647.84", "482.41", "648.44", "599.0" ]

icd9cm

[ [ [] ] ]

[ "33.22", "96.71", "96.6" ]

icd9pcs

[ [ [] ] ]

10305, 10362

6612, 9681

280, 299

10635, 10694

3085, 6036

12111, 12644

2070, 2112

9990, 10282

10383, 10614

9707, 9967

10718, 12088

2127, 3066

233, 242

327, 1811

6053, 6589

1833, 1978

1994, 2054

60,309

178,599

40301

Discharge summary

report

Admission Date: [**2168-8-19**] Discharge Date: [**2168-8-23**] Date of Birth: [**2098-12-1**] Sex: M Service: MEDICINE Allergies: Ciprofloxacin Attending:[**First Name3 (LF) 2641**] Chief Complaint: PE Major Surgical or Invasive Procedure: none History of Present Illness: 69M history of colon cancer, status post resection in [**Month (only) 404**], complains of progressive dyspnea on exertion since Monday and severe dyspnea at rest today, as well as a vague feeling of abdominal fullness. He presented to [**Hospital3 5365**] where they obtained a CT torso showing extensive bilateral pulmonary emboli with suggestion of RV strain, and questionable gallbladder wall thickening. He was started on a heparin bolus and drip and transferred to [**Hospital1 18**] because he receives his usual care here. Patient denied fever, chills, cough, chest pain, significant abdominal pain, nausea, vomiting, diarrhea, melena, hematochezia. Regarding prior malignancy history a lesion was found on colonoscopy on [**2167-11-23**]. He had an abdominal CT to evaluate extent of the lesion and was found to have incidental pulmonary embolus which was treated with lovenox then bridged to coumadin until [**5-/2168**] when it was discontinued per PCP. . ED course: presenting vitals: 98.5 110 119/75 94% 4L NC. He was noted to be persistently tachycardic. FAST exam notable for RV strain. He was continued on the heparin drip. Labs notable for WBC 11.6, PTT 142, normal creatinine, BNP<5, trop 0.13, and ALT/AST 53/46. Right upper quadrant ultrasound showed some GB wall thickening and possible hemangioma 1.7cm. Admitted to MICU green for management of PE. Vitals prior to transfer: 108 115/70 99% 3L NC. Access: 20g R-ac, 20g-L-ac. . On the floor he confirms the above story and hx of prior PE, anticoagulation history and recent symptomatology. Pt denied abd pain or fullness and reported that breathing was somewhat improved. He also pt reports long car trip 2 weeks ago. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough or hemoptysis. 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: Hypertension Diabetes Mellitus type 2 Psoriasis High grade dysplasia on colonoscopy s/p colectomy [**12/2167**] Social History: Patient lives with his wife. Retired from [**Name (NI) 29723**] Brothers. [**Name (NI) 1139**]: never ETOH: none Family History: No known history of cancer. Nephew has a hypercoaguable disorder. Physical Exam: Admission Physical Exam Vitals: t96.8 hr 110 bp 116/78 rr22 O296/3L NC General: Alert, oriented, male lying flat in bed no acute distress, speaking in full sentences HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: mild dry rales b/l bases, no wheezes or ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge physical exam: Vitals: T 96 BP 121/80 HR 72 RR 18 SO2 94% RA Unchanged from above, except: General: NAD, comfortable Lungs: CTAB Pertinent Results: TTE ([**2168-8-20**]) The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is >=15 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. Apical function is preserved ([**Last Name (un) 13367**] sign). There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is mild posterior leaflet systolic A late systolic jet of mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Right ventricular cavity enlargement with free wall hypokinesis. Moderate pulmonary artery systolic hypertension. Mild mitral valve prolapse with mild mitral regurgitation CXR ([**2168-8-19**]) FINDINGS: There are no old films available for comparison. The lung volumes are slightly low. There is a patchy area of volume loss at the left base which partially obscures the left hemidiaphragm that could represent small area of infiltrate versus volume loss. Otherwise, the lungs are clear. The heart is upper limits normal in size. There is no effusion. LENIs ([**2168-8-20**]) IMPRESSION: 1. In right lower extremity, occlusive thrombus extending from right calf veins to the common femoral vein at the level of the greater saphenous vein, though minimal surrounding flow is noted in the right popliteal vein. 2. Chronic partially occlusive thrombus within the left popliteal vein. LIVER OR GALLBLADDER US ([**2168-8-19**]) IMPRESSION: 1. Mild gallbladder distention and gallbladder wall edema without stones or sludge. These findings are nonspecific and may be related to third spacing or possible hepatitis. Acute acalculous cholecystitis is considered unlikely, however, if clinical suspicion for acalculous cholecystitis is high, a HIDA scan may be obtained for further evaluation. 2. 1.5 x 1.4 x 1.7 cm echogenic lesion in the right lobe of the liver, likely a hemangioma; however, due to patient's history of colon cancer, a metastatic lesion cannot be fully excluded. As a result, MRI is recommended for further evaluation. 3. Septated cyst visualized in the left lobe of the liver. MRSA SCREEN (Final [**2168-8-22**]): No MRSA isolated. Labs on admission Chem: Glucose-111* Na-141 K-4.5 Cl-107 calHCO3-21 UreaN-16 Creat-1.0 CBC: WBC-11.6* RBC-4.61 Hgb-15.1 Hct-41.6 MCV-90 Plt Ct-108*# Neuts-83.5* Lymphs-11.5* Monos-3.6 Eos-0.7 Baso-0.7 Coags: PT-13.7* PTT-142.2* INR(PT)-1.2* LFTs: ALT-53* AST-46* AlkPhos-58 TotBili-0.5 Lipase-27 [**2168-8-19**] 12:48PM BLOOD cTropnT-0.13* proBNP-<5 [**2168-8-20**] 04:19AM BLOOD cTropnT-0.07* Labs on discharge Chem: Glucose-93 UreaN-14 Creat-1.0 Na-144 K-4.2 Cl-104 HCO3-31 CBC: WBC-7.0 RBC-4.78 Hgb-15.6 Hct-43.5 MCV-91 Plt Ct-126* Coags: PT-12.4 PTT-28.8 INR(PT)-1.0 Pending Labs Lupus-PND ACA IgG-PND ACA IgM-PND BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA, IGM, IGG)-PND Brief Hospital Course: 69y M hx of prior PE (off anticoag since [**Month (only) **]), HTN, [**Hospital 88414**] transferred from OSH on heparin gtt for management. . # PE: OSH report suggests extensive thrombus b/l pulmonary arteries and each lobar branch with increased exertional dyspnea over past few days. Evidence of intraventricular septum flattening on CT chest report and on FAST u/s in ED with RV dysfunction. Chest xray showed low lung volumes, no consolidation, effusion or pneumothorax. He was switched from a heparin gtt to LMWH given normal renal fxn, body habitus and malignancy history. LENIs documented new RLE DVT; TTE confirmed RV dysfunction. Pt was transfered from the MICU to the general medicine floor on [**2168-8-20**]. On [**2168-8-21**] pt had HR to the 160s and was found to be in atrial fibrillation; pt. returned to sinus rhythym with HR in 120's after 5 mg IV metoprolol. Pt placed on standing metoprolol. He remained in sinus rhythym through the rest of his hospitalization. On [**8-23**] pt was satting well on RA. . # HTN: We held his home atenolol in the context of a PE; given the management of the atrial fibrillation episode outlined above, we continued to hold atenolol and placed him instead on metoprolol. . # NIDDM: We held home metformin and placed on a sliding scale. Blood sugars were well controlled throughout hospitalization. . # Liver lesion: Right upper quadrant ultrasound in ED showed some GB wall thickening and possible hemangioma 1.7cm with recommended f/u by MRI. Previous MRI abd w/ w/out contrast at [**Location (un) 2274**] ([**2168-5-11**]) identified a 15 mm lesion in segment 8 consistent with hemangioma. Per radiology, there is no need for outpatient MRI to evaluate this; he should continue imaging as recommended by his outpatient [**Month/Day/Year 21339**]. . TRANSITIONS IN CARE -will need to continue lovenox indefintiely -will need to consider metoprolol vs. atenolol -f/u on Lupus, beta-2-glycoprotein, and anti-cardiolipin antibodies. Medications on Admission: 1.atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Medications: 1. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 2. enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg Subcutaneous Q12H (every 12 hours). Disp:*60 syringe* Refills:*6* 3. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS pulmonary embolism SECONDARY DIAGNOSIS atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 88415**], It was a pleasure to take care of you during your stay at [**Hospital 61**] [**Hospital 1225**] Hospital. You presented to our emergency department with a known diagnosis of bilateral extensive pulmonary embolism. This was diagnosed at at [**Hospital3 5365**], where you came earlier that morning with dyspnea and had a CT scan showing pulmonary embolism, a blood clot in your lungs. We gave you extra oxygen to help you breath and enoxaparin to help dissolve your clot and prevent other clots from forming. You were admitted you to the medical intensive care unit for close monitoring. While at the medical intensive care unit, you remained hemodynamically stable, and the next day ([**2168-8-20**]) you were transferred to the general medical service. There, we found that your heart was beating irregularly (atrial fibrillation), which we treated by giving you the beta blocker metoprolol. By [**2168-8-23**], you were breathing comfortably without needing any additional oxygen, and your heart at returned to its normal rhythym. We also did an ultrasound which found that the source of the clot in your lungs was a clot in your legs. We sent several laboratory tests to help evaluate possible causes of the clot; you should follow up on these with your [**Month/Day/Year 21339**]. MEDICATIONS TO CONTINUE -all of your home medications EXCEPT atenolol MEDICATIONS TO START -enoxaparin 90 mg injection twice a day -metoprolol 12.5 mg twice a day by mouth MEDICATIONS TO STOP -atenolol Please follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 21339**] as cheduled below. Followup Instructions: Name: [**Last Name (un) **],ZULFIQAR A. MD Location: [**Location (un) 2274**]-[**Hospital1 **] Address: [**Location (un) 17467**], [**Hospital1 **],[**Numeric Identifier 10727**] Phone: [**Telephone/Fax (1) 68410**] When: [**Last Name (LF) 2974**], [**2167-8-27**]:40AM Name: [**Last Name (LF) **], [**Name8 (MD) **] MD Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3468**] When: Tuesday, [**9-13**], 1:30PM Completed by:[**2168-8-23**]

[ "250.00", "453.51", "401.9", "696.1", "228.09", "573.8", "V45.89", "427.31", "415.19", "453.41", "V10.05", "287.5" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9324, 9330

6843, 8835

277, 284

9452, 9452

3536, 6820

11288, 11821

2711, 2779

9010, 9301

9351, 9431

8861, 8987

9603, 11265

2794, 3372

2023, 2425

235, 239

312, 2004

9467, 9579

2447, 2561

2577, 2695

3397, 3517

25,216

170,224

45792+45793

Discharge summary

report+report

Admission Date: [**2113-3-1**] Discharge Date: [**2113-3-7**] Date of Birth: [**2055-1-28**] Sex: M Service: ADMITTING DIAGNOSIS: Status post split thickness skin graft of the right foot. HISTORY OF PRESENT ILLNESS: The patient is a 50 year old gentleman with a history of type I diabetes, depression, history of below the knee amputation, insulin dependent with no known drug allergies, here for status post split thickness skin grafts of the right foot. He has had history of non healing foot ulcers, right heel ulcers in the past. HOSPITAL COURSE: The patient was put on p.o. Levaquin. There were no complications to the hospital stay. The [**Last Name (un) 3208**] Diabetes Center was consulted due to the patient's labile diabetic glucose levels. In the last couple of days, the patient's glucose levels remained stable [**First Name8 (NamePattern2) **] [**Last Name (un) 3208**]. They adjusted his doses of Humilog insulin, according to a sliding scale. The patient is being discharged in stable condition. The patient will follow-up with Dr. [**Last Name (STitle) 13797**] in two weeks. The patient will go home with VNA services for dressing changes every day, as well as heparin flushes to the PICC line if that is still in place. DISCHARGE MEDICATIONS: Ambien 5 mg p.o. q h.s. Levaquin 500 mg p.o. q. day. Percocet one to two tablets p.o. every four to six hours. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 19095**], M.D. [**MD Number(1) 19096**] Dictated By:[**Last Name (NamePattern1) 19796**] MEDQUIST36 D: [**2113-3-7**] 04:46 T: [**2113-3-7**] 17:09 JOB#: [**Job Number 97556**] Admission Date: [**2113-3-1**] Discharge Date: [**2113-3-7**] Date of Birth: [**2055-1-28**] Sex: M Service: PLASTIC CHIEF COMPLAINT: The patient is here for split thickness skin graft of the right foot. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 58 year-old gentleman with type 1 diabetes for nine years, history of diabetic ketoacidosis, depression with no known drug allergies taking insulin here with a history of multiple grafts to his right foot due to nonhealing ulcers. PHYSICAL EXAMINATION: On examination vital signs were within normal limits. Pupils are equal, round and reactive to light. Extraocular movements intact. Heart regular rate and rhythm. Lungs were clear to auscultation bilaterally. Abdomen was soft, nontender, nondistended. HOSPITAL COURSE: Unremarkable. The patient was placed on po Levaquin and the patient had a split thickness skin graft performed and currently is asymptomatic. Hospital course has been benign. [**Last Name (un) **] diabetes consult was obtained due to managing the patient's diabetes. The patient was placed on an insulin sliding scale, which was adjusted by [**Last Name (un) **] consult. The patient is being discharged on 28th in stable condition. The patient will be discharged with VNA Services and requested to follow up with Dr. [**Last Name (STitle) 13797**] in two weeks. VNA dressing changes will be performed every day. the patient will also be given a resting night splint. DISCHARGE MEDICATIONS: Percocet one to two tabs po q 4 to 6 hours, Ambien 5 mg po q.h.s., Tylenol 325 one to two tablets q 4 to 6 hours and Levaquin 500 mg po q day for seven days, aspirin 325 mg po q day. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 19095**], M.D. [**MD Number(1) 19096**] Dictated By:[**Last Name (NamePattern1) 97557**] MEDQUIST36 D: [**2113-3-7**] 04:18 T: [**2113-3-8**] 05:52 JOB#: [**Job Number **]

[ "707.14", "V49.75", "250.61" ]

icd9cm

[ [ [] ] ]

[ "86.69" ]

icd9pcs

[ [ [] ] ]

3196, 3656

2496, 3172

2222, 2478

1836, 1907

1936, 2199

146, 205

109

158,943

14808

Discharge summary

report

Admission Date: [**2142-3-21**] Discharge Date: [**2142-3-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 2167**] Chief Complaint: Abdominal Pain, Shortness of breath, Chest discomfort Major Surgical or Invasive Procedure: HD [**2142-3-21**] and [**2142-3-23**] History of Present Illness: The pt is a 24 y.o. F with ESRD on HD, SLE, malignant HTN, history of SVC syndrome, PRES, recently discharged on [**2142-3-18**] after admission for abdominal pain, MSSA bacteremia, paroxysmal hypertension and ESRD line, presents with central crampy abdominal pain, chest discomfort, SOB, HTN to 230s. Pt states that at around 11pm last night developed shortness of breath that felt as though someone was sitting on her chest. She states that she feels as though she cannot catch her breath. Pt also describes chest discomfort which she states that she has not had before. She also has her chronic abdominal pain. She states that it comes and goes and is unchanged from her baseline. . In the ED, initial vitals: 98.9 [**Telephone/Fax (3) 43508**]4 100%RA. SBP as high as 241 recorded. She received Labetalol 20 IV x 2 without improvement. She was given hydral 20 IV without improvement, so she was placed on a Labetalol gtt @ 4 mg/min with improvement of SBP 220. She was given IV Zofran, IV dilaudid, Hydralazine 50mg po, Labetolol 200mg po, Labetolol 100mg IV x 3, Levofloxacin 750mg IV, Ceftriaxone 1g IV, Vancomycin 1g IV, weregiven for question of infiltrate on CXR prior to CT. Nitroprusside gtt added and .5 mg/kg, pressure initially improved to 180s. Tried to wean off the nitroprusside and pressure went back up to 208. Chest pain has resolved, still SOB with abdominal pain. Pan-scan w/o contrast showed interval worsening of chronic pulmonary edema. Pleural and pericardial effusions stable. Ativan seemed to help symptoms. One blood culture was sent in the ED. Per report, EKG showed LVH, ST depression in V6. Trop a little more elevated than normal but CKs flat. [**Telephone/Fax (3) **] was discussed with renal and it was not felt that HTN is a volume issue so no need for emergent [**Telephone/Fax (3) 2286**]. . Upon arrival to the floor, her SBP was 203. She continued to complain of abdominal pain and shortness of breath though her chest discomfort was improved. Respiratory rate up to 30. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated [**Year (4 digits) 2286**] [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought due to the posterior reversible leukoencephalopathy syndrome, associated with LE paresis in [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - 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: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**], getting Vanc with HD. . PSHx: 1. Placement of multiple catheters including [**Year (4 digits) 2286**]. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Denies any substance abuse (EtOH, tobacco, illicits). She lives with her mother. On disability for multiple medical problems. Family History: No known autoimmune disease but there is a history of cardiovascular disease and cerebrovascular accident in her grandfather. Physical Exam: PE: 98.6 128/98 82 20 100% on 2L NC vitals Gen- NAD HEENT- MMM CV- Regular, nl S1, s2, + s3. Lungs- CTA bilat Abd- + BS, soft, ND. Tender only to deep palpation Ext- 2+ DP bilat. trace pedal edema Neuro- AA+Ox3. Pertinent Results: Admission Labs: [**2142-3-21**] 02:20AM WBC-5.0 RBC-2.61* HGB-7.7* HCT-23.5* MCV-90 MCH-29.4 MCHC-32.6 RDW-19.3* [**2142-3-21**] 02:20AM NEUTS-76.1* BANDS-0 LYMPHS-17.9* MONOS-4.5 EOS-1.1 BASOS-0.5 [**2142-3-21**] 02:20AM PLT SMR-NORMAL PLT COUNT-168 [**2142-3-21**] 02:20AM PT-21.8* PTT-34.7 INR(PT)-2.1* [**2142-3-21**] 02:20AM cTropnT-0.12* [**2142-3-21**] 02:20AM ALT(SGPT)-46* AST(SGOT)-94* CK(CPK)-76 ALK PHOS-173* TOT BILI-0.4 [**2142-3-21**] 02:20AM GLUCOSE-74 UREA N-47* CREAT-7.3* SODIUM-140 POTASSIUM-5.8* CHLORIDE-109* TOTAL CO2-19* ANION GAP-18 [**2142-3-21**] 04:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2142-3-21**] 08:00AM URINE BLOOD-SM NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2142-3-21**] 12:58PM CK-MB-NotDone cTropnT-0.12* . CT C/A/P - [**2142-3-20**] - 1. Interval worsening of pulmonary edema, now moderate to severe. Unchanged moderate pericardial effusion. Periportal edema persists. 2. Small right pleural effusion, unchanged. 3. Small amount of ascites. 4. No evidence of bowel obstruction. Contrast material reaches the rectum. 5. Redemonstration of extensive mediastinal and hilar lymphadenopathy. The study and the report were reviewed by the staff radiologist. Discharge labs: [**2142-3-23**] 12:00PM BLOOD WBC-3.7* RBC-2.87* Hgb-8.7* Hct-26.1* MCV-91 MCH-30.3 MCHC-33.3 RDW-19.4* Plt Ct-130* [**2142-3-23**] 12:00PM BLOOD Plt Ct-130* [**2142-3-23**] 12:00PM BLOOD PT-28.8* PTT-58.6* INR(PT)-2.9* [**2142-3-23**] 12:00PM BLOOD Glucose-77 UreaN-31* Creat-6.0*# Na-137 K-4.8 Cl-104 HCO3-24 AnGap-14 [**2142-3-23**] 12:00PM BLOOD Calcium-8.4 Phos-5.7* Mg-1.9 Brief Hospital Course: This is a 24 y.o F with SLE, ESRD on HD and malignant hypertension presenting with abd pain, diarrhea, and HTN. . # Hypertension: The patient had very high blood pressures on presentation (200's/100's) that nevertheless are within levels she's certainly reached during previous admissions. Initial attempts were made to control her BP with hydralazine and labetalol IV but after these failed to control her blood pressure, she was started on a labetalol and nitroprusside drip and admitted to the ICU. This was then changed to a nicardipine drip. She was successfully transitioned to home medications of clonidine, labetalol, aliskiren, nifedipine and hydralazine on [**3-22**] and transferred to the medicine floor. The next day, her BP remained within goal of 120's/80's. She was dialyzed and sent home. . Tachypnea/Shortness of breath - On admission, likely due to pulmonary edema, however, cannot rule out cardiac etiology in setting of small enzyme leak. Has OSA. CE's were cycled and were negative. CPAP was continued as tolerated at home settings. SOB resolved after HD on [**2142-3-21**] . # abdominal pain: Consistent with patient's baseline chronic abdominal pain. Medication effect also possible. CT prelim neg for small bowel obstruction. LFTs doubled from [**2142-3-18**]. On arrival to the floor, abd pain was back to baseline and well controlled on Dilaudid 2mg PO q 4hrs . # ESRD: Renal followed. HD given [**3-21**] and [**3-23**] . # Coagulopathy: patient on lifetime anticoagulation for hx of multiple thrombotic events. Continued coumadin . # HOCM: evidence of myocardial hypertrophy on Echo. Currently not symptomatic. Continued labetalol. Medications on Admission: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 2. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4PM. 5. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 6. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 7. Labetalol 200 mg Tablet Sig: 4.5 Tablets PO TID (3 times a day). 8. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for abdominal pain. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 12. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY 13. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO three times a day as needed for nausea for 4 days. 14. Vancomycin at HD Discharge Medications: 1. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 6. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid () as needed for Severe HTN. 7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Month/Year (2) **]:*30 Tablet(s)* Refills:*2* 8. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 9. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed. 10. Labetalol 200 mg Tablet Sig: 4.5 Tablets PO TID (3 times a day). 11. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Discharge Disposition: Home Discharge Diagnosis: SLE ESRD on HD Malignant hypertension Chronic abdominal pain Discharge Condition: Good. Tolerating POs. BP 110's/80's Discharge Instructions: You were admitted with hypertension and abdominal pain. While you were here, we treated your hypertension with medications and dialyzed you. Your hypertension is resolved at the time of discharge. Your belly pain partially resolved and at time of discharge is comparable to your chronic belly pain. . Please follow up as below. . Please continue your medications as prescribed. . Please call your doctor or return to the ED if you have any headaches, lightheadedness, changes in vision, vomitting, blood in your stool, loss of consciousness or any other concerning symptoms. Followup Instructions: Please follow up with your primary care doctor within 1 week. You need to schedule an appointment with either your PCP or OB/GYN for a pap smear as soon as possible. You should also get a repeat urinalysis and urine culture if you have any UTI symptoms. . Please continue [**Month/Year (2) 2286**] sessions as directed by the nephrology team- your next session should be on Tuesday. Completed by:[**2142-3-26**]

[ "E879.1", "V58.61", "599.0", "276.2", "423.9", "289.81", "V45.12", "276.7", "789.00", "041.12", "710.0", "327.23", "786.59", "996.62", "285.21", "276.6", "425.4", "585.6", "403.01", "041.04", "582.81", "338.29", "V12.51", "459.2", "425.1", "790.7", "287.5" ]

icd9cm

[ [ [] ] ]

[ "93.90", "39.95", "99.04" ]

icd9pcs

[ [ [] ] ]

10690, 10696

6785, 8452

336, 377

10801, 10839

5021, 5021

11462, 11876

4646, 4773

9652, 10667

10717, 10780

8478, 9629

10863, 11439

6382, 6762

4788, 5002

243, 298

405, 2419

5038, 6365

2441, 4484

4500, 4630

40,351

162,364

28147

Discharge summary

report

Admission Date: [**2165-3-13**] Discharge Date: [**2165-4-2**] Date of Birth: [**2097-6-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 800**] Chief Complaint: Chest pain. Major Surgical or Invasive Procedure: Esophageogastroduodenal endoscopy x 3 Variceal banding (?) Paracentesis x 2 History of Present Illness: 67 yo M with history of CAD s/p CABG, HTN, DM, Afib, seizure disorder, schizophrenia, presents from nursing home with complaints of chest pain. Story unable to be verified with patient as he is very sedated from morphine and poor historian. Per ED signout, patient was having [**7-9**] mid-left sided chest pain which may have radiated to his left hand. While at the nursing home, he received 3 tablets of SL NTG which did not relieve the pain, so he was transferred to [**Hospital3 **]. There, he was found to have troponin of 21.9 and found to have ST elevations in III and AVF with some mild ST elevations in V2-V3. Patient received fentanyl and morphine with some resolution of pain. He also received ASA, lipitor, and kayexalate for K of 5.7. . There was some confusion about his DNR paperwork at the nursing home, it was poorly documented who his HCP is. His daughter was listed, but when called, she said she was unsure if she was the HCP. [**Name (NI) **] was transferred to [**Hospital1 18**] for possible cath as it was uncertain what his code status was and who the HCP is. . In the ED, VS were: 98.5, 99/60, 72, 18, 100%RA. Patient complained of whole body pain, but did not seem to have true chest pain. He received 4mg of morphine with resolution of pain. Warfarin was held as his INR returned at 4.4. Troponin was 3.04. CXR showed hazy atelectasis. EKG was repeated and showed subtle V2-V3 ST elevations. A bedside TTE showed mild hypokinesis along the inferior wall, questionable if there are changes from previous TTE. Patient had received 600 mg of plavix on arrival to ED, but it was decided later that cardiac catheterization would not be pursued for now. On transfer, patient's vital were: 97.7, 117/74, 67, 14, 99%2L . On the floor, patient is very sedated, likely from morphine. His is only minimally responsive, will open eyes to touch, but does not answer questions. Past Medical History: - CAD s/p CABG - HTN - DM with gastropathy neuropathy - A fib on warfarin and digoxin - Seizure disorder - followed by Dr. [**Last Name (STitle) 68427**]. - "Schizophrenia" per [**Hospital1 18**] records, but no evidence clinically, no previous treatment and uncertainty about this diagnosis by PCP and nursing home. - Reported remote microscopic intracranial hemorrhages of unclear etiology - Stroke, [**2162**], numerous earlier lacunes with right pontine stroke in early [**2162**]. Residual left sided weakness. - Chronic Gait disorder, s/p cerebrovascular disease (?) - Polyneuropathy Social History: Lives in nursing home. Previous would call HCP daily, but less more recently. - Tobacco history: denies - ETOH: denies - Illicit drugs: denies Family History: History of DM. Pt is otherwise unsure. Physical Exam: Admission Exam: VS: 96.9, 115/63, 72, 97, 97% 2L GENERAL: sedated, opens eyes to touch and voice. HEENT: PERRL. Dry MM. Blood in mouth, cut on tip of tongue NECK: Supple with no JVD CARDIAC: S1S2, RRR, no m/r/g LUNGS: CTA b/l on anterior exam ABDOMEN: Soft, diffusely tender, nondistended +BS. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: Portable TTE (Focused views) Done [**2165-3-13**] at 6:00:12 AM The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. There is severe regional left ventricular systolic dysfunction with akinesis of the inferior and inferolateral walls. Overall left ventricular systolic function is mildly depressed (LVEF= 45-50 %). Right ventricular chamber size is normal with mild global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**12-1**]+) mitral regurgitation is seen. Cardiac Enzymes [**2165-3-16**] 05:35AM BLOOD CK-MB-9 cTropnT-7.52* [**2165-3-15**] 12:20PM BLOOD CK-MB-12* MB Indx-4.1 cTropnT-8.24* [**2165-3-14**] 07:05AM BLOOD CK-MB-45* MB Indx-5.9 cTropnT-6.40* [**2165-3-13**] 03:05PM BLOOD CK-MB-24* MB Indx-5.2 cTropnT-3.60* [**2165-3-13**] 05:30AM BLOOD cTropnT-3.04* [**2165-3-13**] 05:30AM BLOOD CK-MB-41* MB Indx-6.4* proBNP-9793* [**2165-3-13**] 05:30AM BLOOD WBC-7.5 RBC-3.58* Hgb-9.3* Hct-29.2* MCV-81* MCH-25.9* MCHC-31.9 RDW-16.9* Plt Ct-50* [**2165-3-17**] 03:47AM BLOOD WBC-12.3*# RBC-2.50* Hgb-6.4* Hct-19.8* MCV-79* MCH-25.8* MCHC-32.6 RDW-17.3* Plt Ct-215# [**2165-3-17**] 06:29PM BLOOD WBC-14.0* RBC-3.43* Hgb-9.3*# Hct-28.2*# MCV-82 MCH-27.2 MCHC-33.1 RDW-16.6* Plt Ct-113*# [**2165-3-20**] 06:00AM BLOOD WBC-10.7 RBC-3.76* Hgb-10.6* Hct-31.8* MCV-85 MCH-28.1 MCHC-33.3 RDW-17.4* Plt Ct-110* [**2165-3-26**] 09:19PM BLOOD WBC-9.8 RBC-2.70* Hgb-7.7* Hct-23.0* MCV-85 MCH-28.5 MCHC-33.5 RDW-17.2* Plt Ct-103* [**2165-3-29**] 05:30AM BLOOD WBC-12.0* RBC-2.85* Hgb-7.8* Hct-24.3* MCV-85 MCH-27.3 MCHC-32.0 RDW-16.9* Plt Ct-153 [**2165-3-13**] 05:30AM BLOOD PT-41.3* PTT-40.3* INR(PT)-4.4* [**2165-3-14**] 02:49PM BLOOD PT-57.1* PTT-43.8* INR(PT)-6.4* [**2165-3-17**] 03:17PM BLOOD PT-17.4* PTT-30.8 INR(PT)-1.6* [**2165-3-22**] 05:04AM BLOOD PT-14.4* PTT-26.6 INR(PT)-1.2* [**2165-3-29**] 05:30AM BLOOD PT-17.7* PTT-35.6* INR(PT)-1.6* [**2165-3-17**] 08:57AM BLOOD Fibrino-530* [**2165-3-17**] 04:23AM BLOOD FDP-10-40* [**2165-3-26**] 03:22PM BLOOD Ret Aut-4.6* [**2165-3-13**] 05:30AM BLOOD Glucose-150* UreaN-22* Creat-1.3* Na-140 K-5.0 Cl-104 HCO3-28 AnGap-13 [**2165-3-15**] 12:20PM BLOOD Glucose-140* UreaN-36* Creat-1.7* Na-140 K-5.3* Cl-107 HCO3-26 AnGap-12 [**2165-3-22**] 05:24PM BLOOD Glucose-231* UreaN-69* Creat-3.5* Na-142 K-3.9 Cl-106 HCO3-27 AnGap-13 [**2165-3-29**] 05:30AM BLOOD Glucose-182* UreaN-78* Creat-6.3* Na-142 K-4.0 Cl-102 HCO3-24 AnGap-20 [**2165-3-13**] 05:30AM BLOOD ALT-19 AST-113* CK(CPK)-636* AlkPhos-60 TotBili-0.4 [**2165-3-29**] 05:30AM BLOOD ALT-5 AST-10 AlkPhos-63 TotBili-0.8 [**2165-3-22**] 05:04AM BLOOD Lipase-50 [**2165-3-17**] 08:57AM BLOOD D-Dimer-607* [**2165-3-23**] 05:45AM BLOOD calTIBC-161* Ferritn-282 TRF-124* [**2165-3-23**] 04:58PM BLOOD Ammonia-23 [**2165-3-21**] 05:08AM BLOOD TSH-3.4 [**2165-3-26**] 01:46PM BLOOD Cortsol-10.6 [**2165-3-26**] 02:43PM BLOOD Cortsol-21.2* [**2165-3-26**] 03:23PM BLOOD Cortsol-24.1* [**2165-3-22**] 05:24PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2165-3-13**] 05:30AM BLOOD Digoxin-0.7* [**2165-3-26**] 07:13AM BLOOD Digoxin-1.3 [**2165-3-23**] 05:45AM BLOOD Valproa-46* [**2165-3-22**] 05:24PM BLOOD HCV Ab-NEGATIVE Radiology Report CT ABDOMEN W/O CONTRAST Study Date of [**2165-3-26**] 11:40 AM CT OF THE ABDOMEN WITHOUT IV CONTRAST: There are bilateral small pleural effusions, with neighboring compressive bibasilar atelectasis. No pulmonary masses or nodules are detected. A small epicardial node is present (2:7). The heart is mildly enlarged, and demonstrates severe atherosclerotic calcifications within the coronary arteries. There is no pericardial effusion. Assessment of the solid abdominal organs is limited due to lack of IV contrast. The liver contour is nodular, compatible with known history of cirrhosis. A subcentimeter hypodense lesion within the right lobe (2:22) is too small to characterize. No other hepatic lesions are identified. There is a moderate amount of ascites throughout the abdomen. The gallbladder is distended, and the gallbladder wall is ill-defined, with neighboring [**Name2 (NI) **] stranding. A dependent hyperdense gallstone is present (2:38). Inferiorly, the hepatic flexure demonstrates mild wall edema. The spleen is enlarged, measuring 19 cm craniocaudally. The stomach and intra-abdominal loops of small bowel appear unremarkable. The pancreas appears normal. Adrenal glands and the kidneys are also unremarkable. Moderate atherosclerotic calcifications are present throughout the aorta, iliac branches, and splenic artery. Scattered mesenteric and retroperitoneal lymph nodes are prominent but do not meet CT criteria for lymphadenopathy. CT OF THE PELVIS WITHOUT IV CONTRAST: The rectum, sigmoid colon and intrapelvic loops of small and large bowel appear unremarkable. A large amount of ascites is present within the intrapelvic region. A Foley catheter terminates peripherally within the bladder. There is no inguinal or intrapelvic lymphadenopathy detected. OSSEOUS STRUCTURES: Minimal dextroscoliosis of the lumber spine is seen. There is no acute fracture or dislocation. Moderate degenerative changes are present, predominantly within the lumbar region. No sclerotic or lytic lesions are detected. IMPRESSION: 1. Moderate amount of abdominal and intrapelvic ascites. No hemoperitoneum. 2. Distended gallbladder with neighboring [**Name2 (NI) **] stranding is a nonspecific finding within the context of ascites and diffuse liver disease. However, cholecystitis cannot be excluded, and if there is a clinical suspicion for cholecystitis an ultrasound or a gallbladder scan (HIDA) can be considered . 3. Nodular-appearing liver consistent with cirrhosis. Subcentimeter hepatic hypodensity too small to characterize. Mild right hepatic flexure wall edema is likely secondary to neighboring diffuse liver disease and ascites, however colitis could be considered in the appropriate clinical context. 4. Bilateral pleural effusions with neighboring compressive atelectasis at the lung bases. 5. Severe atherosclerotic changes within the coronary arteries. Brief Hospital Course: 67 yo M with history of CAD s/p CABG, HTN, DM, Afib presents from nursing home with complaints of chest pain found to have a STEMI but unable to be intervened upon with cardiac catheterization because refused to temporarily reverse DNR/DNI status. Patient also has seizure disorder and cognitive impairment that were likely incorrectly attributed to schizophrenia. Developed UGIB in this context, later attributed to liver failure and varices. Transferred to the CCU given GIB and melena, Hct drop. Hospital course was later complicated by acute renal failure, cirrhosis (likely NASH), ascites and abdominal discomfort. Rare blood type complicated transfusion. Renal failure appeared in the context of this hypotension and tense ascites. Paracentesis improved renal function. Early hospital course also complicated by tachyarrhythmias, ventricular, which were controlled pharmacologically. Coronary Artery Disease Patient has history of CABG. Found to have ST elevation in III and AVF at OSH and very elevated troponins to 21 at OSH. On admission, troponins had already trended down to 3.04, but then trended up again, peaking at 8.24 before trending down again. Unable to bring to cath because of DNR/DNI status, had no HCP to consent for him, and elevated INR. Was medically managed for his STEMI, with morphine used for pain control. Nitro could not be utilized as patient had been continuously hypotensive. STEMI Had inferior resolving STEMI by the time he presented to [**Hospital1 18**]. He had been managed medically due to inability to consent to catheterization and length of time between MI and presentation for cath. Had been holding aspirin, plavix, given bleeding. Continued atorvastatin until became CMO. Acute on Chronic Systolic Heart Failure Patient found to have hypokinesis of inferior wall on bedside echo, questionable if it is a significant change from his last TTE in [**2162**]. Patient was initially continued on metoprolol and furosemide, but was later held because of hypotension. Patient clearly volume overloaded, however no evidence of right heart systolic dysfunction on echo. Likely cirrhosis/low albumin/distributive state contributing. Initially Lasix gtt with metolazone as above until he became anuric. CVVH was discussed with renal, but not felt to be indicated given his multiple other co-morbidities. Also discussed with HCP who agreed to no escalation of care. Arrhythmias - Atrial and Ventricular History of Afib on warfarin and digoxin. Warfarin was held as patient was found to have INR of 4.4 on admission. After transfer to CCU for GI bleed, he was having bursts of VT. Tachycardia, Ventricular and in context of AF Improved. It was controlled with digoxin to help reduce exacerbation of hypotension by diltiazem. He persisted in atrial fibrillation with reasonable rate control until all medications were discontinued. Was initially on digoxin, but this was discontinued as his renal failure worsened. As his blood pressure tolerated, he was continued on propranolol 20mg TID and was well rate-controlled. Telemetry was discontinued when the patient became CMO. Hypertension Hypotensive on this admission, likely due to infarction of myocardium. Metoprolol and furosemide were held. This likely contributed to acute on chronic renal insufficiency. Maintained SBP > 100 mmHg. Upper GI bleed and Esophageal Varices Patient had guaiac positive stools with a gradual downtrending of his hematocrit on admission in setting of elevated INR. He has a rare anti-k (Cellano) antibody which is difficult to match blood for. Blood was requested from the Red Cross and was in-house prior to GI bleed, however these units could not be transfused because of other incompatabilities and with high concerns for anaphylaxis. Hematocrit never dropped below 21 and patient was never hemodynamically unstable. Esophageal Varices Not observed on first EGD, but now appreciated on those images retrospectively. Had very small varices, no need to band as per liver. Likely cause of bleeding and secondary to portal hypertension. H. pylori negative. Maintained on protonix 40mg [**Hospital1 **]. Maintained on propranolol until made CMO. Cirrhosis and Ascites Ascites tapped on [**3-22**] with 6L removed ?????? chemistry consistent with cirrhosis as a cause of ascites. Likely NASH, but other etiologies possible with pending hepatitis serology and anti-mitochondrial antibody. Other autoimmune process possible and of particularly interest given red cell antibody and encephalopathy (very unlikely). C/b portal hypertension, as evidenced by varices. Cause of UGIB also. Effect on physiology, along with hypotension with arrhythmia, STEMI and GIB, along with ascites and increased intraabdominal pressure resulted in renal failure with features of ATN. Ascites re-accumulated very quickly. Bladder pressures never exceeded 20mmHg. Pt denied alcohol use, no asterixis on exam. Pt at risk for viral hepatitis given multiple transfusions in the past, but were negative. INR elevated, suggestive of liver failure. Initially maintained on midodrine and octreotide with albumin. Had repeated therapeutic paracenteses. Also had diagnosis of SBP, started on vancomycin and zosyn, but two days after starting this treatment, had fluid studies with rising PMN count and zosyn was switched to meropenem. These antibiotics, albumin, and midodrine/octreotide were continued until the patient was made CMO. Renal Failure secondary to ATN versus hepatorenal syndrome Likely contributions as described above, particularly including increased intraabdominal pressure. Based on muddy brown casts in urine sediment. Patient was initially on a lasix gtt, but became oliguric. CVVH was discussed with renal, but not felt to be indicated given his multiple other co-morbidities. Also discussed with HCP who agreed to no escalation of care. Altered mental status Conflicting reports from nursing home regarding baseline. Was told by RN taking care of patient that constant yelling and need for reassurance is baseline. Psychiatry [**Name (NI) 653**] nursing home and received a different story from PCP, [**Name10 (NameIs) 68428**] this is not his baseline. Altered mental status may be from delirium caused by infection, ICU psychosis, toxic, or metabolic, with the lion-share of baseline dysfunction due to cerebrovascular disease (that appears embolic). Eventually, thought that the majority of his delirium was due to uremia and hepatic encephalopathy. Cerebrovascular Disease Extensive lacunar infarctions in forebrain white matter, as seen on previous MRI. Lacune in right pons on this study and recent CT head. Likely cause of left sided upper motor neuron signs. Given lowish INR and AF, along with new Chain-[**Doctor Last Name **] respiration concerning for further thromboembolic cerebrovascular disease, particularly given possibility that mental status is further from baseline. This could localize to hypothalamus, also consistent with persistent thirst and somnolence. Seizure Disorder Appears that he may have had a seizure disorder since childhood. Taking levetiracetam, Divalproex and benzodiazepines (unclear if this was for seizure control and thought to be more likely for sedation) at admission. Doses were adjusted in light of acute on chronic renal insufficiency. He was continued on IV levetiracetam and valproic acid even after he was made CMO. He did pull out his PICC line after transfer to the floor, but a peripheral IV was placed for the anti-seizure medications. ??????Schizophrenia?????? No evidence of schizophrenia and unclear how this entered record, although it was already mentioned in the neurology outpatient note and discharge summary from [**2162**] (without any comment), but not in a prior neuroophthalmology note. Psychiatry were doubtful. More likely delirium, cerebrovascular, metabolic, pharmacologic. No evidence of psychosis. Coagulopathy Likely due to impaired synthetic function. Pt failed anticoagulation in setting of GI bleed, likely variceal, so anticoagulation was not restarted despite high CHADS2 score. Diabetes Glyburide was held on this admission, patient was maintained on lantus qhs with HISS. Comfort Measure Only Patient was in significant pain from abdominal distension and back pain. He required such frequent doses of IV hydromorphone that he was started on a fentanyl patch. He was given a combination of IV hydromorphone and oral liquid concentrated morphine as needed for pain. He passed away peacefully on [**2165-4-2**]. Guardianship HCP is [**Name (NI) **] [**Name (NI) **]. She initially said that she never agreed or signed anything saying that she would be his HCP, but subsequently relented. She is not his daughter as recorded by the [**Name (NI) **], is not related to his family at all. Patient did not have any children, spouse, or next of [**Doctor First Name **] that he is in contact with. [**Name2 (NI) **] has two estranged brothers, but [**Name (NI) **] and his [**Name (NI) **] does not know their names or any contact information. [**Name2 (NI) **] at this point is not consentable. He made his DNR/DNI decision 2 years ago when he was still deemed competent to make decisions per his PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 5656**]. Legal was consulted and states that interventions that are "reasonable" can be done, which is different from heroic life prolonging measures such as CPR that the pt likely would not want. Eventually, due to the irreversible nature of Mr. [**Known lastname 68429**] medical issues, and his discomfort/pain, after discussion with HCP, [**Name (NI) **] [**Name (NI) **], Mr. [**Known lastname **] was made Comfort Measures Only on [**2165-3-29**] at 4pm. He passed away on [**2165-4-2**]. Medications on Admission: Multivitamin 1 tablet daily Warfarin 8.5mg daily Lantus 34 units qhs Novolog 8 units TID with meals Novolin R insulin sliding scale Digoxin 0.125 mg daily Furosemide 40 mg daily Glyburide 10 mg qAM Glyburide 5 mg qPM Fluticasone 50 mcg 2 sprays each nostril daily Trazodone 50 mg qAM Trazodone 100 mg qhs Omeprazole 20 mg [**Hospital1 **] Levetiracetam 500 mg [**Hospital1 **] Metoprolol 50 mg [**Hospital1 **] Docusate sodium 100 mg daily Clonazepam 0.5 mg [**Hospital1 **] Ferrous sulfate 325 mg [**Hospital1 **] Lactulose 45 mL [**Hospital1 **] Simvastatin 80 mg daily Divalproex ER 1000 mg qhs Senna 2 tabs qhs Guiatuss 10 mL q4h PRN cough MOM 30 mL PO daily prn constipation Maalox 30 mL q4h prn dyspepsia Bisacodyul PR 10 mg daily prn constipation Lorazepam 1 mg q4h prn agitation Benadryl 25 mg q6h prn pruritis Loperamide 2 mg PRN loose stool Prochlorperazine 10 mg q4h prn nausea Trazadone 50 mg [**Hospital1 **] prn anxiety Acetaminophen 650 mg q4h PRN pain, fever Discharge Disposition: Expired Discharge Diagnosis: Diagnoses: ST Elevation Myocardial Infarction Upper GI Bleed Esophageal Varices Acute on Chronic Systolic Heart Failure Acute Renal Failure Acute Liver Failure Seizure Disorder Altered Mental Status Cerebrovascular Disease Discharge Condition: Expired. Discharge Instructions: None Followup Instructions: none [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]

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icd9cm

[ [ [] ] ]

[ "45.13", "38.93", "54.91" ]

icd9pcs

[ [ [] ] ]

20973, 20982

10142, 19947

325, 402

21249, 21259

3797, 10119

21312, 21447

3128, 3168

21003, 21228

19973, 20950

21283, 21289

3183, 3778

274, 287

430, 2339

2361, 2952

2968, 3112

25,720

171,766

30819

Discharge summary

report

Admission Date: [**2190-4-13**] Discharge Date: [**2190-4-14**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 443**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: none History of Present Illness: 99-yo-woman w/ h/o severe aortic stenosis (valve area 0.7 cm2), CAD, CRI presented to [**Hospital1 **] [**Location (un) 620**] this AM w/ severe substernal chest pain x 2 hours (started 2AM). Per pt was feeling "not usual self" yesterday. Went to bed, but felt "restless". In middle of night (2AM) developed b/l chest pressure that was "very bad". Therefore presented to [**Hospital1 **] [**Location (un) 620**] ED. Upon presentation to [**Hospital1 **] [**Location (un) 620**], she was found to have atrial fib w/ rate 120s, ST elevations in the anterior leads, elevated troponin (Trop T 0.165). She was treated w/ ASA, metoprolol 5 mg IV, low dose nitro gtt, and heparin gtt and transferred to [**Hospital1 18**] for further care. On arrival to [**Hospital1 18**] ([**Location (un) 86**]) [**Name (NI) **], pt remained in AFib with RVR, continued SSCP, other VSS. She was maintained on hep gtt, started on integrillin gtt, plavix loaded (300mg PO x 1), also given lasix 20mg IV x 1, metoprolol 2.5mg IV x 1. She was seen by cardiology in ED and decided that she does not wish to have cardiac cath after discussions - wishes only medical management. Admitted to CCU for further care. Currently, pt denies any CP/pressure, SOB. Does c/o dizziness/fatigue. Past Medical History: - aortic stenosis: severe, valve area 0.7 cm2 - CAD: NSTEMI 1 year ago (peri-operative in setting of hip surgery) - hyperlipidemia - chronic kidney disease: unclear baseline creat (?1.3-1.4 [**First Name8 (NamePattern2) **] [**Location (un) 620**] labs over last year) - s/p appy - s/p hysterectomy - hip fx . Cardiac Risk Factors: Dyslipidemia Social History: Non-smoker, no EtOH, lives in [**Hospital3 **]. Family History: n/c Physical Exam: VS: T 97 BP 104/64 HR 120 RR 25 O2 100% on 4L NC Gen: Elderly woman appears slightly tachypnic, somewhat lethargic. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP to angle of jaw. CV: Irregulary irregular, tachycardic, grade IV/VI SEM. Chest: Slightly tachypnic, crackles b/l throughout lung fields. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: Cool extremities b/l, 1+ LE edema b/l. Pertinent Results: LABS ON ADMISSION: 141 104 51 -------------< 114 5.4 23 2.0 CK: 2089 MB: 331 MBI: 15.8 Trop-T: 10.39 Ca: 9.2 Mg: 2.2 P: 6.4 . 11.2 5.4 >----< 266 35.2 EKG [**4-14**]: Atrial fibrillation. Acute anteroseptal myocardial infarction with Q waves in leads V2-V3. Left anterior fascicular block . CXR: IMPRESSION: 1. Moderate cardiac failure with bilateral pleural effusions. 2. Unusual right cardiac shodow may represent atelectasis, consolidation, pleural fluid, or mass. PA and lateral examination recommended for further characterization. . Trends [**2190-4-13**] 04:00PM BLOOD CK(CPK)-2089* [**2190-4-14**] 04:51AM BLOOD CK(CPK)-1680* [**2190-4-13**] 04:00PM BLOOD CK-MB-331* MB Indx-15.8* cTropnT-10.39* [**2190-4-14**] 04:51AM BLOOD CK-MB-219* MB Indx-13.0* cTropnT-11.33* Brief Hospital Course: The patient was admitted to the CCU for management of acute STEMI. In discussion with the patient she did not want [**Hospital 70883**] medical management. It was decided not to perform invasive tests and in fact the patient very much wished to go home with hospice care. This was coordinated through her home health care agency and she was discharged by ambulance with hospice care. Medications on Admission: - ASA occasionally - lasix 20 mg daily Discharge Medications: 1. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO Q 1 hour as needed for pain. Disp:*60 ml* Refills:*0* 2. Levsin/SL 0.125 mg Tablet, Sublingual Sig: 1-2 tablets Sublingual every four (4) hours as needed for secreations. Disp:*60 tablets* Refills:*2* 3. Ativan 1 mg Tablet Sig: 1-2 Tablets PO 1-2 hours as needed for anxiety: Give sublingually. Disp:*120 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company **] Discharge Diagnosis: Acute STEMI . Aortic Stenosis CAD Acute Renal Failure chronic renal failure hip fx Discharge Condition: patient is comfortable Discharge Instructions: Please take all medications as prescribed. Please inform your health care providers if you are uncomfortable or in pain. Followup Instructions: none

[ "584.9", "272.0", "414.01", "410.11", "424.1", "427.31", "585.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

4340, 4385

3454, 3839

272, 279

4513, 4538

2639, 2644

4707, 4715

2015, 2020

3929, 4317

4406, 4492

3865, 3906

4562, 4684

2035, 2620

222, 234

307, 1565

2658, 3431

1587, 1934

1950, 1999

56,854

170,501

52887

Discharge summary

report

Admission Date: [**2201-6-2**] Discharge Date: [**2201-6-13**] Date of Birth: [**2121-8-5**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7708**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: [**2201-6-3**] Intubation [**2201-6-7**] Re-intubation s/p self-extubation [**2201-6-11**] Extubation History of Present Illness: Mr. [**Known lastname 33667**] is a 79 year old male with past medical history of recent aortic aneurysm repair, complicated by ischemic bowel and sepsis, also with history of coronary artery disease who presents from rehabilitation today with hypoxia. Per report from the ED, patient was reported to be not feeling well and intermittently confused over the weekend. Today an oxygen saturation was checked and it was reported to be 70%, so EMS was called. Of note, patient was started on Remeron recently, which was felt to initially be the etiology of his symptoms. . In the ED, initially his blood pressure was 90/ . A chest x-ray was completed that demonstrated a left lower lobe pneumonia. He was given 750 mg of levofloxacin, and started on some intravenous fluids. . On the floor ABG: 7.47/43/77, tachypnic, tachycardic, triggered. . ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: 1. CAD s/p MI (EF 40%), CABG [**4-/2184**], multiple PCI's/stent to circ/RCA 2. Hyperlipidemia 3. HTN 4. Cervical myelopathy 5. s/p cervical fusion 6. GERD 7. Schatzki's ring 8. Mohs surgery 9. s/p open pararenal AAA [**2201-2-2**] ([**Doctor Last Name **]) 10. s/p takeback for retroperitoneal bleeding [**2201-2-2**] ([**Doctor Last Name **]) 11. s/p L colectomy [**2201-2-3**] ([**Doctor Last Name **]) 12. s/p completion sigmoid colectomy, proctectomy, transverse colectomy [**2201-2-4**] ([**Doctor Last Name **]) 13. s/p end transverse colostomy [**2201-2-6**] ([**Doctor Last Name **]) 14. s/p fascial closure [**2201-2-10**] ([**Doctor Last Name **]) 15. s/p bedside perc trach [**2201-2-17**] ([**Doctor Last Name **]) 16. s/p Klebseilla and MSSA VAP [**3-/2201**] 17. s/p Fungemia [**3-/2201**] 18. Zoster over left eye. Social History: Married with three children and worked as a lawyer, rare alcohol Family History: NC Physical Exam: On admission: Vitals: T: 100.4, BP: 94/50, HR: 100, RR: 42, 02 sat: 95% 3L GENERAL: Mild respiratory distress, diaphoretic. HEENT: MM dry, OP clear CARDIAC: S1+, S2+, Tachycardic, No M/R/G LUNG: Coarse BS on right, decreased BS on left. Using accessory muscles to breath. ABDOMEN: Soft, NT, ND, +BS EXT: No edema b/l NEURO: Grossly normal. Occasional myotonic jerks. Pertinent Results: On admission: [**2201-6-2**] 04:50PM BLOOD WBC-14.5* RBC-2.69* Hgb-8.1* Hct-25.4* MCV-94 MCH-30.0 MCHC-31.9 RDW-16.9* Plt Ct-520*# [**2201-6-2**] 04:50PM BLOOD Neuts-91.5* Lymphs-4.3* Monos-2.6 Eos-1.3 Baso-0.3 [**2201-6-2**] 04:50PM BLOOD PT-14.7* PTT-24.6 INR(PT)-1.3* [**2201-6-2**] 04:50PM BLOOD Glucose-110* UreaN-27* Creat-0.9 Na-136 K-4.7 Cl-97 HCO3-27 AnGap-17 [**2201-6-3**] 06:30AM BLOOD Calcium-8.7 Phos-5.6* Mg-2.0 [**2201-6-4**] 05:33AM BLOOD CK(CPK)-18* CK-MB-NotDone cTropnT-0.30* [**2201-6-5**] 09:25AM BLOOD CK(CPK)-20* CK-MB-NotDone cTropnT-0.82* [**2201-6-7**] 02:17AM BLOOD CK(CPK)-8* CK-MB-NotDone cTropnT-0.86* [**2201-6-2**] CXR: Left basilar opacity which could represent atelectasis or pneumonia with a small to moderate-sized left pleural effusion, increased in the interval. [**2201-6-4**] CT chest: 1. No pulmonary embolism to the subsegmental level. 2. Small right and moderate left nonhemorrhagic layering bilateral pleural effusion, increased since [**2201-5-15**]. Complete collapse of the left lower lobe, collapse of basilar segments of the right lower lobe, and dependent opacities in both upper lobes, likely atelectasis. 3. Signs of mild interstitial edema. Mild upper lobe predominant emphysema. 4. Severe coronary artery calcifications. Prior CABG. Minimal aortic valve calcifications, of unknown hemodynamic significance. [**2201-6-4**] CT head: 1. No acute intracranial process, including no hemorrhage, edema, or mass. MR [**First Name (Titles) 151**] [**Last Name (Titles) 3631**]-weighted imaging is most sensitive for evaluation of acute infarction. 2. Right corona radiata hypodensities, most likely representing chronic lacunar infarcts. 3. Paranasal sinus disease as described above. [**2201-6-4**] CT abd/pelvis: 1. Increasing size of loculated fluid collection in the left retroperitoneal space since [**2201-5-15**] without evidence of rim enhancement to suggest abscess. This likely represents loculated hematoma. There is no evidence of active extravasation. 2. Stable post colostomy bowel without evidence of obstruction. 3. No evidence of abdominal aortic aneurysm leak post repair. [**2201-6-4**] TTE: The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild global left ventricular hypokinesis (LVEF = XX %). Overall left ventricular systolic function is mildly depressed (LVEF= XX %). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. Significant pulmonic regurgitation is seen. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2201-3-23**], the left ventricular dysfunction seems to be more global on the current study. No vegetations identified. If clinically suggested, the absence of a vegetation by 2D echocardiography does not exclude endocarditis. [**2201-6-5**] UENI: No evidence of DVT involving the bilateral upper extremities. Somewhat limited evaluation of the right cephalic vein, which compresses normally. [**2201-6-5**] LENI: Normal bilateral lower extremity ultrasound examination. No evidence of DVT. [**2201-6-8**] Renal U/S: 1. No evidence of hydronephrosis. 2. Known mid to upper pole complex cystic lesion in the left kidney, seen on prior CT, is not well seen and is incompletely evaluated on this study. [**2201-6-10**] CT abd/pelvis: 1. Bilateral effusions and atelectasis. Mild ascites and anasarca. 2. Decreased size of the previously described left retroperitoneal fluid collection, with residual phlegmonous inflammation extending to the left flank soft tissue defect. Given rapid decrease in size of this collection, spontaneous decompression and drainage via the left flank wound is most likely. 3. Unchanged size of complex left upper pole renal cyst likely hemorrhagic/inflammatory change involving previously identified simple renalcyst. 4. Unchanged appearance of the stomach, small bowel, and residual ascending and proximal transverse colon, which terminates in a right lower quadrant end colostomy. 5. Unremarkable appearance of the rectal stump, with no pelvic abscess identified. 6. Bilateral fat- and fluid-containing inguinal hernias. [**2201-6-12**] CXR: Increased bilateral pleural effusions and likely relaxation atelectasis. To evaluate possible pulmonary edema, recommend conventional PAand lateral. Brief Hospital Course: 79-year-old man with recent aortic aneurysm repair ([**1-/2201**]), complicated by ischemic bowel and sepsis with subsequent wound dehiscence, also with h/o CAD s/p CABG who is transferred from the medical floor for hypoxia and hypercapnia. # Hypoxic and hypercarbic respiratory failure: Pt was started on vanc and zosyn while inpatient for presumed HAP. However, he became tachypneic on the floor to the 30s-40s with progressive hypoxia to the 80s, tachycardia, hypotension to the 80s, and delirium. ABG 7.28/74/73. Pt transferred to the MICU and placed on Bipap with repeat ABG 7.16/91/133 leading to intubation. He was continued empirically on broad antibiotics but given absence of positive bacterial cultures, these were discontinued for treatment of pneumonia on [**2201-6-8**]. His respiratory failure was thought to be primarily to be due to bilateral pleural effusions with compressive atelectasis; these were too small to be drained. Given his very low respiratory drive when he self-extubated on [**2201-6-7**], EMG study was done which was consistent with critical illness neuromyopathy rather than a pre-synaptic disorder of neuromuscular transmission. Pt was successfully extubated on [**2201-6-11**] and in this setting, expressed his desire to be DNR/DNI. He failed a speech and swallow evaluation and he and his wife refused [**Name2 (NI) 282**] tube. After this he and his wife decided to pursue comfort measures only and palliative care was consulted. The patient was then transferred to the general medical floor. Non-comfort-directed medications were discontinued, as well as vitals and bloodwork. Pt made comfortable with pain control and prn morphine. He passed away the night after transfer from cardiopulmonary arrest. # Recent AAA repair, colectomy, wound infections: Pt with loculated fluid collection measuring 8x6x11 in left retroperitoneal on CT abdomen on [**6-4**], increased since [**5-15**]. He was noted to have purulent drainage from his incision site on [**2201-6-9**] and restarted on vanc/zosyn. Wound culture grew out corynebacterium diptheroids. CT abd/pelvis on [**2201-6-10**] showed decreased size of fluid collection consistent with spontaneous decommpression and drainage via the incision site. Pt remained afebrile with resolution of initial leukocytosis. # CAD: Pt with h/o CABG in [**2184**] and s/p multiple PCI. ECG unchanged from prior with no active issues or complaints. Aspirin initally held given possibility of surgery but restarted. Metoprolol initially held in setting of hypotension but restarted at low-dose. Statin restarted. All meds held when made CMO. Medications on Admission: Acetaminophen 500 mg prn Albuterol Sulfate nebs Ascorbic Acid 500 mg Tablet [**Hospital1 **] Aspirin 81 mg Tablet, Daily Atorvastatin 10 mg Tablet daily Camphor-Menthol 0.5-0.5 % Lotion Q4:PRN Diphenhydramine HCl 50 mg/mL Solution prn Erythromycin 5 mg/g Ointment qHS Ferrous Sulfate 325 mg (65 mg Iron) Daily Heparin (Porcine) 5,000 unit/mL Solution TID Insulin Lispro Sliding scale Ipratropium Bromide 0.02 % Solution NEBS Megestrol 400 mg/10 mL Suspension daily Metoclopramide 5 mg Tablet QIDACHS Metoprolol Tartrate 12.5 mg Tablet [**Hospital1 **] Multivitamin Naphazoline-Pheniramine 0.025-0.3 % Drops [**Hospital1 **] Omeprazole 20 mg Capsule, daily Oxycodone 5 mg/5 q4:prn Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Primary: - Cardiopulmonary arrest - pneumonia - Respiratory failure Secondary: - S/p complicated AAA repair - CAD - Hypertension - Hyperlipidemia - Cervical Myelopathy Discharge Condition: Deceased Discharge Instructions: N/A Followup Instructions: N/A [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7476**] MD [**MD Number(1) 7715**] Completed by:[**2201-6-23**]

[ "038.9", "518.0", "492.8", "995.92", "530.81", "401.9", "518.84", "721.1", "412", "511.9", "998.59", "272.4", "486", "276.3", "584.9", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "96.72", "33.24", "96.04", "38.93", "38.91", "96.6" ]

icd9pcs

[ [ [] ] ]

11247, 11256

7866, 10488

321, 424

11468, 11478

2903, 2903

11530, 11690

2497, 2501

11218, 11224

11277, 11447

10514, 11195

11502, 11507

2516, 2516

274, 283

452, 1544

4293, 7843

2917, 4284

1566, 2398

2414, 2481

25,367

151,193

52528

Discharge summary

report

Admission Date: [**2155-4-7**] Discharge Date: [**2155-4-17**] Service: MEDICINE Allergies: Penicillins / Ultracet / Codeine / Flagyl Attending:[**First Name3 (LF) 3507**] Chief Complaint: Fever, Chills Major Surgical or Invasive Procedure: Endoscopic retrograde cholangiopancreatography History of Present Illness: The pt is an 84M with stage two metastastic pancreatic cancer with palliative CBD stent placement who presents with fevers and chills for 1 day. He does not endorse feeling particularly short of breath although he admits now that he feels better with oxygen. He measured his temperature at home to be ~100.6. He also notes continued abdominal bloating that he has had for months, although he feels it is actually slightly better now. He does not have any focal abdominal tenderness. He states he had dysuria about 1-2 weeks ago but this stopped a few days ago. . In the ED CXR showed a right-sided PNA. His UA was floridly positive. After discussion with the ID fellow, he was treated with Levo and clinda due to allergies to PCN and Flagyl. His SBP was mostly in the 120s initially. His LFTs were found to be markedly abnormal, and he was sent for RUQ US that showed air in the gallbladder, indicating patency of the CBD stent; sludge and stones in the GB; and thickening of the CBD wall that may represent infiltration of tumor. Upon return from US, his SBP dropped to the high 70s but responded to the 90s-100s with an additional 1L of IVF. He received a total of ~2L IVF in the ED. He was admitted to the MICU for further fluids and monitoring. Past Medical History: Past Onc Hx: He was Diagnosed with pancreatic ca in [**7-27**] after an episode of cholangitis and sepsis. He had ERCP w/ stenting and PTC placed. He is s/p biliary stent ([**10-27**]). His disease was felt to be unresectable due to the confluence of the splenic vein and lack of fat planes for resection. He was treated w/ palliative, weekly Gemcitabine x 3 from [**2153-11-27**] to [**2153-12-11**]. His postchemo course was c/b prolonged periods of neutropenia fevers and infections such as klebsiella bacteremia. He underwent cyberknife therapy in [**3-28**]. PET [**1-29**] was notable for a FDG-avid infiltrating mass originating in pancreatic head that extends to porta hepatitis and which abuts, but does not appear to extend beyond, the site of fiducial markers. No evidence of remote FDG-avid metastatic disease. Ca19-9 on [**2154-2-8**] - 126 from 11 in [**8-28**]. . Other PMH: CRI (1.6-2) GERD Lumbar stenosis s/p repair COPD Peripheral [**Month/Year (2) 1106**] disease Prostatectomy for early stage prostate CA Hernia repair Hypertension CVA- TIA [**2146**] years ago, no residual deficits chronic constipation rheumatic fever as a child Social History: Lives in [**Location 3307**] with wife of 12 [**Name2 (NI) 1686**]. Retired president of insurance company. The patient is a 100-pack year smoker but quit 25 [**Name2 (NI) 1686**] ago. He used to drink alcohol socially, but currently not drinking at all. No children. He is an only child. Wife is very supportive. Family History: non-contirbutory Physical Exam: VS: 98.3, 108/52, 91, 96% 4L NC Gen: NAD, pleasant elderly man appearing younger than stated age HEENT: PERRL, EOMI, anicteric, MM dry, OP clear Neck: no LAD, supple, no JVD Lungs: CTAB CV: RRR, nl S1S2, I/VI HSM LUSB Abd: +BS, soft, nontender, distended, tympanitic Ext: no c/c/e, 2+ DP pulses b/l Neuro: AAOx3, CN II-XII intact, sensory/motor grossly intact Pertinent Results: [**2155-4-6**] LIVER OR GALLBLADDER US: 1. Air in the biliary system indicating patency of the common bile duct stent. 2. Sludge and stones in the gallbladder, with focus of air in the gallbladder also suggesting patency with the biliary system. 3. Unchanged appearance since [**2155-3-14**] CT scan of thickening of the common bile duct, which itself is normal caliber. . [**2155-4-6**] CXR: No evidence of acute cardiopulmonary process. . [**2155-4-6**] ECG: Sinus rhythm. Low limb lead voltage. Delayed precordial R wave progression. Compared to the previous tracing of [**2153-7-28**] the rate has slowed and there is variation in precordial lead placement. Otherwise, no diagnostic interim change. . [**2155-4-8**] CXR: Compared with 4/16, the CHF/fluid overload has almost completely cleared. . [**2155-4-9**] CXR: No evidence of lung consolidation. . [**2155-4-12**] ABDOMEN (SUPINE & ERECT): Non-specific bowel gas pattern which includes dilated loops of small bowel. However air and stool are seen in the colon. If there is persistent pain, followup radiographs or cross-sectional imaging is recommended. . [**2155-4-15**] CXR: Small bilateral pleural effusions with no evidence of pulmonary edema. . [**2155-4-15**] ABDOMEN (SUPINE & ERECT): Mildly distended gas-filled loops of large bowel with multiple air-fluid levels, which likely represents ileus. the appearance is improved when compared to the prior study. . [**2155-4-8**] ERCP: A metal stent was found in the major papilla. Cannulation of the biliary duct was successful and deep with a sphincterotome through the metal stent seen in good position at the ampulla. Contrast medium was injected resulting in complete opacification. Filling defects in the stent within the CBD were noted. The intrahepatic ducts were normal.Biliary debris and purulent bile was extracted successfully using sweeps with a balloon catheter. The stent allowed passage of a fully inflated 12mm balloon. Occlusion cholangiogram performed at the end of the procedure revealed no overgrowth or ingrowth of tumor into the stent. . [**2155-4-17**] 08:10AM BLOOD WBC-9.4 RBC-3.27* Hgb-9.9* Hct-29.4* MCV-90 MCH-30.1 MCHC-33.5 RDW-16.1* Plt Ct-211 [**2155-4-6**] 08:00PM BLOOD WBC-4.4 RBC-3.43* Hgb-9.9* Hct-28.9* MCV-84 MCH-28.8 MCHC-34.3 RDW-15.8* Plt Ct-110* [**2155-4-17**] 08:10AM BLOOD Plt Ct-211 [**2155-4-12**] 07:10AM BLOOD Plt Ct-65* [**2155-4-12**] 07:10AM BLOOD PT-15.5* PTT-29.2 INR(PT)-1.4* [**2155-4-9**] 05:11AM BLOOD Plt Ct-59* [**2155-4-7**] 12:44AM BLOOD Plt Ct-80* [**2155-4-17**] 08:10AM BLOOD Glucose-110* UreaN-21* Creat-1.3* Na-131* K-4.4 Cl-93* HCO3-29 AnGap-13 [**2155-4-6**] 08:00PM BLOOD Glucose-171* UreaN-24* Creat-1.3* Na-129* K-3.8 Cl-94* HCO3-21* AnGap-18 [**2155-4-17**] 08:10AM BLOOD ALT-48* AST-28 AlkPhos-357* TotBili-1.3 [**2155-4-13**] 07:08AM BLOOD ALT-120* AST-54* AlkPhos-541* TotBili-2.3* [**2155-4-11**] 07:50AM BLOOD ALT-165* AST-62* AlkPhos-548* TotBili-2.5* [**2155-4-6**] 08:00PM BLOOD ALT-779* AST-565* AlkPhos-515* Amylase-27 TotBili-2.3* [**2155-4-14**] 07:20AM BLOOD Lipase-37 [**2155-4-14**] 07:20AM BLOOD calTIBC-182* Ferritn-649* TRF-140* [**2155-4-7**] 08:35PM BLOOD Lactate-6.1* HIT AB: negative Brief Hospital Course: #Biliary Sepsis/GNR bacteremia: underwent ERCP which showed biliary debris and purulent bile which was extracted successfully. Blood cultures grew E. Coli, Morganella, and C. perfringens. Treated with 14 day course of [**Month/Day/Year 621**] (initially Vanc/Gent/[**Last Name (un) **]-->CTX-->Cefpodox/Cipro on discharge). . #COPD: started on Advair and Albuterol prn. . #Thrombocytopenia: Resolved, HIT negative. Likely [**1-24**] sepsis. . #Narcotic Induced ileus: resolved with aggressive bowel regimine. . #Anemia of Chronic Disease: HCT stable, no indication for transfusion. . #Mild hypoxia: developed mild hypoxia (high 80s/low 90s). ABG without C02 retention, CTA without PE. Likely from volume overload from resuscitation. Improved after diuresis. Medications on Admission: 1. Nexium 40 mg qd 2. Atorvastatin 5 mg QOD (recently stopped) 3. Toprol XL 25 mg qd 4. Ecotrin 325 mg qd 5. Docusate Sodium 100 mg [**Hospital1 **] 6. Senna 8.6 mg Tablet [**Hospital1 **] 7. Hexavitamin qd 8. Simethicone 80 mg qid prn 9. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Three (3) Cap PO TID W/MEALS 10. Claritin 10 mg prn 11. erythromycin 250 mg tid (recently stopped) Discharge Medications: 1. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 3. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: Three (3) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 7. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day for 6 days. Disp:*12 Tablet(s)* Refills:*0* 8. Simethicone 80 mg Tablet, Chewable Sig: 0.5 Tablet, Chewable PO QID (4 times a day). 9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 6 days. Disp:*12 Tablet(s)* Refills:*0* 10. Atorvastatin 10 mg Tablet Sig: .5 Tablet PO every other day. 11. Ecotrin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 12. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*1 Disk with Device(s)* Refills:*2* 13. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) inhalation Inhalation every 4-6 hours. Disp:*1 inhaler* Refills:*2* Discharge Disposition: Home With Service Facility: CareGroup Discharge Diagnosis: 1. Biliary Sepsis/GNR bacteremia 2. Pancreatic CA 3. COPD 4. Hypertension 5. Thrombocytopenia, resolved 6. Narcotic Induced ileus, resolved 7. Anemia of Chronic Disease Discharge Condition: stable Discharge Instructions: Please return to the Emergency Room should you develop any fevers, chills, sweats, nausea, vomiting, abdominal pain, shortness of breath or any other complaints. Followup Instructions: Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2155-4-30**] 10:00 Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2155-5-12**] 10:00 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 7721**] [**Name11 (NameIs) **] [**Name11 (NameIs) 3628**] (NHB) Date/Time:[**2156-1-19**] 10:00

[ "443.9", "496", "038.40", "576.1", "995.91", "157.8", "287.4", "401.9", "560.1", "530.81", "285.22" ]

icd9cm

[ [ [] ] ]

[ "51.10" ]

icd9pcs

[ [ [] ] ]

9350, 9390

6747, 7513

262, 310

9610, 9619

3528, 6724

9829, 10206

3113, 3131

7960, 9327

9411, 9589

7539, 7937

9643, 9806

3146, 3509

209, 224

338, 1588

1610, 2765

2781, 3097

22,419

128,780

27622

Discharge summary

report

Unit No: [**Numeric Identifier 67488**] Admission Date: [**2156-8-16**] Discharge Date: [**2156-8-23**] Date of Birth: [**2082-9-9**] Sex: M Service: GU CHIEF COMPLAINT: Bladder cancer. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 67489**] is a 73-year-old man with known bladder cancer diagnosed on [**2156-7-15**]. He is here for a cystectomy and stoma scheduled for [**2156-8-17**]. ALLERGIES: No known drug allergies. OUTPATIENT MEDICATIONS: Atenolol. PAST MEDICAL HISTORY: Prostate cancer, radical resection of the prostate in [**2148**], severe gunshot wound to the abdomen, 3 to 4 exploratory laparoscopies for pus and adhesions secondary to these gunshot wounds. The gunshot wounds were a result of injuries in hunting accidents. PAST SURGICAL HISTORY: RRP [**2148**], abdominal ex-laps. FAMILY HISTORY: There is a questionable history of prostate cancer in his father. SOCIAL HISTORY: He quit smoking 30 years ago and prior to that smoked one pack per day for 20 years. INPATIENT MEDICATIONS: 1. Acetaminophen. 2. Atenolol 25 mg PO once daily. 3. Diphenhydramine 25 PO q6 hours. 4. Dolasetron mesylate. 5. Docusate sodium. 6. Famotidine 20 b.i.d. 7. Oxycodone-acetaminophen 1 to 2 tablets PO q.4 to 6 hours. 8. Phenaseptic throat spray. 9. Sarna lotion. PHYSICAL EXAMINATION: Temperature Max. 97.6, heart rate 46, BP 154/80, respiratory rate 18, oxygen saturations 99% on room air. Chest clear to auscultation bilaterally. CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: With urostomy in place and stents draining into urostomy. No erythema or exudate or other sign of infection. Abdomen is nontender, nondistended, and soft. Extremities warm and well perfused. No clubbing, cyanosis or edema. BRIEF HOSPITAL COURSE: Mr. [**Known lastname 67489**] was admitted on [**2156-8-16**]. His preoperative labs were all within normal limits. He was typed and crossed for 4 units of blood. On [**8-17**], postoperative day 1, he did well and was kept in the SICU overnight for monitoring. He was also started on Ancef and clindamycin for a total of 3 doses. On postoperative day 2, Dr. [**Last Name (STitle) 9125**] discussed the results of the surgery with him. Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], oncology, and Dr. [**First Name11 (Name Pattern1) 11312**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 656**], radiation oncology, were consulted. On postoperative day 3, the NG tube and the JP drain were discontinued secondary to little output. The patient tolerated PO intakes very well and was ambulating very well and was tolerating oral pain medications with Percocet. On hospital day 5, CT scan for staging was obtained. The CT scan showed a moderate bilateral hydronephrosis, hydroureter and on one side the stent located on the left within the ureter and the other stent was located in the ileal conduit. The patient continued to drain and complained of no pain or dysuria or discomfort in the area of the stent and therefore they were left as is. The patient was discharged home the following day with Percocet for pain as well as Colace to soften his stools. He was also given a witch [**Female First Name (un) **] type of cream for his hemorrhoids. A followup appointment with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] has been arranged. The patient was instructed to call Dr.[**Name (NI) 15380**] office to confirm that appointment and also a followup appointment with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 365**] was made. The patient was given instructions and was discharged in good condition. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 13269**] Dictated By:[**Name8 (MD) 560**] MEDQUIST36 D: [**2156-8-24**] 03:49:52 T: [**2156-8-24**] 08:12:45 Job#: [**Job Number 67490**]

[ "285.9", "591", "V10.46", "198.1", "568.0", "593.5" ]

icd9cm

[ [ [] ] ]

[ "54.59", "56.51", "59.8", "57.34" ]

icd9pcs

[ [ [] ] ]

1768, 4016

836, 903

783, 819

464, 475

1323, 1744

177, 194

223, 439

498, 759

920, 1300

18,402

157,228

20900

Discharge summary

report

Admission Date: [**2102-5-26**] Discharge Date: [**2102-5-31**] Date of Birth: [**2047-3-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1493**] Chief Complaint: coffee ground hematemesis and melena Major Surgical or Invasive Procedure: Paracentesis History of Present Illness: Patient is a 55 year old male with pmh sig for CRI, cirrhosis(on liver-kidney transplant list) complicated by grade I esophageal varicies presenting with one day of coffee ground hematemesis and melena. He awoke with slight nausea, then proceded to have coffee ground emesis x 2 episodes, no BRB. He initially presented to OSH, and was transfered to [**Hospital1 18**] for further care. He reports chest tightness since this AM, similar to pain he has with exertion (walking >4 blocks). No SOB, or diaphoresis. He had a stress MIBI in [**10-29**] which was normal. He denies abdominal pain or palpitations. . On review of the [**Name (NI) **], pt complained of BRBPR in early [**2101**], a colonoscopy was performed which showed grade 1 external hemorrhoids. Additionally, he has had an EGD performed in [**2101-10-19**] that revealed only grade 1 varices. . He was transferred to the floor where he was stable and he did not get any transfusions. He had paracentesis 3 times during this hospitalization and had almot [**11-5**] lts taken out. He got albumin during all these taps. Past Medical History: Hepatitis C/ETOH induced cirrhosis (SBP [**2100-1-7**], no variceal bleeds, EGD [**2101-10-19**] Grade 1 varices) Mitral valve prolapse Hypertension Gout Osteopenia CKD - baseline creatinine 2.0 Anemia Social History: The pt denies current cigarette use, but reports smoking 10 cig/day for 20 years. He also quit drinking 1 [**12-26**] yr ago but prior had drank for 23 years with 1 pint of gin or brandy a day. He denies IVDU, but has snorted cocaine in the past. He works at the JP VA currently and lives in the [**Location (un) 4398**] alone. His sister is his HCP and is very supportive Family History: Father-HTN, MI in his 80s Mother- "spine cancer" Physical Exam: Vitals: T 98.2 BP: 104/82 HR: 82 RR: 14 O2: 100%RA . Gen: Comfortable, pleasant, A+Ox3, no acute distress HEENT: NCAT, PERRL, EOMI, slt scleral icterus, no LAD, flat JVP OP: Clear, no lesions, no dried blood Chest: CTA Bilateral, no wheeze or rhonchi Cor: RRR no murmurs rubs or gallops Abd: massively distended, + bulging flanks, + fluid wave, NT Ext: warm, well perfused, 2+DP/PT bilaterally Pertinent Results: [**2102-5-31**] 05:05AM BLOOD WBC-4.9 RBC-3.40* Hgb-10.6* Hct-31.5* MCV-93 MCH-31.0 MCHC-33.5 RDW-18.1* Plt Ct-57* [**2102-5-28**] 09:40AM BLOOD Neuts-53.6 Lymphs-36.3 Monos-6.0 Eos-3.3 Baso-0.9 [**2102-5-31**] 05:05AM BLOOD Plt Ct-57* [**2102-5-31**] 05:05AM BLOOD PT-19.5* PTT-41.1* INR(PT)-1.9* [**2102-5-31**] 05:05AM BLOOD Glucose-93 UreaN-33* Creat-2.3* Na-143 K-3.6 Cl-116* HCO3-16* AnGap-15 [**2102-5-29**] 05:35AM BLOOD ALT-25 AST-79* LD(LDH)-198 AlkPhos-119* TotBili-3.2* [**2102-5-31**] 05:05AM BLOOD Calcium-8.5 Phos-2.3* Mg-1.7 [**2102-5-28**] 04:00PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2102-5-28**] 09:40AM BLOOD CK-MB-9 cTropnT-0.07* [**2102-5-26**] 02:10PM BLOOD CK-MB-8 cTropnT-<0.01 [**2102-5-27**] 08:14AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG [**2102-5-26**] 02:26PM BLOOD Hgb-9.1* calcHCT-27 *** LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2102-5-30**] 1. Patent hepatic and portal vessels. 2. Cholelithiasis. 3. There are no focal liver lesions. *** Brief Hospital Course: #GI Bleed: Likely upper GI bleed given hematemesis, EGD showeds Gr. I varices, esophagitis, portal gastropathy but no actively bleeding lesion. Hemodynamically stable. Got transfused in ICU and was stable. Did not require transfusion on floor. Octreotide gtt dc'd. NO melanotic stools/hematemesis in ICU. Continued levofloxacin prophylaxis (at request of liver team) . . # Chest pain: c/o chest discomfort w/ dizziness. EKG shows new T-wave in III, aVF. Could have been demand ischemia from low HCT. CE's cycled --> ruled out for MI. . # Hep C/ETOH cirrhosis - MELD score 27 (was 21 on [**5-9**]). Had total of around [**11-5**] lts of peritoneal fluid taken out. Was given albumin during these procedures. There was no evidence of SBP from the analysis of the peritoneal fluid. Lactulose dose increased (given pt hx sleep-wake reversal). Had liver usg which did not show portal vein thrombosis or focal liver lesions. . #Acute on Chronic renal failure: etiology unclear, ?hypertensive. FeNa 0.33%, c/w prerenal failure. U na+ 22. Was on octreotide, midodrine for hepatorenal failure. Cont IV volume support with 5% albumin . #HTN: held Atenolol for SBPs were marginal. Patient was not sent home on Atenolol as he had an appointment with Dr. [**Last Name (STitle) 497**] in 1 week at which time he could discuss with Dr.[**Last Name (STitle) 497**] about starting back on Atenolol. . #Gout: stable, asymptomatic. Continued on allopurinol, colchicine. . #FEN - Na+ restricted diet, Fluid restrict <1500cc/d, follow/replete lytes Medications on Admission: Lactulose 30ml po tid-qid for BM 3-4x per day Allopurinol - 100 mg po qd Colchicine - 0.6 mg p qd Atenolol - 50mg po qhs Omeprazole - 20mg po qd Levofloxacin 500mg po qd Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 2. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 4. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 5. Lactulose 10 g/15 mL Syrup Sig: Forty Five (45) ML PO TID (3 times a day). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Discharge Disposition: Home Discharge Diagnosis: Gastrointestinal bleed Cirrhosis Ascites Discharge Condition: all vitals are stable Discharge Instructions: Please take all your medications and follow up with all your appointments. Please report to the ED or to your physician if you have shortness of breath, cough, blood in vomit or stools, dark stools, dizziness, chest pain or any other concerns. . Your blood pressure medication (Atenolol) is being held as your blood pressure has been low during this hospitalization and you had bleeding from your GI tract. Please discuss about restarting this medication with Dr. [**Last Name (STitle) 497**] when you see him on the 14th of this month. If you have any headache, chest pain, blurriness of visiion or other concerns regarding high blood pressure, please call Dr. [**Last Name (STitle) 497**] or come to the ED. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2102-6-7**] 3:20 Completed by:[**2102-5-31**]

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icd9cm

[ [ [] ] ]

[ "99.04", "45.13", "54.91" ]

icd9pcs

[ [ [] ] ]

5901, 5907

3593, 5123

352, 367

5992, 6016

2595, 3570

6774, 6924

2114, 2164

5344, 5878

5928, 5971

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6040, 6751

2179, 2576

276, 314

395, 1478

1500, 1703

1719, 2098

76,820

169,015

6654

Discharge summary

report

Admission Date: [**2200-3-12**] Discharge Date: [**2200-3-19**] Date of Birth: [**2119-10-30**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 10593**] Chief Complaint: bright red blood per rectum Major Surgical or Invasive Procedure: Upper endoscopy with clipping of a dieulafoy lesion Colonoscopy with colonic polyp removal and biopsy of rectal polyp Sigmoidoscopy with clipping of colonic ulcer History of Present Illness: 80M CAD (s/p cath [**2200-1-16**] for stable angina, 95% mid-LAD stenosis, DES placed), HTN, AFib w/ h/o CVA in [**2197**] on coumadin, here w/ worsening weakness and black stools. He had been feeling generalized weakness for almost 2 months, but it has been significantly worse for last 5 days. He has felt short of breath with minimal activity, had dizziness, and severe fatigue. Three days ago he had a dark, bloody bowel movement that he did not tell his family about. He then had another mixed dark and brighter red bowel movement. He told his daughter and they brought him to the [**Name (NI) **]. Of note, 2 days ago, after dinner he felt dizzy and had an episode of non-bloody/non-bilious vomiting 2 days ago. In the ED, initial VS were: 98 70 143/44 14 100%. He was given 1L fluid. BP was stable throughout, and he looked pale, but was conversant. NG lavage negative. Black stool on guaiac. He was found to have a Hct of 20.8 and was transferred to the MICU and was given two units of pRBCs, wchich increased his Hct to 24.0, received one more unit and his Hct went up to 26.8. The pt who takes warfarin with an intial INR 0f 3.2 and low platelet count of 113 was given Vitamin K and 1 unit of FFP and his INR went down to 1.4 and platelets increasd to 178. The pt had an EGD done which showed possible Dieulafoy lesion that was clipped. Of note he has iron deficiency anemia. His Hct today is stable at 26.2. On arrival to the floor, the patient is resting comfortably. He denies pain or SOB at rest. Denies fever, chills, night sweats, recent weight loss or gain. Denies headache. Denies wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Atrial fibrillation s/p electrical cardioversion [**2197-3-23**] on coumadin CAD s/p anterior myocardial infarction in [**Country **] in [**2187**] Hypertension Hyperlipidemia Cardiomyopathy, EF 35-40% in [**1-13**] s/p bilateral cataract surgery (left [**1-12**], right [**3-14**]) Irritative urinary symptoms s/p Greenlight TURP Abdominal operations in [**Country **] including stoma and three surgeries for colon Erectile Dysfunction Essential tremor GERD Social History: He lives with his daughter who will be planning on attending school here. Retired army officer from [**Country **], has been in US for [**12-20**] yrs. - Tobacco: 40pack-year history, continues smoking three cigarettes per day. - Alcohol: drinks 1-2 drinks nightly on weekends - Illicits: none Family History: Family history of peptic-ulcer disease, HTN Physical Exam: Physical Exam on Admssion VS 98.2 118/68 65 16 98RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly. Well-healed mid-line abdominal scar and RLQ scar. GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, gait deferred, finger-to-nose intact Physical Exam on Discharge VS 97.9 122/71 69 16 98RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly. Well-healed mid-line abdominal scar and RLQ scar. GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, gait deferred, finger-to-nose intact Pertinent Results: Labs on Admission: [**2200-3-12**] 11:40AM BLOOD WBC-5.4 RBC-2.35*# Hgb-6.9*# Hct-20.8*# MCV-88# MCH-29.3 MCHC-33.2 RDW-14.6 Plt Ct-263 [**2200-3-12**] 11:40AM BLOOD PT-33.0* PTT-34.3 INR(PT)-3.2* [**2200-3-12**] 11:40AM BLOOD Plt Ct-263 [**2200-3-12**] 11:40AM BLOOD Glucose-113* UreaN-22* Creat-1.4* Na-137 K-4.4 Cl-103 HCO3-26 AnGap-12 [**2200-3-12**] 11:56AM BLOOD Lactate-1.9 Micro: [**2200-3-12**] 3:53 pm MRSA SCREEEN (Final [**2200-3-15**]): No MRSA isolated. Imaging: [**2200-3-12**] EGD: Large hiatal hernia Dieulafoy lesion in the fundus (endoclip) Normal mucosa in the duodenum Angioectasia in the second part of the duodenum Otherwise normal EGD to third part of the duodenum [**2200-3-14**] Colonoscopy: Polyp in the sigmoid colon (polypectomy) Polyp in the rectum (biopsy) Otherwise normal colonoscopy to cecum [**2200-3-18**] Colonoscopy: Ulcer in the colon (endoclip) Polyp in the colon Otherwise normal sigmoidoscopy to sigmoid colon Pathology: A. (Sigmoid colon polypectomy): Hyperplastic polyp. B. (Rectal polyp, biopsy): Fragments of adenoma. Brief Hospital Course: 80yo male w/ CAD s/p DES to the LAD [**2200-1-16**], Afib s/p CVA in [**2197**] and distant h/o PUD, who presented with 5 days of worsening weakness, dark bloody stools. # Gastrointestinal bleeding and acute blood loss anemia: The patient presented with melena and was found to have a Hct of 20.8 when he came into the ED. He was transferred to the MICU for close monitoring and was given three units of pRBCs. The pt who takes warfarin had an intial INR of 3.2 and a low platelet count of 113. He was given Vitamin K and 1 unit of FFP. He was started on an IV PPI. The patient underwent EGD on [**3-12**] that showed a Dieulafoy lesion that was clipped. He had no further bloody bowel movements in the intensive care unit and was transferred to medicine [**Hospital1 **]. Per the gastroenterology team, the patient underwent a colonoscpy to rule out a lower cause of GIB, as he had been off warfarin and had a subtherapeutic INR. He underwent a colonoscopy on [**3-14**] which showed a polyp in the sigmoid colon (s/p piecemeal polypectomy) and a polyp in the rectum (which was biopsied). After 24 hrs post-biopsy without any bloody bowel movements, he was restarted back on the warfarin with a heparin bridge. Heparin gtt was switched to lovenox after 24 hours without bleed in anticipation of discharge. The patient began to have multiple bloody bowel movements (30-40cc at a time) with down-trending hct. His warfarin and lovenox were stopped, and he was given 1 unit of pRBCs. He was monitored off anticoagulation, but continued to have BRBPR and underwent flexible sigmoidoscopy on [**3-18**]. The sigmoidoscopy showed the previously biposed friable polyp with a pinpoint ulcer with no stigmata of bleeding at the area of prior biopsy. A post-biopsy ulcer was also seen at the site of the prior piecemeal polypectomy in the sigmoid colon and one endoclip was successfully applied. The patient's bloody bowel movements resolved and after speaking to his outpatient cardiologist, he was discharged off anticoagulation until follow-up with his cardiologist in 2 weeks. His home PPI dose was increased on discharge. # Atrial fibrillation: The patient remained in Afib with good rate control. Patient has a CHADS2 score of 4 and ischemic stroke in [**2197**]. Given his recent bleeding after colonoscopy, his cardiologist (Dr.[**Last Name (STitle) **]) suggested holding the warfarin for 2 weeks, and that the patient would then follow up with him 2 weeks after discharge to re-evaluate starting warfarin again. # Coronary artery disease s/p anterior MI in [**2187**]: The patient had a recent intervention w/ DES to mid-LAD [**2200-1-16**] by Dr. [**Last Name (STitle) **]. He was continued on his home Aspirin and Plavix throughout his hospital stay and on discharge. # BPH: The patient's tamusolin was held initially in the setting of GI bleed but was subsequently restarted while in the ICU. # Hypertension: The patient's home Lisinopril was held while in-house. Given his blood pressures remained well controlled off Lisinopril, he was discharged off lisinopril with instructions to follow up with his PCP to discuss further blood pressure management. # Dyslipidemia: The patient was maintained on his home rosuvastatin 10mg daily. Transitional Issues: - GI f/u for rectal biopsy results ([**Last Name (LF) 25402**], [**First Name3 (LF) **] likely need removal after off anti-coagulation) - f/u with Dr. [**Last Name (STitle) **], cardiologist, regarding reinitiation of anticoagulation for afib in 2 weeks (appointment in place) - f/u with PCP [**Last Name (NamePattern4) **]: re-initiation of Lisinopril which was stopped in the setting of GI bleed Medications on Admission: - Plavix 75mg daily - lisinopril 10mg daily - nitroglycerin 0.4mg SL PRN - pantoprazole 20mg daily - propranolol - PRN symptomatic - rosuvastatin 10mg daily - tamsulosin 0.4mg daily - trazodone 150mg QHS - vernicline 1mg [**Hospital1 **] (started recently) - warfarin - 5mg one day a week, rest of week (6 days) 3.75mg daily. - aspirin 81mg daily - centrum multivitamin Discharge Medications: 1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 4. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual q5minutes as needed for chest pain: Take up to three as needed, as instructed by your cardiologist. 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. trazodone 150 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 8. Chantix Oral 9. multivit-iron-min-folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 10. propranolol 10 mg Tablet Sig: One (1) Tablet PO once a day as needed for palpitations. Discharge Disposition: Home Discharge Diagnosis: Upper gastrointestinal bleed secondary to dieulafoy lesion Colonic and rectal polyp Lower gastrointestinal bleed secondary to polyp biopsy Secondary Diagnosis: Coronary artery disease Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for black stool requiring blood transfusions. On endoscopy, you were found to have a lesion believed to have caused your bleeding which was clipped to prevent further bleeding. On colonoscopy, you were found to have a polyp in your colon that was removed, and a polyp in your rectum that was biopsied. Please follow up the biopsy results with your gastroenterologist at your follow-up appointment, as this will determine whether the rectal polyp will need to be removed. Your Coumadin was temporarily stopped until these procedures were performed, and re-started in the hospital. After restarting your Coumadin you started having bloody bowel movements, and was stopped again. You had a repeat colonoscopy which showed a small ulcer near the prior biopsy site, presumably where the bleeding was coming from. This small ulcer was clipped and you stopped having bloody bowel movements. You will be discharged home without Coumadin and you will be off of Coumadin for 2 weeks. You will then have a follow-up appoinment with your cardiologist in 2 weeks to re-evaluate whether to restart you on Coumadin at that point. The following changes were made to your home medications: - Coumdain was STOPPED; please follow up with your cardiologist before re-starting this medication - Pantoprazole twice daily was INCREASED in dose and frequency - Lisinopril was STOPPED for bleeding; please follow up with your primary care physician or your cardiologist before re-starting this medication - Restart home Propranolol on discharge Followup Instructions: Please call your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], at [**Telephone/Fax (1) 2010**] to schedule an appointment within 7-10 days of discharge. You have the following appointments scheduled: Department: CARDIAC SERVICES When: FRIDAY [**2200-4-4**] at 9:40 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: WEDNESDAY [**2200-4-2**] at 12:40 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: Gastroenterology Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**] Phone: [**Telephone/Fax (1) 682**] Date: [**2200-4-7**] at 1pm Department: CARDIAC SERVICES When: WEDNESDAY [**2200-6-4**] at 11:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "44.43", "45.42", "48.24", "45.43" ]

icd9pcs

[ [ [] ] ]

10705, 10711

5646, 8901

334, 499

10960, 10960

4548, 4553

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2803, 3099

24,785

124,880

46492

Discharge summary

report

Admission Date: [**2167-10-25**] Discharge Date: [**2167-11-28**] Date of Birth: [**2087-10-1**] Sex: M Service: MEDICINE Allergies: Percocet Attending:[**First Name3 (LF) 905**] Chief Complaint: Dyspnea . Major Surgical or Invasive Procedure: hemodialysis History of Present Illness: This is a 80M with systolic and diastolic CHF, ESRD on HD m/w/f, 2V CABG in [**2161**], hypertension, hyperlipidemia, diabetes mellitus, peripheral arterial disease, presenting with shortness of breath over the past week. The patient is currently residing at [**Hospital **] rehab and began to complain of chest tightness and pressure on [**10-25**]. he was brought to [**Hospital **] hospital where he was hypotensive 79/54 and 98% on NRB. ekg did not show any ischemic changes. The patient was transferred to [**Hospital1 18**] ED. . In the [**Hospital1 18**] ED, initial blood pressure was 100/53. This transiently decreased to 86/45, a right EJ was placed and dopamine was begun. CXR showed bilateral infiltrates consistent with CHF exacerbation, and BNP was also elevated to 38,495. The patient expressed wishes to be DNI and was begun on CPAP. He became disoriented on CPAP and was switched to BiPap. VBG was 7.36/52. The patient was begun on vancomycin, flagyl, and ceftriaxone. Bedside echo did not reveal effusion or tamponade. Vitals after administration of dopamine were 97.7, 71, 105/60, 19 O2 sat 80-90% on 10L NRB. He denies fevers, weight loss, headaches, hematochezia, melena, joint pains. he reports substernal chest pain, difficulty breathing, and orthopnea. . MICU course: Pt was syncopizing at HD and was unable to tolerate full fluid removal at HD and became progressively more fluid overloaded. Has been on CVVH since admission with significant improvement. Dopamine switched to levo x 2 days, d/c'd yesterday. BPs have been stable at . ? sepsis. Received empiric CTX and vanc, now on augmentin for UTI (ucx from OSH with ESBL e-coli, s to augmentin, plan to complete course for this) currently day [**2-15**]. Plan to HD today (first time this admission) CVVH stopped this am. Has a RIJ CVL, also has R SC tunneled HD line also has L midline. BPs 114/51 94. . Past Medical History: 1. CHF: diastolic & systolic HF with CRI, EF 40-45% in [**1-13**] and [**5-14**] 2. CAD s/p 2V-CABG [**2161**] 3. CVA: ([**2154**]) 3-4 days of slurred speech and right facial droop without residual symptoms. s/p CEA (documented however patient without memory of this procedure) 4. HTN 5. Hyperlipidemia 6. IDDM (retinopathy, nephropathy, neuropathy) 7. NSVT 8. Afib 9. PVD s/p R fem-[**Doctor Last Name **] ([**2154**]), R 2nd toe amputation, gangrene L 1st toe s/p amp ([**10-11**]), angio with L SFA stenosis & ratty AT ([**12-11**]), CABG x 2, LLE AT angioplasty ([**6-2**]) 10. CRI (b/l around 2.9-3.1) 11. Colon ca s/p hemicolectomy 12. H/o diverticulosis 13. H/o angioectasia in stomach w/UGIB [**3-/2161**] and again [**7-/2166**] 14. Prostate ca (dx'd [**2150**]): s/p orchiectomy ([**2150**]), TURP ([**2153**]) & pelvic XRT ([**2155**]) with radiation 'proctopathy'. 15. Iron deficiency anemia on bone marrow aspirate ([**2157**]) 16. Interstitial lung disease w/mediastinal LAD & a negative CMA. (Differential diagnosis included burned out sarcoidosis versus interstitial pulmonary fibrosis versus malignancy.) s/p flexible bronchoscopy and cervical mediastinoscopy with biopsies ([**5-9**]) 17. Left cataract surgery [**77**]. UGIB [**2-7**] angioectasia ([**3-8**], [**7-13**], [**5-14**]) 19. CEA 20. Cervical mediastinoscopy with biopsies ([**5-9**]) Social History: Social history is significant for the absence of current tobacco use; he has a remote history of tobacco use but quit in his 20s. There is no history of alcohol abuse or illicit drug use. Patient is widowed and transferred from [**Hospital3 1186**]. He is a retired foreman for [**Company 2676**]. Family History: Father: DM, alcohol related death Mother: DM,passed away giving birth to 22nd child Daughter: macular degeneration Physical Exam: Vitals: T: P:70 BP:96/44 R:25 SaO2:76% General: Awake, alert, NAD, tachypneic HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted, MMM, no lesions noted in OP Neck: , no JVD appreciated Pulmonary: crackles and wheezes bilaterally Cardiac: irregularly irregular, bradycardic nl. S1S2, no M/R/G noted Abdomen: anasarcic, soft, NT/ND, no masses or organomegaly noted. Extremities: RBKA, abrasions present, clean and intact. Left lower extremity hyperpigmented, 1+ edema, 1st and second digits missing. upper extremities 2+ edema bilaterally. Neurologic: -mental status: Alert, oriented x 2, knew name, location, did not know year, said [**2149**], then [**2067**]. did not know month, did know season was autumn. Brief Hospital Course: 80M with hx CHF (EF 30%), ESRD on HD, p/w hypotension and pressor-dependent HD. # Comfort measures only (CMO) status and subsequent death: In brief, Mr. [**Known lastname 25143**] experienced multiple adverse health events during his hospital stay, including infections, cerebrovascular accident in the setting of hypotension, deep vein thromboses, and episodes of acute respiratory distress. He expressed a desire to no longer undergo dialysis or other interventions such as nasopharangeal suction during his episodes of respiratory distress. His comorbidites and wishes were discussed with his family, and his family members made the decision to change the goals of care to comfort measures. Hemodialysis was withheld and the patient subsequently expired on [**2167-11-28**]. The immediate cause of death was cardiopulmonary arrest. # CVA: Patient had altered mental status and dysarthria after HD on [**2167-11-16**]. As described above, he was hypotensive to a SBP of 70 during hemodilaysis and likely suffered a hypoperfusive stroke. His Head CT was negative for acute changes, though it did show progression of chronic, right frontal subcortical changes. He was , advanced since prior head CT in [**5-13**], but no acute evidence of infarction. # Acute on chronic left ventricular systolic and diastolic dysfunction: The patient was admitted to the intensive care unit upon admission and diuresed with CVVH with support with norepinephrine infusion. He was felt to be in decompensated heart failure with pulmonary edema as well as decreased cardiac output. He was transitioned to the floor, but then quickly had recurrence of pulmonary edema requiring ICU transfer. He was further diuresed with CVVH but required vasopressor support for fluid removal. He was briefly covered with antibiotics in case pneumonia/infection was contributing to respiratory distress. Patient was then transitioned back to hemodialysis without pressor support. Afterload was aided with daily midodrine, and initially, with hydrocortisone. He appeared to be tolerating dialysis well until [**2167-11-16**] when he had an altered mental status acutely after dialysis during a session in which his SBP fell to 70. His altered mental status was attributed to a likely CVA in the setting of hypotension. # Urinary Tract Infection: The patient had an outside hospital urine culture grow EColi ESBL, but susceptible to augmentin and zosyn. He was initially treated with augmentin, and then changed to meropenem. After 9 days of therapy, he had a repeat U/A that showed pyuria, and was restarted on meropenem. His UTI appeared to resolve but another urine culture taken approximately one week prior to his death was again positive for enterococcus sensitive to only linezolid and doxycycline. He was treated with linezolid until the decision to make his CMO was reached. # C diff: Patient had loose stools and a C diff toxin was positive. He was treated with flagyl. # Right pleural effusion: On admission, the patient was noted to have a developing right pleural effusion, but the family and the patient initally refused thoracentesis. With elevated white count and fever spike, empiric antibiotics were started with meropenem because of concern for parapnuemonic effusion. [**Hospital **] health care proxy then agreed to thoracentesis, which was performed, removing 1.5 liters of transudative fluid, cytology was sent. Antibiotics were changed to levofloxacin on [**11-11**] and an 8-day course was completed on [**11-13**]. The pleural fluid was ultimately found to be a transudate by Light's criteria. # ESRD: Patient initially required pressor support during hemodialysis stabilized afterward. However, he experienced a hypotensive CVA during or after hemodialysis on [**11-16**] as described above. # DVTs: Patient had DVTs involving the right internal jugular, left subclavian, and axillary veins. He was started on warfarin on [**11-10**] and heparinized prior to that date. Medications on Admission: 1. Amiodarone 200 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 DAILY (Daily). 3. Digoxin 125 mcg Tablet Sig: 0.5 tabs Tablet PO once a day: Total dose 0.0625 daily. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at [**Month/Day (4) 21013**]). 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 9. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Insulin Insulin SC (per Insulin Flowsheet) 11. Lantus 100 unit/mL Cartridge Sig: One (1) 9 units Subcutaneous at [**Month/Day (4) 21013**]: with SSI humulog. 12. Tramadol 50 mg Tablet Sig: 0.5 tabs Tablet PO three times a day: prn. 13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day: hold for SBP less then 100 / HR less then 60. Discharge Medications: Expired Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary: Systolic heart failure Hypotension Pneumonia Deep vein thrombosis Anemia . Secondary: Hypertension Diabetes Dyslipidemia Discharge Condition: Expired [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**] Completed by:[**2167-12-1**]

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icd9cm

[ [ [] ] ]

[ "39.95", "34.91", "99.04", "00.17", "38.93" ]

icd9pcs

[ [ [] ] ]

10057, 10136

4820, 8815

280, 294

10310, 10443

3936, 4052

10025, 10034

10157, 10289

8841, 10002

4067, 4637

231, 242

322, 2207

4652, 4797

2229, 3602

3618, 3920

19,079

121,855

25600

Discharge summary

report

Admission Date: [**2175-7-30**] Discharge Date: [**2175-8-22**] Date of Birth: [**2108-10-16**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Back Pain Major Surgical or Invasive Procedure: [**2175-8-8**] - Right subclavian->carotid bypass/redo sternotomy w/asc ao replacement and bil caotid bypass/ao arch endovascular stent History of Present Illness: This 66-year-old gentleman has previously had an aortic valve replacement many years ago. He has an aneurysm involving his ascending aorta and transverse arch. He is undergoing our ascending arch aneurysm replacement and repair using a hybrid combination procedure. The patient has previously undergone a right carotid subclavian bypass for an anomaly of his right subclavian artery, coming off the aorta, distal to his left subclavian artery. This was done successfully last week. Past Medical History: HTN Hyperlipidemia ? Diabetes CVA [**2164**], [**2166**] Asc aorta aneurysm BPH Chronic UTI's AVR [**2146**] Social History: Lives with wife. [**Name (NI) 4084**] smoked. Occasional alcoholic beverage. Family History: Mother died in her 60's of heart disease Physical Exam: GEN: WDWN in NAD HEENT: Unremarkable, edentulous LUNGS: Clear HEART: RRR, pronounced click ABD: Obese, soft, nontender, nondistended, NABS EXT: Warm, no edema, right GSV varicosed. Pulses 2+ Pertinent Results: [**2175-7-30**] 04:00PM WBC-4.1 RBC-4.13* HGB-13.1* HCT-38.5* MCV-93 MCH-31.8 MCHC-34.2 RDW-13.4 [**2175-7-30**] 04:00PM ALT(SGPT)-21 AST(SGOT)-44* LD(LDH)-241 ALK PHOS-90 AMYLASE-132* TOT BILI-0.4 [**2175-7-30**] 04:00PM GLUCOSE-106* UREA N-22* CREAT-1.0 SODIUM-143 POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-25 ANION GAP-15 [**2175-7-30**] 04:00PM PT-13.9* PTT-23.9 INR(PT)-1.3 [**2175-8-22**] 05:50AM BLOOD WBC-9.7 RBC-3.03* Hgb-9.4* Hct-27.6* MCV-91 MCH-31.1 MCHC-34.2 RDW-14.0 Plt Ct-437 [**2175-8-22**] 05:50AM BLOOD Plt Ct-437 [**2175-8-22**] 05:50AM BLOOD Glucose-167* UreaN-51* Creat-1.6* Na-134 K-4.4 Cl-95* HCO3-30 AnGap-13 [**2175-8-19**] CXR No pneumothorax. Bilateral linear atelectases. [**2175-8-16**] CT scan 1. Extensive postoperative changes as described above. 2. No evidence of endoleak or contrast extravasation. 3. Stable renal and pancreatic cysts. 4. Cystic area posterior to the body/tail of the pancreas measuring 11 mm is also unchanged. [**2175-7-30**] CT Scan 1. No evidence of aortic dissection or intramural hematoma. 2. Status post aortic valve repair and Bentall procedure with proximal ascending aortic aneurysmal dilatation with maximal diameter of 6.2 cm. 3. Multiple low-density lesions within both kidneys, likely representing cysts, all of which are not well characterized on this examination. An MRI can be performed for further evaluation. 4. 11-mm cystic lesion within the body/tail of the pancreas. An MRI can be performed for further evaluation of the cystic lesion and can be performed at the same time the renal lesions are characterized. 5. Enlarged prostate. 6. Aberrant right subclavian artery. 7. Left thyroid nodule. This can be more fully evaluated with a thyroid ultrasound [**2175-8-2**] Carotid Series No evidence of stenosis in either carotid artery. [**2175-8-8**] EKG Sinus rhythm, 68 Left axis deviation Extensive T wave changes may be due to myocardial ischemia which are new from previous - consider ischemia [**2175-8-1**] MRI 1. Enhancing 2 cm solid mass within the lower pole of the right kidney with possible pseudocapsule around it. These findings are concerning for renal cell carcinoma, possibly low-grade. 2. Two cysts within the body/tail of the pancreas, the larger of which is 1 cm in size without evidence of pancreatic duct dilatation. Followup of these lesions with MRI is recommended within one year. 3. Multiple hepatic simple cysts. [**Last Name (NamePattern4) 4125**]ospital Course: Mr. [**Known lastname 63902**] was admitted to the [**Hospital1 18**] on [**2175-7-30**] for surgical management of dilated aortic root and ascending aortic aneurysm. Heparin was started in place of his Coumadin. A preoperative CT angiogram was performed which incidentally identified an 11-mm cystic lesion within the body/tail of the pancreas. The general surgery service was consulted who recommended an MRI. This revealed two cysts within the body/tail of the pancreas, the larger of which is 1 cm in size without evidence of pancreatic duct dilatation. An enhancing 2 cm solid mass within the lower pole of the right kidney was identified with a possible pseudocapsule around it. Follow-Up of these lesions with MRI was recommended within one year. The urology service was consulted in regards to his renal mass. No immediate surgery was recommended however a follow-up scan in [**1-27**] months was recommended as well as a cystoscopy at some point. On CT scan, an aberrant right subclavian artery was identified. A carotid duplex ultrasound was negative for any flow limiting disease in his internal carotids. The vascular surgery service was consulted for a subclavian-carotid bypass. On 9/805, Mr. [**Known lastname 63902**] was taken to the operating room where he underwent bypass from his right subclavian to his right common carotid artery without complication. He was allowed to recover for a couple days. On [**2175-8-8**], Mr. [**Known lastname 63902**] was taken to the operating room where he underwent a redo-sternotomy with an ascending aorta replacement to bilateral carotid artery bypass as well as an aortic arch endovascular stent graft. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, he developed atrial fibrillation for which amiodarone was started. Later on postoperative day one, Mr. [**Known lastname 63902**] [**Last Name (Titles) 5058**] confused and was extubated. He required aggressive diuresis and chest PT. Nicardipine was used for hypertension. Heparin and coumadin were resumed for anticoagulation for his mechanical heart valve. He was gently diuresed towards his preoperative weight. The physical therapy service worked with him daily to help increase his strength and mobility. On postoperative day seven he was transferred to the cardiac surgical step down unit for further recovery. He developed some sternal drainage for betadine dressing changes were started and a wound culture was sent which revealed no bacteria. Vancomycin was started prophylactically. Mr. [**Known lastname 63902**] developed some dysuria for which levofloxacin was started given his history of recurrent urinary tract infections. His confusion slowly improved. A postoperative CT scan showed normal postoperative changes without an endoleak. His sternal drainage ceased and his vancomycin was stopped. Mr. [**Known lastname 63902**] continued to make steady progress and was discharged home on [**2175-8-22**]. He will follow-up with Dr. [**Last Name (Prefixes) **], his cardiologist, the vascular surgery service and his primary care physician as an outpatient. Medications on Admission: Coumadin Avodart Diovan Zyrtec Diltiazem Flomax Mobic Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO BID (2 times a day). Disp:*60 Capsule, Sust. Release 24HR(s)* Refills:*2* 5. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO QD (). Disp:*30 Capsule(s)* Refills:*2* 6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 7. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 8. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 10. Zyrtec 10 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 11. Coumadin 3 mg Tablet Sig: Two (2) Tablet PO every other day: Take as directed for INR goal of [**1-26**].5. Disp:*30 Tablet(s)* Refills:*2* 12. Coumadin 7.5 mg Tablet Sig: One (1) Tablet PO every other day: Take as directed by Dr. [**Last Name (STitle) 11863**] for INR goal of [**1-26**].5. Disp:*15 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: VNA of RI Discharge Diagnosis: s/p Rt subclav ->Rt Carotid bypass/redo sternotomy w asc ao replacement and bil carotid bypass/ao arch endovascular stent. Urinary retention PMH:AVR(mechanical),HTN,^chol,DM,CVA,BPH,LBP,Rt ing hernia repair, lipoma removal Discharge Condition: good Discharge Instructions: Follow medications on discharge instructions. Do not lift more than 10 lbs. for 2 months. You may not drive for 4 weeks. You should shower daily, let water flow over wounds, pat dry with a towel. Do not use creams, lotions, or powders on wounds. Call our office for sternal drainage, temp > 101.5 [**Last Name (NamePattern4) 2138**]p Instructions: wound clinic in 2 weeks Dr. [**Last Name (Prefixes) **] in 4 weeks Dr. [**Last Name (STitle) **] in 4 weeks Dr. [**Last Name (STitle) **] in [**11-27**] weeks. Dr. [**Last Name (STitle) 11863**] in [**11-27**] weeks. Your urologist in 1 week. Completed by:[**2175-8-22**]

[ "293.0", "577.2", "V58.61", "599.0", "788.20", "793.5", "441.2", "401.9", "747.21", "427.31" ]

icd9cm

[ [ [] ] ]

[ "39.61", "39.22", "39.79", "88.42", "38.45", "38.42" ]

icd9pcs

[ [ [] ] ]

8750, 8790

332, 469

9057, 9064

1492, 3914

1224, 1266

7220, 8727

8811, 9036

7141, 7197

9088, 9386

9437, 9711

1281, 1473

3965, 7115

283, 294

497, 982

1004, 1114

1130, 1208

59,828

196,412

42129

Discharge summary

report

Admission Date: [**2147-12-11**] Discharge Date: [**2147-12-16**] Date of Birth: [**2082-1-7**] Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3190**] Chief Complaint: Trauma L1 fracture Major Surgical or Invasive Procedure: 1. Extra cavitary and transpedicular decompression of L1. 2. Laminectomies of T11 and 12, and L2 and 3. 3. Laminotomies T11-12, T10, 11 and 12, as well as L2 and 3. History of Present Illness: 65 Year old male arrives as transfer from [**Hospital3 **] Hospital where he was treated after he fell two steps off of a step stool earlier today. He was found to have an unstable L1 burst fracture. Since the fall, he has been experiencing severe lower back pain but no numbness, weakness or tingling in his lower extremities. Also, he initially had neck pain, but it has since subsided. His C-spine has been cleared at the referring hospital. Patient reports he has pain when he takes deep breaths. Per the patient, he had a negative CT of his neck and a negative chest X-ray at [**Hospital3 **] Hospital. He received dilaudid for pain control prior to transfer. Patient is an insulin-dependent diabetic. He has had a nephrectomy due to a tumor per his wife. [**Name (NI) **] also had a knee replacement 6 months ago. Patient denies history of myocardial infarction or pulmonary disease. Timing: Constant Severity: [**9-30**] Severe Duration: Hours Location: Lower back Context/Circumstances: Fell two steps off of a step stool Mod.Factors: Worse with Movement PAST FAMILY AND SOCIAL HISTORY Nursing triage/initial assessment reviewed and confirmed Past Medical History: Renal cancer with nephrectomy, IDDM, HTN, Knee replacement 6 months ago Medications: Includes: gemfibrozil, Diovan, Lipitor, allopurinol, insulin Allergies and Reactions: NKDA Social History: Denies Smoking REVIEW OF SYSTEMS Positive for Back pain. Constitutional: Normal Head / Eyes: Normal Chest/Respiratory: Pain with deep breaths, Normal Cardiovascular: Normal GI / Abdominal: Normal GU/Flank: Normal Skin: Normal Neuro: No numbness or tingling in lower extremities, numbness in left fingers Psych: Normal PHYSICAL EXAMINATION Temp: 97.1 HR: 95 BP: 123/97 Resp: 16 O(2)Sat: 100 Normal Constitutional: Mildly uncomfortable lying on right side HEENT: Normocephalic, atraumatic Cervical spine was non-tender Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm Abdominal: Soft, Nontender, Nondistended Rectal: Per resident exam GU/Flank: No costovertebral angle tenderness Extr/Back: Lower midline back tenderness, No cyanosis, clubbing or edema Skin: No rash, Warm and dry Neuro: Gross motor and sensory are intact bilateral lower extremities, Speech fluent Psych: Normal mood, Normal mentation ECG Heart Rate: 93 Rhythm: Sinus Ischemia: Non-Specific ECG Axis: Normal Intervals: Left bundle branch block RADIOLOGY Note(s): MRI L-spine: MEDICAL DECISION MAKING Preliminary Diagnosis 1: Unstable L-spine fracture 65 Year old male arrives as transfer from [**Hospital3 **] Hospital with unstable L1 burst fracture that he sustained after falling off of a step stool earlier today. Normal vital signs. Neurologically intact. We will consult spine and obtain the MRI of his L-spine. Service Consulted at 22:01 Spine Final ED Diagnosis 1: L1 burst fracture This uploaded version of the chart may not be the final one; some addenda and test results may not be entered into this OMR note. This Emergency Department patient encounter note may have been created using voice-recognition software and in real time during the ED visit. Please excuse any typographical errors that have not been edited out. Past Medical History: see HPI Social History: see HPI Family History: see HPI Physical Exam: AVSS Well appearing, NAD, comfortable BUE: SILT C5-T1 dermatomal distributions BUE: [**4-25**] [**Doctor First Name **]/Tri/Bic/WE/WF. Finger flexion and grip is weak [**3-25**] BUE: tone normal, negative [**Doctor Last Name 937**], 2+ symmetric DTR bic/bra/tri All fingers WWP, brisk capillary refill, 2+ distal pulses BLE: SILT L1-S1 dermatomal distributions RLE: Toes [**3-25**] Ankle [**2-25**] rest 0/5 LLE: Grade [**4-25**] BLE: tone normal, no clonus, toes downgoing, 2+ DTR knee/ankle All toes WWP, brisk capillary refill, 2+ distal pulses Pertinent Results: [**2147-12-11**] 04:53PM HGB-8.3* calcHCT-25 [**2147-12-11**] 03:36PM TYPE-ART PO2-265* PCO2-45 PH-7.28* TOTAL CO2-22 BASE XS--5 INTUBATED-INTUBATED VENT-CONTROLLED [**2147-12-11**] 03:36PM freeCa-1.02* [**2147-12-11**] 02:39PM HGB-9.0* calcHCT-27 Cervical spine 1 No evidence of cervical spinal cord injury. 2. Evidence of acute injury to the inter- and supraspinous ligament complexes from the C3 to the C6 level. 3. T1-T2: Left posterolateral disc protrusion that contacts the spinal cord. MRI Lumbar spine 1. Chance fracture involving the T12/L1 intervertebral disc, L1 pedicles, spinous process and inferior facets. 2. Burst fracture of L1. 3. Extensive ligamentous involvement and epidural hematoma. 2. Significant compression of the conus at T12/L1 level with signs of contusion. Brief Hospital Course: Patient was admitted to the [**Hospital1 18**] Spine Surgery Service and taken to the Operating Room for the above procedure. Refer to the dictated operative note for further details. Patient had a postoperative neurological deficit which as progressively improved. In the left LLE he has grade [**4-25**] and on the right side he has [**2-25**] power in the toes and ankles. Rest of the right side has 0/5 power. He as bilateral grip weakness. He has baseline neck pain with is treated with a neck collar. He as no acute fracture in the neck. Patient was treated in ICU for 3 days. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were continued for 24hrs postop per standard protocol. Initial postop pain was controlled with a PCA. Diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. Physical therapy was consulted for mobilization OOB with a brace. Patient is afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. He is able to get out of bed to chair with help. He is unable to walk due to neurological weakness in his legs. Patient is on insulin sliding scale and fixed dose insulin for blood sugar control. Medications on Admission: gemfibrozil, Diovan, Lipitor, allopurinol, insulin Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 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 for pain. 5. oxycodone 5 mg Tablet Sig: 1 to 3 Tablet PO Q3H (every 3 hours) as needed for pain. Disp:*100 Tablet(s)* Refills:*0* 6. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. insulin fixed dose and Insulin sliding scale (Insulin flow order sheet attached) Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Fracture dislocation through L1. Discharge Condition: Activity Status: Bedbound. Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Discharge Instructions: Immediately after the operation: - Activity: Please attempt to get out of bed for all meals. - 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 when you are out of 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. - 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. - Follow up: o Please Call the office and make an appointment for 2 weeks after the day of your operation if this has not been done already. o At the 2-week visit we will check your incision, take baseline X-rays and answer any questions. We may at that time start physical therapy. o We will then see you at 6 weeks from the day of the operation and at that time release you to full activity. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Followup Instructions: Please schedule an appointment with Dr [**Last Name (STitle) 363**] 2 weeks after the date of surgery. [**Numeric Identifier 91385**]

[ "997.09", "278.01", "E878.8", "584.9", "272.4", "V45.73", "336.9", "806.29", "V85.42", "V58.67", "401.9", "V43.65", "V10.52", "E881.0", "285.1", "274.9", "805.4", "250.00" ]

icd9cm

[ [ [] ] ]

[ "03.53", "03.09", "81.08", "77.79", "81.63", "96.71", "00.94", "81.07" ]

icd9pcs

[ [ [] ] ]

7736, 7783

5667, 6925

328, 499

7860, 7934

4841, 5644

9898, 10035

4248, 4257

7089, 7713

7804, 7839

6951, 7066

7995, 7995

4272, 4822

9385, 9875

8029, 8348

270, 290

8360, 9374

527, 1855

7949, 7971

4198, 4207

4223, 4232

81,247

144,506

43154

Discharge summary

report

Admission Date: [**2184-9-15**] Discharge Date: [**2184-9-17**] Date of Birth: [**2113-8-15**] Sex: M Service: MEDICINE Allergies: Bactrim DS / Atenolol Attending:[**First Name3 (LF) 443**] Chief Complaint: Chest Pain, STEMI Major Surgical or Invasive Procedure: Cardiac catheterization with 3 bare metal stents placed in the SVG-to-LAD graft History of Present Illness: 71 yo M w PMH of Stable Angina, CAD (CABG [**54**] SVG-LAD (2 stents), and LIMA-OM, SVG-RCA(100% occlusion, non-revascularizable), LMA 100% prox occlusion)), PVD, One episode of Afib (post MI [**Month (only) **] [**2184**], none since then, stopped warfarin after consultation with Dr. [**Last Name (STitle) **]. - Presented to Urgent care clinic with Dr.[**Name (NI) 93011**] [**9-15**] 9:30AM due to chest pain, EKG there suggested, SVG-LAD occlusion => activated cath lab for direct-to-cath. Symptoms started on Sunday night when he awoke with chest pain without any other associated symptoms, pain was localized to the left chest without radiation. Pain relieved with 1 SL Nitro. On Monday he took SL Nitro q 4 hours which prevented pain that day, on Tuesday he had to teach a finance class so he took Nitro patch which also prevented pain that day. On Wednesday morning pain returned and refractory to 4 SL Nitro, taken prior to visit with Dr. [**Last Name (STitle) 16157**]. At baseline difficulty walking due to spinal stenosis, but no SOB or DOE or PND. Plays golf regularly and on average uses 1 SL Nitro every 3-4 days which alleviates his Angina. - In Cath Lab had 3 non-continuous stents to proximal, mid, and distal SVG-LAD graft. - On transfer to CCU pt was NS @ 75cc/hr, Integrilin gtt, and 2L NC SaO2 100%. HD stable with HR 78, BP 135/75, comfortable, in Sinus Rhythm Past Medical History: - CAD (CABG [**54**], LIMA-OM, SVG-LAD (h/o 2 stents), SVG-RCA(100% occlusion, non revascularizable), LMA 100% prox occlusion) - Mild chronic stable angina, - Hyperlipidemia, - PAD (R [**Name (NI) 1793**] PTA/stent) - Episode of Afib post MI [**2184-1-4**] Social History: - never smoked - glass of wine with dinner - former avid runner (up to 20 mi/day before 1st CABG) - Lives with wife - [**Name (NI) **] teaches finance in [**University/College 5130**] [**Location (un) **]. Family History: - Father died of MI at 62 - Mother died of CA at 65 - Brother alive with CABG in his 60s Physical Exam: Admission: VS: 98.2, 78, 135/75, 100% on 2L GENERAL: Thin caucasian male, looks younger than stated age, in NAD Oriented x3. Mood, affect appropriate. Laynig flat. HEENT: Sclera anicteric. EOMI. Conjunctiva were moist. NECK: Flat neck veins. CARDIAC: RRR, No m/r/g. Midline vertical scar. LUNGS: Clear anteriorly, on 2L, speaking in full sentences, comfrotable. no accessory muscle use. No wheezes or rhonchi. ABDOMEN: Soft, NTND. EXTREMITIES: right groin Aline and sheath in place. Right and left shin with scars, Warm, No edema. PULSES: Palpable DP b/l, [**Name (NI) **] PT. . Discharge: GENERAL: Thin caucasian male, looks younger than stated age, in NAD Oriented x3. Mood, affect appropriate. Lying flat. HEENT: Sclera anicteric. EOMI. Conjunctiva were moist. NECK: Flat neck veins. CARDIAC: RRR, No m/r/g. Midline vertical scar. LUNGS: Clear anteriorly, on 2L, speaking in full sentences, comfortable. No accessory muscle use. No wheezes or rhonchi. ABDOMEN: Soft, NTND. EXTREMITIES: No rashes, erythema. No femoral bruits. Femoral site C/D/I. PULSES: Palpable DP b/l, [**Name (NI) **] PT. Pertinent Results: LABS: [**2184-9-15**] 12:00PM PT-11.5 INR(PT)-1.1 [**2184-9-15**] 12:05PM PLT COUNT-247 [**2184-9-15**] 12:05PM NEUTS-74.2* LYMPHS-18.3 MONOS-5.5 EOS-1.7 BASOS-0.4 [**2184-9-15**] 12:05PM WBC-9.3 RBC-3.89* HGB-11.5* HCT-34.4* MCV-88 MCH-29.4 MCHC-33.3 RDW-14.4 [**2184-9-15**] 12:05PM CALCIUM-8.9 PHOSPHATE-3.0 MAGNESIUM-2.2 [**2184-9-15**] 12:05PM CK-MB-26* MB INDX-14.4* cTropnT-0.25* [**2184-9-15**] 12:05PM CK(CPK)-181 [**2184-9-15**] 12:05PM estGFR-Using this [**2184-9-15**] 12:05PM GLUCOSE-104* UREA N-20 CREAT-1.0 SODIUM-137 POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-21* ANION GAP-17 [**2184-9-15**] 06:06PM PLT COUNT-244 [**2184-9-15**] 06:06PM CK-MB-66* MB INDX-12.1* cTropnT-1.54* [**2184-9-15**] 06:06PM CK(CPK)-546* [**2184-9-15**] 06:06PM SODIUM-137 POTASSIUM-3.5 CHLORIDE-101 . EKG [**2184-9-15**]: Sinus with ST Elevation in aVR, depression in II, III, aVF, V4-V6 . CATH [**2184-9-15**]: COMMENTS: 1. Venous conduit angiography demonstrated total SVG-LAD occlusion proximally. 2. Limited resting hemodynamics revealed normal systemic arterial pressure with a central aortic pressure of 132/75 mmHg. 3. Successful stenting of the distal SVG-LAD with a 3.0x16mm Promus Element RX stent which was postdilated to 3.0mm. 4. Successful PTCA and stenting of the mid vessel SVG-LAD stent thrombosis with a 4.0x28mm Promus Element RX stent which was postdilated distal and mi to 4.0mm and proximally to 4.5mm. 5. Successful PTCA and stenting of the proximal SVG-LAD stenosis with a 3.5x20mm Promus Element RX stent which was postdilated to 4.0mm. FINAL DIAGNOSIS: 1. Total proximal occlusion of SVG-LAD graft. 2. Normal systemic arterial pressure. 3. Successful PCI of the distal SVG-LAD with a DES. 4. Successful PCI of the mid SVG-LAD with a DES. 5. Successful PCI of the proximal SVG-LAD with a DES . ECHO [**2184-9-16**]: IMPRESSION: Normal left ventricular cavity size and wall thickness with globally preserved left ventricular systolic function (EF>55%) in the presence of hypokineisis of the basal and mid inferior and inferolateral, as well as the mid and distal septal segments. At least moderate mitral regurgitation. There is mitral valve leaflet buckling, but frank mitral valve leaflet prolapse is not appreciated. Significant pulmonic regurgitation. Indeterminate pulmonary artery systolic pressure. Compared with the prior study (images reviewed) of [**2184-3-26**], the septal wall motion abnormalities are new and the severity of mitral regurgitation has increased (previously mild to moderate). Brief Hospital Course: 71 yo male with long h/o CAD, mild stable angina, who presented to clinic with severe chest pain not relieved by SL Nitro and EKG consistent with STEMI with global ischemia. . # STEMI: The patient was taken to the catheterization lab where he recieved 3 non-consecutive BMS to SVG-LAD. His chest pain resolved. He was hemodynamically datble with no evidence of arrythmia and no signs or symptoms of volume overload. Integrilin was continued for 18 hours after the patient was admitted to the CCU from the cath lab. He was treated with ASA 325, Plavix, Crestor 40mg, and Metop succinate 25mg [**Hospital1 **]. He was also started on a low dose ACEI prior to discharge. Follow-up echo on [**9-16**] showed normal left ventricular cavity size and wall thickness with globally preserved LV systolic function (EF>55%) in the presence of hypokinesis of the basal and mid inferior and inferolateral, as well as the mid and distal septal segments. The option of a second CABG for repair of the SVG was discussed with the patient, but he was not interested in this option. He was discharged on [**9-17**] in improved condition. He will follow up with his PCP for hospital [**Name9 (PRE) 702**] and with Dr. [**Last Name (STitle) **] in Cardiology. . # dCHF with Mild MR: The patient has a history of diastolic heart failure, but was euvolemic during his hospital stay. His home HCTZ was stopped, but Metop succinate 25 [**Hospital1 **] was continued. Follow-up echo on [**9-16**] showed Normal left ventricular cavity size and wall thickness with globally preserved left ventricular systolic function in the presence of hypokineisis of the basal and mid inferior and inferolateral, as well as the mid and distal septal segments. At least moderate mitral regurgitation. There is mitral valve leaflet buckling, but frank mitral valve leaflet prolapse is not appreciated. Significant pulmonic regurgitation. Indeterminate pulmonary artery systolic pressure. He was treated with medical management as noted above and will follow-up with cardiology as an outpatient.. . # Vasovagal Episode: The patient had an episode of bradycardia to the 30s-40s accompanied by sweating and dizziness, with SBPs into the 60s. He has a history of vasovagal episodes in the past, usually with some medical intervention, such as the placement of an IV in his hand or the removal of an arterial sheath. However, during this hospitalization, he was resting when he experienced these symptoms. The head of his bed was reclined, and he was given IV fluids, which brought up his pressure and his heart rate. The episode lasted only a couple minutes, and the patient did not lose consciousness. . # Chronic Mild Stable Angina: The patient was asymptomatic during his hospital stay. He was discharged on medications as outlined above in addition to Nitro SL. No additional anti-anginal medications were started during this hospitalization. However, he may benefit from longer acting nitro or ranexa in the future if angina persists and is unresponsive to Nitro SL. He will be followed closely as an outpatient. . # History of Afib: The patient was not in atrial fibrillation during this hospital stay. Metoprolol was contined for rate control during this hospital stay. . # Hyperlipidemia: Home Crestor was increased from 20mg daily to 40mg daily. . # Hemorrhoids: Home hydrocortisone suppository was continued. . Transitional Issues: - consider long dose nitro for additional anti-angina benefit - consider Ranexa Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Hydrochlorothiazide 25 mg PO DAILY Hold for SBP<90 2. Hydrocortisone Acetate Suppository 1 SUPP PR DAILY: PRN hemorrhoids 3. Lorazepam 0.5 mg PO DAILY:PRN anxiety, insomnia 4. Omeprazole 10 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Nitroglycerin SL 0.3 mg SL PRN chest pain 7. Rosuvastatin Calcium 20 mg PO DAILY PATIENT HAS NOT BEEN TAKING THIS PRESCRIBED MEDICATION 8. Metoprolol Succinate XL 25 mg PO BID Discharge Medications: 1. Aspirin EC 325 mg PO DAILY 2. Hydrocortisone Acetate Suppository 1 SUPP PR DAILY: PRN hemorrhoids 3. Lorazepam 0.5 mg PO DAILY:PRN anxiety, insomnia 4. Metoprolol Succinate XL 25 mg PO BID 5. Omeprazole 10 mg PO DAILY 6. Clopidogrel 75 mg PO DAILY for at least one year as per Dr. [**Last Name (STitle) **] RX *clopidogrel 75 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*11 7. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain RX *tramadol 50 mg one tablet(s) by mouth every 4 hours Disp #*30 Tablet Refills:*2 8. Nitroglycerin SL 0.3 mg SL PRN chest pain 9. Atorvastatin 80 mg PO DAILY RX *atorvastatin 80 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 10. Lisinopril 2.5 mg PO DAILY RX *lisinopril 2.5 mg one tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 Discharge Disposition: Home Discharge Diagnosis: St elevation myocardial infarction Peripheral vascular disease Spinal stenosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you at [**Hospital1 18**]. You were having chest pain at home and was found to be having a heart attack. In the cardiac catheterization lab, 3 drug eluting stents were placed in your left anterior descending artery. An echocardiogram showed the area of the heart where the muscle is not moving well but overall your heart function is OK. You will need to restart some of the medicines you were on in the past to ensure that your heart muscle recovers well. You are back on clopidogrel (Plavix) to prevent the stent from clotting off. Do not stop taking plavix or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr. [**Last Name (STitle) **] tells you it is OK to do so. Please seek medical attention immediately for any signs of serious bleeding. Followup Instructions: Department: [**Hospital3 249**] When: WEDNESDAY [**2184-9-22**] at 2:20 PM With: Dr. [**Last Name (STitle) **] [**Name (STitle) **] Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] North [**Hospital **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor in follow up. Department: [**Hospital3 249**] When: FRIDAY [**2184-10-15**] at 9:00 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: FRIDAY [**2184-10-15**] at 10:40 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: VOICE SPEECH & SWALLOWING When: MONDAY [**2184-10-4**] at 8:30 AM With: [**Doctor Last Name **] WORTH, MS SLP [**Telephone/Fax (1) 3731**] Building: Span Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage

[ "440.20", "428.0", "428.32", "410.91", "455.6", "780.2", "424.0", "272.4", "724.5", "414.02", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "00.66", "00.47", "00.40", "36.07", "88.56" ]

icd9pcs

[ [ [] ] ]

10974, 10980

6113, 9506

299, 380

11103, 11103

3539, 5116

12082, 13629

2313, 2403

10166, 10951

11001, 11082

9634, 10143

5133, 6090

11254, 12059

2418, 3520

9527, 9608

242, 261

408, 1794

11118, 11230

1816, 2074

2090, 2297

48,123

111,089

35251

Discharge summary

report

Admission Date: [**2173-10-30**] Discharge Date: [**2173-11-9**] Date of Birth: [**2137-6-17**] Sex: M Service: SURGERY Allergies: Unasyn Attending:[**First Name3 (LF) 695**] Chief Complaint: Budd Chiari/HCC/cirrhosis Major Surgical or Invasive Procedure: [**2173-10-31**] Orthotopic deceased-donor liver transplant (piggyback) with portal vein to portal vein anastomosis, common hepatic artery in the donor to branch patch of the left hepatic artery in the recipient, common bile duct to common bile duct anastomosis. [**2173-11-3**] Exploratory laparotomy, Roux-En-Y hepaticojejunostomy, and Liver biopsy for bile leak History of Present Illness: 36M w/ hx of HCC, cirrhosis, Budd-Chiari w/ esophageal varices and portocaval shunt being admitted for OLT. He was diagnosed w/ Budd-Chiari at age 12 but did not undergo a side-to-side portocaval shunt at that time. He did well until [**2164**], when he experienced hematemesis/melena and required banding of esophageal varices. Since [**2169**], he has had multiple additional episodes of variceal bleeding, some requiring transfusions. A liver biopsy in [**2169**] showed cirrhosis, and he did receive a portocaval shunt in [**2170**]. In late [**2171**], he had a biopsy showing HCC and has undergone both TACE and RFA since. Patient has recently been feeling well. He denies chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, food intolerance, jaundice, swelling, recent encephalopathy. Of note the patient has been working out recently. AB compatible liver donor was available and patient was called to come in for preoperative assessment. Revision of systems Denies nausea, vomiting, fever, abdominal pain, hematemesis, melena, BRBPR, chest pain, shortness of breath, urinary symptoms or any other symptoms Past Medical History: # Hepatocellular carcinoma, dx 12/[**2171**]. # Budd-Chiari Syndrome, dx age 12. - Esophageal varices, first in [**2164**] with recurrent episodes. - EGD [**6-/2170**] with grade II and III esophageal varices s/p banding, and portal hypertensive gastropathy. - Portocaval shunt [**2170-8-17**]. # History of positive PPD, quantiferon +, s/p 9 months of INH treatment. # Cholecystectomy. Social History: Originally from El [**Country 19118**]. Adopted, moved to the United States at the age of 6 months. Former roofer, currently on disability. Lives with his girlfriend. [**Name (NI) **] denies smoking, drinking alcohol, or illicit drug use. Family History: Adopted. Physical Exam: Preop PE: Vitals: 98.4 66 123/79 18 100%RA Exam: GEN NAD, looks well HEENT PERRL, MMM, anicteric sclera CV RRR RESP CTAB GI Soft NT/ND, nml BS, liver edge palpable, well healed right subcostal scar EXT WWP, no C/C/E, 2+ DPs NEURO CN 2-12 grossly intact PSYCH AOx3 Labs: 139 104 15 ------------<86 AGap=12 3.5 27 1.0 estGFR: >75 (click for details) Ca: 8.9 Mg: 2.1 P: 2.9 ALT: 90 AP: 394 Tbili: 1.7 Alb: 4.1 AST: 110 12.7 4.7 >--< 91 37.1 PT: 14.4 PTT: 37.4 INR: 1.3 Fibrinogen: 302 UA: neg for UTI EKG: No acute ischemic changes CXR: Heart size and mediastinum are stable. Lungs are clear. Right middle lobe opacity seen on multiple prior studies is re-demonstrated on the current examination with no appreciable change since prior exams Pertinent Results: [**2173-10-30**] 04:25PM BLOOD WBC-4.7 RBC-4.15* Hgb-12.7* Hct-37.1* MCV-89 MCH-30.6 MCHC-34.2 RDW-16.5* Plt Ct-91* [**2173-11-9**] 05:10AM BLOOD WBC-12.5* RBC-3.65* Hgb-11.2* Hct-32.8* MCV-90 MCH-30.7 MCHC-34.3 RDW-16.8* Plt Ct-182 [**2173-11-9**] 05:10AM BLOOD PT-11.9 INR(PT)-1.1 [**2173-11-9**] 05:10AM BLOOD Glucose-82 UreaN-11 Creat-0.9 Na-139 K-3.5 Cl-107 HCO3-25 AnGap-11 [**2173-11-8**] 04:10AM BLOOD ALT-135* AST-76* AlkPhos-96 TotBili-0.6 [**2173-11-9**] 05:10AM BLOOD ALT-152* AST-76* AlkPhos-130 TotBili-0.5 [**2173-11-8**] 04:10AM BLOOD tacroFK-9.9 [**2173-11-9**] 05:10AM BLOOD tacroFK-10.4 Brief Hospital Course: On [**2173-10-31**], he underwent Orthotopic deceased-donor liver transplant (piggyback) with portal vein to portal vein anastomosis, common hepatic artery in the donor to branch patch of the left hepatic artery in the recipient, common bile duct to common bile duct anastomosis. Two JP drains were placed as well as Roux tube. Surgeon was Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] assisted by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please refer to operative note for details. On [**11-3**], medial drain became bilious on postoperative day 2. An angiogram demonstrated appropriate flow in the hepatic artery and he was taken back for surgical revision of his biliary tree. Exploratory laparotomy, Roux-En-Y hepaticojejunostomy and Liver biopsy were done. Surgeon was Dr. [**First Name4 (NamePattern1) 3742**] [**Last Name (NamePattern1) **]. See operative note for details. Biopsy demonstrated rare portal area with mild neutrophilic infiltrate and minimal bile duct proliferation, see note. No rejection. Iron stains were pending. Postop, he was cared for in the SICU. JP drains were non-bilious. Roux tube had bilious drainage. LFTs decreased. He was extubated. NG was removed and sips were started. Diet was advanced and tolerated. Abdominal incision was intact with staples. He had a scant amount of serosanguinous drainage at the apex of the incision. He was transferred out of the SICU and was ambulating independently on [**11-8**]. Lateral JP was removed on [**11-8**]. Medial JP output was 290cc on [**11-8**]. Gravity cholangiogram was done on [**11-8**]. However, the roux tube was in the bowel and anastomosis was unable to be assessed. Roux tube was capped. The next day alt and alk phos were increased ( alt 152 from 135, t.bili 130 from 96). He was started on a heparin drip on [**11-8**] for Budd Chiari unknown etiology. Coumadin 2mg was started on [**11-8**]. Heparin was switched to Lovenox as a bridge. He was taught how to self inject and was able to demonstrate injection. Immunosuppression consisted of tapering steroid down to 20mg per day per protocol. He required minimal insulin for slightly elevated glucose. Cellcept was well tolerated. Prograf was adjusted per trough levels. PT cleared him for home without PT serices. He was anxious to go home and medication teaching was reviewed on several days. [**Hospital1 **] VNA was arranged to assist him at home with drain care as well as review of medications. Given slight elevation in LFts, labs were to be drawn on [**11-11**] a C lab. INR/Coumadin was to managed by [**Hospital1 18**] Transplant service. Medications on Admission: - amiloride 10 PO mg DAILY - furosemide 60 PO mg DAILY - omeprazole 40 PO mg DAILY - lactulose 15 ml daily - rifaximin 550 mg ordered [**Hospital1 **] but taking daily - multivitamin DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Enoxaparin Sodium 120 mg SC DAILY 3. Fluconazole 400 mg PO Q24H 4. HYDROmorphone (Dilaudid) 2-4 mg PO Q3H:PRN pain RX *hydromorphone [Dilaudid] 2 mg [**2-8**] tablet(s) by mouth every four (4) hours Disp #*60 Tablet Refills:*0 5. Mycophenolate Mofetil 1000 mg PO BID 6. Omeprazole 20 mg PO DAILY 7. PredniSONE 20 mg PO DAILY POD #6 and ongoing 8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 9. ValGANCIclovir 900 mg PO Q24H 10. Warfarin 2 mg PO ONCE Duration: 1 Doses 11. Tacrolimus 1.5 mg PO Q12H Discharge Disposition: Home With Service Facility: [**Hospital1 **] VNA, [**Hospital1 1559**] Discharge Diagnosis: Budd Chiari Bile leak Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: [**Hospital1 **] Visiting Nurse Service has been arranged. You will receive a call from nurse to set up a visit. Please call the Transplant Office [**Telephone/Fax (1) 673**] if you have any of the following: temperature of 101 or greater, chills, nausea, vomiting, jaundice, inability to eat/drink or take any of your medication, increased incision/abdominal pain or abdominal distension, incision or drain site appears red or has drainage, constipation or diarrhea, or any concerns -You will have blood drawn twice weekly for transplant lab monitoring. ***You need to have next labs on [**11-11**]*** -You may shower with soap and water, but no tub baths or swimming -Do not apply powder,lotion or ointment to incision -Take all of your medication as instructed/ordered -Please avoid sun exposure, and always wear sun screen when you are outside on all exposed skin Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14955**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2173-11-18**] 1:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2173-11-24**] 9:40 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14254**], [**Name12 (NameIs) 1046**] Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2173-11-24**] 11:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2173-11-9**]

[ "584.9", "456.21", "E878.0", "572.3", "453.0", "V45.89", "571.5", "997.49", "998.12", "V10.07", "788.5" ]

icd9cm

[ [ [] ] ]

[ "87.54", "00.93", "50.12", "50.59", "51.37" ]

icd9pcs

[ [ [] ] ]

7520, 7593

4038, 6724

292, 660

7659, 7659

3408, 4015

8702, 9361

2523, 2533

6964, 7497

7614, 7638

6750, 6941

7810, 8679

2548, 3389

227, 254

688, 1836

7674, 7786

1858, 2246

2262, 2507

21,649

103,899

1313

Discharge summary

report

Admission Date: [**2149-10-22**] Discharge Date: [**2149-10-26**] Date of Birth: [**2106-9-6**] Sex: F Service: ADMISSION DIAGNOSES: Left breast cancer. DISCHARGE DIAGNOSES: Left breast cancer. ATTENDING PHYSICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3228**], [**Name Initial (NameIs) **].D. DISCHARGE MEDICATIONS: 1. Percocet 325 mg 1-2 tablets po q.4-6h p.r.n. for pain. 2. Clindamycin 150 mg capsules 2 capsules po q.6h x1 week. 3. Colace 100 mg po b.i.d. x2 weeks. DISPOSITION: The patient was discharged to home with follow up instructions for an appointment with Dr. [**First Name (STitle) 3228**] in 7 to 10 days. HOSPITAL COURSE: The patient is a 43 year old African- American female who was admitted on [**2149-10-22**] to undergo a skin sparing left mastectomy and immediate [**Last Name (un) 5884**] flap reconstruction. She tolerated this without complication and postoperatively recovered in the post anesthesia care unit. On day #1 her flap was noted to be well perfused and the patient was allowed out of bed to a chair. Her diet was advanced to clears. On postoperative day #2 the patient had a migraine headache overnight that was relieved with narcotic administration. She had a low grade temperature to 101.1, but was afebrile by morning. Her left breast flap remained well perfused and the patient was allowed out of bed to ambulate with assistance. Her Foley catheter was removed and her diet was advanced to regular as tolerated. On postoperative day #3 the patient was allowed to ambulate with increased frequency and was allowed to shower and sponge bathe. She was tolerating a regular diet and some mild nausea had improved with antiemetic medication. On postoperative day #4 the patient was without significant pain, was ambulating without difficulty, was voiding spontaneously, and was tolerating a regular diet. She was felt to be in stable and satisfactory condition for discharge to home. PROCEDURES PERFORMED: Procedures performed during this admission was a left mastectomy on [**2149-10-22**], and also a left [**Last Name (un) 5884**] flap reconstruction on [**2149-10-22**]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3228**], M.D. [**MD Number(2) 8076**] Dictated By:[**Last Name (NamePattern1) 8077**] MEDQUIST36 D: [**2150-2-24**] 09:45:39 T: [**2150-2-24**] 10:18:59 Job#: [**Job Number 8078**]

[ "401.9", "233.0", "780.6", "998.89" ]

icd9cm

[ [ [] ] ]

[ "85.43", "85.84" ]

icd9pcs

[ [ [] ] ]

197, 344

367, 677

695, 2443

154, 175

48,895

115,022

37228

Discharge summary

report

Admission Date: [**2101-11-10**] Discharge Date: [**2101-12-1**] Date of Birth: [**2021-4-27**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1115**] Chief Complaint: Failure to wean off ventilator, question of tracheobronchomalacia Major Surgical or Invasive Procedure: Arterial line History of Present Illness: HISTORY OF PRESENT ILLNESS: 80 y o Creole-speaking male with PMHx significant for COPD, asthma, HTN, hyperlipidemia, sick sinus syndrome s/p pacemaker placement who presented from [**Hospital 107**] Hospital in [**State 792**]for evaluation by interventional pulmonology of tracheobroncheomalacia for possible stenting. Patient admitted to [**Hospital 796**] Hospital in RI on [**2101-9-9**] for SOB (and has been in hospital since admission date), treated for COPD exacerbation and URI, required intubation for respiratory failure. Complications during the hospitalization at the OSH included VAP (serratia, pseudomonas) treated with cefepime. Had a CT on [**10-4**] with BL pleural effusion, with compressive atelectasis. Also had ? sick sinus syndrome s/p pacemaker placement on [**10-27**], shock liver and DIC secondary to sepsis, severe C.diff colitis now resolved, and anasarca. Underwent tracheostomy on [**2101-9-29**] and despite this has failed weaning attempts. Per outside hospital notes, he was seen by cardiology consultant on [**10-11**], because there were several episodes fo bradycardia/PEA during repositioning thought [**2-14**] mucous plugging. He also had an episode of narrow complex tachycardia that may have been A fib. Patient was transfered from OSH on [**11-11**] for evaluation by IP for possible stent placement for TBM. Upon transfer from OSH, routine EKG was performed and found to be abnormal. EKG showed 0.5-1mm STD in II/III/AVF, trops 0.4 with normal renal function. Repeat troponins stable (0.41) this AM. Echo this AM, with EF >55%, no focal WMA. Cardiology was consulted on patient, would like to cycle troponins, and if these increase will plan to do cardiac catheterization, otherwise would like to medically manage. Since arrival patient has had antibiotics stopped, and pan-culted; has been afebrile here, MAP 60. Patient is making appropriate urine, 1.4L urine since midnight. Patient was also started on Diamox for alkalosis. For rate control patient was changed from diltiazem to beta blocker, with good rate control. Nutrition was also consulted on the patient, and per their recs tube feeds were started. . Review of systems positive for right eye pain, increased right eye pain with right eye movement, and decreased vision in right eye. 14 point review of systems reviewed and otherwise negative. Past Medical History: Asthma COPD HTN Hyperlipidemia Anasarca Sick sinus syndrome, s/p pacemaker placement [**10-27**] Ventilator associated PNA (serratia, pseudomonas) Tracheobroncheomalacia Respiratory failure s/p tracheostomy and PEG Shock liver [**2-14**] sepsis and DIC now resolved Severe C.diff colitis now resolved Social History: Patient [**Name (NI) 7979**], has been in USA approximately 12 yrs. However, sister reports that patient recently traveled to [**Country **] for approximately 9 mos, returned in [**2101-4-13**]. Reports he used to work as a shoemaker, after that worked in government at a desk job. Only tobacco exposure is intranasal tobacco (snuff). Denies alcohol or illegal drug use. Family History: Noncontributory Physical Exam: On Admission: T=96.8 BP=114/50 HR=90 RR=16 O2= 97% PHYSICAL EXAM GENERAL: Elderly, primarily Creole-speaking elderly gentleman, appears chronically ill, in NAD HEENT: Normocephalic, atraumatic. Right sclera red and injected; area around the eye surrounded by macular rash. MMM. OP whitish exudate on tongue. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. Heart sounds slightly distant LUNGS: CTA anteriorly ABDOMEN: NABS. Soft, NT, ND. No HSM. PEG tube in place EXTREMITIES: Diffuse 2+ pitting edema. Left arm skin weeping. SKIN: Per nursing, multiple ulcerations including sacral ulcer; ulcer stage IV on ear visualized NEURO: Difficult to assess orientation due to language barrier, also patient can only nod, shake head. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. PSYCH: Listens and responds to questions appropriately, pleasant . On Discharge: VS: 98.3 130/104 96 18 100% on 40%TM GEN: NAD, just awoken comfortable HEENT: EOMI, right eye with conjunctival injection NECK: trach mask in place, closed for voice. PULM: wheezing/rhochi bilaterally CARD: Tachycardic, nl S1, nl S2, no audible murmur ABD: PEG tube in place with dressing, clear dry intact. no tenderness to palpation ABS. EXT: 2+ swelling of feet only SKIN: Sacral decubitus ulcer dressing c/d/i Pertinent Results: Labs on admission: WBC 11.8 N60 L18.5 M6.2 E 14.8 B0.4 Hct 32.4 MCV 89 Plts 456 PT 14.3 PTT 26.8 INR 1.2 Fibrino 329 Retic 2.8 146 109 32 ------------------ Glucose 80 4.3 32 0.7 Ca 8.8 Mg 2.0 Phos 3.2 ALT/AST 24/31 CK 25 AlkP 236 --> 179 Tbili 0.5 Dbili 0.2 Ibili 0.3 alb 2.9 prealbumin low CK MB negative x5 Trop 0.4 --> peak 0.61 iron 45 TIBC 137 Ferritin 988 Transferrin 105 cholest 129 Trigly 130 HDL 33 LDL 70 Cortisol random am 1.8 Cortisol stim test 1.0 --> 5.5 Repeat cortisol stim 2.4 --> 5.8 30 mins --> 6.3 60 mins Aldosterone pending x3 Renin x3 pending ACTH normal x3 during [**Last Name (un) 104**] stim test IgE high 141 Aspergillus negative Labs on discharge: WBC 9.2 Hct 25.0 Plts 392 Coags 13.0/26.9/1.1 139 97 32 -------------- Gluc 102 3.7 35 0.5 Ca 8.8 Mg 1.9 Phos 4.5 Tbili 0.5 IMAGING, siginificant. For full list of images see OMR [**2101-11-11**] EKG Atrial paced rhythm. Slight inferior ST segment elevation. Clinical correlation is suggested. No previous tracing available for comparison. [**2101-11-11**] Echo The left atrium and right atrium are normal in cavity 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. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. Mild mitral regurgitation. Mild pulmonary hypertension. [**11-11**] CXR FINDINGS: No previous images. There is hyperexpansion of the lungs with flattening of the hemidiaphragms, consistent with chronic pulmonary disease. Blunting of the costophrenic angles is consistent with pleural effusions. Tracheostomy tube is in place, as is a dual-channel pacemaker device. No evidence of acute pneumonia or vascular congestion. [**11-13**] EEG IMPRESSION: This telemetry captured no pushbutton activations. Routine sampling and other recordings showed a mildly slow background in wakefulness suggestive of an encephalopathy. Nevertheless, there were no areas of prominent focal slowing. There were no epileptiform features in the recording, whether by routine sampling or by automated detection programs. There were no electrographic seizures. [**11-13**] CT head without contrast IMPRESSION: 1. Severely limited study secondary to streak artifact from metallic EEG leads rendering the study nearly nondiagnostic. No definite acute intracranial process identified. Repeat exam is highly recommended following removal of metallic leads. 2. Diffuse opacification of the sinuses, which may be related to intubation. Infection cannot be excluded. [**2101-11-14**] EEG IMPRESSION: This telemetry captured no pushbutton activations. Routine sampling showed a mild to moderately diffusely encephalopathic background consisting of mostly theta activity with occasional periods of slower delta activity. There were no areas of prominent focal slowing and there were no epileptiform features noted. [**2101-11-14**] CT chest without contrast IMPRESSION: 1)Bilateral pleural effusions which are small to moderate on the right and small on the left side. 2)Diffuse mild bronchial wall thickening and small clusters of centrilobular nodules and peribronchovascular ground-glass opacities suggest recent infection or inflammation possibly due to aspiration. No consolidation or radiological evidence of central airway tracheobronchomalacia. 3)Liver hypodensities are most likely cysts. 4)Small pericardial effusion. [**2101-11-15**] CXR IMPRESSION: Bilateral small pleural effusions with associated bibasilar atelectasis, with interval increase in the right pleural effusion. Please see attached data with endocrine labs. Brief Hospital Course: Brief Hospital Course By Problem 1. Failure to wean from ventilator: Patient has a history of COPD, per family's report he was able to climb one flight of stairs prior to hospitalization, but was using inhalers and home O2 for month prior to [**8-21**] hospitalization. Per notes from OSH, it appears that patient had severe COPD requiring intermittent steroids prior to hospitalization. Was sent from OSH for evaluation of tracheobronchomalacia seen during bronchoscopy. Patient found to have elevated troponins and EKG changes on admission, so IP did not do bronchoscopy on admission because they wanted to wait until he was medically cleared. Patient got a CT chest with protocol to assess TBM on [**11-14**] which showed bilateral effusions, diffuse mild bronchial wall thickening but no TBM, small pericardial effusion. For this reason IP decided not to take the patient for bronchoscopy and stenting. Patient's respiratory status improved slightly over the course of his hospitalization with both a lasix drip for diuresis and steroids. Patient was slowly weaned to trach mask. At discharge the patient was tolerating room air and was talking with passy-muir valve. 2.Elevated troponins: Patient presented with EKG changes and elevated troponins and was seen and evaluated by cardiology. They found no evidence of ACS given that the patient had no chest pain, and felt that most likely the elevation in his troponins was secondary to demand ischemia; they felt there was no indication for cardiac catheterization and that medical management with ASA and beta blockade was most appropriate. Patient had 3 sets of stable troponins. Patient continued to be tachycardic at a rate of 100s-110s, so another troponin was obtained on [**11-14**], continued to be elevated. This was thought to be due to continued demand ischemia in the setting of most likely worse renal function than his creatinine would indicate given that he has very little overall muscle mass. Patient's beta blocker was increased again to maintain his heart rate around 90s-100s. Patient also recieved an Electrophysiology consult because it was thought that his pacemaker was set at a rate of 90 bpm (atrially paced. EP examined the patient and reported that he had normal pacemaker function; also that the atrial pacing rate above lower rate of 60 seen on [**2101-11-11**] EKG is due to rate adaptive function, so therefore no changes made to current settings. 3.Right eye injection/macular rash around orbit: Patient had right eye pain on presentation. Patient was seen by ID & opthomology at OSH, initially on Acyclovir, but optho felt that not consistent with herpetic eye involvement, most likely chronic conjunctival chemosis. Patient was seen by ophthomology for further recommendations here, they felt that eye pain may have been secondary to pilocarpine as this can cause pain. Also felt that injection was likely blepheritis, no chemosis, reccomended polysporin ointment q3hrs and vigamox QID and Lacrilube QID as well as hot compresses QID. There was some concern also that he may have early ulcer formation. Ophthomology recommended outpatient follow up. . 4. Anasarca: Patient presented with upper extremity edema much greater than lower extremity edema. Patient was gently diuresed with Lasix drip initially, and then changed to Lasix 40mg IV BID to allow for gentle diuresis. Diuresis was held several times for episodes of hypotension. However, overall we were able to diurese the patient with a significant improvement in his overall edema with upper extremity edema trace pitting edema on day of discharge. Patient also recieved upper extremity doppler out of concern for possible DVT; however, there was no evidence of DVT. 5.Leukocytosis: Patient was transfered on multiple antibiotics for several infections he experienced during 2 months at OSH. All antibiotics were discontinued in the ICU; from that point he remained afebrile. He had a mild leukocytosis which trended down. Sputum culture grew pseudomonas, thought to be a colonizer. Patient was C.diff negative x2. After transfer to the floor, WBC improved. 6. Eosinophilia: Presented to OSH with eosinophilia. [**Month (only) 116**] be secondary to adrenal insufficiency, may be secondary to parasitic infection given recent travel to [**Country 3587**]; may be secondary to medication. Stool was negative for O&P x3. Patient was found to have adrenal insufficiency; however, eosinophilia only trended down but did not fully improve with addition of prednisone. Therefore, it was thought that medications may have also played a role and therefore all unecassary medications were minimized. . 7. Adrenal Insufficiency: Patient was thought to be adrenally insufficient secondary to inconsistent prednisone dosing. Cortisyntropin stim test 1.0, 5.5 after 1 mcg cosyntropin: positive for adrenal insufficiency. Given prednisone 5 mg PO daily which improved eosinophilia. Also had multiple labs per endocrine including baseline morning ACTH, cortisol, PRA, [**Male First Name (un) **], then give 250mcg Cosyntropin, then the same labs at 30 and 60 mins. Patient requires endocrine follow up as an outpatient. . 8. Anemia: Consistent with anemia of chronic disease per iron studies. . 9. Elevated alk phos: Alk phos elevated at 236 on arrival, trended down to 187 on [**11-13**] and then 179 on [**11-14**]. Should be followed as an outpatient. . 10. Decreased albumin: Patient most likely chronically malnourished given long hospital course. Pt was maintained on nighttime tube feeds, and encouraged to take po intake. . 11. Ulcers: Patient has a stage III decubitus ulcer on sacrum/coccyx with minimal amount of serous drainage, and Stage IV ulcer on left ear helix with very scant amount of serous drainage. Patient also has circular healed pressure ulcer to right post acromium process. All present on arrival to [**Hospital1 18**]. Patient was followed by wound care throughout his stay and received frequent repositioning. He was also seen by nutrition and his nutrition was optimized with tube feedings. . 12. Possible seizure: Patient had a brief episode of altered responsiveness with right sided twitching after pulling the IJ, cleared after several minutes, concern for seizure vs air embolism. EEG was done and showed no evidence of seizure activity. Patient had no other episodes while in the hospital. Medications on Admission: TRANSFER MEDICATIONS : 1) Vigamox *NF* 0.5 % OU QID 10 minutes prior to ointment 2) Artificial Tear Ointment 1 Appl BOTH EYES Q6H Alternate Q3H with Polysporin. 3) Bacitracin/Polymyxin B Sulfate Opht. Oint 1 Appl BOTH EYES Q6H Alternate Q3H with Lacrilube 4) PredniSONE 5 mg PO/NG Q0600 5) Metoprolol Tartrate 25 mg PO/NG Q6H 6) Ranitidine 75 mg PO/NG DAILY 7) Montelukast Sodium 10 mg PO/NG DAILY 8) Simvastatin 40 mg NG DAILY 9) Aspirin 325 mg NG DAILY 10) Multivitamins 1 TAB NG DAILY 11) Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] 12) Albuterol-Ipratropium [**1-14**] PUFF IH Q6H:PRN wheezing 13) Acetaminophen 325-650 mg NG Q6H:PRN fever 14) Heparin 5000 UNIT SC TID Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units units Injection TID (3 times a day). 2. Acetaminophen 160 mg/5 mL Solution Sig: [**1-14**] teaspoons PO Q6H (every 6 hours) as needed for fever or pain. 3. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-14**] Puffs Inhalation Q6H (every 6 hours) as needed for wheezing. 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Ranitidine HCl 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours): hold for SBP < 100 or HR < 60. 11. Prednisone 5 mg Tablet Sig: One (1) Tablet PO qAM. 12. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One (1) Appl Ophthalmic Q6H (every 6 hours). 13. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic Q6H (every 6 hours). 14. Moxifloxacin 0.5 % Drops Sig: 1-2 drops Ophthalmic QID (4 times a day). 15. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 16. Senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day as needed for constipation. Discharge Disposition: Extended Care Facility: Rehab Hospital Of [**Doctor Last Name **] Discharge Diagnosis: primary: respiratory failure due to volume overload secondary: adrenal insufficiency, blepharitis, anasarca, anemia, hypoalbuminemia and malnutrition Discharge Condition: stable, afebrile, O2 sat 98% on 40% TM Discharge Instructions: You were admitted for evaluation of possible softening of the trachea. We did not find that symptoms were consistent with this type of condition per our evaluatioin. During your stay your respiratory status improved and you were making fewer secretions, therefore able to breath comfortably with a trach mask. You were noted to have a condition called adrenal insufficiency for which you were started on a medication called prednisone. Lab work was obtained which needs to be followed up by endocrinology. This is important because if you are to become critically ill, you will require high doses of steroid hormones as your body is unable to as instructed below. During your hospitalization it was also noted that you had redness in your eye which was thought to be due an infection. You were evaluated by opthalmology and you were treated appropriately. It is important that you follow up with an eye doctor early next week. Many of your medications were changed during this hospitalization. Please see attached medication list for new medications. You should continue on your tube feeds atleast until your ulcers heal entirely. After this time you should readress this issue with your doctor. Please call your doctor or go to the emergency room if you develop chest pain, shortness of breath, blood in your stool, fevers >101 or any other concerning symptom. Followup Instructions: Follow with an ophthalmologist early next week. You currently have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 3540**] on [**12-13**], 2pm Endocrinology, [**Location (un) 453**] [**Hospital Ward Name 452**] Rose Bldg, GI [**Location (un) 83825**]. [**Telephone/Fax (1) 7714**]. If you are unable to make this appointment, please call and cancel. However, you will require a follow up appointment with endocrinology to review your lab tests for adrenal insufficiency. Completed by:[**2101-12-2**]

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icd9cm

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49841+49816

Discharge summary

report+report

Admission Date: [**2165-2-7**] Discharge Date: [**2137-2-18**] Date of Birth: [**2120-9-25**] Sex: F Service: TRANSPLANT SURGERY HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 104077**] is a 44 year-old female with a past medical history significant for cadaveric renal transplantation times two who presented to this institution on [**2165-2-7**] with complaints of nausea, vomiting, diarrhea and persistent emesis after eating. The patient's first transplantation failed due to chronic rejection. Her second transplant was complicated by ureteral necrosis requiring ............ DICTATION ENDED [**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. [**MD Number(1) 1346**] Dictated By:[**Last Name (NamePattern1) 26023**] MEDQUIST36 D: [**2165-3-20**] 07:17 T: [**2165-3-21**] 10:19 JOB#: [**Job Number 104139**] Admission Date: [**2165-2-7**] Discharge Date: [**2165-3-29**] Date of Birth: [**2120-9-25**] Sex: F Service: Transplant Surgery HISTORY OF PRESENT ILLNESS: The patient is a 44 year old female with end stage renal disease secondary to diabetes Type 1 since the age of 10 who had undergone living related renal transplantation in [**2151-2-18**]. Subsequently the patient suffered a chronic rejection and required a retransplantation on [**2164-10-24**]. This was a living, unrelated male transplantation. Postoperative course was complicated by Klebsiella urinary tract infection and ureteral necrosis requiring ureteropyeloplasty with stent on [**2164-11-21**], and required a percutaneous nephrostomy tube. Since then the patient has had several admissions due to abdominal pain. In [**2164-12-20**], the patient was admitted and was found to have urine leaking from her wound. Nephrogram at the time showed extravasation of urine from the anastomosis between the transplanted kidney and the ureter. An internal/external stent was placed and the patient continued on her antibiotics. The patient was discharged to a rehabilitation hospital on [**2165-1-29**], only to return to [**Hospital6 256**] on [**2165-2-7**], again complaining of abdominal pain, nausea and vomiting. Staff at the rehabilitation hospital noted that the patient's p.o. intake was poor due to nausea and vomiting and the patient also had several regular bowel movements, mostly soft up to four times a day. On arrival to [**Hospital6 1760**], the patient was her usual state, uncooperative with the medical staff and complaining that she was nauseous. PAST MEDICAL HISTORY: End stage renal disease, secondary to diabetes Type 1, Stage 10, status post living related renal transplantation in [**2150**], complicated by chronic rejection status post a living unrelated renal transplantation on [**2164-10-24**], history of postoperative complication noted as above. Initially, the patient suffered recurrent urinary tract infection with Enterobacter cloacae. In addition, the patient has a history of hypothyroidism, osteopenia, diabetic myonecrosis, a long history of depression, personality disorder, myocardiac and benzodiazepine dependence, eating disorder, diabetes-related neuropathy, nephropathy and retinopathy, neopathic bladder, gastroparesis, hypercholesterolemia, history of vaginal cancer in situ and otitis media. ALLERGIES: Sulfa, Ativan/Haldol. MEDICATIONS ON ADMISSION: Tacrolimus 1 mg p.o. b.i.d., CellCept [**Pager number **] mg b.i.d., Ambien, Protonix, Lopressor 25 mg b.i.d., Meropenem 5 mg b.i.d., Synthroid, insulin sliding scale with Glargine, Reglan 10 mg q. 6 hours. LABORATORY DATA: Laboratory studies on admission revealed white count 7.9, hematocrit 40.6, platelets 351. Chemistries, sodium 140, potassium 4.3, chloride 104, carbon dioxide of 24, BUN 21, creatinine 1.2, glucose 172, calcium was 9.7, magnesium 1.4, phosphorus 1.9, PT 14.1, PTT 29.8 with an INR of 1.3. PHYSICAL EXAMINATION: Physical examination on admission revealed the patient is afebrile at 97.0, heart rate 68, blood pressure 165/80, respiratory rate 18, sating 99% on room air, fingerstick was 177. The patient was alert and oriented times three, noncooperative, thin-appearing woman. No jugulovenous distension, supple neck. Cardiovascular examination, rate and rhythm regular, S1 and S2 without murmurs. Respiratory clear to auscultation bilaterally. Abdomen, soft, nondistended and nontender with nephrostomy tube in place. There is discomfort over the bladder noted. HOSPITAL COURSE: Given the patient's complicated history of transplanted kidney and bladder problems, Neurology was consulted before Foley catheter was placed, and nephrostomy study was planned to investigate the patient's persistent nausea and vomiting the patient underwent a barium esophagogram on [**2165-2-11**]. The esophagus was normal in caliber and although this was a very limited study the majority of the barium passed out of the esophagus into the stomach and proximal small bowel in ten minutes. The patient reported to the floor after this study and was given lunch, and soon thereafter the patient was found by the nursing staff to be lying on the right side in a pool of vomit and blood. The patient was unresponsive, cyanotic, "gasping for air," and incontinent of stool. Vital signs at the time revealed the patient had a heart rate of 80 with blood pressure 160/90, breathing with her mouth with some difficulty, 99% on room air with a blood sugar of 443. Because the patient was unresponsive, the patient was emergently transferred to the Intensive Care Unit where the patient was intubated for airway production and underwent workup of her acute mental status change. The patient's Intensive Care Unit stay from [**2165-2-11**] went to [**2165-3-4**] will be summarized by systems. Central nervous system - The patient was found to be unresponsive on transfer to Intensive Care Unit. She was flaccid and her neck was stiff. Her eyes were deviated to the right side and she had upgoing toes bilaterally. The patient underwent emergent computerized tomography scan of the head without contrast which showed no evidence of acute infarct or hemorrhage, the only findings were microvascular angiopathy consistent with a history of hypertension. The patient also underwent an emergent magnetic resonance of the head and magnetic resonance angiography of the head which showed no infarct or hemorrhages. There was no evidence of mass effect, and the circle of [**Location (un) 431**] and the major tributaries in the head showed no evidence of aneurysmal flow abnormality. The patient was suspected to have had a seizure and was empirically started on Dilantin. The patient also underwent an electroencephalogram which did not show any epileptiforms. When the patient was intubated for airway production the patient needed to be placed on Propofol for sedation. The patient underwent an lumbar puncture to rule out encephalitis and there was no evidence consistent with infectious causes of encephalitis. The patient underwent a repeat magnetic resonance imaging scan of the head on [**2165-2-21**] which showed profound changes in the appearance of the brain with large areas of elevated P2 signal and diffusion restrictions symmetrically within the posterior temporal and occipital lobes. There were also abnormal signs of the left ischial cortex and the subtemporal white matter on the left, all demonstrating extensive enhancement. The distribution of these abnormalities all raise the possibility of Tacrolimus toxicity in this leukoencephalopathy. It should be noted that on retrospect the patient had Tacrolimus level of 14.2 the morning of [**2165-2-11**]. The patient was weaned off Propofol and extubated on [**2-25**] and her neurological status was carefully observed. The patient enjoyed initial improvements, however, it was clear that the patient remained below baseline in terms of her mental status, showing impairment in higher cortical functions. The patient came out of the unit on [**2165-3-4**] and continued to be monitored carefully on the floor with respect to her mental status. The patient underwent a repeat magnetic resonance imaging scan of the brain on [**2165-3-11**] which showed a resolution of the diffusion abnormality seen on the scan from [**2-21**] with the remaining flares. This was interpreted by Radiology to be nonsuggestive of a leukoencephalopathy but more suggestive of encephalitis or infarction. However, Tacrolimus associated toxicity does not always result in irreversible changes on the scans and it is the opinion of the transplant team that the patient suffered Tacrolimus toxicity-related leukoencephalopathy. The patient underwent repeat electroencephalogram on [**3-14**] which showed diffuse swelling consistent with encephalopathy with cortical and subcortical involvement and there were no epileptiforms. Neurology Team had been consulted since the event on [**2165-2-11**], and suggested that since there was no evidence of epilepsy, electroencephalogram as well as the clinical observation, the patient be taken off of Dilantin, however, the patient remained on Keppra on discharge as per recommendations from the Neurology Consult Team. The patient was examined by Neurology Team member on the day of discharge, complaining of decrease in vision, difficulty using call buttons and so on. The patient was found to be awake, alert and oriented to self, and to location but not oriented to date or the year. The patient had fluent speech but frequent difficulty finding words and had phonetic errors. The patient was able to follow simple commands but was unable to follow complex multi-step commands. She showed neglect of left space visually but able to name left and right hands, the patient shows extinguishment on the left side. On examination, the patient showed a left pupil which was briskly reactive, right pupil which was postoperative and nonreactive. The patient demonstrates left hemifield vision loss, left facial droop with upper motor neuron pattern and tongue in the midline. The patient shows a slight left pronator drift with mild left hemithoraces, out of proportion to the over-deconditioning. All of these findings were consistent with the findings on the magnetic resonance imaging scan. Neurology Team recommends repeat magnetic resonance imaging scan in one month. The patient had been followed by Psychiatry prior to this admission and again as the patient became alert and responsive was again followed by Psychiatry Service. As mentioned above, the patient has a long history of depression as well as personality disorder, eating disorder and dependence on medications of narcotic and benzodiazepines. The patient was re-evaluated once the patient came onto the floor. She was thought to be having delirium secondary to possible metabolic abnormalities which were consistent with hyperglycemia and hypoglycemia which she has suffered. The delirium superimposing the underlying diffuse cortical injury, manifested with the patient's becoming very anxious, having some paranoid ideations requiring one to one observation as well as Haldol. The patient improved with Haldol and is improving in her other medical conditions. The patient improved psychiatrically without any suicidal or homicidal ideations or without any apparent paranoia or delusions. On the day of discharge, the patient was re-evaluated by the psychiatry attending who found the patient to be stable for transfer to a rehabilitation hospital. Cardiovascular - The patient was hypotensive initially on admission to the Intensive Care Unit with elevated white count and fever requiring some pressor support. This was consistent with the patient's picture of sepsis and once the patient was treated appropriately, the patient was weaned off of pressors without any difficulty. Otherwise the patient did not have any cardiovascular issues. Respiratory - The patient was intubated upon transfer to the Intensive Care Unit for airway protection and developed bilateral infiltrates on computerized axial tomography scans and worsening chest x-rays. This was consistent with aspiration pneumonitis. The patient eventually developed Aspergillus in the sputum culture as well as Methicillin-resistant Staphylococcus aureus. The patient was treated appropriately and was successfully extubated on [**2165-2-25**]. Since her extubation, the patient did not suffer any further respiratory issues. Gastrointestinal - Upon transfer to the Intensive Care Unit after the patient was stabilized, the patient was given a post pyloric feeding tube and was started on tube feeds. This continued to support her nutritionally, however, became a problem once the patient was extubated and was awake at which time the patient started pulling out her feeding tube after several attempts at trying to keep the feeding tube. The patient was started on total parenteral nutrition and was supported with total parenteral nutrition for some time before she was weaned off. By the time of discharge, the patient had improved significantly enough that she was taking adequate p.o. intake, not requiring any parenteral nutritional support. The patient did not suffer any episodes of gastrointestinal bleeding and otherwise had intact course of stay with respect to the gastrointestinal system. Renal - Upon transfer to the Intensive Care Unit, the patient was found to have decreased urine output. Eventually it was discovered that the patient was suffering from acute tubal necrosis, however, she recovered rather quickly from this episode, and did well. The patient's highest creatinine was 1.8. The patient returned to her baseline creatinine of 1.0 by the time of discharge. Her transplanted kidney, continued on her immunosuppressive therapy, upon transfer to the Intensive Care Unit, she was taking Prograf 1 mg b.i.d. and CellCept [**Pager number **] mg b.i.d. The patient was maintained on Prograf with measurement of her levels to make sure that she was not toxic. When magnetic resonance imaging scan findings suggested that this acute mental status event of [**2-11**], may be due to Tacrolimus toxicity, the patient was taken off of Tacrolimus and instead was started on Rapamycin. The patient initially started off with Rapamycin 1 mg q.d. and was titrated up to her current level of 6 mg q.d., the last Rapamycin level was 7.6 which was therapeutic on [**2165-2-24**]. The patient's CellCept dose was also adjusted and on discharge, the patient was taking CellCept [**Pager number **] mg p.o. q.i.d. All in all, the patient s transplanted kidney remained functioning well with creatinine of 4.0 on discharge. Prior to discharge, the patient was in mild metabolic acidosis, this is most likely due to the ketoacidosis with the patient not being able to tolerate a basal level of Glargine for some time. Prior to discharge, this acidosis was treated with Bicitra and the patient remains on 30 cc three times a day on discharge. This will be monitored by Transplant Center Team and the course of this will be determined during her follow up visits. The patient had a history of ureteral anastomosis necrosis and leak and had a percutaneous nephrostomy on her admission to the Intensive Care Unit. On [**3-5**], the day after she left the Intensive Care Unit the patient tolerated capping of the percutaneous nephrostomy tubing and on [**3-14**], she underwent internalization of the nephroureteral stent. Since then the patient did not have any difficulty and did not have any urinary leak. She had one episode of urinary retention while on the floor and was treated with Foley catheter. On discharge, the patient tolerated a voiding trial and was able to void without any difficulty. Endocrine system - Given the patient's long history of insulin dependent diabetes, the patient was supported on insulin drip during her stay in the Intensive Care Unit and was treated with Humalog and Glargine while she was on the floor. The patient had widely fluctuating serum glucose level and there was some difficulty attaining a therapeutic level of Glargine without becoming severely hypoglycemic. For some time, the patient became hypoglycemic on even a fraction of the usual dose of Glargine that she was used to taking and required staying off of Glargine for some time. As her mental status improved and her p.o. intake improved, the patient was able to tolerate 5 units of Glargine a day by the time of discharge and was covered with a low level of Humalog sliding scale, please see the attached Humalog sliding scale for further details. The patient has a history of hypothyroidism and was treated with Synthroid. On discharge, the patient is on Synthroid 150 mcg p.o. q.d. and her TSH on discharge was 2.6, within normal limits. Infectious disease - The patient underwent lumbar puncture after acute mental status change which did not show any evidence of infectious encephalitis. The patient was found to have Aspergillus in her sputum which correlated with worsening pulmonary status on radiologic examination. The patient also grew out Methicillin-resistant Staphylococcus aureus in her sputum. The patient was treated appropriately with antibiotics and did not have any further infectious disease related issues until the end of [**Month (only) 958**] at which time her central venous line was taken out. This line was used for total parenteral nutrition and that line grew out Methicillin-sensitive resistant Staphylococcus aureus. Prior to discharge, the patient was found to have urinary tract infection with yeast and was started on Fluconazole. Urine fungal culture was pending at the time of discharge and the patient was discharged with Fluconazole for a two week course, requiring ten additional days of treatment at the rehabilitation. The patient also complained of having some loose bowel movements prior to discharge. The patient was empirically started on Flagyl for treatment of Clostridium Difficile. However, none of her stool samples were positive for Clostridium difficile toxin. The patient is to complete a course of Flagyl for eight more days at the rehabilitation hospital. The patient is also prescribed Metamucil to put more bulk in her bowel movement. DISCHARGE STATUS: Discharged to rehabilitation. DISCHARGE CONDITION: Fair, improving. DISCHARGE DIAGNOSIS: 1. End stage renal disease due to diabetes Type 1. 2. Status post living related renal transplant in [**2150**] and followed by chronic rejection. 3. Status post living unrelated renal transplant in [**2164-10-20**]. 4. Tacrolimus-related leukoencephalopathy. 5. Methicillin-resistant Staphylococcus aureus bacteremia as well as Aspergillus pneumonitis. 6. Ureteral anastomotic leak. 7. Diabetes Type 1 with difficult glycemic control. In addition the patient has a diagnosis of hypothyroidism, hypercholesterolemia, osteoporosis, depression, chronic pain syndrome, chronic heel ulcers, personality disorder. DISCHARGE MEDICATIONS: 1. Miconazole nitrate powder, apply to appropriate areas four times a day. 2. Nystatin 100,000 units per cc, 10 cc p.o. q.i.d. 3. Protonix 40 mg p.o. q.d. 4. CellCept [**Pager number **] mg one capsule p.o. q. 6. 5. Synthroid 150 mcg p.o. q.d. 6. Combivent 103-18 mcg for activation one to two puffs inhaled q. 4 hours. 7. Keppra 500 mg p.o. b.i.d. 8. Glargine 5 units subcutaneous at dinnertime and Humalog subcutaneous per sliding scale. 9. Bicitra 350/500 mg per 5 cc, 30 cc p.o. t.i.d. 10. Haldol 1 mg p.o. t.i.d. and Haldol 0.5 mg p.o. t.i.d. prn. It should be noted that Haldol is prescribed only for treatment of her delirium and is not to continue on as permanent psychiatric medication. 11. Flagyl 500 mg p.o. t.i.d. for eight days. 12. Fluconazole 400 mg p.o. q.d. for ten days. 13. Rapamycin 6 mg p.o. q.d. until change by Transplant Center. 14. Metamucil one packet p.o. t.i.d. FOLLOW UP: The patient is to follow up with Dr. [**Last Name (STitle) **] at the Transplant Center on [**2165-4-4**] at 1 PM. The patient needs to have her blood drawn every Monday and Thursday for complete blood count, chem-10, Rapamycin level and results faxed to the Transplant Center, fax #[**Telephone/Fax (1) 697**]. The patient will have follow up with Dr. [**First Name8 (NamePattern2) 1692**] [**Last Name (NamePattern1) 1693**] from Neurology Service in approximately three weeks and is recommended to have a repeat magnetic resonance imaging scan of the brain with contrast in one month. The patient is to continue on Keppra until follow up with Neurology. The patient is to continue follow up with the Psychiatry Department at the rehabilitation hospital and the patient will need a neuropsychiatric evaluation in the future, no sooner than four weeks. [**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. [**MD Number(1) 1346**] Dictated By:[**Last Name (NamePattern1) 10201**] MEDQUIST36 D: [**2165-3-29**] 17:56 T: [**2165-3-29**] 18:55 JOB#: [**Job Number **]

[ "276.5", "996.81", "250.41", "484.6", "584.5", "482.41", "117.3", "250.11", "507.0" ]

icd9cm

[ [ [] ] ]

[ "96.6", "99.15", "88.72", "38.93", "38.91", "96.04", "96.72", "99.04", "33.24", "03.31", "57.94", "59.8" ]

icd9pcs

[ [ [] ] ]

18354, 18372

19034, 19935

18393, 19011

3371, 3887

4485, 18332

19947, 21051

3910, 4467

1053, 2531

2554, 3344

409

105,471

11021

Discharge summary

report

Admission Date: [**2159-9-17**] Discharge Date: [**2159-9-25**] Date of Birth: [**2093-9-29**] Sex: M Service: CARDIAC SURGERY HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This is a 65 year-old gentelman who is status post coronary artery bypass graft in [**2138**] and status post re-do coronary artery bypass graft in [**2149**] who presented with continued angina and had a positive exercise treadmill test. Cardiac catheterization showed an ejection fraction of 70%. The left internal mammary coronary artery to left anterior descending coronary artery graft was patent. Previous vein grafts were occluded. The patient was scheduled for coronary artery bypass graft by Dr. [**Last Name (Prefixes) 411**]. PAST MEDICAL HISTORY: 1. Status post coronary artery bypass graft in [**2138**]. 2. Status post re-do coronary artery bypass graft in [**2149**]. 3. Hypercholesterolemia. 4. Hypoglycemia. 5. Status post ear surgery. ALLERGIES: No known drug allergies. PREOPERATIVE MEDICATIONS: 1. Isordil 120 mg po q day. 2. Prevacid 15 mg po q day. 3. Atenolol 50 mg po q day. 4. Altace 10 mg po q day. 5. Aspirin 325 mg po q day. 6. Lipitor 20 mg po q day. PHYSICAL EXAMINATION: Vital signs, pulse 74 regular rate and rhythm. Blood pressure 128/68. Respiratory rate 22. Room air oxygen saturation 98%. Weight 170 pounds. This is a well appearing 65 year-old male in no acute distress. Skin without lesions or rashes. HEENT is unremarkable. Neck is supple. Chest lungs are clear to auscultation bilaterally. Heart S1 and S2 regular rate and rhythm. Abdomen is soft, nontender, nondistended. Extremities are warm and well profuse with trace pedal edema. LABORATORY DATA: White blood cell count 7.7, hematocrit 42.6, platelet count 159, sodium 143, potassium 4.5, chloride 106, bicarb 27, BUN 13, creatinine 1.1. Electrocardiogram showed normal sinus rhythm with borderline IZCD. HO[**Last Name (STitle) **] COURSE: The patient was taken to the Operating Room by Dr. [**Last Name (Prefixes) **] on [**2159-9-17**] for a coronary artery bypass graft times three, radial artery to obtuse marginal, saphenous vein graft to diagonal and saphenous vein graft to posterior descending coronary artery. The patient was transferred to the Intensive Care Unit in stable condition. The patient was weaned from mechanical ventilation and extubated on postoperative day number one. The patient required neosinephrine and fusion to maintain adequate blood pressure. The patient was also maintained on a nitroglycerin drip for the radial artery graft. Neosinephrine was weaned to off by postoperative day number three. The patient was able to maintain adequate blood pressure. The patient remained in the Intensive Care Unit requiring aggressive pulmonary toilet for what was thought to be an upper respiratory infection or bronchitis. Sputum cultures from [**9-19**] showed only oropharyngeal flora. Chest x-ray showed right lower lobe atelectasis and small left effusion. No identifiable infiltrate. The patient was started on Levaquin for presumed bronchitis. The patient had reported being on antibiotics for bronchitis prior to entering the hospital. The patient was requiring around the clock nebulizer treatments with Albuterol and Atrovent as well as humidified O2 and aggressive chest physical therapy. The patient's coughing and sputum production gradually subsided as O2 requirement decreased and the patient was transferred out of the Intensive Care Unit on postoperative day number four. The patient continued to require aggressive pulmonary toilet with around the clock nebulizer treatments. The patient remained afebrile during this time. The patient's white blood cell count rose to high of 14.7 on postoperative number two, but quickly returned to [**Location 213**] by postoperative number four. By postoperative number seven the patient was weaned from nasal cannula. The patient was ambulating 500 feet and climbing stairs with physical therapy on room air tolerating activity well. On postoperative day number eight the patient was cleared for discharge. CONDITION ON DISCHARGE: Temperature max 98.2. Pulse 80 sinus rhythm with frequent premature atrial contractions. Blood pressure 116/60. Respiratory rate 20. Room air oxygen saturation 98%. Weight 78.4 kilograms. Neurological intact. Cardiovascular regular rate and rhythm without rub or murmur. Respiratory breath sounds clear bilaterally, moderately productive cough for yellow sputum. Gastrointestinal, positive bowel sounds, soft, nontender, nondistended, tolerating a regular diet although with decreased appetite. Sternal incision is clean and dry without drainage or erythema. Sternum is stable. Left radial artery graft harvest site is clean and dry with minimal erythema. No drainage. Saphenectomy sites are clean and dry without erythema. Electrocardiogram on [**2159-9-25**] showed sinus arrhythmia with a right bundle branch block. Chest x-ray from [**2159-9-21**] showed small bilateral effusions with right lower lobe atelectasis. LABORATORY ON DISCHARGE: White blood cell count 10.6, hematocrit 31.5, platelet count 244, sodium 136, potassium 4.8, chloride 99, bicarb 29, BUN 26, creatinine 0.9. The patient is to be discharged to home in stable condition. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass graft second re-do. 2. Status post coronary artery bypass graft [**2138**]. 3. Status post coronary artery bypass graft [**2149**]. 4. Hypercholesterolemia. 5. Hyperglycemia. 6. Status post ear surgery. DISCHARGE MEDICATIONS: 1. Lopressor 25 mg po b.i.d. 2. Lasix 20 mg po q day times seven days. 3. K-Ciel 20 milliequivalents po q day times seven days. 4. Guaifenesin 400 mg po q.i.d. times seven days. 5. Levaquin 500 mg po q day times six days. 6. Aspirin 81 mg po q day. 7. Lipitor 20 mg po q.h.s. 7. Percocet 5/325 one to two tabs po q 4 to 6 hours prn. 8. Ibuprofen 400 mg po q 4 to 6 hours prn. 9. Combivent MDI with spacer two puffs q.i.d. times one week and then prn. 10. Imdur 30 mg po q day times three months. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 3870**] MEDQUIST36 D: [**2159-9-25**] 12:28 T: [**2159-9-25**] 12:33 JOB#: [**Job Number 35688**]

[ "490", "272.0", "414.02", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "36.13" ]

icd9pcs

[ [ [] ] ]

5352, 5600

5624, 6406

1032, 1205

1228, 4143

5127, 5331

764, 1005

4168, 5112

53,432

120,167

34867

Discharge summary

report

Admission Date: [**2112-11-29**] Discharge Date: [**2112-11-30**] Date of Birth: [**2058-2-28**] Sex: F Service: MEDICINE Allergies: Penicillins / Vancomycin / Dilaudid (PF) Attending:[**First Name3 (LF) 3984**] Chief Complaint: Dehydration. Major Surgical or Invasive Procedure: None. History of Present Illness: 54 yo woman with metastatic pancreatic cancer to lungs admitted for dehydration after chemotherapy. She was given cycle #1 FOLFIRINOX [**2112-11-23**] and subsequently developed nausea, diarrhea, and weakness. Yesterday, she also had a nose bleed. She notes dizziness upon standing, severe fatigue and weakness, and dyspnea/orthopnea. She has difficulty speaking and her family notes recent confusion and somnolence. In the clinic, she was given 1000mL Normal Saline and directly admitted to the floor (11R) prior to her labs returning. During transport, a sodium of 113 and K 5.9 returned and ICU transfer was initiated prior to the patient arriving on the floor. Also she has recently taken ibuprofen for pain. ROS: She notes abdominal discomfort. The diarrhea resolved three days ago, but she has not been eating. She denies F/C/S, headache, visual/hearing changes, chest pain, cough, back pain, constipation, hematochezia, hematuria, other urinary symptoms, parasthesias, focal weakness, or rash. All other ROS were negative. ONCOLOGIC HISTORY: pancreatic head mass after p/w obstructive jaundice 08/[**2109**]. Although the overall picture was c/w a pancreatic adenocarcinoma, multiple biopsies were (-). On [**2110-11-27**], Dr. [**Last Name (STitle) 468**] performed an open pancreatic biopsy w/ Roux-en-Y hepaticojejunostomy, open cholecystectomy, & gastrojejunostomy. Pathology confirmed the presence of well-differentiated pancreatic adenocarcinoma. Gemcitabine was started [**2110-12-31**]. She underwent CyberKnife stereotactic radiation therapy [**105-10-10**]. She continued gemcitabine after XRT w/ treatment course c/b by thrombocytopenia requiring doses to be held and dose reduction. She completed 6 cycles of gemcitabine [**2111-6-10**], although C6 D15 was held for thrombocytopenia. She had been observed since completion of chemotherapy. Pt was admitted to [**Hospital1 18**] [**Date range (1) 79826**] due to melena/light-headedness, she underwent EGD w/ variceal banding as well as PRBC transfusion. She stopped coumadin which she was taking for portal vein thrombosis. She had CT torso [**2112-7-27**] notable for mild progression of multiple pulmonary nodules present since [**12/2111**], concerning for metastatic disease, along with 2 liver lesions also concerning for metastatic disease. She then underwent Liver MRI [**2112-8-8**], and the lesions corresponded to areas of fatty infiltration. Her CA19-9 has been slowly rising during this time. She was seen in follow-up [**2112-8-29**] and discussion about possible need to re-initiate chemotherapy was discussed. She had repeat CT torso [**2112-10-28**] and this showed pulmonary nodules had increased slightly in size. She was seen in follow-up [**2112-10-31**] and was noted to have ongoing hyponatremia despite having stopped her furosemide three days prior. She was instructed to stop her spironolactone as well. Cycle #1 FOLFIRINOX was administered [**2112-11-23**]. Past Medical History: - Pancreatic cancer, s/p Whipple, chemotherapy, CyberKnife. - Portal vein thrombosis - Psoriasis - Severe osteoporosis - Hip fracture after a fall in [**2109-3-10**]. - Breast surgery (removal of mass, negative cytology) [**2103**] - Tubal Ligation [**2091**] - ERCP - EUS Lap staging procedure [**9-16**] - GERD Social History: She lives in [**Location **], [**State 350**] with her husband. She has 1 son who lives in [**Name (NI) 8449**] and 1 daughter who lives in [**Name (NI) 8117**], [**Name (NI) 3844**]. She continues to work as a paralegal for a medical device company. She has approximately [**12-12**] alcoholic beverages per week, does not smoke, and denies illicit drug use. Family History: Her mother had rheumatoid arthritis and died last year of vascular dementia at the age of 82. Her father is 86 years old and has colon cancer with liver metastases and has suffered from cardiovascular disease. She has a sister who is 64 years old and has rheumatoid arthritis. Physical Exam: ADMISSION EXAM: VS: T - afebrile. GEN: A&O, difficulty speaking, ill appearing, cachetic. HEENT: Scleral icterus, EOM intact, dry MM. Neck: Supple, no thyromegaly. Lymph nodes: No cervical, supraclavicular or axillary LAD. CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops. RESP: Good air movement bilaterally, no rhonchi or wheezing. ABD: Soft, moderately tender, distended, no inguinal LAD. EXTR: No edema or calf tenderness. No clubbing. DERM: No rash. Neuro: Difficulty speaking, very weak (generalized), no other focal deficits. PSYCH: Appropriate and calm. Pertinent Results: ADMISSION LABS: [**2112-11-29**] 03:40PM BLOOD WBC-PND RBC-4.12*# Hgb-11.5* Hct-34.9* MCV-85 MCH-27.9 MCHC-33.0 RDW-14.7 Plt Ct-PND [**2112-11-29**] 03:40PM BLOOD UreaN-67* Creat-1.8*# Na-113* K-5.9* Cl-84* HCO3-21* AnGap-14 [**2112-11-29**] 03:40PM BLOOD Albumin-PND Calcium-10.8* Phos-5.1*# Mg-2.2 [**2112-11-29**] 03:40PM BLOOD ALT-34 AST-21 LD(LDH)-PND AlkPhos-127* TotBili-6.1* Brief Hospital Course: Assessment/Plan: A 54 yo woman with metastatic pancreatic cancer admitted for dehydration after FOLFIRINOX cycle #1 chemotherapy. Ms. [**Known lastname 79825**] was severely dehydrated as evidenced by the severe hyponatremia, severe hyperkalemia, and acute renal failure. She received intravenous fluid boluses and started on continuous infusion of normal saline for low blood pressure and low urine output. Despite this, her blood pressure continued to fall and she required increasing doses of Levophed to maintain perfusion. When her blood pressure continued to fall, vasopressin was added. An echocardiogram was done that showed global systolic dysfunction consistent with toxic/metabolic insult. The patient was treated broadly from the time of admission for infection with intravenous vancomycin, cefepime, ciprofloxacin, and metronidazole. Blood cultures from admission came back positive for gram positive cocci in pairs and chains on the first hospital day. When the patient's blood pressure and oxygen saturations continued to decline, despite aggressive volume resuscitation, antibiotics, and non-invasive positive-pressure ventilation, a discussion was held with family members. The decision was made not to escalate care, as patient had clearly expressed prior to this admission that she did not want to be intubated or resuscitated. She passed away on the first hospital day from multiorgan system failure complicating severe septic shock. Medications on Admission: Lidocaine patch 5% 12hr on prn Lorazepam 1-1.5mg PO q4-6hr prn Nadolol 10mg PO daily Ondansetron 8mg q8hr prn Oxycodone 5-10mg PO q4-6hr prn Prochlorperazine 10mg q6hr prn Discharge Medications: PATIENT EXPIRED Discharge Disposition: Expired Discharge Diagnosis: PATIENT EXPRIED PRIMARY DIAGNOSIS: Multiorgan failure from overwhelming sepsis. SECONDARY DIAGNOSIS: Pancreatic Cancer. Discharge Condition: PATIENT EXPIRED Discharge Instructions: PATIENT EXPIRED Followup Instructions: PATIENT EXPIRED [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**] Completed by:[**2112-11-30**]

[ "276.7", "038.9", "275.42", "V10.09", "782.4", "276.1", "V49.86", "572.8", "288.00", "197.7", "V12.51", "197.0", "518.81", "530.81", "584.9", "733.00", "276.2", "284.1", "995.92" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7074, 7083

5354, 6812

316, 323

7249, 7266

4946, 4946

7330, 7503

4058, 4338

7034, 7051

7104, 7121

6838, 7011

7290, 7307

4353, 4927

264, 278

351, 3326

7207, 7228

4962, 5331

7140, 7186

3348, 3662

3678, 4042

56,867

100,496

52376+59423

Discharge summary

report+addendum

Admission Date: [**2142-11-19**] Discharge Date: [**2142-12-2**] Date of Birth: [**2084-9-17**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 4282**] Chief Complaint: fever, fatigue Major Surgical or Invasive Procedure: none History of Present Illness: 58 year-old lifetime nonsmoking female with metastatic lung adenocarcinoma with widespread liver and spine metastases, EGFR mutation positive, s/p radiation of T7-S1 finishing [**2142-10-10**], on erlotinib 150 mg daily started [**2142-10-12**], who presented to clinic today with fever, nausea and fatigue x 1 day. . Over the past 24 hours she has felt increasingly fatigued. This morning she had nausea and some diaphoresis. She was seen in pain clinic where she was noted to have a temperature of 102 and she was sent to [**Hospital 478**] clinic where an emergency chest film shows a probable LLL pneumonia despite the absence of cough or other respiratory symptoms. She has no urinary symptoms but is quite bothered by her "clamshell" back brace. Past Medical History: ONCOLOGIC HISTORY: # metastatic lung cancer: - [**6-/2142**]: experienced laryngitis and 2 episodes of hemoptysis - [**7-/2142**]: diagnosed with right shoulder tendinitis - [**8-/2142**]: had lower back pain, decreased appetite and early satiety. CT at [**Hospital **] hospital on [**2142-9-14**] revealed mass lesion in the posterior inferior left hilum, involving the superior segment of the left lower lobe. Multiple bony mets were found in the spine and multiple liver mets noted. Liver biopsy on [**2142-9-18**] confirmed adenocarcinoma that is TTF+. MRI of the brain showed no intracranial mets but a right parietal bony met with soft tissue mass. Being followed by Dr. [**Last Name (STitle) **] [**Name (STitle) **] at [**Location (un) **] Oncology with a plan for chemotherapy. OTHER MEDICAL HISTORY: OCD osteopenia depression and anxiety Social History: SOCIAL HISTORY: Never smokes. No alcohol use. Works in the food service. Married with 2 children. Family History: FAMILY HISTORY: no family history of cancer Physical Exam: GENERAL: No acute distress, pleasant HEENT: sclera anicteric, mucous membranes moist. Oropharynx clear without lesion. HEART: regular rhythm and rate without murmur, rub, or gallop LUNGS: clear to auscultation bilaterally ABDOMEN: soft, nontender, nondistended EXTREMITIES: warm, well perfused without clubbing, cyanosis, or edema NEURO: cranial nerves II-XII grossly intact. Strength 5/5 x4 extremities, sensation intact to light touch x4 extremities Pertinent Results: [**2142-11-19**] 10:39PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005 [**2142-11-19**] 10:39PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2142-11-19**] 06:55PM GLUCOSE-134* UREA N-9 CREAT-0.2* SODIUM-136 POTASSIUM-3.5 CHLORIDE-102 TOTAL CO2-27 ANION GAP-11 [**2142-11-19**] 06:55PM estGFR-Using this [**2142-11-19**] 06:55PM ALT(SGPT)-55* AST(SGOT)-48* ALK PHOS-192* TOT BILI-0.4 [**2142-11-19**] 06:55PM CK-MB-2 cTropnT-<0.01 [**2142-11-19**] 06:55PM CALCIUM-7.9* PHOSPHATE-2.4* MAGNESIUM-2.0 [**2142-11-19**] 06:55PM WBC-3.4* RBC-3.19* HGB-9.6* HCT-29.0* MCV-91 MCH-30.0 MCHC-33.1 RDW-20.0* [**2142-11-19**] 06:55PM PLT COUNT-203 [**2142-11-19**] 01:39PM WBC-4.7 RBC-3.73* HGB-11.0* HCT-34.1* MCV-91 MCH-29.5 MCHC-32.3 RDW-19.9* [**2142-11-19**] 01:39PM NEUTS-93.7* LYMPHS-2.8* MONOS-3.1 EOS-0.3 BASOS-0.1 [**2142-11-19**] 01:39PM PLT COUNT-220 Brief Hospital Course: 58 year-old lifetime nonsmoking female with metastatic lung adenocarcinoma with widespread liver and spine metastases, EGFR mutation positive, s/p radiation of T7-S1 finishing [**2142-10-10**], on erlotinib 150 mg daily started [**2142-10-12**], admitted with pneumonia presumed to be PCP s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 153**] stay [**Date range (1) 22045**]. . #PNA, presumed PCP: [**Name10 (NameIs) **] with fever/new oxygen requirement with CTA negative for PE, negative blood/urine cx, and normal cardiac enzymes/ekg. CXR concerning for pneumonia. Bglucan elevated. Bronchoscopy deferred. Unable to obtain sputum sample despite multiple attempts. Developed hypoxic respiratory failure [**11-23**] and transferred to [**Hospital Unit Name 153**]. Improved on bactrim treatment and transferred back to OMED [**11-26**]. Will continue bactrim DS 2 tabs TID for total 21 days. Continue prednisone taper. histo antigen pending upon discharge. Primary oncologist notified and will f/u regarding need for PCP [**Name Initial (PRE) 1102**]. . #Diarrhea: developed diarrea [**11-23**] with placement of rectal tube, removed [**11-27**]. C diff negative x 2. Resolved prior to discharge . #Back Brace: pt complaing of discomfort with brace. re-evaluated by orthopedic spine team who concluded that patient needs to continue to wear the back brace. Medications on Admission: CITALOPRAM - (Prescribed by Other Provider) - 20 mg Tablet - 3 Tablet(s) by mouth DAILY (Daily) DEXAMETHASONE - (Prescribed by Other Provider) - 4 mg Tablet - 1 Tablet(s) by mouth twice a day for 5 days then [**11-12**] begin 4mg daily for 5 days, then 2mg daily for 5 days, then 2 mg every other day until [**2142-11-29**] then stop. ERLOTINIB [TARCEVA] - 150 mg Tablet - 1 Tablet(s) by mouth once a day GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth three times a day HYDROMORPHONE [DILAUDID] - 2 mg Tablet - 1 Tablet(s) by mouth q 3-4 hrs as needed for pain not to exceed 6 per day HYDROMORPHONE [DILAUDID] - 4 mg Tablet - [**1-20**] Tablet(s) by mouth q 3-4 hrs as needed for pain no more than 12 tabs per day LACTULOSE - (Prescribed by Other Provider) - 10 gram/15 mL Solution - 30 ml by mouth daily as needed for constipation LIDOCAINE - (Prescribed by Other Provider) - 5 % (700 mg/patch) Adhesive Patch, Medicated - 1 patch to affected area 12 hours daily LORAZEPAM - (Prescribed by Other Provider) - 0.5 mg Tablet - 1 Tablet(s) by mouth every six (6) hours as needed for anxiety MORPHINE - 100 mg Tablet Sustained Release - 1 Tablet(s) by mouth three times a day POLYETHYLENE GLYCOL 3350 - (Prescribed by Other Provider) - 17 gram/dose Powder - 1 Powder(s) by mouth DAILY (Daily) as needed for constipation RANITIDINE HCL - (Prescribed by Other Provider) - 150 mg Tablet - 1 Tablet(s) by mouth twice a day Medications - OTC DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg Capsule - 1 Capsule(s) by mouth twice a day SENNA - (Prescribed by Other Provider) - 8.6 mg Tablet - 2 Tablet(s) by mouth twice a day Discharge Medications: 1. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for PCP [**Name Initial (PRE) **] 15 days. Disp:*84 Tablet(s)* Refills:*0* 2. prednisone 20 mg Tablet Sig: [**1-20**] as directed below Tablets PO DAILY (Daily) for 15 days: Please take 2 tablets (40 mg) daily until [**12-3**]. Then take 1 tablet (20 mg) daily until [**12-14**]. Disp:*20 Tablet(s)* Refills:*0* 3. citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 4. erlotinib 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 6. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**4-24**] hours as needed for pain: Do not combine with alcohol. please do not drive while taking this medication as it may make you sleepy. Disp:*30 Tablet(s)* Refills:*0* 7. lactulose 10 gram/15 mL Solution Sig: Thirty (30) ml PO once a day as needed for constipation. 8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 1 patch to affected area 12 hours daily . 9. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 10. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) powder PO DAILY (Daily) as needed for constipation. 11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. 12. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. Disp:*20 Tablet, Rapid Dissolve(s)* Refills:*2* 13. MS Contin 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day: This medication may make you sleepy. Please do not drive while taking narcotic medications. Disp:*60 Tablet Sustained Release(s)* Refills:*2* 14. MS Contin 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day: This medication may make you sleepy. Please do not drive while taking narcotic medications. Disp:*60 Tablet Sustained Release(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: pneumonia, presumed PCP Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to [**Hospital1 **] for fever and fatigue. You were found to have pneumonia, likely due to an infection from pneumocystis (PCP). You developed difficulty breathing requiring a stay in the ICU from [**11-23**] to [**11-26**]. Your breathing improved as you were treated for PCP with antibiotics and steroids. You should discuss with your oncologist whether or not you should continue with your steroids after you finish the prednisone and if you continue with the prednisone or dexamethasone you should take bactrim prophylaxis for PCP which is usually one tablet three times per week. Please make the following changes to your medications: START Bactrim DS 2 tabs three times daily for a total of 21 days until [**12-14**] START Prednisone 40 mg daily until [**12-3**], then 20 mg daily until [**12-14**] STOP Dexamethasone Please STOP your current pain regimen of morphine and dilaudid. Please START the following regimen: MS Contin 45 mg twice a day (take one 30 mg tablet and one 15 mg tablet for a total of 45 mg) Dilaudid 2 mg every 4-6 hrs as needed for pain. Please follow up with your oncologist and in pain clinic. Please continue all other home medications Followup Instructions: The following appointments have been made for you: Department: Primary Care Name: Dr. [**First Name (STitle) 1154**] MAZZONI When: Tuesday [**2142-12-11**] at 10:10 AM Location: [**Location (un) 2274**]-[**Location (un) **] Address: 2 [**Location (un) **] CENTER DR, [**Location (un) **],[**Numeric Identifier 29936**] Phone: [**Telephone/Fax (1) 79695**] Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2142-12-6**] at 9:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: THURSDAY [**2142-12-6**] at 9:30 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6575**], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PAIN MANAGEMENT CENTER When: MONDAY [**2142-12-17**] at 11:00 AM With: [**First Name4 (NamePattern1) 3049**] [**Last Name (NamePattern1) 8155**], NP [**Telephone/Fax (1) 1652**] Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Parking on Site Name: [**Known lastname 16727**],[**Known firstname 1683**] T. Unit No: [**Numeric Identifier 17699**] Admission Date: [**2142-11-19**] Discharge Date: [**2142-12-2**] Date of Birth: [**2084-9-17**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 12206**] Addendum: **Seizure** . Pt had seizure when IV was being pulled out for discharge [**11-30**]. Husband witnessed event and said patient became rigid with eyes deviated up. Pt breathing with pulse. Self-resolved without IM ativan. Lasted approximately 1 minute. No prior history of seizure. . STAT CT head was obtained and showed no acute process or brain metastases (other than known mets to parietal bone). Neurology was consulted. MRI head was obtained to further assess for intracranial process with negative wet read. Electrolytes were obtained and revealed Na 123 post-seizure although recheck in AM was 131. . Discussed electrolyte changes with neurology who believe the drop in Na is unlikely to be related to seizure. Unusual for Na to drop and increase so rapidly leading to question of erroneous lab error. Urine lytes showed osm 683 and Na 71. SIADH may be possible although patient seemed hypovolemic on exam and was given IVF overnight. She was free water restricted while encouraging intake of gatorade, ensure, etc. . Per neurology recommendations, an LP was obtained with gram stain/cxs, cytology, HSV PCR. Cell counts from LP unconcerning for infection. No need to start prophylactic acyclovir per neurology. Neurology would like patient to have EEG (can be done as outpatient) and f/u with neurology in clinic. . Patient was observed [**Date range (1) 17700**] overnight with no further evidence of seizure activity. Discharge Disposition: Home With Service Facility: [**Hospital 136**] Homecare [**Doctor First Name **] [**Last Name (NamePattern5) 12216**] MD [**MD Number(2) 12217**] Completed by:[**2142-12-1**]

[ "338.3", "162.8", "787.91", "276.1", "518.81", "V58.65", "707.03", "198.5", "136.3", "300.3", "285.22", "300.4", "733.90", "197.7", "780.39", "733.13", "707.09", "707.23" ]

icd9cm

[ [ [] ] ]

[ "38.93", "03.31", "99.25" ]

icd9pcs

[ [ [] ] ]

13421, 13627

3617, 5003

309, 315

8893, 8893

2638, 3594

10260, 13398

2121, 2150

6695, 8745

8847, 8872

5029, 6672

9043, 9677

2165, 2619

9706, 10237

254, 271

343, 1097

8908, 9019

1119, 1973

2005, 2089

31,277

131,948

18188

Discharge summary

report

Admission Date: [**2119-10-5**] Discharge Date: [**2119-10-5**] Date of Birth: [**2075-12-21**] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 2817**] Chief Complaint: agitation Major Surgical or Invasive Procedure: none History of Present Illness: 43 yo male brought in to ED after arrest for [**Name (NI) **] (pt was reportedly preparing to drive, police observed his behvaior and became concenced, pt refused breathalizer and was arrested) and reportedly found to be carrying a knife. At the time of arrest he had endorsed methamphetamine and cocaine use. While in police custody, the pt was noted to be beating his head against the wall of his cell to attract attention. Reportedly no LOC; the pt endorsed HA but denied neck, chest, abd and back pain on arrival to ED. In the ED, initial vitals were 98.2, 75, 16, 124/73 and 98% RA. The pt was noted to be persistently agitated despite receiving multiple rounds of Haldol and Ativan, then 10mg IV valium. As his agitation could not be controlled, he was electively intubated so that an urgent head CT could be performed. ROS: Could not be obtained as pt is intubated and sedated. Past Medical History: h/o self injurious behavior MVA in [**2106**], occured while intoxicated, thrown from car mugging with question head injury in [**2113**] Hep C probable ADD herniated L4/L5 discs s/p SDH evacuation in [**2113**] genital herpes depression Social History: Known drug abuse. Family History: Reportedly no FH of psychiatric disease. Physical Exam: Gen: Well appearing adult male, no acute distress. HEENT: PERRL, EOMI. MMM. Conjunctiva well pigmented. Neck: Supple, without adenopathy or JVD. No tenderness with palpation. Chest: CTAB anterior and posterior. Cor: Normal S1, S2. RRR. No murmurs appreciated. Abdomen: Soft, non-tender and non-distended. +BS, no HSM. Extremity: Warm, without edema. 2+ DP pulses bilat. Neuro: Alert and oriented. CN 2-12 intact. Motor strength intact in all extremities. Sensation intact grossly. Pertinent Results: WBC-12.8* RBC-4.99 HGB-13.9* HCT-41.3 MCV-83 MCH-27.9 MCHC-33.7 RDW-14.6 NEUTS-73.4* LYMPHS-21.1 MONOS-4.0 EOS-1.2 BASOS-0.3 ASA-NEG ETHANOL-88* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG GLUCOSE-104 UREA N-7 CREAT-0.7 SODIUM-138 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-25 ANION GAP-16 . ECG: SR at 80. Normal axis and intervals. Peaked p waves c/w with possible RAA. Poor baseline but no significant ST-T changes. Comparison made with tracing from [**1-21**]; no significant changes noted. . CXR: No acute cardiopulmonary process. ET tube ~9cm from carina. . Head CT: No acute intracranial abnormalities. Mucosal thickening of the paranasal sinuses. Brief Hospital Course: 43 yo male with h/o ADD, probable past TBI, substance abuse admitted for agitation in setting of acute methamphetamine and cocaine intoxication. . #Acute intoxication: Pt with urine tox positive for cocaine, serum tox positive for EtOH and admission of recent methamphetamine use. At admission, there was a concern for possible self-inflicted head trauma while in police custody. The pt was intubated in the ED so that adequet sedation for a head CT could be achieved. This was performed and was negative for acute findings. The pt was admitted to the ICU for monitoring and was quickly extubated. He awoke shortly thereafter and reported feeling well without any specific complaints. He denied trying to harm himself at any point in the days prior to admission. After several hours of monitoring without further findings, the pt was discharged to the custody of the police. Medications on Admission: Valium 10 mg TID PRN acyclovir 400mg PRN herpes outbreaks Concerta 54 mg extended release daily Albuterol 2 puffs q6 PRN Fluoxetin 40mg daily MS [**Last Name (Titles) 1367**] 30mg PO bid oxycodone 5 mg q6 PRN trazaone 50-100 qhs PRN Viagra Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing, SOB. 2. Fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day. 3. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 4. Valium 10 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety. 5. CONCERTA 54 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. Discharge Disposition: Home with Service Discharge Diagnosis: polysubstance intoxication Discharge Condition: Improved; vitals stable, ambulating well, mental status cleared. Discharge Instructions: -You were admitted after being intoxicated with multiple substances and intentionally hitting your head while in police custody. We evaluated you and do not believe you have sustained any injuries. While in the hospital, a breathing tube was placed in your throat so you could be sedated for a scan of your head. This tube has now been removed and you are breathing well on your own. The toxic substances you ingested appear to have cleared from your body. You are now being discharged to the custody of the police. -It is important that you continue to take your medications as directed. No changes were made to your medications on this admission. -Contact your doctor or come to the Emergency Room should your symptoms return. Also seek medical attention if you develop any new fever, chills, trouble breathing, chest pain, nausea, vomiting or unusual stools. Followup Instructions: Please contact your PCP for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 702**] appointment within the next six weeks.

[ "311", "314.00", "305.70", "722.10", "V02.62", "305.60", "305.00" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

4533, 4552

2893, 3769

307, 314

4623, 4690

2101, 2777

5600, 5736

1542, 1585

4059, 4510

4573, 4602

3795, 4036

4714, 5577

1600, 2082

258, 269

342, 1230

2786, 2870

1252, 1491

1507, 1526

60,881

126,547

36533

Discharge summary

report

Admission Date: [**2101-6-18**] Discharge Date: [**2101-6-25**] Date of Birth: [**2062-4-27**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2569**] Chief Complaint: Headache, nausea Major Surgical or Invasive Procedure: None History of Present Illness: 39 yo W with no significant PMH other than occasional headaches (once every 2 months) who woke-up 2 days ago with HA on the left occipital area, accompanied by nausea, that was mostly throbbing and when worsened when she stood-up. She occasionally has headaches, similar in character as this one (last one was last [**Holiday **]). On that day she took aspirin, alternating with ibuprofen with some relief. She went to work and felt somewhat lightheaded. Back home at night she vomited throughout the night. The following day she was taken to [**Hospital 745**] Hospital where a head CT was negative. She had an LP there where the opening preassure was reportedly 45 and closing preassure 25 (WBC 2 normal protein); a CTA head showed superior sagital sinus thrombosis. She received a bolus of heparin of 500U and was continued on 1000U/hour and she was transferred here for further management. ROS: The patient denied visual difficulty, hearing changes, difficulty speaking, language problems, memory difficulty, difficulty swallowing, vertigo, unsteady gait, paresthesias, sensory loss, weakness, or falls. The patient denied fever, wt loss, appetite changes, cp, palpitations, DOE, sob, cough, wheeze, nausea, vomiting, diarrhea, constipation, abd pain, fecal incont, dysuria, nocturia, urinary incontinence, muscle or joint pain, hot/cold intolerance, polyuria, polydipsia, easy bruising, depression, anxiety, stress, or psychotic sx. Past Medical History: -occasional headaches (throbbing, intense, nausea but no photophobia) every 2 months Social History: She works as a consultant for [**University/College **] Pilgrim, no history of tobbaco use or alcohol. She is married and she has one healthy child at the age of 2.5 yo Family History: No history of thrombosis or coagulopathy in the family Physical Exam: T-99.6 BP-180/98 HR-80 RR-16 97O2Sat 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: 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 alert after stimuli, [**Name (NI) 18247**] otherwise; she follows commands after repeated stimuli. Oriented to person, place, and date. Attentive, says [**Doctor Last Name 1841**] backwards. Speech is fluent with normal comprehension and repetition; naming intact. No dysarthria. [**Location (un) **] and writing intact. Registers [**4-19**], recalls [**3-22**] in 5 minutes. No right left confusion. No evidence of apraxia or neglect. Cranial Nerves: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Visual fields are full to confrontation. Normal fundi. Extraocular movements intact bilaterally, no nystagmus. Sensation intact V1-V3. Facial movement symmetric. Hearing intact to finger rub bilaterally. Palate elevation symmetrical. Sternocleidomastoid and trapezius normal bilaterally. Tongue midline, movements intact Motor: Normal bulk bilaterally. Tone normal. No observed myoclonus or tremor No pronator drift [**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 Sensation: Intact to light touch, pinprick, vibration and proprioception throughout. No extinction to DSS Reflexes: B T Br Pa Pl Right 1 1 1 1 1 Left 1 1 1 1 1 Toes were downgoing bilaterally. Coordination: finger-nose-finger normal, heel to shin normal, RAMs normal. Gait: Narrow based, steady. Romberg: Negative Pertinent Results: LABS: [**2101-6-18**] 01:15AM BLOOD WBC-13.5* RBC-4.31 Hgb-12.4 Hct-36.3 MCV-84 MCH-28.9 MCHC-34.3 RDW-13.3 Plt Ct-327 [**2101-6-25**] 06:25AM BLOOD WBC-9.3 RBC-4.30 Hgb-12.7 Hct-37.4 MCV-87 MCH-29.6 MCHC-34.0 RDW-13.9 Plt Ct-486* [**2101-6-18**] 01:15AM BLOOD Neuts-84.5* Lymphs-11.8* Monos-3.5 Eos-0 Baso-0.2 [**2101-6-18**] 01:15AM BLOOD PT-15.4* PTT-68.7* INR(PT)-1.4* [**2101-6-25**] 06:25AM BLOOD PT-29.6* PTT-39.6* INR(PT)-3.0* [**2101-6-18**] 01:15AM BLOOD Glucose-141* UreaN-9 Creat-0.7 Na-141 K-3.3 Cl-107 HCO3-22 AnGap-15 [**2101-6-25**] 06:25AM BLOOD Glucose-102 UreaN-13 Creat-0.8 Na-136 K-4.2 Cl-106 HCO3-19* AnGap-15 [**2101-6-18**] 01:15AM BLOOD CK(CPK)-64 [**2101-6-18**] 01:15AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2101-6-18**] 01:15AM BLOOD Calcium-8.7 Phos-2.3* Mg-2.2 [**2101-6-25**] 06:25AM BLOOD Calcium-9.1 Phos-4.0 Mg-2.4 [**2101-6-22**] 07:52PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.009 [**2101-6-22**] 07:52PM URINE Blood-LG Nitrite-POS Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-MOD [**2101-6-22**] 07:52PM URINE RBC-[**7-27**]* WBC-21-50* Bacteri-MOD Yeast-NONE Epi-2 MICRO: Urine Cx ([**6-22**]): URINE CULTURE (Final [**2101-6-26**]): Culture workup discontinued. Further incubation showed contamination with mixed skin/genital flora. Clinical significance of isolate(s) uncertain. Interpret with caution. ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 16 I CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- =>128 R PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S IMAGING: ECG ([**6-18**]): Sinus rhythm at a rate of 73. Modest non-specific anterior ST-T wave changes. Voltage criteria for left ventricular hypertrophy. No previous tracing available for comparison. MRI/MRA/MRV Brain ([**6-18**]): FINDINGS: The conventional images show absence of the usual flow signal within the superior sagittal sinus, extending to the torcular, with high T1 signal, consistent with methemoglobin, within the superior sagittal sinus throughout its course. There is no sign for the presence of an intracranial mass, hydrocephalus, or shift of normally midline structures. Diffusion and susceptibility weighted images of the brain appear within normal limits. There does not appear to be a "blooming" effect to suggest that there is acute clot within the superior sagittal sinus. Moreover, as noted above, the sagittal T1 weighted scans disclose elevated T1 signal throughout the course of the superior sagittal sinus, suggesting that the thrombosis likely has components of the methemoglobin, which is seen in a subacute thrombosis. The surrounding osseous and extracranial soft tissues do not appear to reveal additional abnormalities. The MR venogram appears to confirm the absence of flow within the superior sagittal sinus, as well as both transverse sinuses. Multiple, superficially located vessels, presumably represent collateral venous flow. The source images appear to show visible flow within the internal cerebral veins, vein of [**Male First Name (un) 2096**], and straight sinus, though the projected images do not reveal this latter flow as being as brisk as is normally seen. CONCLUSION: Findings appear consistent with extensive venous sinus thrombosis as noted above. CT Head ([**6-19**]): IMPRESSION: No acute intracranial process, specifically there is no evidence of intracranial hemorrhage given anticoagulation in the setting of superior sagittal sinus thrombosis. ADDENDUM AT ATTENDING REVIEW: Both the prior [**2101-6-17**] and present study clearly show hyperdense superior sagittal and transverse sinuses, consistent with the MRV-demonstrated thrombosis. EEG ([**6-22**]): IMPRESSION: This is a mildly abnormal 24-hour EEG telemetry due to bursts of bifrontal rhythmic delta activity. This indicates an abnormality of deeper midline structures. Such a finding can be seen with increased intracranial pressure, encephalopathy, hydrocephalus, or mid-brain dysfunction. There were no epileptiform features noted. Brief Hospital Course: The patient is a 39 year old woman with a history of occasional headaches and oral contraceptive use who presented with a 2 day history of left occipital throbbing headache and nausea, and found to have superior sagittal and bilateral transverse sinus thrombosis. She intially presented to an OSH, where she had an LP which showed opening preassure 45 and closing pressure 25 (no report on WBC or protein) and a CTA head showed superior sagital thrombosis. She received a bolus of heparin of 500U, continued on 1000U/hour, and transferred to [**Hospital1 18**] for further evaluation. She was initially admitted to the NeuroICU. MRI/MRA/MRV on admission showed absence of flow within the superior sagittal sinus, as well as both transverse sinuses. She was continued on a heparing gtt for bridge to Coumadin 4 mg daily. Hypercoaguable work up which was obtained at NWH prior to transfer was normal: homocysteine 6.9, antithrombin 3: 90, prothrombin negative, Factor V Leiden 2.5, protein C 120, protein S 91, Cardiolipin Abs: IgG 6.6, IgM 11.4, lupus AC screen negative. Her INR was 3.0 at the time of discharge. She was started on Acetazolamide 250 mg q8 hours, given that it may help reduce surrounding edema from her venous thrombosis. She was initially started on Lisinopril for hypertension during this admission, but this was discontinued at the time of discharge as her blood pressure improved as her pain was better controlled. Her OCP was discontinued, and she was instructed to follow up with her PCP regarding and alternate means of contraception. Her headache was controlled with Oxycontin 10 mg [**Hospital1 **], and Percocet prn breakthrough pain. She should be tapered off her pain medications as an outpatient. She was instructed to follow up with lab draws for INR at her [**Hospital 6435**] [**Hospital3 **] as an outpatient. She was scheduled to follow up with Dr. [**First Name (STitle) **] in Neurology as an outpatient. During the admission, the patient complained of episodes of vertical bobbing eye movements lasting 2 hours and usually occuring after Dilaudid IV administration. A 24 hour EEG showed bursts of bifrontal rhythmic delta activity which indicates an abnormality of deeper midline structures. There were no epileptiform features noted. The patient reported symptoms of a UTI, and urine culture grew >100,000 E.coli. Since she was on Coumadin, she was placed on Macrobid to complete a 3 day course. Medications on Admission: Oral contraceptives for the past 5 years (interrupted with her child's pregnancy 2.5 ago) Discharge Medications: 1. Outpatient Lab Work Please check INR on Monday, [**6-27**], Wednesday [**6-29**], and Friday [**7-1**], and have results faxed to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 82717**] 2. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. Disp:*60 Tablet(s)* Refills:*2* 3. Acetazolamide 250 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Disp:*90 Tablet(s)* Refills:*2* 4. Nitrofurantoin (Macrocryst25%) 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 3 doses. Disp:*3 Capsule(s)* Refills:*0* 5. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). Disp:*20 Tablet Sustained Release 12 hr(s)* Refills:*0* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*30 Tablet(s)* Refills:*2* 8. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for breakthrough pain. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Cerebral venous sinus thrombosis, superior sagittal sinus and both transverse sinuses Urinary Tract Infection Discharge Condition: Stable Discharge Instructions: You were admitted with headache and nausea, and were found to have cerebral venous thrombosis. You were started on a heparin drip for a bridge to Coumadin. Your labs did not show that your blood is hypercoaguable. You should have your INR checked as an outpatient and faxed in to your PCP. You should no longer take your oral contraceptive pill, and should talk to Dr. [**Last Name (STitle) **] about alternative methods of contraception. You were started on Coumadin 4 mg daily, and should have your INR checked on this Monday, Wednesday, and Friday and faxed to Dr.[**Name (NI) 82718**] office. You were started on Diamox 250 mg three times per day, and should continue this until you follow up with Dr. [**First Name (STitle) **]. You were found to have a urinary tract infection, and were prescribed Macrobid to complete a 3 day course. Your pain was controlled with Oxycontin 10 mg twice daily, and you should be weaned off of this as an outpatient. You can take Percocet 1 tablet every 6 hours as needed for breakthrough pain. You should take Senna and Colace to prevent constipation while taking narcotic pain medications. . You will need assistance with stairs at least until f/u with your primary care physician. [**Name10 (NameIs) **] should use the cane you were given for walking. If you develop weakness/numbness, difficulty speaking or swallowing, decreased vision or blurry vision, headache, or any other symptoms that concern you, call your PCP or return to the ED. Followup Instructions: You have a follow up appointment with Dr. [**Last Name (STitle) **] (your PCP, [**Telephone/Fax (1) 17794**]) on [**2101-6-28**] at 12:30. You will need to make an appointment with the [**Hospital **] at Dr.[**Name (NI) 82718**] office by calling [**Telephone/Fax (1) 82719**]. Their fax number is [**Telephone/Fax (1) 31021**]. You have a follow up appointment with Dr. [**First Name (STitle) **] in Neurology ([**Telephone/Fax (1) 2574**]) on [**2101-8-12**] at 10:30 in the [**Hospital Ward Name 23**] Center, [**Location (un) 6749**]. You will need to contact the office prior to the appointment to update your information, and will need to obtain a referral from your PCP. [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

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icd9pcs

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12411, 12417

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277, 295

368, 1809

3039, 4039

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2558, 2558

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1934, 2105

72,097

183,461

52517

Discharge summary

report

Admission Date: [**2144-4-13**] Discharge Date: [**2144-4-28**] Date of Birth: [**2060-3-9**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4980**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: percutaneous cholecystostomy tube History of Present Illness: Ms. [**Known lastname **] is 84F with history of Parkinson's disease, glaucoma c/b vision loss, and recent diagnosis of depression, recently admitted for abdominal pain, found to have Cdiff d/ced home with 14d course flagyl (end date [**2144-4-15**]) who is presenting now with abdominal pain. The patient reports having intermittent, persistent lower abdominal pain. Unchanged to pain that she was experiencing prior to being hospitalized and treated for Cdiff. The patient also reports being worn out and fatigued; she reports not drinking a lot, and as per her daughter, the patient also does not eat much at her baseline. The patient reports still having diarrhea, but only on BM today. She thinks that her bowel movements have decreased in frequency since being started on antibiotics for her Cdiff, but she is unsure. The patient is also reporting some RUQ abdominal pain which she says is new and different than her lower abdominal pain. Reports that this pain just started today. Of note, imaging during his last admission was notable for GB dilatation and sludge on RUQ u/s. HIDA scan was defered. On ROS, denies any fevers/chills, denies any chest pain/shortness of breath. No blood in stool, denies any urinary symptoms. Does report having flatus. While in the ED, initial VS 98.4 83 130/77 16 98%. The patient's exam was pertinent for generalized abdominla pain, with RUQ tenderness and + [**Doctor Last Name 515**] sign. She was guic negative. Labs notable for white count of 36.4 with lactate of 1.6. RUQ u/s was done --> e/o increasing GB and biliary distension. GB wall edema and probable US [**Doctor Last Name **] sign. Findings suggest obstructing stone/mass in CBD -> ERCP/MRCP. Superimposed acute cholecystitis and cholangitis are not excluded. The patient was evaluated by surgery in the ED, and they recommended a non urgent cholecysectomy. However, the patient and her family refused any surgical care at this time. Past Medical History: Parkinson's disease, followed at the [**Hospital6 15291**]. 2. Detached left eye retina. 3. History of Lyme disease. 4. Glaucoma. 5. Osteoporosis. 6. Cystocele. 7. Vitamin B12 deficiency. 8. Depression PAST SURGICAL HISTORY: 1. Oophorectomy, [**2091**]. 2. Cyst removal from breast [**2132**] Social History: The patient is divorced. She has five children with whom she is very involved. She worked in the past in the Emergency Medical System for the state of [**State 350**]. She became an attorney at age 55, retiring at age 70. She now is involved taking classes at [**University/College **] [**Location (un) **]. SHe lives alone and is able to take care of all of her own medications. She gets some meals from her son who comes by. Her daughter [**Name (NI) 636**] and son [**Name (NI) **] are near by and very invovled. Family History: Both parents died in their 70s. Mother had diabetes and died of myocardial infarction. Father had myocardial infarction, hypercholesterolemia, hypertension. She had a sister who died of metastatic breast cancer. Physical Exam: Admission PE: VS: 98.2 116/70 86 16 93 RA General: pleasant, well appearing elderly female, NAD, laying comfortably in bed HEENT: dry mucous membranes CV: 2/6 SEM heard loudest at LUSB lungs: clear to ausculation b/l, no wheezes/rhonchi/crackles abdomen: +RUQ tenderness, did not appreciated +[**Doctor Last Name 515**] sign, mild lower abdominal tenderness, no rebound or guarding, +BS extremities: warm, well perfused, no LE edema, 2+ DP pulses Neuro: alert, interactive, and appropriate, normal muscle strength and sensation throughout Discharge: Vitals: 98.1 130/80 60 18 94 RA General: NAD, calm CV: RRR, no MRG Lungs: crackles at bases B/L Abdomen: soft, nontender, no guarding or rigidity, per chole tube in place with dark bile. no pus. Extremities: warm, well perfused, 1+ LE edema up to knees, 2+ DP pulses Pertinent Results: Admission labs: [**2144-4-13**] 02:40AM BLOOD WBC-36.4*# RBC-4.30 Hgb-13.0 Hct-40.1 MCV-93 MCH-30.3 MCHC-32.5 RDW-12.8 Plt Ct-328# [**2144-4-13**] 07:00PM BLOOD WBC-45.0* RBC-4.19* Hgb-12.3 Hct-38.9 MCV-93 MCH-29.4 MCHC-31.7 RDW-12.7 Plt Ct-341 [**2144-4-13**] 02:40AM BLOOD Neuts-96.1* Lymphs-2.2* Monos-1.6* Eos-0 Baso-0.1 [**2144-4-13**] 02:40AM BLOOD Plt Ct-328# [**2144-4-13**] 02:40AM BLOOD Glucose-187* UreaN-16 Creat-0.5 Na-134 K-3.6 Cl-97 HCO3-25 AnGap-16 [**2144-4-13**] 02:40AM BLOOD ALT-3 AST-14 AlkPhos-68 TotBili-1.0 [**2144-4-13**] 02:40AM BLOOD Albumin-3.4* [**2144-4-13**] 07:00PM BLOOD Albumin-3.1* [**2144-4-13**] 05:54AM BLOOD Lactate-1.6 [**2144-4-13**] Liver/Gallbladder Ultrasound: IMPRESSION: 1. Progression of biliary dilation. 2. Increasingly distended gallbladder, with wall edema and pericholecystic fluid. Review of prior CT shows a rounded filling defect in the distal CBD, suggesting an obstructing mass. Given patient presentation, superimposed acute cholecystitis and cholangitis are not excluded. MRCP or ERCP would be more sensitive for evaluation. [**2144-4-14**] CT Abdomen/Pelvis: Small bilateral pleural effusions are noted. These are new. There is atelectasis involving the lower lobes bilaterally. There is no ascites. The liver is without focal lesions; however, there is intrahepatic biliary ductal dilatation. The common bile duct is dilated and this can be followed to the head of the pancreas. This is unchanged in appearance. The gallbladder is distended. No stones are seen. There is hypoenhancement of the mucosa particularly in the fundus and the gallbladderwall appears irregular. The spleen is normal in size. The pancreas is unremarkable. The adrenal glands are normal. In the upper pole of the left kidney, there is a 1.2-cm hypodense lesion that measures 42 Hounsfield units and is indeterminate by CT criteria. Two too small to characterize hypodense lesions are seen in the left kidney in the lower pole and a 1.5-cm hypodense lesion in the right lower pole measures 26 Hounsfield units. There is no hydronephrosis. There is no retroperitoneal lymphadenopathy. The aorta is normal in caliber. There is massive wall thickening of the colon involving the ascending, transverse and descending colon. There is severe adjacent fat stranding. There is no evidence for extraluminal air or focal fluid collection. CT OF THE PELVIS WITH IV CONTRAST: A Foley catheter is identified in the bladder. A rectal tube is noted. There is a small amount of ascites in the pelvis. There is no extraluminal air or focal fluid collection. On bone windows, there are extensive degenerative changes involving the lumbar spine. There is loss of height in L1 through L3 and this is stable in appearance. 1. Dilated gallbladder to 6 cm in diameter. There is some disruption in the mucosal enhancement which raises concern for gangrenous cholecystitis. 2. Severe colitis extending from the sigmoid colon to the cecum. The imaging appearance is consistent with C. diff colitis, although other etiologies such as inflammatory or ischemic processes cannot be excluded. There is currently no evidence for perforation. No abscess is identified. 3. New ascites and bilateral pleural effusions with adjacent atelectasis. 4. Biliary obstruction at the level of the head of the pancreas. An obstructing mass is not visualized, and this may be due to an obstructing stone. This could be further evaluated with MRCP. 5. Bilateral renal lesions cannot be classified as simple cysts, but may be proteinaceous cysts. This could be confirmed with ultrasound. [**2144-4-15**] ECHO: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 considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm/premature beats. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**11-18**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild to moderate mitral regurgitation. At least moderate pulmonary artery systolic hypertension. MICROBIOLOGY: [**2144-4-16**] URINE URINE CULTURE-FINAL INPATIENT [**2144-4-15**] BILE GRAM STAIN-PRELIMINARY; FLUID CULTURE-PRELIMINARY {GRAM NEGATIVE ROD(S)}; ANAEROBIC CULTURE-PRELIMINARY INPATIENT [**2144-4-14**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS} INPATIENT [**2144-4-14**] STOOL C. difficile DNA amplification assay-FINAL INPATIENT [**2144-4-14**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2144-4-13**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2144-4-13**] URINE URINE CULTURE-FINAL Brief Hospital Course: Ms. [**Known lastname **] is 84F with history of Parkinson's disease, glaucoma c/b vision loss, and recent diagnosis of depression, recently admitted for abdominal pain, found to have Cdiff d/ced home with 14d course flagyl (end date [**2144-4-15**]) who presented with abdominal pain, found to have increasing GB and biliary distension on ultrasound in the setting of leukocytosis. Patient was initially admitted to medicine floor and was started on cipro IV, flaygl IV, and vancomycin PO, but developed hypotension. Her hypotension did not improve with 3 one liter fluid boluses and she was transferred to ICU for care of sepsis. # Sepsis / C. Diff colitis / acaculus cholecystitis: Source is most likely C.diff colitis, with additional source of possible acaculus cholecystitis. Patient had CT scan after arrival to ICU showing pancolitis, ascites, and dialated gallbladder with pericholecystic fluid. Surgery evaluated patient and considered possible colectemy. Patient was continued on PO vanc, IV flagyl, and cipro was changed to cefepime. She initially required CVL placement and pressors with neosynephrine. Her pressors were weaned off within the first 24 hours of arrival to ICU. Patient underwent percutaneous gallbladder drainage in the event that acalculus cholecytisis was contributing to presentation. Patient continued to have improving abdominal exam and leukocytosis suggesting C.diff is improving. She was called out to the floor on [**2144-4-18**]. Infectious disease team was consulted and they recommended continued ceftriaxone for her biliary process until [**2144-4-27**] which was done. Finally, they recommended continuing PO vancomycin until [**2144-5-5**] for C.Diff. She remained hemodynamically stable and her WBC count improved with antibiotics and the drain was kept in place to be addressed with [**Hospital1 18**] surgery at followup appointment later in [**Month (only) **]. # Delerium: Patient had intermittent delerium in ICU, mostly in evening. Likely multifactorial, secondary to sepsis, sedating/deleriogenic medications (versed fentanyl) given during the percutaneous gallbladder drain, and altered sleep wake cycle. Sleep wake cycle currently very disrupted. Patient was frequently reoriented. She received seroquel PRN agitation while in ICU. She continued to clear throughout the remainder of her hospital course. # Atrial fibrillation with rapid ventricular rate: Paroxsysmal and new since MICU admission. Patient would intermittently go into a. fib with HR in the 120s - 150s and then go back into sinus usually with only a few hours. Likely precipitant was infection. Loaded with amiodarone IV and transitioned to PO amiodarone Wed. Remained mostly in sinus rhythm since that time. Patient was also started on aspirin 325 mg daily. Anticoagulation with coumadin was also held given patient's possible need for surgery. The question of starting coumadin as outpatient should be addressed with rehabiliation facility and primary care doctor. # Glaucoma: The patient was continued on her home medications, including Dorzolamide 2%/Timolol 0.5% Ophth [**Hospital1 **], Latanoprost 0.005% Ophth. Soln. qhs, and Pilocarpine 1% R eye q8h. # Depression: The patient was continued on her home vanlafaxine. # HTN: The patient's lisinopril was held in the setting of her hypotension to be resumed at rehab. # Parkinson's disease: The patient was continued on her home Carbidopa-Levodopa. . Transitions of care: -Bilateral renal lesions cannot be classified as simple cysts, but may be proteinaceous cysts. This could be confirmed with ultrasound. -The question of starting coumadin as outpatient should be addressed with rehabiliation facility and primary care doctor. -Please cap the biliary drain 2 days prior to coming in for your surgery appointment so they can see that you dont have symptoms before removing the drain. If you develop worsening pain after the drain is capped, please uncap the drain and call Dr. [**Last Name (STitle) **] at the general surgery clinic at [**Telephone/Fax (1) 600**] for recommendations. Medications on Admission: carbidopa-levodopa 25-100 mg PO qhs carbidopa-levodopa 25-100 mg 2tabs TID 6am, 11am, 4pm lisinopril 10 mg qhs cyanocobalamin (vitamin B-12) 1000 mcg qday pilocarpine HCl 1 % Drops 2 drops q8h R eye latanoprost 0.005 % Drops 1 drop qhs dorzolamide-timolol 2-0.5 % Drops 1 drop [**Hospital1 **] venlafaxine 75 mg qday metronidazole 500 mg 1 tablet q8h (end date [**2144-4-15**]) tramadol 50 mg Q6H PRN pain (15 tablets) acetaminophen 325 mg 1-2 Tablets PO TID Discharge Medications: 1. vancomycin 125 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) for 7 days. 2. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 3. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. carbidopa-levodopa 25-100 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): please give 6AM, 11AM, and 4PM. 6. lisinopril 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 7. pilocarpine HCl 1 % Drops Sig: Two (2) Drop Ophthalmic Q8H (every 8 hours): 2 drops to RIGHT EYE . 8. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 9. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 10. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). 11. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: 1.5 Tablet Extended Release 24 hrs PO DAILY (Daily). Discharge Disposition: Extended Care Facility: Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**] Discharge Diagnosis: Primary: clostrium difficile colitis gangrenous cholecystitis Secondary: parkinson's atrial fibrillation delirium Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure participating in your care at [**Hospital1 18**]. You were admitted to the hospital for clostridium difficile infection and a gallbladder infection. You were treated with antibiotics and a drain placed into the gallbladder through the skin. REGARDING YOUR MEDICATIONS... Medications STARTED that you should continue: aspirin (started for atrial fibrillation) metoprolol XL (started for atrial fibrillation) Oral vancomycin - to be stopped on [**2144-5-5**] Otherwise, it is very important that you take all of your usual home medications as directed in your discharge paperwork. Please cap the biliary drain 2 days prior to coming in for your surgery appointment so they can see that you dont have symptoms before removing the drain. If you develop worsening pain after the drain is capped, please uncap the drain and call Dr. [**Last Name (STitle) **] at the general surgery clinic at [**Telephone/Fax (1) 600**] for recommendations. Followup Instructions: Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] When: THURSDAY [**2144-5-14**] at 2:00 PM With Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Please discuss with the staff at the facility a follow up appointment with your PCP when you are ready for discharge. Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Hospital1 **] DIVISION OF GERONTOLOGY Address: [**Doctor First Name **], STE 1B, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 719**] Please call Dr. [**First Name (STitle) **] [**Name (STitle) **] office as listed below to schedule an appointment to see her office within the next 2 months. [**Location (un) 830**] - KS 228 [**Location (un) 86**], [**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 1942**] Fax: [**Telephone/Fax (1) 21564**] Completed by:[**2144-4-29**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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43697

Discharge summary

report

Admission Date: [**2131-9-20**] Discharge Date: [**2131-10-2**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1**] Chief Complaint: Wound infection Major Surgical or Invasive Procedure: [**9-20**] Exploratory laparotomy with resection of anastomosis, Hartmann's with ascending colostomy [**9-21**] Placement of central venous catheter [**9-21**] Left chest tube insertion [**9-22**] Left chest tube insertion (#2) [**9-26**] Left chest tube removal and left apical chest tube replacement [**9-28**] Left VATS exploration with doxycycline pleurodesis History of Present Illness: Mr. [**Known lastname 93929**] is a 82 year old male who was admitted to [**Hospital1 18**] on [**9-20**] from the surgical clinic with a wound infection. He is s/p a laparoscopic colectomy on [**9-10**] for an obstructing mass at splenic flexure which was biospy proven adenocarcinoma of the colon, he had an un-complicated post-operative course except for a localized wound cellulitis. He was discharged home on oral antibiotics for seven days. He was seen in the surgical clinic on [**9-20**] with reports of drainage from wound over the last four days, initially it was serous but it changed to more feculent material. The wound was completely opened in the ED with findings of wound dehiscence of th superior portion and feculent drainage. A CT scan revealed free air with no level of obstruction, contrast did not reach level of anastomosis. He was taken to the OR with findings of breakdown of the anastomosis with leakage of stool; he [**Month/Day (1) 1834**] a resection of anastomosis with placement of a colostomy. Past Medical History: Past Medical History: Adenocarcinoma of colon Aortic sclerosis Past Surgical History: [**9-10**] Laparoscopic colectomy Mastoid surgery at age 5 Remote testicular surgery at age 10 Social History: Non-smoker, has [**2-17**] drinks of alcohol each week Family History: Non-contributory Physical Exam: On admission to surgical service: 97.5 70 94/61 20 100% room air Gen: Alert and oriented to time, place, and person Lungs: Cleart to auscultation bilaterally CV: Regular rate and rhythm Abd: Soft, non-tender, non-distended; +erythema along wound, +feculent material from wound Pertinent Results: Admission: [**2131-9-20**] 01:10PM BLOOD WBC-15.0* RBC-4.08* Hgb-10.8* Hct-32.3* MCV-79* MCH-26.4* MCHC-33.3 RDW-14.8 Plt Ct-575*# [**2131-9-20**] 01:10PM BLOOD Neuts-79.4* Lymphs-15.2* Monos-4.0 Eos-1.4 Baso-0.1 [**2131-9-20**] 01:10PM BLOOD PT-12.5 PTT-25.7 INR(PT)-1.1 [**2131-9-20**] 01:10PM BLOOD Glucose-90 UreaN-13 Creat-1.0 Na-138 K-4.7 Cl-101 HCO3-27 AnGap-15 [**2131-9-20**] 01:10PM BLOOD Calcium-9.1 Phos-4.2 Mg-2.0 During hospitalization: [**2131-9-22**] 01:18AM BLOOD WBC-19.4*# RBC-3.03*# Hgb-8.3*# Hct-23.6*# MCV-78* MCH-27.3 MCHC-34.9 RDW-14.9 Plt Ct-505* [**2131-9-24**] 06:20AM BLOOD WBC-20.1* RBC-3.68* Hgb-10.1* Hct-29.1* MCV-79* MCH-27.5 MCHC-34.8 RDW-15.5 Plt Ct-544* [**2131-9-21**] 01:35AM BLOOD CK-MB-3 cTropnT-0.02* [**2131-9-21**] 05:46PM BLOOD CK-MB-7 cTropnT-<0.01 [**2131-9-22**] 01:18AM BLOOD CK-MB-5 cTropnT-<0.01 [**2131-9-21**] 01:35AM BLOOD CK(CPK)-88 [**2131-9-21**] 05:46PM BLOOD CK(CPK)-855* [**2131-9-22**] 01:18AM BLOOD CK(CPK)-826* [**2131-9-20**] 1:10 pm SWAB **FINAL REPORT [**2131-9-26**]** GRAM STAIN (Final [**2131-9-20**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). WOUND CULTURE (Final [**2131-9-24**]): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for Pseudomonas aeruginosa, Staphylococcus aureus and beta streptococcus). GRAM NEGATIVE ROD #1. MODERATE GROWTH. GRAM NEGATIVE ROD(S). SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES. PROBABLE ENTEROCOCCUS. SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 2 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ 2 S IMIPENEM-------------- <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S ANAEROBIC CULTURE (Final [**2131-9-26**]): BACTEROIDES FRAGILIS GROUP. MODERATE GROWTH. BETA LACTAMASE POSITIVE. [**2131-9-29**] 9:43 am URINE **FINAL REPORT [**2131-9-30**]** URINE CULTURE (Final [**2131-9-30**]): NO GROWTH. [**2131-10-1**] 7:06 am SWAB Site: ABDOMEN Source: abdominal wound. GRAM STAIN (Final [**2131-10-1**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Pending): ANAEROBIC CULTURE (Pending): Discharge: [**2131-10-2**] 07:15AM BLOOD WBC-12.1* RBC-3.64* Hgb-9.9* Hct-29.3* MCV-81* MCH-27.2 MCHC-33.8 RDW-16.8* Plt Ct-410 [**2131-10-2**] 07:15AM BLOOD Plt Ct-410 [**2131-9-29**] 06:20AM BLOOD Glucose-86 UreaN-7 Creat-0.7 Na-139 K-4.0 Cl-104 HCO3-26 AnGap-13 [**2131-9-29**] 06:20AM BLOOD Calcium-8.0* Phos-4.3 Mg-2.3 OPERATIVE REPORT FIRST ASSISTANT: [**Doctor First Name **] [**Doctor Last Name **], RES PREOPERATIVE DIAGNOSIS: Anastomotic leak following partial colectomy with dehiscence of abdominal closure. POSTOPERATIVE DIAGNOSIS: Anastomotic leak following partial colectomy with dehiscence of abdominal closure. OPERATION: Exploratory laparotomy, lysis of adhesions, resection of colonic anastomosis and closure of distal colon and end colostomy. INDICATION: 82-year-old male had undergone transverse colectomy 10 days ago for colon cancer. He did well postoperatively and was discharged home. Shortly prior to his discharge home he had some erythema around some staples and was placed on Keflex for cellulitis. Once he went home, I was called about 3 days later to say he had a small amount of drainage from his wound but was otherwise feeling well and I advised him to apply gauze to this and keep me informed. On the night before admission I was called to say that he noted a temperature of 99.3. He was due to see me in the office this morning and therefore I said that we would address this issue then. When I saw the patient in the office, his wound was clearly contaminated with fecal material and I took out some staples which revealed more fecal material. I therefore transferred him to the emergency room and saw him after the Resident team had removed the rest of the staples and confirmed the findings of a partial dehiscence of his abdominal wall incision, as well as fecal matter within the wound. We did obtain a CAT scan to just make sure that there was not a significant collection of fluid anywhere in the peritoneal cavity that we might not be able to address readily in surgery and then took him to the operating room. PREPARATION: Once the patient was suitably anesthetized, the abdomen was prepared and draped appropriately. INCISION: The old incision was reopened and extended below. FINDINGS: There was actually a paucity of any reaction anywhere in the peritoneal cavity except for under the incision and by the anastomosis. The anastomosis was clearly the source of the problem. The small bowel was adherent to 1 area of this anastomosis and was taken off it without injuring it. TECHNIQUE: We dissected the small bowel off the anastomosis and mobilized the colon proximally and distally to the anastomosis. The bowel was controlled distally and then stapled closed with an Endo [**Female First Name (un) 3224**] green cartridge and then the colon was resected back past the anastomosis. At this point, the right colon was gently mobilized and enough of it brought medially to reach a right lower quadrant circular incision that we made to accommodate the colon as a colostomy. The colonic anastomosis was resected with another application of the [**Female First Name (un) 3224**] and the fresh colon was then brought out through the right lower quadrant incision which we made to accommodate the colostomy. We then irrigated copiously with saline and then closed the abdominal wall after debriding it with #1 PDS. We left the wound open and then matured the colostomy with 3-0 Vicryl. The patient tolerated the procedure well and was returned to the recovery room. CT ABDOMEN W/CONTRAST [**2131-9-20**] 2:53 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Reason: fistula Field of view: 35 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 82 year old man with recent colectomy, now concerned for enterocut fistula REASON FOR THIS EXAMINATION: fistula CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 82-year-old man with a transverse colectomy for adenocarcinoma approximately one week ago now with concern for an enterocutaneous fistula. COMPARISON: No prior studies are available for comparison. TECHNIQUE: Multidetector CT scanning of the abdomen and pelvis was performed after the administration of oral and intravenous contrast. Coronal and sagittal reformations were obtained. CT OF THE ABDOMEN: The lung bases demonstrate small pleural effusions and dependent atelectasis. The liver, adrenal glands, spleen, and pancreas appear normal. A 4mm hypodensity in the right lobe of the liver is incompletely characterized. The gallbladder is distended but thin walled without any intraluminal stones or sludge identified. The kidneys enhance and excrete contrast symmetrically without hydronephrosis. Two small incompletely characterized cysts, the larger measuring 9 mm, are seen in the right kidney. There is a small cortical defect in the left kidney which could represent prior infection. No dilated loops of bowel are identified. The patient is status post a transverse colectomy and surgical suture material is seen in the mid abdomen connecting remaining loops of colon. There is a large anterior abdominal wall defect in the region of the anastomosis. Contrast has reached the mid small bowel. There is an extensive amount of free intraperitoneal air still evident. There is a small amount of subhepatic/subphrenic ascites. Mesenteric stranding in the region of the surgery is also seen as well as multiple surgical clips. Multiple small retroperitoneal lymph nodes are seen, which do not meet criteria for pathologic enlargement. There is atherosclerosis of the abdominal aorta and its branches. CT OF THE PELVIS: The bladder, prostate, seminal vesicles, and rectum appear unremarkable apart from minor prostatic calcifications. No free fluid is seen in the pelvis. No drainable fluid collections are seen in the abdomen or pelvis. OSSEOUS STRUCTURES: There is grade 1 anterolisthesis of L4 on L5 with extensive degenerative change at this level. There is a rounded region of sclerosis in the sacrum, likely a bone island. No concerning lytic or sclerotic lesions are identified. IMPRESSION: 1. Post-surgical changes in the abdomen and large anterior abdominal wall defect with persistent extensive pneumoperitoneum and a small amount of ascites. No drainable fluid collections. 2. Small bilateral pleural effusions with associated atelectasis. 3. 4-mm hypodensity in the right lobe of the liver, incompletely characterized. 4. IncoRADIOLOGY Final Report CHEST (PORTABLE AP) [**2131-9-21**] 3:18 PM Reason: improvement in L pneumo [**Hospital 93**] MEDICAL CONDITION: 82 year old man with s/p traverse colectomy, anastomic leak - s/p L chest tube for PTX REASON FOR THIS EXAMINATION: improvement in L pneumo AP CHEST, 3:19 P.M., [**9-21**]. HISTORY: Left chest tube. No pneumothorax. IMPRESSION: AP chest compared to 1:57 p.m.: Left pneumothorax has decreased only minimally, still quite large, despite placement of left pleural tube. Mediastinum, however, has returned to the midline. Heart mildly enlarged. Right lung is low in volume but essentially clear. Findings were discussed with the house officer caring for this patient, by telephone, at the time of dictation. RADIOLOGY Final Report CHEST PORT. LINE PLACEMENT [**2131-9-21**] 8:49 AM Reason: s/p triple lumen placement [**Hospital 93**] MEDICAL CONDITION: 82 year old man with REASON FOR THIS EXAMINATION: s/p triple lumen placement INDICATION: 82-year-old man status post central venous catheter placement. No prior studies are available for comparison. FINDINGS: Right-sided subclavian approach central venous catheter is noted with its tip projecting at the level of the right subclavian and internal jugular junction. A NG tube is visualized with its tip projecting over the stomach. The cardiac silhouette is within normal limits. The aorta is tortuous with calcification in its arch. Lung volumes are low. Bibasilar linear opacities likely represent atelectasis. Mild blunting of the left costophrenic angle may represent small pleural effusion. Free air below the right hemidiaphragm is noted. Thoracic scoliosis is noted. IMPRESSION: 1. Right central venous catheter with its tip projecting at the level of the right subclavian and internal jugular junction. 2. Pneumoperitoneum. 3. NG tube with its tip projecting over the stomach. Findings were discussed with Dr. [**Last Name (STitle) **] on [**2131-9-21**]. RADIOLOGY Final Report CHEST (PORTABLE AP) [**2131-9-22**] 12:20 PM CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN Reason: Status of PTX [**Hospital 93**] MEDICAL CONDITION: 82 year old man with s/p traverse colectomy, anastomic leak - repositioning of L chest tube for PTX; assess for interval change in lung expansion REASON FOR THIS EXAMINATION: Status of PTX PORTABLE CHEST ON [**2131-9-22**] AT 12:15. INDICATION: Left chest tube placement. COMPARISON: [**2131-9-22**] at 05:28. FINDINGS: The left pneumothorax persists and is unchanged. The right lung appears better aerated. NGT has been removed and left CVL remains in place. IMPRESSION: No change in the left PTX. CHEST (PORTABLE AP) [**2131-9-27**] 7:57 AM Reason: assess for interval changes [**Hospital 93**] MEDICAL CONDITION: 82 year old man with s/p CT x2 for PTX. REASON FOR THIS EXAMINATION: assess for interval changes INDICATION: Status post chest tube placement, for evaluation of pneumothorax. PORTABLE AP CHEST. COMPARISON: [**2131-9-26**]. The heart size is normal. Aorta is unfolded. A small left-sided pneumothorax is noted. Two chest tubes are seen in place with interval removal of one of the chest tubes. Small bilateral pleural effusions are again noted with low lung volumes. IMPRESSION: 1. Small left-sided pneumothorax and bilateral small pleural effusions. Interval removal of the third chest tube from the left. 2. Low lung volumes. RADIOLOGY Final Report CT CHEST W/O CONTRAST [**2131-9-28**] 8:56 AM CT CHEST W/O CONTRAST Reason: Please eval PTX/chest tubes; please obtain in early AM [**Hospital 93**] MEDICAL CONDITION: 82 year old man w/ continuous air leak REASON FOR THIS EXAMINATION: Please eval PTX/chest tubes; please obtain in early AM CONTRAINDICATIONS for IV CONTRAST: None. REASON FOR EXAMINATION: Evaluation of a long standing pleural effusion. COMPARISON: Serial chest radiograph from [**2131-9-21**] to [**2131-9-28**]. FINDINGS: Multiple mediastinal nodes are mildly enlarged measuring up to 1 cm in the supracarinal location . The hilar lymphadenopathy is hard to estimate due to lack of contrast but no significant lymphadenopathy is present. There is no axillary lymphadenopathy. The heart is mildly enlarged with tiny pericardial effusion. Coronary calcification involves both right and left coronary arteries. Aortic valve calcifications are present. Several left intrapleural air collections are small involving the apex, the lateral and the anterior low pleural spaces. The apical chest tube ends anteriorly with adjacent pleural surfaces all apposed. Subcutaneous emphysema is minimal. The right pleural effusion is small, larger than the left. Bibasilar consolidation with is most likely atelectasis, but aspiration cannot be excluded. The images of the upper abdomen demonstrate mild ascites. No significant abnormalities demonstrated within the liver, kidneys, spleen, adrenals and pancreas. Surgical clips are in the left upper abdomen. There are no bone lesions suspicious for malignancy. IMPRESSION: 1. Several small intrapleural air pocket on the left. CT is not able to show a pleural defect from central venous line insertion; no large defect is present. The bilateral pleural effusions are small, right worse than left with adjacent consolidation most likely atelectasis. 2. Mild ascites. 3. Coronary calcifications. OPERATIVE REPORT [**Last Name (LF) 1533**],[**First Name3 (LF) 1532**] P. Signed Electronically by [**Doctor Last Name 1533**],[**Last Name (un) **] on TUE [**2131-10-2**] 8:56 AM Name: [**Known lastname **],[**Known firstname 870**] Unit No: [**Numeric Identifier 93930**] Service: Date: [**2131-9-28**] Sex: M Surgeon: [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 67965**] PREOPERATIVE DIAGNOSIS: Left pneumothorax. POSTOPERATIVE DIAGNOSIS: Left pneumothorax. PROCEDURE: Left VATS exploration and doxycycline pleurodesis. ASSISTANT: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 33888**] ANESTHESIA: General endotracheal plus 40 cc of 0.375% Marcaine with epinephrine and local and rib blocks. IV FLUIDS: 1800 cc. URINE OUTPUT: 180 cc. ESTIMATED BLOOD LOSS: Less than 25 cc. INDICATIONS FOR PROCEDURE: Mr. [**Known lastname 93929**] is an 82-year-old gentleman who had recently undergone a transverse colectomy for colon cancer and subsequent to that developed an anastomotic leak requiring reoperation and creation of an end colostomy [**Doctor Last Name 3379**] pouch. The day after this reoperation, he was noted to have a left pneumothorax following placement of a central line. The initial attempts at treatment of this involved 2 tubes and finally a third tube was placed which was able to resolve the pneumothorax. However, the air leak did not resolve. CT scan was unrevealing of the problem. PROCEDURE IN DETAIL: The patient was positioned supine and through a single-lumen endotracheal tube, flexible bronchoscopy was performed at the segmental airway level bilaterally. There was no endobronchial obstruction. There was no blood, plugging, purulence encountered. There was no mucosal damage which would have potentially led to bronchopleural fistula. The patient then had the double-lumen endotracheal tube placed and he was positioned in the left thoracotomy position. He was prepped and draped in the usual sterile fashion. He had 3 chest tube wounds. Two of these 3 wounds were dehiscing and the third wound was opened as we had just removed the remaining chest tube. Therefore, I decided to prep these copiously using direct iodine application to the tract and tube site and then placed the initial videoscope through one of the chest tubes. Upon introduction of this into the chest, I noted that there were some filmy adhesions and some fibrinous material in the chest but that there was a good view. The lungs themselves looked slightly emphysematous and had quite a lot of anthracotic markings. There was no obvious bulla and clearly no obvious laceration or injury to the lung on initial glance. I placed a new port posteriorly at the tip of the scapula and then used one of the previously placed chest tube ports as the second utility incision for an instrument. I was able to free up the adhesions and then manipulate the lung so that I could view it in 360 degrees, including all aspects of the intralobar fissure. There was no obvious sign of visceral pleural defect whatsoever. I then, therefore, dunked the lung underneath 500 cc of sterile water. I systematically submerged the upper lobe in its entirety and then followed this was submersion of the lower lobe in its entirety. Even with this process and lung inflation to a pressure of 20 cm of water which resulted in good inflation, I did not observe any air streaming from the lung whatsoever. Therefore, we elected to perform doxycycline pleurodesis. We had 500 mg of doxycycline and we injected that into the chest and let it circulate around evenly. We placed two 19-French [**Doctor Last Name 406**] drains in the chest and brought these out through separate tunneled stab incisions. We closed the wounds very loosely with 3-0 and 4-0 Vicryl. All sponge and needle counts were correct x2 and I was present and scrubbed for the entire procedure. The patient was extubated and taken to the recovery room in good condition. RADIOLOGY Preliminary Report CHEST (PORTABLE AP) [**2131-9-29**] 8:05 AM CHEST (PORTABLE AP) Reason: r/o pneumo8am please [**Hospital 93**] MEDICAL CONDITION: 82 year old man with s/p CT x1, with pneumothorax REASON FOR THIS EXAMINATION: r/o pneumo8am please HISTORY: Pneumothorax. Single portable chest radiograph again demonstrates two left-sided chest tubes. There is a small left-sided pleural effusion. There is mild bibasilar atelectasis. Trachea is midline. Cardiomediastinal contours are unchanged. No pneumothorax is detected. S-shaped scoliosis of the cervical, thoracic and lumbar spine is again noted. Surgical clips project over the left upper quadrant. IMPRESSION: Left-sided pleural effusion. No pneumothorax. Bibasilar atelectasis persists. RADIOLOGY Final Report CHEST (PA & LAT) [**2131-9-30**] 12:08 PM [**Hospital 93**] MEDICAL CONDITION: 82 year old man s/p VATS/pleurodesis REASON FOR THIS EXAMINATION: Please eval for PTX, on water seal; please perform study between 12 noon and 1 PM PA AND LATERAL CHEST X-RAY, [**2131-9-30**] COMPARISON: [**2131-9-29**]. INDICATION: Chest tube placed to waterseal. Question pneumothorax. Two chest tubes remain in place in the left hemithorax. On the lateral view, there is a small air-fluid level present anteriorly consistent with an anterior loculated hydropneumothorax. The chest tubes are located posterior to this area. Cardiac and mediastinal contours are stable. Moderate right pleural effusion with intrafissural component is unchanged. Small-to-moderate left pleural effusion has slightly increased laterally, but there has been overall improved aeration in the left lower lobe with improving atelectasis in this region. IMPRESSION: 1. Small left loculated anterior hydropneumothorax. 2. Bilateral pleural effusions, right greater than left. 3. Improving aeration left lower lobe. Date: [**2131-10-1**] Signed by [**First Name11 (Name Pattern1) 2295**] [**Last Name (NamePattern4) 69152**], RN on [**2131-10-1**] Affiliation: [**Hospital1 18**] Mr [**Known lastname 93929**] was seen to apply an ABD binder and to adjust it around the colostomy. The pouch was starting to lift on the medial edge therefore it was changed. The stoma is dark burgundy and protruding. Peristomal skin and mucocutaneous junction are intact. Pouched with [**Location (un) **] high output pouch with [**First Name8 (NamePattern2) **] [**Last Name (un) **] seal. Have placed a medium ABD binder around his ABD and then made an opening in it to allow the pouch to hang out through the opening. He expects to go to rehab soon will update his referral and provide him with d/c ostomy supplies and written ostomy care instructions. Brief Hospital Course: Mr. [**Known lastname 93929**] had no intra-operative complications, he was given intravenous antibiotics of Levaquin and Flagyl pre-operatively which were continued post-operatively. His white blood cell count on admission was 15k. Post-operatively he was hypotensive with low urine outputs despite fluid boluses and was admitted to the surgical intensive care unit for further management and resuscitation. A cardiac work-up was negative for ischemia. Upon admission to the intensive care unit a central line was placed with difficulty on the right side and successful placement on the left internal jugular vein for central venous pressure monitoring, this was complicated by a left pneumothorax requiring placement of a chest tube. On POD 2 his urine output and creatinine had improved with fluid resuscitation from 1.8 to 1.3. His pain was well controlled with a Morphine PCA, he remained afebrile, and his abdominal wound dressing changes continued with wet to dry dressing changes of normal saline. On POD 3 a chest x-ray demonstrated persistent left pneumothorax which was treated with placement of a second chest tube, a thoracic surgery consult was placed with recommendation of continuing current treatment. He was transfused two units of PRBC's for a hematocrit of 24.3 with a repeat hematocrit of 28.2. On POD 4 he was stable for transfer to an in-patient nursing unit, his diet was advanced which he tolerated well, and he had +air from the ostomy. On POD 6 a chest x-ray demonstrated an increased pneumothorax; thoracic surgery removed one of the two left sided chest tubes and replaced one in the apex on the left side at the bedside, an air leak continued from both chest tubes. He tolerated the procedure well, his oxygenation was stable on 2 liters nasal cannula. A repeat chest x-ray showed minimal improvement in the pneumothorax. On POD 8 he had a CT scan of the chest which demonstrated small intrapleural air pockets with bibasilar atelectasis. Since the air leak continued and there was minimal improvement in the pneumothorax he was taken to the operating room on POD 8 for a left VATS, exploration, and mechanical pleurodesis with Doxycycline by thoracic surgery. He had no intra-operative complications and returned to an in-patient nursing unit. On POD [**12-26**] his pain was well controlled with Percocet, he remained afebrile, and two left sided chest tubes were maintained on suction. His abdominal wound was debrided at the bedside and was noted to be granulating well; his white blood cell count was elevated to 19k therefore an abdominal and pelvic CT scan was done. The CT scan demonstrated a large anterior abdominal wall defect involving the subcutaneous fat extending to the anterior abdominal musculature, he also had small loculated fluid collections in the abdomen and pelvis between loops of bowel which appeared to be benign. His diet was advanced to regular food which he tolerated well and his ostomy was functioning well. The abdominal wound dressing changes were changed to dry dressings three times a day since it still had "wet" appearance with cream colored drainage. He was also provided an abdominal binder to wear throughout the day with a hole cut out for the ostomy appliance. On POD [**9-17**] both chest tubes had no air leaks and were placed to water seal, a repeat chest x-ray demonstrated no pneumothorax so both chest tubes were removed by thoracic surgery; post removal chest x-ray demonstrated small stable apical pneumothorax. He was oxygenating well on 2 liters nasal cannula and continued to received aggressive pulmonary toileting. On POD [**11-18**] he was oxygenating well on room air, had minimal pain, was tolerating a regular diet, and his ostomy was functioning well. He remained afebrile with a white blood cell count of 12.1k. His abdominal wound measured 17cm by 3cm with visible fascia and sutures; he continued to receive dressing changes three times a day with packing of dry, sterile gauze. There was still cream colored drainage present with pink granulating tissue as well. He was discharged to [**Hospital1 **] Rehabilitation facility in good condition on [**10-2**]. He will receive 2 more days of oral antibiotics of Levaquin and Flagyl which will total 14 days of treatment. He will continue to receive physical therapy to increase his functional mobility. He will also receive further teaching and instruction regarding care of his ostomy. He will follow-up in the surgical clinic in [**12-18**] weeks for evaluation of his abdominal wound. He will follow-up in the ostomy clinic after discharge from the rehabilitation facility. Medications on Admission: Toprol XL Percocet prn Colace Keflex ASA 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. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 days: Last dose pm of [**10-4**]. 3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days: Last dose on [**10-4**]. 4. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily): Hold for HR < 60 Hold for SBP < 100. 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection twice a day: Give until patient ambulating. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Adenocarcinoma of colon with wound dehiscence Left pneumothorax Discharge Condition: Good Discharge Instructions: Notify MD/NP/PA/RN at rehabilitation facility if you experience: *Increased or persistent pain not relieved by pain medications *Fever > 101.5 or chills *Shortness of breath or difficulty breathing *Nausea or vomiting *Inability to pass gas or stool through ostomy; inability to pass urine *If abdominal wound develops erythema, drainage, or a foul odor *Any other symptoms concerning to you You need to wear the abdominal binder at all times throughout the day You may shower and wash incision and abdominal wound with soap and water, dresssing changes will be done three times a day by the nurses. Please take all medications as ordered Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] in [**12-18**] weeks, call ([**Telephone/Fax (1) 9011**] for an appointment. Follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] after discharge from the rehabilitation facilty for review of your medications and physical exam, call [**Telephone/Fax (1) 904**] for an appointment. Completed by:[**2131-10-2**]

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Discharge summary

report

Admission Date: [**2182-4-23**] Discharge Date: [**2182-4-29**] Date of Birth: [**2119-4-24**] Sex: M Service: CARDIOTHORACIC Allergies: Lisinopril Attending:[**First Name3 (LF) 1406**] Chief Complaint: Chest pressure Major Surgical or Invasive Procedure: [**2182-4-23**] left hesrt catheterization, coronary angiogram and placement of intra aortic balloon [**2182-4-24**] Coronary artery bypass grafting x4 (left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to posterior descending artery, obtuse marginal artery and second diagonal artery). History of Present Illness: This 62 year old male presented with a complaint of chest burning on exertion. The first episode was 2 months ago while walking. He experienced chest burning that lasted about 15 seconds and was releived with rest. He had no other associated symptoms. He experienced chest burning again while exercising on a treadmill when he was about 6-7 minutes into the workout. An exercise stress test was ordered and the patient was given a presciption for nitroglycerin, which he used 3 days ago for similar chest pain. On [**2182-4-15**] he had an exercise stress which showed ischemic EKG changes with blood pressure drop in the presence of anginal symptoms and referred for cardiac catheterization. Past Medical History: Coronary artery disease Hypertension Obesity Diabetes mellitus type 2 Hyperlipidemia Depression benign prostatic hypertrophy gastroesophageal reflux Social History: Married; Works as an administrator for a social services agency Tobaccco: 40 pack year history ETOH: denies Family History: non-contributory Physical Exam: Admission: VS: T=98.4 BP=163/68 HR=53 RR=15 O2 sat= 95% RA GENERAL: WDWN in NAD. Oriented x3. Mood annoyed/aggitated by questioning, affect labile. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no elevated JVP. CARDIAC: RR, normal S1, S2. difficult to appreciate extra heart sounds [**2-26**] assist device LUNGS: Resp were unlabored, no accessory muscle use. CTAB in anterior [**Last Name (un) 8434**], although difficult to appreciate rhales due to device noise. ABDOMEN: Soft, NTND. +BS EXTREMITIES: No edema, warm and well perfused SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Popliteal 2+ DP 2+ PT 2+ Left: Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [**2182-4-27**] 04:54AM BLOOD WBC-8.8 RBC-3.06* Hgb-10.0* Hct-27.7* MCV-91 MCH-32.8* MCHC-36.2* RDW-14.0 Plt Ct-167 [**2182-4-23**] 01:28PM BLOOD WBC-7.1 RBC-4.37* Hgb-14.0 Hct-38.9* MCV-89 MCH-32.1* MCHC-36.1* RDW-13.5 Plt Ct-174 [**2182-4-27**] 04:54AM BLOOD Plt Ct-167 [**2182-4-23**] 01:28PM BLOOD Plt Ct-174 [**2182-4-23**] 01:28PM BLOOD PT-14.4* PTT-108.4* INR(PT)-1.2* [**2182-4-27**] 04:54AM BLOOD Glucose-140* UreaN-19 Creat-0.9 Na-133 K-4.3 Cl-98 HCO3-31 AnGap-8 [**2182-4-23**] 01:28PM BLOOD Glucose-136* UreaN-13 Creat-0.9 Na-140 K-4.1 Cl-104 HCO3-22 AnGap-18 [**2182-4-23**] 01:28PM BLOOD ALT-7 AST-23 AlkPhos-37* TotBili-0.5 [**2182-4-24**] 06:30AM BLOOD CK-MB-NotDone cTropnT-0.05* [**2182-4-27**] 04:54AM BLOOD Mg-2.1 [**2182-4-23**] 01:28PM BLOOD Albumin-3.8 [**2182-4-24**] 06:30AM BLOOD Calcium-8.9 Phos-3.1 Mg-2.0 [**2182-4-23**] 01:28PM BLOOD %HbA1c-6.8* eAG-148* Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 55% to 60% >= 55% Aorta - Ascending: 3.0 cm <= 3.4 cm Findings LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. LEFT VENTRICLE: Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial MR. TRICUSPID VALVE: Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: No PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Conclusions Pre-CPB: 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) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is no pericardial effusion. The IABP is correctly positioned just beyond the left sublcavian artery. Post bypass Patient is A paced and receiving an infusion of phenylephrine. Biventricular systolic function is normal. Aorta is intact post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting physician CLINICAL HISTORY: Status post CABG. CHEST: The heart is somewhat prominent. Some widening of the mediastinum consistent with postoperative state is present. The lung fields are essentially clear. Atelectasis at the left base is seen. No effusions or evidence of failure are present. IMPRESSION: No failure. Chest clear. Operative film. Brief Hospital Course: Cardiac catheterization revealed severe left main and triple vessel disease with preserved LV function. An intra aortic balloon was placed and he remained stable. He was referred for surgical revascularization which was accomplished on [**4-24**] without incident. See operative note for details. He remained stable, weaned from pressors and the balloon pump was weaned and removed without incident. He was transferred to the floor where beta blockers were resumed and he was diuresed towards his preoperative weight. He had transient atrial fibrillation, treated with Amiodarone with conversion to sinus rhythm. CTs and temporary pacing wires were removed without problem. Physical Therapy worked with him for strength and mobility. He remained in SR and was cleared for discharge. Medications, precautions and follow up instructions were discussed at length. Medications on Admission: ALBUTEROL 2 puffs TID PRN for cough wheeze ASPIRIN - 325 MG EC PO Q day ESCITALOPRAM [LEXAPRO] - 20 mg Q day IBUPROFEN - 800 mg [**Hospital1 **] to TID PRN for pain METOPROLOL TARTRATE - 50 mg Tablet [**Hospital1 **] (recently decreased from 100 mg [**Hospital1 **]) NITROGLYCERIN - 0.4 mg Tablet, PRN OMEPRAZOLE - 20 mg (E.C.) PO Q day SIMVASTATIN - 80 mg PO QHS Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 3. Escitalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours). Disp:*qs qs* Refills:*0* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 4 weeks. Disp:*60 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day): please take total of 75 mg twice a day . Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Coronary artery disease s/p cabg Hypertension Obesity Diabetes mellitus type 2 Hyperlipidemia Depression benign prstatic hypertrophy Discharge Condition: Alert and oriented x3, nonfocal Ambulating, gait steady Sternal pain managed with Percocet prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Please call to schedule appointments Cardiologist Dr [**First Name (STitle) **] [**Name (STitle) **] in [**1-26**] weeks Appointments already scheduled Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2182-5-29**] at 1:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3404**], MD Date/Time:[**2182-5-31**] 10:00 Completed by:[**2182-4-29**]

[ "401.9", "600.00", "272.4", "427.31", "530.81", "413.9", "311", "250.00", "V45.82", "V58.66", "278.00", "414.01" ]

icd9cm

[ [ [] ] ]

[ "37.61", "36.13", "39.61", "37.22", "36.15", "88.56" ]

icd9pcs

[ [ [] ] ]

7924, 7983

5726, 6595

293, 630

8160, 8257

2478, 5703

8797, 9225

1668, 1687

7010, 7901

8004, 8139

6621, 6987

8281, 8774

1702, 2459

238, 255

658, 1354

1376, 1526

1542, 1652

64,089

122,626

10113

Discharge summary

report

Admission Date: [**2157-4-6**] Discharge Date: [**2157-4-11**] Date of Birth: [**2117-6-4**] Sex: M Service: NEUROSURGERY Allergies: Lipitor Attending:[**First Name3 (LF) 14802**] Chief Complaint: Elective resection of 4th ventricular cyst, neurocystersarcosis Major Surgical or Invasive Procedure: [**2157-4-6**] Suboccipital craniotomy for resection of 4th ventricular cyst History of Present Illness: 39-year-old gentleman from [**Country 149**] who was recently admitted to [**Hospital1 **] for treatment of obstructive hydrocephalus secondary to neurocysticercosis. The patient has a cyst in the fourth ventricle, which is obstructing CSF flow. The patient underwent surgery to place a ventriculoperitoneal shunt during that hospital admission and his symptoms have improved. Initially, he had some difficulty with abdominal pain and continuing headache, but these symptoms have essentially resolved. We had extensive discussions and a clinical meeting regarding the patient's case. During this discussion, it was clear that contemporary management of fourth ventricular cysts from neurocysticercosis are amenable to surgical resection and that in many ways this is preferable to simply treating with anti-parasitic medications. The reason for this as suggested by the literature is that the shunts are prone to obstruction particularly due to debris in the CSF. For this reason, the Infectious Disease doctors feel that it is in the patient's best interest to have the lesion surgically removed and it is for that reason the patient presents today. Past Medical History: hyperlipidemia Chronic low back pain- receives epidural steroid injections last [**2157-1-25**] Elevated Ck in setting of alcohol binge and hypothyroidism Hypothyroidism Depression Vitamin d deficiency Carpal Tunnel Social History: He lives with his wife and two children. Alcohol on holidays. no smoking, no illicit drugs. He is a landscaper. He immigrated from [**Country 7192**] 20 years ago and last trip back was 3 years ago. Family History: Mom is age 59 with hypertension and diabetes. Dad is age 60 with headaches. He has three brothers and eight sisters. One brother has kidney problems, patient is unsure what. Physical Exam: On Admission: General: Reveals a normally developed male who appears his stated age. He is alert and fully oriented. His expressive and receptive language functions are normal in his native tongue. HEENT: His pupils are equal and reactive to light. His extraocular movements are full. His face is symmetric. His tongue and palate are midline. Extremities: His motor tone and bulk are normal. His strength is [**6-4**] throughout. There was no upper extremity drift. Deep tendon reflexes are 2+ throughout. Toes are downgoing. There is no clonus. The patient ambulates on a narrow base. He can turn on a dime. Romberg is negative. On Discharge: Stable, incision is clean and dry; well-approximated with nylon sutures in place. PERRL, EOM intact, face symmetric, no dysmetria, gait is slow and broadbased. Motor is full, sensory intact. Pertinent Results: MRI Head [**4-6**] 1. Interval insertion of ventriculostomy catheter and decompression of lateral and third ventricles. Unchanged appearance of cystic lesion in the fourth ventricle. Multiple scattered foci of abnormal susceptibility in bilateral cerebral Findings are suspicious for neurocysticercosis. CT Head [**4-6**] post op 1. No hemorrhage or hydrocephalus MRI HEAD [**4-8**] FINDINGS: There are new changes from a suboccipital craniotomy. There is enhancement in the fourth ventricle which may be related to recent surgery. There is susceptibility artifact from intracranial pneumocephalus. Small amount of blood products is seen in the fourth ventricle.There is a right frontal ventriculostomy catheter terminating against the septum pellucidum. Ventricles are stable in size. Mild gliosis is now seen along the ventriculostomy tract. There is mild pachymeningeal thickening and enhancement which has progressed since the previous MRI and may be related to interval surgery. Intracranial flow voids are maintained. No evidence for acute ischemia or hydrocephalus. Calcifications noted on the prior CT are not well seen There is a retention cyst in the right maxillary sinus. IMPRESSION: Status post suboccipital craniotomy for fourth ventricular lesion. No definite lesion is identified within the fourth ventricle and the ventricle itself is smaller in size compared to preoperative study. Recommend high-resolution sagittal 3D-CISS images if there remains concern for residual cyst in the fourth ventricle. Brief Hospital Course: Pt was admitted to the neurosurgery service and underwent craniotomy for 4th ventricular cyst resection. He tolerated this procedure well with no complications. Post operatively he was transferred to the ICU for further care including q1 neurochecks and SBP control. On post op exam he was non focal and his head CT showed no hemorrhage or hydrocephalus. He had no issues overnight and was transferred to the SDU on POD #1. His hemovac drain put out 45cc of bloody drainage and remained in until POD#2 when it was removed without difficulty. He was transferred to the floor. Post op MRI was complete - see reports section for results. He was ambulatory in the halls with assistance of his family. Meclezine was strated for continued intermittent dizziness and nausea. Patient was seen and evaluated by physical therapy who felt that he was safe to discharge home. ID was formally consulted and they did not recommend treatment with antibiotics at this time but to follow-up with Dr. [**Last Name (STitle) **] in 1 week. At the time of dishcarge he was tolerating a regular diet, ambulating without difficulty, afebrile with stable vital signs. Medications on Admission: LEVETIRACETAM - 250 mg Tablet - 3 Tablet(s) by mouth twice a day LEVOTHYROXINE - (Prescribed by Other Provider) - Dosage uncertain PRAVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth at bedtime Medications - OTC ACETAMINOPHEN - (OTC) - Dosage uncertain CALCIUM CARBONATE-VITAMIN D3 - 500 mg (1,250 mg)-400 unit Tablet, Chewable - 1 Tablet(s) by mouth twice a day Avoid taking within 2 hours of taking Thyroid medication because thyroid medicaiton does not absorb well if taking with this medication FISH OIL-FAT ACID COMB.8-HB137 [OMEGA 3-6-9] - (OTC) - Dosage uncertain Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain or fever. 2. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 5. dexamethasone 1 mg Tablet Sig: Taper as below PO Taper as below: [**4-11**]: 3mg 3x daily; [**4-12**]: 2mg 3x daily; [**4-13**]: 1mg 3x daily [**4-14**]: stop. Disp:*18 Tablet(s)* Refills:*0* 6. methocarbamol 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for muscle spasm. Disp:*60 Tablet(s)* Refills:*0* 7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 10. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for nausea. Disp:*60 Tablet(s)* Refills:*0* 11. meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for nausea. Disp:*60 Tablet(s)* Refills:*0* 12. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 13. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day: while taking dexamethasone. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Cerebral Neurocystersarcosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office [**4-18**] for removal of your staples/sutures and/or a wound check. Please make this appointment by calling [**Telephone/Fax (1) 1669**] to make arrangements. ??????Please call ([**Telephone/Fax (1) 88**] to also schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in 4 weeks or as indicated. - You also have an appointment with Infectious Disease on [**4-18**] for follow-up with Dr. [**Last Name (STitle) **]. Please call [**Telephone/Fax (1) 457**] to confirm Completed by:[**2157-4-11**]

[ "338.29", "272.4", "V45.2", "123.1", "244.9", "331.4", "724.2" ]

icd9cm

[ [ [] ] ]

[ "01.59" ]

icd9pcs

[ [ [] ] ]

8019, 8025

4698, 5848

335, 414

8098, 8098

3141, 4675

9785, 10377

2075, 2252

6473, 7996

8046, 8077

5874, 6450

8249, 9762

2267, 2267

2928, 3122

232, 297

442, 1602

2281, 2914

8113, 8225

1624, 1842

1858, 2059

6,156

146,623

50936

Discharge summary

report

Admission Date: [**2108-12-12**] Discharge Date: [**2108-12-17**] Date of Birth: [**2047-2-3**] Sex: F Service: MEDICINE Allergies: Ambien / Percocet / Iodine; Iodine Containing Attending:[**Doctor First Name 1402**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catheterization with 2 stents placed to the LAD History of Present Illness: Ms. [**Known lastname 13469**] is a 61 year-old woman with a history of coronary artery disease with CABG x 3 (LIMA-LAD, SVG-OM, SVG-RCA) with known occluded vein grafts and recent admission with stenting to her LAD who presents with chest pain. Was admitted from [**11-28**] - [**12-4**] for NSTEMI. At that time, her ECG showed ST depressions and her CK peaked at 839 and troponin of 1.97. Cardiac catheterization showed in-stent restenosis of her BMS to LAD was seen which was [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 105862**]. She continued to have chest pain post intervention and subsequently underwent persantine MIBI on [**2108-12-3**]; this showed no reversible ischemia. Her hospital course was complicated by intermittent junctional rhythm and possible AV dissociation. As a result, her metoprolol dose was decreased. Reports return of her anginal symptoms (back pain with radiation to arm; chest pressure) beginning a few days after discharge. These episodes would last minutes and would always be responsive to nitro though she would use spray/tabs up to 14+ times per day. Some mild SOB and diapheresis with these episodes. Not always with exertion. Overall, these episodes were similar to those experienced after her cath on her last admission. On the evening of admission, she returned home after shopping and - after moving 4 bags of packages into her home - she began to experience her angina. It was more severe ([**8-5**]) and persisted. She took [**3-31**] SL nitro and many sprays without relief and called her PCP. [**Name10 (NameIs) **] then drove herself to an OSH. Initially presented to an OSH where she was noted to have ST-depressions and was given morphine, metoprolol and started on a nitro gtt. Troponin T returned at 0.017. In the ED, T 98.7, HR 112, BP 209/89, RR 14. Recieved morphine 4mg IV and dilaudid 0.5mg IV. BP improved ot 133/95 at the time of transfer with nitro gtt up to 0.98mcg/kg/min. Past Medical History: 1. CARDIAC RISK FACTORS: (-) Diabetes (+) Dyslipidemia (+) Hypertension . 2. CARDIAC HISTORY: -CABG: [**2097**] at [**Hospital1 112**]: LIMA->LAD; SVG->OM1; SVG->RCA -PCI: [**2102-5-8**]: OM3 with a proximal 95% stenosis --> POBA [**2102-8-29**]: Failed attempt to open occluded native OM3 [**2103-5-3**]: No interventions [**2104-9-16**]: balloon PTCA [**69**]% OM1 lesion c/b dissection of the native LCX --> overlapping proximal distal Cypher [**Year (2 digits) **] [**2107-2-21**]: 70% left subclavian artery stenosis --> BMS [**2108-1-5**]: 50% left subclavian artery instent stenosis --> stented [**2108-10-1**]: proximal 80% LAD lesion --> BMS. [**2108-11-29**]: proximal LAD in-stent restenosis --> Xience [**Month/Day/Year **]; POBA of LAD into the diagonal branch distal to the stent . 3. OTHER PAST MEDICAL HISTORY: - Aortic Stenosis/ASD s/p [**Month/Day/Year 1291**] and ASD closure ([**2107-2-22**]) - History of post-op Atrial Fibrillation - Hypothyroidism - Osteoarthritis - Rheumatoid arthritis - Iron deficiency anemia - Depression - Fibromyalgia - S/P cholecystectomy ([**2108-7-9**]) - S/P appendectomy - S/P total abdominal hysterectomy Social History: No tobacco or alcohol use. Lives alone, has 3 children. Family History: Mother with CABG at age 48, died of CAD at age 68. Father had diabetes and coronary artery disease and died of an MI vs. prostate cancer. Physical Exam: VS: BP 144/71, HR 91, 97% on room air. GENERAL: Lying in bed. Intermittantly tearful. Overall appears comfortable. HEENT: NCAT. Sclera anicteric. PERRL (3mm --> 2mm). Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. No dentition. CARDIAC: PMI located in 5th intercostal space, midclavicular line. Regular. Normal S1; mechanical S2. [**3-1**] murmur at LUSB. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Slight crackles. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: Admission Labs: [**2108-12-12**] 02:14AM GLUCOSE-109* UREA N-15 CREAT-0.8 SODIUM-141 POTASSIUM-5.2* CHLORIDE-108 TOTAL CO2-25 ANION GAP-13 [**2108-12-12**] 02:14AM CK(CPK)-178* [**2108-12-12**] 02:14AM cTropnT-0.14* [**2108-12-12**] 02:14AM CK-MB-19* MB INDX-10.7* [**2108-12-12**] 02:14AM CALCIUM-9.2 PHOSPHATE-4.4 MAGNESIUM-2.1 [**2108-12-12**] 02:14AM WBC-6.3 RBC-4.28 HGB-10.1* HCT-31.7* MCV-74* MCH-23.5* MCHC-31.8 RDW-14.6 [**2108-12-12**] 02:14AM NEUTS-66.8 BANDS-0 LYMPHS-25.9 MONOS-5.0 EOS-1.3 BASOS-0.9 [**2108-12-12**] 02:14AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL [**2108-12-12**] 02:14AM PT-16.1* PTT-27.8 INR(PT)-1.4* Cardiac enzymes: [**2108-12-12**] 02:14AM BLOOD CK(CPK)-178* [**2108-12-12**] 09:58AM BLOOD CK(CPK)-528* [**2108-12-13**] 05:24AM BLOOD CK(CPK)-567* [**2108-12-13**] 09:31AM BLOOD CK(CPK)-452* [**2108-12-12**] 02:14AM BLOOD CK-MB-19* MB Indx-10.7* [**2108-12-12**] 02:14AM BLOOD cTropnT-0.14* [**2108-12-12**] 09:58AM BLOOD CK-MB-62* MB Indx-11.7* cTropnT-1.28* [**2108-12-13**] 05:24AM BLOOD CK-MB-57* MB Indx-10.1* cTropnT-1.97* [**2108-12-13**] 09:31AM BLOOD CK-MB-47* MB Indx-10.4* STUDIES: ECG #1 ([**12-11**] at 22:29; OSH): NST at 109. 3 PVCs noted. LVH with LBBB morphology. ST-depressions in V3-V6 in the setting of LVH. ECG #2 ([**12-12**] at 0:30; [**Hospital1 **]): NST at 77. PAC noted. TWI in I/L (old). Long QT? 2D-ECHOCARDIOGRAM ([**2107-4-14**]) 1. LA is moderately dilated 2. Mild symmetric LVH with normal cavity size 3. Mild regional LV systolic dysfunction with inferior hypokinesis (LVEF 50%) 4. RV chamber size and free wall motion are normal 5. A bileaflet AV prosthesis is present 6. Mild (1+) aortic regurgitation is seen. 7. MV leaflets are mildly thickened; no mitral valve prolapse PERSANTINE MIBI ([**2108-12-3**]): 1. Improvement of the previously described fixed inferior wall perfusion defect. No definite new or reversible perfusion defects identified, although the myocardium appears heterogeneous. 2. Global hypokinesis with an LVEF of 36%. CARDIAC CATH ([**2108-11-29**]): - LMCA: short with diffuse disease - LAD: 99% ISRS in the proximal LAD with TIMI 1 flow into the diagonal - LCX: 50-60% diffuse disease proximally - RCA: 100% chronic proximal total occlusion - LIMA->LAD: patent - SVG->OM and SVG->RCA: occluded Cardiac cath ([**12-12**]): 1- Limited selective coronary angiography of the revealed mild disease throughout the short LMCA and subtotal occlusion with evident thrombosis in the recently placed proximal LAD [**Month/Year (2) **] with extension distally of thrombus versus dissection into the LAD-Diagonal distribution. The LCX was a non-dominant vessel with diffuse 60-70% diffuse proximal disease (unchanged from prior). The RCA (known occluded), LIMA (known patent) and SVGs were not engaged (known to be occluded). 2- Limited resting hemodynamic assessment revealed normal systemic arterial pressure (125/66 mmHg). 3- Successful PTCA and stenting of the proximal LAD into a large D1 branch with two overlapping 2.25x28 mm MiniVision (distal) and 2.5x18 mm Vision (proximal) bare-metal stents, both posted with the 2.5x18 mm stent balloon (low pressure distally, high pressure proximally). A contained perforation of a small branch was noted following advancement of the PTGI wire with no expansion of the dye capping area on repeated angographic views (over 15 minutes) and complete hemodynamic stability. A bedside echocardiogram also confirmed the absence of pericardial effusion. Final angiography revealed 0% residual stenosis and no dissection or distal emboli. TIMI III flow was evident. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Subtotally occluded proximal LAD due to thrombosis of the recently placed Xience [**Month/Year (2) **] with extensive thrombus into the diagonal branch (vs. dissection). 3. Successful PTCA and stenting of the proximal LAD into the diagonal branch with two overlapping BMSs. 4- The procedure was complicated by a contained (within the myocardium) perforation of a small branch with dye capping that remained stable on repeated angiographic views. 5- Admit to CCU for overnight observation. 6. D/C Heparin and repeat echocardiogram in AM. [**Month (only) 116**] resume Heparin if no significant pericardial effusion. 7- Lifelong Plavix. TTE ([**12-13**]): The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with basal to mid inferior hypokinesis. Overall left ventricular systolic function is low normal (LVEF 50-55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. 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 mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2107-4-14**], moderate pulmonary hypertension is now detected. Brief Hospital Course: #. CORONARIES/NSTEMI: The patient had a recent admission within the last month at which time she underwent cath which showed an instent thrombosis in the proximal LAD s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) 5175**]. She Now presented with 3+ hours of chest pain and positive cardiac biomarkers. Her ECG at the time of admission did not show significant change. He chest pain improved with IV nitro. She underwent a cardiac catheterization given the rising cardiac enzymes and she was found to have a subtotally occluded proximal LAD stent (Xience 2.5x15 mm [**Last Name (Prefixes) **] placed [**2108-11-29**]) with thrombus evident within the stent and extending distally (versus dissection) involving the LAD-Diagonal distribution. She had 2 BMS placed. During the cath a guide wire entered a small branch vessel with subsequent perforation. An immediate TTE showed no pericardial effusion and a repeat TTE the next am again showed no pericardial effusion. She was continued on plavis 75 mg daily and ASA 81 mg daily. She was continued on her statin and metoprolol. Once her nitro gtt (which was started for hypertensive emergency as below) was weaned off she was restarted on imdur 90 mg daily. It is unclear why the patient presented with restenosis of her proximal LAD stent such a short time after her recent intervention. If the patient represents with chest pain, a platelet aggregation study should be checked as she may be resistent to plavix. #. CHEST PAIN: The patient had another episode of chest pain after the catheterization and stent placement with no EKG changes. She states that her chest pain often is triggered or exacerbated by cold which could indicate esophageal spasm or coronary artery spasm as a possible origin for her pain. Other causes include anxiety, fibromyalgia, or persistent angina from nonvisualized coronary bloackage. She was given ativan prn for anxiety. She was treated for her fibromyalgia syndrome with her home regimen of Morphine SR and Morphine IR prn. She was started on diltiazem 30 mg qid for esophageal spasm and it was planned to discharge her on 120 mg daily, however this was discontinued the day prior to discharge as she was slightly hypotensive. She was continued on imdur 90 mg daily and nitro prn for possible anginal pain. #. PUMP: The patient has a history of mild LV systolic dysfunction, with an EF of 55%. On admission she appeared euvolemic on exam. She had a TTE here which showed mild regional left ventricular systolic dysfunction with an EF of 50-55% and increased left ventricular filling pressure. She was continued on lisinopril and her metoprolol (although this was decreased from her home dose). She had been restarted on lasix as an outpatient, however this was held here given her low SBPs and compelling indications for her multiple other BP medications. #. [**Month/Day/Year 1291**]: The patient was subtherapeutic with an INR of 1.4 on admission. She was started on a heparin gtt which was briefly held after her cath given the perforation of a small branch of her LAD, but was restarted after a TTE showed no pericardial effusion so the heparin was restarted until her INR was therapeutic on coumadin. She was also restarted on coumadin and her INR at discharge was 3.0. #. HTN: The patient was hypertensive with SBP's in the 190's at presentation with chest pain, consistent with hypertensive emergency and was acutely controlled with a nitroglycerin gtt. She was initially continued on her home amlodipine, lisinopril, imdur, and Toprol. Her Toprol was briefly stopped as she was started on diltiazem as above for possible esophageal spasm and her BP became low, however it was restarted at a lower dose of 100 mg daily and her amlodpinine and diltiazem were stopped. #. RHYTHM: The patient has a history of atrial fibrillation, but remained in sinus rhythm during this hospitalization. #. DEPRESSION: The patient was continued on duloxetine. #. HYPOTHYROIDISM: The patient was continued on her outpatient levothyroxine dose. #. ANEMIA: The patient is known to have a chronic microycytic anemia and was continued on supplemental iron. Medications on Admission: 1. Aspirin 325 mg daily 2. Clopidogrel 75 mg daily 3. Metoprolol 50 mg TID 4. Atorvastatin 80 mg daily 5. Amlodipine 5 mg daily 6. Lisinopril 40 mg daily 7. Nitrostat 0.4 mg PRN 8. Imdur 90 mg daily 9. Warfarin 7.5 mg daily 10. Levothyroxine 50 mcg daily 11. Morphine 15 mg SR Q12H 12. Morphine 15 mg Q4H PRN 13. Duloxetine 60 mg daily 14. Ascorbic Acid 1000 mg daily 15. Omeprazole 40 mg daily 16. Milk of Magnesia PRN 17. Trazodone 100 mg [**12-29**] QHS PRN 18. Ferrous Sulfate 325 mg daily 19. Acetaminophen 325 mg PRN 20. Magnesium Hydroxide PRN 21. Docusate Sodium 100 mg [**Hospital1 **] Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). [**Hospital1 **]:*60 Tablet(s)* Refills:*2* 3. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). [**Hospital1 **]:*60 Tablet Sustained Release(s)* Refills:*0* 4. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. [**Hospital1 **]:*40 Tablet(s)* Refills:*0* 5. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Three (3) Capsule, Delayed Release(E.C.) PO DAILY (Daily). [**Hospital1 **]:*90 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 6. Ascorbic Acid 500 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). [**Hospital1 **]:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 8. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. [**Hospital1 **]:*10 Tablet(s)* Refills:*0* 9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*11* 12. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). [**Hospital1 **]:*30 Tablet, Sublingual(s)* Refills:*2* 13. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). [**Hospital1 **]:*90 Tablet Sustained Release 24 hr(s)* Refills:*2* 14. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed for anxiety. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 15. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). [**Hospital1 **]:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 16. Meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for dizziness. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 17. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 18. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. [**Hospital1 **]:*90 Tablet(s)* Refills:*2* 19. Zofran 4 mg Tablet Sig: 1-2 Tablets PO q8 hours PRN. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 20. Nitroglycerin 0.4 mg/Dose Spray, Non-Aerosol Sig: One (1) spray Translingual PRN: every 5 minutes as needed. [**Hospital1 **]:*1 bottle* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Primary Diagnosis: 1. Non ST elevation myocardial infarction 2. Vertigo 3. Chest Pain Secondary Diagnoses: 4. s/p Aortic Valve Repair 5. Depression 6. Anxiety 7. Hypothyroidism 8. Hypertension Discharge Condition: stable; chest pain free Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 2 liters You were admitted for chest pain. You had a heart attack based on the cardiac lab tests that we checked. You were taken to cardiac catheterization, where you had a stent placed. You had intermittent episodes of chest pain after the procedure. Your home medications were adjusted to help control your chronic chest pain. You were started on Meclizine for vertigo. Upon arrival to the hospital, your INR level was low, therefore your coumadin dose was adjusted accordingly. You must take your medications every day, and have your INR checked regularly per your PCP. [**Name10 (NameIs) 357**] have your INR checked on Tuesday, [**12-18**] and send this result to your PCP. Please continue all medications as prescribed. The diltiazem was stopped the day prior to discharge. Do not take this medicaiton. Please keep all follow up appointments with your physicians. If you develop any of the following concerning symptoms, please call your PCP, [**Name10 (NameIs) 2085**], or go to the ED: worsening chest pains, shortness of breath, fevers, chills, nausea, or vomiting. Followup Instructions: Please keep your appointment on [**12-21**] with your primary doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 17753**]). Please call your cardiologist to be seen in the next 2-4 weeks. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 19117**] [**Telephone/Fax (1) 4105**] Follow-up appointment should be in 1 month Please have your INR checked on Tuesday, [**12-18**] and send these results to your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. Completed by:[**2108-12-17**]

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icd9cm

[ [ [] ] ]

[ "36.06", "00.46", "37.22", "00.66", "00.40", "88.56" ]

icd9pcs

[ [ [] ] ]

17662, 17733

10101, 14300

319, 377

17971, 17997

4644, 4644

19252, 19806

3642, 3781

14945, 17639

17754, 17754

14326, 14922

8360, 10078

18021, 19229

3796, 4625

17862, 17950

2487, 3190

5397, 8343

269, 281

405, 2371

4660, 5380

17773, 17841

3221, 3552

2393, 2467

3568, 3626

22,796

147,284

52020

Discharge summary

report

Admission Date: [**2190-11-8**] Discharge Date: [**2190-11-19**] Date of Birth: [**2112-11-22**] Sex: F Service: CARDIOTHORACIC Allergies: Codeine / Levofloxacin / Niacin / Ibuprofen Attending:[**First Name3 (LF) 1283**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2190-11-12**] Aortic Valve Replacment(23 millmeter CE Magna Pericardial) and Mitral Valve Replacement(27 millimeter CE Pericardial) with Partial Pericardiectomy History of Present Illness: Mrs. [**Last Name (STitle) **] is a 77 year old female with known AR and MR. She has been admitted multiple times for CHF. She was admitted today for reversal of her Warfarin and surgical management of her mitral and aortic valve disease. Past Medical History: Congestive Heart Failure; History of Rheumatic fever; Atrial Fibrillation; Obesity; History of Lower Extremity Cellulitis; History of Deep Vein Thrombosis; s/p Total Knee Replacements; s/p Colecystectomy Social History: Lives alone. Retired. No alcohol. Non-smoker. Family History: Non-contributory Physical Exam: VITALS: T 98.1, P 52, BP 112/50, RR 18, SAT 93% RA GENERAL: Elderly female in no acute distress NEURO: alert and oriented, no focal deficits noted NECK: supple, no JVD PULM: Clear bilaterally HEART: regular rate, normal s1s2, 3/6 systolic murmur best heard at apex ABD: Obese, soft, nontender, nondistended. Normoactive bowel sounds EXT: Warm, well perfused. Bilateral LE shiny, diffuse erythema, and 2+ edema. (Pt states this is much improved from 1-2 months ago.) Pertinent Results: [**2190-11-8**] 05:05PM PT-14.9* PTT-26.0 INR(PT)-1.5 [**2190-11-8**] 05:05PM WBC-8.4 RBC-5.15 HGB-15.5 HCT-44.0 MCV-85 MCH-30.1 MCHC-35.2* RDW-13.8 [**2190-11-8**] 05:05PM ALT(SGPT)-26 AST(SGOT)-30 LD(LDH)-225 ALK PHOS-108 AMYLASE-44 TOT BILI-0.5 [**2190-11-8**] 07:25PM %HbA1c-7.3* [Hgb]-DONE [A1c]-DONE [**2190-11-8**] 07:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2190-11-8**] CXR - No acute cardiopulmonary process [**2190-11-9**] EKG - Sinus bradycardia. Modest diffuse low amplitude T waves with prolonged Q-Tc interval. [**2190-11-18**] 05:30AM BLOOD WBC-11.2* RBC-3.59* Hgb-11.1* Hct-32.9* MCV-92 MCH-30.9 MCHC-33.7 RDW-14.5 Plt Ct-186 [**2190-11-19**] 03:00AM BLOOD PT-15.1* PTT-90.7* INR(PT)-1.6 [**2190-11-18**] 05:30AM BLOOD Glucose-157* UreaN-16 Creat-0.4 Na-142 K-3.8 Cl-101 HCO3-33* AnGap-12 [**2190-11-17**] 05:21AM BLOOD ALT-16 AST-17 AlkPhos-85 Amylase-38 TotBili-0.6 [**2190-11-17**] 05:21AM BLOOD Mg-2.0 [**2190-11-8**] 07:25PM BLOOD %HbA1c-7.3* [Hgb]-DONE [A1c]-DONE Brief Hospital Course: Ms. [**Name13 (STitle) **] was admitted to the [**Hospital1 18**] on [**2190-11-8**] for surgical managemnet of her valvular heart disease. Warfarin was discontinued in anticipation of surgery. She was started on Heparin for anticoagulation when her INR dropped below 2.0. She underwent routine preoperative evaluation which included vascular and ID consults given her history of leg cellulitis and deep vein thrombosis. There was no evidence of active cellulitis and she was subsequently cleared for surgery. Workup was otherwise unremarkable. She remained stable on intravenous Heparin and medical therapy. Vitamin K was required to improve her INR prior to the operation. On [**2190-11-12**], Dr. [**Last Name (STitle) 1290**] performed an aortic valve replacment(23 millmeter CE Magna Pericardial) and mitral valve replacement(27 millimeter CE Pericardial) with partial pericardiectomy. Following the operation, she was brought to the CSRU for invasive monitoring. Within 24 hours, she awoke neurologically intact and was extubated. She weaned from inotropic support without difficulty. She was aggressively diuresed but initially required 40% face tent to maintain oxygen saturations. She also required agressive pulmonary toilet. She was initially noted to have a first degree AV block. Low dose beta blockade was eventually resumed. She maintained stable hemodynamics and eventually transferred to the SDU on postoperative day four. She went back into atrial fibrillation. Temp. pacing wires were removed prior to coumadin resumption, and she continued on amiodarone.Heparin drip was started for coverage until INR was therapeutic ( goal 2.0-2.5). Foley removed on POD #5 and beta blockade increased.KUB done for distended abdomen which revealed possible ileus, but no obstruction. This improved the next day and diet was advanced slowly. She had some diffuse rhonchi and aggressive pulmonary toilet was encouraged. Screened for rehab. INR 1.6 on POD #7, and cleared for discharge to rehab. AFib at 50, 118/86 sat 99% on 4L NC RR 20. Lopressor decreased today to 25 [**Hospital1 **]. Discharged on [**2190-11-19**]. Medications on Admission: Amiodarone 400 [**Hospital1 **], Lopressor 75 [**Hospital1 **], Lasix 80 [**Hospital1 **], Norvasc 5 qd, Lisinopril 10 qd, Warfarin 2 mg Qd, Aspirin 81 qd, KCL 40 tid, Iron 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. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Metoprolol Tartrate 25 mg Tablet Sig: 1 Tablet PO BID (2 times a day). 6. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Four (4) Capsule, Sustained Release PO Q12H (every 12 hours). 7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (once) for 1 doses: dose for Friday [**11-19**] only . 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at [**Hospital6 1109**] - [**Location (un) 1110**] Discharge Diagnosis: Congestive Heart Failure - s/p Aortic Valve Replacment(23 millmeter CE Magna Pericardial) and Mitral Valve Replacement(27 millimeter CE Pericardial) with Partial Pericardiectomy; Atrial Fibrillation; Obesity; History of Lower Extremity Cellulitis; History of Deep Vein Thrombosis; s/p Total Knee Replacements; s/p Colecystectomy Discharge Condition: Good Discharge Instructions: 1) Shower, wash incision with soap and water and pat dry. No lotions, creams or powders or baths. 2) Call with redness or drainage from incision, fever greater then 100.5, or weight gain more than 2 pounds in one day or five in one week. 3) No heavy lifting or driving until follow up with surgeon. 4) Call with any questions or concerns. 5) blood draw for INR tomorrow/ daily coumadin dosing [**Name6 (MD) **] rehab MD Followup Instructions: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1290**] in [**4-20**] weeks Dr. [**Last Name (STitle) 1266**](PCP) in 3 weeks - call for appt Local cardiologist in 3 weeks - call for appt Resume Warfarin management as outpatient with Dr. [**Last Name (STitle) 1266**] after rehab discharge. [**Telephone/Fax (1) 608**] Goal INR 2.0-2.5 Completed by:[**2190-11-19**]

[ "250.00", "423.2", "790.92", "459.81", "V43.65", "396.3", "V12.51", "397.0", "398.91", "427.31", "278.00" ]

icd9cm

[ [ [] ] ]

[ "35.21", "35.23", "38.93", "39.61", "37.31" ]

icd9pcs

[ [ [] ] ]

5776, 5921

2687, 4814

332, 498

6294, 6301

1591, 2664

6769, 7160

1072, 1090

5037, 5753

5942, 6273

4840, 5014

6325, 6746

1105, 1572

273, 294

526, 766

788, 993

1009, 1056

19,246

193,292

3459

Discharge summary

report

Admission Date: [**2130-12-20**] Discharge Date: [**2130-12-27**] Date of Birth: [**2067-10-24**] Sex: F Service: MEDICINE Allergies: Ceclor / Cephalexin / Codeine / Sulfonamides / Alprazolam Attending:[**First Name3 (LF) 7202**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: none History of Present Illness: CC:[**CC Contact Info 15943**]. HPI: Patient is a 63 yo female with logn standing h/o ischemic CM, EF 20-25% on chronic dopamine, mechanical MVR, h/o UBIB and AVM, presents from [**Hospital1 **] with GI bleed and BRBPR times [**12-22**] days. Patient reports brown stool with BRBPR and bright blood in toilet bowel. Patient also had nause and vomited times 1 today that was clear. Patient's HCT dropped to 15.3, (24-29) and BP 80/40,and patient sent to the [**Hospital1 18**] ED, on NS at 200cc/Hr. In the ED, patient not complaining of dizziness, weakness, CP, SOB and SBPs in 80s (baseline 90s). Patient also reporting no melena, coffee ground emesis, and pain. Patient ordered for 1U FFP and 1U Blood, 5 mg Vit K, and GI consulted. Patient admitted to the MICU. Patient also seen by GI in the ED. Patient was transfused 4U PRBC and 3U FFP and Dopa increased to 16 from baseline of 8. Patient had a right ankle fracture in [**2130-8-19**], S/P I&D and [**Last Name (un) **] on [**2130-11-22**] for an exposed ORIF site. She was discharged to complete a 6 week course of Augmentin after her I&D and [**Last Name (un) **]. Patient dcd her Augmentin [**12-21**] diarrhea and readmitted on [**2130-12-5**] with CP. She was restarted on vancomycin and unasyn to complete a 6 week course ending on [**2131-1-16**]. She was also continued on a wound vac during hospitalization and followed by the orthopaedics service. Prior to discharge, her wound vac was D/C'ed and she was changed to wet-to-dry dressings, per recommendations by orthopaedics discharge. Four of four bottles were also positive for [**Female First Name (un) **] parapsilosis. She was emperically started on ambisome at 5 mg/kg. Surveillance cultures were drawn daily, and remained positive through [**12-4**]. Subsequent cultures were negative. Given her high grade fungemia, there was concern for seeding of her mechanical mitral valve. TEE on [**2130-12-12**] which showed a clean prosthetic valve (results detailed above). Her right PICC line was also exchanged for a left PICC line, placed by interventional radiology. She was evaluated by ophthalmology and ruled out for endophthalmitis. She also had a right upper extremity doppler to rule out septic thrombus. She was changed from IV ambisome to PO fluconazole, to complete a course ending on [**2131-1-2**]. Patient was also ruled out for MI and remained stable in terms of her CHF and anticogulation . Currently no complains of pain, nausea, vomiting, CP, SOB or other complaints. She is still having dark stool in rectal tube output. Past Medical History: 1. CAD s/p CABG '[**20**] (revision '[**23**]) -Revision: Coronary artery bypass graft x3 aortosaphenous vein graft to left anterior descending artery; aortosaphenous vein graft performed sequentially to the first diagonal branch and then to the first obtuse marginal branch. 2. ischemic cardiomyopathy 3. CHF 20-25% on chronic dopamine pump at 8mcg/kg/min since [**2124**] 4. Afib/Aflutter s/p ablation & Pacer placement 5. h/o GIB + AVM 6. PUD 7. Anemia of chronic disease, iron def anemia 8. s/p MVR w/ mechanical valve in '[**17**] goal INR ~ 2.5 due to GI bleed 9. h/o nocardia bacteremia with septic emboli 10. h/o c-section x3 [**35**]. h/o DM, not currently on any meds, not being monitored Social History: Reports that she quit smoking about 2wks ago. Previously smoke 1/2ppd. Has been on dopa gtt for 6yrs. Physical Exam: PE: VS T981.3 P80-86 paced BP 91-111/51-55 R16-24 SAt 95% RAdopa @ 5mcg/kg/hr GEN aao, nad HEENT PERRL, MMM, flat JVD CHEST CTAB no crackles CV RRR with loud second heart sound with murmur ABD soft NT/ND, +BS EXT no edema, right ankle in cast Pertinent Results: TEE ([**2130-12-12**]): [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6878**], complex (>4mm) non-mobile atheroma in the aortic arch and simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but without discrete vegetation. Trace aortic regurgitation is seen. A well-seated bileaflet mechanical mitral valve prosthesis is present. The motion of the mitral valve prosthetic leaflets appears normal. There is a very mild paravalvular leak. No mass or vegetation is seen on the mitral valve. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. Brief Hospital Course: A/P: 69 yo female with h/o ischemic CM, s/p pacer, mechanical MVR, h/o upper GIB, and recent ORIF complicated by fungemia, presents with GIB without clear source. . 1. GIB: She had a bleeding study on [**12-21**] that was negative for lower GI bleed. Her EGD on [**2130-12-22**] showed no source of bleed, normal esophagus, and slight mosaic appearance of stomach mucosa. She continued to have dark stool in her rectal tube. Her Hct was initially stable, but dropped again. Colonoscopy was done on [**2130-12-24**], with no source of bleeding identified. She was maintained on heparin for her MVR. She received a total of 8U PRBC and 3U FFP. She had no further episodes of melena or BRBPR, and her Hct remained stable at 30.0. She was restarted on Coumadin, to be titrated at rehab. . 2. Ischemic CM and CHF: Ruled out for MI. No evidence of CHF exacerbation. She was continued on her dopamine gtt as per home regimen. Primary cardiologist, Dr [**First Name (STitle) 437**], [**First Name3 (LF) **] try to wean in future. She was continued on spironolactone and furosemide. Her carvediolol and enalapril were initially held for concern for hypotension. They were added back and tolerated well, to be titrated by PCP and cardiologist. She appeared euvolemic on discharge. . 3. Afib/flutter: She was stable s/p ablation on amiodarone and with AVpacer. Her carvedilol was later restarted. . 4. Osteomyelitis: S/p I&D and [**Last Name (un) **] on [**2130-11-22**] for exposed ORIF site. Ortho following, walk boot in place. She was continued on vancomycin and amp/sulbactam, planned for a 6-week course. She has follow up with ID on [**2131-1-16**]. . 5. Candidemia: [**Female First Name (un) 564**] parapsilosis on [**12-1**], likely source R PICC, which was discharged. Ophtho eval showed no endophthalmitis and TTE on [**12-11**] showed no definite vegetation. Stable on fluconazole, to complete a 4 week course through [**2131-1-2**] per ID recs. . 6. DM: Stable on humalog sliding scale. ACE-inhibitor restarted once BP stable. . 7. Code: FULL Medications on Admission: MEDS on admission: 1. Aspirin 81 mg Tablet QD 2. Atorvastatin 10 mg DAILY 3. Carvedilol 6.25 mg [**Hospital1 **] 4. Enalapril Maleate 5 mg [**Hospital1 **] 5. Furosemide 120mg [**Hospital1 **] 6. Spironolactone 25 mg DAILY 7. Dopamine 8 mcg/kg/min continuous infusion 8. Amiodarone 200 mg DAILY 9. Ampicillin-Sulbactam 3 gm IV Q6H 10. Vancomycin 750 mg Q24H 11. Fluconazole 400 mg PO Q24H 12. Warfarin 5 mg Tablet HS 13. Ferrous Sulfate 325 QD 14. Pantoprazole 40 mg Q24H 15. Sertraline 100 mg [**Hospital1 **] 16.Fexofenadine 60 mg [**Hospital1 **] PRN 17. Oxycodone 10 mg Tablet Sustained Release 18. Oxycodone 5 mg PO Q6H PRN 19. Insulin Lispro (Human) 100 unit/mL Solution 20. Epogen 10,000 unit/mL once a week. . Meds on Transfer: Heparin IV Sliding Scale Acetaminophen 325-650 mg PO Q4-6H:PRN Insulin SC Sliding Scale Amiodarone HCl 200 mg PO DAILY Atorvastatin 10 mg PO DAILY Pantoprazole 40 mg IV Q12H Dolasetron Mesylate 12.5 mg IV Q8H:PRN DopAmine 5-20 mcg/kg/min IV DRIP TITRATE Sertraline HCl 100 mg PO BID Furosemide 120 mg PO BID Spironolactone 25 mg PO DAILY Vancomycin HCl 750 mg IV Q 24H Ampicillin-Sulbactam 3 gm IV Q6H Fluconazole 400 mg IV Q24H Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Sertraline 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Dopamine in D5W 1,600 mcg/mL Solution Sig: 6-20 mcg/kg/min Intravenous TITRATE TO (titrate to desired clinical effect (please specify)). 6. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 7. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 8. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Ampicillin-Sulbactam [**12-20**] g Recon Soln Sig: Three (3) g Injection Q6H (every 6 hours). 15. Vancomycin 500 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750) mg Intravenous Q 24H (Every 24 Hours). 16. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: Eight [**Age over 90 1230**]y (850) units/hr Intravenous ASDIR (AS DIRECTED): Continue existing infusion at 850 units/hr Target PTT: 60 - 100 seconds . 18. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary: Gastrointestinal bleed, unclear source Congestive Heart Failure, systolic Discharge Condition: good, stable hematocrit and hemodynamics Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1.5L Please take all of your medications as prescribed. If you experience any chest pain, shortness of breath, lightheadedness, bloody or black stools, or other concerning symptoms, please contact your doctor or return to the ER. Followup Instructions: 1) PCP: [**Name10 (NameIs) 357**] call Dr. [**First Name (STitle) 2031**] ([**Telephone/Fax (1) 15944**] to schedule a follow up appointment within the next 1-2 weeks. 2) ID: You have an appointment with Dr. [**First Name (STitle) 2505**] on [**2131-1-16**] at 9:00am ([**Telephone/Fax (1) 6732**]. 3) Cardiology: Please call Dr. [**First Name (STitle) 437**] ([**Telephone/Fax (1) 4965**] to schedule a follow up appointment within the next month. 4) Antibiotics/Antifungals: - Continue Unasyn (ampicillin/sulbactam) until [**2131-1-16**]. - Continue Vancomycin until [**2131-1-16**] - Continue Fluconazole until [**2131-1-2**] Completed by:[**2130-12-29**]

[ "414.8", "V43.3", "V45.01", "428.22", "730.27", "112.5", "578.9", "427.31", "V45.81", "397.0", "285.1", "428.0", "250.00" ]

icd9cm

[ [ [] ] ]

[ "99.04", "99.07", "45.23", "45.13", "00.17" ]

icd9pcs

[ [ [] ] ]

9652, 9731

4730, 6797

327, 333

9858, 9901

4053, 4707

10300, 10965

8015, 9629

9752, 9837

6824, 6829

9925, 10277

3787, 4034

282, 289

361, 2928

6843, 7543

2950, 3651

3667, 3772

7561, 7992

76,693

122,483

12712

Discharge summary

report

Admission Date: [**2165-3-26**] Discharge Date: [**2165-4-15**] Date of Birth: [**2085-4-6**] Sex: F Service: SURGERY Allergies: Heparin Agents Attending:[**First Name3 (LF) 371**] Chief Complaint: s/p MVC, multiple traumatic injuries Major Surgical or Invasive Procedure: [**2165-3-29**] 1. TFN fixation of left hip with 11 x 170 x 130 nail. 2. Open reduction internal fixation right ankle with examination under anesthesia with fluoroscopy for assessment of stability. 3. Open reduction internal fixation left ankle with examination under anesthesia with fluoroscopy for assessment of mortise stability. 4. Open reduction internal fixation of right tibial plateau fracture with examination under anesthesia with fluorosocopy for stability. 5. Closed treatment left fibular shaft fracture [**2165-3-29**] 1. Ultrasound-guided puncture of right common femoral vein. 2. Inferior venacavogram. 3. Deployment of Celect inferior vena cava filter at L4. [**2165-4-2**] Right chest tube thoracostomy [**2165-4-10**] PICC line placement History of Present Illness: Mrs. [**Known lastname 39231**] is a 79 year old woman t-boned during an MVC during which she lost consciousness. She was initially transferred to [**Hospital3 **] Hospital where imaging revealed multiple injuries, including posterior L 6th rib fx, L intertrochanteric fracture, L ankle fracture, L superior ramus fracture, R tibial plateau fracture, and R ankle fracture. She became hypotensive while at [**Hospital3 **] Hospital so was urgently transferred to our institution for further management. Past Medical History: PMH: "cardiac disease"+angina, diabetes, HTN Social History: Denies smoking, no ETOH Family History: non-contributory Physical Exam: Exam on admission: HR:60 BP:97/p Resp:18 O(2)Sat:92% Low Constitutional: Comfortable HEENT: ecchymosis R forehead, EOMI c collar in place Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Soft, Nontender, Nondistended GU/Flank: stable pelvis Extr/Back: + DP pulses on doppler Skin: ecchymosis R thigh Neuro: Speech fluent Psych: Normal mood, Normal mentation Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae Pertinent Results: [**2165-3-26**] CXR: There is a large right pneumothorax with right upper lobe and likely right middle lobe collapse. The right hemidiaphragm is depressed. No mediastinal shift is appreciated. Heart size is top normal. The left lung is well aerated. A left seventh rib fracture is seen. [**2165-3-27**] ECHO: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 10-15mmHg. 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 cavity is mildly dilated with borderline normal free wall function. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly 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. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. [**2165-3-27**] XR PELVIS: Left femoral intertrochanteric fracture. No definite pelvic fracture, but if there is clinical concern for occult fracture, CT could be performed. [**2165-3-29**] Renal US : 1. No evidence for renal artery stenosis. 2. Multiple parenchymal and parapelvic cysts bilaterally. No evidence of hydronephrosis. [**2165-3-30**] Head CT : Normal head CT. A small amount of subcutaneous air in the neck posteriorly [**2165-4-1**] MRI Head : No evidence of acute intracranial process. Scattered FLAIR hyperintensities within the periventricular and subcortical white matter are present which likely represent the sequela of chronic small vessel ischemic disease. [**2165-4-6**] Duplex scan B/L lower extremities : 1. Thrombus in the right greater saphenous vein, and non-occlusive thrombus within the right common femoral vein. 2. Occlusive thrombus within the left common femoral vein extending into the left proximal superficial vein and greater saphenous vein. 3. The right popliteal vein was noted to demonstrate flow; however, was not interrogated for compression. The left popliteal vein and bilateral calf veins were not assessed due to presence of brace. [**2165-4-9**] CXR : AP single view of the chest has been obtained with patient in upright position. Available for comparison is the next preceding portable supine chest examination of the same day obtained nine hours earlier. During the interval, the previously existing right-sided chest tube has been removed. The lung remains well aerated and no pneumothorax has developed. No new pulmonary abnormalities are seen. [**2165-3-26**] 03:50PM WBC-20.4* RBC-3.50* HGB-10.7* HCT-30.8* MCV-88 MCH-30.5 MCHC-34.7 RDW-13.7 [**2165-3-26**] 03:50PM PT-14.8* PTT-22.6 INR(PT)-1.3* [**2165-3-26**] 03:50PM PLT COUNT-158 [**2165-3-26**] 03:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2165-3-26**] 03:50PM UREA N-53* CREAT-1.8* [**2165-3-26**] 03:53PM HGB-11.1* calcHCT-33 O2 SAT-78 CARBOXYHB-2 MET HGB-0 [**2165-3-26**] 03:53PM GLUCOSE-219* LACTATE-4.0* NA+-139 K+-4.8 CL--101 TCO2-25 TEST RESULT ---- ------ HEPARIN DEPENDENT ANTIBODIES Positive COMMENT: Positive for Heparin PF4 Antibody Test by [**Doctor First Name **]. Result reported to [**Last Name (LF) **], [**Name8 (MD) **] RN on [**2165-4-8**] @3:58PM Complete report on file in the laboratory. Brief Hospital Course: After initial resuscitation and stabilization in the trauma bay, the patient was admitted to the trauma ICU for close monitoring under the acute care surgery service. Her hospital course is as follows by systems: NEURO: The patient's pain was initially controlled with a dilaudid PCA. Later, after she was intubated, she was placed on a fentanyl drip. On [**4-1**], the patient had persistent decreased mental status and both CT and MR of her head were obtained. These showed no acute changes and her mental status changes were attributed to her metabolic derangements and acute disease. This was followed and returned to her baseline through the course of her ICU stay. CVS: The patient was transferred to our institution because of hypotension with SBPs down to the 70s. She received close to 5L of crystalloids and 2units of blood to support her BPs on the first day of her accident. She was transiently placed on pressors (levophed) in the early morning [**2165-3-27**]. Given her history of CAD and CHF, an echo was performed [**2165-3-27**] which revealed preserved LV global systolic function and LVEF of >55%. PULM: At the outside hospital, the patient's O2 sats were 100% on 2L. In the trauma bay at our institution, in the course of attempting to place a R subclavian central line, there was aspiration of air. A post-procedure CXR was obtained which did not show evidence of PTX. However, later in the evening, the patient began to desat down into the mid-80s despite increasing her supplemental oxygen. A CXR that evening showed a large R-sided tension PTX. The next morning on HD2, the patient was intubated and a R-sided chest tube was placed. She remained intubated for several days and after return from the OR with orthopedics, while her pulmonary mechanics were sufficient for extubation, it was determined that she would most likely not be able to protect her airway [**2-13**] mental status and she was left intubated. She was left intubated until her mental status was improving, and developed a haemophilus influenzae pneumonia for which she was treated with vancomycin and zosyn, and this prolonged her intubation. A family meeting was held regarding this and the [**Hospital 228**] health care proxy requested extubation, acknowledging that this could potentially be a terminal extubation. After further discussing between the ICU team, ACS team, Ethics committee and the patients family, the patient was left intubated until [**4-8**] at which point she was extubated successfully. FEN/GI: The patient was initially kept NPO on admission. She was initially started on IV fluids. However, when she started to have respiratory problems, her fluids were heplocked due to concerns that she might be developing pulmonary edema in light of her cardiac history. She was restarted on fluids in the evening of HD2 since her FeNa from the previous day showed that she was prerenal. The patient also developed hyperkalemia HD1 with a K as high as 6.0. An EKG was checked which did not show peaked T waves. She was given kayexalate the following day with improvement of her K level to 4.8. He electrolytes were stable for the remainder of her ICU admission. GU: The patient's initial Cr at the OSH was 1.5. This gradually trended upwards over the course of the next few days and the patient was oliguric. FeNa was 0.5 so patient was given IV fluid resuscitation. Following this her Cr improved but remained elevated for the duration of her admission. HEME: Serial hct checks were performed. Her initial hct on admission was 30.8. After 2 units of pRBC, her hct was 33.4. Her hct gradually drifted down to 24 by the next day and she was transfused another 2 units of pRBC given her hypotension and cardiac history. She received several additional transfusions through her course to maintain an adequate hematocrit, but never demonstrated any acute bleeding. She also had thrombocytopenia noted just after admission to a low of 30K on [**2165-4-7**]. Heparin was stopped and Argatroban was used for anticoagulation. A HIT panel was positive. Coumadin was started on [**2165-4-9**] for bilateral DVT's for pprotection along with her IVC filter. ENDO: The patient was a type I diabetic and was initially put on a regular insulin sliding scale since we did not know what her normal insulin regimen was. Her blood glucose levels were not well-controlled on this regimen so she was put on an insulin drip until adequate control was achieved after which she was maintained on an insulin sliding scale/basal insulin. ID: During the patients ICU course she developed an H. Influenzae pneumonia for which she was treated with vancomycin and zosyn. Following transfer to the Trauma floor her mental status gradually improved though she had periods of being withdrawn. She was seen by the Speech and swallow service and began a diet of nectar thick liquids and ground solids. After a period of time she was started on Mirtazapine for appetite stimulation at a low dose. Calorie counts along with protein supplements were also added. Although she is able to feed herself, at times she needs assistance. She worked with the Physical and Occupational Therapy services to help improve her ability to get from bed to chair as she remains non weight bearing on both lower extremities. On [**2165-4-12**] she was found obtunded in the early morning with a blood sugar of 26. She received D50 and her blood sugar increased along with her mantal status. She was transferred back to the ICU to assure stabelization which was the case. Unfortunately she was very discouraged and decided against rehab and actually expressed that she have nothing more done to promote recovery. Both she and her family wanted to meet with the Palliative Care team: please see note in OMR by Dr. [**First Name (STitle) **] in regard to the outcome of this meeting. Coumadin was held since [**2165-4-11**] as she had only 2 doses (5mg followed by 2.5 mg) and her INR rose to 7.1. She had an IVC filter in place and she had not received FFP or Vitamin K. On [**2165-4-15**] a family meeting with the surgical team and social work had been scheduled to define goals of care and to determine wether the patient was going to be made CMO and, in case of discharge, wether she would go to a rehabilitation facility, an hospice or home to her family. On the same day, while the family was present, [**Known lastname 39232**] respiratory status started to rapidly deteriorate. The family decided to make her CMO and she expired shortly thereafter, with the family at the bedside. Her death report was completed and the medical examiner notified (Dr.[**First Name (STitle) 39233**]) and accepted the case. Medications on Admission: atenolol, lipitor, KDur, Ditropan, ASA, Zetia, Accupril, Humalog (70/30), Lasix, Nitrostat, Imdur Discharge Disposition: Expired Discharge Diagnosis: S/P MVC 1. Bilateral ankle fractures 2. Right tibial plateau fracture 3. Left peritrochanteric hip fracture 4. Right pubic rami fracture 5. Left 6th rib fracture 6. Right pneumothorax 7. + HIT 8. Haemophilus pneumonia 9. Acute renal failure 10.Acute blood loss anemia Discharge Condition: Pt expired shortly after being made CMO by the family and HCP Discharge Instructions: NA Followup Instructions: NA Completed by:[**2165-4-15**]

[ "276.1", "920", "458.8", "250.80", "584.9", "428.22", "453.41", "799.02", "808.2", "428.0", "820.21", "V49.86", "807.01", "482.2", "780.09", "824.4", "287.5", "V43.64", "E812.0", "518.5", "V58.61", "787.20", "278.00", "289.84", "E879.8", "E932.3", "707.03", "823.01", "823.02", "276.7", "414.01", "707.22", "V66.7", "401.9", "512.1", "285.1", "272.0", "998.81", "413.9" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.6", "79.06", "38.93", "96.72", "34.09", "38.97", "38.91", "79.15", "81.47", "88.51", "79.36", "38.7" ]

icd9pcs

[ [ [] ] ]

12921, 12930

6086, 12772

309, 1091

13242, 13306

2294, 6063

13357, 13391

1748, 1766

12951, 13221

12798, 12898

13330, 13334

1781, 1786

233, 271

1119, 1622

1801, 2275

1644, 1691

1707, 1732

47,133

171,415

39889

Discharge summary

report

Admission Date: [**2143-10-31**] Discharge Date: [**2143-11-12**] Date of Birth: [**2075-3-2**] Sex: M Service: NEUROLOGY Allergies: Sulfa (Sulfonamide Antibiotics) / Penicillins Attending:[**First Name3 (LF) 618**] Chief Complaint: Left facial droop, left sided weakness Major Surgical or Invasive Procedure: PEG tube placement on [**2143-11-8**] History of Present Illness: [**Known firstname **] [**Known lastname **] is a 68 yo man with a history of hypertension and coronary artery disease who comes to us as a transfer from [**Hospital1 **]. The history is obtained from the patient's wife. Apparently, Mr. [**First Name (Titles) 40798**] [**Last Name (Titles) 5058**] this morning and felt tightness in his left face- on review in the mirror he notes a left facial droop. He was brought to [**Hospital **] hospital by this family and there he had slurred speech and drooling from his left face. He apparently had no other symptoms and a diagnosis of bell's palsy was made and the patient was discharged home with prednisone. He went home, ate lunch, showered and took a the presnisone, promptly vomiting after the first dose. He took a nap around 3 or 4pm and when he woke up around 6:30pm, be began vomiting and complaining of pain behind his eyes. He was taken to [**Hospital1 **] again. Blood pressures ranged from 160-204/87-119. CT of the head showed a large, right frontoparietal hemorrhage with scattered areas of subarachnoid blood. He was transferred here for further evaluation. The patient is currently non-verbal and cannot participate in a ROS. Per his family, there has been no recent illness. There is no known head trauma. He has no history of stroke. Past Medical History: - CAD: MI in [**2111**], S/p bypass in [**2121**], has had cardiac stents placed in [**2132**]. - HTN - HLD Social History: From [**State 3908**], here visiting his daughter. [**Name (NI) **] is a retired businessman. Married. No smoking, drinks a glass of wine daily, martinis on the weekend. Family History: Father w/ MI Brther w/MI Mother with diabetes Physical Exam: T 101.5 BP 167/88 HR 59 RR 18 100% 2L Head and Neck: no cranial abnormalities, no scleral icterus noted, mmm, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs clear to auscultation bilaterally Cardiac: regular rate and rhythm, normal s1/s2. No murmurs Abdomen: soft, non-tender, normoactive bowel sounds, no masses or organomegaly noted. Extremities: 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: General: resting with eyes closed, rouses to voice. Right head deviation, slight rightward eye deviation. Does not answer questions or offer any verbal response. Follows midline and appendicular commands. -Cranial Nerves: I: Olfaction not tested. II: Pupils 3 to 2mm on left, 2.5-1.5 on right. Forced eye closure on the right. Unable to assess VF secondary to cooperation. III, IV, VI: OCR intact VII: left facial droop IX, X: Palate elevates symmetrically. XII: Tongue protrudes in midline. -Motor: Normal bulk, right arm flaccid. No rigidity. No adventitious movements, such as tremors, noted. No asterixis. Delt Bic Tri FFl FE IO IP Quad Ham TA Gastroc L 0 0 0 0 0 0 3 3 3 4+ 5 R 5 5 5 5 5 5 5 5 5 5 5 -Sensory: Difficult to assess. Left arm without withdrawal or grimace to noxious. Attempt to withdraw left leg with + grimace. Not able to test neglect as pt is not cooperative with testing. -Deep tendon reflexes: [**Hospital1 **] Tri [**Last Name (un) 1035**] Pat Ach L 0 0 0 2 1 R 2 2 2 2 1 Right Plantar response was flexor, left mute. -Coordination: not able to test -Gait: not able to test DISCHARGE T 98 P 61 BP 140/85 R 18 SpO2 98% RA GEN: NAD, lying comforatbly in bed HEENT: non-icteric CV: RRR, no murmurs PULM: CTABL Abd: PEG in place, c/d/i, no erythema Ext: well-perfused, no edema Neuro MS: alert, oriented x3, language dysarthric but fluent, no paraphasias, no anomia CN: L facial droop, otherwise normal Motor: L arm ant-gravity, L leg antigravity leg stronger than arm. Right side full strength Reflexes: muted on left, normal on right Sensation: intact to light touch and pinprick throughout Coordination: limited on the left, normal on right Gait: unable to test Pertinent Results: CT: Right frontal intraparenchymal hemorrhage 1. Moderate-sized right frontal intraparenchymal hematoma with possible fluid levels/ongoing hemorrhage related to the hypodense areas. Correlate for risk factors for coagulopathy. 2. Mild-to-moderate surrounding edema and mild mass effect on the right lateral ventricle. Areas of subarachnoid and intraventricular hemorrhage. 3. Suboptimal CTA head and neck, with no contrast visualized in the arteries of interest. Consider repeating the study when an appropriate/INR consult. Other details as above. Pending review of the 3D reformations. 3D reformations fo the arteries could not be obtained due to lack of enhancement in the arteries. Consider repeating the study. 4. Fullness in the left fossa of Rosenmuller, right piriform sinus and vallecula- correlate with direct examination. MRI: 1. Moderate-large acute/subacute hematoma in the right frontal lobe with surrounding edema, effacement of the cerebral sulci and mild mass effect on the right lateral ventricle. No obvious nodular enhancement noted to suggest an obvious mass. However, an underlying mass lesion cannot be completely excluded. 2. Few linear T2-hypointense foci noted on the axial T2-weighted images within the region of the hematoma are of uncertain nature. Vascular cause cannot be completely excluded. Fluid level noted within the hematoma, raising the possibility of ongoing hemorrhage. Relate for risk factors such as coagulopathy. 3. Consider interventional neuroradiology consult for further management. Additionally, repeat CT angiogram can be considered when appropriate as the recent CT angiogram was suboptimal due to delayed bolus timing. Assessment for any associated infarction is limited given the presence of blood products. 4. Subarachnoid hemorrhage in the right frontal, lef tparietal and occipital lobes and intraventricualr hemorrhage as above. HgA1c 5.2 FLP LDL74 HDL 74 Chol 160 Tg 59 Brief Hospital Course: Intraparenchymal hemorrhage Mr. [**Known lastname **] was admitted with new onset of left facial droop and progressive left-sided weakness while at home. Initially he was seen at [**Hospital1 **], but was transferred to [**Hospital1 18**] for definitive care. He was initially in the neuro-ICU where his blood pressure was corrected and his aspirin/plavix were discontinued. His exam was notable for significant L-sided weakness in the arm > leg as well as a left facial droop. He was dysarthric, had a left facial droop, somewhat confused, disoriented, and inattentive as well as moderate left-sided weakness. He was transferred out of the unit after 2 days to a stepdown unit and eventually to the general floor. He had issues with his swallowing, and had initially passed the exam, but had a likely episode of aspiration pneumonitis. He had an NGT in place and was eventually scheduled for a PEG placement on [**2143-11-8**] by GI. He tolerated the procedure well. He was seen by PT/OT and felt to be a candidate for an acute rehab and was transferred to [**Hospital 38**] rehab on [**2143-11-12**]. His deficits were in his level of arousal which improved over his course. He had a left facial weakness, was dysarthric and had a left hemiparesis with arm weaker than the leg but both anti-gravity. He was restarted on aspirin 81 mg on discharge for his CAD and history of stents. He was started on phenytoin for seizure prophylaxis when he came in. He had no apparent seizure activity, and a tapering schedule was ordered as an outpatient. PVCs He had been on propranolol as an outpatient for frequent PVCs. This medication was stopped for bradycardia to the 30s, but restarted at TID dosing when he had more frequent PVCs. These improved with the new dosing schedule. Aspiration pneumonitis He initially passed speech and swallow, and was taking food by mouth, but had an acute leukocytosis with low grade temps. Urine cultures, blood cultures and CXR were clear. He had some increased secretion. He was started on ciprofloxacin for 5 days, which was d/c'd when all infectious w/u was negative. Medications on Admission: Aspirin 81mg Plavix 75mg Propranolol 50mg daily Pravastatin 20mg daily Discharge Medications: 1. docusate sodium 50 mg/5 mL Liquid [**Date Range **]: One (1) PO BID (2 times a day). 2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Date Range **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 3. lactulose 10 gram/15 mL Syrup [**Date Range **]: Fifteen (15) ML PO Q8H (every 8 hours) as needed for Constipation. 4. propranolol 10 mg Tablet [**Date Range **]: Two (2) Tablet PO TID (3 times a day). 5. heparin (porcine) 5,000 unit/mL Solution [**Date Range **]: 5000 (5000) units Injection TID (3 times a day). 6. lisinopril 20 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 7. amlodipine 5 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 8. aspirin 81 mg Tablet, Chewable [**Date Range **]: One (1) Tablet, Chewable PO DAILY (Daily). 9. phenytoin 125 mg/5 mL Suspension [**Date Range **]: One Hundred (100) mg PO Q12H (every 12 hours). 10. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 11. acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever, pain. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Right Frontal Hemorrhagic Stroke frequent PVCs Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Dysarthric speech - but understandable Discharge Instructions: You were admitted to [**Hospital1 18**] after [**Hospital **] transferred from [**Hospital1 **] for slowly evolving facial weakness, nausea, emesis, and a CT that showed evidence of a right frontal intraparenchymal hemorrhage. You were initially admitted to the neuro-ICU and then transferred to the floor once you were stabilized. You continued to have deficits in terms of left arm and leg weakness and some waxing and [**Doctor Last Name 688**] level of alertness. You were unable to pass speech and swallow and had an episode of aspiration pneumonitis which led to a PEG tube placement on Friday [**2143-11-8**] by GI. You had PVCs which were part of your medical history prior to admission, and were increased when propranolol was stopped. We restarted you on propranolol and you had less frequent PVCs. Physical therapy felt you would be a good candidate for acute rehab and you were transferred to [**Hospital 38**] Rehab. Follow up MRI with contrast was scheduled for [**2142-12-21**] at [**Hospital1 18**]. Taper off your Dilantin You will be discharged on dilantin 100 mg [**Hospital1 **]. You should decrease to 100 mg once daily on [**2143-11-19**] and stop the medication on [**2143-11-26**]. Medications changed 1. On Dilantin (Phenytoin) w/ a scheduled taper - finished on [**2143-11-26**] 2. Changed to propranolol 20 mg TID 3. Started on amlodipine 5 mg daily 4. Stopped Plavix 5. Continue aspirin 81 mg daily Followup Instructions: Prior to your appointment you need to contact hospital registration to update your information. Registration [**Telephone/Fax (1) 10676**] MRI with contrast scheduled for [**2143-12-21**] Dr. [**First Name (STitle) **] [**Name (STitle) **] [**2143-12-31**] at 1:30 pm Phone: [**Telephone/Fax (1) 2574**] Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2143-12-31**] 1:30 [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Completed by:[**2143-11-12**]

[ "412", "V45.82", "507.0", "784.51", "414.01", "342.90", "401.9", "431", "V45.81", "427.89" ]

icd9cm

[ [ [] ] ]

[ "96.6", "43.11" ]

icd9pcs

[ [ [] ] ]

9830, 9927

6390, 8493

346, 386

10018, 10149

4432, 6367

11627, 12213

2065, 2113

8615, 9807

9948, 9997

8519, 8592

10173, 11604

2863, 4413

2128, 2624

268, 308

414, 1727

2639, 2846

1749, 1859

1875, 2049

53,032

133,904

38988

Discharge summary

report

Admission Date: [**2141-5-5**] Discharge Date: [**2141-5-10**] Date of Birth: [**2083-12-30**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: slurred speech Major Surgical or Invasive Procedure: [**2141-5-5**] Closure of patent foramen ovale through a minimally invasive approach. [**2141-5-9**] Transesophageal echocardiogram and cardioversion History of Present Illness: 57 year old male hospitalized in [**2141-1-13**] with slurred speech. CVA treated with TPA and discharged home with no residual deficit. During workup he was found to have PFO by echocardiogram. Past Medical History: CVA [**1-22**] (treated with TPA) right knee [**Doctor First Name **]. Social History: Lives with: adult son Occupation: chemist Tobacco: none ETOH: none recreational drug use: none Family History: no premature CAD Physical Exam: Pulse: 57 Resp: 18 O2 sat: 98%-RA B/P Right: 126/78 Left: 130/81 Height: 5'8" Weight: 160 lbs General:A&Ox3, NAD Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [] 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 + [] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: Left: DP Right: Left: PT [**Name (NI) 167**]: Left: Radial Right: Left: Carotid Bruit none Right: 2+ Left:2+ Pertinent Results: [**2141-5-7**] Chest X-ray: Small pleural effusions are noted in the dorsal aspect of the sinus. The size of the cardiac silhouette has minimally increased. No evidence of pneumonia. No pulmonary edema. Moderate tortuosity of the thoracic aorta. No pneumothorax. [**2141-5-7**] 05:04AM BLOOD WBC-10.0 RBC-4.19* Hgb-12.6* Hct-36.5* MCV-87 MCH-30.2 MCHC-34.6 RDW-13.5 Plt Ct-127* [**2141-5-8**] 05:40AM BLOOD UreaN-16 Creat-1.0 K-4.5 [**2141-5-7**] 05:04AM BLOOD Glucose-123* UreaN-12 Creat-0.9 Na-138 K-3.9 Cl-103 HCO3-30 AnGap-9 [**2141-5-10**] 01:35AM BLOOD PT-14.1* PTT-46.2* INR(PT)-1.2* Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: >= 55% >= 55% Findings LEFT ATRIUM: No spontaneous echo contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: No spontaneous echo contrast in the body of the RA or RAA. No ASD by 2D or color Doppler. LEFT VENTRICLE: Overall normal LVEF (>55%). RIGHT VENTRICLE: RV not well seen. AORTA: Normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. Simple atheroma in aortic arch. AORTIC VALVE: Normal aortic valve leaflets (3). Trace AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**] throughout the procedure. The patient was monitored by a nurse in [**Last Name (Titles) 9833**] throughout the procedure. Local anesthesia was provided by benzocaine topical spray. The patient was sedated for the TEE. Medications and dosages are listed above (see Test Information section). The posterior pharynx was anesthetized with 2% viscous lidocaine. No TEE related complications. The rhythm appears to be atrial flutter. Conclusions No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No spontaneous echo contrast is seen in the body of the right atrium or right atrial appendage. No flow is seen across the intra-atrial septum by color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 35cm from the incisors. There are simple atheroma in the aortic arch. 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. IMPRESSION: No evidence of intracardiac thrombus. No flow across the intra-atrial septum by color doppler. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2141-5-9**] 15:52 Brief Hospital Course: Admitted [**2141-5-5**] and underwent minimally invasive PFO closure by Dr. [**Last Name (STitle) **] - see operative note for details. Following the operation, he was transferred to the CVICU in stable condition on titrated phenylephrine and propofol drips. Within 24 hours, he awoke neurologically intact and was extubated without incident. He maintained stable hemodynamics and transferred to the step down unit on postoperative day one. Chest tube was removed per cardiac surgery protocol. He had atrial flutter that did not respond to medications, so he underwent TEE to rule out thrombus and was cardioverted back to sinus rhythm were he remained. He was ready discharge home on POD 5 with services. Medications on Admission: Simvastatin 40 mg daily, ASA 325 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:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 4. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for minimally invasive for 1 months. Disp:*90 Tablet(s)* Refills:*0* 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: please take 400 mg once a day for 1 week then decrease to 200 mg once a day until follow up with Dr [**Last Name (STitle) 1655**] . Disp:*37 Tablet(s)* Refills:*0* 9. Warfarin 5 mg Tablet Sig: goal INR 2.0-2.5 Tablets PO once a day: dose to vary based on INR . Disp:*60 Tablet(s)* Refills:*0* 10. Warfarin 2 mg Tablet Sig: goal INR 2.0-2.5 Tablets PO once a day: dose to vary based on INR . Disp:*60 Tablet(s)* Refills:*0* 11. coumadin please take 7.5mg of coumadin/warfarin on [**5-11**] - lab to be drawn [**5-12**] for further dosing by [**Hospital1 **] heart center coumadin clinic [**Telephone/Fax (1) 6256**] 12. Outpatient Lab Work Labs: PT/INR for coumadin dosing for atrial fibrillation with goal INR 2.0-2.5 with results to [**Hospital1 **] heart center coumadin clinic [**Telephone/Fax (1) 6256**] with first draw [**5-12**] Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: patent foramen ovale s/p closure Post operative atrial flutter s/p cardioversion Past medical history Stroke s/p TPA Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Right minimally invasive thoracotomy pain controlled with percocet prn Right chest incision with resolving ecchymosis no erythema/drainage Right groin incision healing with steri strips no erythema/drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Appointments already scheduled Dr [**Last Name (STitle) **] at [**Hospital1 **] heart center [**Telephone/Fax (2) 6256**] - on thrusday [**5-25**] at 9 am Please call to schedule appointments Primary Care Dr. [**Last Name (STitle) 27187**] in [**1-14**] weeks Cardiologist Dr.[**Last Name (STitle) 1655**] in [**1-14**] weeks [**Telephone/Fax (1) 6256**] Labs: PT/INR for coumadin dosing for atrial fibrillation with goal INR 2.0-2.5 with results to [**Hospital1 **] heart center coumadin clinic [**Telephone/Fax (1) 6256**] with first draw [**5-12**] Completed by:[**2141-5-10**]

[ "V12.54", "511.9", "427.31", "427.32", "745.5", "E878.8", "997.1" ]

icd9cm

[ [ [] ] ]

[ "39.61", "99.62", "88.72", "35.71" ]

icd9pcs

[ [ [] ] ]

7470, 7529

4872, 5582

336, 488

7690, 7954

1610, 4849

8495, 9082

936, 954

5674, 7447

7550, 7669

5608, 5651

7978, 8472

969, 1591

282, 298

516, 713

735, 807

823, 920

1,358

193,262

16556

Discharge summary

report

Admission Date: [**2102-12-25**] Discharge Date: [**2102-12-28**] Date of Birth: Sex: F Service: Medical Intensive Care Unit HISTORY OF PRESENT ILLNESS: This is a 68-year-old woman with a past medical history of insulin-dependent diabetes mellitus, ALS, with progressive bulbar palsy, and low-grade lymphoma who presents to [**Hospital1 69**] for bronchoscopy through an electively placed tracheostomy for concern about tracheal stenosis. The patient received a tracheostomy and a percutaneous endoscopic gastrostomy tube on [**2102-11-9**] as elective procedures due to progressive dysphagia and respiratory distress from her progressive bulbar palsy. The patient has had several problems with her tracheostomy since getting the tracheostomy placed. She has had difficulty with speech when on tracheostomy mask and difficulty weaning from the tracheostomy mask ventilation. However, she has had no fevers, chills, sweats, or shortness of breath, and she has been able to ambulate and due a small amount of activity while not on the ventilator. She has been on a ventilator wean for several weeks; being ventilated only at night and going eight to ten hours during the day without mechanical ventilation. PHYSICAL EXAMINATION ON PRESENTATION: Her physical examination on admission revealed she was afebrile, with a heart rate of 90, respiratory rate was 23, saturating 100% on 4 liters through her tracheostomy mask. Her blood pressure was 130/70. She was in no acute distress. She was alert and oriented times three. She is Spanish-speaking only. She had a tracheostomy in place with no erythema, no exudate, and no bleeding from the tracheostomy site. Her neck was supple with no lymphadenopathy. Her lungs were clear to auscultation bilaterally. Her heart was regular in terms of rate with no murmurs, rubs, or gallops. Her abdomen was obese, soft, and nontender with active bowel sounds. No hepatosplenomegaly was noted. The patient had 1+ edema in her lower extremities bilaterally. Her cranial nerves II through XII were intact bilaterally. Pupils were equal, round, and reactive to light. She had [**5-21**] upper and lower extremity strength bilaterally with 1+ deep tendon reflexes in the upper and lower extremities bilaterally. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on admission revealed white blood cell count was 12.9, hemoglobin was 1.1, hematocrit was 35, and platelets were 552 (with 80% neutrophils, 15% lymphocytes, 3% monocytes, and 3% eosinophils). INR was 1.2, PT was 13, PTT was 32. Chemistry-7 revealed sodium was 139, potassium was 4.2, chloride was 100, bicarbonate was 30, blood urea nitrogen was 16, creatinine was 0.8, and blood glucose was 246. Anion gap was 9. Calcium was 8.9, phosphate was 4, magnesium was 2. HOSPITAL COURSE: 1. TRACHEAL STENOSIS: The patient had tracheal stenosis based on a report from an outside hospital bronchoscopy. The patient was taken for bronchoscopy to confirm tracheal stenosis which was done on hospital day two. The patient tolerated the procedure well, and a dilation procedure was planned for the next day. The patient also had a computed tomography scan of the trachea which revealed tracheal wall thickening adjacent to the tracheostomy tube; most likely reflecting granulation tissue. This resulted in mild narrowing of the trachea adjacent to the tracheostomy tube. The trachea distal to this level was normal in appearance as were the central and main bronchi with no evidence malacia in the trachea or main stem bronchi. When available, additional multiplanar and 3-D images will be obtained to review images with axial images. On hospital day three, the patient was taken for balloon dilatation which was successful and without complications. The patient tolerated the procedure well. The patient had slight resolution of symptoms but continued improvement was expected. The patient had no bleeding. No evidence of infection. No fevers, chills, or sweats and was afebrile throughout her hospitalization. 2. INSULIN-DEPENDENT DIABETES MELLITUS: The patient was covered with a regular insulin sliding-scale and not given her NPH during admission, as her tube feeds were held for the greater part of her admission due to the multiple procedures that were done. The patient had sugars ranging in the 100-range to 200-range based on fingerstick and every day laboratory checks. 3. FLUIDS/ELECTROLYTES/NUTRITION/GASTROINTESTINAL: The patient's tube feeds were held at various times for procedures; however, she was put back on her ProMod with fiber at about a 60-cc per hour rate. The patient's electrolytes did not need repletion throughout her hospitalization. 4. HYPERTENSION: The patient was continued on her home regimen of blood pressure medications including amlodipine, lisinopril, and Lopressor. 5. PROPHYLAXIS: The patient was given Pneumo boots for deep venous thrombosis prophylaxis and was continued on ranitidine for peptic ulcer disease prophylaxis. 6. VENTILATOR WEAN: The patient had been ventilated each night on her ventilator wean program and [**Hospital1 21979**]. However, during her admission for tracheal stenosis, she was not ventilated at night; although, she was observed in the Medical Intensive Care Unit. She did not require mechanical ventilation and was able to actually ventilate fine without ventilatory support. DISCHARGE STATUS: The patient was to be discharged back to [**Hospital1 700**]. CONDITION AT DISCHARGE: Condition on discharge was good. DISCHARGE DIAGNOSES: 1. Tracheal stenosis. 2. ALS. 3. Insulin-dependent diabetes mellitus. 4. Hypertension. 5. Respiratory failure. MEDICATIONS ON DISCHARGE: (The patient's discharge medications included) 1. Amlodipine 5 mg p.o. q.d. 2. Aspirin 81 mg p.o. q.d. 3. Lipitor 20 mg p.o. q.d. 4. Docusate as needed. 5. Iron 300 mg p.o. b.i.d. 6. Lisinopril 40 mg p.o. q.d. 7. Lopressor 150 mg p.o. b.i.d. 8. Ranitidine 300 mg p.o. q.d. 9. Regular insulin sliding-scale. 10. NPH insulin 28 units in the morning. 11. Tylenol p.o. as needed. 12. Ambien 5 mg p.o. q.h.s. 13. ProMod with fiber at 60 cc per hour. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**] Dictated By:[**Last Name (NamePattern1) 7942**] MEDQUIST36 D: [**2102-12-28**] 07:58 T: [**2102-12-28**] 08:06 JOB#: [**Job Number 46999**]

[ "401.9", "V10.79", "335.20", "519.1", "518.81", "250.01" ]

icd9cm

[ [ [] ] ]

[ "96.05", "96.6", "33.21", "31.99" ]

icd9pcs

[ [ [] ] ]

5590, 5707

5734, 6447

2840, 5520

5535, 5569

186, 2822

76,529

178,352

44407+58716

Discharge summary

report+addendum

Admission Date: [**2122-10-20**] Discharge Date: [**2122-10-29**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2122-10-25**] - Dental Extractions [**2122-10-23**] - Placement of a [**Company 1543**] Dual Chamber Pacemaker ([**Company 1543**] Sensia DR [**Last Name (STitle) **] via left cephalic) History of Present Illness: 88 year old female s/p CABG/AVR on [**2122-10-12**] with Dr. [**Last Name (STitle) **]. She was discharged to rehab on postopertaive day five. This morning she developed shortness of breath, wheezing and was taken to the [**Hospital3 **] ED. She was found to be in atrial fibrillation with runs of nonsustained ventricular tachycardia and amiodarone was started. She was thus transferred to the [**Hospital1 18**] for further management. Past Medical History: Chronic Diastolic Cardiac Dysfunction Hypertension Aortic stenosis Dyslipidemia Glaucoma s/p appendectomy, left knee surgery, cataract surgery and hysterectomy Social History: Distant smoking history, occasional alcohol, no illicit drug use, lives alone in Rye [**Location (un) 3844**], has daughter who is HCP [**Name (NI) **] [**Telephone/Fax (1) 95201**] or [**Telephone/Fax (1) 95202**] Family History: No family history of early cardiac events or sudden death. Physical Exam: 51 irregular 20 144/85 4'[**24**]" 59kg GEN: Elderly female with SOB SKIN: Sternal wound c/d/i, staples inplace, stable. Left leg endovein incision C/D/I. HEENT: Unremarkable NECK: Supple, No JVD LUNGS: Decreased BS at right base. HEART: Irregular rate and rhythm, I/VI systolic ejection murmur ABD: Soft/Nontender/Nondistended/NABS EXT: Warm, well perfused, 3+ LE Edema, Pulses 1+ throughout Pertinent Results: [**2122-10-20**] 10:12PM PT-15.2* PTT-23.7 INR(PT)-1.3* [**2122-10-20**] 10:12PM WBC-14.6* RBC-3.09* HGB-9.8* HCT-28.2* MCV-91 MCH-31.9 MCHC-34.9 RDW-15.7* [**2122-10-20**] 10:12PM ALBUMIN-3.3* CALCIUM-8.5 PHOSPHATE-3.3 MAGNESIUM-1.7 [**2122-10-20**] 10:12PM ALT(SGPT)-43* AST(SGOT)-29 LD(LDH)-534* ALK PHOS-74 TOT BILI-1.8* [**2122-10-20**] 10:12PM GLUCOSE-153* UREA N-25* CREAT-1.0 SODIUM-142 POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-30 ANION GAP-16 [**2122-10-20**] 10:13PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.5 LEUK-NEG [**2122-10-20**] CXR Moderate bilateral pleural effusion, left greater than right, increased since [**10-16**]. Moderate-to-severe enlargement of the cardiac silhouette may be due in part to pericardial effusion, but there is no substantial azygous distention to suggest hemodynamic significance. Left basal atelectasis increased due to pleural effusion. Upper lungs clear. No pulmonary edema. [**2122-10-28**] 05:35AM BLOOD Hct-28.9* [**2122-10-26**] 05:35AM BLOOD WBC-9.5 RBC-2.87* Hgb-8.8* Hct-26.1* MCV-91 MCH-30.6 MCHC-33.7 RDW-15.5 Plt Ct-418 [**2122-10-20**] 10:12PM BLOOD WBC-14.6* RBC-3.09* Hgb-9.8* Hct-28.2* MCV-91 MCH-31.9 MCHC-34.9 RDW-15.7* Plt Ct-460*# [**2122-10-28**] 05:35AM BLOOD PT-29.7* INR(PT)-3.0* [**2122-10-20**] 10:12PM BLOOD PT-15.2* PTT-23.7 INR(PT)-1.3* [**2122-10-28**] 05:35AM BLOOD K-3.7 [**2122-10-26**] 05:35AM BLOOD Glucose-77 UreaN-17 Creat-0.8 Na-141 K-3.3 Cl-101 HCO3-31 AnGap-12 [**2122-10-26**] 05:35AM BLOOD Calcium-8.3* Mg-2.0 OPERATIVE REPORT [**Last Name (LF) **],[**First Name3 (LF) 6811**] R Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) 6811**] on TUE [**2122-10-27**] 5:42 PM Name: [**Known lastname **], [**Known firstname **] M. Unit No: [**Numeric Identifier **] Service: Date: [**2122-10-26**] [**Year (4 digits) **]: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2866**], DENT [**Numeric Identifier 95206**] Ms. [**Known lastname **] was admitted to the hospital a few weeks ago for AVR surgery. She was admitted emergently. The patient had poor dentition. It was decided to take the patient to the operating room to take care of the heart valve. The patient was discharged to follow up with outside dentist for extraction of numerous infected teeth. The patient was admitted to the [**Hospital1 **] two weeks later with uncontrolled atrial fibrillation. The patient now in-house, [**Hospital1 **]. Dental situation reevaluated, called to evaluate dental situation. Decided to take the patient to the operating room to surgically extract teeth #17, #18, #19, #29, #30 and #32 and #5, all caries, nonrestorative infected teeth. Patient interviewed in the holding area, consent signed. OPERATIVE NOTE: The patient was taken to the operating room. The patient was prepped and draped, nasally intubated in the usual oral maxillofacial surgical manner. Oral cavity suctioned free of saliva. Moistened throat pack placed. Attention directed to all four quadrants, placing 8.5 cubic centimeters, 0.25% Marcaine, no epinephrine, infiltration and block followed by development of flaps and elevation with teeth #17, #18, #19, #29, #30, #32 and #5 with the use of periosteal elevators and forceps, [**Doctor Last Name **] drill and elevated. Area copiously irrigated. Bacitracin irrigation. Closed all wound sites with 3-0 chromic gut and Surgicel in sockets on lower left quadrant to maintain heme. The patient's oral cavity was suctioned free of saliva and blood and moistened throat pack removed. The patient was extubated PACU stable. FINAL DIAGNOSIS: Caries, nonrestorable infected teeth #17, #18, #19, tooth #5, tooth #29, #30 and #32. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2866**], DENT [**Numeric Identifier 95206**] I certify that I was present in compliance with HCFA regulations. Dictated By:[**Doctor Last Name 95207**] Brief Hospital Course: Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] cardiac surgical intensive care unit on [**2122-10-20**] for further management of her atrial fibrillation. The EP service was consulted and amiodarone and beta blockade were continued. Heparin was started for anticoagulation. Diuresis was initiated as she had bilateral pleural effusions and peripheral edema. A chest tube was placed in her right pleura which drained 450ml. The oral surgery service was consulted for her teeth extraction which was originally planned for her last admission. Ms. [**Known lastname **] continued to have runs of rapid atrial fibrillation alternating with pauses and sinus bradycardia. The EP service recommended placement of a permenant pacemaker for adequate treatment of her atrial fibrillation. On [**2122-10-23**], Ms. [**Known lastname **] [**Last Name (Titles) 1834**] placement of a dual chamber pacemaker without complication. Postoperatively she was sent to the cardiac surgical step down unit for further recovery. Her teeth were sxtracted on [**2122-10-25**] without issue. Coumadin and heparin were then resumed. She continued to require aggressive diuresis but responded well to metolazone and lasix. Her INR was 2.6 on [**2122-10-27**] (up from 1.3 on day prior) and her coumadin was held. INR on [**10-28**] was 3 and she was given 0.5 mg PO coumadin per Dr [**Last Name (STitle) **]. She remained stable and was discharged to rehab on [**2122-10-28**]. Medications on Admission: colace 100'', zantac 150', zocor 20', brimonidine 0.15%''', latanoprost 0.005%hs, brinzolamide 1%''', ultram 50prn, asa 81', amio 200', lopressor 12.5'' Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 5. Brinzolamide 1 % Drops, Suspension Sig: One (1) gtt/ou Ophthalmic TID (3 times a day). 6. Latanoprost 0.005 % Drops Sig: One (1) Drop(s)/ou Ophthalmic HS (at bedtime). 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): 200mg [**Hospital1 **] x 7days then 200mg QD. 12. Warfarin 1 mg Tablet Sig: as directed Tablet PO Once Daily at 4 PM: target INR 2-2.5. 13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: CAD/AS s/p CABG/AVR [**2122-10-12**] s/p PPM [**2122-10-23**] AF Tachy-brady syndrome Pleural effusion Dyslipidemia HTN Chronic Diastolic Dysfunction Glaucoma Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**] Please follow-up with Dr. [**Last Name (STitle) 73**] as instrcuted Please follow-up with Dr. [**Last Name (STitle) 1270**] in 2 weeks. Device clinic in 1 week Completed by:[**2122-10-28**] Name: [**Known lastname 299**],[**Known firstname 2219**] M. Unit No: [**Numeric Identifier 15067**] Admission Date: [**2122-10-20**] Discharge Date: [**2122-10-29**] Date of Birth: [**2034-3-2**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4551**] Addendum: Mrs. [**Known lastname **] did not get discharged to rehab on [**10-28**] as no bed was available. A small of serous drainage continues from her leg incision. Leg staples are to be removed when the wound is dry. Her INR on [**10-29**] is 3.1. A bed is available and she will be discharged today. Discharge Disposition: Extended Care Facility: [**Hospital3 14**] & Rehab Center - [**Hospital1 15**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 358**] MD [**MD Number(1) 359**] Completed by:[**2122-10-29**]

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icd9cm

[ [ [] ] ]

[ "23.09", "37.83", "34.91", "37.72", "34.04" ]

icd9pcs

[ [ [] ] ]

10911, 11148

5984, 7453

290, 480

9119, 9128

1872, 5581

9906, 10888

1380, 1440

7657, 8814

8937, 9098

7479, 7634

5599, 5961

9152, 9883

1455, 1853

231, 252

508, 947

969, 1131

1147, 1364

54,930

186,852

52225

Discharge summary

report

Admission Date: [**2157-7-13**] Discharge Date: [**2157-7-27**] Date of Birth: [**2107-3-20**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1363**] Chief Complaint: b/l lower leg weakness Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 50yo female with metastatic cecal adenocarcinoma and recent hospitalization [**Date range (1) 16125**] for heaviness in legs now presenting with several days of weakness and tingling of bilateral legs. Pt had home PT today but her physical therapist sent her to the ED as she was unable to participate in exercises. Additionally pt had a fall from bed today without LOC or head strike. Pt's recent admission was for a similar presentation and s/p mechanical fall on stairs thought to be multifactorial due to dehydration and deconditioning and she was sent home with home PT. Pt reports that she continues to have "no mobility" in her legs, having trouble getting up to go to the bathroom. She denies any pain in her legs but does report "tingling" everywhere in her legs with some subjective knee swelling. Prior to leaving the hospital yesterday, pt reports that she was able to walk with a walker and is now unable to do so. In the ED, initial VS were: 97.8 100 150/81 20 97%RA. While in the [**Name (NI) **] pt had oral temp to 103 and rectal temp to 104.8+. In the [**Name (NI) **], pt received zofran, ceftriaxone 1g IV, tylenol PR and 3L NS. Labs were notable for Hct 27.9, D-dimer 3669, and lactate 3.2. CT-PE protocol showed pulmonary involving all lobar pulmonary arteries (RU, RM, RL, [**Doctor Last Name **], LL, lingular). Additionally, bowing of right ventricle suggestive of right heart strain and moderate bilateral pleural effusions (R>L). CT Head showed no evidence of metastasis or intracranial process. On arrival to the MICU, patient's VS. were T983., P134, BP 123/84, R23, 95%RA. Pt soon had fever to 101.2. She had no complaints other than continued tingling and weakness of her legs and thirst. No pain or SOB. Past Medical History: - Metastatic Cecal Adenocarcinoma s/p 2 cycles of FLOX - Asthma - Hypertension - Uterine fibroids Social History: Works as an accountant. Drinks wine occasionally but not in recent months. Non-smoker. No illicits. She is currently single. Family History: No family history of IBD or GI cancers. + family h/o sickle cell Physical Exam: Upon admission ====================== General: Alert, awake, no acute distress CV: tachycardic, regular rhythm, no m/r/g Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: +BS, soft, non-tender, non-distended, no rebound or guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: 2/5 strength bilateral thighs (unable to lift legs off bed or hold up against gravity), 4/5 strength ankle and big toes bilaterally; sensation diminished to light touch bilateral legs Rectal: normal tone, guaiac positive Upon Discharge ====================== Vitals: Tc-98, HR 90s, BP 100-140s/60-90s, RR 18-19, 97-100% RA I/O: [**Telephone/Fax (1) 108035**]+ General: lying in bed, in NAD, flat affect HEENT: gauze in R nare clean and dry CV: RRR, no m/r/g Lungs: Clear to auscultation with shallow breathing, no wheezes, rales, ronchi Abdomen: +BS, soft, non-tender, non-distended Ext: Warm, well perfused, no edema Neuro: 5/5 strength in both feet with dorsi/plantar-flexion; able to lift knee off bed bilaterally which is improvement; sensation to light touch intact and symmetric in LE Pertinent Results: Admission Labs: [**2157-7-12**] 05:30AM WBC-3.9* RBC-2.93* HGB-7.9* HCT-25.0* MCV-85 MCH-26.8* MCHC-31.4 RDW-24.3* [**2157-7-12**] 05:30AM GLUCOSE-103* UREA N-8 CREAT-0.5 SODIUM-137 POTASSIUM-3.4 CHLORIDE-109* TOTAL CO2-24 ANION GAP-7* [**2157-7-13**] 07:29PM D-DIMER-3669* Imaging: [**2157-7-13**] CTA 1. Massive pulmonary emboli involving all lobar pulmonary arteries. Bowing of right ventricle suggests right heart strain. 2. Moderate-sized bilateral pleural effusions, right greater than left, with adjacent compressive atelectasis. Size of effusions has improved since [**5-18**], [**2156**]. 3. Multiple hepatic hypodense metastases, similar to [**2157-5-18**]. [**2157-7-13**] Head CT w/o contrast 1. No acute intracranial process. 2. No CT evidence of large intracranial mass. However, for evaluation of subtle metastases, gadolinium-enhanced MRI is superior. 3. Redemonstration of post-surgical changes in the left anterior ethmoidal sinus and orbit, with persistent expansile soft tissue in the left anterior ethmoidal region. Recommend correlation with prior imaging and clinical history if available and possible MRI evaluation as previously suggested. [**7-13**] Echo Normal left ventricular cavity size and wall thickness with preserved global and regional biventricular systolic function. Mild tricuspid regurgitation. Moderate pulmonary artery systolic hypertension. Mild pulmonary artery diastolic hypertension [**7-14**] MRI spine 1. No evidence of bony metastasis in the cervical, thoracic or lumbar region. 2. No evidence of cord compression or an obvious intraspinal mass. 3. Gadolinium-enhanced images were not obtained which although slightly limit evaluation for a mass, no large intraspinal mass identified. No abnormal signal seen within the spinal cord. 4. Bilateral pleural effusions and small amount of fluid in the pelvis. [**7-14**] LENIs - No evidence of DVT Discharge labs: [**2157-7-27**] 05:19AM BLOOD WBC-10.6 RBC-3.35* Hgb-9.8* Hct-30.1* MCV-90 MCH-29.3 MCHC-32.6 RDW-21.3* Plt Ct-258 [**2157-7-27**] 05:19AM BLOOD Glucose-94 UreaN-8 Creat-0.4 Na-133 K-3.6 Cl-100 HCO3-26 AnGap-11 [**2157-7-27**] 05:19AM BLOOD Calcium-8.1* Phos-3.5 Mg-2.0 Brief Hospital Course: Brief Course: 50 yo female with PMH notable for metastatic cecal adenocarcinoma now admitted with many pulmonary emboli and right heart strain along with concerning neurologic exam. Active Issues =================== # Pulmonary emboli: Pt with many risk factors for PE including metastatic cancer, recent hospitalization, and deconditioning. She was started on heparin gtt and transitioned to lovenox. LENIs were negative for DVT. With no evidence of clot burden in her legs, she was not believed to be a candidate for IVC filter placement. Echo revealed Normal left ventricular cavity size and wall thickness with preserved global and regional biventricular systolic function. Mild tricuspid regurgitation. Moderate pulmonary artery systolic hypertension. Mild pulmonary artery diastolic hypertension. Pt will be discharged on lovenox. # Abnormal LE sensation/weakness thought secondary to conversion d/o: Pt reports new onset bilateral weakness, tingling and found to have weakness and diminished sensation on exam. Concern for metastases compressing spinal canal or nerve roots. MRI and CT of spine revealed no cord compression. Neurology was consulted and recommended EMG, which was normal. Neuro exam was inconsistent during hospital stay, so thought to be component of somatization. There was discussion of obtaining CT abd to evaluate the lumbar plexus, but neuro and radiology determined little utility in obtaining scan. Psych was consulted and believed pt fit criteria for conversion disorder. Physical therapy was consulted and recommended rehab. # Fevers: High fevers in this asymptomatic patient may be due to her significant clot burden and underlying malignancy. No evidence of occult infection by history, exam or chest imaging. Urine cultures were negative. Blood cultures were negative. Afebrile >7days at time of discharge. # Anemia: Recent slow downward trend in Hct starting in [**Month (only) **] from baseline of 36. Possibly due to chemotherapy. [**Month (only) 116**] have some component of anemia of chronic disease. Patient was guaiac positive. Pt transfused with 2 units PRBCs on [**7-16**], 1u PRBCs [**7-25**]. # Low UOP: Pt with low UOP during course of admission secondary to poor PO intake. UOP improved. Creatinine remained normal. Renal U/S normal. # Diarrhea: C diff negative, stool culture negative. Loperamide given and diarrhea resolved. # Depression: Psych found pt met criteria for MDD. Started on Celexa 10mg QD. SW consulted to provide pt with resources for depression and cancer Dx. # Epistaxis: Pt noted to have epistaxis near end of admission requiring ENT to pack the nose. Lovenox was not stopped. ENT recommending MRI sinuses to evaluate h/o L ethmoidal fibrosarcoma, which did not show evidence of local recurrence. Pt will f/u with ENT as OP. Chronic Issues ======================== # Stage IV adenocarcinoma: Recently completed cycle 2 of FLOX palliative chemotherapy. Continued pain and nausea mgmt. # HTN: Continued home verapamil. # Asthma: continued Albuterol PRN Transitional Issues ========================= Pt discharged to rehab. Pt will continue lovenox at home; checked with pharmacy and covered by insurance. Pt will f/u with heme/onc. Pt with flat affect during hospitalization and will likely need extensive rehab for improvement in LE strength to return in baseline ambulation status. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientwebOMR. 1. Acetaminophen 325-650 mg PO Q6H:PRN pain 2. Docusate Sodium 200 mg PO DAILY:PRN constipation 3. Famotidine 40 mg PO DAILY 4. Prochlorperazine 5-10 mg PO Q6H:PRN nausea 5. Verapamil SR 240 mg PO Q24H 6. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB or wheeze 7. Lidocaine-Prilocaine 1 Appl TP PRN pain 8. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 9. Senna 1 TAB PO DAILY Discharge Medications: 1. Enoxaparin Sodium 80 mg SC Q12H RX *enoxaparin 80 mg/0.8 mL 1 injection (80mg) every 12 hours Disp #*60 Syringe Refills:*0 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB or wheeze 3. Docusate Sodium 200 mg PO DAILY:PRN constipation 4. Famotidine 40 mg PO DAILY 5. Prochlorperazine 5-10 mg PO Q6H:PRN nausea 6. Senna 1 TAB PO DAILY 7. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 8. Verapamil SR 240 mg PO Q24H 9. Citalopram 10 mg PO DAILY 10. Acetaminophen 325-650 mg PO Q6H:PRN pain 11. Lidocaine-Prilocaine 1 Appl TP PRN pain 12. Sodium Chloride Nasal [**12-20**] SPRY NU QID 13. Oxymetazoline 1 SPRY NU ONCE:PRN epistaxis Duration: 1 Doses Discharge Disposition: Extended Care Facility: [**Hospital 671**] [**Hospital 4094**] Hospital - [**Location (un) 86**] Discharge Diagnosis: Primary: 1. Leg weakness 2. Pulmonary emboli 3. Depression 4. Conversion disorder Secondary: 1. Metastatic colon cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: Dear Ms. [**Known lastname 2816**] [**Known lastname **], It was a pleasure taking care of you during this admission. You were admitted because you had weakness in your legs. An MRI of your spine did not show any abnormalities and nerve studies were normal. Neurology and psychiatry saw you to help evaluate your leg weakness. You were found to have blood clots in your lungs which is why you are on lovenox, which you will continue after discharge. Additional meds were added to your home regimen. Please see the attached list. Resume your other home medications as you were taking them prior to this admission. For your nosebleeds, you will need to follow epistaxis precautions for 2 weeks: - do not blow nose - sneeze with mouth open - no vigorous activity, straining, or heavy lifting x 2 weeks - do not place anything inside nose except medicine as advised (no fingers, tissues, q-tips etc.) - use a humidifier, especially at night while sleeping - nasal saline mist 2 sprays each nostril at least four times daily and as needed - if you begin to bleed, spray 3 sprays of afrin in each nostril, then hold pressure by holding your nostrils closed at the bottom of the nose and lean with the head tilted forward for 15 minutes without letting go. -If supplemental O2 is needed, give via humidified face mask or shovel mask; avoid nasal cannula Followup Instructions: Department: OTOLARYNGOLOGY (ENT) When: WEDNESDAY [**2157-8-17**] at 10:15 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], M.D. [**Telephone/Fax (1) 41**] Building: LM [**Hospital Unit Name **] [**Location (un) 895**] Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE Hematology/Oncology Appointment: PENDING With:Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 6568**] **We are working on a follow up appointment with Dr. [**Last Name (STitle) **] in the next week. You will be called at the rehab with the appointment. If you have not heard within 2 business days or have questions, please call the number above. Department: [**Hospital3 1935**] CENTER When: FRIDAY [**2157-11-25**] at 10:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14290**], OD [**Telephone/Fax (1) 253**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1368**] Completed by:[**2157-7-27**]

[ "584.9", "415.19", "401.9", "493.90", "784.7", "153.4", "197.7", "729.89", "311", "218.9", "300.11", "276.8", "285.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10404, 10503

5857, 9222

327, 334

10668, 10668

3632, 3632

12151, 13286

2402, 2469

9741, 10381

10524, 10647

9248, 9718

10776, 12128

5563, 5834

2484, 3613

265, 289

362, 2121

3648, 5547

10683, 10752

2143, 2243

2259, 2386

82,377

149,484

37063

Discharge summary

report

Admission Date: [**2175-6-15**] Discharge Date: [**2175-6-30**] Date of Birth: [**2107-3-27**] Sex: M Service: MEDICINE Allergies: Morphine / Iodine Containing Agents Classifier Attending:[**First Name3 (LF) 25936**] Chief Complaint: Chest pain, SOB Major Surgical or Invasive Procedure: s/p Cathetrization on [**6-17**] History of Present Illness: 67 yo M with CAD s/p CABG & multiple PCI, CHF, DMII who presented [**6-14**] to [**Hospital3 **] with chest pain. He had previously been admitted there [**Date range (1) 25856**] with unstable angina and renal failure, but had refused cath because he was concerned about his kidneys. He then had increasing chest pain so he re-presented to LGH and EKG there showed ST depressions in V2-V6, trop 1= 0.01, troponin 2= 3.2, troponin 3= 3.64 troponin 4= 2.92(done at 6/24 16:00). ECHO was done that showed EF 60%. He has been chest pain free since 11PM on [**6-14**] on nitro gtt 30mcg and heparin gtt 1200. He received mucomyst at 11am due to creatinine of 1.5. REVIEW OF SYSTEMS: he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, cough, hemoptysis, black stools or red stools. he denies recent fevers, chills or rigors. he denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: [**2153**] -PERCUTANEOUS CORONARY INTERVENTIONS: five caths since CABG, ATRIUS records attached. -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: -DMII -CKD stage III -GOUT -hypothyroidism -S/P staph infection of sternum requiring complete excision of sternum -chronic lung dz attributed to restrictive physiology after removal of sternum -BPH -Depression Social History: -Tobacco history: distant, none x over 25 years -ETOH: none currently -Illicit drugs: denies -lives with partner -disabled, uses wheelchair for ambulation Family History: Father MI at age 49, mother CAD alive at 83 Physical Exam: PHYSICAL EXAMINATION: VS: 98.0 144/73 62 18 98% on 1.5L GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP at level of clavicle at 30%. CARDIAC: RR, III/VI HSM LSB No r/g. No thrills, lifts. No S3 or S4. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Large ventral hernia, eccymosis throughout the lower abdomen, obese, Soft, NTND. Could not palpate Abd aorta EXTREMITIES: 2+ BILATERAL PITTING EDEMA to mid calf Right: Carotid 2+ DP 2+ Left: Carotid 2+ DP 2+ Pertinent Results: Portable Chest X-Ray [**6-16**]: Right PICC tip is in the mid SVC. Small bilateral pleural effusions are larger on the left side. Cardiac size is top normal. Aside from minimal atelectasis in the left lower lobe, the lungs are clear. Patient is status post CABG. Cardiac Cath [**6-16**]: 1. Selective coronary angiography in this right dominant system demonstrated three vessel disease. The LMCA had a 60% diffuse stenosis. The LAD had an 80% ostial stenosis and 50% midvessel diffuse stenosis; and 80% ostial stenosis of D1 and a 95% ostial stenosis of D2. The LCx had a 99% ostial stenosis with TIMI I flow; 100% stenosis of OM1. The RCA had an 80% mid-vessel stenosis. 2. Graft angiography revealed a patent LIMA-LAD. The RIMA-RPL was widely patent. The SVG-OM1 had a 30% in-stent restenosis in the proximal portion of the graft and a 90% stenosis in the native OM1 just distal to the anastamosis; OM1 is a small calibur vessel. 3. Limited resting hemodynamics revealed SBP 104 mm Hg and DBP of 51 mm Hg. FINAL DIAGNOSIS: 1. Left main and three vessel coronary artery disease. 2. LIMA-LAD patent, RIMA-RPL patent, SVG-OM1 patent. 3. Most likely culprit for current presentation is native LCx which is most likely sub-totally occluded. Other areas of ischemia include OM1, D1, and D2. Brief Hospital Course: Mr. [**Known lastname 83557**] is a 67 y/o male with a history of CAD s/p CABG in [**2153**](LIMA-LAD, RIMA-RPL, SVG-OM) and multiple PCI's, CHF, who was transferred from an OSH with episodes of chest pain with positive cardiac enzymes and EKG changes suggestive of NSTEMI. # NSTEMI: Patient had positive troponins and ST changes on EKG with associated chest pain suggestive of NSTEMI. Patient with previous admission for unstable angina, three vessel disease s/p CABG (LIMA-LAD, RIMA-RPL, SVG-OM1) and failed PCIs. He had cardiac arrest during previous cath, so initially refused cath at the OSH. Patient was very nervous about whether or not he would survive cath and whether or not it would help him symptomatically. However due to increasing frequency and duration of pain on a nitro drip he consented. He was also very concerned about his kidney function and the dye load he would receive. He is s/p cath on [**6-16**] which revealed native three vessel disease with worsening Cx and left main disease. They did not intervene however they recommended going back to cath on [**6-19**] for intervention on the Cx and possibley the left main. He was subsequently optimized medically with aspirin, plavix, IV heparin, metoprolol, and atorvastatin. He was also on a nitro drip and was pain free. He did have 2 episodes of chest pain on the nitro drip with associated ST depressions in V2-V6 and ST elevation in aVR. Early after transfer to CCU for management of SBO, his angina became more unstable, eventually requiring an esmolol drip to control his HR as his angina is very HR dependent. ST depressions seen with CP. Integrilin started because of inability to take Plavix given SBO. # Abdominal Pain/Nausea/Vomiting: Patient developed nausea and abdominal pain with 3 subsequent bouts of vomiting on [**6-17**]. He first attributed his nausea to his lunch but he continued to vomit even after antiemetics were administered. It was also noted that his large vental hernia was distended and difficult to reduce. This was concerning for obstruction so surgery was consulted. They recommended NG tube placement and IV fluid thereapy. KUB showed a nonspecific bowel gas pattern with air and stool seen throughout colon and non-dilated loops of small bowel. Due to his instability, he was transferred to the CCU for closer monitoring. Pt was NPO with NG tube for decompression for aproximately 9 days. # Congestive Heart failure: Very mildly fluid overloaded on exam with most notable symptoms beiing worsened orthopnea. His Bumex 3mg was reduced to once a day, continued lopressor. # DMII: Patient was on a sliding scale and blood sugars were well controlled. # Acute on Chronic Renal Failure: At previous admission to OSH, diuretics were held and kidney function improved to baseline (1.7). Bumex 3mg po tid was started [**6-9**], but aldactone and metolazone were still on hold and ACE inhibitor was also not restarted. He was at baseline creatinine pre and post cath. # Hypothyroidism: He continued his levothyroxine Medications on Admission: Home Medications: confirmed with pt and pill bottles. Aspirin 325 daily Plavix 75 Imdur 60mg po BID Nitroglycerin spray 0.4mg, 2 sprays up to 12 times daily for chest pain Lipitor 80mg daily Metoprolol tartrate 100 po BID Metoprolol 25 mg po prn Morphine 10mg/5ml, 5 ml every 4 hours prn for chest pain Amlodipine 10 mg [**Hospital1 **] Flomax 0.4mg po daily Levothyroxine 50mcg daily except 100mcg on Sunday Bumex 3mg po TID Potassium 40 meq for each 1mg of Bumex daily Percocet prn Temazepam 15mg po qhs MVI 1 tab po daily vitamin B12 1000mcg IM q month Vitamin D 1000u PO daily Calcium 600 mg po daily Insulin pump with Humalog Miralax 17 gram daily Ranexa 500 mg PO q 6 hours Odansetron 4mg PO prn, take with percocet or morphine Discharge Disposition: Home With Service Facility: [**Hospital1 3894**] Health VNA Discharge Diagnosis: Primary: NSTEMI Seconday: Acute on chronic diastolic Congestive Heart Failure Partial bowel Obstruction Acute on chronic Kidney Disease Hypernatremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: You were admitted for having a mild heart attack. You had a catheterization that showed many blocked blood vessels and one of them was opened with a bare metal stent. You may need some additional procedures in the future. It is very important that you take Aspirin 325 mg and Plavix 75 mg daily for at least one month and probably longer to keep the stent open. Do not stop taking Plavix or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr. [**First Name (STitle) **] tells you to. You also had a partial bowel obstruction that resolved on its own with rest and time. Your bowels seem to be functioning normally now. You have been having worsening anemia. We would like you to see a hematologist for this. Your primary care doctor will recommend a hematologist for you and give you a referral. You also had some fluid overload and needed a lasix IV drip to remove the fluid. Your weight today is 220 pounds which is close to your dry weight. Medications changed during your hospitalization: 1. Take Imdur 120 mg daily instead of 60 mg twice daily 2. Decrease amlodipine to 10 mg once daily 3. Start pantoprazole daily to prevent bleeding 4. Decrease Bumex to 1mg twice daily for diuresis 5. Decrease Potassium to 40 meq twice daily to take with bumex. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. Followup Instructions: Pulmonary: Department: PULMONARY FUNCTION LAB When: TUESDAY [**2175-8-22**] at 10:40 AM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: TUESDAY [**2175-8-22**] at 11:00 AM With: DR [**Last Name (STitle) **] & DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Primary Care: Name:[**Known firstname **] [**Last Name (NamePattern4) 83558**],MD Specialty: Primary Care When: Wednesday, [**7-5**] at 10:20am Location: [**Location (un) 2274**] [**Location (un) **] Address: 26 CITY [**Doctor Last Name **] MALL, [**Location (un) **],[**Numeric Identifier 6086**] Phone: [**Telephone/Fax (1) 83559**] Please discuss a follow up appt with a hematologist for your anemia at his visit. . Cardiology: Name:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 83560**], MD Specialty: Cardiology When: Wednesday, [**7-19**] at 1:30pm Location: [**Hospital1 641**] Address: [**Hospital1 **], [**University/College **], [**Numeric Identifier **] Phone: [**Telephone/Fax (1) 72622**] Completed by:[**2175-7-3**]

[ "414.01", "428.33", "276.0", "585.3", "414.02", "274.9", "410.71", "552.20", "428.0", "250.00", "244.9", "584.9" ]

icd9cm

[ [ [] ] ]

[ "00.45", "38.93", "00.40", "00.66", "88.56", "36.06", "37.22" ]

icd9pcs

[ [ [] ] ]

7903, 7965

4091, 7118

324, 358

8160, 8160

2776, 3786

9693, 11018

2032, 2077

7986, 8139

7144, 7144

3803, 4068

8268, 9670

2092, 2092

1479, 1601

7162, 7880

2114, 2757

1065, 1371

269, 286

386, 1046

8175, 8244

1632, 1844

1393, 1459

1860, 2016

8,086

194,197

27648

Discharge summary

report

Admission Date: [**2145-8-19**] Discharge Date: [**2145-9-15**] Date of Birth: [**2072-12-23**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2969**] Chief Complaint: mental status changes, sepsis esophageal leak Major Surgical or Invasive Procedure: multiple bronchoscopies, RML [**First Name3 (LF) **] placement History of Present Illness: Patient presented from rehab facility with fevers, increasing wbc, and positive wound cultures from pseudommonas as well as altered mental status Past Medical History: Thoracic Aortic Aneurysm, Chronic Obstructive Pulmonary Disease, Emphysema, History of Asbestosis versus Mesotheilioma - s/p RUL lung resection, Hypertension, Renal Cell Carcinoma - s/p Nephrectomy, Depression, Cholelithiasis Received pneumococcal vaccine -[**2143**] +MRSA- blood cx [**3-4**] [**2145-6-20**] and [**4-5**] by [**Hospital3 **] Hosp porgress note [**2145-7-26**] on transfer docs. Blood culture data in pertinent results section Social History: Lives in nursing home. Admits to 100-120 pack year history of tobacco. Admits to [**2-1**] ETOH drink daily. Family History: Denies premature CAD. Physical Exam: VS 101 102 107/39 16 100%RA Cor: irreg, irreg lungs: crackles b/l. cough weak and ineffective. needs NTS to clear secretions prn. Abd: soft, round, NT, ND, +bs. abd wound healing w/ good granulation tissue -no drainage. extrem: b/l LE & UE edema with L arm picc aite erythematous, tender, and with lymphangitis. neuro: alert and answers questions approp. not consistently A+Ox3 Pertinent Results: [**2145-8-19**] 12:15 am BLOOD CULTURE **FINAL REPORT [**2145-8-27**]** AEROBIC BOTTLE (Final [**2145-8-27**]): REPORTED BY PHONE TO [**Doctor Last Name **] [**Last Name (un) **] [**2145-8-20**] 12:30P. PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES. SENSITIVE TO AMIKACIN 16 MCG/ML. COLISTIN Sensitivities performed by [**Hospital1 **] laboratories. COLISTIN. <=2 MCG/ML. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- =>64 R CEFTAZIDIME----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R IMIPENEM-------------- 8 I MEROPENEM------------- =>16 R PIPERACILLIN---------- =>128 R PIPERACILLIN/TAZO----- =>128 R TOBRAMYCIN------------ =>16 R ANAEROBIC BOTTLE (Final [**2145-8-25**]): NO GROWTH. [**2145-9-12**] 11:15 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2145-9-14**]** GRAM STAIN (Final [**2145-9-12**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2145-9-14**]): OROPHARYNGEAL FLORA ABSENT. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- =>64 R CEFTAZIDIME----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R IMIPENEM-------------- =>16 R MEROPENEM------------- =>16 R PIPERACILLIN---------- =>128 R PIPERACILLIN/TAZO----- =>128 R TOBRAMYCIN------------ =>16 R CHEST (PORTABLE AP) [**2145-9-13**] 7:15 AM [**Hospital 93**] MEDICAL CONDITION: HISTORY: Esophageal rupture, bronchomalacia and right lung atelectasis. IMPRESSION: AP chest compared to [**9-4**] through 13: Right lung previously entirely collapsed on [**9-11**] showed some improvement in aeration on [**9-12**], but more atelectasis and at least a small right pleural effusion today. Mild interstitial edema in the left lung which worsened from [**9-11**] through 13 has stabilized. Small left pleural effusion has decreased. Cardiac silhouette size is difficult to assess, but may be enlarged relative to [**9-4**]. Stents are seen in the descending thoracic aorta and right main bronchus. Feeding tube passes through the mid stomach and out of view. chest CXR for dobhoff placement [**2145-9-13**] IMPRESSION: Successful nasointestinal tube placement with the tip located within the third portion of the duodenum. Brief Hospital Course: On [**2145-8-19**] Patient was admitted to the thoracic surgery service with sepsis, MS changes, was started on broad spectrum anitbiotics. PICC line was dc'd and tip sent for culture. CT chest showed decrease in size of collection around the posterior distal esophagus and not a walled-off abscess, no evidence of perforation. HD Ct negative for bleed. Blood Cultures from the [**8-19**] and [**8-20**] grew out pan Resistance pseudomonas -only with intermediate sensitivty to amikacin. [**8-20**]: video swallow with some aspiration, so NPO. no evidence of esophageal leak. [**8-21**]: Patient was transferred to the ICu for closer monitoring and pulmonary toilet. CVL was placed for TPN and antibiotics bedside bronch for RLL collapse [**3-4**] to mucus plug - purulent secretion were seen throughout right lung bronchi. , BAL/Urine/Blood showed pseudomonas. Got 2U rbcs. [**8-23**]: PICC line placed for abx; Video: nectar thick liquids, ground solids ok; Renal US: good perfusion, no obstruction. transferred back to the floor. [**8-25**]: ID consulted for management for MDR pseudommonas. Patient was allowed po intake, but TPN continued for calories. ` [**8-27**]: Bronch=95% bronchomalacia, FB RUL, lots secretions; BAl still grew pseudommonas. remained confused after the procedure. 2U rbcs. [**8-29**]: HR to 30s, unresponsive, intubated, tx to CSRU. started on pressors for low BP, cardiac enzymes negative. CVL placed again. Bronch for secreation/diagnosis - still bronchomalacia with RML/RLL collapse, BAl still grew pseudommonas [**8-30**]: TPN dc'd and TF started via NGT. renal US normal. 1u rbc . amio drip for Afib [**8-31**]: CT - no sinusitis, stable chest effusion, no abdominal abscess. Dilt for rate [**9-1**]: rigid bronch, R MS [**Last Name (Titles) **]. Blood Cx neg. CVL changed over wire [**9-2**]: RUQ US for soem tenderness - negative; wound care consulted for weeping UE. Blood cx neg. lasix gtt started. TF increased to goal. heparin started for Afib anticoagulation.spiking fevers x 2 days. [**9-5**]: RISB 81, on CPAP. amio to po. [**9-6**]: bronch/BAL - pan R pseudomonas .lasix gtt continued for diuresis [**9-7**]: bronch for secretions, extubated, DNR/DNI. Transitioned from haparin to coumadin for Afib. [**9-8**]: IR for NJT placement. vanc/fluc dc'd [**9-10**]: PICC placed again, CVL dc'd [**9-11**]: R lung collapse, pulled out NJ-tube, bronch for secretions w/ good results. diamox for diuresis [**9-12**]: bronch for lots of secretions [**9-13**]: replace NJT for 3rd time [**9-14**]: 2U FFP for high INR (4.7), coumadin being held UNTIL INR at goal 2.0. Biggest problem upon discharge is respiratory - still has copious amount of secretions requing frequent suctioning. Otherwise, cardiovasculary stable, making good urine, on TF, finishing course of antibiotics. by myself for d/c today. Medications on Admission: Protonix 40', Enalapril 5', Lasix 20', KCL, Prednisone 10', Remeron 15qhs, Mucinex, Ativan qhs, Iron, Zithromax, Diltiazem 180', ASA 162' Discharge Medications: 1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 3. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 6. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q6H (every 6 hours) as needed. 7. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One (1) PO DAILY (Daily). 8. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q4H (every 4 hours). 10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. 11. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours): d/c on [**2145-9-24**]. 12. Amikacin 250 mg/mL Solution Sig: One (1) Injection Q36H (every 36 hours): d/c [**2145-9-24**]. 13. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 14. Morphine 10 mg/5 mL Solution Sig: 5-10 mg PO Q2hrs as needed for shortness of breath or wheezing: po /sublingual. 15. Ativan 1 mg Tablet Sig: [**2-1**] to 1 Tablet PO q1 hr: prn SOB. Discharge Disposition: Extended Care Discharge Diagnosis: PMH:severe Chronic obstructive pulmonary disease;hypertension, renal cell cancer, cholelithiasis, anemia, depression, + smoker 120pk/yrs; PSH; S/p thoracic aortic aneurysm repair [**7-6**], left nephrectomy, right upper lobe lobectomy. s/p esophageal perforation and leak [**2145-7-28**] s/p TAA repair; s/p CT guided drainage of paraesophageal abscess, [**2145-8-19**] pneumonia and bacteremia-- Pseudomonas Discharge Condition: fair Discharge Instructions: Please Dr.[**Doctor Last Name 4738**] /Thoracic Surgery office at [**Telephone/Fax (1) 170**] for any post hospitalization issues. medications per discharge medication instructions continue humidified oxygen face tent 50% Followup Instructions: Please call Dr.[**Doctor Last Name 4738**] /Thoracic Surgery office at [**Telephone/Fax (1) 170**]. Completed by:[**2145-9-15**]

[ "305.1", "112.84", "799.1", "496", "530.19", "427.31", "V45.73", "401.9", "V09.0", "V10.52", "519.1", "501", "599.0", "482.1", "038.43", "041.7", "584.9", "518.0", "995.92", "V45.76", "518.81", "V58.61" ]

icd9cm

[ [ [] ] ]

[ "99.15", "96.56", "99.21", "38.93", "33.23", "38.91", "99.04", "96.04", "96.05", "96.72" ]

icd9pcs

[ [ [] ] ]

8891, 8906

4503, 7341

368, 433

9359, 9365

1657, 3601

9635, 9766

1221, 1244

7529, 8868

3638, 4480

8927, 9338

7367, 7506

9389, 9612

1259, 1638

283, 330

461, 608

630, 1078

1094, 1205

22,227

170,629

25030

Discharge summary

report

Admission Date: [**2136-9-17**] Discharge Date: [**2136-9-27**] Date of Birth: [**2065-1-28**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6346**] Chief Complaint: perforated near obstructing colon cancer secondary to neoplasm Major Surgical or Invasive Procedure: Exploratory laparotomy, low anterior resection with Hartmann's pouch and colostomy, left colectomy, appendectomy, colonic lavage, splenectomy, LUQ and pelvic drain placement. History of Present Illness: 71-year-old gentleman with a history of a colonoscopy that showed a lesion in the colon that was biopsied and showed high grade dysplasia. He underwent a staging CT scan as an outpatient of the torso which showed free air without significant symptoms. He was sent emergently to the ER. He was admitted to the surgical service, put on broad-spectrum antibiotics. Due to the nature of the findings on the CT scan and a near-obstructing lesion in the pelvis, surgical intervention was offered. Likely ostomy was predicted. Past Medical History: None Social History: Smokes [**1-5**] cigarettes per day and drinks one beer per day. Pt speaks Cantonese. Lives in [**Hospital1 1562**], Ma. Wife is schizophrenic and they have no children. Pt has family in [**Name (NI) 86**], niece and nephew. Family History: Unknown Physical Exam: On admission: 98.7 83 134/79 24 97% RA NAD RRR CTAB soft non-distended, LLQ tenderness, no peritoneal signs. Rectal guiaic negative no edema Pertinent Results: [**2136-9-17**] 06:15PM BLOOD WBC-6.7 RBC-4.64 Hgb-15.0 Hct-41.8 MCV-90 MCH-32.3* MCHC-35.9* RDW-14.7 Plt Ct-260 [**2136-9-23**] 09:19AM BLOOD WBC-8.1 RBC-4.27* Hgb-13.1* Hct-37.9* MCV-89 MCH-30.8 MCHC-34.7 RDW-14.8 Plt Ct-241 [**2136-9-17**] 06:15PM BLOOD Plt Ct-260 [**2136-9-17**] 07:27PM BLOOD PT-13.6* PTT-28.0 INR(PT)-1.2 [**2136-9-23**] 09:19AM BLOOD Plt Ct-241 [**2136-9-25**] 09:51AM BLOOD Glucose-91 UreaN-22* Creat-1.1 Na-148* K-3.1* Cl-97 HCO3-33* AnGap-21* [**2136-9-17**] 06:15PM BLOOD Glucose-98 UreaN-13 Creat-1.2 Na-143 K-3.3 Cl-100 HCO3-28 AnGap-18 [**2136-9-20**] 05:43PM BLOOD CK(CPK)-477* [**2136-9-18**] 01:12AM BLOOD LD(LDH)-129 [**2136-9-18**] 11:15PM BLOOD Lipase-24 [**2136-9-18**] 06:59AM BLOOD Lipase-24 [**2136-9-20**] 05:43PM BLOOD CK-MB-2 [**2136-9-20**] 10:59AM BLOOD CK-MB-2 [**2136-9-20**] 02:11AM BLOOD CK-MB-2 cTropnT-<0.01 [**2136-9-25**] 09:51AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.8 [**2136-9-18**] 01:12AM BLOOD Calcium-8.5 Phos-2.5* Mg-1.6 Brief Hospital Course: Pt was admitted to surgery, given levoflox and flagyl. He was taken to OR for emergent operation on [**9-18**]. In OR patient was given 11000cc of IVF, 8 units pRBC, 4 units FFP, 1 unit cryo and had an EBL of 3000cc. He was stable and transferred to SICU, intubated post-op for CV resusitation. He was transfused 2 Units pRBC, POD2 Hct 31.1. Ampicillin was added, and TPN started, stoma was found to be intact. POD4 Hct 36.3. POD5 pt transferred to surgical floor started on PO diet and advanced as tolerated. Pt received post-splenectomy vaccinations. Pathology shows stage 4 disease, with 4/15 LN positive and invasion of small bowel. Pt discharged POD9 to rehab in good condition with good ostomy function for stoma teaching and PT. Medications on Admission: none 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:*45 Tablet(s)* Refills:*0* 2. Colace 100 mg Capsule Sig: One (1) Capsule PO three times a day for 1 months. Disp:*90 Capsule(s)* Refills:*3* Discharge Disposition: Extended Care Facility: [**Hospital6 1643**] Discharge Diagnosis: 1. Colonic adenocarcinoma 2. Diverticular disease Discharge Condition: Good Discharge Instructions: Please call doctor [**First Name (Titles) **] [**Last Name (Titles) **] greater than 101, nausea/vomiting, inability to eat, wound redness/warmth/swelling/foul smelling drainage, abdominal pain or pain around ostomy not controlled by pain medications or any other concerns you have. Please resume taking all medications as taken prior to this surgery and pain medications and stool softener as prescribed. You may resume your regular diet, but avoid food high in fiber. Please follow-up as directed. A visiting nurse will come to your home to help with the care of your ostomy. No heavy lifting for 4-6 weeks or until directed otherwise. [**Month (only) 116**] leave wound open to air, please leave steri-strips intact until they fall off. Followup Instructions: Please follow up at already arrangd appointments: Dr. [**First Name (STitle) **],LMOB-3A (NHB) Date/Time: [**2136-10-4**] 4:00 ([**Telephone/Fax (1) 35203**] [**First Name11 (Name Pattern1) 396**] [**Last Name (NamePattern4) 397**], MD Date/Time: [**2136-10-17**] 3:00 ([**Telephone/Fax (1) 26385**]

[ "569.83", "305.1", "401.9", "197.6", "196.2", "197.4", "562.10", "153.3" ]

icd9cm

[ [ [] ] ]

[ "45.95", "45.75", "45.62", "54.19", "46.13", "99.04", "45.76", "41.5", "99.07", "47.09" ]

icd9pcs

[ [ [] ] ]

3669, 3716

2586, 3333

377, 554

3812, 3819

1585, 2563

4613, 4927

1393, 1402

3388, 3646

3737, 3791

3359, 3365

3843, 4590

1417, 1417

275, 339

582, 1103

1431, 1566

1125, 1131

1147, 1377

22,935

147,421

23730

Discharge summary

report

Admission Date: [**2197-3-24**] Discharge Date: [**2197-3-27**] Date of Birth: [**2176-12-12**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 943**] Chief Complaint: Obtundation: OSH Transfer for Hepatic Failure Major Surgical or Invasive Procedure: None History of Present Illness: 20M with HCV and current IV heroin abuse admitted with obtundation and hepatic failure. He used IV heroin and cocaine on the day PTA, but does not remember any of the preceeding events. He presented to [**Hospital 1263**] Hospital on [**2197-3-23**] after being found unresponsive in his bathtub, which was filled with water and vomit. He was brought to [**Doctor Last Name 1263**] and was then responsive, but mildly hypotensive. He was treated for aspiration pneumonia despite having a clear CXR, and was transfered to [**Hospital1 18**] for possible fulminant hepatic failure. Of note, he reports two weeks of URI symptoms, including malaise, sore throat, productive cough, dyspnea (mainly exertional). He knows of know sick contacts and has no recent travel. Currently he feels almost completely well, except for a mild cough. He has no pain, nausea, vomiting, confusion, bleeding, dyspnea, dysuria or any other complaints. His urine is darker than normal. A discussion in regards to his illicit drug use was deferred to a later time, as his entire family was in the room. MICU Course: On admission, he was alert and in NAD. He had recovered greatly since being at [**Hospital 1263**] Hospital. Admission VS: T97.9 HR86 BP130/68 RR15 and OS97%RA. Mild RUQ tenderness. Marked ALT>AST transaminitits. Seen by Liver. Given Vit K x 1 for INR of 2. Thus, relatively uneventful course. Now transferred to floor. Past Medical History: HCV Infection and IVDU. Social History: He lives at home with his parents and is no longer in school. He works as a plumber. He has one brother and sister. [**Name (NI) **] currently smokes cigarettes and uses cocaine (?) and IV heroin. He has a large tattoo of a cross on his back. Family History: No known hepatobilliary disease. His MGF died of pancreatic CA in his 70s. Physical Exam: Exam on Transfer from MICU to Medicine: Tc/Tm 98.1 BP118/57 (100s-130s/40s-60s) HR79 (70s-80s) RR16 (15-24) OS95-88%RA GEN - NAD. ALERT AND INTERACTIVE. SOMEWHAT WITHDRAWN. COMFORTABLE. SISTER AND MOTHER AT BEDSIDE. HEENT - CLEAR OP. MMM. RESP - CTAB. NO CRW. CV - RRR. NML S1/S2. NO MGR. ABD - S/NT/ND. NO HSM. POS BS. EXT - NO CCE. DP 2+. NEURO - A&OX3. CNII-XII INTACT. STRENGTH AND [**Last Name (un) **] TO LT WNL. Pertinent Results: Portable CXR ([**2197-3-25**]) - Prominent cardic sillouette. Subtle increased retrocardiac opacity at hemidiaphram. No other active cardiopulmonary disease. Repeat CXR (AP/LAT): WNL. ABD U/S ([**2197-3-25**]) - WNL. [**2197-3-24**] 11:15PM BLOOD HCV Ab-PND [**2197-3-24**] 11:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2197-3-24**] 11:15PM BLOOD HBsAg-NEGATIVE HBsAb-PND HBcAb-NEGATIVE HAV Ab-PND [**2197-3-24**] 11:15PM BLOOD TSH-1.8 [**2197-3-24**] 11:15PM BLOOD calTIBC-235* Ferritn-GREATER TH TRF-181* [**2197-3-24**] 11:15PM BLOOD Albumin-3.6 Calcium-8.3* Phos-1.4* Mg-1.9 UricAcd-5.0 Iron-226* [**2197-3-24**] 11:15PM BLOOD ALT-7074* AST-5778* LD(LDH)-2964* CK(CPK)-536* AlkPhos-88 Amylase-48 TotBili-2.2* [**2197-3-25**] 06:00AM BLOOD ALT-6460* AST-4020* AlkPhos-85 TotBili-2.1* [**2197-3-26**] 06:25AM BLOOD ALT-4106* AST-1355* LD(LDH)-270* AlkPhos-84 TotBili-3.2* [**2197-3-24**] 11:15PM BLOOD Glucose-99 UreaN-12 Creat-0.7 Na-140 K-3.7 Cl-108 HCO3-24 AnGap-12 [**2197-3-24**] 11:15PM BLOOD PT-19.2* PTT-50.2* INR(PT)-2.3 [**2197-3-24**] 11:15PM BLOOD Plt Ct-47* [**2197-3-24**] 11:15PM BLOOD Neuts-64.2 Lymphs-30.5 Monos-4.3 Eos-0.4 Baso-0.7 [**2197-3-24**] 11:15PM BLOOD WBC-10.1 RBC-4.92 Hgb-14.8 Hct-40.7 MCV-83 MCH-30.1 MCHC-36.4* RDW-12.8 Plt Ct-47* [**2197-3-26**] 06:25AM BLOOD WBC-7.3 RBC-4.66 Hgb-13.9* Hct-39.3* MCV-84 MCH-29.9 MCHC-35.5* RDW-13.1 Plt Ct-85*# [**2197-3-26**] 06:25AM BLOOD PT-13.6 INR(PT)-1.2 Brief Hospital Course: Mr [**Known lastname 3989**] was admitted to an OSH with obtundation and acute liver injury and failure after an episode of IV drug abuse. The etiology of his liver failure was not apparent, but he quickly improved and his lab anomalies were normalizing by discharge. He felt totally well on discharge. 1. Hepatic Failure - The patient was initially admitted to the MICU and had a short course. The etiology of his liver failure was not clear, but possibly due to a background of HCV liver disease in conjunction with shock liver in the setting of hypotension and drug overdose. Given his recent IVDU, the acute hepatitis could have represented impurities or contaminant in heroin formulation (he reported only mixing his heroin with water). He had no known Tylenol or ETOH exposure. Initially, he had marked ALT over AST transaminitis (in the several thousands) with an INR peaking in the low 2.0's. An abdominal ultrasound was normal. All these lab abnormalities downtrended by discharge, at which point he felt totally well. HAV, HBV, and HCV serologies were pending at discharge. Follow-up with the liver team in regards to his known HCV infection and liver injury was provided. 2. Addition: He was seen by additiction support (social work) and given recommendations about psychologic follow-up. The patient wanted to be sober, and doesn't know why he relapsed: "I don't like my life when I'm using." Medications on Admission: None Discharge Medications: 1. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). Disp:*30 Patch 24HR(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1) Idiopathic Liver Failure (After Heroin Injection). 2) Heroin Abuse. Secondary Diagnosis: 3) HCV Infection. 4) Viral Upper Respiratory Tract Infection Discharge Condition: Good/Stable. Discharge Instructions: 1) Do not use illicit drugs. If you feel the urge or need to use or inject illicit drugs, please contact the help line provided to you by the social worker. Your most recent illness, induced by injection drugs nearly cost your life. As we know it is difficult to remain sober, we encourage to continue to ask for help from professionals, including entering a detox center. 2) Call your doctor or return to the ER if you have any fevers, chills, pains, yellowing of the skin, dizziness, increasing fatigue, or any other concerning symptoms. 3) You have been prescribed a Nicotine patch. We urge you to stop smoking. If you decide to start smoking, please stop using the nicotine patch, as both smoking and use of the patch can make you sick. Followup Instructions: 1) Please see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] (the liver doctor) for the following appointment. He can be reached at [**Telephone/Fax (1) 673**]. Dr. [**Last Name (STitle) 497**] will follow-up with your hepatitis tests and your hepatitis C infection. Please contact your primary doctor for the proper referal to Dr. [**Last Name (STitle) 497**]: Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Where: LM [**Hospital Unit Name 7129**] CENTER Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2197-6-2**] 11:20 2) Please see your doctor ([**Last Name (LF) 60617**],[**First Name3 (LF) 251**] J [**Telephone/Fax (1) **]) in the next 1-2 weeks. 3) Please see your social worker regularly, as dictated by the social worker you saw in the hospital.

[ "070.70", "465.9", "570", "304.01", "304.21", "507.0", "287.5" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5769, 5775

4159, 5567

361, 368

5992, 6006

2662, 4136

6797, 7623

2131, 2207

5622, 5746

5796, 5796

5593, 5599

6030, 6774

2222, 2643

276, 323

396, 1808

5908, 5971

5815, 5887

1830, 1855

1871, 2115

9,356

135,610

26994

Discharge summary

report

Admission Date: [**2113-6-7**] Discharge Date: [**2113-7-14**] Date of Birth: [**2063-3-16**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1384**] Chief Complaint: HCV cirrhosis Major Surgical or Invasive Procedure: liver transplant [**2113-6-7**] History of Present Illness: 50 Male with HCV cirrhosis/HIV/HCC s/p RF [**3-31**] and DM II who presented for liver transplant. He denied recent infections or illnesses. Past Medical History: HIV HCV cirrhosis HCC s/p RFA [**3-31**] (4.5x3.4 cm hepatoma, which was biopsy-proven hepatocellular carcinoma (HCC).) DM II Appendectomy at age 18 multiple R inquinal hernia repairs Social History: He lives alone in [**Hospital1 3494**], MA. He is not currently in a romantic relationship. He has no children. He is a high school graduate. For the last 25 years, he has worked primarily as a disk jockey in the [**Location (un) 86**] area. He also has worked part time as a security officer in the past. He is currently on medical disability and reports that he last worked about 1 year ago. He has no military history. h/o iv cocaine use in 80s, heavy etoh use and occas marijuana use in the past Has several friends that are very supportive and committed to help post transplant Physical Exam: PE: AVSS NAD no scleral icterus, MMM CTAB RRR soft, NT/ND, no fluid wave, well-healed para-median scar no edema, warm well-perfused, 2+ DP/PT b/l Pertinent Results: [**2113-6-7**] 03:00AM PT-16.3* PTT-35.4* INR(PT)-1.5* [**2113-6-7**] 03:00AM FIBRINOGE-206 [**2113-6-7**] 03:00AM WBC-2.8* RBC-3.78* HGB-14.5 HCT-39.0* MCV-103* MCH-38.3* MCHC-37.1* RDW-15.0 [**2113-6-7**] 03:00AM PLT COUNT-48* [**2113-6-7**] 03:00AM ALBUMIN-2.8* CALCIUM-8.3* PHOSPHATE-1.9* MAGNESIUM-2.4 [**2113-6-7**] 03:00AM ALT(SGPT)-44* AST(SGOT)-120* ALK PHOS-266* TOT BILI-3.3* [**2113-6-7**] 03:00AM GLUCOSE-192* UREA N-12 CREAT-0.9 SODIUM-134 POTASSIUM-5.3* CHLORIDE-108 TOTAL CO2-20* ANION GAP-11 [**2113-6-7**] 04:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-250 KETONE-NEG BILIRUBIN-SM UROBILNGN-12* PH-7.0 LEUK-NEG Brief Hospital Course: on [**6-7**] he underwent cadaveric liver transplant with conduit from superior mesenteric vein to portal vein for portal vein thrombosis. See operative note for details. Postop, he went to the SICU, intubated and was hemodynamically stable. LFTs were elevated. Repeat labs 3 hours later required transfusion with blood products. There was concern for poor liver function; ABD ultrasound on POD1 showed "Patent transplant hepatic vessels. Low resistive indices in hepatic arteries. Fluid collection posterior to liver, most likely hematoma, but fluid-debris level could represent bile leak." LFT's continued to rise. . On POD2, ASA and SC heparin were resumed and pt was started on sips. LFT's trended down, and coagulation studies were only moderately abnormal. . On POD3 ([**6-10**]), pt was tolerating PO's and passing flatus. He was started on low dose Prograf. An US on POD3 showed patent vessels. LFT's trended down. Prograf continued at 0.5mg [**Hospital1 **]. . On POD 4, diet was advanced. Drain output became less bilious. He was transfered to the floor. Labs gradually improved, with LFT's trending down. FK was adjusted. . On POD5 ([**6-12**]), the lateral JP and foley were removed. HIV meds continued to be held. LFT's trended down. Prograf was held. He had increased drainage from his incision on POD7 ([**6-14**]); CT scan was unremarkable with no changes. On POD8, Lasix was increased for edema. The incision continued to leak serosang drainage. On [**6-16**], an ostomy appliance was applied around the wound to help control drainage due to ascitic leak. On [**6-19**], a hepatic arteriogram demonstrated mild narrowing at the hepatic artery anastomosis with interval improvement since the last study, however the portal vein could not be visulaized. The following day, an ultrasound demonstrated abnormal arterial, hepatic venous and portal flows, essentially unchanged, however the proximal portal vein was not clearly appreciated. The portal venous flows were decreased. His ascitic output was replaced with albumin. On [**6-21**], a CTA demonstrated a thrombosis of the donor portal vein extending to the iliac vein anastomosis. The iliac vein graft was also thrombosed to the level of the SMV anastomosis. He was immediately taken back to the OR for an exploratory laparotomy, portal vein thrombectomy, portal venous revision with Hemashield patch angioplasty, and excision of common bile duct and liver biopsy (subsequently showing subfulminant hepatic necrosis). He lost 5 liters of blood and recieved 9 units of RBCs, 9 units of FFP, and 6 liters of crystalloid. Please see operative report for details. He was transferred to the SICU intubated and sedated with an open abdomen and on a heparin drip with a goal PTT greater than 50. HIs bilirubin was 7.8. He had an NG tube, 2 JPs, and a biliary drain and he was on Vancomycin and Zosyn. On POD 1, he required low dose Neosynepherine and 5 liters of fluid to maintain his BP. Drain output was replaced 1/2 cc:cc with NS. An Angio was done to assess for residual clot in the PV. Angio demonstrated a nonocclusive intraluminal filling defect in the main portal vein, likely thrombus in the vicinity of the presumed anastomosis. The hepatic artery was patent. The following day, he was taken to IR again and an angiogram demonstrated sluggish right main portal vein flow with multiple filling defects suggestive of thrombosis, which contributed to inability to pass the guidewire into central location. An ultrasoud showed persistent nonocclusive thrombus in the portal vein. On POD 2, he went to IR for a thrombectomy. A portogram demonstrated two areas of nonocclusive thrombus (SMV/iliac anastomosis and at the right/left bifurcation) as well as multiple narrow areas of possible stenosis, most significant at the SMV/iliac graft anastomosis. An angiojet thrombectomy and TPA infusion were performed within the portal system. A follow-up angiogram showed improving but persistent nonocclusive thrombus in the portal vein. Direct thrombolysis therapy was continued with TPA. Albumin was given to repalce his drain output. On POD 3, bilirubin was 15. Urine output was adequate. Drains outputs were 975cc and 1500cc of ascitic fluid. An ultrasound demonstrated a non-occlusive intraluminal filling defect in the main portal vein with likely thrombus in the vicinity of the anastomosis. An angiogram demonstrated no significant interval change in the size of the nonocclusive thrombi and TPA was continued. On POD 4, he was afebrile, intubated and stable off of pressors. Bilirubin was 12. A portal venogram demonstrated no change and the TPA catheter was discontinued. On [**6-25**] Dr. [**First Name (STitle) **] took him back to the OR for a scheduled second look laparotomy. At that time, he had a Roux-en-Y pedicle jejunostomy, right and left liver biopsy and abdominal wall closure. See operative note for details. Due to significant intraoperative mesenteric and bowel swelling, the biliary anastamosis had not been completed the last time he was in the OR. The operation went well. He was transferred back to the SICU intubated. Two JPs and a t tube were present. On POD 1 he spiked a fever to 101 and was pan-cultured, but these cultures were negative. The heparin drip was continued. The ascitic leak was replaced with albumin. Urine output was adequate. Vancomycin and Zosyn were continued. Caspofungin was added empirically. He was extubated on POD 2. Prograf was started. JPs put out close to 3 liters. An ultrasound showed unchanged portal venous velocities. On POD 3, he was somnolent. A CT of his head was negative. On POD 4, Caspofungin was switched to Fluconazole and cholangiogram was normal. A post-pyloric feeding tube was placed and tube feeds were started and advanced. Bilirubin was 10. On POD 5, he was more alert but still confused. Pain medication was not required. He was being transitioned to coumadin from heparin. Vancomycin and Zosyn were discontinued. He was transferred to the floor ([**2113-6-30**]). On POD 6, lasix was started to keep him 1 liter negative. Bilirubin was 9. Tube feeds were changed to Nutren renal. On POD 7, mental status improved. The T-tube was capped. Antiretrovral medications were stated on POD 8 ([**7-3**]). He remained on Prograf 3mg [**Hospital1 **], Cellcept and Prednisone taper. Lasix was increased to 80 for fluid retention. On [**7-5**], HARRT medications were stopped due to elevated Prograf levels greater than 30. Prograf was held. ID followed. Bili eventually decreased to 3 with improved LFTs. A PFFT was placed for tube feeds due to insufficient kcals. He experienced frequent stools. C.diff was sent x6 with all specs negative. On [**7-7**] he complained of increasing abd pain, hot flashes, nausea and vomited undigested food. The PPFT was dislodged requiring removal. An ekg was wnl and IV hydration was given. Abd discomfort resolved. KUB showed dilated bowel with air fluid levels. Abd continued to appear distended, but soft. Kcals counts were sufficient with supplements to not replace tube feeds. [**Last Name (un) **] followed making adjustments to insulin. He required tapering of pm dosage due to am hypoglycemia on several days. He required FFP for supratherapeutic inr of 5.7 on [**7-6**]. Heparin drip stopped on [**7-9**]. INR was then 2.3. Coumadin was resumed on [**7-12**] at 0.5mg. HARRT (Abacavir, tenofovir, & Kaletra) was resumed on [**7-8**] when HIV VL was 1450. Prior level was <50 on [**6-30**]. Doses were based on elevated creatinine 1.4. ID noted that doses would require adjustment based on cr clearance. Azithromycin was started for CD4 count less than 50 for MAC prophylaxis. Prograf continued to be held until levels were <10. On [**7-14**] FK level was 9.0. Prograf 0.5mg was scheduled to be given once on [**7-15**] then based on drug levels twice weekly per the Transplant Office. On [**7-12**] an U/S of the liver was done to assess flow and the portal vein. This demonstrated normal intrahepatic portal flow. The extrahepatic portal vein could not be imaged due to overlying bowel gas. A hypoechoic area in the right hepatic lobe was unchanged. Splenomegaly and a small amount of ascites were unchanged. PT/OT cleared him for home. He was motivated and expressed the wish to be discharged home with assist from a friend rather than go to rehab. On [**7-14**], Coumadin was to continue at 0.5mg qd. INR was 2.2. On [**7-14**], he was afebrile. BP ranged between 101/76 to 118/86, HR 83-100, RR 18-22. Glucoses ranged between 96-150's. Wt was 72.5 kg. He was ambulatory and was tolerating a carb consistent diet with sugar free supplement. Incision staples and drain sutures were removed. Incision was c/d/i. He was discharged home with Care Group Home care for PT and nursing. Medications on Admission: Nadolol 20 mg per day Protonix 40 mg once a day Kaletra 2 tabs b.i.d. Bactrim single strength Valtrex 500 mg b.i.d. for an outbreak abacavir 300 mg 1 tab b.i.d. tenofovir 300 mg once a day metformin 500 mg b.i.d. Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*2* 2. Kayexalate Powder Sig: Thirty (30) grams PO prn per instructions from Transplant Office: for high potassium. Disp:*4 * Refills:*2* 3. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Abacavir 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Lopinavir-Ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 12. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO once a day: Transplant Coordinator to call you when you need dose based on blood drug level . Capsule(s) 13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Forty Two (42) units Subcutaneous once a day. 14. Insulin Regular Human 100 unit/mL Solution Sig: follow sliding scale Injection four times a day. Disp:*1 bottle* Refills:*2* 15. syringes low dose for [**Hospital1 **] NPH and prn regular insulin 1 box refill: 2 16. Test Strips One Touch Ultra 1 box 1 refill 17. Lancets 1 box-qid accuchecks refill: 2 18. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO once a day: See prednisone taper. 19. Warfarin 1 mg Tablet Sig: [**12-27**] Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* 20. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO once a week: Take once a week on Saturday. Disp:*8 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: esld s/p liver liver transplant HIV HCV portal vein thrombus malnutrition DM Discharge Condition: good Discharge Instructions: please call transplant office [**Telephone/Fax (1) 673**] if fevers, chills, nausea, vomiting, inability to take medications, increased abdominal distension/discomfort, redness/bleeding/drainage from incision or old drain sites,jaundice or any questions. Labs every Monday and Thursday Followup Instructions: [**Name6 (MD) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2113-7-20**] 11:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2113-7-20**] 1:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2113-7-26**] 2:40 Completed by:[**2113-7-14**]

[ "070.54", "459.89", "E878.0", "452", "286.7", "263.9", "557.0", "707.03", "560.1", "250.00", "996.82", "293.0", "155.2", "V08", "570" ]

icd9cm

[ [ [] ] ]

[ "45.91", "88.47", "50.59", "99.05", "99.04", "00.93", "50.11", "39.1", "87.54", "99.10", "51.37", "38.87", "88.64", "38.07", "96.6", "99.07" ]

icd9pcs

[ [ [] ] ]

13177, 13235

2204, 11015

327, 360

13356, 13363

1527, 2181

13697, 14158

11279, 13154

13256, 13335

11041, 11256

13387, 13674

1360, 1508

274, 289

388, 530

552, 738

754, 1345

51,601

197,326

52060

Discharge summary

report

Admission Date: [**2114-2-8**] Discharge Date: [**2114-2-14**] Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Morphine Attending:[**First Name3 (LF) 2641**] Chief Complaint: Fever Major Surgical or Invasive Procedure: Central line placement History of Present Illness: 86 YO F NH resident w/afib s/p CABG p/w chills and fever. Patient is a poor historian. Per caretaker, the patient was feeling tired in the last couple of days, denies any headaches, neck stiffness, denies any URI, cough. Per caretaker, denies any abdmoninal pain, diarrhea, urinary incontinence or disuria. She was brought to the ED this am with increase lethargy fevers and element of confusion. Per caretaker, baseline mental status is alert and oriented times 3 In the emergency department 102.7 --> 104 83 124/54 24 98% 3L NC. 3l. Exam unremarkable. CXR showed ? LLL PNA. CT done to look for source of fever showed large spleno-portal varix. SBP drifted down to the 80s despite 3L NS. Left IJ was placed. SBP 95/45 90s 100% on 3L. She was given vanc, zosyn and levofloxacin. She is DNR but unclear if ok to intubate. . Past Medical History: Atrial fibrillation on coumadin 4 vessel CABG [**12**] years ago CABG (4 artery) Knee repair ORIF left olecranon fracture Left hip Hemiarthroplasty Hypertension R arm ORIF after fall Social History: Lives in group home. Family History: Non-contributory Physical Exam: Discharge EXAM: VS: Temp: 97.0 BP:140/75 P:80 RR: O2:97% on RA GENERAL: NAD, comfortable, appropriate HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear. NECK: Supple, no thyromegaly, no JVD, no carotid bruits. LUNGS: basal crackles basal lung fields b/l otherwise clear, no wheezes . HEART: iregular iregular, nonradiating systolic murmur [**12-24**] heard in 4th intercostal space. ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding. EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses. SKIN: bruise on right hip. NEURO: Awake, A&Ox2, with impaired concentration and attention Pertinent Results: ADMISSION LABS: [**2114-2-8**] 03:30PM BLOOD WBC-12.7* RBC-3.99*# Hgb-12.2# Hct-37.3# MCV-93 MCH-30.7 MCHC-32.8 RDW-15.0 Plt Ct-239 [**2114-2-8**] 03:30PM BLOOD Neuts-91.5* Lymphs-5.5* Monos-2.0 Eos-0.8 Baso-0.3 [**2114-2-8**] 03:30PM BLOOD Glucose-158* UreaN-22* Creat-0.8 Na-134 K-3.8 Cl-97 HCO3-25 AnGap-16 [**2114-2-8**] 03:30PM BLOOD ALT-41* AST-35 CK(CPK)-33 AlkPhos-158* TotBili-1.3 [**2114-2-8**] 03:30PM BLOOD Lipase-36 [**2114-2-8**] 03:30PM BLOOD CK-MB-2 proBNP-2610* [**2114-2-8**] 03:30PM BLOOD Albumin-3.9 [**2114-2-8**] 03:46PM BLOOD Lactate-2.1* OTHER PERTINENT LABS: [**2114-2-9**] 02:11AM BLOOD PT-30.4* PTT-45.7* INR(PT)-3.0* [**2114-2-8**] 03:30PM BLOOD cTropnT-<0.01 [**2114-2-9**] 02:11AM BLOOD CK-MB-3 cTropnT-<0.01 [**2114-2-9**] 02:11AM BLOOD Calcium-7.2* Phos-3.4 Mg-1.2* MICRO: [**2-8**] Blood cultures: gram positive cocci in chains [**2-8**] Urine culture: negative [**2-8**] Urine legionella antigen: negative [**2-9**] Respiratory viral antigen screen: negative [**2-9**] Blood cultures: IMAGING: [**2-8**] CT Head w/o: 1. No acute intracranial pathology. 2. Chronic small vessel ischemic disease. [**2-8**] CXR: Low lung volumes with stable scarring in the right upper lobe. No acute cardiopulmonary pathology. [**2-8**] CT Abd/Pelvis w/contrast: 1. A large venous varix at the portosystemic confluence, with an intraluminal filling defect, which likely represents thrombus. Differntial consideration is given to a less likely rare primary tumor, such as a spindle cell sarcoma of the portal vein. Recommended a non-emergent ultrasound for further assessment of internal vascularity. Associated chronic thrombosis of the right portal vein and aneurysmal dilation of the left and main portal veins. 2. No acute intra-abdominal pathology identified to explain the patient's fever. 3. Large left renal cortical cyst, a smaller left renal hypodense lesion is not characterized in this study, may represent a hyperdense cyst. 4. Multiple thoracic vertebral compression fractures, likely chronic. Old pelvic fractures. [**2-10**] CXR: Left IJ catheter unchanged. Status post CABG. Mild cardiomegaly. Multifocal airspace opacities unchanged. Hyperinflation of the lungs. Small left retrocardiac opacity unchanged. Mild interstitial edema unchanged. . Discharge Labs [**2114-2-13**] 07:10AM BLOOD WBC-7.2 RBC-3.35* Hgb-10.5* Hct-31.3* MCV-93 MCH-31.2 MCHC-33.4 RDW-14.7 Plt Ct-256 [**2114-2-10**] 03:23AM BLOOD Neuts-85.4* Lymphs-12.0* Monos-1.9* Eos-0.5 Baso-0.2 [**2114-2-9**] 02:11AM BLOOD Neuts-91.9* Lymphs-6.4* Monos-1.5* Eos-0.2 Baso-0.1 [**2114-2-13**] 07:10AM BLOOD Plt Ct-256 [**2114-2-13**] 07:10AM BLOOD PT-21.2* INR(PT)-2.0* [**2114-2-12**] 06:45AM BLOOD Plt Ct-214 [**2114-2-11**] 06:27AM BLOOD PT-30.8* PTT-38.8* INR(PT)-3.0* [**2114-2-10**] 03:23AM BLOOD Plt Ct-161 [**2114-2-13**] 07:10AM BLOOD ESR-22* [**2114-2-13**] 07:10AM BLOOD Glucose-84 UreaN-10 Creat-0.6 Na-139 K-3.7 Cl-104 HCO3-28 AnGap-11 [**2114-2-12**] 06:45AM BLOOD Glucose-95 UreaN-14 Creat-0.6 Na-136 K-3.9 Cl-105 HCO3-25 AnGap-10 [**2114-2-9**] 02:11AM BLOOD CK(CPK)-37 [**2114-2-8**] 03:30PM BLOOD ALT-41* AST-35 CK(CPK)-33 AlkPhos-158* TotBili-1.3 [**2114-2-9**] 02:11AM BLOOD CK-MB-3 cTropnT-<0.01 [**2114-2-8**] 03:30PM BLOOD cTropnT-<0.01 [**2114-2-13**] 07:10AM BLOOD Calcium-8.1* Phos-2.8 Mg-1.7 [**2114-2-12**] 06:45AM BLOOD Calcium-8.0* Phos-2.8 Mg-1.8 [**2114-2-11**] 06:27AM BLOOD Calcium-7.9* Phos-2.4* Mg-2.0 [**2114-2-9**] 03:07AM BLOOD Lactate-1.3 . Abdominal US . Very large splenoportal varix, partly filled by echogenic material, likely thrombus, less likely neoplasm. MRI could be performed to furhter assess. 2. Thrombosis of the right portal vein. Main left portal vein not well demonstrated at the hilum. Left portal vein patent. 3. Large left kidney lower pole renal cyst. The upper pole cyst of the left kidney is incompletely imaged due to breathing motion; suboptimal evaluation. Repeat renal ultarsound in a non-urgent can be considered. 4. Cholelithiasis; no acute cholecystitis. . Echocardiogram The left 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. Regional left ventricular wall motion is normal. There is mild global left ventricular hypokinesis (LVEF = 45 %). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. If indicated, a TEE would better exclude a small valvular vegetation. . [**2-13**] ultrasound of liver with doppler The liver appears normal in size, echogenicity and architecture. There are no focal liver lesions seen. Multiple small subcentimeter gallstones are present without signs of cholecystitis and there is no evidence of bile duct dilatation. There is no evidence of ascites or splenomegaly. Grayscale, color flow and pulse Doppler assessment of the portal venous system was next performed. Once again there is evidence of aneurysmal dilatation of the splenic/portal vein confluence, with an AP diameter of 5.3 cm. Most of the aneurysm is filled with organized clot which has partially retracted from the walls and around which there is continuous venous flow. Immediately to the right of the spleno-portal aneurysm there is evidence of cavernous transformation of the portal vein with numerous dilated collateral channels which reconstitute at the portal bifurcation. The left portal vein is patent and somewhat dilated. Today's study demonstrates the right portal vein to be small, but also patent in both the trunk and the anterior and posterior branches, patency confirmed both by color flow and pulse Doppler evaluation. CONCLUSION: 1. There is cavernous transformation of the portal vein with reconstitution of both the left and right intrahepatic portal trunks with patency confirmed by Doppler. Just proximal to the cavernous transformation is aneurysmal dilatation of the SV/PV confluence, and a large but nonocclusive clot is present within the aneurysm. 2. Cholelithiasis. Brief Hospital Course: 86 YO F NH resident w/afib s/p CABG presented with fever and hypotension . #Hypotension: Met criteria for septic shock in setting of refractory hypotension. Most likely etiology was pneumonia of either viral or bacterial origin initially. CXR showed possible opacification in right upper lobe which corroborated with crackles on physical exam. She lives in group home and was at risk for MDR pathogens. Meningitis and encephelitis were considered less likely given that she had no headaches and no meningial signs on exam. Abdominal infection and UTI less likely considering normal physical exam and normal UA. There were some evidence of sinusitis on CTA however no clinical evidence and thus it was lower on the differential. She had urine, blood and sputum cultures sent, including legionell cultures. She was started imperically on vancomyin, zoysn, levoquin and osletamivir ([**2-9**]) for empiric coverage for HCAP and influenza. She had a central line placed for access and cvp monitoring which was later removed after she was hemodynamically stable. She was briefly on levophed to support her blood pressure, however this was quickly weaned within 24 hours. Her osletamivir was stopped when her flu screen was negative. She did have [**2-19**] blood cultures from [**2-8**] which grew gram positive Cocci which later speciated as strep. viridans. Her legionella antigen was negative. The levoquin was then stopped given the culture results. Her urine culture was negative. She was narrowed down to Ceftriaxone and recieved a TTE which was negative for valvular vegetations, though she had mitral regurg. She did have a CT abdomen looking for a source of her original fever which revealed the incidental finding of portal vein thrombus and spleno-portal varix of undtermined age. ID was consulted to assist with duration of therapy and recomended 1 month of Ceftriaxone treatment ( unitl [**3-12**]) with CRP, ESR , RF levels to guide assessment of endocarditis. AT the time of the discharge ESR 22 and RF 6. A TEE was not done because of anxiety the patient was experiencing during the admission and the significant sedatives she would require for such a procedure. Blood cultures pending at the time of discharge . Panorex of the mandible was done to assess dentition as cause of her strep viridans and was negative according to dental consult for signs of infection. . #.Dyspnea. This was of an unclear etiology, but likely do to her pneumonia and bacteremia. She improved with antibiotic therapy and fluids, and nebs. . #.Delirium/dementia: Patient's baseline mental status was not clear at time of admission, however, per caretaker, AxOx3. [**Month (only) 116**] have been the result of infective process. She has waxed and waned during her stay, she was frequently reoriented.On discharge she was alert and oriented X2, only not oriented to time. . #Atrial Fibrilation: Patient in afib on admission to ICU, but was not tachycardic. Held metoprolol initially given hypotension secondary to sepsis. Held anticoagulation with warfarin as INR therapeutic at 3.0. As her clnical condition improved, her home beta-blocker was restarted. Coumadin was restarted at 1 mg daily given antibiotic interaction. . #Hypothyroidism: Her home levothyroxine was continued. . . # Porto-splenic varix: Seen incidentally on CT. Abdominal ultrasound ordered to investigate for thrombus, which was seen in portal vein. Ultrasound with doppler were repeated to assess the porto-spleno varix and portal vein thrombus with cavernous transformation seen of portal vein and aneurysm proximally seen near portal spelnic junction with nonocclusive clot.Family made aware. . ____________________________________ Outpatient follow up - Might need further follow imaging for her incidental spleno-portal varix and portal vein thrombus , f/u outpatient MRI abdomen -Will need Ceftriaxone 2 gm daily until [**3-12**] for 1 month of therapy -Will need reassessment of albuterol therapy she required at times during the admission for wheezing -Will need INR checks and redosing of her Coumadin as appropiate -Blood cultures pending at time of discharge from [**2-9**] and [**2-12**] -Will poentially need hypercoagulable workup and primary cancer screening given portal vein thrombus Medications on Admission: - Lactulose 10 gram/15 mL Syrup Oral 2 Syrup(s) Once Daily, as needed - Senna 8.6 mg Cap Oral 2 Capsule(s) , at bedtime - Oxycodone 5 mg Cap Oral 0.5 Capsule(s) Twice Daily, as needed - Coumadin 1 mg Tab Oral 1 Tablet(s) TU-TH-FR-[**Doctor First Name **] - Coumadin 2 mg Tab Oral 1 Tablet(s) M-W-SA - Ativan 0.5 mg Tab Oral 1 Tablet(s) , as needed - Remeron 15 mg Tab Oral 1 Tablet(s) , at bedtime - Zetia 10 mg Tab Oral 1 Tablet(s) , at bedtime - M.V.I. Adult 1 Solution(s) Once Daily - Synthroid 125 mcg Tab Oral 1 Tablet(s) Once Daily MONDAY THRU SATURDAY - Synthroid 125 mcg Tab Oral 2 Tablet(s) ON SUNDAY - Lipitor 40 mg Tab Oral 1 Tablet(s) Once Daily - Atenolol 50 mg Tab Oral 1 Tablet(s) Twice Daily - Tylenol 325 mg Tab Oral 2 Tablet(s) Four times daily, as needed - [**Doctor Last Name **] Milk of Magnesia 30CC Suspension(s) Once Daily, as needed - Zofran 4 mg Tab Oral 1 Tablet(s) , as needed - Simethicone -- Unknown Strength Unknown sig - Omeprazole 20 mg Tab Once Daily Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 2. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 3. atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea . 5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing . 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 9. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 26 days: Please continue to [**2114-3-12**] . 10. Multiple Vitamins Tablet Sig: One (1) Tablet PO once a day. 11. Synthroid 125 mcg Tablet Sig: One (1) Tablet PO once a day: Monday through Saturday . 12. Synthroid 125 mcg Tablet Sig: One (1) Tablet PO twice a day: Please take only on Sunday . 13. Remeron 15 mg Tablet Sig: One (1) Tablet PO at bedtime. 14. lactulose 10 gram/15 mL Solution Sig: One (1) PO once a day as needed for constipation. 15. Zetia 10 mg Tablet Sig: One (1) Tablet PO at bedtime. 16. Milk of Magnesia 400 mg/5 mL Suspension Sig: One (1) PO once a day as needed for indigestion. 17. Outpatient Lab Work Q weekly CBC with diff., basic metabolic panel, ESR, CRP and LFT's All laboratory results should be faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**] Discharge Disposition: Extended Care Facility: [**Hospital1 599**] Senior Healthcare of [**Location (un) 55**] Discharge Diagnosis: Primary Diagnosis Strep. Viridans Bacteremia Spleno-Portal Varix and Portal Vein thrombosis Secondary Diagnosis Atrial Fibrilliation HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure to care for you. . You were brought to the hospital because of low blood pressure which was probably due to a bacterial infection in your blood. After several imaging tests it was determined you will need approximately 3 more weeks of additional antibiotics for this infection. . START Ceftriaxone 2GM Daily IV until [**2114-3-12**] . We decreased your Coumadin to 1mg daily, you will need a INR check in the next week. . Please START Albuterol inhaler only as needed for wheezing . Please discontinue Oxycodone and Tylenol as you did not require these medications during your hospital stay. . Please continue to take the rest of your home medications as your were before coming to the hospital. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] Date: [**2114-2-23**]:40AM Location: [**Hospital1 **] PHYSICIAN GROUP Address: [**Street Address(2) 107757**], [**Location (un) **],[**Numeric Identifier 1700**] Phone: [**Telephone/Fax (1) 24396**] Fax: [**Telephone/Fax (1) 96684**]

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Discharge summary

report

Admission Date: [**2178-11-12**] Discharge Date: [**2178-11-25**] Date of Birth: [**2095-4-30**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2777**] Chief Complaint: psoas abcess wrapping around aorta with penetrating ulcer growing unknown AFB organism, epidural abcess L3-L5 with effacement and osteomyelitis / discitis at L4, L5 level Major Surgical or Invasive Procedure: [**2178-11-13**]: s/p Right-sided axillobifemoral bypass graft; Extensive aortic debridement with ligation of the infrarenal aorta and bilateral common iliac arteries; Extensive retroperitoneal debridement; Lumbar disk debridement by Dr. [**Last Name (STitle) 1352**]; Drain placement. History of Present Illness: 83 F who presents for admission for psoas abcess wrapping around aorta with penetrating ulcer growing unknown AFB organism, epidural abcess L3-L5 with effacement and osteomyelitis / discitis at L4, L5 level. The patient states that she acquired the infection after a right lower extremity VNUS procedure in [**State 8842**]. At that time, she developed shingles and was treated with acyclovir. Upon her return home to [**Location (un) 3844**], she fell a couple of times believed to be due to her spinal stenosis. However, she began to use her walker more frequently, progressing to the inability to get out of bed. In mid [**Month (only) 205**] she went to local ER. There on examination they felt that she had an anuersym on exam. They shipped her out to [**University/College **] for further work-up. No sugical interventions were peformed. She did have multiple FNA of psoas abcess peri aortic wall fluid and epidural abcess L3-L5. She states that a lesion on her Right wrist was biopsied. She states her biopsies and FNA were negative. She was treated with moxifloxacin and Vancomycin for six weeks. Four days after her discharge, she developed groin pain, fever to 102, and hypotension. She was transferred back to DHMC and treated empirically for sepsis given her hypotension. Treated aggressively with volume. Antibiotics were changed to daptomycin, monofloxacin. Got one dose of ceftazidime. She stabalized quickly. Blood cultures remained negative. The hypotension was also thought to be secondary to narcotics. Pt also experienced ATN. On DC her creatinine was trending down. Pt had repeat MRI of psoas abcess after ATN improved, showed no change in size. Vascular and NS recommended no surgical intervention. ID recommended a workup for TB, pt did have a history of positive PPD with no treatment. This workup remains negative. (Quantiferon gold assay was negativ, 3 induced sputum cx's negative). Pt also had repeat FNA, originally cx's were negative. They eventually grew out AFB not consistant with TB or MAC. Her antibiotics then were switched to Imipenem, Rifaximin for an additional 2 weeks [**7-21**] - [**8-8**], Clarithromycin for life time. Pt was still experiencing hypotension at this time, Vascular recommended repeat scan which showed increase size of the psoas abcess and worsening of the discitis. Upon discharge pt seemed to be improving rapidly and was nearly independent in early [**Month (only) 359**]. However, a few weeks prior to her presentations, she began experiencing back pain, increasing weakness, and fevers. Workup included a CT scan that showed and enlarging paraaortic abscess. Her PCP referred her for 2nd opinion with Dr. [**Last Name (STitle) **] at [**Hospital1 18**]. He reviewed her records and instructed her to come in for admission and emergent surgery on [**11-13**]. Past Medical History: VASCULAR HISTORY: AAA, : New. Carotid Endarectomy, : L CEA. PAST MEDICAL HISTORY: Rheumatoid Nodule, MGUS, Angular Chelitis, Dermatomyositis, Thrombocytosis, Pulmonary Hypertension, Spinal Stenosis, Depression, Osteoporosis, Ectopic pregnancy with perotinitis, Rheumatoid arthritis, [**Last Name (un) 39070**] Hunt Syndrome with Left sided Bells Palsy PAST SURGICAL HISTORY: L CEA, B/L knee replacements, C section, R carpal tunnel release, VNUS RLE Social History: Remote Smoker Drinks Rarely Lives Independently at Retirement Community Family History: Son deceased of testicular Cancer Physical Exam: Vital Signs: Temp: 98 RR: 18 Pulse: 73 BP: 133/46 96%RA Neuro/Psych: Oriented x3, Affect Normal, NAD. Neck: No masses, Trachea midline, Thyroid normal size, non-tender, no masses or nodules, No right carotid bruit, No left carotid bruit, abnormal: Facial Palsy Left. Nodes: No clavicular/cervical adenopathy, No inguinal adenopathy. Skin: No atypical lesions. Heart: Regular rate and rhythm. Lungs: Clear, Normal respiratory effort. Gastrointestinal: Non distended, Guarding or rebound, No hepatosplenomegally, No hernia, abnormal: Palpabel Mass umbilical region. Extremities: No popiteal aneurysm, No femoral bruit/thrill, No RLE/LLE 1+ edema, Pulse Exam (P=Palpation, D=Dopplerable, N=None) RUE Radial: P. Ulnar: P. Brachial: P. LUE Radial: P. Ulnar: P. Brachial: P. RLE Femoral: P. Popiteal: P. DP: D. PT: D. LLE Femoral: P. Popiteal: P. DP: D. PT: D. Pertinent Results: [**2178-11-25**] 05:22AM BLOOD WBC-6.7 RBC-3.44* Hgb-10.5* Hct-31.7* MCV-92 MCH-30.5 MCHC-33.0 RDW-14.2 Plt Ct-196 [**2178-11-24**] 06:09AM BLOOD WBC-5.4 RBC-3.46* Hgb-10.4* Hct-30.7* MCV-89 MCH-30.2 MCHC-34.0 RDW-14.2 Plt Ct-175 [**2178-11-12**] 11:03AM BLOOD WBC-7.6 RBC-3.92* Hgb-11.4* Hct-35.8* MCV-91 MCH-29.0 MCHC-31.8 RDW-13.7 Plt Ct-386 [**2178-11-18**] 10:10AM BLOOD Neuts-83.3* Lymphs-10.0* Monos-4.1 Eos-2.5 Baso-0.2 [**2178-11-18**] 10:10AM BLOOD Neuts-83.3* Lymphs-10.0* Monos-4.1 Eos-2.5 Baso-0.2 [**2178-11-13**] 07:00PM BLOOD Neuts-91.6* Lymphs-5.8* Monos-2.3 Eos-0.1 Baso-0.2 [**2178-11-25**] 05:22AM BLOOD Plt Ct-196 [**2178-11-23**] 05:00AM BLOOD PT-11.7 PTT-24.3 INR(PT)-1.0 [**2178-11-12**] 11:03AM BLOOD PT-12.7 PTT-24.2 INR(PT)-1.1 [**2178-11-25**] 05:22AM BLOOD Glucose-130* UreaN-22* Creat-0.6 Na-135 K-4.1 Cl-101 HCO3-27 AnGap-11 [**2178-11-12**] 11:03AM BLOOD Albumin-4.2 Calcium-10.0 Phos-3.2 Mg-2.4 Iron-22* Time Taken Not Noted Log-In Date/Time: [**2178-11-13**] 10:05 pm SWAB AORTIC ABS R/O ACTINOMYCES. GRAM STAIN (Final [**2178-11-13**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2178-11-20**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2178-11-21**]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. A swab is not the optimal specimen for recovery of mycobacteria or filamentous fungi. A negative result should be interpreted with caution. Whenever possible tissue biopsy or aspirated fluid should be submitted. ACID FAST CULTURE (Preliminary): A swab is not the optimal specimen for recovery of mycobacteria or filamentous fungi. A negative result should be interpreted with caution. Whenever possible tissue biopsy or aspirated fluid should be submitted. NO MYCOBACTERIA ISOLATED. ACID FAST SMEAR (Final [**2178-11-15**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. [**2178-11-13**] 3:50 pm TISSUE R/O ACTINOMYCES. AORTIC TISS. GRAM STAIN (Final [**2178-11-13**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [**2178-11-20**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2178-11-21**]): NO GROWTH. POTASSIUM HYDROXIDE PREPARATION (Final [**2178-11-16**]): NO FUNGAL ELEMENTS SEEN. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. ACID FAST SMEAR (Final [**2178-11-15**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. Time Taken Not Noted Log-In Date/Time: [**2178-11-13**] 9:58 pm ABSCESS AORTIC ABSCESS. R/O ACTINOMYCES. GRAM STAIN (Final [**2178-11-13**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2178-11-20**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2178-11-21**]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. ACID FAST SMEAR (Final [**2178-11-15**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2178-11-16**]): NO FUNGAL ELEMENTS SEEN. [**2178-11-13**] 5:00 pm TISSUE SOURCE IS SPINAL BONE. R/O ACTINOMYCES. GRAM STAIN (Final [**2178-11-13**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [**2178-11-20**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2178-11-21**]): NO GROWTH. ACID FAST SMEAR (Final [**2178-11-15**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2178-11-16**]): NO FUNGAL ELEMENTS SEEN. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. [**2178-11-12**] 3:45 pm BLOOD CULTURE **FINAL REPORT [**2178-11-18**]** Blood Culture, Routine (Final [**2178-11-18**]): NO GROWTH. Brief Hospital Course: Pt presented to the hospital on [**2178-11-12**] with psoas abscess wrapping around aorta with penetrating ulcer growing unknown AFB organism (mycobacterium chlonae), epidural abscess L3-L5 with effacement and osteomyelitis/discitis at L4, L5 level. She agreed to have surgery. Preoperatively an ID consult was obtained. Pre-operatively, she was consented. A CXR, EKG, UA, CBC, Electrolytes, type and screen were obtained. On [**2178-11-13**] she was taken to the operating room for right axillary artery to bilateral femoral artery bypass with PTFE, resection and debridement of infrarenal aorta, debridement of L4/L5 discs. Postoperatively, she was transferred to the CVICU intubated for close monitoring overnight. She was placed on TB/respiratory precautions for +PPD. [**Date range (1) 93377**]: Extubated, ID following Amikacin 850mg, Linezolid continued. Non productive cough, sputum cx pending. C/O severe pain, pain consult initiated. [**11-16**] pain consult obtained for acute on chronic pain- long standing spinal stenosis with long term narcotic and antidepressant use) now with spinal debridement. Home med lyrica restarted, Oxycodone and Dilaudid increased. JP bulb intact, draining moderate mounts. [**12-6**] + edema, lasix started. [**Date range (1) 52935**] Ortho/spine- Dr. [**Last Name (STitle) **] following. Cleared patient for activities from spine perspective. Off TB precautions per ID. VSS. On clears/advancing as tolerated, positive flatus. Physical therapy initiated. ID closely following, awaiting final cultures. [**11-19**] PICC line placed in IR for long term ABX. Nutrition consulted. Calorie counts initiated. VSS. [**11-20**] Geriatrics consulted. Nutritional labs obtained and supplements provided/encouraged. TPN initiated for poor po intake. Geriatrics recs- 6 small meals, boost supplements and aggressive bowel regime. No Dobbhoff, no tube feeds. [**Date range (1) 69262**] VSS. No events. Poor po intake, continued regular diet and TPN. Pain controlled on current regime. JP drain discontinued on [**11-25**]. ID continues to follow cultures. Will have weekly labs at rehab. Follow up apptmoints scheduled for ortho, ID and Dr. [**Last Name (STitle) **]. Medications on Admission: acyclovir [Zovirax] - 5 % Cream clarithromycin - 500 mg Tablet"' folic acid - 1 mg Tablet' metoprolol tartrate - 25 mg Tablet" naproxen - 250 mg Tablet oxycodone - 10 mg Tablet pregabalin [Lyrica] - 50 mg Capsule"' risedronate [Actonel] - 35 mg Tablet venlafaxine - 75 mg Capsule, Sust. Release 24 hr' aspirin - 81 mg Tablet, Delayed Release (E.C.) calcium carb-mag oxide-vit D3 [Calcium Magnesium + D] - 400 mg-167 mg-133 unit Tablet docusate sodium - 100 mg Capsule ergocalciferol (vitamin D2) [Vitamin D] - 400 unit Capsule multivitamin psyllium [Metamucil] - 0.52 gram Capsule vit A,C & E-lutein-minerals [I-Vite] - 1,000 unit-[**Unit Number **] mg-60 unit-[**Unit Number **] mg-55 mcg-2 mg-2 mg Tablet Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO DAILY (Daily). 3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) 5000 Injection TID (3 times a day). 5. oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q8H (every 8 hours). 6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 10. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 12. pregabalin 25 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 13. amikacin 250 mg/mL Solution Sig: 850mg Injection Q24H (every 24 hours): Management by Dr. [**Last Name (STitle) 9461**]/ID [**Telephone/Fax (1) 457**], fax [**Telephone/Fax (1) 1419**]. Last through at 1500 at [**Hospital1 18**] [**2178-11-25**]. 14. Regular Insulin sliding scale Fingerstick QACHSInsulin SC Sliding Scale Q6H Regular Glucose Insulin Dose 0-70 mg/dL Proceed with hypoglycemia protocol 71-150 mg/dL 0 Units 151-200 mg/dL 2 Units 201-250 mg/dL 4 Units 251-300 mg/dL 6 Units 301-350 mg/dL 8 Units 351-400 mg/dL 10 Units > 400 mg/dL Notify M.D. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: 1. Mycotic contained rupture with infection of the infrarenal aorta. 2. Psoas abscess. 3. Diskitis L4-5. 4. Osteomyelitis of L4 and L5. 5. Spondylolisthesis of L4 on 5. 6. Severe lumbar stenosis. 7. Peripheral Vascular Disease 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: Division of Vascular and Endovascular Surgery Lower Extremity Bypass Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ??????You should get up out of bed every day and gradually increase your activity each day ??????Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ??????Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ??????Elevate your leg above the level of your heart (use [**1-7**] pillows or a recliner) every 2-3 hours throughout the day and at night ??????Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ??????You will probably lose your taste for food and lose some weight ??????Eat small frequent meals ??????It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ??????To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ??????No driving until post-op visit and you are no longer taking pain medications ??????Unless you were told not to bear any weight on operative foot: ??????You should get up every day, get dressed and walk ??????You should gradually increase your activity ??????You may up and down stairs, go outside and/or ride in a car ??????Increase your activities as you can tolerate- do not do too much right away! ??????No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ??????You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ??????Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ??????Take all the medications you were taking before surgery, unless otherwise directed ??????Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ??????Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ??????Redness that extends away from your incision ??????A sudden increase in pain that is not controlled with pain medication ??????A sudden change in the ability to move or use your leg or the ability to feel your leg ??????Temperature greater than 100.5F for 24 hours ??????Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Provider: [**Name10 (NameIs) 1412**] [**Name Initial (NameIs) **] [**Name12 (NameIs) 1413**], M.D. Date/Time:[**2178-12-3**] 1:30 Infectious DIsease. [**Hospital Ward Name **] LMOB Basement [**Telephone/Fax (1) 457**] Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 9462**] [**2179-1-6**] 10:00a Infectious Disease. [**Hospital Ward Name **] LMOB Basement [**Telephone/Fax (1) 457**] Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2178-12-17**] 9:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**] Date/Time:[**2178-12-17**] 11:30 Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**] (ortho/spine) [**Telephone/Fax (1) 3736**]. [**2178-12-14**] 1040am. Office- [**Hospital Ward Name 23**] [**Location (un) **], [**Hospital Ward Name **] Completed by:[**2178-11-25**]

[ "724.02", "756.12", "722.93", "324.1", "730.28", "567.31", "416.8", "714.0", "440.20", "733.00", "311", "441.4", "031.8" ]

icd9cm

[ [ [] ] ]

[ "38.93", "39.29", "54.4", "81.62", "38.86", "81.06", "96.6", "38.84", "80.99" ]

icd9pcs

[ [ [] ] ]

14187, 14253

9542, 11745

477, 765

14527, 14527

5132, 6444

17625, 18536

4205, 4240

12503, 14164

14274, 14506

11771, 12480

14703, 17172

17203, 17602

4021, 4098

4255, 5113

9109, 9140

9173, 9519

266, 439

793, 3623

14542, 14679

3727, 3998

4114, 4189

8,388

171,391

45407

Discharge summary

report

Admission Date: [**2195-7-19**] Discharge Date: [**2195-7-25**] Date of Birth: [**2124-7-21**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 759**] Chief Complaint: found down Major Surgical or Invasive Procedure: s/p fasciotomy followed by closure of right arm for compartment syndrome History of Present Illness: 69M with hx of seizure disorder and med noncompliance who was admitted to [**Hospital1 18**] on [**7-19**] after being found down in his home. Pt states he felt dizzy which is typical for how he feel before a seizure and he has no memory after that. Per patient he was found about 12 hours later on his basement floor by his sister. At the time he was unable to move his RUE and had multiple abrasions and therefore was sent to the ED. . In the ED his vitals were T 99.7, HR 95, BP 136/91, 93 % on RA, 98 % on 2 L, CK was found to be [**Numeric Identifier 95493**], lactate 3.9, cr 2.2, CT head and CXR negative and plain films of right arm with no fracture. He received 3 NS, I L D5W with 3 amps of HCO3, ASA 325 mg, gabitril 4 mg x1, lamictal 300 mg x1, paxil, zonegran 300 mg x1 (his home meds). He was evaluated by orthopedic surgery and was found to have a compartment syndrome (loss of radial pulse) and was taken to the OR for compartment release. . In the MICU, he was given ~4L of bicarb in D5W to keep UOP>200 cc per hour. He was then transitioned to normal saline. His creatinine and CPK trended down with fluid resuscitation. . On arrival to the floor, pt reported mild pain and tingling in his right arm. Otherwise, feeling well, good appetite, no headache. Past Medical History: 1. Epilepsy - since childhood. Difficult to control. Poorly compliant with medications. 2. Mental retardation. 3. Obstructive-sleep apnea. 4. Spinal degenerative joint disease. 5. Depression. 6. Anxiety. 7. h/o gallstones/choledocholithiasis 8. Questionable history of nephrolithiasis. Social History: Lives at home alone. An elderly neighbor used to help with his medications, but now no longer lives there. Per OMR notes, there has been concern recently about his ability to manage his medications. His older sister (age 84) also helps out, but has raised the question of a group home for him. No history of alcohol, tobacco, or IV drug use. Right now, per patient he has a cleaning lady and his brother has labeled his medications to help him remember which medications to take. Family History: Father deceased in his 40s secondary to cancer, unknown which type. Mother deceased at age 62 secondary to CHF and CAD, brother deceased at age 66 secondary to unknown cancer, and another brother with high cholesterol. Physical Exam: temp 97.3, BP 110/48, HR 69, R 18, O2 95%RA I/O: 24 hrs 10.2/3.4, today 3.2/3.3, LOS +6.7L Gen: Elderly male with dressing on right arm, NAD, pleasant HEENT: MM dry, EOMI, PERRL, lacerations on right temple Neck: no cervical LAD, no bruits Lungs: clear, bandage on right chest CV: RRR, 1/6 systolic murmur at RUSB Abd: + BS, soft, NT/ND Ext: no edema in lower ext bilaterally, 2+ DP; right arm with 1+ radial pulse, decreased sensation when compared to the left, strength 3/5 on right, [**4-10**] on left Neuro: AO x 2 (place, person); moves all extremities, sensation intact in lower ext Pertinent Results: [**2195-7-19**] 08:47PM LACTATE-3.9* [**2195-7-19**] 08:38PM GLUCOSE-117* UREA N-40* CREAT-2.2* SODIUM-145 POTASSIUM-5.0 CHLORIDE-106 TOTAL CO2-15* ANION GAP-29* [**2195-7-19**] 08:38PM CALCIUM-10.3* PHOSPHATE-5.0* MAGNESIUM-2.6 [**2195-7-19**] 08:38PM CK(CPK)-[**Numeric Identifier 95493**]* [**2195-7-19**] 08:38PM CK-MB-289* MB INDX-1.0 . [**2195-7-19**] 08:38PM WBC-20.9*# RBC-6.41*# HGB-17.4# HCT-52.9* MCV-83 MCH-27.1 MCHC-32.9 RDW-14.0 [**2195-7-19**] 08:38PM NEUTS-82* BANDS-8* LYMPHS-4* MONOS-6 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2195-7-19**] 08:38PM PLT COUNT-422 . [**2195-7-19**] 08:40PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.019 [**2195-7-19**] 08:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2195-7-19**] 08:40PM URINE RBC-[**10-26**]* WBC-0-2 BACTERIA-FEW YEAST-RARE EPI-0-2 TRANS EPI-0-2 RENAL EPI-[**2-8**] . Right arm x-ray: No fracture or dislocation of the right shoulder, right elbow, or right hand. . CXR: Linear opacities of the right middle lobe are more likely atelectasis. In the appropriate clinical context, pneumonia is a possibility. . Head CT: No intracranial hemorrhage or other acute intracranial pathology. No significant change from [**2193-11-6**]. Brief Hospital Course: A/P: 69M with hx of mental retardation, seizure disorder, medical noncompliance who was down for a prolonged time after a seizure which led to rhabdo, acute renal failure and compartment syndrome s/p release surgery . 1. Rhabdomyolysis: Likely in setting of fall and being down for several hours. s/p several liters of fluid in MICU with resolution of CK (down from peak of 25,000) and creatinine. . 2. Compartment syndrome: Developed in setting of being down on arm for several hours. Ortho took patient to OR on admission for fasciotomy of right arm given lose of radial pulse. He was then taken back to the OR five days later for closure. On discharge, pt had decreased sensation of his right hand along with 2/5 hand grip strength. Ortho evaluated the patient and stated that he was OK for discharge. he will follow-up with ortho in 2 weeks for suture removal. He should been non-weight bearing to the right arm with dressing changes daily. . 3. ARF: Likely due to rhabdo. Creatinine peaked at 2.4 and improved to 1.4-1.5 with fluids. His baseline appears to be 1.2-1.5. . 4. fall/seizure disorder: Pt has a hx of seizure disorder. Due to his history of mental retardation, the patient's neighbor had been helping him take his medications on time on the weekend and on the weekdays, the patient was supervised at his workplace. However, the neighbor recently moved away, thus the patient no longer had the supervision. He has seizure episodes in the past for similar reasons. Arrhythmia was ruled out with monitoring on telemetry and cardiac enzymes were negative x 2. His outpatient neurologist was contact[**Name (NI) **] and she recommended continuing his outpatient regimen. He was maintained on lamictal, zonisamide and topamax. Per the neurologist, the zonisamide capsules were to be opened and the contents sprinkled into one teaspoonful of soft solid, since the patient was unable to swallow the pill. . # Anemia: The patient's hematocrit dropped from 52.9 --> 42.5 --> 35.8. This was attributed to hemodilution since the patient received a large amount of IV hydration. He had no signs of acute blood loss and he remained hemodynamically stable. . # Leukocytosis: The white blood cell count was elevated on initial presentation and was attributed to stress reaction. No other source of infection was found and the white count elevation resolved afterward. . # Anxiety/depression: Patient was maintained on his outpatient regimen of paroxetine. . # Comm: Sister [**Name (NI) 2155**] [**Name (NI) **] [**Telephone/Fax (1) 96927**] . Medications on Admission: GABITRIL 4MG--One by mouth twice a day LAMICTAL 100MG--3 tabs by mouth twice a day PAXIL 40MG--One pill every day ZONEGRAN 100MG--3 tabs by mouth twice a day Discharge Medications: 1. Lamotrigine 100 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 2. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Tiagabine 4 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Zonisamide 100 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day): Please open capsule and sprinkle into ONE SPOONFUL of soft solid. 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: Primary Diagnosis: 1. Rhabdomyolysis 2. Compartment syndrome of right arm s/p fasciotomy 3. Seizure disorder 4. Acute Renal failure, now resolved Secondary Diagnosis: 1. Mental retardation 2. Anxiety/Depression Discharge Condition: good Discharge Instructions: You had compartment syndrome of your right arm after you had a seizure. Orthopedics had to repair the arm and you will need to follow up with ortho in [**1-9**] weeks. It is very important to take all of your seizure medications (exactly as instructed) every day and go to all follow-up appointments. Please call your PCP of go to the ER if you lose the radial pulse in your right arm, lose sensation in the right hand or have loss of strength. Followup Instructions: You will follow up with orthopedic surgery (Dr. [**Last Name (STitle) 1005**] on [**2195-8-11**] at 10:50am. [**Hospital Ward Name 23**] building, [**Location (un) **] Provider: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 6531**] RN Phone:[**Telephone/Fax (1) 876**] Date/Time:[**2195-9-2**] 9:00 Completed by:[**2195-7-29**]

[ "327.23", "958.8", "317", "584.9", "300.4", "345.90", "728.88" ]

icd9cm

[ [ [] ] ]

[ "83.45", "83.65", "83.14" ]

icd9pcs

[ [ [] ] ]

7908, 7993

4697, 7257

325, 400

8249, 8256

3369, 4553

8752, 9103

2524, 2744

7466, 7885

8014, 8014

7283, 7443

8280, 8729

2759, 3350

275, 287

428, 1701

8182, 8228

4562, 4674

8033, 8161

1723, 2011

2027, 2508

16,516

188,281

19039

Discharge summary

report

Admission Date: [**2133-8-11**] Discharge Date: [**2133-8-15**] Date of Birth: [**2064-10-24**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2597**] Chief Complaint: R 2nd toe infection Major Surgical or Invasive Procedure: [**2133-8-11**] Right femoral to anterior tibial bypass with in situ saphenous vein and angioscopy. History of Present Illness: This is a 68M well-known to Dr. [**Last Name (STitle) **] who is s/p AAA endovascular stent graft repair ([**2122**]) with subsequent thrombosis and R foot ischemia, s/p aorto-bifemoral graft ([**8-3**]) without improvement in R foot ischemia, s/p R fem-AT PTFE graft. He had been recently hospitalized ([**Date range (1) 51997**]) for R 2nd toe infection which responded to heparin gtt and IV antibiotics. Noninvasives suggested that his R fem-AT bypass had occluded. An MRA demonstrated R SFA and popliteal occlusion with distal AT and aortobifem graft patency. He was admitted for R femoral to anterior tibial bypass. Past Medical History: PMH: IDDM, HTN, lower extremity DVT (no document U/S), PVD, postop ARF PSH: R eye cataract surgery; AAA endovascular stent graft for AAA ([**2122**]); aorto-bifem ([**8-3**]); R femoral to AT bypass with PTFE ([**8-3**]); umbilical hernia repair; R first toe amputation ([**11-4**]); R 2nd toe PIP joint arthroplasty, R 3rd toe manipulation of arthrofibrosis, R 2nd toe MTP joint capsulotomy with extensor tenotomy ([**3-7**]) Social History: Smoker, remote EtOH. Family History: Positive hx of DM. Physical Exam: On discharge: 98.6 82 118/46 18 96%RA Gen: NAD, A&O x 3 CVS: RRR, nl S1S2, no m/r/g Pulm: CTA b/l Abd: soft, obese, NT, ND, +BS Ext: R 2nd toe ulcer with minimal surrouding erythema, L DP palpable, L PT [**Name (NI) **], R DP [**Name (NI) **], R PT [**Name (NI) **], R graft palpable Pertinent Results: On admission: [**2133-8-11**] 08:21PM BLOOD WBC-9.1 RBC-3.20* Hgb-10.0* Hct-29.9* MCV-94 MCH-31.2 MCHC-33.4 RDW-14.3 Plt Ct-255 [**2133-8-11**] 08:21PM BLOOD PT-16.4* PTT-46.7* INR(PT)-1.5* [**2133-8-11**] 08:21PM BLOOD Glucose-135* UreaN-51* Creat-1.9* Na-136 K-5.2* Cl-111* HCO3-19* AnGap-11 [**2133-8-11**] 08:21PM BLOOD Calcium-8.5 Phos-3.4 Mg-1.5* AXR ([**8-14**]): There are mildly distended air-filled loops of small and large bowel with no air in the rectum. No air-fluid levels are noted. R foot XR ([**8-14**]): No soft tissue air is visualized and there is no plain film evidence of osteomyelitis. On discharge: [**2133-8-13**] 04:57AM BLOOD WBC-7.4 RBC-3.38* Hgb-10.6* Hct-31.9* MCV-94 MCH-31.4 MCHC-33.3 RDW-14.7 Plt Ct-222 [**2133-8-15**] 05:06AM BLOOD PT-15.2* INR(PT)-1.4* [**2133-8-15**] 05:06AM BLOOD Glucose-100 UreaN-18 Creat-1.3* Na-140 K-3.7 Cl-106 HCO3-25 AnGap-13 [**2133-8-15**] 05:06AM BLOOD Calcium-8.5 Phos-2.6* Mg-1.8 Brief Hospital Course: Patient underwent R femoral to anterior tibial bypass with in situ saphenous vein and angioscopy on [**8-11**]. Please see operative note for further details. Postoperatively, he received 1U PRBC for Hct 28 and low UOP. He was on Cipro/Flagyl/vanco for his R toe ulcer. On POD 2, PT ambulated him and cleared him for eventual d/c home. He was diuresed with Lasix 40 mg PO; his UOP for the day was 3025. Coumadin was started. His Foley was d/c'd and he voided without difficulty. On POD 3, he was nauseous and vomited x 1. He reported that he had not had a bowel movement since admission and believed the nausea to be secondary to constipation. He had minimal distention on exam. An EKG was unchanged from prior. There were no air-fluid levels on AXR. He was given milk of magnesia with +BM. Podiatry was consulted for management of his R 2nd toe ulcer. Conservative management was recommended. He was discharged on POD 4. On discharge, he was afebrile with stable vital signs, ambulating, tolerating regular diet, and his pain was well-controlled with PO medication. Medications on Admission: 1. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO qd (). 2. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Niacin 100 mg Tablet Sig: 7.5 Tablets PO TID (3 times a day). 7. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 9. Rosiglitazone 8 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 12. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO every other day: Alternate with 5mg daily. 13. Coumadin 5 mg Tablet Sig: One (1) Tablet PO every other day: Alternate with 2.5mg. 14. Lovenox 100 mg/mL Syringe Sig: One (1) Subcutaneous once a day for 7 days: Administer to abdomen daily, rotate sites. Disp:*7 7* Refills:*0* 15. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: 20 units Subcutaneous at bedtime: Resume home blood sugar medication and finger sticks. 16. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily) for 2 weeks. Disp:*14 Patch 24 hr(s)* Refills:*1* 17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Discharge Medications: 1. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 2. Insulin Fixed dose and sliding scale Insulin SC Fixed Dose Orders Bedtime NPH 20 Units Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Glucose Insulin 0-50 mg/dL 4 oz. Juice 51-150 mg/dL 0 Units 0 Units 0 Units 0 Units 151-200 mg/dL 2 Units 2 Units 2 Units 2 Units 201-250 mg/dL 4 Units 4 Units 4 Units 4 Units 251-300 mg/dL 6 Units 6 Units 6 Units 6 Units 301-350 mg/dL 8 Units 8 Units 8 Units 8 Units 351-400 mg/dL 10 Units 10 Units 10 Units 10 Units 3. Fenofibrate Micronized 134 mg Capsule Sig: One (1) Capsule PO once a day. 4. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Niacin 250 mg Capsule, Sustained Release Sig: Three (3) Capsule, Sustained Release PO TID (3 times a day). 8. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 10. Rosiglitazone 8 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 13. Humulin N 100 unit/mL Suspension Sig: Twenty (20) units Subcutaneous at bedtime. 14. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime: Please have your PCP monitor your INR and adjust coumading dose accordingly. Tablet(s) 15. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous twice a day: d/c once INR is therapeutic. Disp:*14 QS* Refills:*0* 16. Outpatient Lab Work INR on Monday [**2133-8-17**] Discharge Disposition: Home Discharge Diagnosis: peripheral vascular disease, ischemic R 2nd toe ulcer Discharge Condition: good Discharge Instructions: Division of Vascular and Endovascular Surgery Lower Extremity Bypass Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [**1-3**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Call Dr.[**Name (NI) 5695**] office at [**Telephone/Fax (1) 3121**] for an appointment. Please have Dr.[**Name (NI) 5695**] or your PCP check your INR on Monday morning, and adjust your coumading dose accordingly. Completed by:[**2133-8-31**]

[ "V45.61", "V58.67", "V12.51", "440.23", "707.15", "593.9", "250.00" ]

icd9cm

[ [ [] ] ]

[ "99.04", "39.29" ]

icd9pcs

[ [ [] ] ]

7592, 7598

2914, 3998

335, 437

7696, 7703

1937, 1937

10545, 10790

1594, 1614

5644, 7569

7619, 7675

4024, 5621

7727, 10113

10139, 10522

1629, 1629

2566, 2891

276, 297

465, 1090

1951, 2552

1112, 1540

1556, 1578

82,451

183,958

36489

Discharge summary

report

Admission Date: [**2105-7-28**] Discharge Date: [**2105-8-2**] Date of Birth: [**2021-7-31**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Egg Attending:[**First Name3 (LF) 1505**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2105-7-28**] - Aortic valve replacement(25mm [**Company 1543**] Mosaic Porcine valve)/Ascending aorta replacement (32mm Gelweave graft)/Coronary artery bypass graftingx1 (Left internal mammary artery->Left anterior descending artery). History of Present Illness: 83-year-old gentleman who has had increasing shortness of breath with occasional episodes of palpitations this past spring. He was hospitalized for heart failure in late [**Month (only) 547**] and treated with diuretics. He admits to worsening shortness of breath and some lower extremity edema. Ultimately this prompted echocardiogram and cardiac catheterization, which showed single-vessel coronary artery disease, aortic insufficiency and a dilated aorta. He was seen by Dr. [**Last Name (STitle) **] in [**Month (only) 205**] for surgical management and presents today for preoperative testing. He is scheduled for surgery on [**2105-7-28**] which will be an ascending aorta replacement, aortic valve replacement and coronary artery bypass grafting versus a bental procedure with bypass grafting. Past Medical History: chronic diastolic heart failure aortic insufficiency aortic stenosis aortic aneurysm hypertension hypercholesterolemia childhood asthma peptic ulcer disease Question of hepatitis C left lower extremity varicosities diverticular disease left bundle branch block severely hard of hearing in both ears bilateral hernia repair colectomy tonsillectomy bilateral cataract surgeries Social History: He is currently retired. He quit smoking 40 years ago and had only a five-pack-year history. He does not use any alcohol. He lives with his wife of many years in [**Name (NI) 6151**] MA. Family History: non contriibutory Physical Exam: Pulse: 56-60 irregular Resp: 16 O2 sat: 98% RA B/P Right: 128/48 Left: 122/40 Height: 70" Weight: 140lbs General: Thin somewhat frail appearing elderly gentleman in NAD. Skin: Warm, dry, intact. Bilateral lower extremity chronic venous stasis changes. HEENT: NCAT, PERRLA, Sclera anicteric, OP benign. Edentulous. Neck: Supple [X] Full ROM [X], Mild JVD Chest: Lungs clear bilaterally [X] Heart: SB->RRR with PVC's and skipped beats. III/VI SEM with a II/VI Diastolic murmur. Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] No Edema Varicosities: Mild varicosities L>R Mostly supeficial. If vein needed, right GSV appears most suitable. Neuro: [**Last Name (LF) **], [**First Name3 (LF) 2995**], Gait steady, Strength 5/5. Non-focal exam.. Pulses: Femoral Right: 2 Left: 2 DP Right: 2 Left: 2 PT [**Name (NI) 167**]: 2 Left: 2 Radial Right: 2 Left: 2 Carotid Bruit Murmur radiates bilaterally. Likely + left bruit. Pertinent Results: ECHO [**2105-7-28**] PRE BYPASS The left atrium is elongated. The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately to severely dilated. There is moderate regional left ventricular systolic dysfunction with severe apical hypokinesis and mild global hypokinesis. Overall left ventricular systolic function is moderately depressed (LVEF= 35 %). Right ventricular chamber size and free wall motion are normal. The aortic root is markedly dilated at the sinus level. The ascending aorta is markedly dilated. The aortic arch is mildly dilated. There are simple atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Severe (4+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. The base of the posterior mitral leaflet is particularly thickened and calcified. Mild (1+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results in the operating room at the time of the study. POST BYPASS The patient is being atrially paced. The patient is receiving epinephrine by infusion. There is normal right ventricular systolic function. The left ventricle displays moderate to severe apical hypokinesis with mild global left ventricular hypokinesis. Ejection fraction is in the 35-40% range. There is a bioprosthesis in the aortic position. It appears well seated. Initially, after separation from bypass, several jets of aortic regurgitation were seen. One appeared to be a trace to mild jet of paravalvular AI that transversed the left ventricular outflow tract. The other jets appeared to be trace and valvular in origin. 30 minutes later, only a single jet of trace AI was seen, it's origin not identifiable. The leaflets of the bioprosthesis are not seen. The effective valve area of the valve was about 2 cm2 with a peak gradient of 13 mmHg and a mean of 7 mmHg. The ascending aortic graft is seen only poorly in situ. The rest of the thoracic aorta apperas unchanged. Mild mitral regurgitation persists. Brief Hospital Course: Admitted same day surgery and was brought to the operating room for Ascending aorta replacement, aortic valve replacement and coronary artery bypass graft surgery. See operative report for further details. He received vancomycin for perioperative antibiotics. Postoperatively he was transferred to the intensive care unit for hemodynamic management. In the first twenty four hours he was weaned from sedation, awoke neurologically intact, and was extubated without complications. He was progressively weaned off pressors on post operative day one. He developed atrial fibrillation which he was treated with beta blockers and amiodarone. On postoperative day two he converted to normal sinus rhythm, and was transferred to the postoperative floor. His chest tubes and temporary pacing wires were removed per protocol. Physical therapy worked with him on strength and mobility. He was cleared for discharge to home with his family and 24 hr care which was already in place and VNA services. Of note Mr. [**Known lastname 82656**] was discharged on 10meq of potassium supplement while he is not takin his lisinopril. once his lisinopril starts, he may need the potassium stopped. Medications on Admission: Lisinopril 5 mg daily Simvastatin 20 mg daily Omeprazole 20 mg twice a day Furosemide 80 mg twice a day Metoprolol 25 mg twice a day Iron 325mg daily Centrum silver daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 4. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*0* 5. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 7. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day: home dose. Disp:*60 Tablet(s)* Refills:*2* 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*45 Tablet(s)* Refills:*0* 9. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): your doctor will tell you if and when to stop this mdication. Disp:*30 Tablet(s)* Refills:*2* 11. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day: your doctor may stop this medication at your follow up visit. Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 1376**] Discharge Diagnosis: Coronary artery disease s/p CABG Aortic insufficiency s/p AVR Ascending Aortic aneurysm s/p Ascending aorta replacement Post operative atrial fibrillation acute on chronic systolic and diastolic heart failure hypertension hypercholesterolemia childhood asthma peptic ulcer disease Questionable hepatitis C left lower extremity varicosities diverticular disease left bundle branch block severely hard of hearing in both ears Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. Please report any and all wound issues to your surgeon at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) Please wash incision with soap and water daily and gently pat dry. No lotions, creams or powders to incisions until they have healed. No bathing or submerging incisions for 1 month. 5) No lifting greater then 10 pounds for 10 weeks from date of surgery. 6) No driving for 1 month. 7) Please call with any questions or concerns. [**Telephone/Fax (1) 170**] Followup Instructions: Please call to schedule appointments Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 1504**] Dr. [**Last Name (STitle) 2912**] in [**11-28**] weeks. Dr. [**Last Name (STitle) **] in [**11-28**] weeks. wound check appointment [**Hospital Ward Name 121**] 6 please schedule with RN [**Telephone/Fax (1) 3071**] Completed by:[**2105-8-2**]

[ "441.2", "E878.2", "414.01", "428.0", "428.43", "427.31", "070.54", "585.9", "424.1", "272.0", "997.1", "403.90" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

8506, 8557

5581, 6767

303, 543

9025, 9032

3080, 5558

9734, 10088

1995, 2014

6989, 8483

8578, 9004

6793, 6966

9056, 9711

2029, 3061

244, 265

571, 1375

1397, 1775

1791, 1979

15,380

167,842

8891

Discharge summary

report

Admission Date: [**2162-5-3**] Discharge Date: [**2162-5-8**] Date of Birth: [**2088-11-29**] Sex: F Service: MEDICINE Allergies: Sulfonamides / Flagyl Attending:[**First Name3 (LF) 297**] Chief Complaint: transferred from OSH after PEA arrest Major Surgical or Invasive Procedure: none History of Present Illness: 73 y/o F w/COPD/asthma, OSA s/p multiple trachs with revision, diastolic dysfxn, recent pseudomonal pna/sepsis on [**11-14**], who was in her USOH at her [**Hospital3 **] facility until 2 pm on [**5-1**] when she was attempting to suction herself and dislodge a mucus plug. She was unsuccessful and then called EMS via her lifeline. Unclear response time but between 4-20 minutes. EMS found her in PEA arrest, cyanotic, and began CPR and gave atropine and epi. They were able to dislodge her obstructed airway and ventilate her trach. At [**Hospital3 **], she was admitted to the MICU. She was hypotensive, and her neuro status was significant for responding to noxious stimuli but otherwise not following commands. Her labs showed a WBC of 19, INR 5.3. She required pressors (dopamine) and her neuro exam deteriorated to where she did not respond to anything, was decerebrate posturing, and had some seizure activity. She was loaded with dilantin. Head CT did not show a new bleed. EEG showed anoxic brain injury. She was transferred to [**Hospital1 18**] at this point. Past Medical History: 1. CHF (R sided diastolic failure). Last echo [**9-13**] showed dilated LA, mild LVH, dilated RV with depressed RV fxn, [**12-13**]+MR, 2+TR, small pericardial effusion. EF 50-55% 2. asthma 3. COPD FEV1 35%, FVC 38%, ratio 91% 4. OSA (on home BIPAP) 5. HTN 6. Afib 7. remote h/o colon ca at age 29, with partial colectomy 8. s/p trach placement [**2161-6-23**] by CT [**Doctor First Name **], followed by interventional pulmonary here Social History: Divorced, with four children. Retired software engineer. 25 pack years, quit 10 years ago. Denies EtOH, other illicit drugs. Has VNA and full time health aides. Family History: Multiple members with colon CA Physical Exam: T: 97.6 P: 81 BP: 119/60 RR: 23 98% on 60% FiOw, PS 16/8 Gen: intubated, unresponsive HEENT: pupils minimally reactive, equal, MM dry Lungs: CTA anteriorly CV: irregular, no m/r/g Abd: large lower lateral abd hernia, soft, nt/nd. +bs. Ext: no edema Neuro: does not respond to voice or follow commands, off sedation. Does respond to noxious stimuli. No corneal reflex. Doll's eye absent. DTRs unable to illicit. Babinski present bilaterally. Pertinent Results: [**2162-5-3**] 09:10PM BLOOD WBC-21.4*# RBC-4.45 Hgb-11.1* Hct-34.1* MCV-77* MCH-24.9* MCHC-32.4 RDW-17.6* Plt Ct-287 [**2162-5-4**] 10:00AM BLOOD WBC-20.6* RBC-4.34 Hgb-10.4* Hct-33.4* MCV-77* MCH-24.1* MCHC-31.3 RDW-17.5* Plt Ct-284 [**2162-5-5**] 04:04AM BLOOD WBC-19.7* RBC-3.85* Hgb-9.6* Hct-30.0* MCV-78* MCH-24.8* MCHC-31.9 RDW-17.1* Plt Ct-262 [**2162-5-7**] 03:11AM BLOOD WBC-17.9* RBC-4.01* Hgb-10.0* Hct-30.8* MCV-77* MCH-25.0* MCHC-32.6 RDW-16.9* Plt Ct-334 [**2162-5-3**] 09:10PM BLOOD PT-17.6* PTT-34.4 INR(PT)-2.0 [**2162-5-7**] 03:11AM BLOOD Glucose-151* UreaN-20 Creat-0.8 Na-139 K-4.1 Cl-105 HCO3-25 AnGap-13 [**2162-5-3**] 09:10PM BLOOD ALT-33 AST-69* LD(LDH)-276* AlkPhos-102 TotBili-0.6 [**2162-5-6**] 04:47AM BLOOD CK(CPK)-86 [**2162-5-3**] 09:10PM BLOOD Albumin-2.9* Calcium-8.8 Phos-3.7 Mg-2.0 [**2162-5-5**] 01:50PM BLOOD Cortsol-23.3* [**2162-5-5**] 02:08PM BLOOD Cortsol-40.3* [**2162-5-5**] 02:47PM BLOOD Cortsol-43.6* [**2162-5-3**] 09:10PM BLOOD Digoxin-0.8* [**2162-5-4**] 10:00AM BLOOD Phenyto-12.2 [**2162-5-4**] 05:03PM BLOOD Phenyto-11.9 [**2162-5-3**] 10:14PM BLOOD Type-ART Rates-/20 PEEP-16 FiO2-60 pO2-110* pCO2-43 pH-7.45 calHCO3-31* Base XS-4 [**2162-5-5**] 12:25AM BLOOD Type-ART Temp-37.7 Rates-20/4 Tidal V-450 FiO2-60 pO2-123* pCO2-40 pH-7.45 calHCO3-29 Base XS-4 -ASSIST/CON Intubat-INTUBATED [**2162-5-5**] 05:34AM BLOOD Type-ART Temp-37.7 Rates-20/5 Tidal V-450 PEEP-8 FiO2-40 pO2-70* pCO2-38 pH-7.46* calHCO3-28 Base XS-2 -ASSIST/CON Intubat-INTUBATED [**2162-5-5**] 09:01PM BLOOD Type-ART Temp-37.4 Rates-20/2 Tidal V-450 PEEP-10 FiO2-50 pO2-87 pCO2-39 pH-7.45 calHCO3-28 Base XS-2 -ASSIST/CON Intubat-INTUBATED [**2162-5-6**] 01:04PM BLOOD Type-ART Temp-37.8 pO2-108* pCO2-36 pH-7.42 calHCO3-24 Base XS-0 Intubat-INTUBATED [**2162-5-6**] 01:04PM BLOOD Lactate-1.8 EEG: FINDINGS: ABNORMALITY #1: Throughout the recording the background rhythm remained very slow and of extremely low voltage. ABNORMALITY #2: There were frequent generalized low voltage spikes or sharp waves. These were very brief and did not disturb the background substantially. There were no repetitive discharges. HYPERVENTILATION: Could not be performed. INTERMITTENT PHOTIC STIMULATION: Could not be performed. SLEEP: No normal waking or sleeping morphologies were seen. CARDIAC MONITOR: Showed an irregularly irregular rhythm suggestive of atrial fibrillation. IMPRESSION: Markedly abnormal portable EEG due to the near absence of background of cortical origin. This suggests a widespread and extremely severe encephalopathy. There were frequent to very brief sharp discharges indicating some hyperexcitability, but there were no repetitive discharges or prolonged discharges to suggest ongoing seizures. CXR: FINDINGS: A right central venous catheter is seen with the tip in the distal SVC. A tracheostomy tube is seen with the tip approximately 7 cm above the carina. An NG tube is seen positioned within the stomach. There is a left retrocardiac opacity with associated pleural effusion. The pulmonary vasculature is unchanged. Soft tissue and osseous structures are stable in appearance. IMPRESSION: Left retrocardiac opacity, which may represent consolidation, less likely atelectasis. Associated left small pleural effusion. Brief Hospital Course: Mrs. [**Known lastname **] was admitted to the medical ICU. It was felt that her arrest was related to hypoxia from a mucus plug. She was given antibiotics for pneumonia, and she had been febrile and having large amts of green sputum. She was also treated for a COPD flare. Neurology was consulted to assess her prognosis after this arrest and felt that she had a very poor prognosis based on lack of improvement approximately 72 hours after her event. She became hypotensive requiring levophed, felt to be due to sepsis as she had gram positive cocci growing from her blood. Her dilantin was discontinued per neurology recommendations. She then developed myoclonic jerking and was reloaded with dilantin. EEG demonstrated severe encephalopathy. At this point a family meeting was held and it was decided to make her comfort measures only. She died on [**2162-5-8**] at 9:21 pm with her family by her side. Medications on Admission: dilantin lopressor tequin digoxin magnesium oxide pepcid Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: anoxic brain injury pneumonia Discharge Condition: expired Discharge Instructions: none Followup Instructions: none

[ "V10.05", "780.57", "428.30", "276.3", "427.31", "V44.0", "401.9", "427.5", "281.9", "790.92", "458.9", "493.22", "V66.7", "428.0", "348.1", "934.9", "518.81" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

6952, 6961

5898, 6816

318, 324

7034, 7043

2615, 5875

7096, 7103

2097, 2129

6923, 6929

6982, 7013

6842, 6900

7067, 7073

2144, 2596

241, 280

352, 1437

1459, 1898

1914, 2081

74,765

124,475

35617

Discharge summary

report

Admission Date: [**2108-2-19**] Discharge Date: [**2108-2-25**] Date of Birth: [**2042-1-22**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 618**] Chief Complaint: L medullary bleed Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 66 year old right handed woman with a history of mechanical MVR on Coumadin, atrial fibrillation s/p PPM, DM on insulin pump, hypertension, hyperlipidemia, CHF, and COPD who presents with left upper and middle back pain and SOB s/p fall Saturday morning with head CT showing hemorrhage in the left medulla and small focus of SAH. The patient reports that on Saturday [**2-18**] at 3:00 am, she woke up to use the restroom which she often needs to do since she is on Lasix. While walking back to bed, she tripped over a metal garbage can and fell on top of the trash can. She landed on her left side and back, and did not initially think she hit her head and denied LOC. She got back in to bed to sleep. She woke up Saturday morning, and had left sided mid back pain which was [**3-9**] in intensity and worse with movement. She did not take any medications for this because she was concerned it would interact with her other medications. She woke up Sunday morning with worsened back pain which was up to [**7-9**] in intensity. She also noticed a contusion in her left posterior head, which she had not seen before. She complained of being more short of breath than usual, so her daughter called urgent care and took her to the ED. On ROS, she denied headache, lightheadness, dizziness, nausea/vomitting, weakness/numbness, diplopia/blurry vision, dysarthria, or dysphagia. She initially presented to [**Hospital1 **], where vitals on admission were bp 126/77, HR 60, RR 20, temp 98.9, SaO2 95% on RA. Her exam was "speaking in full sentences, contusion in left occipital region, tenderness to palpation of left posterior chest wall, no vertebral point tenderness or step-offs, cranial II-XII wnl, motor, sensory and cerebellar functions normal." Labs showed Hct 35.2, WBC 6.6, plt 198, Na 135, Cr 0.92, INR 2.6. Per report, head CT showed an 8 mm bleed in the left medulla. CT abdomen/pelvis was ordered to rule out retroperitoneal bleed which was preliminarily negative. Dr. [**First Name (STitle) **] in cardiology recommended 2 U FFP, which was given. She also received Percocet 2 tabs PO x1. She was transferred to [**Hospital1 18**]. At [**Hospital1 18**], Head CT wet read showed similar appearing hemmorhagic posterior medulla focus, possible slightly increased anterior medulla hemmorhagic focus. no evidence of herniation, and small focus of subarachnoid hemmorhge likely unchanged. Neurosurgery was consulted who thought that the bleed was due to a cavernous malformation in medulla with acute blood. She did complain of nausea after laying down for the head CT. She currently denies back pain. She received Zofran 4 mg IV x1, and since her repeat INR was 2.2 she was scheduled to receive another 2 U FFP. Past Medical History: s/p mechanical MVR in [**2101**] for MR [**First Name (Titles) **] [**Last Name (Titles) 2177**], on Coumadin since the surgery Atrial fibrillation s/p PPM and defibrillator Diabetes mellitus since [**2098**], on insulin pump Hypertension Hyperlipidemia CHF COPD, not on home O2 Hypothyroidism Ulcers Anemia and "chronic bleeding", 2 months ago Hct dropped from 34 to 18, s/p endoscopy, colonoscopy, and capsule endoscopy wihtout source of bleed, Hct been back up to 35 over past 5-6 weeks Osteoporosis Social History: She moved in with her daughter in [**Name (NI) 205**]. She has had recent falls at home, and 4 months ago broke her wrist when falling over an open dishwasher door. She is retired from customer service in AAA. She smoked 2 ppd for 40 years, but quit 10 years ago. She denies EtOH or illicit drug use. Family History: Both of her parents died of an MI. She denies a family history of stroke and DM. Physical Exam: VS: HR 60, bp 135/45, RR 19, SaO2 96% on 2L Genl: Awake, alert, NAD HEENT: Sclerae anicteric, no conjunctival injection, oropharynx clear, slight contusion palpated in left posterior occiput CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops Chest: Bilateral crackles to the apices, no wheezes or rhonchi Abd: Quiet BS, soft, NTND abdomen Spine: No tenderness to palpation of the spinous processes Back: 2 large ecchymoses in the left upper and middle lateral back, tender to palpation Neurologic examination: Mental status: Awake and alert, cooperative with exam, normal affect. Oriented to person, place, and date. Attentive, says [**Doctor Last Name 1841**] backwards. Speech is fluent with normal comprehension and repetition; naming intact. No dysarthria. [**Location (un) **] intact. Registers [**1-31**], recalls [**12-3**] in 5 minutes even with prompting. No right-left confusion. No evidence of apraxia or neglect. Cranial Nerves: Fundoscopic examination reveals sharp disc margins. Pupils equally round and reactive to light, 5 to 3 mm bilaterally. Visual fields are full in all 4 quadrants. Extraocular movements intact bilaterally with 2-3 beats of nystagmus at left end-gaze. Sensation intact V1-V3. Facial movement symmetric. Hearing intact to finger rub bilaterally. Palate elevation symmetric. Sternocleidomastoid and trapezius full strength bilaterally. Tongue midline, movements intact. Motor: Normal bulk bilaterally. No observed myoclonus, asterixis, or tremor. No pronator drift. [**Doctor First Name **] Tri [**Hospital1 **] WE FE FF IP H Q DF PF TE R 5 5 5 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 5 5 Sensation: Intact to pinprick, position sense, and cold sensation throughout. Patient unable to feel vibration sense at the left great toe, but intact at the left ankle. Decreased vibration sense of the right great toe (8 seconds). No extinction to DSS. Reflexes: 2+ and symmetric in biceps, brachioradialis. 3+ and symmetric in knees. 1+ and symmetric in triceps. 0 and symmetric in ankles. Toes upgoing bilaterally. Coordination: Mild dysmetria on L with FTF and HTS. Gait: Took a few steps (limited by oxygen/telemetry/IV). Romberg negative. Pertinent Results: [**2108-2-20**] 03:26AM BLOOD WBC-4.3 RBC-3.38* Hgb-8.7* Hct-27.2* MCV-81* MCH-25.7* MCHC-31.9 RDW-14.8 Plt Ct-154 [**2108-2-20**] 03:26AM BLOOD PT-18.3* PTT-30.7 INR(PT)-1.7* [**2108-2-19**] 08:05PM BLOOD PT-22.8* PTT-32.1 INR(PT)-2.2* [**2108-2-20**] 03:26AM BLOOD TSH-0.18* [**2108-2-19**] 08:05PM BLOOD Calcium-9.4 Phos-3.4 Mg-1.8 [**2108-2-19**] 08:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG CT HEAD [**2-19**]: Similar-appearing medullary hemorrhagic foci and possible tiny left frontal subarachnoid hemmorhage. Brief Hospital Course: The patient is a 66 year old right handed woman with a history of mechanical MVR on Coumadin, atrial fibrillation s/p PPM, DM on insulin pump, hypertension, hyperlipidemia, CHF, and COPD who presents with left upper and middle back pain and SOB s/p fall Saturday morning with head CT showing hemorrhage in the left medulla and possible small focus of SAH. She reports a mechanical fall over a garbage can 2 days ago, and then developed left sided back pain, and presented to an OSH with SOB. Head CT there showed an 6 mm medullary hemorrhage, and she received 2 U FFP for INR 2.6. Her INR on arrival to [**Hospital1 18**] was 2.2 hence received 2 more units of FFP and repeat head CT showed no change. She had no lateral medullary finding including vertigo, hemisensory findings (ipsilateral face and contralateral hemibody for pain and temperature) or ataxia. She does have slight L sided dysmetria with FTF and HTS. She also had no nausea or headache but did have significant left sided back pain. She was initially admitted to ICU where she remained stable with no further deterioration and CTA (MRI unable to be obtained due to pacemaker) showed no obivous vascular malformation. Her hemorrhage most likely cavernoma with bled due to trauma and the fact that she is anticoagulated hence more prone to bleed. Since she does have significant risk factor for stroke without anticoagulation with her mechanical valve, she had repeat head CT on HD#2 ([**2-21**]) as well as on [**2-23**], both of which showed stability of her bleed. She had been off of her coumadin and her INR drifted down to 1.6. At this point she was started on a heparin gtt and re-started on coumadin. The heparin gtt was later DC'd and she was started on full dose lovenox in anticipation of her discharge. Patient also had significant hematocrit drop from admission (35 at [**Hospital1 **] then 27 here on [**2-20**]). Given risk factor for possible hematoma since she had a fall and was anticoagulated, CT torso was obtained which showed no evidence of hematoma. Her Hct subsequently stabilized around 30. Her course was also complicated by a one-time fever to 102 F. Her urine was mildly dirty and she was started on Bactrim for 10 days given her prior indwelling foley. There was no other identifiable source of infection, though some atelectasis was noted on her CXR which may have also been contributing to her fever. Her course was also complicated by mild ARF (Cre 1.4) which we felt was the product of over-diuresis in the setting of decresed PO intake. Her lasix was held for one day and she received a half-dose (20 mg) the following day. She also received 500 mL NS. Her Cre subsequently improved and her usual dose of lasix was resumed (40 mg). Medications on Admission: Lasix 40 mg daily Coumadin 3 mg daily Lisionpril 5 mg daily Lipitor 40 mg daily Celexa 40 mg daily Metoprolol 25 mg [**Hospital1 **] Protonix 40 mg [**Hospital1 **] Levothyroxine 150 mcg daily Albuterol 90 tid prn Humalog Insulin pump Iron 150-160 U tid She stopped taking ASA 81 mg daily 2 months ago with recent Hct drop. Discharge Disposition: Home With Service Facility: [**Hospital **] Hospice and VNA Discharge Diagnosis: left medullary bleed Discharge Condition: stable Discharge Instructions: You were admitted with a small medullary bleed in the context of being on coumadin after a fall. Fortunately you have had little deficit on your neurological exam. You were off coumadin for several days, but it has beenr restarted now. You will need a CAT scan of your head in one week to ensure stability of the bleed. Please return to the ER if you experience any focal weakness, change in sensation, vision, language, or cognition, develop any severe headaches, vertigo, limb clumsiness, or anything else that concerns you seriously. Followup Instructions: PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 27772**] Phone: Date/Time: [**2108-3-6**] 12:00pm Provider (neurology): [**Name6 (MD) **] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2108-4-3**] 3:30 Head CT in about one week after discharge. Call [**Telephone/Fax (1) 327**] to schedule. [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Completed by:[**2108-4-5**]

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icd9cm

[ [ [] ] ]

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icd9pcs

[ [ [] ] ]

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333, 339

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27,172

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49077

Discharge summary

report

Admission Date: [**2109-4-16**] Discharge Date: [**2109-5-1**] Date of Birth: [**2055-11-20**] Sex: M Service: MEDICINE Allergies: Heparin Agents / Penicillins / Aspirin / Ibuprofen / Ciprofloxacin Attending:[**First Name3 (LF) 943**] Chief Complaint: GI bleed . Major Surgical or Invasive Procedure: Paracenteses Thoracenteses . History of Present Illness: Mr. [**Known lastname 102989**] is a 53 year-old man with a history of alcoholic cirrhosis with known grade II esophageal varices and portal gastropathy who was transferred from the [**Hospital 882**] Hospital MICU last night for continued management of variceal bleeding. Of note, he was recently hospitalized here at [**Hospital1 18**] from [**Date range (1) 102992**] with hematemesis; EGD at that time showed two cords of nonbleeding grade II esophageal varices and nonbleeding portal gastropathy. He was discharged on [**4-11**] to [**Hospital 100**] Rehab and then began having acute hematemesis on [**4-12**] requiring intubation prior to even the arrival of EMS; by report, he had no palpable BP or pulse, but was moving and breathing spontaneously. He was taken to the [**Hospital 882**] Hospital ED where his BP was initially recorded at 60/palp. An NGT returned bright red blood and he underwent emergent EGD with placement of 7 bands to his varices. He was put on octreotide and pantoprazole continuous infusions, as well as ceftazidime and metronidazole for bactermia prophylaxis. His admission labs were notable for a WBC 18.1 (93% PMNs), Hct 27.4 (unclear how many pRBCs he had received at that time), platelets 96, an INR of 1.9 (peaked at 2.1 during admission), and a creatinine of 1.3; he also had transaminases in the [**2100**], which gradually trended downwards down to 800s on the day of transfer. He received 7 units of pRBCs as well as FFP and platelets. He was extubated the following day ([**4-13**]), taken off of the continuous infusions, transferred to PO medications, and transferred to the floor. On [**4-16**], he acutely vomitted bright red blood and received an additional 4 units of pRBCs, 1 unit of platelets, and 2 units of FFP; his octreotide infusion was resumed. He returned to the MICU and underwent repeat EGD; this failed to show the prior bands, and he received 5 new bands to his varices; no evidence of active bleeding was seen. . Review of Systems: Denies fevers, chills, sweats, abdominal pain. Has had a productive cough and intermittent dyspnea for several days. He denies any confusion. . Past Medical History: alcoholic cirrhosis, listed for transplant - prior ascites - prior hepatorenal syndrome requiring several sessions of hemodialysis - known grade II esophageal varices and portal gastropathy by EGD [**2109-4-9**] - history of candidal and bacterial (SBP) peritonitis - colorectal cancer (stage unknown) s/p colectomy in [**11/2108**] - cervical stenosis - hyperlipidemia - hypertension - history of C Diff colitis - anemia with baseline Hct 27-30 - history of Torsades while on ciprofloxacin - depression - history of positive PF4 antibody - BPH Social History: Home: Lived with wife and daughter in [**Name2 (NI) **] prior to hospitalization in [**Month (only) 958**]. Has since been at [**Hospital1 100**]/[**Hospital 8218**] rehab Occupation: used to work as construction worker. EtOH: denies ETOH for past 5 years, extensive in the past Drugs: denies h/o IVDA Tobacco: Tobacco: [**Date range (1) 61126**] PPD x 30 years; quit in 2/[**2108**]. . Family History: Denies fhx of early MI, stroke, cancer. . Physical Exam: Tc 97.9 Tm 97.9 BP 126/85 HR 81 RR 13 Sat 95% 4 L/min Weight: 82.7 kg General: comfortable, lying upright in bed HEENT: no oral lesions; (+) icterus Neck: biphasic JVP to 8cm Chest: significantly decreased breath sounds at both bases; (+) loud ronchi in anterior lung fields CV: regular rate/rhythm, Abdomen: distended, nontender, (+) BS, unable to palpate liver/spleen due to distension; (+) shifting dullness and fluid wave; no caput Extremities: 2+ edema to lower shins bilaterally Skin: (+) jaundice Neuro: alert, appropriate, oriented x3; CN 2-12 intact, [**4-1**] strength in both UEs/LEs; no asterixis . Pertinent Results: PERTINENT LABS: [**2109-4-16**] WBC-8.7 HGB-13.2 HCT-37.1 MCV-85# PLT SMR-LOW PLT COUNT-105* [**2109-4-16**] PT-18.4* PTT-34.1 INR(PT)-1.7* [**2109-4-16**] GLUCOSE-129* UREA N-35* CREAT-1.0 SODIUM-140 POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-28 [**2109-4-16**] ALT-511* AST-302* LDH-214 ALK PHOS-113 AMYLASE-28 TOT BILI-13.3 [**2109-4-16**] ALBUMIN-3.7 CALCIUM-9.2 PHOSPHATE-3.9 MAGNESIUM-2.5 . Pleural fluid [**4-17**]: GRAM STAIN (Final [**2109-4-17**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [**2109-4-20**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2109-4-23**]): NO GROWTH. . NEGATIVE FOR MALIGNANT CELLS. . Peritoneal Fluid [**4-23**]: GRAM STAIN (Final [**2109-4-23**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [**2109-4-26**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2109-4-29**]): NO GROWTH. . [**4-26**] URINE CX: URINE CULTURE (Final [**2109-4-29**]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S NITROFURANTOIN-------- 128 R TETRACYCLINE---------- =>16 R VANCOMYCIN------------ =>32 R . [**4-28**] BLOOD CX: pending [**4-29**] URINE CX: pending . . STUDIES: CXR [**4-17**]: In comparison with study of [**4-4**], there is extensive opacification causing generalized haziness of the left hemithorax with opacification along the left lateral chest wall. This is consistent with a substantial left pleural effusion. Obliquity of the patient to the right may account for much of the apparent shift of the mediastinum to the contralateral side. . TTE [**4-17**]: The left atrium is normal in size. 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 regurgitation. The mitral valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. . RUQ U/S [**4-18**]: 1. Interval development of the partially-occluding thrombus of the right portal vein. 2. Findings compatible with cirrhosis and portal hypertension and splenomegaly. Large volume of ascites is noted. No focal liver lesion is detected . Brief Hospital Course: Mr. [**Known lastname 102989**] is a 53 yo male with PMH significant for ETOH cirrhosis on liver transplant list who is being transferred from OSH for management of variceal bleed with possible TIPS evalation. 1)Upper GI bleed: Patient presents with significant variceal bleed. He was discharged from [**Hospital1 18**] on [**4-11**] and underwent an endoscopy during this admission which showed stable, non-bleeding grade 2 varices. No intervention was done at this time. He presented to [**Hospital 882**] Hospital with several episodes of hematemesis requiring endoscopy x 2. Seven bands were placed on the first endoscopy followed by 5 bands during the second endoscopy. He received approximately 11 units pRBCs at OSH along with FFPs, platelets, and vitamin K. He does not appear to be actively bleeding at this time. He maintained adequate IV access. During his ICU stay, he required no blood transfusions. He received an octretide drip. He received ceftriaxone for SBP prophylaxis for 5 days then converted to oral antibiotics. He had a TTE to eval for TIPS that could not measure PA pressures. He had a liver ultrasound that showed a partially occlusive portal vein thrombus that was thought not prohibitive for a TIPS. On the floor, his Hct remained stable off the octreotide gtt and patient had no hematemesis. He had repeat EGD which revealed 3 grade II varices that were banded. He was started on sucralfate for a 2 week course and will require repeat EGD one week after discharge. Nadolol was held in the setting of UGI bleed and re-started on the day of discharge. . 2)ETOH cirrhosis: Patient currently listed for liver transplantation. He has a history of ascites requiring paracenteses, pleural effusions, and esophageal varices. Per OMR he does not have significant history of hepatic encephalopathy. He is currently awake and alert. Per OSH records pt had elevated LFTs in 1000's which then returned to baseline. His transaminase elevation was thought to be secondary to ischemic hepatopathy from the cardiac arrest. His transaminase levels improved steadily. He continued on Lactulose PO TID, Aldactone, and Rifaximin. His nadolol was held briefly then resumed. The patient had a paracentesis for ascites and thoracentesis for left hepatic hydrothorax on [**2109-4-17**]. His respiratory status remained stable on the floor. Diuretics were held briefly for a rise in creatinine and then resumed. Had paracentesis x 2 on the floor with 5L and then 8L removed. Will need to consider TIPS evaluation, although he has a partial PVT (not an absolute contraindication). He will need a paracentesis next week in clinic. If creatinine remains stable on re-check on [**5-2**], would increase lasix to 40mg daily and spironolactone to 100mg daily. . 3) Hypoxia: The patient had an episode of hypoxia that was most likely related to a large left sided pleural effusion. The pleural effusion was drained. The fluid was most likely related to trans-diaphragmatic translocation of peritoneal ascites. His supplemental oxygen was weaned steadily. On the floor, the patient remained stable on RA. . 4) Partial L portal vein thrombosis - seen on RUQ US on [**4-18**] but patient definitely not a candidate for anticoagulation given his recent bleeding . 5) Urinary retention: On [**4-28**], the patient developed urinary retention requiring a foley. He failed a spontaneous voiding trial the following 2 days with up to 1L of retained urine. This was attributed to increased ascites, though did not improve s/p paracentesis and the patient had to be discharged with a foley in place. No anti-cholinergic medications. No intra-abdominal mass or BPH. Urine culture on [**4-26**] had >100K VRE ([**Last Name (un) 36**] to linezolid). Repeat UA was unremarkable so no antibiotics were initiated. He will need repeated voiding trials as an outpatient with goal of discontinuing the foley as soon as possible. If continues to have urinary retention, would consider urology consult. . 6)Cervical stenosis: Patient has chronic upper extremity and back pain. s/p fall and cervical vertebral fracture requiring surgical repair/stabilization with chronic neuropathic pain. He remained on his home pain medicine regimen. . 7) Nutrition: Calorie count revealed that the patient was not taking adequate POs. A dobhoff tube was placed and tube feeds initiated. . Medications on Admission: Ceftazidime 2gm IV TID Pantoprazole 10mg IV BID Oxycodone IR 15mg PO Q6H PRN Spironolactone 50mg PO daily Rifaximin 400mg PO TID Folate 1mg PO daily Colace 100mg PO BID Albuterol MDI Lactulose 30cc Q6H Nadolol 20mg PO daily Octreotride 500mg IV Q10H Discharge Medications: 1. Rifaximin 200 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. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. 4. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 6. Cephalexin 250 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 4 days. 7. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day) for 7 days. 8. Lactulose 10 gram/15 mL Syrup Sig: Five (5) ML PO TID (3 times a day): titrate to maintain 4 documented BMs per day. 9. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): hold for SBP<100. 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): hold for SBP<100. 11. Nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): hold for SBP<95. 12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. . Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Final diagnosis Upper gastrointestinal bleed Bleeding esophageal varices . Secondary diagnosis Alcoholic cirrhosis . Discharge Condition: Stable . Discharge Instructions: You were admitted to the [**Hospital 882**] hospital as you were noted have large amounts of bloody vomitus requiring intubation, multiple transfusions, and 2 episodes of banding there. Your heart also had stopped briefly and you were successfully resuscitated. When you were stable, you were transferred to the [**Hospital1 **] ICU and improved so you were transferred to the medicine floor. You had fluid taken out of your lung and abdomen for comfort. . Please continue all medications as prescribed. . Please keep all your appointments below. . Please call your physician or return to the hospital if you experience any continued bloody vomitus, have active bleeding, palpitations, chest pain, shortness of breath, fever, chills, or any new or worrisome symptoms. . Followup Instructions: You will need EGD and paracentesis next week. You also need to be scheduled for liver orientation. The liver center will call your rehab tomorrow to facilitate this. . Scheduled Appointments : Provider TRANSPLANT [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2109-5-22**] 1:00 . Provider [**Name9 (PRE) 1382**] [**Name9 (PRE) 1383**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2109-6-3**] 9:30 .

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icd9cm

[ [ [] ] ]

[ "34.91", "96.6", "45.13", "42.33", "54.91" ]

icd9pcs

[ [ [] ] ]

12928, 12994

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337, 368

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136,637

26009

Discharge summary

report

Admission Date: [**2111-3-9**] Discharge Date: [**2111-3-10**] Service: NEUROSURGERY Allergies: Lipitor Attending:[**First Name3 (LF) 78**] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: None History of Present Illness: 87 yo F with h/o L MCA stroke s/p fall at rehab presented to the ED. She has expressive aphasia at baseline, unable to give history. Family was not present at her fall, but states she is more agitated than usual. Past Medical History: Past Medical History - from chart - Afib - detected on [**11/2103**] admission, on coumadin - HTN - dyslipidemia - DM - on lantus at [**Hospital 100**] Rehab - anemia - iron deficiency - hiatal hernia - EGD on [**3-/2105**]: hiatus hernia, mild gastritis. - mild gastritis - [**2107-1-24**] admitted to [**Hospital1 **] with NSTEMI - L MCA stroke: residual R hemiparesis, aphasia, dysphagia. PEG placed. - thrombocytopenia - glaucoma - hemorhoids - CAD NSTEMI [**2105**] with BMS to proximal LAD Social History: Social History: patient is originally from [**Location (un) 3155**], [**Location (un) 3156**]. Moved to the United States in [**2093**]. Lives with her husband. She is geologist by training. Denies any tobacco history. No EtOH use. She has one child, [**Doctor First Name 335**]. Family History: Family History: NC, most of her family were killed in WWII. Physical Exam: On admission: PHYSICAL EXAM: O: T: 96.3 BP: 151/55 HR:63 R 18 O2Sats 99% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: R pupil 3->2mm, unable to assess L pupil secondary to periorbital edema EOMs non-cooperative with exam Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake, agitated, expressive aphasia follows commands on the left, moves L with good strength, right hemiplegic R Pupil equally round and reactive to light, 3 to 2 mm, unable to assess L pupil secondary to edema. On discharge: EO to voice, expressive aphasia, follows commands with visual cues. L sided hemi at baseline. Pertinent Results: Head CT [**2111-3-9**]: IMPRESSION: 1. Acute subarachnoid hemorrhage along the left aspect of the midbrain and pons as well as within the left temporal lobe. Large area of hypodensity in the left MCA distribution, as above, consistent with prior infarct. 2. Marked left pre-septal soft tissue swelling/hematoma as well as left inferolateral subcutaneous hematoma, as above. Questionable non-displaced fracture of the lateral left orbit. CT Cspine [**2111-3-9**]: No fractures. DJD. Head CT [**2111-3-10**]: Stable appearance of known SAH. Brief Hospital Course: 87F w/traumatic SAH. Admitted overnight to the Neuro ICU for observation. Repeat CT head on [**2111-3-10**] appeared stable and her exam remained unchanged and stable. She was cleared for discharge to nursing facility on [**3-10**] and was discharged on [**3-10**]. Medications on Admission: lisinopril, oxycodone, ativan, tylenol, ASA 81mg, senna, prilosec, baclofen, timoptic Discharge Medications: 1. acetaminophen 325 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. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. 6. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for agitation/anxiety. 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. baclofen 10 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 9. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 10. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 11. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). Discharge Disposition: Extended Care Facility: [**Hospital3 **] Center Discharge Diagnosis: Left temporal SAH Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: 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 may safely resume taking this 7 days from injury. Followup Instructions: Please follow-up with Dr. [**First Name (STitle) **] in 4 weeks with a Head CT w/o contrast. Please call [**Telephone/Fax (1) 4296**] to make this appointment. You should follow-up with your Opthamologist regarding your L eye. Completed by:[**2111-3-10**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

4003, 4053

2676, 2943

225, 232

4115, 4115

2110, 2653

5015, 5274

1329, 1375

3080, 3980

4074, 4094

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260, 477

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4130, 4268

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1030, 1297

41,107

130,510

51336

Discharge summary

report

Admission Date: [**2108-4-20**] Discharge Date: [**2108-4-27**] Date of Birth: [**2044-6-17**] Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1835**] Chief Complaint: Ataxia and dizziness Major Surgical or Invasive Procedure: [**4-23**]: Occipital Craniotomy and resection of supratentorial and infratentorial mass History of Present Illness: Ms. [**Known lastname **] is a 63 year old left handed female with HTN and hyper lipidemia who was trasferred to the ED with new right cerebellar mass. Basically, for the past 4-5 years she has had gait ataxia and dizziness. She was seen today, with similar symptoms but was seen by another provider who notice her gait was very ataxic. A brain MRI was obtained which demonstrated a large homegenous enhancing mass of the right cerebellar consistent with meningioma. Today, she also complains of head fullness and occasional headaches. She has noticed decrease taste in her mouth recently. She denies any nausea, vomiting, weakness, paresthesia or blurry vision Past Medical History: hypertension, hyperlipidemia, depression Social History: left handed, married with 2 children, live in [**Location (un) **], sells text book for a living, no tobacco, occ etoh, no ilicit drug use Family History: non-contributory Physical Exam: Admission: [**4-20**] Gen: WD/WN, comfortable, NAD, looks nervous. HEENT: atraumatic, normocephalic, eyes are clear, conjunctiva clear, hearing grossly intact, Nasal passages [**Last Name (un) **], oropharynx is pinkwithout exudate Pupils: 4-2mm b/l EOMs - full no nystagumus Neck: Supple, no thyromegaly Lungs: CTA bilaterally, no w/c/r, A/P diameter normal, resonant to percussion Cardiac: RRR. S1/S2. no murmurs Abd: Soft, NT, BS+, no organomegaly Extrem: Warm and well-perfused, no clubbing, cyanosis, edema Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**3-29**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue deviates to the unaffected side (left), no fasciulations Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-31**] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 2+---------- Left 2+---------- Toes downgoing bilaterally Coordination: slight dysmetria on the right with finger-nose-finger, rapid alternating movements intact, ataxia more porofoudn with heel-to-toe walking On Discharge: A&OX3 PERRL EOMs intact Face symmetrical Slight deviation of tongue to L No pronator Motor full Pertinent Results: [**4-20**] Brain MRI OSH ([**Hospital1 **]) - Brain MRI - homogenously enhancing mass extending from right sphenoid [**Doctor First Name 362**] distally to right cerebellar lesion measuring ~6.2 x 5.6 x 4.5 cm with effacement of thh 4th ventricle and brainstem. Dilated ventricles bilaterally with prominent temporal horns. [**4-22**] MRI Brain here Large posterior fossa mass consistent with meningioma with mass effect and obstructive hydrocephalus. The mass also has produced cerebellar tonsillar herniation and a small syrinx is visualized in the cervical spinal cord at C3 level. MR HEAD W & W/O CONTRAST [**2108-4-24**] Expected post-operative changes from subtotal resection of right posterior fossa meningioma. While there is decrease in mass effect, persistent deformity of the cerebellum and brainstem is seen with persistent herniation of the cerebellar tonsils and a small syrinx in the cervical spinal cord. Hydrocephalus has improved slightly. Brief Hospital Course: Ms. [**Known lastname **] was admitted to Neurosurgery on [**4-20**] for further management. On [**4-23**] she went to the OR for a suboccipital craniotomy for resection of her lesion. She tolerated the procedure without intraoperative complications. See the operative report for full details. She was transferred to the ICU post-operatively. Head CT revealed no hemorrhage and almost complete resection of the mass. On [**4-24**], her physical examination was significant for being afebrile, mild tongue deviation to the left, antigravity extremities x 4, following commands, and no drift which was her baseline. EVD was continued at 5cmH20 and open cont with vancomycin, nafcillin & ceftazadime for prophylaxis & CSF was sent for cx, gram stain, prot & glucose. She was cleared for transfer to the stepdown unit. On [**4-25**] she was transferred to the SDU for further care and her EVD was discontinued. She worked briefly with PT as well. On 3.31 she was deemed stable enoguh to transfer to floor status and was mobilized with PT. PT recommends home with services and walker. She was discharged home with PT and keflex x 2 weeks on [**4-27**]. She was given a stool softners and enema to help her have BM, she was was passing flatus at time of discharge. She should follow up with BTC on [**5-7**] and been seen in clinic for a wound check. Medications on Admission: Celexa 40mg daily simvistatis 20mg daily fosamax 20mg Q sunday Ativan .5mg as needed for sleep 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. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every Sunday). 5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*90 Tablet(s)* Refills:*0* 6. dexamethasone 2 mg Tablet Sig: as directed Tablet PO every eight (8) hours for 5 days: please take 4mg (2 tabs)every 8 hrs on [**4-27**], take 3mg (1.5 tabs) every 8 hrs on [**4-28**], take 2mg every 8 hrs on [**4-29**], then 2mg twice a day [**4-30**]. Disp:*16 Tablet(s)* Refills:*0* 7. Lorazepam 0.5 mg IV Q6H:PRN anxiety 8. CefTAZidime 2 g IV Q8H 9. Keflex 500 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 2 weeks. Disp:*56 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Brain mass 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: ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. If you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? If you are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: increasing redness, increased swelling, increased tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: ??????Please return to the office in [**8-5**] days (from your date of surgery) for removal of your staples/sutures and/or a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2108-5-7**] at 3:00pm. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 5074**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your appointment, or require additional directions. Completed by:[**2108-4-27**]

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icd9cm

[ [ [] ] ]

[ "38.91", "02.12", "01.51" ]

icd9pcs

[ [ [] ] ]

6696, 6745

4273, 5623

329, 420

6800, 6800

3285, 4250

9158, 9967

1356, 1374

5769, 6673

6766, 6779

5649, 5746

6983, 9135

1389, 1916

3169, 3266

269, 291

448, 1118

2209, 3155

6815, 6959

1140, 1183

1199, 1340

14,432

166,169

20207

Discharge summary

report

Admission Date: [**2168-5-27**] Discharge Date: [**2168-6-3**] Date of Birth: [**2128-10-27**] Sex: F Service: MEDICINE Allergies: Vancomycin Attending:[**First Name3 (LF) 16983**] Chief Complaint: fever, chills, myalgias Major Surgical or Invasive Procedure: none History of Present Illness: HISTORY OF PRESENT ILLNESS: This is a 39-year-old woman who is being admitted for fevers and neutropenia. . Ms. [**Known lastname 54295**] was diagnosed in [**2166-11-11**] with acute myeloblastic leukemia when she presented with the neutropenia and low-grade fevers. Initial white blood count was 5500. The bone marrow was diagnostic for acute myeloblastic leukemia. She underwent and induction chemotherapy and attained a complete remission. She required two cycles of induction.( 7+3;5+2) Following induction, she received three cycles of high-dose ARA-C consolidation therapy. She has remained in complete remission for 18 months. Mrs [**Known lastname 54295**] has completed another cycle of induction chemotherapy of (7+3), and was discharged . BmBX [**5-11**] demonstrated hypopocellular marrow (5%) with left-shifted myelopoiesis and focal interstitial clusters of immature mononuclear cells suspicious for blasts. . Ms. [**Known lastname 54295**] notes a two day history of intermittent myalgias, head ache, low-grade fevers, mild odynophagia and chest pain. Pt denies any cough, sinus pain, ear pain, nausea/vomiting, diarrhea, abdominal pain, pain or burning on urination, neck stiffness, or photophobia. She was seen 3 days ago for follow up after being place on Neurontin 300mg qd for lower extremity peripheral neuropathy and pain and was doing well. Pt has been on Levaquin for the past 2 months s/p consolidation therapy, and fluconazole since her d/c on [**5-17**]. . Pt was recently d'ced from [**Hospital1 **] on [**2168-5-17**] after a 5 week hospitalization for relapsed AML/neutropenic fever. She was d'ced on Levaquin and Fluconazole, which she had continued until present admission. Past Medical History: 1) AML, diagnosed in [**10-29**]. (a) normal cytogenetics. (b) positive CD34; positive CD13, and positive CD17. (c) status post 7+3; status post 5+2 in [**2166-11-27**]. (d) bone marrow biopsy with remission in early [**2166**]. (e) she is status post HIDAC consolidation in [**2166-12-28**], complicated by fever and neutropenia with no clear source with an admission in [**2167-1-26**]. (f) status post HIDAC two on [**2167-1-26**] with mild transaminitis (last dose held). (g) She received her third and last cycle of HiDAC consolidation in [**2167-2-26**]. 2) Has noted heavy periods and was recently diagnosed with fibroids. Social History: The patient is married with two children. She denies use of alcohol or illicit drugs. She has a sister with a human leukocyte antigen match in [**Country 3992**]. She speaks Cantonese and some English. Family History: Non-contributory Physical Exam: PHYSICAL EXAMINATION: VS: Wt. 98.4 lbs P 145 BP 108/71 T 101.6 %O2 Sat 100 GENERAL: A well-developed, well-nourished 39-year-old Asian woman in moderate distress, rigoring at times during exam. HEENT: Sclerae is anicteric, PERRLA, normal female hair pattern. No sinus tenderness. Throat is mildly injected. Tonsils are not enlarged. She has tenderness over the left subauricular area and no crepitus. Trachea is midline. Thyroid is not enlarged. No cervical, supraclavicular, occipital adenopathy. No meningeal signs. Neck is supple. Neg Kernig's, Brudzinski's. LUNGS: Clear to percussion and auscultation. No c/w/r. HEART: Regular rate. Nml s1,s2. No murmurs, rubs, thrills, or gallops. CHEST: Indwelling line, with no sign of erythema, and no tenderness to palpation over line. ABDOMEN: Nontender, no hepatosplenomegaly, no rebound. Normal bowel sounds. No inguinal adenopathy. EXTREMITIES: No cyanosis, clubbing, or edema. SKIN: No cutaneous lesions. Rectal exam deferred d/t neutropenia. Pertinent Results: [**2168-5-27**] 10:40AM BLOOD WBC-0.5* RBC-3.44* Hgb-10.0* Hct-26.7* MCV-78* MCH-29.1 MCHC-37.5* RDW-12.3 Plt Ct-79* [**2168-5-27**] 10:40AM BLOOD Neuts-36* Bands-0 Lymphs-56* Monos-8 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2168-5-27**] 10:40AM BLOOD WBC-0.5* RBC-3.44* Hgb-10.0* Hct-26.7* MCV-78* MCH-29.1 MCHC-37.5* RDW-12.3 Plt Ct-79* [**2168-5-27**] 10:40AM BLOOD Plt Ct-79* [**2168-5-27**] 10:40AM BLOOD Glucose-125* UreaN-7 Creat-0.6 Na-138 K-3.6 Cl-100 HCO3-23 AnGap-19 [**2168-5-27**] 10:40AM BLOOD Albumin-4.7 Calcium-9.4 Phos-3.3 Mg-1.8 [**2168-5-11**] BmBx DIAGNOSIS: Hypocellular marrow (5%) with left-shifted myelopoiesis and focal interstitial clusters of immature mononuclear cells suspicious for blasts, see note. Note: The morphologic findings are worrisome for minimal involvement by patient's known acute leukemia. An alternative consideration includes early recovery. Please correlate with clinical findings. A repeat biopsy may be contributory in further assessment, if clinically indicated. Findings discussed with Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 1557**]. CLOT SECTION AND BIOPSY SLIDES Cellularity of the marrow biopsy is 5%. There is an interstitial infiltrate of immature mononuclear cells consistent with blasts occurring singly and in small clusters occupying 30% of marrow cellularity. However, by immunohistochemistry, CD34 highlights occasional scattered interstitial cells, overall comprising ~5% of marrow cellularity. ASPIRATE SMEARS: The aspirate material is adequate for evaluation. The aspirate smear shows hypocellular spicules with many stripped nuclei. Abundant stromal cells fat, and hemosiderin-laden macrophages are seen. M:E ratio is 5:1. Myeloid and erythroid cells appear decreased. Scant erythroid maturation appears normoblastic. Scant granulocyte maturation is normal. Megakaryocytes are present in markedly decreased numbers; abnormal forms are not seen. Differential shows: Blasts 11%, Promyelocytes 1%, Myelocytes 2%, Metamyelocytes 2%, Bands/Neutrophils 4%, Plasma cells 35 %, Lymphocytes 25%, Erythroid 8%, Monocytes 12%. Brief Hospital Course: ASSESSMENT AND PLAN: Ms. [**Known lastname 54295**] [**Known firstname **] is a 39-year-old woman with relapsed acute myeloblastic leukemia, admitted for 2 day hx of myalgias, mild sore throat and febrile neutropenia. Pt was given cefepime in the ER. On the floor of the first night, pt was hypotense, tachycardic, and remained so after several liters of IVF boluses. Due to her instability, pt was immediately added daptomycin for broader gram + coverage, and transferred to the unit for better monitoring. Pt continued on antibiotics, and never required intubation, or pressors. Pt was monitored and over 2 days, pt was stabilized, BP and HR returned to baseline, and pt was transferred back to the floors. Pt grew out coag neg staph, fairly resistant to most ABx, but clincally improved on the current regimen. She remained stable on the floors. Her source was her indwelling catheter, which cath tip grew. Because of this, patient is to be given a TTE, ruled out for endocarditis, and once stable home on Abx. . 1. Neutropenic Fever -Pt was in unit for 2 days for sepsis, now currently afebrile on cefepime/daptomycin. ID??????ed as coag negative staph, resistance as above. Likely resistant to the cefepime d/t b-lactam resistance. Pending [**Last Name (un) 36**] to daptomycin, but likely responding since clinical status improved. -Continue cefepime for neutropenic fever coverage. -Line pulled, catheter likely source of infection. -BP and HR stable this AM. Vitals as above. -Cont to follow culture for resolution -TTE in AM to check for seeding of valves. -fungal cultures couldn??????t be drawn d/t overseeding with bacteria. f/u once cleared of bacterial infection -ID following. App. Input. 2. Relapsed AML -Per Dr.[**Name (NI) 6168**] outpatient notes from [**5-23**], pt has experienced relapse of her AML, the bone marrow aspirate was to be repeated in 2 weeks time. The possibilily of BMT remains great. -Follow up on results of BM aspirate once read. -Defer treatment to Dr. [**First Name (STitle) 1557**]. 3. Effusion -Seen on CXR, lat/PA/decub. F/u on effusion and resolution. 4. Tachycardic- resolved -Likely early sepsis vs. dehydration. Cont IVFs, encourage PO intake, cont abx. 5. F/E/N -Neutropenic diet. Repleted lytes as needed. 6. PPx -Protonix, Heparin SQ, bowel regimen, neutropenic precautions. Medications on Admission: Meds on admission: 1. Oxycodone 5 mg Tablet PO Q4-6H PRN 2. Docusate Sodium 100 mg [**Hospital1 **] PRN 3. Senna 8.6 mg Tablet [**Hospital1 **] PRN 4. Acetaminophen 325 mg Tablet PRN 5. Cepacol 2 mg Lozenge PRN 6. Levofloxacin 500 mg Tablet QD 7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)QD 8. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H9. 9. Acetaminophen-Caff-Butalbital [**Medical Record Number 3668**] mg Tablet Sig: [**11-29**] Tablets PO Q4-6H (every 4 to 6 hours) as needed for headache. Discharge Disposition: Home With Service Facility: Critical Care Systems. Discharge Diagnosis: Acute Myelocytic Leukemia Discharge Condition: Afebrile, Stable Discharge Instructions: Please follow up with [**Last Name (LF) 54296**],[**First Name3 (LF) 2801**] on [**6-9**] at 10am. Please finish your course of Daptomycin Please call you doctor if you experience a fever over 100.4C, chills, nausea, vomitting, or worsening headache. Followup Instructions: Please Follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Where: [**Hospital6 29**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2168-6-9**] 10:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16984**] MD, [**MD Number(3) 16985**] Completed by:[**2168-6-24**]

[ "276.5", "285.22", "996.62", "785.52", "038.19", "507.0", "205.01", "786.52", "288.0", "995.92", "458.0" ]

icd9cm

[ [ [] ] ]

[ "38.93", "41.31", "99.04", "99.28" ]

icd9pcs

[ [ [] ] ]

9064, 9117

6141, 8494

296, 302

9187, 9205

3994, 6118

9506, 9866

2945, 2963

9138, 9166

8520, 8525

9229, 9483

2978, 2978

3000, 3975

233, 258

358, 2045

8539, 9041

2067, 2706

2722, 2929

83,128

110,577

32470

Discharge summary

report

Admission Date: [**2116-10-12**] Discharge Date: [**2116-10-17**] Date of Birth: [**2045-10-30**] Sex: F Service: CARDIOTHORACIC Allergies: Bactrim / Heparin Agents Attending:[**First Name3 (LF) 1267**] Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: CABG x4/repair LV aneurysm/CX endarterectomy [**2116-10-12**] (LIMA to LAD, SVG to OM, SVG to OM, SVG to PDA) History of Present Illness: 70 yo female with DOE and wheezing noted in early [**9-16**]. PCP rx with [**Name9 (PRE) 621**], but no improvement. She worsened and ruled in for NSTEMI in the ER. Cath revealed severe 3VD. Past Medical History: CAD s/p silent MI c/b LV mural thrombus (resolved, off warfarin) PAD s/p left SFA angioplasty and stent DM2 HTN OA spinal stenosis Hyperthyroidism s/p cholecystectomy s/p appendectomy s/p TAH Social History: Denies tobacco, EtOH lives with husband Family History: No family history of early MI, otherwise non-contributory. Physical Exam: at discharge: VS: 97.4, 121/54, 80SR, 20, 97%RA Gen: NAD, overweight WF Lungs: crackles b/l bases, o/w clear heart: RRR, no murmur or rub abd: obese, NABS, soft, non-tender, non-distended ext: warm, trace edema b/l sternal wound: c/d/i, no erythema or drainage EVH: c/d/i, no erythema or drainage Pertinent Results: PRE-CPB: 1. The left atrium is moderately dilated. No spontaneous echo contrast is seen in the body of the left atrium. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is an antero-apical left ventricular aneurysm. There is moderate regional left ventricular systolic dysfunction with anteroseptal and anteroapical hypokinesis. There is an inferoapical aneurysm with no thrombus seen.. No masses or thrombi are seen in the left ventricle. Overall left ventricular systolic function is moderately depressed (LVEF= 35 %). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the aortic root. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma, nonmobile, in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 7. The tricuspid valve leaflets are mildly thickened. 8. There is a trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results. POST-CPB: On infusions of epinephrine, phenylephrine. There is improvement of global LV systolic function on inotropic support. LVEF is now 40%. There is evidence of a suture-repair of the lv apical aneurysm. MR remains trace. 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, Interpreting physician [**Last Name (NamePattern4) **] [**2116-10-13**] 08:38 ?????? [**2110**] CareGroup IS. All rights reserved. [**2116-10-16**] 05:45AM BLOOD WBC-8.8 RBC-3.53* Hgb-10.1* Hct-30.4* MCV-86 MCH-28.6 MCHC-33.2 RDW-15.0 Plt Ct-189 [**2116-10-16**] 05:45AM BLOOD Glucose-91 UreaN-18 Creat-0.5 Na-138 K-4.5 Cl-105 HCO3-24 AnGap-14 [**2116-10-17**] 07:15AM BLOOD WBC-8.7 RBC-3.35* Hgb-10.0* Hct-29.0* MCV-86 MCH-29.9 MCHC-34.6 RDW-15.1 Plt Ct-293# [**2116-10-17**] 07:15AM BLOOD Glucose-267* UreaN-16 Creat-0.6 Na-134 K-4.1 Cl-97 HCO3-30 AnGap-11 Brief Hospital Course: Admitted [**10-12**] and underwent surgery with Dr. [**Last Name (STitle) **]. transferred to the CVICU in stable condition on epinephrine, insulin and propofol drips. Extubated later that evening. Transferred to the floor on POD #2, but went into rapid A Fib and was transferred back to the CVICU for better IV access. Amiodarone was started. Transferred back to the floor on POD #3 to begin increasing her activity level. [**Last Name (un) **] was consulted regarding glucose management. Gently diuresed toward her preop weight. The patient made excellent progress with physical therapy, showing good strength and balance before discharge. Chest tubes and pacing wires were discontinued without complication. By the time of discharge on POD 5, the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. Medications on Admission: lipitor 80 mg daily ASA 325 mg daily isosorbide MN 30 mg daily methimazole 10 mg daily protonix 40 mg daily lisinopril 20 mg daily chlorazepate dipotassium 3.75 mg daily toprol XL 50 mg daily insulin levemir 32 units Q PM novolog 8 units Q AM novolog 14 units Q PM Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 2. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. 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* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg 2x/day for 4 days, then 200mg 2x/day for 1 week, then 200mg/day. Disp:*120 Tablet(s)* Refills:*0* 8. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*0* 9. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) for 2 weeks. Disp:*qs * Refills:*0* 10. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day for 1 weeks. Disp:*14 Tablet(s)* Refills:*0* 11. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H (every 12 hours) for 1 weeks. Disp:*14 Packet(s)* Refills:*0* 12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 13. Insulin Detemir 100 unit/mL Insulin Pen Sig: 40 units Subcutaneous q am. Disp:*30 * Refills:*0* 14. Novolog Flexpen 100 unit/mL Insulin Pen Sig: per scale Subcutaneous ac, hs: dose to be determined by sliding scale. Disp:*30 * Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: CAD/apical aneurysm s/p CABG x4/rep. LV aneurysm postop A Fib MI IDDM hyperthyroidism OA spinal stenosis retroperitoneal bleed s/p cath PVD with L SFA stent/PTCA Discharge Condition: good Discharge Instructions: no lotions, creams or powders on any incision shower daily and pat incisions dry no driving for one month and until off all narcotics for pain no lifting greater than 10 pounds for 10 weeks call for fever greater than 100.5, redness or drainage call for weight gain greater than 2 pounds in one day, or 5 pounds in a week Followup Instructions: Dr. [**Last Name (STitle) **] 1 week see Dr. [**Last Name (STitle) 75782**] in [**12-11**] weeks see Dr. [**Last Name (STitle) **] in [**1-12**] weeks see Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] please call for all appts. Completed by:[**2116-10-17**]

[ "413.9", "242.90", "401.9", "410.72", "414.01", "414.10", "427.31", "440.20", "997.1", "250.00", "E878.2" ]

icd9cm

[ [ [] ] ]

[ "37.32", "36.15", "36.13", "39.61" ]

icd9pcs

[ [ [] ] ]

6827, 6878

3779, 4634

314, 427

7084, 7091

1330, 3756

7461, 7745

937, 998

4949, 6804

6899, 7063

4660, 4926

7115, 7438

1013, 1013

1027, 1311

255, 276

455, 647

669, 863

879, 921

82,021

175,202

53776+59551

Discharge summary

report+addendum

Admission Date: [**2144-5-11**] Discharge Date: [**2144-5-15**] Date of Birth: [**2101-3-4**] Sex: M Service: SURGERY Allergies: flu vaccine [**2143**]-[**2144**](18 yr +) / Penicillins Attending:[**First Name3 (LF) 371**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 110371**] is a 43 year-old male with a history of afib, Hep C, DM, COPD, chronic low back pain presenting with abdominal pain that started yesterday afternoon. The pain had sudden onset, diffuse, crampy in nature, without radiation and not associated with activity or PO intake. He reports two days of constipation, normal of [**1-13**] bowel movements per day is normal for him. He continues to have flatus and reports no nausea, vomiting or diarrhea. He presented to [**Hospital 5503**] Hospital this evening with persistent pain and underwent a CT scan which per report showed focal segment of colon with multiple diverticula, wall thickening and surrounding inflammatory change with scattered free intraperitoneal air and trace free fluid along the left pelvis. He denies fevers, chills, chest pain, or shortness-of-breath. Past Medical History: afib not anticoagulated, hep C (type F) dx 10 years ago, chronic low back pain, asthma, DM, COPD Past Surgical History: R knee surgery for torn ACL [**2134**] Social History: EtOH use: Denies Tobacco use: 3ppd Previous smoker: 3ppd x 20 years Recreational drugs (marijuana, heroin, crack pills or other): Denies Marital status:Lives in [**Location (un) 5503**]. Unemployed but previously employed as a Fisherman. Family History: Noncontributory Physical Exam: On admission: Vitals: Weight: 350lbs 97.2 104 164/92 16 97% 2LNC GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Morbidly obese, soft, TTP LLQ and RUQ, no rebound or guarding, normoactive bowel sounds, no palpable masses DRE: normal tone, no gross or occult blood Ext: No LE edema, LE warm and well perfused On discharge: VS: 98.4 84 134/76 18 98% on 1L NC GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR PULM: Diminished at bases ABD: Obese, soft, slightly tender to LLQ but improved significantly. No rebound or gaurding. No palpable masses. EXTR: No edema, warm and well perfused Pertinent Results: On admission: 140 | 101 | 22 / ---------------- 107 3.3 | 30 | 0.7 \ \ 15.4 / 18.1 ------ 180 / 48.6 \ CT A/P [**2144-5-11**]: 1. Sigmoid diverticulitis with air and fluid surrounding the sigmoid colon with small left pelvic fluid collection. Extensive free intraperitoneal and retroperitoneal air with air tracking into a fat-containing umbilical hernia. 2. Asymmetric ground glass opacity at the right lung base, which may represent infection or aspiration. 3. Aortic valve calcification, of indeterminate hemodynamic significance. Left ventricular hypertrophy. CHEST PORT. LINE PLACEMENT [**2144-5-11**]: 1. Right PICC line with the tip in the right atrium. Recommend pulling back 2-3 cm. 2. Mild pulmonary edema. On discharge: [**2144-5-15**] 04:51AM BLOOD WBC-11.8* RBC-5.20 Hgb-15.5 Hct-48.2 MCV-93 MCH-29.8 MCHC-32.1 RDW-14.0 Plt Ct-223 [**2144-5-15**] 04:51AM BLOOD Glucose-138* UreaN-7 Creat-0.6 Na-140 K-3.3 Cl-100 HCO3-33* AnGap-10 [**2144-5-15**] 04:51AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.5* Brief Hospital Course: Mr. [**Known lastname 110371**] was admitted on [**2144-5-11**] to the trauma SICU for close observation given his diagnosis of perforated diverticulitis and free air seen on CT scan. He did not have evidence of peritoneal signs on exam and was only moderately tender. He was kept NPO and aggressively resuscitated. He was also started on IV cipro/flagyl. His heart rate in the ICU was poorly controlled in the setting of atrial fibrillation. This improved with diltiazem and on HD 2 he was restarted on his home doses of sotalol and digoxin. Overall he did well in the ICU with improved abdominal exam so was transferred to the floor on [**5-12**]. On the floor he was monitored on telemetery and he remained in atrial fibrillation with rate well controlled. His vital signs were routinely monitored and he remained afebrile and hemodynamically stable. His oxygen saturation decreased to the 80's on room air but was in the mid to high 90's on minimal supplemental O2 via nasal cannula. Pulmonary toilet and incentive spirometry were encouraged and he was started on nebulizer treatments. A chest x-ray on [**5-12**] showed significant improvement with only minimal residual signs of CHF. I&O's were monitored and he was voiding adequate amounts of urine. He was started on SC heparin for DVT prophylaxis. His blood glucose was monitored and he required very minimal coverage with insulin sliding scale, with his blood sugars remaining in the 100's throughout his hospital stay. His abdominal exams were monitored serially and improved over the the 3 days that he was on the floor. His tenderness had decreased significantly and his WBC count trended downward from its peak at 18.1 on admission to 11.8 at discharge on [**5-15**]. He had a large bowel movement on [**5-14**] and his diet was slowly advanced over 24 hours to regular which he tolerated without increased abdominal pain or nausea. He was continued on the cipro/flagyl and discharged to rehab on [**5-15**] to complete a total 2 week course. Follow up was scheduled in [**Hospital 2536**] clinic prior to discharge. Medications on Admission: Medications: Dabigatran 150mg daily (not taking), digoxin 0.25mg daily, diltiazem 120mg daily, furosemide 40mg daily (not taking), gabapentin 900mg QID, ipratropium/albuterol prn, lisinopril/HCTZ (20/12.5) daily, nicotine patch 21mg Q24H, pantoprazole 40mg daily (not taking), prednisone 40mg daily (not taking), sotalol 160mg [**Hospital1 **], nitroglycerin 0.4mg prn Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) inj Injection TID (3 times a day). 2. sotalol 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 5. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO QID (4 times a day). 6. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. metronidazole in NaCl (iso-os) 500 mg/100 mL Piggyback Sig: One Hundred (100) mL Intravenous Q8H (every 8 hours) for 11 days: Last day [**2144-5-25**]. 9. ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: Two Hundred (200) mL Intravenous Q12H (every 12 hours) for 11 days: Last day [**2144-5-25**]. 10. sodium chloride 0.9 % 0.9 % Parenteral Solution Sig: Three (3) ML Intravenous Q8H (every 8 hours) as needed for line flush. 11. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 12. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOB, wheezing. Discharge Disposition: Extended Care Facility: [**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**] Discharge Diagnosis: Perforated diverticulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with perforated diverticulitis. You were placed on bowel rest and given IV antibiotics. Your pain has improved and you have been advanced to a regular diet. You are now being discharged to rehab to complete a 2 week course of IV antibiotics and continue your recovery from your hospitalization. Please follow up in the Acute Care Surgery clinic at the appointment listed below. You should also follow up with your primary care provider after leaving the rehab facility. Followup Instructions: Department: GENERAL SURGERY/[**Hospital Unit Name 2193**] When: TUESDAY [**2144-6-2**] at 2:30 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:[**2144-5-15**] Name: [**Known lastname 18085**],[**Known firstname **] Unit No: [**Numeric Identifier 18086**] Admission Date: [**2144-5-11**] Discharge Date: [**2144-5-15**] Date of Birth: [**2101-3-4**] Sex: M Service: SURGERY Allergies: flu vaccine [**2143**]-[**2144**](18 yr +) / Penicillins Attending:[**First Name3 (LF) 844**] Addendum: Please see changes to discharge medications. Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) inj Injection TID (3 times a day). 2. sotalol 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 5. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO QID (4 times a day). 6. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. metronidazole in NaCl (iso-os) 500 mg/100 mL Piggyback Sig: One Hundred (100) mL Intravenous Q8H (every 8 hours) for 11 days: Last day [**2144-5-25**]. 9. ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: Two Hundred (200) mL Intravenous Q12H (every 12 hours) for 11 days: Last day [**2144-5-25**]. 10. sodium chloride 0.9 % 0.9 % Parenteral Solution Sig: Three (3) ML Intravenous Q8H (every 8 hours) as needed for line flush. 11. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 12. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOB, wheezing. 14. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 15. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 16. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 17. Senna Concentrate 8.6 mg Tablet Sig: One (1) Tablet PO once a day as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital 2653**] [**Hospital **] Hospital - [**Location (un) 2653**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 845**] MD [**MD Number(1) 846**] Completed by:[**2144-5-15**]

[ "493.20", "278.01", "724.2", "305.1", "070.54", "562.11", "300.00", "427.31", "250.00", "401.9" ]

icd9cm

[ [ [] ] ]

[ "38.97" ]

icd9pcs

[ [ [] ] ]

10649, 10902

3466, 5550

329, 335

7465, 7465

2421, 2421

8146, 8956

1676, 1694

8979, 10626

7416, 7444

5576, 5947

7616, 8123

1363, 1403

1709, 1709

3171, 3443

275, 291

363, 1220

2436, 3156

7480, 7592

1242, 1340

1419, 1660

1,399

131,945

53082

Discharge summary

report

Admission Date: [**2108-6-5**] Discharge Date: [**2108-6-15**] Date of Birth: #14 Sex: M Service: SURGICAL HISTORY OF PRESENT ILLNESS: This 74 year old man presents with a hepatic flexure lesion for surgical resection. He was noted to have anemia. This was manifested by increasing dyspnea. He had an endoscopy and colonoscopy which showed recent hepatic flexure which showed at least atypical cells. PAST MEDICAL HISTORY: Notable for significant medical problems: 1. Significant congestive heart failure. 2. Atrial fibrillation. 3. Two myocardial infarctions. 4. He has had ICD placed for significant arrhythmias. 5. He has also had significant chronic obstructive pulmonary disease. 6. Hypertension. 7. Hypercholesterolemia. 8. Hypothyroidism. ALLERGIES: He is allergic to amiodarone. MEDICATIONS: Present medications include: 1. Aldactone. 2. Allopurinol. 3. Coumadin. 4. Levoxyl. 5. Digoxin. 6. Lasix. 7. Mevacor. 8. Vanceril inhaler. 9. Albuterol inhaler. 10. Atrovent inhaler. 11. Multivitamins. PAST SURGICAL HISTORY: 1. Splenectomy for trauma. 2. Biopsy of a left carotid body tumor and subsequent radiation therapy. PHYSICAL EXAMINATION: On examination, a well developed, overweight gentleman. The neck was supple without mass, nodes or thyromegaly. There was some induration of his neck status post surgery and radiation. He had distant breath sounds. There is an ICD placed in the right chest. There are no masses palpable. HOSPITAL COURSE: The patient was admitted with the diagnosis of a colon cancer and underwent a right hemicolectomy on the date of admission via a lateral transverse incision. Findings at operation included a large tumor which was successfully resected. The patient was admitted to the Intensive Care Unit for postoperative cardiac monitoring. The patient had some difficulties with shortness of breath and was monitored with a Swan-Ganz catheter. He was noted to have an increased INR of unknown etiology. He continued to have congestive heart failure and was kept in the Intensive Care Unit for approximately one week, at which time his bowels began to function. He was progressed to a diet that was somewhat tenuous and required close observation. He was then sent to the Floor. There was a small amount of seepage from the wound, but otherwise, he seemed to recovery reasonably well. His tumor returned a T3 lesion with negative nodes. The patient was seen in consultation by the oncologist. He continued to have his medical regimen tailored and then was discharged on [**2108-6-15**]. FINAL DIAGNOSES: 1. Colon cancer. 2. Coronary artery disease with congestive heart failure. 3. Chronic obstructive pulmonary disease. 4. Arrhythmias. 5. Hypothyroidism. 6. Gout. DISCHARGE MEDICATIONS: 1. Allopurinol 25 mg twice a day. 2. Albuterol inhaler. 3. Capoten 50 mg twice a day. 4. Coumadin 3 mg p.o. q. day. 5. Levoxyl 50 micrograms p.o. q. day. 6. Digoxin 0.125 mg p.o. q. day. DISPOSITION: The patient was discharged on approval to be followed as an outpatient. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**] Dictated By:[**Last Name (NamePattern4) 9706**] MEDQUIST36 D: [**2108-11-27**] 21:10 T: [**2108-11-30**] 11:11 JOB#: [**Job Number 109360**]

[ "412", "425.4", "250.00", "153.4", "427.31", "416.8", "197.6", "493.20", "428.0" ]

icd9cm

[ [ [] ] ]

[ "38.93", "45.73" ]

icd9pcs

[ [ [] ] ]

2813, 3369

1522, 2605

1080, 1187

2622, 2790

1210, 1504

159, 429

452, 1057

46,441

136,283

50286

Discharge summary

report

Admission Date: [**2173-4-3**] Discharge Date: [**2173-4-10**] Date of Birth: [**2100-5-9**] Sex: F Service: MEDICINE Allergies: Aspirin / Calcium / anesthesia tray / Shellfish Derived / Soy Attending:[**First Name3 (LF) 7651**] Chief Complaint: out of hospital cardiac arrest Major Surgical or Invasive Procedure: central line placement intubation arterial line placement transvenous pacer placement post-arrest cooling History of Present Illness: Ms. [**Known lastname **] is a 72 year old W with a history of HTN, chronic PE's on Coumadin, repeated syncopal episodes and OSA who presents after an out of hospital VF arrest. Per the EMS and her daughter's report she went into the bathroom tonight, called for help and her daughter found her on the floor unresponsive. Her daughter called 911, and the ambulance arrived within two mintues since they were in the area. On arrival she was found to be in ventricular fibrillation so she was shocked once, she then went into asystole, at which time she received CPR, one round of epinephrine with ROSC, at which time she was reportedly in A.fib. She was unable to be intubated in the field, and transferred to the [**Hospital1 18**] ER. . In the ED, initial vitals were: 78, 142/68, RR of 14-16 with oxygen sats in the high 90's to 100 on nasal cannula. She remained unresponsive during her time in the ER so she was intubated for airway protection with etomidate and succinylcholine, then given fentanyl at 100mcg and midazolam at 7mg drips for sedation. A CTA was negative for PE, and a CT of her head was negative for any acute process. The post arrest team was consulted who recommended therapeutic cooling for neuro protection, keeping her oxygen saturation around 94% to minimize free radical damage, and HOB elevation. She was started on the Artic Sun Cooling Protocol and admitted to the CCU. Vital signs on admission were: T-36.6, HR-110, BP-127/74, 100% on AC 500x18, PEEP of 5 and FiO2 of 100%, with an ABG of 7.3/48/317. . Unable to obtain ROS given patient is intubated, sedated, non-responsive. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: None -PACING/ICD: None -[**Doctor Last Name **] OF HEARTS: (per OMR) no ventricular arrhythmia, fourteen recordings of sinus tachycardia at rates up to 126 BPM. Also had one recording of SVT (likely atrial tachycardia) with 2 sinus beats with maximum heart rate of 146 BPM. 3. OTHER PAST MEDICAL HISTORY: - Chronic PE - Bipolar disorder - Depression - H/o syncope - Hypertension - Obstructive sleep apnea - Osteoporosis - Polyneuropathy - Osteoarthritis - Spinal stenosis - Scoliosis - Distant ETOH abuse - ?Thalassemia Social History: (per OMR) She is currently unemployed and occasionally has help at home with ADLs. She has 3 children. She has a h/o ETOH abuse, but quit 15 yrs ago. She smoked 1 ppd for 40 yrs, but quit 15 yrs ago. She denies any h/o illicit drug use. She lives in Mission [**Doctor Last Name **] and walks around to the extent that she can be social with her various neighbors. Family History: (per OMR) There is no history of neurologic disease. There is a history of cardiac disease in her mother, unspecified, and in her daughter. [**Name (NI) **] daughter does have anginal symptoms, which may or may not be related to a history of cocaine abuse; however, she does not have any knowledge of her parent's medical history given their relationship. Physical Exam: Admission Exam ([**2173-4-3**]): 36.1, 87, 125/90, 20, 99% GENERAL: obese, intubated, sedated, paralyzed HEENT: NCAT, sclera anicteric, PERRL, conjunctiva pink NECK: obese, unable to appreciate JVP CARDIAC: unable to hear cardiac sounds LUNGS: no chest wall deformities, coarse ventilated lung sounds, diffuse wheeze ABDOMEN: obese, multi-lobulated pannus with R-sided ?femoral hernia EXTREMITIES: no clubbing, cyanosis, or edema SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: symmetric bilaterally Discharge Exam: Patient passed during AM of [**2173-4-10**] after being extubated and having pacer stopped at family request. Patient went asystolic and was pulseless without spontaneous respirations or response to stimuli. Pertinent Results: [**2173-4-3**]: -WBC-16.3* RBC-4.34 Hgb-10.8* Hct-34.4* MCV-79* MCH-24.9* MCHC-31.5 RDW-18.3* Plt Ct-253 Neuts-86.3* Lymphs-11.3* Monos-1.7* Eos-0.2 Baso-0.6 -PT-23.6* PTT-23.1 INR(PT)-2.2* -Fibrino-414* -Glucose-198* UreaN-15 Creat-0.9 Na-137 K-3.6 Cl-101 HCO3-25 AnGap-15 -ALT-52* AST-93* LD(LDH)-417* CK(CPK)-165 AlkPhos-84 TotBili-0.3 -cTropnT-0.01 -CK-MB-12* MB Indx-3.3 cTropnT-0.14* [**2173-4-4**]: -06:15AM CK-MB-15* MB Indx-4.0 cTropnT-0.14* -02:01PM CK-MB-15* MB Indx-4.9 cTropnT-0.08* Micro: [**2173-4-6**] 3:16 pm ASPIRATE Source: Sinus. **FINAL REPORT [**2173-4-10**]** GRAM STAIN (Final [**2173-4-6**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S). 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN SHORT CHAINS. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [**2173-4-8**]): SPARSE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. MODERATE GROWTH. _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R 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 ANAEROBIC CULTURE (Final [**2173-4-10**]): Mixed bacterial flora-culture screened for B. fragilis, C. perfringens, and C. septicum. None isolated. [**2173-4-7**] 5:59 am BLOOD CULTURE Source: Line-aline. **FINAL REPORT [**2173-4-13**]** Blood Culture, Routine (Final [**2173-4-13**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. Anaerobic Bottle Gram Stain (Final [**2173-4-8**]): REPORTED BY PHONE TO DR. [**First Name4 (NamePattern1) 5147**] [**Last Name (NamePattern1) **] @ 1420, [**2173-4-8**]. GRAM POSITIVE COCCI IN CLUSTERS. [**2173-4-7**] 5:59 am SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2173-4-7**]): <10 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Final [**2173-4-9**]): Commensal Respiratory Flora Absent. STAPH AUREUS COAG +. MODERATE GROWTH. | CLINDAMYCIN----------- =>8 R 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 . - Ucx (multiple): negative - Bcx (multiple): all negative except for one cx noted above . Admission CXR: 1. Tip of the endotracheal tube is difficult to identify, but appears to lie at least 3 cm from the carina. Nasogastric tube in appropriate position. 2. Diffuse airspace opacities. Findings may represent a combination of pulmonary edema with more focal opacities in the left lung base suggestive of atelectasis. Aspiration or infection in the left lung base however is not excluded. . Admission CTA: 1. No pulmonary embolus or acute aortic syndrome. 2. Dilated right atrium and ventricle with mild-to-moderate pulmonary edema. Nodularity within the central lungs may be related to pulmonary edema though aspiration is not excluded given secretions seen within the trachea and left mainstem bronchi. 3. Non-displaced sternal fracture and numerous anterior rib fractures related to recent chest compressions. A focus of consolidation in the right upper lobe likely represents a pulmonary contusion. 4. Trace pneumomediastinum, again possibly related to recent chest compressions. . Admission Head CT: 1. No acute intracranial hemorrhage. 2. Subtle blurring of [**Doctor Last Name 352**]-white differentiation in the bilateral frontal and parietal lobes which is concerning for ischemia. MR can be obtained for further evaluation . Initial EEG ([**2173-4-4**]): This is an abnormal continuous EEG due the presence of a burst suppression pattern, with periods of suppression which gradually shorten over the course of the tracing as described above. This pattern is consistent with severe diffuse cerebral dysfunction, likely postanoxic but also likely affected by pharmacologic sedation and cooling, with shorter periods of suppression consistent with gradual rewarming. In addition, there are frequent epileptiform discharges over the left temporal region, phase reversing at T3, consistent with a focus with epileptogenic potential. There are no electrographic seizures seen. . Last EEG ([**2173-4-8**]): This is an abnormal continuous EEG due the presence of a mostly discontinuous background during the initial portion of the EEG with nearly continuous superimposed bilateral independent periodic epileptiform discharges (0.5-1 Hz BiPLEDs). The frequency and amplitude of the BiPLED activity decreases over the tracing. This pattern is consistent with a severe diffuse encephalopathy and commonly seen with bilateral or multifocal hypoxic ischemic (watershed) injury with high epileptogenic potential with slight improvement toward the end of the tracing. Furthermore, there are frequent periods of a [**7-13**] Hz posterior dominant rhythm which appear spontaneously and in reaction to voice during bedside examination with a decrease in the frequency in the interictal discharges. This pattern is clinically consistent with reactivity and represents an improvement compared to the prior tracing. There are no electrographic seizures seen. Brief Hospital Course: HOSPITAL COURSE: 72 yo morbidly-obese W with Hx of HTN, chronic PE's on Coumadin, multiple syncopal episodes attributed to neurocardiogenic etiology, OSA and bipolar disorder who presents s/p out-of-hospital V Fib arrest, admitted to CCU and undergoing therapuetic hypothermia for neuroprotection. . ACTIVE ISSUES: . # VENTRICULAR FIBRILLATION ARREST: Occurred in the community. Found unresponsive after calling for help. Per report, EMS arrived within two minutes. CPR was not initiated prior to their arrival. Patient was in V Fib, shocked, went into asystole, started CPR and given Epinephrine, then had return of spontaneous circulation. Etiology unclear. [**Name2 (NI) **] history of structural heart disease, no evidence to support myocardial infarction, no rhythm abnormalities on EKG to support long QT syndrome, Brugada syndrome, or WPW. No gross electrolyte abnormalities on admission and toxicology screen negative. CTA was negative for pulmonary embolism. History of being on the toilet most likely supports a relationship to the patiet's neurocardiogenic syncope. She was started on the Artic Sun cooling protocol for hypothermic neuroprotection and remained hemodynamically stable. Electrophysiology was consulted for ICD placement and placed temporary transvenous ventricular pacer which supported heart rate over coming days. A couple days after pacer placement, difficulty with pacer capture started developing with output intermittently having to be raised to regain capture. Any time patient was moved pt would lose capture and there would be no underlying rhythm. In light of [**Known lastname **] neurologic recovery over 1 week and fact that pt was unlikely to recover past the point of severe disability, the family made the decision to make CMO and withdraw care. Patient was extubated and transvenous pacing turned off on [**4-10**] and patient passed shortly thereafter. . # THERAPUETIC HYPOTHERMIA: The patient was placed on the Artic Sun cooling protocol for neuroprotection s/p cardiac arrest. Prior to, it was reported that she was not responsive, but breathing on her own. She was cooled to 33 degrees on [**2173-4-4**] at 0330, and remained hypothermic for 24 hours. During this time she was kept sedated and paralyzed. We monitored her labs for electrolyte abnormalities and corrected as needed. We weaned her ventilator settings to decrease FiO2 as tolerated to prevent free radial formation. We provided tight glucose control with ISS. Neurology was consulted and the patient underwent continuous video EEG monitoring which showed mild changes and improvements over the next week but no significant improvement that would indicate meaningful neurologic recovery. Pt tolerated re-warming without incident but as mentioned above decision was made to withdraw care after 1 week when patient failed to show evidence of significant recovery or likely recovery. . # RESPIRATORY/INTUBATION: The patient was intubated on arrival to the ED for airway protection. We monitored her arterial blood gas samples and adjusted ventilator settings as appropriate. She required minimal settings and remained intubated for neuroprotection. Later in admission patient developed sputum/tracheal secretions and ultimately grew MRSA out of sputum, blood, and sinus fluid. Patient was started on Vancomycin for the MRSA after being emperically started on Unasyn for a sinus infection. Care was ultimately withdrawn as noted above. . # CARDIAC: No documented history of CAD; however, patient was obese with hx of hypertension and had Q waves on prior EKG. EKG on presentation consistent with prior except for 1mm STE in III and aVF. She was treated for ACS on presentation; however, ruled-out for myocardial infarction. A TTE was obtained that revealed preserved systolic function with no isolated areas of hypokinesis and only mild LVH. Pt was monitored on telemetry and remained in sinus rhythm initially but was then given transvenous pacing and when pacer off had underlying slow junctional rhythm or asystole. . # LEUKOCYTOSIS: Blood, urine, and sputum cultures were obtained intially showing no evidence of infection. However, later in admission pt developed sinus discharge and tracheal secretions and sputum, sinus aspirate, and one blood culture all grew out MRSA. Pt was started on Unasyn and Vancomycin as noted above but decision was ultimately made to withdraw care shortly thereafter. . # CHRONIC PULMONARY EMBOLISMS: CTA on admission was negative for pulmonary embolism. Coumadin was held and the patient was started on a Heparin gtt for anticoagulation. . # ANEMIA: Microcytic with questionable history of thalassemia documented in OMR. No evidence to suggest acute bleeding. She was kept on an H2 blocker for GI prophylaxis while ventilated. . # BIPOLAR DISORDER: Outpatient medication regimen (Celexa) was held on admission. Medications on Admission: alendronate 70 mg Tablet q weekly citalopram 20 mg Tablet TID gabapentin 100 mg [**3-11**] capsules by mouth TID (2 AM & afternoon, 3 PM) lisinopril 5 mg Tablet once a day methotrexate sodium (unsure if still currently taking) warfarin 5 mg Tablet up to 3 by mouth at bedtime or ASDIR acetaminophen [Tylenol] calcium carbonate-vitamin D3 [Calcium 500 + D] cyanocobalamin (vitamin B-12) [Vitamin B-12] folic acid 0.4 mg Tablet once a day loperamide 2 mg Tablet q6 as needed for diarrhea, incontinence multivitamin once a day omega-3 fatty acids potassium vitamin E Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Patient Deceased Discharge Condition: Patient Deceased Discharge Instructions: N/A Followup Instructions: N/A

[ "348.1", "511.9", "V66.7", "356.9", "V12.51", "327.23", "427.41", "518.81", "426.0", "280.9", "780.01", "427.5", "V15.82", "733.00", "724.00", "715.90", "401.9", "790.01", "V58.61", "278.01", "296.80" ]

icd9cm

[ [ [] ] ]

[ "37.78", "96.04", "38.91", "96.72" ]

icd9pcs

[ [ [] ] ]

15862, 15871

10364, 10364

351, 458

15931, 15950

4340, 8487

16002, 16008

3205, 3563

15834, 15839

15892, 15910

15245, 15811

10381, 10664

15974, 15979

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2234, 2561

4112, 4321

281, 313

10679, 15219

486, 2104

8496, 10341

2592, 2808

2148, 2214

2824, 3189

13,761

183,434

20449

Discharge summary

report

Admission Date: [**2191-1-21**] Discharge Date: [**2191-1-30**] Date of Birth: [**2121-4-30**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1974**] Chief Complaint: abd pain Major Surgical or Invasive Procedure: hemodialysis History of Present Illness: This is a 69 yo female with ESRD on HD, DM and CHF who presents from nursing home complaining of abd pain x 1 day. She is not a good historian with gaps in her memory, but she describes a sharp infra-abdominal pain that started after hemodialysis yesterday. It is intermittent and is associated with nausea. She denies vomit. She had a bowel movement this morning that was non-bloody; no diarrhea or constipation. . Of note, she had two admission in [**9-/2190**] for abd pain attributed to constipation that resolved with bowel movements from enemas. . On this admission, in the ED, her abd pain resolved spontaneously. KUB did not reveal any obstruction. Originally the plan was to send her back to her nursing home, but her blood pressure escalated. Her vitals initially were: 98.4, 89, 178/92, 14, 100%RA. Then her bp rose to 229/91. She complained of "feeling uncomfortable" but she cannot describe her symptoms. She denies headache, nausea, abd pain or vision changes. She was given a total of metoprolol 50 mg po, captopril 100mg po, and hydralazine 25mg po, 20mg IV. Her BP came down to 167/96 and she was admitted to medicine for futher care. . Currently, she feels comfortable without any complaints. She has no abd pain, nausea, vomit, diarrhea or constipation. She is passing gas. . ROS: She denies chest pain, shortness of breath or dysuria. Past Medical History: # HTN # DM, requiring insulin # ESRD on HD MWF # s/p left AV fistula revision/declotting [**12-7**], tunneled HD catheter [**6-/2190**] # h/o GI bleed with gastric ulcer # ? h/o chronic pancreatitis # chronic constipation (admit to ED [**9-/2190**], resolved with enemas) # Left ventricular thrombus: With h/o embolus to left toe # DVT bilateral lower extremities # CHF: EF >55%, LVH # Anemia, on EPO with HD # Cortical blindness: Can see light/dark, but no figures # Hypothyroidism: TSH 3.4 ([**10/2190**]) # Seizure disorder, diagnosed with ICU admission [**2188-4-3**] # gastritis # cerebellar stroke # dementia Social History: Lives at Presentation Manor. Has a [**Year (4 digits) 802**] in [**State 760**] and a sister in SC. Retired nursing aide. 80 pk yr tob history, none currently. No alcohol/drug use. . Family History: CAD in mother and father. [**Name (NI) 6961**] not living. Sister and [**Name2 (NI) 802**] healthy. No history of bleeding disorders, coagulopathies. Physical Exam: VITALS: 96.6 96 148/90 18 94%RA GEN: A+Ox1, cooperative and pleasant HEENT: eyes with strabismus, MMM, OP clear NECK: no carotid bruit, no JVD, no LAD CV: Soft heart sounds. RRR, [**2-8**] holosystolic murmur at LLSB. PULM: Distant breath sounds. mild expiratory wheezes at bases. no rhonchi, crackles. ABD: soft, nondistended. Tender at LUQ and RLQ. No guarding or rebound. Guaiac negative in ED. EXT: no c/e/c. diminished pedal pulses. wwp. NEURO: answers most questions appropriately if simple, inappropriate if questions are complex or compound. memory is poor; she cannot remember phone numbers or current president. she cannot remember her last BM or her HD schedule. mobilizes all extremities spontaneously. Pertinent Results: [**2191-1-20**] WBC-8.7# RBC-4.50 Hgb-13.0 Hct-42.0 MCV-93 MCH-28.9 MCHC-31.0 RDW-16.3* Plt Ct-200 [**2191-1-22**] WBC-5.4 RBC-4.14* Hgb-12.5 Hct-37.8 MCV-91 MCH-30.2 MCHC-33.0 RDW-16.6* Plt Ct-149* [**2191-1-24**] WBC-10.6 RBC-3.77* Hgb-11.2* Hct-34.5* MCV-92 MCH-29.7 MCHC-32.5 RDW-16.6* Plt Ct-127* [**2191-1-26**] WBC-6.0 RBC-3.61* Hgb-10.6* Hct-33.6* MCV-93 MCH-29.5 MCHC-31.6 RDW-17.4* Plt Ct-134* [**2191-1-29**] WBC-7.6 RBC-3.73* Hgb-11.2* Hct-35.1* MCV-94 MCH-29.9 MCHC-31.9 RDW-17.7* Plt Ct-157 [**2191-1-30**] WBC-6.9 RBC-3.82* Hgb-11.1* Hct-36.7 MCV-96 MCH-29.1 MCHC-30.3* RDW-17.6* Plt Ct-120* . [**2191-1-20**] 05:40PM BLOOD PT-12.5 PTT-116.4* INR(PT)-1.1 . [**2191-1-20**] Glucose-122* UreaN-12 Creat-3.7*# Na-141 K-3.3 Cl-97 HCO3-34* Calcium-9.0 Phos-2.0*# Mg-1.9 [**2191-1-22**] Glucose-62* UreaN-15 Creat-4.3*# Na-139 K-3.8 Cl-97 HCO3-23 Albumin-3.7 Calcium-9.4 Phos-2.9 Mg-2.0 [**2191-1-24**] Glucose-70 UreaN-25* Creat-6.6*# Na-132* K-4.6 Cl-93* HCO3-25 [**2191-1-26**] Glucose-77 UreaN-21* Creat-6.6*# Na-147* K-4.0 Cl-103 HCO3-27 [**2191-1-28**] Glucose-75 UreaN-13 Creat-5.2*# Na-142 K-4.7 Cl-101 HCO3-26 . [**2191-1-20**] 05:40PM ALT-16 AST-24 AlkPhos-154* Amylase-79 TotBili-0.3 [**2191-1-22**] 07:44PM AlkPhos-146* Amylase-70 TotBili-0.2 Lipase-10 . [**2191-1-20**] 05:40PM CK(CPK)-27 MB note done cTropnT-0.09* [**2191-1-22**] 07:44PM CK(CPK)-23* CK-MB-3 cTropnT-0.11* . [**2191-1-20**] 08:55PM BLOOD TSH-0.89 [**2191-1-20**] 09:06PM BLOOD Lactate-1.1 . [**2191-1-29**] 08:20AM BLOOD Vanco-26.8* . KUB [**2191-1-21**]: No dilated loops of bowel are seen. There is no free air. Air and moderate amount of stool are seen within the colon and rectum in a nonobstructive bowel gas pattern. Lung bases are clear. An infusion catheter overlies the left chest, with its tip in approximately the cavoatrial junction. IMPRESSION: No evidence of small-bowel obstruction. . CT ABD WITH CONTRAST [**2191-1-21**]: PRELIM: 1. Extensive infrarenal abdominal aortic calcified plaques with near occlusion, however, distal to this extensive atherosclerotic calcification, the aorta is patent, as is the [**Female First Name (un) 899**] and the common iliac arteries bilaterally. 2. Small focal loop of bowel thickening in the mid abdomen (series 2, image 35) could be secondary to nondistention. 3. Sequelae of chronic pancreatitis, unchanged from multiple prior studies. 4. Left adnexal cystic mass with a thickened wall. Further evaluation with ultrasound of clinical correlation is recommended. 5. Thickening of the anterior wall of the bladder despite being moderately distended of uncertain etiology. . EGD [**11/2190**] for f/u gastric ulcer: Ulcer in the fundus (biopsy) Polyp in the stomach body Otherwise normal EGD to second part of the duodenum Recommendations: Follow-up biopsy results Repeat EGD in 1 year to follow up gastric ulcer . EGD BX [**11/2190**]: Foveolar hyperplastic polyp. . COLONOSCOPY [**4-/2190**]: Normal colon to cecum. Recommendations: Normal colonoscopy but visualization was limited by poor prep. . [**1-26**] CXR: AP chest compared to [**2190-4-10**], through [**1-22**], [**2191**]: Lungs clear. Heart size normal. No pleural effusion or evidence of central adenopathy. Dual-channel left subclavian dialysis catheter tips are at the superior cavoatrial junction and upper right atrium respectively. Brief Hospital Course: 69yoW with dementia, ESRD on HD, presenting after episode of unresponsiveness and hypotension found to have MSSA line infection . # Line infection- Methicillin sensitive Staph Aureus moderate growth from Blood culture [**2191-1-22**]. Renal recommended Vancomycin dosing w/hemodialysis through the line for total of two weeks (first dose was [**1-24**] so plan to continue until [**2191-2-7**]). Future blood culture sets on [**1-24**], [**1-27**], [**1-28**] were no growth to date). Vanco level was 26.8 on [**1-29**] prior to HD so no dose was given with HD. (The reason Vanco was chosen was that patient did have a fever on Nafcillin). She will need continued Vanco with HD until [**2191-2-7**] and vanco level should be checked at next HD session. . # Abdominal pain- GI was consulted as patient had abdominal pain episodes associated with hypotension at hemodialysis. GI felt this was most consistent with constipation and bowel regimen was increased. There was initial concern for possible mesenteric ischemia, although given improvement with bowel regimen it was felt less likely. Could consider outpatient MRI/MRA Abd if symptoms were to persist. . # Mental status change: associated with hypotensive episode at HD on [**2191-1-21**]. This improved and mental status was felt to be baseline. . # hypotensive episodes- w/HD- now resolved. TTE [**2191-1-25**] normal cardiac function, no signs of ischemia. EKG w/o si of ischemic changes. . # ESRD: on HD. will follow electrolytes . # DM: continued sliding scale insulin, monitored finger sticks. . # HTN: holding antihypertensives (beta-blocker, isosorbide, lisinopril). Will likely need to be restarted slowly as outpatient, although blood pressure currently well-controlled (systolic 120's) prior to discharge. . # FEN: patient tolerating renal diet prior to discharge . # PPx: SC heparin for dvt prophylaxis, PPI, bowel regimen . # Code: DNR/DNI . # Dispo: back to nursing home with continued outpatient hemodialysis. Vancomycin should be continued at HD until [**2191-2-7**] for 2 week total course. Patient should have a vancomycin level checked at her next outpatient hemodialysis session. Antihypertensives were held in the hospital for hypotension at hemodialysis and should be slowly restarted as needed as an outpatient. Medications on Admission: # Metoprolol Tartrate 125 mg TID # Isosorbide Dinitrate 20 mg [**Hospital1 **] # Lisinopril 20 mg DAILY # Mirtazapine 15 HS # Levothyroxine 125 mcg DAILY # Cyanocobalamin 100 mcg DAILY # Pantoprazole 40 mg Q24H # Docusate Sodium 100 mg [**Hospital1 **] # Senna 8.6 mg Tablet [**Hospital1 **] # Bisacodyl 10 mg Suppository DAILY # Heparin (Porcine) 5,000 unit/mL Solution TID # Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q6H PRN # Regular insulin sliding scale QID # Sevelamer 800 mg TID # Folic Acid 1 mg DAILY 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. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 7. Insulin Regular Human 100 unit/mL Solution Sig: PER SLIDING SCALE Injection ASDIR (AS DIRECTED). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [**Hospital1 **] (2 times a day). 11. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day) as needed for constipation. 12. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous QHD for 7 days: please continue until [**2191-2-7**] at hemodialysis. Discharge Disposition: Extended Care Facility: [**Hospital3 8221**] - [**Location (un) 583**] Discharge Diagnosis: PRIMARY constipation SECONDARY # HTN # DM, requiring insulin # ESRD on HD MWF # s/p left AV fistula revision/declotting [**12-7**], tunneled HD catheter [**6-/2190**] # h/o GI bleed with gastric ulcer # ? h/o chronic pancreatitis # chronic constipation (admit to ED [**9-/2190**], resolved with enemas) # Left ventricular thrombus: With h/o embolus to left toe # DVT bilateral lower extremities # CHF: EF >55%, LVH # Anemia, on EPO with HD # Cortical blindness: Can see light/dark, but no figures # Hypothyroidism: TSH 3.4 ([**10/2190**]) # Seizure disorder, diagnosed with ICU admission [**2188-4-3**] # gastritis # cerebellar stroke # dementia Discharge Condition: hemodynamically stable, tolerating po's Discharge Instructions: Please take all medication as prescribed. Keep all appointments listed below. If you have abdominal pain or nausea or vomit, please call your doctor or go to the emergency room. In general. you should call your PCP if you have any medical questions or concerns. Followup Instructions: Please follow up with your PCP [**Last Name (NamePattern4) **] 1 week: [**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 42391**]

[ "403.01", "285.9", "428.0", "585.6", "780.39", "244.9", "564.00", "996.62" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

10871, 10944

6899, 9203

324, 338

11635, 11677

3508, 6876

11990, 12140

2592, 2743

9771, 10848

10965, 11614

9229, 9748

11701, 11967

2758, 3489

276, 286

366, 1737

1759, 2375

2391, 2576

59,225

163,772

34840

Discharge summary

report

Admission Date: [**2139-6-23**] Discharge Date: [**2139-6-27**] Date of Birth: [**2085-8-11**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Cardizem / Bumetanide Attending:[**Known firstname 943**] Chief Complaint: AMS Major Surgical or Invasive Procedure: Intubation and Extubation History of Present Illness: The patient is a 53yo M on the [**Known firstname **] list, cryptogenic cirrhosis c/b portal HTN and variceal bleeding, s/p splenorenal shunt and splenectomy, HTN, a-fib, h/o PE/DVT on coumadin, CRI who presented to an OSH with altered mental status. The patient was recently admitted to [**Hospital1 18**] from [**Date range (1) 79779**] with similar complaints, which was attributed to hepatic encephalopathy with possible exacerbation from medication non-compliance or pneumonia. While there was no overwhelming suspicion of pneumonia, he was discharged to complete a course of levofloxacin. The patient was discharged home with services. . It appears that since dischage he was readmitted to [**Hospital1 3325**] with complaints of lightheadedness. This was attributed to the numerous medications started recently, and some of his BP mediations were discontinue. It was noted by the patient's sister during that hospitalization that the patinet has been having increasing difficulties tolerating lactulose, and the dose was deceased to 30ml. . On the day of presentation, the patient was found by his sister to be difficult to arrouns, responding only to painful stiumuli. The patient was ultimatly intubed at [**Hospital3 **] to protect his airway. The patien'ts ammonia level was checked at 420. The patient was given zosyn and lactulose and transfered to [**Hospital1 18**] for further evaluation. . At [**Hospital1 18**], vitals wer BP 110/70, HR 66, 100% on the vent. He was given 2L of NS and 1 dose of vanc, and admitted to the MICU for further mangement. Past Medical History: - cryptogenic cirrhosis c/b portal HTN and variceal bleeding - s/p splenorenal shunt and splenectomy with splenic vein anastamosed to left renal vein - UGIB [**2-23**] portacaval shunt - s/p end vena cava o superior mesenteric vein anastamosis - hepatic encephalopathy [**2138**] w/ mult admits - DVT - pulmonary emboli 2-3 years ago - atrial fib - CRI b/l Cr ~1.5 - htn - GERD - HOH - The patient is s/p a central splenorenal shunt and splenectomy in [**2094**]. - In [**2096**] underwent a mesocaval shunt. - Recent CT scan of his chest revealed a stable 3 mm noncalcified left lower lobe pulmonary nodule seen on MRI, a 2 mm right middle lobe noncalcified pulmonary nodule. Social History: Mr. [**Known lastname 4702**] currently lives with his brother-in-law, [**Name (NI) **], and sister [**Name (NI) **]. They have three cats and one dog. He is currently disabled and previously worked in a shoe factory and at Victory Market. He does not drink alcoholic beverages and has never smoked cigarettes. He is originally from [**Location (un) 5583**], [**State 350**]. While working in the shoe factory he was exposed to latex and acetone. Family History: He is adopted and family history is unknown. His adopted father was a long term cigarette smoker, and thus he was exposed to secondhand smoke as a child. Physical Exam: Vitals: T: BP: P: R: 18 O2: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ======= Labs ======= [**2139-6-23**] 04:20AM BLOOD WBC-11.9* RBC-4.84 Hgb-14.5 Hct-43.0 MCV-89 MCH-29.9 MCHC-33.7 RDW-14.8 Plt Ct-187 [**2139-6-24**] 04:11AM BLOOD WBC-12.8* RBC-4.88 Hgb-14.6 Hct-42.8 MCV-88 MCH-30.0 MCHC-34.2 RDW-14.9 Plt Ct-195 [**2139-6-25**] 05:50AM BLOOD WBC-10.0 RBC-4.69 Hgb-13.9* Hct-42.0 MCV-90 MCH-29.8 MCHC-33.2 RDW-14.8 Plt Ct-190 [**2139-6-26**] 05:15AM BLOOD WBC-8.1 RBC-4.21* Hgb-12.5* Hct-37.4* MCV-89 MCH-29.8 MCHC-33.5 RDW-15.1 Plt Ct-174 [**2139-6-23**] 04:35AM BLOOD PT-28.7* PTT-35.1* INR(PT)-2.9* [**2139-6-25**] 05:50AM BLOOD PT-43.7* PTT-38.8* INR(PT)-4.8* [**2139-6-26**] 05:15AM BLOOD PT-38.0* PTT-39.1* INR(PT)-4.1* [**2139-6-23**] 04:20AM BLOOD Glucose-165* UreaN-27* Creat-1.7* Na-139 K-4.3 Cl-106 HCO3-22 AnGap-15 [**2139-6-24**] 04:11AM BLOOD Glucose-108* UreaN-23* Creat-1.8* Na-146* K-3.8 Cl-109* HCO3-24 AnGap-17 [**2139-6-25**] 05:50AM BLOOD Glucose-110* UreaN-28* Creat-1.9* Na-144 K-3.2* Cl-106 HCO3-29 AnGap-12 [**2139-6-26**] 05:15AM BLOOD Glucose-100 UreaN-27* Creat-1.9* Na-137 K-3.3 Cl-104 HCO3-24 AnGap-12 [**2139-6-23**] 04:20AM BLOOD ALT-43* AST-46* AlkPhos-71 TotBili-1.3 [**2139-6-25**] 05:50AM BLOOD ALT-39 AST-33 AlkPhos-67 TotBili-1.4 [**2139-6-26**] 05:15AM BLOOD ALT-38 AST-35 AlkPhos-60 TotBili-1.0 [**2139-6-23**] 04:20AM BLOOD VitB12-1081* [**2139-6-24**] 04:11AM BLOOD TSH-1.4 . ========= Micro ========= Blood culture [**6-23**] x2 negative. RPR nonreactive . ========= Radiology ========= RUQ US: 1. 2.2 x 2.3 x 2.7 cm heterogeneous focal lesion in the left lobe of the liver, slightly enlarged compared to prior CT in [**2138**]. Appearance is not consistent with a hemangioma, as described above. Given interval increase in size, well differentiated HCC cannot be excluded. Differential diagnosis inlcudes FNH or adenoma. MRI with BOPTA could be considered. 2. Nonvisualization of the main portal vein. This is consistent with findings of prior CT and MRI, and implies chronic portal vein thrombosis. 3. Cholelithiasis with no son[**Name (NI) 493**] evidence of acute cholecystitis. 4. Normal flow in the hepatic veins and hepatic arteries. . ============ Cardiology ============ EKG: Sinus Rhythm at 60, no ischemic changes. Brief Hospital Course: #. Change in Mental Status: Given the patient's history of hepatic encephalopathy, markedly elevated ammonia level, and normal HCT, most likely etiology felt to be hepatic encephalopathy in the setting of med non-compliance. In consideration of other causes, head CTs showed no intracranial pathology, there were no focal deficits on exam. Additionally, there no orher blatent infectious etiologies. His CXR was unchanged, no major leukocytosis, afebrile. His UA was unremarkable and no c/o abd dysfunction. His U/S showed no ascites so felt unlikely SBP. He was continued on lactulose and rifaximin with marked improvement in his mental status. Vitamin B12, TSH, RPR were checked and were unremarkable. Patient was oriented on discharged and continued on lactulose and rifaximin. # Respiratory Support: Patient intubated to protect his airway. No significant underlying lung issues, and extubated on day one of admission. . #. Cirrhosis: Pt with cryptogenic cirrhosis dx as a child. Likely hepatic encephalapthy was the cause of patient's change in mental status, see above. LFTs were withint normal range for this patient. # Chronic Renal Insuff: Baseline Cr has ranged 1.8-2.6. On admission Cr was 1.7. Nephrotoxins were avoided and medications were renally dosed. He was diuresed as above. . #. Hepatic Lesion: The patient had a RUQ that showed a 2.2 x 2.3 x 2.7 cm heterogeneous focal lesion in the left lobe of the liver, slightly enlarged compared to prior CT in [**2138**]. There is concern for possible HCC and it is recommended he has follow-up as an outpatient. #. Supratherapeutic INR/h/o PE/DVT: Pt with PE 2-3 years ago. INR was supratherapeutic in house and patient was discharged with INR of 4.1 with plan to hold coumadin until INR could be rechecked in 2 days. . # h/o A-fib: Continued anticoagulation and rate control with metoprolol. . # PPX: PPI, coumadin, lactulose . # CONTACT: [**Name (NI) **] (sister and HCP) [**Telephone/Fax (1) 79778**] Medications on Admission: 1. Amlodipine 5 mg Tablet PO DAILY 2. Hydrochlorothiazide 25 mg PO once 3. Lactulose Thirty ML PO Q4H 4. Lisinopril 2.55 mg PO DAILY 5. Metoprolol Succinate 12.5 mg 6. Omeprazole 20 mg PO daily 7. Rifaximin 400 mg PO TID 8. Warfarin 9. Multivitamin 10. Caltrate 600 600 mg (1,500 mg) PO daily 11. Ergocalciferol (Vitamin D2) Oral Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 3. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q4H (every 4 hours). 4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO once a day. 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 8. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 9. Warfarin 1 mg Tablet Sig: as directed Tablet PO once a day: please do not resume until you have INR checked on [**6-29**] abd discuss with your PCP. 10. Caltrate 600 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO twice a day. 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* 12. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Hepatic encephalopathy Discharge Condition: Stable, alert and oriented to person, place and time, afebrile Discharge Instructions: You were admitted to the hospital with confusion. We think that this was due to your chronic liver disease. We treated you with lactulose and your confusion resolved. Your INR level was elevated (4.1) and we held your coumadin. You should continue to hold this until monday and get your INR checked. Discuss the timing of restarting your coumadin with your PCP. No changes were made to your medications. Please call your doctor or go to the ER if you have worsening confusion, shortness of breath, severe abdominal pain, chest pain, weight gain >2 pounds in one day. You should adhere to a fluid-restricted diet. You should not take in > 2L of fluid in one day. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 2L Followup Instructions: Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2139-7-27**] 10:00 Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2139-7-27**] 10:00 Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4506**] NP/DR [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2139-7-27**] 11:15 . Please follow up with your PCP and Dr. [**Last Name (STitle) 497**] next week. Completed by:[**2139-6-30**]

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icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

9553, 9604

6023, 6036

307, 334

9671, 9736

3794, 6000

10577, 11126

3122, 3279

8386, 9530

9625, 9650

8028, 8363

9760, 10554

3294, 3775

264, 269

362, 1938

6051, 8002

1960, 2641

2657, 3106

11,487

126,809

16466

Discharge summary

report

Admission Date: [**2200-11-25**] Discharge Date: [**2200-11-28**] Date of Birth: Sex: Service: PLEASE NOTE: The projected date of discharge is [**2200-11-29**]. HISTORY OF THE PRESENT ILLNESS: The patient is an 87-year-old lady with a history of dementia and hypertension who presented with a basal ganglia bleed. According to the patient, she has been living at [**Hospital1 **] [**Location (un) **] [**Hospital3 **] for the past year. Her family states that she cannot take care of herself. She has a long history of gait imbalance and falling backwards. Yesterday, she fell once while she was with her son. On [**Holiday 1451**] she fell while putting clothing in the drawer. Yesterday, she fell after hanging up her coat and then turning around. Each time she could not get up on her own because she states that she was weak and unsteady. She was sent to [**Hospital3 2063**] in the morning and told the staff at [**Hospital1 **] about her fall. The staff at [**Hospital1 **] have no further details about her falls or gait imbalance. PAST MEDICAL HISTORY: 1. Dementia. 2. Hypertension. 3. History of prior stroke, details unknown, the patient denied. ADMISSION MEDICATIONS: 1. Aspirin. 2. Plavix. 3. Atican. 4. Detrol. 5. Toprol. 6. Aricept. 7. Prilosec. 8. Quinine. SOCIAL HISTORY: She lives in the [**Hospital1 **] [**Location (un) **] [**Hospital3 **]. She walks without assistance but is unsteady, as stated. She is otherwise independent in her activities of essential living. She denied smoking or drinking alcohol. PHYSICAL EXAMINATION ON ADMISSION: On physical examination, the blood pressure was 212/80, heart rate 84, respiratory rate 18. The patient appeared comfortable. The oropharynx was clear. There were no carotid bruits. There was no JVD. No thyromegaly. The cardiac examination was notable for a regular rate and rhythm. The chest was clear to auscultation. The abdomen was benign. No clubbing, cyanosis or edema of the extremities. There was periorbital ecchymoses in different stages of blood product breakdown. On the neurological examination, on mental status, the patient was awake, alert, and oriented times three. She was slow in the month, year backwards and stopped midway. Language testing demonstrated normal naming of high and low frequency, objects and good repetition. Normal fluency and comprehension. The patient could read and write sentences to dictation. She remember me 30 minutes later. Formal memory testing was not performed. The cranial nerves revealed that the optic disks were normal. Pupils were equal, round, and reactive to light. The extraocular muscles were intact. Visual fields were full to confrontation, [**4-23**] through [**4-25**] were intact to light touch and to pinprick. There was a subtle left facial droop. The tongue, palate, and sternocleidomastoid moved symmetrically. Hearing was intact to finger rub bilaterally. On motor examination, she had no drift or asterixis. She has a mild left hemiparesis of the arms. She has symmetrical give-way weakness of the legs. Sensory examination revealed light touch, pinprick, and joint position sense were normal. Reflexes: Biceps, triceps, brachial, patella, ankle, and plantar were 2 throughout. Her toes are upgoing bilaterally. Coordination, finger-to-nose, rapid alternating movements, and fast finger movements were normal. Gait was slow and cautious, but steady and she did not fall. LABORATORY DATA/OTHER STUDIES: A CT showed a right basal ganglia bleed, around 40 cc, impinging on the lateral ventricle without extension, shift, or evidence of hydrocephalus. There was also an old area of encephalomalacia in the right occipital and temporal lobes. HOSPITAL COURSE: The patient was admitted to the Neurology Service. She was restarted on her outpatient medications with the exception of aspirin and Plavix which were discontinued because of her hemorrhage. She had blood pressures in the 170-210 range and, therefore, was started on Norvasc 5 mg p.o. q.d. to be titrated up. The etiology of her intracerebral hemorrhage is presumed to be hypertensive and Norvasc was felt to be the best [**Doctor Last Name 360**] to control her hypertension. The patient had minimal deficits by hospital day number two and was seen by Physical Therapy who recommended that she could be discharged back to her [**Hospital3 **] facility. The patient will be discharged back on [**2200-11-29**]. DISCHARGE DIAGNOSIS: 1. Right basal ganglia hemorrhage. 2. Hypertension. 3. History of prior stroke. 4. Dementia. MEDICATIONS ON DISCHARGE: 1. Atican 32 mg p.o. q.d. 2. Protonix 40 mg p.o. q.d. 3. Toprol 25 mg p.o. q.d. 4. Multivitamin one capsule p.o. q.d. 5. Aricept 10 mg p.o. q.h.s. 6. Lipitor 10 mg p.o. q.d. 7. Norvasc 5 mg p.o. q.d. FOLLOW-UP: The patient will follow-up with me, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1206**], [**Telephone/Fax (1) 46808**], for Neurology as an outpatient. [**Doctor Last Name **] [**Name8 (MD) 8346**], M.D. [**MD Number(1) **] Dictated By:[**Last Name (NamePattern1) 5476**] MEDQUIST36 D: [**2200-11-28**] 17:08 T: [**2200-12-2**] 21:05 JOB#: [**Job Number 46809**]

[ "599.0", "E947.8", "294.8", "780.2", "431", "401.9", "719.45", "244.9", "781.2" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

4511, 4609

4635, 5278

3774, 4490

1220, 1322

1617, 3756

1098, 1197

1339, 1602

23,888

108,085

44028

Discharge summary

report

Admission Date: [**2123-4-18**] Discharge Date: [**2123-5-5**] Date of Birth: [**2061-3-8**] Sex: F Service: HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is an unfortunate 62 year old female with a past medical history significant for insulin dependent diabetes mellitus, chronic obstructive pulmonary disease, chronic renal insufficiency, coronary artery disease. History of left breast cancer. B-cell lymphatic lymphoma. Gastroesophageal reflux disease. Deep vein thrombosis and peripheral vascular disease. She presented with a several week history of increased abdominal pain, mild nausea, decreased appetite and ultimately presented with painless jaundice. She was admitted to the hospital on [**2123-4-18**]. She underwent a CT scan of the abdomen on [**2123-4-20**], after a failed attempt at endoscopic retrograde cholangiopancreatography, secondary to a duodenal stenosis. CT scan showed evidence of upstream dilatation of both the pancreatic duct and marked dilatation of the common bile duct, as well as a 3.3 by 3.3 cm mass in the head of the pancreas. There were multiple small lymph nodes seen adjacent to the pancreatic head. The mass, by CT criteria, extended up to but did not frankly invade the duodenum. After this scan was performed, and the information obtained, she underwent a percutaneous transhepatic cholangiogram with Dr. [**Last Name (STitle) 94542**] under the care of the Interventional Radiology Service. This procedure confirmed the CT findings of markedly dilated bilateral hepatic ducts and common bile duct, with a high grade obstruction at the level of the distal common bile duct. They successfully placed an #8 French internal and external biliary drain across that common bile duct lesion and placed her bag to drainage. drainage. Given her CT angiogram with pancreatic protocol, showing that there was no evidence of anatomic unresectability, it was felt that the patient would benefit from percutaneous transhepatic catheter drainage and preoperative optimization for ultimate Whipple procedure. The remainder of her hospital course will be described in the body of this dictation. PAST MEDICAL HISTORY: This patient suffers from: 1. Chronic obstructive pulmonary disease. 2. Chronic renal insufficiency with a baseline creatinine between 1.5 and 2. 3. Coronary artery disease. 4. Insulin dependent diabetes mellitus. 5. Psoriasis. 6. Depression. 7. History of left breast cancer. 8. History of an ovarian mass. 9. History of stage 3-B B-cell lymphoma. 10. History of gastroesophageal reflux disease. 11. History of deep vein thrombosis. 12. Hospital course of peripheral vascular disease. PAST SURGICAL HISTORY: 1. Status post bilateral mastectomy. 2. Status post laparotomy and oophorectomy. ALLERGIES: Morphine. OUTPATIENT MEDICATIONS: Not available at the time of this discharge summary. FAMILY HISTORY: Unremarkable. Negative for any hypertension or coronary artery disease. There may have been a history of pancreatic disease in her husband; however, this was not a genetic relative. REVIEW OF SYSTEMS: She had a 15 to 20 pound weight loss, up until the timing of her admission on [**2123-4-18**]. She had a several week history of intermittent abdominal pain and jaundice. PHYSICAL EXAMINATION: Notable for being afebrile; vital signs stable. She was in mild distress and complaining of abdominal pain. She was obviously jaundiced in her sclera and skin. She was otherwise normal cephalic, atraumatic. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements intact. 4 to 2 and brisk bilaterally. Trachea was midline. Oropharynx was negative. Chest was clear, decreased breath sounds with occasional expiratory wheezing. heart was regular without murmur. Abdomen was soft, nondistended, slightly tender in the right upper quadrant and periumbilical region. No peritoneal signs noted. No [**Doctor Last Name **]-[**Doctor Last Name 27210**] or [**Doctor Last Name **] signs noted. She had no hernia. Previous incision of the midline abdomen was noted and well healed without evidence of herniation. Distal extremity pulses were intact bilaterally. She had normal capillary refill. Rectal examination was guaiac negative. LABORATORY DATA: Hematocrit of 33. Platelet count 380. INR of 0.9. Serum chemistries notable for sodium of 132; potassium of 3.5; chloride 97; bicarbonate of 26; BUN and creatinine of 15 and 0.6 with a serum glucose of 264. AST was 84; ALT 92; alkaline phosphatase 755; amylase 78; total bilirubin was 21.2; lipase was 487; calcium 9.8; phosphorus of 2.6; magnesium of 1.7. CEA level was 14. CA-99 level was 14,469 with a normal reference range of 0 to 37 units per ml. Admission stress test showed no evidence of anginal symptoms or ischemic ST segment changes. She underwent a Persantine MIBI scan on [**2123-4-22**] which showed no evidence of myocardial perfusion defects in the presence of diaphragmatic attenuation. Her ejection fraction by Persantine MIBI was estimated to be 58%. The remainder of the [**Hospital 228**] hospital course, after these initial diagnostic and therapeutic radiographic studies were performed, was notable for having a nutrition consult, getting supplemental nutrition enterally and parenterally. She ultimately waxed and waned on the floor, to the point that on [**2123-5-4**], she precipitously worsened to the point of having severe abdominal pain, tachycardia and hypotension. She was immediately transferred to the Intensive Care Unit. Additionally, at this time, she was experiencing mental status changes. All of these factors necessitated the patient to be intubated for airway protection and for ventilatory support. A pulmonary artery catheter was inserted showing very low filling pressures in the setting of hyperdynamic physiology, confirming the likely suspicion that the patient was now septic. Her abdominal examination was notable for having some diffuse guarding and rebound. Laboratory studies at this time showed a rising white count into the 20+ thousand range. Her hematocrit was otherwise stable. Her coagulation studies were notable for an INR of 1.4. Her serum creatinine was otherwise unchanged. Her white count was peaked at 31,000. Hematocrit was 34. Platelets were 575 and her INR was 1.4. Initially, it was as high as 1.9 on the evening of [**2123-5-4**]. Creatinine was .4. The remainder of her electrolytes were within normal limits. Serum glucose was 180. Alkaline phosphatase was mildly elevated at 462, which was trending up. Her initial alkaline phosphatase went higher; however, post PTC, her liver function tests improved until this acute decompensation. She underwent a repeat CT scan of the abdomen, showing diffuse ascites and some thickening in the area of the porta. The pancreatic mass looked unchanged. There was a small amount of free air that was thought to be secondary to her PTC catheter insertion done back on the 22nd. The patient was placed on broad spectrum antibiotics, including Zosyn and Fluconazole. She was pan cultured and supported with Crystalloid effusion. She had Vasopressor dependent shock, necessitating augmentation with Vasopressin and Levophed to maintain her mean arterial pressure greater than 60. She had a massive ongoing fluid requirement and, after discussion with Dr. [**Last Name (STitle) 468**], the patient's family decided to bring the patient to the operating room, with presumed diagnosis of possible bile peritonitis and cholangitis. The patient was started on antifungal therapy for [**Female First Name (un) **] albicans which grew out from her bio clusters from [**2123-5-3**]. Additionally, she was continued on Bactrim, which was started on [**2123-4-28**], after a positive urine culture had shown Citrobacter fungi. The patient was taken to the operating room in critical and guarded condition. She underwent a laparotomy which revealed several liters of gross bile within her peritoneal cavity. After a wash-out and exploration, it was determined that the patient had a serial and proximal pyloric blow-out. It was unclear if this was secondary to an ulcer or likely secondary to her malignancy. A [**Doctor Last Name **]-hard mass was felt in the head of the pancreas. This was felt to be a sentinel event, somewhat grave situation. The patient had a very, very poor outcome, even in the best case scenario. With this insult added, the undue amount of morbidity and mortality to this patient's overall clinical outlook, and after direct conversation with the [**Hospital 228**] health care proxy, [**Name (NI) **] [**Known lastname **], the patient's daughter, Dr. [**Last Name (STitle) 468**] abided by their wishes to make the patient DNI/DNR and CMO. The patient's abdomen was, thereafter, closed. She was brought back to the Intensive Care Unit, intubated. Support was withdrawn and she was made comfort measures only. Within two hours of leaving the operating room, she was pronounced dead by Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]. The patient's family was, thereafter, notified. [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**] Dictated By:[**Last Name (NamePattern4) 3204**] MEDQUIST36 D: [**2123-5-5**] 04:53 T: [**2123-5-5**] 05:18 JOB#: [**Job Number 94543**] cc:[**Last Name (un) 94544**]

[ "567.2", "112.5", "569.83", "537.0", "567.8", "785.52", "995.92", "157.0", "518.81" ]

icd9cm

[ [ [] ] ]

[ "52.12", "97.05", "44.22", "38.93", "51.98", "89.64", "87.54", "99.15" ]

icd9pcs

[ [ [] ] ]

2912, 3097

2709, 2816

2841, 2895

3313, 9446

3117, 3290

158, 2167

2190, 2686

56,449

142,675

45041

Discharge summary

report

Admission Date: [**2163-2-9**] Discharge Date: [**2163-2-14**] Service: NEUROLOGY Allergies: lisinopril Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: Left sided eye deviation, gibberish words Major Surgical or Invasive Procedure: None History of Present Illness: The pt is a [**Age over 90 **] y/o woman with a history of AD, HTN, CAD s/p CABG, a-fib with AICD presented as a code stroke. Normally she is able to ambulate with a walker and talks and interacts normally. She was seen normal 2 hours before presentation, was found about 30 minutes before EMS arrival with speech disturbance and left gaze deviation. She was taken to [**Hospital1 18**] ED for further care. In the ED she came in and was aphasic, no intelligible words came out. She had spontaneous speech output but it was all gibberish. Did not answer with head nods to questions. Past Medical History: A-fib CAD s/p CABG with AICD DM Prior CVA Dementia Social History: The patient has been at [**Hospital 100**] Rehab for the past three years. She has a remote history of smoking, but does not currently smoke. In the last month, she has difficulty recognizing her family's names and faces. She walks with a walker. She is not oriented to place or time. Family History: Unknown Physical Exam: On Admission: Vitals: T: P:60 R: 20 BP:100/54 SaO2:100 General: Aweyes open, minor distress. HEENT: MMM. Neck: no LAD. Pulmonary: Lungs CTA bilaterally frontal fields Cardiac: RRR Abdomen: soft. Extremities: No edema has right shin superficial ulcer and right foot fungating ulcer. Neurologic: -Mental Status: Alert, Aphasic (global) only followed command to close eyes. Left gaze deviation, not tracking, did not try to force to other side with dolls. Pupils surgical/ reactive. fight facial droop. Arms antigravity bilaterally, no clear asymmetry noted. Legs were flexed at the knee. Drifted down. Said "[**Last Name (un) **]" to pinch in all four extremities. Toes upgoing. Reflexes grade 2 at arms. At discharge: Neuro: awake, alert. oriented to last name inconsistently. Speaks in [**1-14**] word phrases. Follows midline but not appendicular commands inconsistently. Left gaze preference with suspician of some right sided mild neglect. Moves right side with full strength. 4/5 weakness at the left deltoid and tricep although formal strength testing is difficult. Moves all extremities > [**3-14**]. Pertinent Results: Admission Labs: [**2163-2-9**] 12:00PM BLOOD WBC-8.9 RBC-3.67* Hgb-9.0* Hct-28.2* MCV-77* MCH-24.4* MCHC-31.9 RDW-15.2 Plt Ct-245 [**2163-2-9**] 12:00PM BLOOD PT-12.6* PTT-30.3 INR(PT)-1.2* [**2163-2-9**] 12:00PM BLOOD Fibrino-440* [**2163-2-9**] 12:00PM BLOOD UreaN-15 Creat-0.8 Na-131* K-4.8 Cl-96 HCO3-27 AnGap-13 [**2163-2-10**] 02:10AM BLOOD ALT-12 AST-14 [**2163-2-10**] 02:10AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.7 Cholest-131 [**2163-2-9**] 12:00PM BLOOD cTropnT-<0.01 [**2163-2-10**] 02:10AM BLOOD %HbA1c-8.4* eAG-194* [**2163-2-10**] 02:10AM BLOOD Triglyc-92 HDL-48 CHOL/HD-2.7 LDLcalc-65 [**2163-2-10**] 02:10AM BLOOD TSH-2.3 [**2163-2-9**] 01:00PM URINE Blood-MOD Nitrite-NEG Protein-600 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.5 Leuks-LG [**2163-2-9**] 01:00PM URINE RBC-37* WBC->182* Bacteri-MANY Yeast-NONE Epi-0 [**2163-2-9**] 01:00PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.031 Microbiology: [**2163-2-9**] 12:00 pm BLOOD CULTURE 1 OF 2. Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. [**2163-2-9**] Urine Culture: URINE CULTURE (Final [**2163-2-10**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. [**2163-2-9**] CT/CTA head/neck and CTP: 1. Evidence of acute infarction in the left temporal-occiptial region, without hemorrhagic conversion. 2. Relatively [**Name2 (NI) 15403**] region of "ischemic penumbra." 3. Significant atherosclerotic disease and irregular "soft" and calcified plaque in both internal carotid arteries with at least 70% diameter stenosis on the left, and 20% diameter stenosis on the right. 4. Medialization of the internal carotids. 5. Patent cerebral vasculature without acute occlusion. 6. Evidence of mild CHF, with cardiac pacemaker device, incompletely imaged. 7. Moderate-to-severe degenerative changes of the cervical spine, most severe at the C4 through C7 level. 8. Nodularity of the thyroid gland; if warranted on clinical grounds (in this [**Age over 90 **] year-old patient), this could be better evaluated by ultrasound. CXR [**2163-2-9**]: Single AP upright portable view of the chest was obtained. A dual-lead right-sided pacemaker is seen with leads extending to the expected positions of the right atrium and right ventricle. The cardiac silhouette is mildly enlarged. There appears to be a left pericardial fat pad. Small bilateral pleural effusions are likely present. There is mild edema. Patient is status post median sternotomy and CABG. NCHCT [**2163-2-10**]: No hemorrhagic conversion. Unchanged appearance of low attenuation areas in the left temporo-occipital region consistent with a left MCA infarct. CXR [**2163-2-10**]: The left-sided pacemaker leads terminate in the expected location of right atrium and right ventricle. Cardiomegaly is moderate to severe. There is prominence of bilateral hila, most likely reflecting enlarged pulmonary arteries and might be consistent with pulmonary hypertension. The patient is in moderate interstitial pulmonary edema. Infectious process can be obscured and should be again reassessed after diuresis. Small bilateral pleural effusions are most likely present. ... Brief Hospital Course: Ms. [**Known lastname **] was admitted to the Neurointensive care unit for close neuro-monitoring following an infusion of TPA for a left MCA stroke. TPA was infused at approximately 1245PM on [**2163-2-9**]. She is a [**Age over 90 **]yo W with a history of atrial fibrillation s/p AICD placement, CAD s/p CABG, presumed Alzheimer's dementia, old right occipital ischemic stroke and HTN who presented as a code stroke. She was found about 30 minutes before EMS arrival with speech disturbance and left gaze deviation. She was taken to [**Hospital1 18**] ED for further care. In the ED she came in and was aphasic, no intelligible words came out. She had spontaneous speech output but it was all gibberish. Did not answer with head nods to questions. On examination, she was awake, alert and globally aphasic with a strong left gaze deviation without crossing midline. All four extremities withdrew to pain and she had no obvious right hemiparesis. She was seen by the ED Neurology resident and received a CTA head/neck as well as CTP, the results of which are summarized below. After the risks and benefits of TPA were explained to the patient's son, consent was obtained and the patient did receive TPA. She was noted to have a fungating mass on her right foot which was noted to ooze slightly following the infusion of TPA. This was treated with local lidocaine/epinephrine injections and tight dressings. Following TPA administration, she was noted to have a slight improvement in her gaze palsy. She was admitted with standard post TPA protocol orders pertaining to q1hr neuro checks, blood pressure management, HOB angle and instructions for a stat head CT in the setting that her examination worsened. Overnight, there were no acute events. She remained afebrile and hemodynamically stable. She did not require additional labetalol for blood pressure control, and did require some continuous IV fluids. The overnight RN noted that she did reliably stick her tongue out, but that was the only command that she followed. She did require some two point soft wrist restraints as she had a tendency to pull at her lines/tubes. She was started on ciprofloxacin for a dirty UA that was noted on admission, urine cultures showed fecal contamination. She did receive a follow up NCHCT which revealed no hemorrhage and stable left MCA hypodensity. Given her continued hemodynamic and neurologic stability, she was transferred to the floor out of the ICU for continued care. Her family was updated in the ICU. Given the presence of diffuse soft plaque in bilateral carotid arteries (left>right), she was ordered for a heparin drip. Upon arrival to the floor, she became agitated and pulled out her lines and foley catheter. Bilateral soft wrist restraints were placed and in the absence of IV access, the patient received lovenox for anticoagulation. Routine blood cultures revealed the presence of gram positive organisms (1/4 bottles, aerobic) and therefore, the patient was started on IV vancomycin. The vancomycin was stopped on [**1-13**] as only 1 of 4 bottles grew bacteria, which was thought to be a contaminant. During her stay, she continued to have bleeding from the SCC on her foot, for which radiation oncology was consulted. A family meeting was held, and it was decided there would be no intervention on the foot, and that she would be switched from lovenox to Aspirin 325 mg, to reduce her bleeding from her foot. Simvastatin 40mg po daily was also started for its anti-inflammatory properties and secondary stroke risk reduction. Her neurological exam remained unchanged on the floor and she was discharged to [**Hospital 100**] Rehab. Medications on Admission: INsulin NPH 22 QAM Tums 1300mg daily Tylenol PRN Lexapro 10mg daily Brimonidine tartrate 0.2% Daily both eyes 1 gtt Timolol 1 gtt 0.5% daily both eyes Prilosec 20 mg daily Lasix 10mg po daily Seroquel 12.5mg QHS Cozzar 12.5mg daily Metoprolol tartraate 37.5mg po BID Discharge Medications: 1. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 2. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. NPH insulin human recomb 100 unit/mL Suspension Sig: Twenty Two (22) units Subcutaneous qAM. 8. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. furosemide 20 mg Tablet Sig: 0.5 Tablet PO once a day. 10. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO twice a day. 11. Cozaar 25 mg Tablet Sig: 0.5 Tablet PO once a day. 12. Tums 200 mg calcium (500 mg) Tablet, Chewable Sig: Two (2) Tablet, Chewable PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Left MCA stroke History of ischemic stroke Atrial fibrillation Type II Diabetes Mellitus Alzheimer's dementia Discharge Condition: Mental Status: Confused, aphasic at times Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Neuro: awake, alert. oriented to last name inconsistently. Speaks in [**1-14**] word phrases. Follows midline but not appendicular commands inconsistently. Left gaze preference with suspician of some right sided mild neglect. Moves right side with full strength. 4/5 weakness at the left deltoid and tricep although formal strength testing is difficult. Moves all extremities > [**3-14**]. Discharge Instructions: Dear Ms. [**Known lastname **], It was a pleasure taking care of you during this hospitalization. You were admitted to the Neurology wards and the Neuro-intensive care unit of the [**Hospital1 827**] to investigate the cause for some new symptoms of leftward deviation of your eyes and difficulty speaking and understanding language. Through a series of physical examinations, neuroimaging studies and laboratory investigations, we determined that you suffered a stroke in the left part of your brain that is involved in understanding and producing language. For these symptoms, you received TPA (tissue plasminogen activator), a clot-busting [**Doctor Last Name 360**] that can often help with symptoms of an acute stroke. You were briefly monitored in the ICU, following which you were transferred to the floor. The images of your blood vessels show a soft plaque in the left carotid that is likely the source of your stroke. On the floor we continued you on a blood thinner for a few days. Given that you have had trouble with bleeding from the squamous cell carcinoma on your right foot, we spoke with your outpatient dermatologist, the plastic surgery consult team, and the radiation oncology consult service about this. The only possible noninvasive option to help with this would be 15-20 sessions with the radiation oncologists to help stop the bleeding. After discussion with your family, it is thought that returning for these sessions would be too disruptive to complete. Therefore we will hold off on full blood thinners and continue on aspirin. Please continue to take aspirin 325mg by mouth daily to help prevent future strokes. We also started a medication, simvastatin 40mg by mouth daily. This is to decrease inflammation and to help decrease your risk for future strokes. Medications started: aspirin 325mg by mouth daily simvastatin 40mg by mouth daily Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in the [**Hospital1 18**] stroke neurology clinic. This is located on the [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Bldg, [**Location (un) **]. We have made an appointment for you: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2163-4-15**] 1:00pm

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Discharge summary

report

Admission Date: [**2187-12-2**] Discharge Date: [**2187-12-12**] Service: MEDICINE Allergies: Penicillins / Lasix / Erythromycin Base Attending:[**First Name3 (LF) 30**] Chief Complaint: L-anterior CP; hypotension Major Surgical or Invasive Procedure: none History of Present Illness: 89F from [**Hospital3 **] with L ant CP [**4-2**] worse w/ deep inspiration, + nausea/emesis, no diaphoresis. Duration of CP x1 hour. Brought in per EMS, EKG difficult to interpret, LBBB HR 80s-paced, initial CE negative x1. Was unable to give any Nitrates or morphine due to low SBP. CP resolved w/o any medications or interventions. She was given ASA 325x1, CTA done to r/o PE, which was negative. Pt stated that she has been having trouble swallowing x1-2 weeks due to nausea and inability to swallow. She's had poor PO intake since then, with some fluid intake and weight loss. She has no idea why she can't swallow and is frustrated by this. Of note, she had a recent admission to [**Hospital6 4287**] where she was found to have oral thrush and was presumed to have oropharyngeal [**Female First Name (un) **]; a barium swallow was normal. Has also had diarrhea for several days. . ED course: Initial VS T 100.8 Rectally, HR 80-paced, BP 95/56 then dropped to 88/44 MAP 60; RR 13 95%RA. Received 1.7 LNS w/improvement in her SBP. Attempt at placing R and L-IJ unsuccessful, unable to pass guidewire. Successfully placed R-femoral line. Pt also noted to be guaiac + w/brown stools, also noted to have Bright Red Blood in vaginal vault. ? prolapsed uterus. Given increased INR did not proceed w/vaginal exam w/speculum due to ?friable bleeding tissue. CT chest/abd/pelvis done. She received Levo/Vanco/Flagyl. . Of note this is her 3rd hospitalization in 1month. 1st hospitalization at [**Hospital3 2568**] Hosp-Kidney stones s/p stent. 2nd hospitalization at [**Hospital1 96085**], Bacteremia, unclear about [**Name (NI) **] and duration. At her baseline A&Ox3, bed bound per [**Hospital3 **] staff. Uses diapers not due to incontinence but b/c bedbound. Staff at [**Hospital3 **] denied documentation of BRBPR or blood in stool or vagina. She's had a swallow study/barium study-->report not in record at [**Location (un) **]. . On review of systems, the pt. denied recent fever or chills. +HA, No vision changes. Hard of hearing R-ear. Denied cough, shortness of breath. Chest pain-resolved, no palpitations. +N/V x1-2 weeks, no abdominal pain. No dysuria. She's unsure whether she's had blood from below-rectally or vaginally. Denied arthralgias or myalgias. Per niece has had ~50pound weight loss this year. Past Medical History: -shingles w/post herpetic neuralgia CN V involvement on R side of face -R hearing loss -dementia -arthritis -gallstones -pneumonia -chronic eosinophilia -CAD s/p MI -CHF ?EF -s/p pacemaker -atrial fibrillation on coumadin -history of varicose veins -bilateral cataracts -PVD w/peripheral venous stasis skin changes Family History: Notable for brothers with atrial fibrillation and a father who died at age 60 secondary to rectal carcinoma. Physical Exam: Vitals: T: 98.8 HR 80-paced BP: 89/51 SaO2: 100%RA General: Awake, alert, speaking in full sentences, NAD. HEENT: PERRL, EOMI without nystagmus, no scleral icterus noted, dry MM, Cracked tongue w/white exudates on posterior palate, significant tenderness on R side of face-midline from forehead/chin/neck and R shoulder-CN V distribution, no erythema or lesions on face Pulmonary: Lungs CTA bilaterally anteriorly Cardiac: regular, Nml S1,S2, 2/6 SEM at LUSB Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, [**12-25**]+ DP pulses b/l, chronic vascular venous stasis changes Skin: no rashes or lesions noted, mild skin breakdown in rectal area Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. -cranial nerves: II-XII intact, CNV noted above -motor: normal bulk, strength and tone throughout. No abnormal movements noted. Pertinent Results: GLUCOSE-72 UREA N-27* CREAT-1.1 SODIUM-137 POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-19* ANION GAP-14 CK(CPK)-45 CK-MB-NotDone cTropnT-<0.01 CALCIUM-7.4* PHOSPHATE-2.8 MAGNESIUM-1.7 HCT-29.5* LACTATE-1.0 K+-4.4 URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009 URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD; URINE RBC-[**2-25**]* WBC-21-50* BACTERIA-OCC YEAST-NONE EPI-0-2 GLUCOSE-85 UREA N-32* CREAT-1.4* SODIUM-135 POTASSIUM-5.2* CHLORIDE-102 TOTAL CO2-22 ANION GAP-16 CK(CPK)-51, cTropnT-<0.01, CK-MB-NotDone, WBC-11.0# RBC-3.79* HGB-11.3* HCT-33.7* MCV-89 MCH-29.9 MCHC-33.6 RDW-15.1, NEUTS-84.6* LYMPHS-6.5* MONOS-4.4 EOS-4.3* BASOS-0.2, PLT COUNT-392, PT-20.9* PTT-35.2* INR(PT)-2.0* . CT chest/abdomen/pelvis [**2187-12-3**]: 1. No evidence of pulmonary embolism. 2. Bilateral small pleural effusion and associated atelectasis. 3. Severe coronary artery calcifications. 4. Multiple hypoattenuating lesions in both kidneys, too small to characterize. 5. Dilatation of main pulmonary arteries suggestive of pulmonary hypertension. 6. Right ureteral stent. 7. Multiple prominent mesenteric lymph nodes, which do not meet size criteria for pathologic enlargement. 8. Large calcified uterine fibroids. . CXR [**2187-12-4**]: Mild pulmonary edema and small bilateral pleural effusions new since [**12-2**] are unchanged over two hours. There is no pneumothorax. No central venous line or drainage tube projects over the chest. A transvenous right ventricular pacer lead is unchanged in position and at least one nephrostomy tube is seen in the right upper quadrant. No pneumothorax. . ECHO [**2187-12-3**]: The left atrium is elongated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is dilated. Right ventricular systolic function is normal. The aortic root is moderately dilated. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-25**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. . KUB [**2187-12-9**]: The right double-J stent is again visualized. Calcified fibroids in the pelvis are again seen. Contrast is seen in nondistended colon. Small bowel loops are mildly dilated up to 3.5 cm. No air-fluid levels are seen. This most likely represents an ileus. Small bilateral effusions are present. Brief Hospital Course: Assessment and Plan: 89 yo F w/ h/o CAD s/p MI, pacer, CHF, AF, p/w hypotension, N/V and poor PO intake, improved with aggresive IVF, with likely candidal esophagitis contributing to poor PO contributing to hypotension, with clostridium difficile colitis. . 1 Hypotension: Pt has had poor PO intake x1-2 weeks (likely longer), nausea, vomitting, diarrhea as well. Hypotension most likely hypovolemic in nature. Pt w/some note of bright red blood in vaginal area in ED, however this may have been secondary to attempted line placement and her HCT remained stable. Cardiac etiology less likely despite chest pain, ECG unchanged here, cardiac enzymes negative x3 on admission. Sepsis was possible given elevated WBC on admission (now normal), source possible UTI though culture did not grow anything except yeast (not present in UA), no tachycardia but paced, lactate normal, blood cultures [**2187-12-2**] no growth x4. She was mentating normally, with good urine output. Diarrhea was noted prior to admission, no BM from admission thru [**12-7**], then diarrhea, c.difficile positive, may have been contributing to initial presentation. She was treated with 7 days of ciprofloxacin for potential urinary tract infection. She was started on oral flagyl for clostridium difficile infection and will need to complete a 14 day course. She was restarted on metoprololXL on [**12-11**] at 25mg by mouth which she is tolerating. This will need to be titrated up as she tolerates as an outpatient. . 2 Acidosis: Noted during her hosptial course, improved, non-gap, hyperchloremic ? secondary to IVF, will monitor. . 3 Dysphagia: Pt w/difficulty swallowing of unclear etiology, poor PO intake, possibley due to thrush, negative barium swallow at OSH. Has had intermittent improvement but now with nausea/vomitting. Suspected secondary to esophageal [**Female First Name (un) **] though possibly also due to ulceration. GI consulted on this hospitalization and recommended if no improvement with empiric therapy with fluconazole and pantoprazole would consider endoscopy but would favor trying to hold off on this in this medically complicated woman. Speech and swallow evaluation was done and they recommended her for thin liquids, pureed solids. Given low albumin (2.3) likley poor PO for months, c/w weight loss, cont. ensure TID. . 4 Vomitting: This has been present intermittantly during her hospital course. To further assess a KUB was done [**2187-12-9**] which showed small bowel dilation consistent with ileus. This improved on [**12-11**] though she may require further antiemetic therapy. . 5 C.difficile colitis: stool + for c.diff [**2187-12-9**] so she was placed on contact [**Name (NI) 39962**], she was started on 14 day course of po flagyl and diarrhea improved, at this time she was noted to have trace guaiac + stool, so was started on pantoprazole 40mg twice daily. . 6 Elevated INR: on coumadin for a.fib, started on cipro/fluconazole with significant elevation in INR, up to 7.3, s/p 1mg vitamin k IV, held coumadin [**12-5**], INR to 1.4, restarted coumadin [**12-6**], then held again [**12-8**] for potential EGD, now refusing EGD but INR 2.0 despite holding coumadin, will cont. to hold as 2.0 on flagyl, monitor INR closely. . 7 Anasarca: likely combined aggresive IVF (initially she recieved 14L IVF for hypotension) with low albumin, this has improved slowly since tranfer from the ICU to general medicine. She was restarted ethacrynic acid and tolerated that well. . 8 CAD s/p MI: She initially presented with chest pain that resolved with no recurrance, ECG unchanged, CE's neg x3. Aspirin held on admission out of concern for elevated INR but was restarted without incident. ECHO done [**12-3**] shows EF >55%. . 9 Atrial fibrillation: s/p pacer, on coumadin on admission, now subtheraputic, coumadin stopped [**2187-12-8**] in anticipation of procedure, yet INR up to 2.0 through [**2187-12-8**], possibly [**1-25**] flagyl, so this was held but should be restarted on 1mg po qhs and have this titrated to INR 2.0-3.0. . 10 Post herpetic neuralgia: controlled with topamax, oxycodone 5mg as needed, scheduled 2gm/24h tylenol with prn not to exceed 4gm/24h. . 12 Ppx: PPI, heparin sc pending increased inr, bowel regimen, first step mattress, no diapers, miconazole, OOB to chair. . 13 FEN: full liquids, soft (dysphagia), nutrition consult, replete lytes as needed . 14 Code Status: DNR/DNI, per HCP [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 96086**]; [**Hospital3 2558**] [**Telephone/Fax (1) 7233**] [**Location (un) **] Medications on Admission: -Tylenol 650mg PO prn -ASA 81mg daily -Calcium Carbonate 1500mg PO BID -Colace 100mg PO BID prn constipation -Toprol XL 50mg daily -Remeron 22.5mg PO qhs -Prilosec 20mg PO qAM -Oxycodone 5mg PO q6hr -MVI daily -Topamax 25mg PO qhs -viscous lidocaine2% TID prn -Vitamin D 400U po daily -Coumadin 3 mg qhs -Florastor -Ethacrynic acid -fluconozole 200MG POx4 days (day 1=[**12-1**]) -home O2--PM Discharge Medications: 1. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a day. 2. Florastor 250 mg Capsule Sig: One (1) Capsule PO twice a day. 3. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO once a day. 4. Lidocaine Viscous 2 % Solution Sig: [**12-25**] units Mucous membrane at bedtime as needed for pain. 5. Calcium 600 600 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for thrush. 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Maalox 200-200-20 mg/5 mL Suspension Sig: One (1) ML PO QID (4 times a day) as needed for heartburn. ML(s) 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 12. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-25**] Sprays Nasal QID (4 times a day) as needed for nasal congestion. 13. Topiramate 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 14. Mirtazapine 15 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 15. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 16. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for fever, pain: not to exceed 4 grams daily. 17. Ethacrynic Acid 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 19. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 11 days. 20. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 10 days. 21. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 22. Prochlorperazine 25 mg Suppository Sig: One (1) Suppository Rectal Q12H (every 12 hours) as needed for nausea. 23. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 24. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime: please adjust dose to INR 2.0-3.0. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Dysphagia, c.difficile colitis. . Shingles, post-herpetic neuralgia, R hearing loss, dementia, arthritis, gallstones, CAD s/p MI, s/p pacemaker, atrial fibrillation on coumadin, varicose veins, bilateral cataracts, PVD w/peripheral venous stasis skin changes Discharge Condition: Stable. Discharge Instructions: Please take all medications as prescribed and follow-up with your primary care physician. [**Name10 (NameIs) 357**] call your primary care doctor or return to the Emergency Department if you have fevers, chills, worsening of nausea, vomitting, abdominal pain, diarrhea, constipation, chest pain, shortness of breath or any symptoms that concern you. Followup Instructions: Please follow-up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] of your coumadin to INR 2.0-3.0. Please also follow with your primary care doctor for your c.difficile colitis and dysphagia.

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icd9cm

[ [ [] ] ]

[ "38.93", "00.17" ]

icd9pcs

[ [ [] ] ]

14030, 14100

6820, 11383

273, 279

14403, 14413

4059, 6797

14811, 15040

2982, 3092

11826, 14007

14121, 14382

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14437, 14788

3927, 4040

3107, 3831

207, 235

308, 2627

3846, 3910

2649, 2966

27,662

179,644

30950

Discharge summary

report

Admission Date: [**2125-8-9**] Discharge Date: [**2125-8-19**] Date of Birth: [**2069-9-23**] Sex: F Service: MEDICINE Allergies: Iodine; Iodine Containing Attending:[**First Name3 (LF) 2485**] Chief Complaint: Back pain, RUQ pain, dyspnea Major Surgical or Invasive Procedure: Right arterial line History of Present Illness: 55 yo F w/history of metastatic renal cell carcinoma in the setting of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21344**] Lindau syndrome presented to clinic [**8-8**] she appeared ill and complained of three weeks worsening right lower quadrant and back pain, nausea/vomiting, weakness, fatigue, and inability to rise from a chair. She reported a subjective 20lb weight loss. She also had two episodes of bladder incontinence during over the past two days. ED COURSE: Initial vitals 89/62, HR 60 SR an 97% on RA. BP inc to 110/72 after 1 liter NS bolus. she was found to have a K of 6.2 and a Ca of 13.3. For her hyperkalemia she was given 10 units insulin with 1 amp D50, 1 amp calcium gluconate, 30mg kayecelate. For her neurological symptoms, she was given 10 mg decadron and head CT, and thoracolumbar MRI were performed to rule out CNS involvement and cord compression respectively. A UA was also sent. Ms. [**Known lastname **] was then trasferred to the OMED service for further care. FLOOR COURSE: Ms. [**Known lastname **] arrived to the floor with a K of 6.2 and a Ca of 11.5. The patient was having difficulty with word finding and was very sleepy after receiving narcotics. History was therefore obtained from chart. Per these reports, she noted shortness of breath, dyspnea with exertion preventing her from carrying out activities of daily living, diffuse body aches, diarrhea and fecal incontinence. . Given the incontinence and thoracic pain, she had a neurologic work up for ?cord compression, and subsequently an c, t, l spine MRI which was notable for metastatic disease diffusely and evidence of epidural disease at the L5 vertebral body level, but no compression. The patient received lasix, insulin, glucose and bicarb as well as kayexalate for electrolyte management, and also received a total of 3L of NS for acute pancreatitis. Her total uop on the floor in response to the lasix was 720cc. She had a progressive O2 requirement with tachypnea and on the morning of transfer to the [**Hospital Unit Name 153**] was satting 93% on 5L by nasal cannula. She doesn't admit to increased shortness of breath overnight but notes that in general, her dyspnea has been worsening over the last few days. She complains of severe abdominal pain, and admits to LH. She denies chest pain, headache, weakness, but notes that she has severe chronic pain related to spinal metastasis. She was transferred to the [**Hospital Unit Name 153**] for hypoxia and volume management. Past Medical History: Past Oncological History: Initially presented at age 9 with vision changes secondary to hypertensive emergency. She was diagnosed with a pheochromocytoma and underwent left adrenalectomy. She underwent right adrenalectomy in [**2088**] after being diagnosed with a second pheochromocytoma. In [**2111**], she underwent a hysterectomy which was complicated by postoperative bleeding. An ultrasound noted renal cysts leading to a biopsy of the right kidney, which was reported as normal. She then did well until [**2120**] when she was diagnosed with an L2 vertebral hemangioma after presenting with back pain with radicular symptoms. One year prior, her daughter had been diagnosed with a brain tumor, which was likely a hemangioma, and through testing was found to have [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21344**]-Lindau disease. -Nexivar was discontinued in [**2125-5-29**] following progression of disease to her liver. She was seen at [**Hospital1 18**] [**2125-6-27**], and at that time options for treatment with Sutent vs enrollment in a trial on perifosine were discussed. She has remained off therapy and returned to [**Hospital1 18**] with anticipation of enrollment on perifosine. -In [**2121-5-29**], Ms. [**Known lastname **] developed left flank pain and hematuria. Left radical nephrectomy on [**2121-6-2**] revealed a polycystic kidney with five clear cell type renal cell carcinomas ranging in size from 0.6 cm to 9 cm. There was no tumor invasion of the renal capsule, perinephritic adipose tissue, or large renal veins, and margins were negative. No lymph nodes were recovered in the specimen. Her TNM stage was T2 Nx Mx. -Ms. [**Known lastname **] was subsequently followed with MRIs every six months. MRI in [**3-/2124**] was notable for polycystic kidney disease in the right kidney and gradually increasing size of a lesion in the caudate lobe of the liver. Biopsy of this liver lesion on [**2124-6-29**] revealed metastatic clear cell renal cell carcinoma. In [**2124-7-29**], she was started on sorafenib (Nexavar). Because of some confusion, she was taking 200 mg p.o. b.i.d. MRI on [**2125-4-11**] showed growth of the liver lesion to 6 cm. In addition, in the polycystic right kidney, there was a 5 cm mass with enhancement in the peripheral margins and septations, raising concern for a slowly growing cystic neoplasm. The patient went off Nexavar because of progression in the liver and the development of a probable new tumor in the remaining right kidney. . PRIOR TREATMENT: 1. Left adrenalectomy at age 9 and right adrenalectomy at age 18 for pheochromocytomas. 2. Left nephrectomy for renal cell carcinoma (5 independent tumors noted) in [**2121-5-29**]. 3. Biopsy-documented metastatic disease in the caudate lobe of the liver in [**2124-3-29**], after which the patient was started on sorafenib. 4. Development of progressive disease in the liver and a probable new renal primary (or metastases) in the right kidney in the setting of polycystic disease. . Past Medical History: Ms. [**Known lastname **] has never been officially diagnosed with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 21344**]-Lindau disease, but her daughter was diagnosed with it and her personal and family history makes us fairly certain that she has it. She also has hypertension. . Past Surgical History: - L nephrectomy [**5-31**] - Bilat adrenalectomy [**3-2**] pheochromocytoma - TAH/BSO for benign ovarian abnormalities, - appendectomy in [**2088**] - right knee surgery for a ligament tear - resection of a hemangioma in [**2121**]. Social History: -Lives with husband in [**State 2748**] - Remote tobacco use - No EtoH or drug use Family History: - Pt's daughter has been diagnosed with [**Name (NI) **] [**Last Name (NamePattern1) 21354**], she has a hx of benign brain tumors, pheochromocytomas, & bilateral renal cell carcinoma - A brother died from a brain tumor in [**2103**] - Her mother died of renal failure at age 47 - A sister was diagnosed in her late 40s with breast CA - Another sister has diabetes mellitus, diabetic nephropathy & is s/p renal transplant - A brother died of myocardial infarction at age 58 - Maternal grandmother had hx of kidney problems Physical Exam: Vitals: T 97 HR 84 BP 98/60 R 22 Sat 93% on 5L by nasal cannula Gen: 55 yo F, very pale, ill-appearing, round face, no obvious respiratory distress, no accessory muscle use. HEENT: conjunctival pallor, anicteric, PERRL/EOMI, MM dry, op clear. Neck: JVD flat, supple CV - RRR, no MRG Resp: CTAB with faint bibasilar rales ABD - hypoactive BS, with mild distention and marked tenderness to palpation diffusely, but especially in the epigastrium, no rebound/guarding. Skin - pale, dry but warm and well perfused. EXT - no c/c/e, tender to touch Neuro - sleepy but arousable to voice. oriented x 3. Nonfocal exam, but limited secondary to pain. Pertinent Results: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2125-8-17**] 04:05AM 37.3* 3.71* 8.9* 29.0* 78* 23.9* 30.5* 22.0* 178 [**2125-8-16**] 04:38AM 27.1* 3.54* 8.7* 27.3* 77* 24.7* 32.0 21.8* 211 [**2125-8-15**] 04:38AM 20.2*1 3.99* 9.5* 30.7* 77* 23.8* 30.9* 21.5* 270 . [**2125-8-11**] 05:00AM 15.1* 3.00* 6.4* 22.6* 75* 21.3* 28.3* 21.8* 363 [**2125-8-9**] 01:00PM 12.7* 3.14* 6.8* 24.2* 77* 21.6* 28.1* 21.5* 484* [**2125-8-8**] 01:35PM 9.1 3.27* 6.9* 24.5* 75* 21.0* 28.0* 21.7* 596* Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2125-8-17**] 04:05AM 121* 79* 2.1* 143 3.3 105 17* 24* [**2125-8-16**] 04:01PM 124* 72* 2.1* 138 3.1* 103 16* 22* [**2125-8-15**] 02:52PM 119* 73* 2.3* 139 3.2* 100 19* 23* [**2125-8-13**] 08:28PM 80 79* 3.0* 136 4.6 101 12* 28* . [**2125-8-10**] 05:15AM 119* 49* 2.1* 140 5.0 108 19* 18 [**2125-8-9**] 01:00PM 107* 48* 2.1* 135 6.7 107 17* 18 . Alb Calcium Phos Mg [**2125-8-17**] 04:05AM 1.9* 8.8 4.4 2.2 [**2125-8-14**] 07:58PM 10.0 6.2* 2.5 [**2125-8-11**] 05:00AM 2.3* 4.0* 3.5 1.6 [**2125-8-8**] 01:35PM 3.3* 13.3* 3.8 2.5 . ENZYMES & BILIRUBIN - ALT & AST remained WNL during admission - LDH increased from 120's to peak of 870, then was trending down prior to death - Alk Phos at 601 & Amylase was 1789 on admission & continued to trend down during admission to 169 & 78 respectively. . Lactate [**2125-8-17**] 09:05AM 1.6 . MICRO: URINE CULTURE (Final [**2125-8-13**]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. VANCOMYCIN SENSITIVITY CONFIRMED BY ETEST. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 2 S . BLOOD CULTURES X8-NGTD STOOL: C-DIFF X2-Negative VRE-Swab: negative . IMAGING: . Chest xray: - [**2125-8-16**]: Essentially unchanged chest radiograph with left atelectasis and pleural effusion. . - [**2125-8-15**]: AP chest compared to [**8-13**] through 17: Mild pulmonary edema is new. Left lower lobe atelectasis has worsened, and right infrahilar atelectasis is new. Moderate cardiac enlargement persists. Small left pleural effusion may be present, not changed appreciably. No pneumothorax. Nasogastric tube ends in the distal stomach. No pneumothorax. . - [**2125-8-8**]: 1. Enlarged cardiac silhouette. 2. No evidence of acute congestive heart failure or consolidation . CT HEAD: - [**2125-8-16**]: There is no significant interval change compared to prior examination from [**2125-8-8**]. However, due to motion artifact, the study is limited and a subtle lesion cannot be entirely excluded. . [**2125-8-8**]: 1. No acute abnormality including no intracranial hemorrhage is detected. 2. Although no obvious intracranial metastasis was identified, small isodense metastasis cannot be excluded on this non contrast study. MRI of the brain is recommended for further characterization. Small hypodense area in the right frontal [**Doctor Last Name 534**] might represent a metastasis although it is not a proper location for brain metastasis. . CT ABDOMEN & PELVIS: - [**2125-8-16**]: 1. Somewhat limited examination due to the lack of IV contrast however no evidence for abscess. Extensive phlegmon involving the peripancreatic soft tissues and the mesentery. 2. Liver metastases and bone metastases unchanged, pericardial effusion, left pleural effusion stable.3. Multiple cysts in the right kidney with complex lesion in the right lower pole unchanged. . - [**2125-8-9**]: 1. Compared to prior study, there is increased stranding surrounding the pancreas, tracking to the left paracolic space, with mild wall thickening seen in the descending colon. Findings are concerning for acute pancreatitis. . [**2125-8-13**] ECHOCARDIOGRAM: PERICARDIUM: Small pericardial effusion. Effusion echo dense, c/w blood, inflammation or other cellular elements. No RV diastolic collapse. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. Significant, accentuated respiratory variation in mitral/tricuspid valve inflows, c/w impaired ventricular filling. Left ventricular systolic function is hyperdynamic (EF>75%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. Small pericardial effusion without overt tamponade. . [**2125-8-13**] RUQ Ultrasound: 1. No evidence of cholelithiasis. A mildly distended gallbladder lumen with moderate amount of sludge is not uncommon in an ICU patient. If high clinical suspicion for acute cholecystitis, can consider correlation with HIDA scan. 2. Reidentification of known hepatic metastatic lesions and complex right renal cysts. Brief Hospital Course: A/P: 55 yo F with metastatic RCC in the setting of VHL who presented with acute pancreatitis from hypercalcemia, ARF, mental status changes, respiratory distress and significant back pain. . #. Respiratory Distress: Mild hypoxemia on 3L NC she was initially placed in a NRB and her O2 sats improved. In the setting of severe pancreatitis we were concerned about ARDS, however, she never required intubation for airway protection. Her CXRs on multiple occassions were clear without evidence of a consolidation. However, she remained hypoxic most likely caused by continued severe LLL atelectasis + small pleural/pericardial effusions, as well as a depressed mental status. She was not diuresed due to pancreatitis, her narcotic regimen was initially held to help improve her mental status, which did not clear. She remained on supplemental O2 throughout her hospital course and was not intubated. . #. Acute Renal Failure: Baseline creatinine unknown admitted with Cr 2.1, likely compromised by L nephrectomy thus single kidney with polycystic kidney disease in the setting of VHL, >5cm RCC mass in R kidney. Also in the setting of poor PO intake possibly pre-renal. - Continued anion gap metabolic acidosis likely due to chronic renal failure as pt had low lactate levels. - Multiple electrolyte abnormalities during admission including hyperphosphatemia & hypocalcemia requiring therapy; Initially admitted with hyperkalemia & hypercalcemia which resolved. She initially received one dose of Calcitonin on the floor which is possible cause of hypocalcemia. Another possibility of severe hypocalcemia was her pancreatitis. Repleted calcium IV with calcium drip. - Had required bicarbonate repletion, however this was discontinued as pt's bicarb levels improved. - The renal service was consulted, provided recommendations for therapy during admission. . #. Infection/inflammation w/increasing WBC and left shift - Had low grade fevers, however on steroids, at first stress dose then slowly titrated to down, however due to elevated WBC she was remained on stress dose levels. When pt was made CMO her steroids were d/c'd alltogether. - Known enterococcus UTI, not VRE colonized; unlikely source of infection. Other sources of infection included pancreatitis phlegmon & pneumonia/atelectasis. Abd CT showed large peripancreatic phelgmon with increased fat stranding likely resulting in considerable intra-abdominal inflammation. She was started on broad spectrum abx with vanco and zosyn, then switched to ampicillin for entoroccus UTI. Her Vanco was then switched to Meropenem for an abdominal source as noted below. All abx were d/c'd when pt made CMO as noted below. . #. Coagulopathy. likely from decreased nutritional status and antibiotics - INR improved from max 2.9 ->to 1.5 [**8-16**] after vitamin K x1. - Did not actively have any bleeding during admission, but there was concern especially given known hemangiomas. . #. Acute Pancreatitis: Potentially [**3-2**] cyst from VHL complex or metastasis. - Although admitted with elevated amylase, lipase, LDH & alk phos,ALT & AST remained nml. Initially pt was not given aggressive IVF due to her tenous respiratory status. Her T bili trended up to 4.4 on [**8-17**]. She had Increased fat stranding and phlegmon suggests inflammation and likely infection. Her pancreatitis was resolving but she had persistent abdominal pain with a very large 10cm liver mass. An U/S was done c/w biliary sludge, however no cholelithiasis. She was started on Meropenem for an intra-abdominal source of infection on [**8-17**]. Her pain was managed with dilaudid prn as her renal failure prevented use of morphine. However, Morphine drip was started when pt. was made CMO. . #. Cardiovascular dysfunction: -->Pump: Non-contributory pericardial effusion, but appears bloody/cellular/inflammatory on ECHO. EF >75%, mild diastolic dysfunction. -->Rhythm: Continued sinus tach (100-120) with frequent APBs, likely due to pain and infection. Also with a h/o pheochromocytoma on norvasc, labetolol and valsartan, which were all initially held due to hypotension. During her course she became tachycardic HR 150s most likely MAT. She was started on lopressor 5mg TID and titrated to control her HR. HR also controlled with pain control. -->Ischemia: No wall motion abnormalities or signs of ischemic dysfunction . #. Adrenal insufficiency in the setting of bilateral adrenalectomy, home steroid dependence, prednisone 5mg daily. Pt. was placed on stress dose steriods due to hypotension and infection. steroids were d/c'ed once pt was made CMO. . #. Metastatic RCC: CT scans negative for cord compression, however, 10cm liver metastasis, abundant evidence of probable VHL hemangiomas in the cervical, lumbar and thoracic spine. Heme Onc followed pt. & discussed the possibility of treatment with Sutent when pt was stable for d/c to a medicine floor. She was too tenuous throughout her [**Hospital Unit Name 153**] course to receive sutent. Pt's pain was controlled with aggressive pain medication. Palliative care was consulted for pain control and help with goals of care when her clinical status deteriorated. she was managed with a morphine drip once made CMO. . #. MS changes: Pt was drowsy and sedated, but appeared to be in pain with movement. MS changes likely combination of pain, uremia, ICU delerium, inflammation/ infection. She underwent 2 head CTs which did not show an acute process, however due to movement, and a limited study, a subtle lesion could not be entirely excluded. Despite no narcotics for several days she was not interactive or responsive. . #. Code status: Initially full code then made DNR/DNI, and CMO prior to death with help from Palliative care and [**Hospital Unit Name 153**] team as clinical status persistently deteriorated. . #. Goals of care. Ms. [**Known lastname **] had known advanced metastatic RCC with diffuse liver metastases in the setting of severe acute pancreatitis with a rising white count and continued MS changes despite electrolyte normalization and being off sedation. - A family meeting with spouse addressing concerns of worsening status including resp distress, an elevated WBC despite abx, & metastatic RCC, resulted in change of code status to DNR/DNI and shifting care to comfort only. - A morphine drip was initiated to ease pain & make her comfortable; prior to CMO she had adequate pain control via standing pain medications. - Palliative care was following the pt since [**8-10**]. . Pt expired on morning of [**8-19**] at 11am. Per pt's request her organs were donated to NDRI in coordination with our pathology department. Her husband agreed to an autopsy. Medications on Admission: Prednisone 5 mg p.o.daily Norvasc 10 mg p.o. b.i.d. Trandate 200 mg p.o. b.i.d., Diovan 160 mg p.o. daily. Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Deceased Discharge Instructions: n/a Followup Instructions: n/a

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icd9cm

[ [ [] ] ]

[ "99.07", "99.04", "96.6" ]

icd9pcs

[ [ [] ] ]

19797, 19806

12927, 19612

314, 335

19857, 19867

7821, 10616

19919, 19925

6616, 7140

19769, 19774

19827, 19836

19638, 19746

19891, 19896

6265, 6500

7155, 7802

246, 276

363, 2874

10625, 12904

5943, 6242

6516, 6600

71,399

159,345

39413

Discharge summary

report

Admission Date: [**2119-7-13**] Discharge Date: [**2119-7-14**] Date of Birth: [**2082-12-10**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Transient hypoxia, aspiration Major Surgical or Invasive Procedure: None History of Present Illness: Ms [**Known lastname **] is a 36 year-old G2P2 female with PCOS who is undergoing [**Known lastname 10899**] s/p had 35 eggs retrieved today who presented to the ED with dyspnea and hypoxia. During the procedure she became bradycardic to the 20's. She states she was given conscious sedation and doesn't remember the procedure (but states she was not intubated). In the recovery room at [**Location (un) 86**] [**Location (un) 10899**] she had abdominal pain and hypotension. She was given 3L LR and developed progressive hypoxia to the mid 80's which came up to 100% on a NRB. Since the fluid bolus, her BP has remained stable. After the procedure she was complaining of right sided pleuritic chest pain and a cough. She denies any pulmonary symptoms prior to her procedure today or any recent fevers or chills. In the ED, initial vs were: T 98.6 P 100 BP 105/68 R 31 O2 sat 100% on NRB. Labs were significant for a WBC of 13.2. Blood cultures were drawn. CXR showed RLL opacity with concern for aspiration. CTA torso showed no PE, bilateral dependent ground-glass opacities, and enlarged/hyperstimulated ovaries. She was seen by ob/gyn who felt her presentation was more consistent with aspiration pneumonia and less likely ovarian hyperstimulation syndrome. She was given 750 mg IV levofloxacin and 500 mg IV flagyl. She was written for cefepime, but did not receive it in the ED. By the time of transfer she was satting 97% on RA. Currently she feels like she has airway congestion, but denies shortness of breath. She continues to have [**4-27**] crampy bilateral lower abdominal pain. Denies nausea or vomiting, or current chest pain. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pressure, palpitations, or weakness. Denies diarrhea, constipation. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: PCOS complicated by infertility s/p appendectomy in [**2098**] s/p umbilitcal hernia repair in [**2088**] Social History: She lives with her husband and two children. She works as an insurance broker. Denies tobacco or drug use. Drinks 2-3 beers two to three times per week. Family History: Her sister has breast cancer. Physical Exam: Vitals: T: 99.4 BP: 89/57 P: 91 R: 16 O2: 97% on RA General: Young female sitting in bed in NAD. Alert and appropriate. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Breathing comfortably. Slight crackles present at her bases, otherwise clear. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: hypoactive bowel sounds, soft, tender to palpation in the lower quadrants >>> LUQ > RUQ. No rebound or guarding. Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Labs: Na 141 K 3.7 Cl 106 Bicarb 25 BUN 10 Cr 0.6 Glu 136 WBC 13.2 Hct 37.8 Plt 188 95.8% N 3.3% L PT 11.8 PTT 24.0 INR 1.0 Lactate 1.3 Micro: BCx x 2 - pending Images: CT torso: IMPRESSION: 1. No evidence of pulmonary embolus or acute aortic pathology. 2. Dependent ill-defined nodular and ground glass opacities in both upper and lower lobes, most consistent with aspiration pneumonia. 3. Enlarged hyperstimulated ovaries. 4. Small amount of minimally complex fluid in [**Location (un) 6813**] pouch may represent sequelae of recent egg retrieval. CXR: IMPRESSION: Right lower lobe and retrocardiac opacities, suggestive of aspiration or infection. EKG: nl sinus rhythm Brief Hospital Course: 36 year-old G2P2 female with PCOS s/p eggs retrieval today complicated by transient hypoxia likely due to aspiration pneumonia. # Transient hypoxia/Aspiration PNA: The patient had conscious sedation earlier today for her procedure and when she awoke felt lower airway congestion and started coughing suggesting an aspiration event. Her transient hypoxia and her imaging in the ED (both CXR and CTA) are consistent with aspiration. She many only have had a pneumonitis, but is at risk for pneumonia. Given her [**Location (un) 10899**] medications, she is at risk for OHSS which can cause widespread vascular leakage and pulmonary edema. Per gyn note, if this was the cause, she would have had pleural effusions. Her CTA has some focality to it which make aspiration more likely. She had no fevers during her stay. Repeat CXR the morning after admission was unchanged. Blood cultures were pending at the time of discharge. She was treated with flagyl and levofloxacin which were stopped upon discharge. She was given a script for augmentin and told to start this if she developed fevers, increasing cough, or worsening respiratory symptoms (as well as to call her primary doctor). She has follow up scheduled with her [**Location (un) 10899**] doctors [**First Name (Titles) 2593**] [**Last Name (Titles) 16337**]. # Transient hypotension: Thought to be secondary to the conscious sedation she received during her procedure +/- the aspiration event. Her systolic blood pressures remained in the 90's during her stay (which is her baseline). She received additional [**Last Name (Titles) 10899**] overnight. # Abdominal pain s/p egg retrieval: The patient was having crampy abdominal pain which is expected after egg retrieval (per what she was told by the [**Last Name (Titles) 10899**] center). She had a CT torso which did not show any worrisome findings in her abdomen. The enlarge ovaries are expected given her recent egg retreival. She was given pain medications and had good control with motrin. She was discharged with motrin (and already had a precription for percocet). She was eating by time of discharge. Medications on Admission: Metformin (to help conceive), last taken last night Prenatal vitmain hormones for [**Last Name (Titles) 10899**] Discharge Medications: 1. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 2. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day as needed for cough for 7 days. Disp:*30 Tablet Sustained Release(s)* Refills:*0* 3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every [**4-25**] hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 4. Prenatal Vitamin Oral Discharge Disposition: Home Discharge Diagnosis: Primary: Transient hypoxia (low oxygen saturation) due to an aspiration event. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital due to low oxgyen saturation and difficulty breathing. It is thought that you had an aspiration (gastric contents or respiratory secretions which went into the lung) event during your procedure yesterday. You are being treated with antibiotics for possible related infection. You will need to complete a 7 day course. Medication chagnes: 1. You are being sent home with a prescription for agumentin twice daily for 7 days. You should start taking this prescription if you develop fevers, increasing cough, or worsening shortness of breath. Please also call your primary doctor if you feel worse or need to take the augmentin. 2. You can take Guaifenesin 600 mg up to twice daily to help break up your respiratory secretions. 3. For your abdominal pain you can take ibuprofen or the percocet you were given after your procedure. Followup Instructions: Please follow up with your doctors [**First Name8 (NamePattern2) **] [**Last Name (Titles) 86**] [**Name5 (PTitle) 10899**]. You have an appointment next [**Name5 (PTitle) 16337**].

[ "789.09", "796.3", "799.02", "620.2", "507.0", "E937.8" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6792, 6798

4020, 6161

346, 353

6921, 6921

3304, 3997

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6324, 6769

6819, 6900

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2724, 3285

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277, 308

381, 2044

6936, 7048

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2505, 2662

47,271

116,612

35700

Discharge summary

report

Admission Date: [**2122-3-25**] Discharge Date: [**2122-4-16**] Date of Birth: [**2057-1-21**] Sex: F Service: MEDICINE Allergies: Erythromycin Base Attending:[**First Name3 (LF) 552**] Chief Complaint: admitted for AAA repair c/b Mysthenia crisis Major Surgical or Invasive Procedure: -AAA repair and right femoral endarterectomy [**2122-3-25**] -Intubation for respiratory failure ([**Date range (3) 81216**], [**Date range (2) 81217**]) -Plasmapheresis x5 ([**Date range (2) 81218**]) -Right IJ pheresis catheter placement ([**2122-3-31**]) -Right PICC placement ([**2122-4-10**]) History of Present Illness: 65 yo female with h/o of myasthenia [**Last Name (un) 2902**], lung cancer s/p chemoradiation, HTN, hypercholesterolemia, atrial fibrillation, and admitted on [**3-25**] for vascular repair of AAA. Pt was on the vascular service and she was extubated on POD#1 w/o any events. On [**3-28**] pt developed hyponatremia from 138->123, and weakness, and medicine was consulted. The medical consult though the hyponatremia was [**2-9**] SIADH. Over the subsequent days, she was noted to have generalized weakness and fatigueability. Neurology was consulted on [**3-30**] and per their note, she complained of limb weakness, facial weakness marked by difficulty maintaining her eyes open. VC was 0.95L with NIF of -40 on this date. Neurology recommended monitoring of NIF and VC, increasing mestinon to 120mg TID. Pt developed worsening weakness despite mestinon and plasmaphereis was initiated. VC and NIF noted to decrease to 0.90 and -25 respectively. On [**4-1**] pt had worsening weakness respiratory distress with a RR 18 w/ sat 99% on 2L, NIF -30 and VC 900cc. She had a weak cough and grade 2-3/5 power in distal and proximal LE. ABG 7.48/52, and CXR w/ cardiomegaly, RML fullness but no effisons. . In the MICU: Patient had NIFs less than 25 and was intubated on [**4-1**] and started on SoluMedrol 80mg QD. Extubated on [**4-2**], but was reintubated on [**4-3**]. Patient underwent a total of 5 days of plasmapheresis. Pt was extubated on [**4-9**], pt tolerated BiPAP [**10-17**] that evening. NIF post-intubation was -22, but the next day did well since and this morning had NIF of -50. . Other events: - [**3-31**] the RIJ triple lumen was changed over a wire - [**4-5**] completed 3d course of Ctx for UTI - [**4-6**] vasc changed pheresis line - [**4-8**] vascular [**Doctor First Name **] was concerned about seeding hardware and started Ancef - plan to cont until groin wound heels Past Medical History: 1. Myasthenia [**Last Name (un) 2902**]: - [**2121**]: diagnosed; closely followed by primary neurologist in [**Location (un) 38**] - mild crisis in the past marked by visual changes (diplopia) and generalized weakness - has been on mestinon 60mg TID for her maintenance - at baseline, uses wheelchair for any extended travel and walks around the home with a walker most of the time - not really able to perform activities of daily living without substantial support by her husband who is also her primary caretaker 2. Stroke, [**2121**] - felt to be [**2-9**] hypertension - residual weakness in BLLE 3. History of lung CA, s/p chemoradiation 4. Atrial fibrillation 5. Hypertension 6. Hypercholesterolemia 7. OSA 8. GERD 9. Chronic low back pain 10. Spine surgery, [**2120**] 11. Bilateral knee arthroscopy 12. Degenerative arthritis 13. Cholecystectomy Social History: Lives with husband. She is a former heavy smoker up to a pack and a half of cigarettes per day and continues to actively smoke, although she says now only a few cigarettes per day. Family History: Denies any known neurological familial history. Physical Exam: VITALS: BP 177/81, HR 90, 97% on 2 liters GEN: Weak appearing. Lying in bed in no distress. Able to speak though appears to tire. HEENT: Pupils 4mm-->2mm bilaterally. No icterus or pallor. CV: Regular. No murmurs. PULM: Clear though effort poor. ABD: Soft. Non-tender. EXT: Warm. Lower extremity varicosities. NEURO: Pupils as above. EOMI intact. Mild ptosis bilaterally though will open eyes fully on command. Slightly weak shoulder shrug. Gag weak (per neuro note). Tongue midline. Upper extremities [**4-12**] bilaterally proximally and distally. Lower extremties [**3-12**] at the hip and [**4-12**] at ankle. Sensation grossly intact. Pertinent Results: HCT: 36.1 --> 30.9 WBC: 8.4 --> 7.3 PLT: 139 --> 181 . INR: 1.1 . Na: 138 --> 123 --> 134 HCO3: 29 --> 39 --> 35 Cr: 0.8 --> 0.7 . ABG: 7.48/44/135 . UOSM: 164 UNa: 39 . CXR ([**2122-3-26**]): 1. Globoid cardiomegaly without overt CHF or significant pleural effusion. 2. Basilar atelectasis without focal consolidation. 3. Gaseous distention of the stomach, new since [**3-25**]. . CT chest [**4-7**]: 1. No thymoma. 2. Moderate-to-severe emphysema. 3. Bilateral pleural effusions and adjacent atelectasis in the dorsal lung bases. No focal parenchymal opacities to suggest pneumonia. . CXR [**4-10**]: In comparison with the study of [**4-9**], the endotracheal tube is not definitely seen and may have been removed or substantially pulled back. The IJ catheter and NG tube are essentially unchanged. The cardiac silhouette is less prominent than on the previous study and there has been decreased pulmonary congestion and pleural effusion. No evidence of acute focal pneumonia at this time. . EKG: in Afib rate 77, II, III, AVF w/ <1mm ST depressions, TWI in precordial leads Brief Hospital Course: 65F with history of MG, admitted for AAA repair, who developed [**Month/Day (2) 15099**] crisis post-op requiring intubation x 2. HOSPTIAL COURSE BY PROBLEMS: #. Respiratory failure [**2-9**] myasthenia flare: Likely related to post-operative state. Patient intubated on [**4-1**] for worsening respiratory distress in post-operative period after elective AAA repair. Extubation was done on [**4-2**] requiring reintubation the following day for muscle weakness. Received plasmapheresis treatment for 5 days started on [**4-8**]. Pt was extubated on [**2122-4-9**] and had some increased work of breathing and post-extubation NIF of -22; however, did well since and the morning of [**4-12**] had a NIF of -50. Called out to floor on [**4-12**] with stable respiratory status. Pt had nightly CPAP, and NIFs and VC was followed initially q8 on the floor. Pt's NIF stayed stable near -50, and VC near 1.3L. She denied any further SOB or respiratory distress. Pt was transitioned from Solu-Medrol to prednisone 60mg. The pt will be on prednisone for a long-term basis. She may be transitioned to 50mg QD after 1mo, but will have a slow taper. Pt was started on Bactrim 3x/wk for PCP [**Name9 (PRE) 6187**], and Ca/Vit D. Pt should be continued on CPAP at nighttime, and NIFs and VC should be checked daily at least for the 1st week. Pt should also receive nebs as needed, and suction as needed. #. Myasthenia [**Name (NI) **] - Pt had muscle weakness and severe fatigability that is now resolving. In the ICU pt did have mild ptosis bilaterally though will open eyes fully on command, a slightly weak shoulder shrug, weak gag. Her upper extremities [**4-12**] bilaterally proximally and distally. Lower extremties [**3-12**] at the hip and [**4-12**] at ankle. Sensation was grossly intact. While in MICU, patient had 5 runs of plasmapheresis which she tolerated well, and continued on the mestinon. Her strength continued to improve daily and was extubated without complications. Evaluated by CT surgery with CT scan which did not show thymoma. CT surgery will plan to eval for thymectomy at later date. On the floor, her illopsoas was still [**4-12**] b/l, but at time of discharge her motor exam was [**5-12**] b/l UE and LE w/ no ptosis or diplopia. Pt was on TF while her PO intake was small. She had a video swallow and passed. Her dobhoff was removed. Currently she now on a regular diet, and nutrition recommended at least for the next few days to have smaller but more frequent meals to avoid fatiguing, and to continue ensure TID until caloric intake is adqeuete. Pt is to be continued. Pt should be contiued on pyridostigmine 60mg TID, and was also started on Cellcept by neurology to decrease frequency of attacks. These should be kept unchanged unless neurology outpt recommends otherwise. Care should also be taken to be mindful of adding medications that can interact with her [**First Name9 (NamePattern2) 15099**] [**Last Name (un) 2902**], like aminoglycosides. #. Atrial fibrillation: Pt has a history of afib, Verapamil and metoprolol held due to acute MG flare, as a medication known to cause worsening of MG. Pt was continued on digoxin and was therapeutic when the level was checked. Pt remained rate controlled for the most part, but did have short periods of RVR that did not require intervention. Prior to discharge, in discussion with neurology, her metoprolol was restarted, initially at 12.5mg [**Hospital1 **], and discharged at 25mg [**Hospital1 **]. This can be converted to toprol XL 50 if pt tolerates 25 [**Hospital1 **]. Although neurology was weary, in her case the metoprol does not appear to be affecting her [**First Name9 (NamePattern2) 15099**] [**Last Name (un) 2902**]. Her verapamil was not restarted at time of discharge (to avoid 2 nodal agents). She was not on anticoagulation when she arived but w/ signficant CHADS score, it was thought that she would benefit from anticoagulation. We spoke with her outpatient neurologist who said that it was held in the setting of hemorrhagic stroke [**2-9**] htn, but he and vascualar surgery was agreeable to restarting coumadin on discharge. Pt was restarted on her home dose of Coumadin 5mg QD except 2.5 on M,Th. Her INR level should be checked to ensure she is therapeutic at 2-3, with first check on Monday. . #. Hypertension: BPs are high off of her home medications and with verapamil/metop held. So she was started on captopril 100 tid and IV hydral PRN as needed while in the ICU. Did receive dose of IV metoprolol 5mg for afib with RVR on [**4-11**] once for Afib w/ RVR. Pt tolerated without difficulty. Once out of the ICU pt was transitioned ot lisinopril, now on 40mg, and PO hydralizine. Her BP was still systolics 170-190s, and hydrochlorthiazide was also started. Now metoprol may slightly help also. Her BP is much better controlled now, averaging 140s-150s. # Electrolyte abnormalities: Pt had metabolic alkalosis that is resolved, and intially hyponatremia that was thought to be SIADH while in the ICU that also resolved. Pt had hyperkalemia to 5.2 on day of discharge, it was repeated prior to leaving and was 4.7 This may be due to her lisinopril and her BMP and Cr should be monitered for the next two to three days to ensure her electolytes remain stable. #. AAA repair: Pt had successful repair. Vascular surgery was following. Pt had a new occurance of wound hematoma on [**4-7**] during MICU stay during treatment for plasmapheresis, fibrinogen normal, no intervention at this time. She was placed on ancef by vascular surgery due to drainage from the wound. The pt's wound stopped drainined 2 days prior to dishcarge, but per vascualar surgery pt is to continue Keflex for 1 wk after discharge, follow up with [**Hospital **] [**Hospital **] clinic at 1wk, and be given 1 refill of Keflex if needed. #. New DVT- The day prior to discharge pt started complaining of RLE pain. Pt had no focal neurological deficits, and neurology was not . On day of discharge pt's RLE appeared swollen and asymetric. Pt was on Heparin 5000mg TID while patient. LENI was ordered of the RLE and was positive for DVT at R common femoral vein. Pt was given first dose of lovenox 70 sc Q12, to be bridged while coumadin is subtherapeutic. Please check INR and d/c lovenox when coumadin therapeutic. #. R-sided hematoma- s/p AAA repair and endarectomy. Vascular surgery was agreeable to starting anticoagulation on discharge. Pt's hematocrit has been stable, but now that pt is being restarted on lovenox, pt's hematoma at R inguinal area should be visually inspected daily, and hematocrits should be checked daily for the next week to ensure hematoma is not enlarging. Medications on Admission: 1. Aspirin 81 mg QD 2. Verapamil 240 mg QD 3. Digoxin 250mcg QD 4. Metoprolol Succinate 25mg QD 5. Pyridostigmine Bromide 60 mg TID 6. Celexa 30mg Qd 7. Elavil 25mg QD 8. Modafinil 200 mg QD 9. Pantoprazole 40mg QD 10. Folic acid 1mg 11. Ambien 5 mg QD 12. Ascorbic Acid 500 mg QD 13. Calcium Carbonate-Vitamin D3 500 mg (1,250 mg)-200 QD 14. Colace 100mg [**Hospital1 **] 15. Ferrous Sulfate 325 mg QD 16. MVI QD 17. Omega-3 Fatty Acids 1,000 mg Capsule 18. Senna 8.6 mg prn Discharge Medications: 1. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Pyridostigmine Bromide 60 mg/5 mL Syrup Sig: One (1) PO Q8H (every 8 hours). 6. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 7 days. Disp:*28 Capsule(s)* Refills:*1* 7. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR) as needed for PCP prophylaxis while on cellcept. Disp:*12 Tablet(s)* Refills:*4* 8. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO once a day. 9. Modafinil 200 mg Tablet Sig: One (1) Tablet PO once a day. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for osteoporosis PPX while on steroids. 14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily) as needed for osteoporosis PPx while on steroids. 15. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 16. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 17. Multivitamin Capsule Sig: One (1) Capsule PO once a day. 18. Omega-3 Fatty Acids 1,000 mg Capsule Sig: One (1) Capsule PO once a day. 19. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAYS (MO,TH). Disp:*8 Tablet(s)* Refills:*2* 20. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAYS ([**Doctor First Name **],TU,WE,FR,SA). Disp:*35 Tablet(s)* Refills:*2* 21. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 22. Hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 23. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:*120 Tablet(s)* Refills:*2* 24. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB/Wheezing. 25. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 26. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) as needed for myasthenia [**Last Name (un) 2902**]. Disp:*90 Tablet(s)* Refills:*3* 27. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for myasthenia [**Last Name (un) 2902**] maintenence therapy. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: Radius [**Hospital1 392**] Discharge Diagnosis: Primary diagnosis: Myasthenia [**Last Name (un) 2902**] Respiratory failure secondary to myasthenia flare s/p AAA endovascular repair and right femoral endarterectomy Secondary diagnosis: Atrial fibrillation Emphysema HTN Hyponatremia Discharge Condition: good Discharge Instructions: You were admitted to the hospital for surgery to repair an abdominal aortic aneurysm (AAA). After your operation you had a flare of myasthenia [**Last Name (un) 2902**] that led to generalized weakness and respiratory failure. You were treated with pyridostigmine, but eventually had to be intubated to support your breathing. Your myasthenia flare was also treated with corticosteriods and plasmapheresis. Your breathing improved and you were extubated and demonstrated significant recovery of your strength and breathing. During your hospitalization you were treated with antibiotics for a urinary tract infection and to prevent infection of your surgical wounds. . The following changes were made to your medications: 1. Start prednisone 60 mg by mouth daily. Continue for a month on this dose, until tapering to 50 mg daily under the direction of your neurologist. 2. Start cellcept (MMF) 500 mg twice daily. 3. Continue to take the pyridostigmine 60 mg three times daily. 4. Start taking metoprolol 25 mg twice daily. 5. Start taking coumadin 5 mg daily, except Monday and Thursday take 2.5 mg. 6. Stop taking verapamil or other calcium channel blockers because of myasthenia flare. 7. Start taking ipratropium bromide MDI inhale 6 puffs four times daily. 8. Start taking albuterol 0.083% nebulizer inhaled every 6 hours. 9. Start taking cephalexin 500 mg by mouth four times daily. 10. Start taking lisinopril 40 mg by mouth daily. 11. Start taking hydrochlorothiazide 50 mg by mouth daily. 12. Start taking hydralazine 25 mg by mouth every 6 hours. 13. Start taking vitamin D 800 U by mouth every day. 14. Start taking calcium carbonate 500 mg by mouth four times a day. 15. Start taking Bactrim DS 1 tab by mouth every monday/wednesday/friday. 16. Start lansoprazole 30 mg tab by mouth every day. . Please return to the ED if you have a significant difficulty breathing, worsening weakness, chest pain, abdominal pain, bleeding, fever, chills, or for any other symptoms concerning to you. Followup Instructions: Please come to your appointment next week with your [**Hospital1 18**] vascular surgeon as follows: Please follow-up with your PCPProvider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2122-4-23**] 3:00P . Please come to your appointment in [**2-10**] weeks with your PCP (Dr. [**Last Name (STitle) 28436**] Phone: [**Telephone/Fax (1) 17503**], Date/Time: [**2122-4-28**] 1:30P. . Please come to your apptointment next month with your [**Hospital1 18**] neurologist as follows: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2122-5-28**] 11:30A. You should call in a month on [**5-16**] to discuss prednisone taper regimen. . Completed by:[**2122-4-16**]

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icd9cm

[ [ [] ] ]

[ "88.42", "39.71", "96.71", "96.04", "96.6", "38.18", "00.40", "96.72", "38.93", "99.71" ]

icd9pcs

[ [ [] ] ]

15501, 15554

5473, 12157

322, 622

15834, 15841

4370, 5450

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166,425

8693

Discharge summary

report

Admission Date: [**2165-7-11**] Discharge Date: [**2165-7-20**] Date of Birth: [**2118-12-26**] Sex: M Service: TRANSPLANT SURGERY Attending:[**Last Name (NamePattern4) **] HISTORY OF PRESENT ILLNESS: This is a 46 year-old man admitted for liver transplant. He has chronic hepatitis C and hepatitis C cirrhosis. Complications of his cirrhosis no history of bleeding. Ascites status post admission between [**12-2**] and [**12-6**] of [**2164**] for increase of abdominal girth, pain and dyspnea. He underwent therapeutic paracentesis for one and a half liters. He has synthetic dysfunction of the liver with elevated coags and a low albumin. There is no evidence of hepatic encephalopathy, no osteodystrophy and no evidence of hepatocellular carcinoma. PAST MEDICAL HISTORY: Hepatitis C diagnosed in [**2161**] from a blood transfusion for stab wounds. Child's C cirrhosis, ascites, grade three varices, gastroesophageal reflux disease, arthritis. PAST SURGICAL HISTORY: Stab wounds to face (150 stitches), left femoral pin placement (motorcycle accident), severe burns on back, buttock and leg seven years ago. He is status post skin grafting to these sites. SOCIAL HISTORY: He stopped working secondary to health problems. [**Name (NI) **] lives with wife and daughter including another daughter from a previous marriage. He has one pack year history of smoking in high school and has a history of alcohol abuse. He drank heavily until four years ago. He has a history of cocaine use in the past, which was not significant and no history of other drugs. ALLERGIES: Codeine. MEDICATIONS ON ADMISSION: Spironolactone 100, Lasix 40, Colchicine .6, Nadolol 20, calcium 600, vitamin E 400 units, Ursodiol 600 mg. PRETRANSPLANT EVALUATION: Cardiac sinus bradycardia. Echocardiogram shows an ejection fraction of 55%. CMV positive titer from [**2165-4-1**], positive for varicella and toxoplasma as well as EBV. His HCV viral load [**2164-4-1**] is 831,000. Examination on admission, temperature 97.5. Heart rate 60. Blood pressure 118/74. Respiratory rate 20. Sats 98% on room air. Weight 106.4 kilograms. He is alert, oriented and in no distress and jaundice. Neck with no lymphadenopathy. Lungs clear to auscultation bilaterally. Heart regular rate and rhythm. Abdomen soft, nontender, nondistended. Genitalia, he has a right hydrocele. Rectal no mass. Heme negative. LABORATORIES ON ADMISSION: CBC white blood cell count 3.5, hematocrit 33.6, platelets 52. Chem 7 sodium 137, potassium 3.7, chloride 101, bicarb 29, BUN 21, creatinine .7, glucose 87. AST 107, ALT 66, alkaline phosphatase 211. T bili is 5.2, amylase 48, lipase 67. Albumin 2.5. PT 15.8, PTT 39.6, INR of 1.7, calcium 8.7, magnesium 2 and phosphorus is 4.3. Urinalysis was negative. Chest x-ray on admission showed no infiltrate and no effusion. Electrocardiogram on admission showed normal sinus rhythm of 70 with no evidence of ischemia. HOSPITAL COURSE: On [**7-12**] he underwent an orthotopic cadaver liver transplant. During surgery the estimated blood loss was 3000 cc and received 7 units of packed red blood cells, 9 units of fresh frozen platelets and 5 units of platelets and 4 units of cryo. Overall this was an uncomplicated liver transplant and he tolerated the procedure well. He was transferred from the Operating Room to the Postoperative Surgical Intensive Care Unit. His postoperative course is summarized as follows. 1. Neurological: He was kept sedated only during the day of surgery. On postoperative day one sedation was weaned off and he was given pain medications intravenous as needed. His pain was well controlled and prior to discharge he is tolerating oral pain medications with no difficulty. 2. Cardiovascular: He remained stable throughout his hospitalization with no requirements for inotropic or vasoconstrictors. His only cardiac issue was his bradycardia, which is his baseline. He was seen by cardiology for this reason and was recommended that he undergo a Holter study prior to discharge. The Holter was connected to him between [**7-19**] and [**7-20**]. Results of this study are still pending and he is to follow up with cardiology as scheduled after discharge. His rate ranges between 37 to 50 most of the time. He is completely asymptomatic. 3. Respiratory: He was weaned and extubated on postoperative day one with no difficulty. After that he remained stable and maintained high oxygen saturations with no oxygen requirements. 4. Gastrointestinal: He was gradually advanced to a regular diet with no difficulty. 5. Renal: He maintained his renal function and his urine output was good throughout his stay. 6. Hematology: Postoperatively he did require 2 more units of packed red blood cells and eight more units of platelets. These were given to him on postoperative day one and two. After that although his platelet count remained low in the 60s there was no evidence of bleeding and his hematocrit have remained stable. His hematocrit prior to discharge is 42.5, platelet count is 62. 7. Infectious disease: He had no signs of postoperative infection. He was on Unasyn perioperatively and that was stopped on postoperative day two. His wounds are healing well with no discharge and no erythema. His immunosuppressive regimen includes CellCept 1 gram b.i.d., Prednisone 25 mg q.d. and Cyclosporin 250 mg b.i.d. Overall his postoperative course was uncomplicated and he is discharged to home in stable condition and with the following recommendations. MEDICATIONS: As per transplant team. FOLLOW UP: Follow up in clinic on Wednesday [**2165-7-24**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366 Dictated By:[**Name8 (MD) 28532**] MEDQUIST36 D: [**2165-7-20**] 19:06 T: [**2165-7-25**] 08:26 JOB#: [**Job Number 30440**]

[ "572.3", "070.54", "789.5", "575.11", "571.5" ]

icd9cm

[ [ [] ] ]

[ "50.59", "51.22" ]

icd9pcs

[ [ [] ] ]

1640, 2433

2986, 5606

998, 1189

5618, 5924

218, 776

2448, 2968

799, 974

1206, 1613

45,185

156,326

35559

Discharge summary

report

Admission Date: [**2132-8-19**] Discharge Date: [**2132-8-25**] Date of Birth: [**2068-2-20**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 974**] Chief Complaint: Shortness of breath and right-sided thoracic pain Major Surgical or Invasive Procedure: Right chest tube placement. History of Present Illness: 64yo female s/p mechanical fall down stairs with subsequent shortness of breath, right-sided thoracic pain, and head lacerations. Patient brought to [**Hospital1 18**] where she was noted to have right rib fractures of [**3-6**] and a large pneumothorax on CT. Past Medical History: Diabetes mellitus type II, CHF, asthma, cirrhosis, hypothyroidism Social History: Resident of [**State 760**] Family History: Non-contributory Physical Exam: Upon admission: BP-151/76 P-87 R-30 pO2-93 General: WN/WD, NAD, AOx3 HEENT: multiple scalp lacerations CV: RRR Chest: tenderness to palpation over right ribs, no crepitus Abdomen: soft, nontender, nondistended Extremities: multiple abrasions x4 extremities Pertinent Results: [**2132-8-19**] 06:10PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017 [**2132-8-19**] 06:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2132-8-19**] 06:05PM GLUCOSE-174* LACTATE-1.9 NA+-143 K+-3.7 CL--103 TCO2-23 [**2132-8-19**] 05:55PM UREA N-26* CREAT-1.2* [**2132-8-19**] 05:55PM estGFR-Using this [**2132-8-19**] 05:55PM LIPASE-36 [**2132-8-19**] 05:55PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2132-8-19**] 05:55PM WBC-12.5* RBC-4.34 HGB-12.1 HCT-37.0 MCV-85 MCH-28.0 MCHC-32.8 RDW-13.9 [**2132-8-19**] 05:55PM PT-13.1 PTT-23.3 INR(PT)-1.1 [**2132-8-19**] 05:55PM PLT COUNT-380 [**2132-8-19**] 05:55PM FIBRINOGE-342 Brief Hospital Course: Ms. [**Known lastname 54371**] was admitted to [**Hospital1 18**] on [**2132-8-19**], s/p mechanical fall. On CT scan, she was noted to have right 3rd-5th rib fractures and a large right pneumothorax. A chest tube was placed in the emergency department. Since that time, patient has been monitored for respiratory function and pain control. Her hospital course was notable for intermittent post-concussive amnesia and agitation that improved during her inpatient stay. Her chest tube was discontinued on [**2132-8-22**], and she had steadily improving pain control. She was discharged in stable condition. Medications on Admission: Glucovance, Lasix, Synthroid, Lipitor Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Year (4 digits) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. Senna 8.6 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. Metoprolol Tartrate 25 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO BID (2 times a day). 4. Montelukast 10 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily) as needed for asthma. 5. Fexofenadine 60 mg Tablet [**Year (4 digits) **]: Three (3) Tablet PO DAILY (Daily). 6. Furosemide 40 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO BID (2 times a day). 7. Albuterol Sulfate Inhalation 8. Levothyroxine 75 mcg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily). 9. Lithium Carbonate 300 mg Capsule [**Year (4 digits) **]: One (1) Capsule PO 1 DAILY (). 10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 11. Bupropion HCl 75 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a day). 12. Hydrocodone-Acetaminophen 5-500 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 13. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2 times a day) as needed for Constipation. Disp:*30 Capsule(s)* Refills:*0* 14. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: per sliding scale Injection ASDIR (AS DIRECTED). Discharge Disposition: Extended Care Facility: [**Hospital 745**] Healthcare Discharge Diagnosis: 1. Right rib [**3-6**] fractures 2. Pneumothorax Discharge Condition: Stable/good; alert and oriented; ambulating; tolerating PO intake; pain well controlled. Discharge Instructions: You have been treated in the hospital after your fall with subsequent rib fractures and pneumothorax. We managed your pain control as a result of your rib fractures and made sure that you were able to ambulate and tolerate the pain at the time of discharge. Please continue to use your incentive spirometer. Please continue to take pain medications as directed. Please return to the hospital or emergency department if you have fever, chills, chest pain, difficulty breathing, shortness of breath or any other symptoms that you find concerning. Followup Instructions: Trauma - Please schedule a follow-up outpatient appointment with Dr. [**Last Name (STitle) **] in 2 weeks. You should contact [**Telephone/Fax (1) 18052**] to set up this appointment. Please call to make the appointment within the next 24-48 hours. Completed by:[**2132-8-25**]

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icd9cm

[ [ [] ] ]

[ "86.59", "34.04", "03.90" ]

icd9pcs

[ [ [] ] ]

4206, 4262

1937, 2550

363, 393

4355, 4446

1147, 1914

5043, 5325

834, 852

2639, 4183

4283, 4334

2576, 2616

4470, 5020

867, 869

274, 325

421, 684

883, 1128

706, 773

789, 818

16,914

141,243

43999

Discharge summary

report

Admission Date: [**2107-5-3**] Discharge Date: [**2107-5-13**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 473**] Chief Complaint: Abdominal Pain Septic Shock Major Surgical or Invasive Procedure: [**First Name3 (LF) **] with sphicterotomy and stent placement History of Present Illness: The patient is an 84 year old male with a history of CAD s/p DCA of the LAD/D1 bifurcation stenosis in 11/96 and s/p rotational atherectomy and PTCA of the LAD and PTCA of D2 in 1/97, carotid stenosis s/p L CEA [**3-27**], HTN, hyperlipidemia, DM2, and atrial fibrillation on Coumadin who presents with chest pain. . The patient was sitting watching TV on the evening PTA, and at 11 pm developed epigastric pain which he initially thought was due to indigestion. The pain then migrated up to his substernal chest, and was [**2109-4-25**] in intensity. He denies radiation to arm/jaw, SOB, n/v, palpitations. He did report diaphoresis. He has never had a pain like this before, even with his prior cardiac catheterizations. He took NTG SL x2 without relief, and then told his wife to call the ambulance. . He reports decreased exercise tolerance over the past 2 years. He denies DOE and can walk >1 city block. He did report chills at home but no fever. Denied cough, diarrhea, pain/burning on urination, or recent hospitalizations. . In the ambulance, he received Nitrospray and ASA 324 mg with no change in his chest pain. In the ED, temp 98.5, HR 85, bp 146/73, SaO2 100% on NRB. His HR was then up to 110-150 and bp up to 180/118. He was given 2650 mL NS, Diltiazem 10 mg IV x2, 20 mg IV x1, 30 mg x1 and then started on a Diltiazem gtt at 5 mg. CEs: Trop T <0.01, CK 63. proBNP 1499. INR 4.2. He spiked a temp to 103.4, and WBC 10.9 with 86% neutrophils. Lactate 2.5. CXR showed possible left lower lobe opacity due to obscuration of left hemidiaphragm, possible etiologies include atelectasis and pneumonia. UA showed neg leuk, neg nitrite, 0-2 WBC, rare bacteria. Blood cultures x2 were sent. He received Tylenol 1 gm PO x1, Motrin 600 mg PO x1, and Levaquin 750 mg IV x1. . He still had 5/10 chest pain when he hit the floor. He reports his chest pain ressolved at 7 am on the day of admission, but he still has an uneasy filling in his stomach. Past Medical History: -CAD s/p DCA of the LAD/D1 bifurcation stenosis in 11/96 and s/p rotational atherectomy and PTCA of the LAD and PTCA of D2 in [**12/2095**] -s/p left carotid endarterectomy with Dacron patch angioplasty [**2105-4-6**] for 90% left ICA stenosis. Ultrasound [**3-29**] less than 40% right ICA stenosis and no stenosis of the left ICA. -Hypertension -Hypercholesterolemia -Diabetes mellitus, Type 2 -Atrial fibrillation on Coumadin -Chronic Renal Insufficiency -Asthma -Chronic Iron Deficiency Anemia -Prostate cancer about 13 years ago, status post resection. -Prior 4-unit GI bleed in [**5-25**] while on Coumadin with work-up remarkable for antral polyps, Barrett's esophagus, C-scope with colonic polyps (adenoma) and diverticulosis without bleeding, and negative capsule endoscopy. Prior 7 units GIB in [**6-26**] likely due to ulcerated stomach polyps (hyperplastic), colonoscopy normal at that time -Barrett's esophagus . Cardiac Risk Factors: (+)Diabetes, (+)Dyslipidemia, (+)Hypertension . Cardiac History: CABG: none . Pacemaker/ICD: none . Percutaneous coronary intervention, in [**2096-1-20**] anatomy as follows: COMMENTS: 1. Coronary angiography revealed single vessel disease in this right dominant system. The LAD had diffuse restenosis with maximum 80% stenoses in the proximal and mid vessel as well as a 70% at the ostium of D2; D1 was free of restenosis. 2. Successful rotational atherectomy and PTCA of the LAD and PTCA of D2 (see PTCA comments). FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Successful rotational atherectomy and PTCA of the LAD and PTCA of D2 (see PTCA comments). . Percutaneous coronary intervention, in [**2095-11-10**] anatomy as follows: COMMENTS: 1. Coronary angiography revealed single vessel disease in this right dominant system. The LMCA was without hemodynamically significant stenosis. The LAD had an 80% stenosis involving the takeoff of the first diagonal, where there was also an 80% stenosis. There was a 50% stenosis in the distal LAD. The LCx system had mild luminal irregularities. The OM1 had a 40% stenosis at its origin. The RCA proper was without hemodynmically significant stenosis. The PDA had a 40% stenosis. 2. Resting hemodynamic profile revealed normal filling pressures. The cardiac index/output were within normal limits, as were the systemic and pulmonary vascular resistances. 3. Left ventriculography revealed normal systolic function without wall motion abnormality. The estimated ejection fraction was 64%. 4. Successful DCA of the LAD/D1 bifurcation stenosis. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Normal ventricular function. 3. Successful DCA of the LAD/D1 bifurcation stenosis. Social History: Social history is significant for the absence of tobacco use ever. He does have a history of heavy alcohol abuse, and he formery drank 5 martinis/night and Grand Marnier, would drink more on the weekends. He stopped drinking 5 years ago. Denies illicit drug use. He is a former FBI [**Doctor Last Name 360**], and then owned a security business. He lives in [**Location **] with his wife. Family History: There is no family history of premature coronary artery disease or sudden death. His father had an MI at age 62, and his older brother died last week at age [**Age over 90 **] from emphysema. Physical Exam: VS - temp 97.5, bp 116/65, HR 122, RR 20, SaO2 95% on 2L Gen: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple, unable to estimate JVP secondary to neck size. CV: Irregularly irregular, tachycardic. normal S1, S2. No m/r/g. No carotid bruits Chest: Resp were unlabored, no accessory muscle use. Slightly decreased breath sounds on the left, left basilar rales. No wheezes or rhonchi. Abd: Soft, NTND. Quiet BS. Possible spleen tip palptated. No hepatomegaly, but there was tenderness to palpation of the RUQ. Abd aorta not enlarged by palpation. Ext: No c/c/e. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: [**2107-5-3**] 01:45AM BLOOD WBC-10.9# RBC-4.30* Hgb-12.8* Hct-39.2* MCV-91 MCH-29.8 MCHC-32.8 RDW-13.7 Plt Ct-225 [**2107-5-3**] 08:12PM BLOOD WBC-21.5*# RBC-3.49* Hgb-10.1* Hct-32.4* MCV-93 MCH-29.0 MCHC-31.3 RDW-14.2 Plt Ct-164 [**2107-5-10**] 06:50AM BLOOD WBC-10.6 RBC-3.21* Hgb-9.5* Hct-29.1* MCV-91 MCH-29.7 MCHC-32.8 RDW-14.3 Plt Ct-161 [**2107-5-3**] 09:37AM BLOOD PT-45.3* PTT-65.0* INR(PT)-5.1* [**2107-5-6**] 10:02AM BLOOD PT-25.0* PTT-47.8* INR(PT)-2.5* [**2107-5-10**] 06:50AM BLOOD PT-14.5* PTT-35.6* INR(PT)-1.2* [**2107-5-10**] 06:50AM BLOOD ALT-50* AST-30 AlkPhos-164* Amylase-82 TotBili-2.5* [**2107-5-4**] 12:54PM BLOOD ALT-195* AST-145* AlkPhos-219* Amylase-227* TotBili-4.1* [**2107-5-10**] 06:50AM BLOOD Lipase-101* [**2107-5-4**] 02:07AM BLOOD Lipase-476* [**2107-5-3**] 09:37AM BLOOD CK-MB-3 cTropnT-0.01 [**2107-5-3**] 08:12PM BLOOD CK-MB-4 cTropnT-0.02* [**2107-5-3**] 01:45AM BLOOD CK-MB-NotDone proBNP-1499* [**2107-5-9**] 01:53AM BLOOD Albumin-2.9* Calcium-8.7 Phos-2.4* Mg-1.7 [**2107-5-3**] 09:37AM BLOOD %HbA1c-7.4* [**2107-5-3**] 09:37AM BLOOD Triglyc-50 HDL-30 CHOL/HD-3.2 LDLcalc-55 [**2107-5-3**] 08:12PM BLOOD TSH-0.88 [**2107-5-8**] 01:52AM BLOOD TSH-3.4 . ABDOMEN (SUPINE ONLY); ABDOMINAL FLUORO WITHOUT RADIO Reason: [**Month/Day/Year **] [**Month/Day/Year **]: Seven spot fluoroscopic images were obtained without a radiologist. These demonstrate filling defects in a slightly dilated common bile duct, consistent with choledocholithiasis. The last image provided demonstrates a stent overlying the right upper quadrant. . ABDOMEN U.S. (PORTABLE) [**2107-5-3**] 10:05 AM IMPRESSION: 1. Cholelithiasis in a mildly distended gallbladder with associated gallbladder wall edema and a common bile duct at the upper limits of normal. These findings may be in part related to patient age, n.p.o. status, and hypoalbuminemia. However, acute cholecystitis cannot be excluded and consideration should be given to a HIDA scan. . Cardiology Report ECG Study Date of [**2107-5-3**] 11:41:50 AM Atrial fibrillation with rapid ventricular response Premature ventricular contraction Marked left axis deviation Right bundle branch block Consider inferior infarct - age undetermined Consider anteroseptal infarct - age undetermined Lateral ST-T changes Borderline low QRS voltages Since previous tracing of the same date, no significant change Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A. Intervals Axes Rate PR QRS QT/QTc P QRS T 123 0 132 340/450 0 -48 -18 . PORTABLE ABDOMEN [**2107-5-6**] 3:57 PM FINDINGS: The NG tube tip is in the proximal stomach. IMPRESSION: NG tube in proximal stomach. . PORTABLE ABDOMEN [**2107-5-8**] 8:03 PM FINDINGS: Nasogastric tube reaches the stomach. There is a drain projecting over the right upper quadrant. The examination is markedly limited by technique. There is left retrocardiac opacity, which may represent atelectasis, consolidation or combination of both. There appears to be present left pleural effusion. Evaluation for free air is limited on this single supine view. Air and stool appears to be present in the right colon. IMPRESSION: Nasogastric tube reaching the stomach. . CHEST (PA & LAT) [**2107-5-12**] 9:26 AM FINDINGS: The left hemidiaphragm is slightly more sharply seen, raising the possibility of some improvement in the retrocardiac atelectatic change. Left pleural effusion is again seen. Mild prominence of interstitial markings persist consistent with some elevated pulmonary venous pressure. Nasogastric tube remains in place, though the endotracheal tube and right IJ catheter have been removed. . Brief Hospital Course: 84 M hx CAD, hx Afib, now w/cholangitis/cholecystitis, s/p [**Month/Day/Year **] sphincterotomy, stent placement ([**5-3**]) and GNR bacteremia (E.Coli)/sepsis . He presented c/o RUQ pain, fever, and chills x 1 day. Initially he was admitted to Medicine and he still had [**4-30**] Abdominal pain when he hit the floor and he still has an uneasy filling in his stomach. He had persistent afib c RVR c rates up to 130s. He had persistent hypotension c MAPs in the mid to low 60s c despite several liters of volume resuscitation with normal saline. For this, he was admitted to the MICU. . In the MICU, he reported persistent epigastric and RUQ pain worse c palpation. He denied any nausea, vomiting, difficulty breathing, light headedness, dizziness, fevers, chills, shakes, dysuria, headache. He was being volume resuscitated. He underwent RUQ U/S on arrival to MICU, which demonstrated gallbladder wall edema but no pericholecystic fluid, with a CBD of 6mm diameter. . Hypotension: The patient was in septic shock. He met the SIRS criteria - fever and tachycardia and bands from the GNR's bacteremia from the cholangitis, decreased urine output, and borderline MAP > 55 despite volume resuscitation. Hypovolemia was less likely given persistent hypotension despite IVF and clinical appearance. Cardiogenic shock [**1-22**] rapid afib causing poor LV filling was initially considered but the patient's tachycardia did not respond significantly to diltiazem gtt. His EF was 64% on cath [**10/2095**]. His extremities did not feel cool or edematous nor did he have symptoms of orthopnea, SOB. A sputum Cx was sent - Check sputum ctx - Goal MAP > 55 - central line was deferred at this time given response to IVF - Treatment for PNA and cholangitis empirically with piperacillin-tazobactam, metronidazole, and vancomycin. Cholangitis,choledocholithiasis: Impression: 1. Pus was seen draining from the major papilla 2. Cannulation of the biliary duct was performed with a sphincterotome using a free-hand technique. 3. Cholangiogram showed a dilated biliary tree with atleast two large stones in the CBD. The CBD measured around 10 mm. 4. A 9 cm by 10F Cotton [**Doctor Last Name **] stent biliary stent was placed successfully. Post stent placement purulent drainage was seen. Patient intubated [**2107-5-3**] for [**Month/Day/Year **] sphincterotomy and stent placement. He was NPO, with IVF. Patient extubated [**2107-5-6**]. His LFT's, Amylase, Lipase trended down and abdominal pain was much improved. A NGT was placed for tubefeedings. His abdominal pain improved and he passed a swallow evaluation and was allowed ground solids and thin liquids. He continued on tubefeedings and encouraged his PO intake. Please wean his tubefeedings and D/C NGT when tolerating adequate PO's. He was treated with Ciprofloxacin and will complete a 14 day course. . Afib c RVR: Ddx includes pain vs. hypovolemia vs. infection driving high catecholamine state vs. rebound tachycardia from disruption of home medications. Pain and/or infection seem most likely. Some response noted to IVF. Rebound unlikely given poor response of HR to diltiazem. He was Monitored on telemetry. He was rate controlled w IV beta blocker gtt for HR persistently > 100. His coumadin was held and restarted on [**5-9**]. Initially his INR of 5.1 was reversed with Vitamin K 10 PO and 4 units of FFP. He was on PO Diltiazem and PO Lopressor for rate control. He was restarted on his Coumadin. . Delirium: He was acutely confused while in the ICU and required soft wrist restraints, as he was pulling at tubes and lines. His mental status was improving daily. He occasional required reorientation. CAD: The patient is s/p DCA of the LAD/D1 bifurcation stenosis in 11/96 and s/p rotational atherectomy and PTCA of the LAD and PTCA of D2 in 1/97. He presented with epigastric pain radiating to his substernal chest at rest. EKG shows atrial fibrillation with RVR. CEs were negative x3. A lipid panel and HgA1c showed ASA 325 daily and Atorvastatin 20 daily were continued and Coumadin and Enalapril (in the setting of hypotension) were held. As he stablized, his home meds were again restarted. . DM: Blood sugar > 243. This was treated with an aggressive sliding scale c goal FSG < 150. He was started on an insulin gtt for tight blood sugar control His oral diabetes meds were held. The insulin drip was dc'd on HD 3, and he was transferred to the floor on an ISS only. [**Last Name (un) **] was consulted when he reached the floor re Blood Glucose control. . Chronic Renal Insufficiency: Baseline Cr 1.2-1.7, Cr was 1.4 on admission. Renally dose all meds, Followed Cr and UOP. . Asthma: No PFTs on record - Continued Fluticasone, changed Albuterol to Xopenex in setting of tachycardia. . Anemia: In ICU HCT 31.1 down from 39.2 on admission. [**Month (only) 116**] represent dilution in setting of IVF. Microcytic in the past c MCVs in low 80s. Low ferritin in the past. Guiaic negative. His HCT was checked [**Hospital1 **]. Thrombocytopenia: Hi plateltets dropped from 225 on admission to Likely dilutional. If persistent would workup for hemolysis given elevated T. Bilirubin. - PLT [**Hospital1 **] - Transfuse < 10 or bleeding c count < 50. Medications on Admission: Albuterol 90 1-2 puffs''''prn, Atorvastatin 20, Diltiazem 240, Enalapril 5, Fluticasone 110 2 puffs'', Pantoprazole 40'', Rosiglitazone 8, coumadin 5 Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as needed for SOB, wheezing. 2. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6 hours) as needed. 4. Atorvastatin 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 5. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed. 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 7. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Two (2) PO BID (2 times a day). 8. Diltiazem HCl 90 mg Tablet [**Hospital1 **]: One (1) Tablet PO every six (6) hours. 9. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) Injection TID (3 times a day). 10. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff Inhalation QID (4 times a day). 11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 12. Warfarin 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QHS (once a day (at bedtime)): monitor INR. 13. Fluticasone 110 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 14. Insulin NPH Human Recomb 100 unit/mL Suspension [**Hospital1 **]: Twenty (20) Subcutaneous twice a day. 15. Insulin Lispro 100 unit/mL Solution [**Hospital1 **]: Sliding scale Subcutaneous four times a day. 16. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID (3 times a day). 17. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a day). 18. Ciprofloxacin in D5W 400 mg/200 mL Piggyback [**Hospital1 **]: One (1) Intravenous Q24H (every 24 hours): Stop [**2107-5-17**]. 14 day course. 19. Haloperidol Lactate 5 mg/mL Solution [**Month/Day/Year **]: .25 mg Injection [**Hospital1 **] (2 times a day) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Cholangitis, Choledocholithiasis cholecystitis septic shock atrial fibrillation Diabetes ICU Delerium Discharge Condition: Good Continue tubefeeding and wean as PO diet increases Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new or worsening abdominal pain. * You experience new chest pain, pressure, squeezing or tightness. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or 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. * No heavy lifting (>[**10-5**] lbs) until your follow up appointment. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 468**] in 3 weeks. Call [**Telephone/Fax (1) 2835**] to schedule an appointment. Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS Date/Time:[**2107-8-5**] 4:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2107-8-5**] 4:00 Completed by:[**2107-5-13**]

[ "995.92", "585.9", "707.05", "403.90", "293.0", "574.31", "427.31", "272.4", "493.90", "414.01", "280.9", "287.4", "785.52", "V58.61", "250.00", "038.9", "576.1" ]

icd9cm

[ [ [] ] ]

[ "96.6", "51.87", "51.85" ]

icd9pcs

[ [ [] ] ]

17609, 17688

10082, 15310

287, 352

17834, 17892

6444, 10059

19382, 19779

5471, 5664

15511, 17586

17709, 17813

15337, 15488

4920, 5047

17916, 19359

5679, 6425

220, 249

380, 2335

2357, 3822

5063, 5455

73,760

141,240

35803

Discharge summary

report

Admission Date: [**2199-4-12**] Discharge Date: [**2199-4-18**] Date of Birth: [**2118-4-11**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 348**] Chief Complaint: Respiratory Distress Major Surgical or Invasive Procedure: VATS Pleurodesis, Central Line Insertion, Arterial Line Insertion History of Present Illness: 81 year-old male with recurrent L pleural effusion ?chylothorax, was in usual state of health, went to the OR with interventional pulmonology for drainage of the effusion, biopsies, and talc pleurodesis. The patient had MAC sedation and a paravertebral block for pain, required neosynephrine for nearly the entirety of the case. . Following the surgery, the patient returned to the PACU where he rapdidly developed respiratory distress, productive cough, and continued to be hypotensive and hypoxic. The patient was given a total of 60mg of lasix, high-flow oxygen, and eventually placed on bipap. Consideration was made to intubate, but the patient began to improve clinically. . On arrival to the MICU, the patient arrived on bipap and was lethargic, but had stable vital signs but was requiring pressors; lasix and nitroglycerin gtts were started. . Past Medical History: 1. CARDIAC RISK FACTORS:+ Diabetes,+ Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CAD s/p MI at age 45 with resultant cardiomyopathy, LVEF most recently noted at < 20% by echo [**12/2197**] -CABG: CABG in [**2166**] with redo CABG in [**2176**] -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: -[**2186**]: Biventricular ICD for primary prevention with removal of pacing system at [**Hospital3 **] for infection, reimplantation in [**4-/2193**], s/p generator replacement in [**Month (only) 359**] [**2195**] 3. OTHER PAST MEDICAL HISTORY: -Hypertension -Dyslipidemia -NSVT -Paroxysmal atrial fibrillation -Diabetes Type 2 (diet controlled) -Severed/lacerated fingers s/p surgical repair -Open Cholecystectomy -Fractured shoulder -Hard of hearing (bilateral hearing aids) -Hx of biliary tract stenosis s/p stenting Social History: Social: Married. Lives in [**Hospital1 **]. Contact for discharge: Son [**Name (NI) **]: [**Telephone/Fax (1) 81435**] cell Tobacco: (50 pack year history) Quit about 20 year sago ETOH: occasional beer Recreational drugs: Denies Home services: Denies; ambulates independently Family History: Many family members with CAD in their 70's- 80's. No family history, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission Physical Exam: . Physical Exam: Vitals: T: 95.3 BP: 122/62 P: 106 R: 40 O2: 95% 50% bipap General: Somnolent, responds to stimuli, in respiratory distress HEENT: Sclera anicteric, dry oral mucosa, reddish drainage from mouth into bipap mask Neck: supple, difficult to ascertain JVP, suprasternal retractions CV: Tachycardic, there is an AICD in the R chest Lungs: Diffuse rhonchorous breath sounds, there are chest tubes present in the L chest with serosanguineous drainage Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley Ext: cool, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: responds to voice stimula, unable to speak due to bipap mask . Discharge Physical Exam: VSS, no hypoxia Lungs: Slight left sided basilar crackles, otherwise clear. Chest tube site with mild serosanguinous drainage resolved. Pleurex catheter site CDI Heart: Irregular, [**1-22**] holosystolic murmur at apex, no extra heart sounds, no JVD Ext: No edema Pertinent Results: Admission Labs: . [**2199-4-12**] 03:00PM BLOOD WBC-6.4 RBC-4.21* Hgb-10.0* Hct-33.9* MCV-81* MCH-23.7*# MCHC-29.4* RDW-15.6* Plt Ct-212 [**2199-4-12**] 03:00PM BLOOD PT-17.7* PTT-30.7 INR(PT)-1.7* [**2199-4-12**] 03:00PM BLOOD Plt Ct-212 [**2199-4-12**] 03:00PM BLOOD Glucose-105* UreaN-34* Creat-1.3* Na-138 K-3.8 Cl-103 HCO3-23 AnGap-16 [**2199-4-12**] 03:00PM BLOOD CK(CPK)-100 [**2199-4-12**] 03:00PM BLOOD CK-MB-3 cTropnT-0.25* proBNP-[**2161**]* [**2199-4-12**] 03:00PM BLOOD Calcium-8.4 Phos-4.3 Mg-1.9 [**2199-4-12**] 03:06PM BLOOD Type-ART pO2-108* pCO2-48* pH-7.32* calTCO2-26BasXS--1 Intubat-NOT INTUBA05/25/12 04:27PM BLOOD Lactate-2.7* [**2199-4-13**] 03:36AM BLOOD freeCa-1.05* . CXR [**4-12**] Right atrial, ventricular, and coronary sinus pacemaker/defibrillator leads course in expected position. Following left pleurodesis, the left pleural effusion has conerted into a moderate left hydropneumothorax. There is also new subcutaneous air in the left chest wall. Moderate interstitial and airspace pulmonary edema have developed, and moderate cardiomegaly and central venous congestion persist. Probable small right pleural effusion is present. IMPRESSION: 1. Moderate left hydropneumothorax at pleurodesis site. 2. Increased pulmonary edema. . ECHO [**4-13**] The left ventricular cavity size is normal. Overall left ventricular systolic function is severely depressed. RV with global free wall hypokinesis. No aortic regurgitation is seen. Trivial mitral regurgitation is seen. There is no pericardial effusion. CXR [**4-14**]: There is a dual-lead pacemaker, right IJ central venous line which are unchanged in position. There is also a left-sided chest tube. No pneumothoraces are seen. There is a marked cardiomegaly, moderate pulmonary edema and a left retrocardiac opacity. The opacities of the right base have improved since the prior study. No pneumothoraces are present. Pathology from pleural site: Pending DISCHARGE LABS: [**2199-4-18**] 07:44AM BLOOD WBC-11.1* RBC-3.28* Hgb-8.0* Hct-26.6* MCV-81* MCH-24.2* MCHC-29.8* RDW-17.2* Plt Ct-244 [**2199-4-18**] 07:44AM BLOOD PT-15.2* PTT-31.3 INR(PT)-1.4* [**2199-4-18**] 07:44AM BLOOD Glucose-116* UreaN-32* Creat-1.2 Na-132* K-3.6 Cl-96 HCO3-25 AnGap-15 [**2199-4-18**] 07:44AM BLOOD Calcium-8.3* Phos-3.5 Mg-2.0 [**2199-4-17**] 06:55AM BLOOD calTIBC-380 Ferritn-82 TRF-292 [**2199-4-15**] 01:49PM BLOOD Digoxin-0.7* Brief Hospital Course: 81 y/o male with a history of afib, heart failure c/b recurrent transudative pleural effusions presenting with acute respiratory distress following pleurodesis. 1. Hypoxia s/p VATS pleurodesis: There could have been multiple etiologies to his decompensation, including procedural fluid shifts following VATS and CHF exacerbation during and after the procedure. His BNP was elevated and he had evidence of pulmonary edema on CXR. The fast progression of symptoms make acute pulmonary edema the most likely diagnosis. The patient was stabilized on BiPap, his diuretics were restarted, and he was quickly weaned off of oxygen. The patient's chest tube was removed on the floor after the amount of drainage decreased. His pleural fluid culture and tissue culture was negative. He was discharged with the pleurex catheter with VNA to help with intermittent drainage. 2. Hypotension: After the VATS, the patient required transient norepi for blood pressure support. On the floor, the patient's SBP remained in the 80s and 90s. This is slightly below recent baseline, so his home meds and diuretics were carefully reinitiated. On discharge, the patient's SBP was in the low 100s and he was asymptomatic. 3. CHF: Restarted on torsemide 40mg. Spironolactone decreased from 25mg [**Hospital1 **] to Qday. He remained on digoxin. Lisinopril was held on discharge due to recent hypotension. The patient was euvolemic on discharge. 4. Afib: The patient was maintained on Sotalol, Digoxin, and Warfarin. His INR was subtherapeutic on discharge. He will have this rechecked at home. He will have his pacer interrogated by Dr. [**Last Name (STitle) **] in the near future. 5. Anemia: The patient has chronic anemia. After the procedure, his Hct trended down slightly and he tolerated one unit of PRBCs. Iron studies were sent that showed a low iron level, but normal ferritin. The patient's outpatient providers can determine whether the patient should be supplemented with iron pills. TRANSITIONAL: - INR checks - Iron Pills? - Pulmonary Followup Medications on Admission: DIGOXIN - (Prescribed by Other Provider) - 125 mcg Tablet - 1 Tablet(s) by mouth once a day FLURAZEPAM - 30 mg Capsule - 1 Capsule(s) by mouth at bedtime as needed for sleep LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - Tablet(s) by mouth once a day ROSUVASTATIN [CRESTOR] - (Prescribed by Other Provider) - 5 mg Tablet - Tablet(s) by mouth at bedtime SOTALOL - 80 mg Tablet - 0.5 (One half) Tablet(s) by mouth twice a day - No Substitution SPIRONOLACTONE - 25 mg Tablet - 1 Tablet(s) by mouth twice a day TORSEMIDE - 20 mg Tablet - 2 Tablet(s) by mouth once a day WARFARIN - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth daily as directed. Rotating 7.5mg or 10mg . Medications - OTC ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - Tablet(s) by mouth once a day MAGNESIUM OXIDE - (Prescribed by Other Provider) - 400 mg Tablet - 1 Tablet(s) by mouth daily Discharge Medications: 1. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO at bedtime. 2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. sotalol 80 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): No substitutions. 4. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. warfarin 5 mg Tablet Sig: Two (2) Tablet PO 3X/WEEK (MO,WE,FR). 6. warfarin 5 mg Tablet Sig: 1.5 Tablets PO 4X/WEEK ([**Doctor First Name **],TU,TH,SA). 7. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. flurazepam 30 mg Capsule Sig: One (1) Capsule PO at bedtime as needed for insomnia. Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Left Pleural Effusion Hypotension Hypoxia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the ICU following a procedure to drain the fluid from your lung because you were having difficulty breathing and your blood pressure was low. These problems were able to be corrected and you were then transfered to the medical floor for further care. On the floor, we restarted your home medications and monitored your blood pressure. You continued to have a small amount of fluid drained from the Pleurex catheter each day. A nurse will help you with this at home. The following changes have been made to your medications: DECREASE Spironolactone from 25mg twice a day to once a day HOLD Lisinopril for now as your blood pressure was a little low. Your outpatient doctor can restart this if your blood pressure is better. DECREASE Aspirin from 325mg once a day to 81mg once a day Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Please make your follow-up appointments. Please take your medications as prescribed. Followup Instructions: Name: [**Last Name (LF) 81436**],[**First Name3 (LF) 20**] M. Location: [**Hospital **] MEDICAL GROUP Address: [**Street Address(2) 81437**] [**Apartment Address(1) 29156**], [**Location (un) **],[**Numeric Identifier 7359**] Phone: [**Telephone/Fax (1) 28671**] Appointment: Monday [**2199-4-22**] 4:30pm Department: WEST PROCEDURAL CENTER When: MONDAY [**2199-5-6**] at 1:15 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 7769**] Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: WEST PROCEDURAL CENTER When: MONDAY [**2199-5-6**] at 1:15 PM [**Telephone/Fax (1) 5072**] Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: CARDIAC SERVICES When: WEDNESDAY [**2199-5-29**] at 9:30 AM With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "412", "427.31", "285.9", "250.00", "518.4", "518.52", "272.4", "428.0", "V45.02", "V45.81", "401.9", "V58.61", "414.00", "428.22", "458.29", "511.9", "414.8" ]

icd9cm

[ [ [] ] ]

[ "34.6", "34.20", "34.06" ]

icd9pcs

[ [ [] ] ]

9716, 9765

6023, 8062

292, 359

9851, 9851

3593, 3593

11097, 12349

2403, 2556

9022, 9693

9786, 9830

8088, 8999

10034, 11074

5556, 6000

2613, 3284

1352, 1783

232, 254

387, 1244

3609, 5539

9866, 10010

1814, 2091

1266, 1332

2107, 2387

3309, 3574

12,345

199,172

43501

Discharge summary

report

Admission Date: [**2111-11-11**] Discharge Date: [**2111-11-21**] Date of Birth: [**2046-10-28**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 64 year old female with a history of coronary artery disease, who is status post PCI and stent of her left circumflex on [**9-30**]. History of congestive heart failure and hypercholesterolemia and hypertension and noninsulin dependent diabetes mellitus and chronic renal insufficiency, with a baseline creatinine of 1.8. She is status post non ST segment elevation myocardial infarction on [**10-5**] and after PCI, she had decrease in platelets, which were thought to be secondary to Integrilin. She was admitted on [**10-23**] with shortness of breath and chest pain and ruled out for a myocardial infarction. She had a positive MIBI scan and underwent cardiac catheterization on [**2111-10-27**] which revealed the left main to be patent; the left anterior descending artery with diffuse disease and a 70% proximal stenosis. The left circumflex was with patent stents and small filling defect in the right coronary artery with 60% distal stenosis, 80% at the posterior descending artery and an echo revealed an ejection fraction of 40%. She was then referred to Dr. [**Last Name (STitle) 70**] for possible coronary artery bypass grafting. PAST MEDICAL HISTORY: History of coronary artery disease; status post PCI and stents of her left circumflex on [**2111-10-10**]. History of congestive heart failure. History of noninsulin dependent diabetes mellitus. Hypercholesterolemia. Hypertension. Chronic renal insufficiency with a baseline creatinine of 1.8. She is legally blind with a history of retinopathy, a history of osteoarthritis. Status post total abdominal hysterectomy. History of thrombocytopenia. Status post appendectomy. Status post left ankle fracture with pins. SOCIAL HISTORY: She lives with her husband. She quit smoking cigarettes 40 years ago but prior to that, has a 20 pack year history. She does not drink alcohol. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Protonic 40 mg p.o. q. day. Zocor 10 mg p.o. q. day. Plavix 75 mg p.o. q. day. Aspirin 80 mg p.o. q. day. Zoloft 25 mg p.o. q. day. Lasix 20 mg p.o. q. day. Lopid 100 mg p.o. q. day. Insulin 70/30, 40 units q. a.m. and 20 units q. p.m. REVIEW OF SYSTEMS: Noncontributory. PHYSICAL EXAMINATION: She is well-developed, well-nourished female in no apparent distress. Vital signs revealed a temperature of 98.; blood pressure 123/77; heart rate of 60; respirations of 15; oxygen saturation of 97% on two liters. HEAD, EYES, EARS, NOSE AND THROAT: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements intact. Oropharynx is benign with bilateral dentures, right upper and lower. Her neck is supple with full range of motion, no lymphadenopathy or thyromegaly. Carotid pulses are 2+ bilaterally without bruit. Her lungs are clear to auscultation bilaterally. Heart is regular rate and rhythm without murmurs, rubs or gallops. She has a normal S1 and S2. Her abdomen is obese with positive bowel sounds. Soft, nontender, nondistended, with no masses and no hepatosplenomegaly. Extremities are without cyanosis, clubbing or edema. Pulses are 2+ and equal bilaterally throughout her extremities. Neurologic: Nonfocal. HOSPITAL COURSE: On the day of admission, Ms. [**Known lastname 93621**] was taken to the operating room and underwent coronary artery bypass grafting times three with the left internal mammary artery to the diagonal; saphenous vein graft to the left anterior descending artery and saphenous vein graft to the obtuse marginal. The surgery was performed by Dr. [**Last Name (STitle) 70**] with Dr. [**Last Name (STitle) 7625**] and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], PA-C as assistant. The surgery was performed under general endotracheal anesthesia with cardiopulmonary bypass time of 90 minutes and a cross clamp time of 29 minutes. The patient tolerated the procedure well and was transferred to the Intensive Care Unit with two ventricular, one atrial and one ground wire, one mediastinal and one left pleural chest tube. She was transferred on Propofol drip and in normal sinus rhythm. Upon awakening from anesthesia, she was weaned to C-Pap but remained intubated for the next day because of respiratory metabolic acidosis. She did receive multiple amps of bicarbonate and this did normalize and she was able to be extubated on postoperative day number two. Throughout that time, she did require insulin drip and was followed by the renal service. Also, on postoperative day number two, she did have her chest tube discontinued without incident. She did eventually require Dopamine drip at 3 mcg and Neo-Synephrine to increase her blood pressure to help in perfusing her kidneys. She was weaned off of those by postoperative day number two. By postoperative day number three, she was starting to be more aggressively diuresed and was started on 60 three times a day of Lasix. Also, on postoperative day number three, she also went into rapid atrial fibrillation for brief periods of time but converted to a junctional rhythm on her own. At this time, she was noted to have continued junctional rhythm and because her ventricular wires were working but her atrial wires did not. She did have the pads placed in case she did brady down. She was restarted on her Dopamine drip to help with her heart rate and help maintain her but did not have any other recommendations. She was then taken to the catheterization laboratory on [**11-16**] and had a bipolar pacemaker placed. Also during this time, she had been on heparin drip and her platelet count was noted to drop. An HIB antibody test was sent off and she was noted to be HIB positive. On [**11-17**], on postoperative day number six, she was transferred to the surgical floor for more aggressive physical therapy and cardiac rehabilitation. On postoperative day number seven, her pacing wires were discontinued without incident and her Lasix was changed from intravenous to p.o. as she was diuresing well. Also of note, creatinine had risen back to its baseline of 1.8. On postoperative day number eight, she was ambulating some with physical therapy and it was felt that she would benefit from a short rehabilitation stay. On postoperative day number nine, she was screened for rehabilitation and accepted to a short term rehabilitation facility. She will be discharged to this rehabilitation facility on postoperative day number ten, [**2111-11-21**]. Her discharge examination shows her to be alert and oriented times three and in no apparent distress. She is afebrile. Heart rate of 82; blood pressure of 166/67; respirations 18; oxygen saturation of 95% on room air. Heart: Regular rate and rhythm. Lungs are clear to auscultation bilaterally. Her abdomen is soft, nontender, nondistended. Her extremities show 1+ pedal edema. Wounds are clean, dry and intact and her sternum is stable. LABORATORY DATA: White count of 5.1; hematocrit of 31.1% and platelet count of 140,000. Sodium of 141; potassium of 4.8; chloride of 104; C02 31; BUN 46; creatinine 1.6 and blood glucose of 168. Discharge chest x-ray shows no infiltrates and two bilateral small effusions. She will be discharged to rehabilitation in good condition and her discharge medications include the following: 1.) Protonic 40 mg p.o. q. day. 2.) Colace 100 mg p.o. twice a day. 3.) Potassium chloride 20 meq twice a day. 4.) Lasix 40 mg p.o. q. day. 5.) Enteric coated aspirin 325 mg p.o. q. day. 6.) Percocet one to two tablets p.o. every four hours prn for pain. 7.) Plavix 75 mg p.o. q. day. 8.) Zoloft 50 mg p.o. q. day. 9.) Zocor 10 mg p.o. q. day. 10.) Insulin 70/30, 30 units subcutaneous q. a.m. and 10 units subcutaneous q. p.m. and regular insulin sliding scale, which will be attached to her discharge paper work. She should follow-up with Dr. [**First Name (STitle) 18488**], her primary care physician in one to two weeks; with her cardiologist in two to three weeks; with her physicians at the [**Hospital 3208**] Clinic and with Dr. [**Last Name (STitle) 70**] in six weeks. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Last Name (NamePattern1) 93622**] MEDQUIST36 D: [**2111-11-20**] 06:38 T: [**2111-11-20**] 19:00 JOB#: [**Job Number 93623**]

[ "410.72", "272.0", "414.01", "401.9", "250.50", "287.5", "427.31", "V45.82", "428.0" ]

icd9cm

[ [ [] ] ]

[ "37.72", "36.15", "37.83", "36.12", "39.61" ]

icd9pcs

[ [ [] ] ]

2101, 2338

3381, 8642

2399, 3363

2358, 2376

163, 1328

1351, 1873

1890, 2075

13,888

110,288

21323

Discharge summary

report

Admission Date: [**2187-12-13**] Discharge Date: [**2187-12-18**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1654**] Chief Complaint: mouth bleeding Major Surgical or Invasive Procedure: None History of Present Illness: 85F with extensive medical history most notable for CVA with residual left hemiparesis, and PCV had 5 teeth pulled in upper gum on day prior to admission. She experienced persistent bleeding. She was reportedly seen by her dentist, who stated that the suture line was intact and there is no further intervention possible. Pt c/o swallowing blood but denies n/v/light-headedness. . In ED, her initial vitals were 97.6, 78, 121/66, 16, and 99% on RA. She remained hemodynamically stable throughout her time there. She did spike a temp to 100.8 at 11:30 pm on [**12-12**]. There, multiple attempts were made at stopping the bleeding; she had near-constant pressure, placement of gelfoam, vitamin K 5mg SC, 4 units of FFP, surgicel, afrin, silver nitrate, suture placed, and she received 2units of PRBC for a Hct drop of 42.4 to 31.5. She was also agitated and was placed in restraints and given Haldol 2.5mg IV. She was also started on several antibiotics, including flagyl, unasyn, levoflox, clinda, ceftriaxone, [**1-31**] findings of UTI and possible aspiration PNA. . Concerning her persistent bleeding, Dental/OMFS was consulted and there was no response. ENT was consulted, but reported that there was no further intervention to be done other than correcting her coagulopathy. . She has not had any known history of bleeding disorder. ED and Heme/Onc have been in touch with her PCP, [**Name10 (NameIs) 1023**] confirmed that she has not had any history of bleeding before. She was transferred to the [**Hospital Unit Name 153**] for management with Heme/Onc following. Past Medical History: -polycythemia [**Doctor First Name **]: *information obtained by heme/onc fellow: - hydrea x at least 5 years; oncologist's name is [**Name (NI) **] [**Name (NI) 4223**] -CVA with L hemiparesis -HTN -CHF, last EF 55% in [**2182**] -GERD, h/o duodenal ulcer -vertigo -depression -h/o VRE in urine -dementia -hemorrhoids -cataracts -L temple squamous cell carcinoma [**8-2**] -L facial basal cell carcinoma [**8-2**] -? gout -osteoarthritis Social History: resident of [**Hospital 100**] Rehab. She is a hemiplegic s/p CVA. Uses standing lift for transfers. Incontinent of urine. Is usually alert and oriented. She takes a soft diet with supplemental drink at meals. Family History: NC Physical Exam: 97.6 78 121/66 16 99% RA GEN: lying in bed with blood covering mouth and chin, yelling out for help repeatedly, R arm restrained. HEENT: pupils reactive, EOMI Mouth: + bleeding from upper gums diffusely, sutures in place. Gelfoam extruding from side of mouth. CV: RRR Abd: s/nt/nd Rectal: pt refused. Lungs: pt would not cooperate with exam. clear to anterior auscultation Ext: no c/c/e. Neuro: alert and agitated. Oriented to person and "hospital" but not to date or time. Full ROM on R, L hemiparesis in upper and lower extremities. Pertinent Results: CXR: 1. Focal consolidation at right base and patchy consolidation at left base concerning for aspiration pneumonia Vs. aspiration. CT Abd/Pelvis: 1. No evidence of retroperitoneal hematoma. No intra-abdominal fluid. 2. Splenomegaly measuring up to 15 cm, consitent with history of polycythemia [**Doctor First Name **]. 3. Low attenuation within the vessels consistent with moderate/severe anemia. 4. Gallstones. 5. Multiple high and low attenuation lesions in bilateral kidneys, which are inadequately characterized on this non-contrast study. 6. Bilateral adrenal adenomas. 7. Atherosclerosis. TTE: 1. The left atrium is normal in size. The left atrium is elongated. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF>75%). 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. 5.The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. 6.The estimated pulmonary artery systolic pressure is normal. 7.There is no pericardial effusion. [**2187-12-12**] 07:05PM BLOOD WBC-35.8* RBC-4.97 Hgb-13.0 Hct-42.4 MCV-85 MCH-26.1* MCHC-30.6* RDW-18.0* Plt Ct-416 [**2187-12-13**] 06:00AM BLOOD WBC-34.2* RBC-3.69*# Hgb-9.6*# Hct-31.5*# MCV-85 MCH-25.9* MCHC-30.3* RDW-18.2* Plt Ct-408 [**2187-12-13**] 05:00PM BLOOD WBC-36.0* RBC-2.86* Hgb-7.2* Hct-24.1* MCV-84 MCH-25.3* MCHC-30.0* RDW-18.8* Plt Ct-525* [**2187-12-14**] 04:53PM BLOOD WBC-33.6* RBC-3.69* Hgb-10.2* Hct-31.4* MCV-85 MCH-27.5 MCHC-32.3 RDW-17.6* Plt Ct-348 [**2187-12-16**] 09:00AM BLOOD WBC-38.4* RBC-4.20 Hgb-11.6* Hct-36.8 MCV-88 MCH-27.5 MCHC-31.5 RDW-18.5* Plt Ct-343 [**2187-12-14**] 04:11AM BLOOD Neuts-91.0* Bands-0 Lymphs-6.4* Monos-1.5* Eos-0.5 Baso-0.6 Atyps-0 Metas-0 Myelos-0 [**2187-12-12**] 07:05PM BLOOD PT-15.8* PTT-38.7* INR(PT)-1.7 [**2187-12-16**] 02:30PM BLOOD PT-15.5* PTT-31.1 INR(PT)-1.6 [**2187-12-12**] 07:05PM BLOOD Fibrino-186 [**2187-12-13**] 09:35AM BLOOD FDP-0-10 [**2187-12-13**] 04:05PM BLOOD Thrombn-18.4 [**2187-12-14**] 04:11AM BLOOD Ret Aut-2.0 [**2187-12-12**] 07:05PM BLOOD Glucose-92 UreaN-36* Creat-0.7 Na-141 K-4.9 Cl-104 HCO3-25 AnGap-17 [**2187-12-14**] 04:11AM BLOOD LD(LDH)-421* TotBili-0.7 [**2187-12-12**] 07:05PM BLOOD ALT-17 AST-27 LD(LDH)-339* AlkPhos-145* TotBili-0.5 [**2187-12-13**] 09:35AM BLOOD Hapto-54 [**2187-12-13**] 01:10AM BLOOD Lactate-1.8 [**2187-12-13**] 01:07AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017 [**2187-12-13**] 01:07AM URINE Blood-NEG Nitrite-POS Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM [**2187-12-13**] 01:07AM URINE RBC-0 WBC-[**6-8**]* Bacteri-MANY Yeast-NONE Epi-0-2 Urine Culture: E. Coli, pansensitive Blood cultures: NGTD at discharge C. diff negative x 1 Brief Hospital Course: [**Hospital Unit Name 153**] Course: . No evidence of DIC or hemolysis (LDH (277 -> 421), bili (0.7), retic (2) haptoglobin (54 -> 71)). FDP 0-10, Fibrinogen 190->283. Hct continued to slowly drop, requiring several additional transfusions of PRBC. Pt remained hemodynamically stable throughout. Smear w/o evidence of hemolysis except for rare schistos. Platelets normal. No evidence of liver disease on smear (no targets, etc). LFTs normal. Has no h/o liver disease or problems w/ synthetic function. No report of poor nutrition from [**Hospital 100**] Rehab records. No recent h/o heparin, coumadin, or other anticoagulants. ASA and hydrea held. continued allopurinol. . Vitamin K SC initially given, then started on vitamin K 10mg IV qD x 3 days (started on [**12-14**]). Also given Amicar 4-5g IV bolus over one hour, followed by 1g/hr for 8hrs. Visible bleeding resolved on [**12-14**] and has not recurred since. . Wbc count quite elevated throughout [**Hospital Unit Name 153**] course, up to 40. Possibly [**1-31**] infection (UTI or aspiration PNA) vs stress response from bleed, though by report, chronically elevated. Tx with levo (started [**12-13**]) and flagyl (started [**12-15**]) for possible aspiration PNA (10 day course). No evidence of progression to AML/MDS on smear. . Ms. [**Known lastname **] also experienced hypernatremia to 150. Given D5W. She was kept NPO for first day in-house out of concern of gingival bleeding. Was started on liquid diet on [**12-15**]. She was transferred to the floor on [**12-15**], and continued to do well. She had no additional bleeding. Her hydrea and ASA were restarted. A mixing study was sent, with results pending at time of d/c. Received 3 days IV vitamin K, with slight improvement of her INR. INR should be f/u, and Vit K given as necessary. Hct should be checked periodically to ensure Ms. [**Known lastname **] has no additional bleeding. . Ms. [**Known lastname **] also continued to be treated for pan-sensitive UTi and possible aspiration PNA. Blood cultures continued to be negative at time of D/c, and pt was C. diff negative. She is being discharged on Levo/Flagyl, and should continue this course until [**2187-12-24**]. . Ms. [**Known lastname **] had slight worsening of mental status, thought to be delerium [**1-31**] infection. Her psych meds were held, and foley catheter was d/c'ed. Ms. [**Known lastname **] also had a few episodes of tachycardia on telemetry on [**12-17**], thought to be atrial tachycardia with variable block. Her VS were stable, and she was asymptomatic. She was started on metoprolol 12.5mg PO bid, and this arrhythmia has not recurred. A TTE was done that showed no regional WMAs, and preserved EF>75%. Pt is DNR/DNI - discussed with Dr. [**Name (NI) 14936**], pt's PCP; also confirmed with daughter who is health care proxy. . Medications on Admission: MEDS: hydroxyurea 500 qd remeron 45 [**Name (NI) **], kcl 10 qd sorbitol 15 [**Name (NI) **] tramadol 50 [**Hospital1 **] trazodone 25 [**Hospital1 **] allopurinol 200 [**Hospital1 **] asa 81 qd wellbutrin 50 [**Hospital1 **] oscal lasix 20 qam fosamax 70 qwk tylenol 650 [**Hospital1 **] methylcellulose powder (citrucel) 1 heaping tbsp qd MOM prn [**Name2 (NI) **] hydrocortisone cream to rectal area prn hemorrhoid pain artificial tears tid esomeprazole 40mg qd fleet enema 1 pr qd prn Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days: End date: [**2187-12-24**]. 3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 6 days: End date: [**2187-12-24**]. 4. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane TID (3 times a day) as needed. 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): Hold for SBP<100 or HR<60. 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 9. Protonix 40 mg Recon Soln Sig: One (1) Intravenous once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - LTC Discharge Diagnosis: Prolonged gingival bleeding after dental procedure, probably due to vitamin K deficiency vs inhibitors Discharge Condition: Stable. Hct stable, no bleeding since [**12-14**]. Discharge Instructions: Your care is being transferred to the [**Hospital1 5595**]. please have repeat speech and swallow once you have returned to [**Hospital **] rehab WITH YOUR DENTURE IN PLACE to see if nutrition consistency can be upgraded. You should have periodic hematocrit checks to ensure you are not having any occult bleeding. Followup Instructions: You should continue to follow up with your geriatrics attendings at [**Hospital1 5595**]. You should f/u with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 14936**] after your stay at [**Hospital1 5595**].

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icd9cm

[ [ [] ] ]

[ "99.04", "99.07" ]

icd9pcs

[ [ [] ] ]

10320, 10385

6097, 8935

279, 286

10532, 10585

3172, 6074

10950, 11178

2597, 2601

9474, 10297

10406, 10511

8961, 9451

10609, 10927

2616, 3153

225, 241

314, 1890

1912, 2353

2369, 2581

30,983

160,902

33774

Discharge summary

report

Admission Date: [**2199-5-2**] Discharge Date: [**2199-5-20**] Date of Birth: [**2148-10-8**] Sex: F Service: CARDIOTHORACIC Allergies: Iodine / Latex Attending:[**First Name3 (LF) 922**] Chief Complaint: Asymptomatic Major Surgical or Invasive Procedure: [**2199-5-2**] Redo-Thoracoabdominal Aortic Aneurysm Repair History of Present Illness: 50 y/o female who underwent Thoracoabdominal Aneurysm repair in [**2189**] for Aneurysm and Chronic Type B Dissection. Since that time she has been followed by serial chest CT scans for aneurysmal component of visceral patch. She currently remains asymptomatic but last CT showed residual distal descending throracic aortic anuerysm which extends into visceral segment of abdominal aorta and aorto-iliac bypass. Past Medical History: Thoracoabdominal Aortic Aneurysm w/ Type B Dissection s/p Thoracoabdominal Aortic Aneurysm repair and Aorto-Iliac Bypass Graft in [**2189**], Hypercholesterolemia, Hypertension, Obstructive Sleep Apnea, Obesity, s/p Partial Hysterectomy, s/p Tonsillectomy, s/p Tubal ligation Social History: Quit smoking 4yrs ago after 20 pack year history. Occ. ETOH. Family History: Non-contributory Physical Exam: VS: 76 Reg. 124/60 5'3" 209# Gen: WDWN pleasant female in NAD Skin: W/D intact, well-healed thoraco-abdominal incision HEENT: EOMI, PERRL, NCAT Neck: Supple, FROM -JVD, -Carotid bruit Chest: CTAB Heart: RRR faint SEM Abd: Soft, NT/ND +BS Ext: Warm, well-perfused, well-healed left femoral incision Neuro: A&O x 3, MAE, non-focal DISCHARGE EXAM VSS: T:100.4/99.4 BP:106/59, P:90 , R/A=97% General: A&O x3, NAD HEENT: AT/NC, PERRL, wnl CVS:RRR, Lungs:CTA ABD:+BS, soft, NT/ND EXT: warm, neg.C/C +trace edema Right groin wound:open with purulent drainage->packed with DSD Left thoracoabdominal incision with steri strips. C/D/I Pertinent Results: [**2199-5-19**] 12:41PM BLOOD WBC-9.4 RBC-3.41* Hgb-9.4* Hct-28.2* MCV-83 MCH-27.7 MCHC-33.5 RDW-14.9 Plt Ct-568* [**2199-5-19**] 12:41PM BLOOD Glucose-102 UreaN-15 Creat-0.8 Na-138 K-4.1 Cl-99 HCO3-30 AnGap-13 [**5-2**] Echo: PRE-BYPASS: 1. The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. 3. Right ventricular chamber size and free wall motion are normal. 4. The descending thoracic aorta is markedly dilated. There is evidence of intramural hematoma/graft in the distal descending thoracic aorta. 5. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. 6. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. POST- R heart BYPASS: Pt removed from partial R heart bypass on phenylephrine infusion and was in normal sinus rhythm. 1. Valves as noted pre-bypass. 2. No evidence of dissection in the ascending or distal aortic arch post-decannulation or post graft placement. RADIOLOGY Final Report CHEST (PA & LAT) [**2199-5-14**] 2:30 PM CHEST (PA & LAT) Reason: assess for effusions/infiltrates [**Hospital 93**] MEDICAL CONDITION: 50 year old woman s/p thoracoabdm AAA repair REASON FOR THIS EXAMINATION: assess for effusions/infiltrates HISTORY: Postoperative AAA repair. FINDINGS: In comparison with study of [**5-10**], there is little change. Increased opacification at the left base extending along the lateral chest wall is again seen. The atelectatic streaks at the right base have cleared and the right lung shows no evidence of pneumonia. PICC line remains in place. DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**] RADIOLOGY Final Report CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2199-5-8**] 5:18 PM CTA CHEST W&W/O C&RECONS, NON-; CTA ABD W&W/O C & RECONS Reason: s/p redo throcoabdominal abdominal aortic aneurysm [**Hospital 93**] MEDICAL CONDITION: throcoabdominal abdominal aortic aneursym REASON FOR THIS EXAMINATION: s/p redo throcoabdominal abdominal aortic aneurysm CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: 50-year-old female with multiple thoracoabdominal aortic surgeries, for reassessment. TECHNIQUE: CT of the chest, abdomen and pelvis was performed without intravenous contrast followed by CT of the chest, abdomen and pelvis post- administration of intravenous contrast, reconstructions were performed in the axial, sagittal, and coronal planes. Reconstructions were also performed in the 3D imaging lab. COMPARISON: There is no prior examination at this institution. Comparison was made with the available outside study. FINDINGS: CT CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST: There is a left basal effusion with atelectasis most likely related to recent surgery. There are scattered subcentimeter mediastinal lymph nodes. There is no pericardial effusion. CT ABDOMEN WITH AND WITHOUT INTRAVENOUS CONTRAST: There are bilateral renal hypodensities, likely cysts. There is hypoperfusion at the lower pole and the interpolar cortex of the left kidney suggestive of ischemia/infarction. The liver, spleen, adrenal glands, and pancreas appear unremarkable. The gallbladder is unremarkable. There are scattered subcentimeter upper abdominal lymph nodes. There is inflammatory change and fluid in the left upper quadrant abutting the spleen and the aortic graft, most likely postoperative. CT PELVIS PRE- AND POST-ADMINISTRATION OF INTRAVENOUS CONTRAST: There is free fluid in the pelvis, which may represent sequela of the recent abdominal surgery. There are tubal clips seen in situ. There is no pelvic lymphadenopathy. There is colonic diverticulosis without evidence of diverticulitis. MUSCULOSKELETAL: There is extensive subcutaneous edema along the left lower thoracic and abdominal wall, most likely sequelae of recent surgery. There are no worrisome bone lesions. CT ANGIOGRAM: There is a bovine arch. The patient has had multiple abdominal aortic operations. The ascending aorta at the level of the right main pulmonary artery measures 31 x 29 mm, and the descending thoracic aorta at the level of the left inferior pulmonary vein measures 40 x 42 mm. There is no central or segmental pulmonary embolism or aortic dissection. There has been a reanastomosis of the abdominal aortic branches. The celiac trunk shows short segment focal stenosis with post-stenotic dilatation. The luminal diameter at the stenosis is 5 x 4 mm and the post-stenotic luminal diameter is 9 x 10 mm. The superior mesenteric artery is patent. The inferior mesenteric artery fills in retrogradely. The right and left renal arteries are patent. The iliac vessels are diminutive in caliber, although these are patent. CONCLUSION: 1. Patent aortoiliac graft and abdominal vasculature with minimally short segment stenosis of the celiac artery with post-stenotic dilatation as described above. 2. Left basal effusion with atelectasis should be followed up with a chest CT to ensure resolution in two months. 3. Areas of hypoperfusion in the left kidney are most likely ischemic. There are multiple bilateral renal hypodensities likely cysts. 4. Anasarca along the left chest and upper abdominal wall and fluid in the upper abdomen and the pelvis are most likely sequelae of the recent surgical intervention. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 28783**] [**Name (STitle) 28784**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Brief Hospital Course: Mrs. [**Known lastname **] was a same day admit after undergoing all pre-operative work-up as an outpatient. On day of admission she was brought directly to the operating room where she underwent a redo thoracoabdominal aortic aneurysm repair. Please see operative report for surgical details. Following surgery she was transferred to the CVICU for invasive monitoring in stable condition. Infectious disease was consulted on post-op day one following GPC found at anastomosis site of graft from prior aneurysm repair and she remained on vanocmycin. Patient remained intubated for several days as she was a difficult intubation and required significant fluid rescusitation, but was eventually weaned from sedation and diuresed, and awoke neurologically intact and was extubated on post-op day three. She received racemic epi and heliox for stridor which improved. Lumbar drain was removed on [**5-3**]. Chest tubes were removed on post-op day four and she was later transferred to the telemetry floor for further care. It was decided that she receive 6 week course of IV antibiotics due to findings from culture during surgery. Therefore on post-op day five a PICC line was placed. Over the next several days the patient remained in the hospital on IV antibiotics, during this time she continued to have low grade fevers with no obvious source. She was given a 3 day course of cipro for proteus UTI. On POD 12 her groin wound was noted to have purulent drainage, it was opened debrided and packed with wet-dry packing covered with DSD. She was tranfused for HCT 21. CT scan showed no source of bleeding. She continued to have daily low grade temperatures, infectious work up was negative, however eosinophils increased and she was switched from vancomycin to daptomycin. Fevers stopped. On POD 18 she was discharged home with VNA. Medications on Admission: Labetolol 20mg [**Hospital1 **], HCTZ 12.5mg qd, Prinivil 40mg qd, Zocor 20mg qd Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*1* 5. Vancomycin 500 mg Recon Soln Sig: 1500 (1500) mg Intravenous Q 12H (Every 12 Hours) for 6 weeks: 6 wks from surgery, continue thru [**6-13**]. Disp:*qs/6 weeks course mg* Refills:*0* 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 2 weeks. Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 9. Heparin Lock Flush 10 unit/mL Solution Sig: QD and PRN Intravenous once a day: Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. Disp:*qs 45* Refills:*2* Discharge Disposition: Home With Service Facility: [**Last Name (un) 78108**] Home Care VNA in Virginea Discharge Diagnosis: Thoracoabdominal Aortic Aneurysm, s/p Thoracoabdominal Aortic Aneurysm repair in [**2189**] with visceral button aneurysm now s/p Redo-Thoracoabdominal Aortic Aneurysm Repair PMH: Hypercholesterolemia, Hypertension, Obstructive Sleep Apnea, Obesity, s/p Aorto-Iliac Bypass Graft, s/p Partial Hysterectomy, s/p Tonsillectomy, s/p Tubal ligation 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. [**Last Name (STitle) 914**] in 4 weeks [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2199-6-6**] 1:00 Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]/[**Hospital 71793**] Medical in [**University/College 7709**], VA. (Cardiologist) [**Telephone/Fax (1) 78109**] Dr. [**Last Name (STitle) 78110**] (PCP in VA) in 2 weeks Dr. [**First Name (STitle) 745**] (Infectious Diseases in VA) 2-3 weeks [**Telephone/Fax (1) 78111**] Completed by:[**2199-5-20**]

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icd9cm

[ [ [] ] ]

[ "99.04", "87.44", "39.63", "39.61", "86.28", "38.91", "88.72", "38.93", "39.49" ]

icd9pcs

[ [ [] ] ]

10893, 10976

7534, 9368

292, 353

11363, 11369

1866, 3090

11682, 12239

1187, 1205

9499, 10870

3926, 3968

10997, 11342

9394, 9476

11393, 11659

1220, 1847

240, 254

3997, 7511

381, 794

816, 1093

1109, 1171

64,296

199,949

39578

Discharge summary

report

Admission Date: [**2181-5-15**] Discharge Date: [**2181-5-20**] Date of Birth: [**2119-7-29**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 338**] Chief Complaint: worsening weakness Major Surgical or Invasive Procedure: nasotracheal intubation PICC line placement History of Present Illness: Mr [**Known lastname 37393**] is a 61 yo man with a h/o extensive SCLC recently treated with single [**Doctor Last Name 360**] irinotecan presented to clinic today with worsening lower and upper extremity weakness. Pt also seen by ENT last Friday and found to have known bilateral vocal paralyiss by now an opening of only 2 mm. Pt does report increased sob over the past few days. Pt was admitted ealier this month because of worsening upper and lower extremity weakness. He had an MRI the C/T/L spine, a dedicated MRI of the cervical spine and a MRI of the brain. These images showed likely progression/worsening edema of known intramedullary disease of the cervical spine, regression of lumber spinal disease and brain mets. Pt evaluated by both radiation oncology and neurosurgery. At that time neurosurgery thought that no surgical intervention would be of benefit. As pt has received xrt to teh whole spine , no additional radiation tx was recommended either. Pt was startd on decadron and was discharged to rehab with f/u with both the primary oncologist and neuro-oncology.At rehab, pt's weakness has progressed over the past few days and now he is bed bound. He also has more difficulty urinating. Pain is overall well controlled with current regimen of pain medications.+ constipation. He denies fevers, chills, nausea, vomiting, headaches, cough, chest pain, abdominal pain. All ten point ROS is negative. Past Medical History: ONCOLOGIC HISTORY: # extensive-stage small-cell lung cancer Patient complained of shortness of breath and dyspnea on exertion for several months, with worsening hoarseness of his voice and difficulty projecting his voice. He was seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**] at [**Hospital3 **] in the primary care setting for leg pain. At that time, Dr. [**Last Name (STitle) 4469**] noticed the significant dyspnea on exertion and hoarse voice that Mr. [**Known lastname 37393**] had. The patient underwent an extensive workup which included a chest x-ray that revealed an enlarged anterior mediastinal mass. Mr. [**Known lastname 37393**] was referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2180-8-31**] and was also seen the same day by Dr. [**Last Name (STitle) **] for a mediastinal mass biopsy. The biopsy results were consistent with small-cell lung cancer. [**2180-9-5**]: first cycle of cisplatin/etoposide [**2180-9-5**]: Brain MRI: multiple lesions without mass effect consistent with metastatic disease [**2180-9-6**]:cardica echo: mass close to the lateral LV, no frank tamponade but impaired ventricular filling. [**2180-9-6**]:Bone Scan: no metastatic disease [**2180-9-6**]: CT abdomen/pelvis: bilateral small pleural effusions, small pericardial effusion. No other metastatic disease Radiation Oncology evaluation: Recommended whole brain radiation. [**2180-10-5**] TORSO CT: Large left paramediastinal mass with encasement of multiple mediastinal and bronchovascular structures, particularly narrowing the left main pulmonary artery and the left upper lobe bronchus as well as narrowing of the left brachiocephalic vein, pericardial invasion with small pericardial effusion. Stable to decrease in size of pulmonary nodules, small left pleural effusion, no evidence of bony metastases or intra-abdominal metastasis/lymphadenopathy. Completed on [**2180-11-13**] 4 Cycles of cisplatin / etoposide [**2180-12-1**] chest CT: No significant change in size of the large infiltrative left paramediastinal mass with encasement of multiple mediastinal structures, no significant interval change in pulmonary nodules bilaterally, moderate pericardial effusion, slight increase in size without secondary findings of tamponade, moderate left pleural effusion larger in size. [**2180-12-1**] head MRI: Marked improvement in appearance of multiple small infra and supratentorial lesions, no new lesions identified, findings consistent with treatment response. [**2181-3-23**]. He has completed his spinal radiation. [**2181-4-6**] started Irinotecan # laryngeal cancer in [**2169**] s/p radiation therapy . OTHER MEDICAL HISTORY: -GERD -s/p partial colectomy for diverticulitis with ostomy, now s/p takedown of ostomy -s/p hernia repair -s/p cataract removal Social History: The patient lived with his significant other (fiancee) for 26 years until recently.He was recently d/c to rehab. He worked as a maintenance millwright. He is a smoker for 40 years, but currently, he is smoking two cigarettes a day. He denies alcohol and drug use. Family History: The patient's mother is alive and healthy. His father died at age 48 with unknown cause and his siblings are healthy. Physical Exam: T 96.4 BP110/70 P 103 RR 20 O2 sat 99% General : Pt chronically ill appearing, episodes of stridor, hoarse HEENT: Pupils equal and miotic, sclerae non-icteric, o/p clear, mm dry Neck: Supple, No JVD, no thyromegaly. CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops RESP: Good air movement bilaterally, no rhonchi or wheezing, no accessory muscle use. ABD: Soft, non-tender, non distended EXTR: bilateral ankle edema DERM: No rash Neuro: Cranial nerves [**2-3**] grossly intact,quadriperesis, more to teh right and lower. PSYCH: Appropriately anxious Pertinent Results: [**2181-5-15**] 11:50AM BLOOD WBC-10.5 RBC-3.69* Hgb-11.5* Hct-32.8* MCV-89 MCH-31.2 MCHC-35.0 RDW-17.5* Plt Ct-239 [**2181-5-15**] 11:50AM BLOOD Neuts-97* Bands-0 Lymphs-0 Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* [**2181-5-15**] 11:50AM BLOOD UreaN-34* Creat-0.8 Na-133 K-4.4 Cl-93* HCO3-35* AnGap-9 [**2181-5-15**] 11:50AM BLOOD ALT-12 AST-21 LD(LDH)-251* AlkPhos-72 TotBili-0.6 [**2181-5-15**] 11:50AM BLOOD Calcium-8.9 Phos-2.9 Mg-1.9 Brief Hospital Course: 61 yo man with extensive SCLC status post four cycles of cisplatin and etoposide followed by radiation in the residual intrathoracic disease, brain and spine radiation most recently has clinically progressed on single [**Doctor Last Name 360**] irinotecan with progressive quadriplegia and vocal cord paralysis. Pt seen by ENT on day of admission and found with only 1 mm of airway. ENT recommended an elective intubation followed a tracheostomy. This option as well as a palliative approach in which we would manage his symptoms and not prolong his sufferings was discussed with pt. Pt understands that he has end stage cancer with progressing quadriplegia, without any good therapeutic options.The procedure of intubation was also explained to patient. The patient together with his wife, decided that he wished to pursue with elective intubation and afterwards decide if to undergo a tracheostomy or to choose palliative care without a tracheostomy. While intubated in the ICU, he was noted to have hypotension and was on dopamine via peripheral IV. This was discontinued as IV infiltrated, raising concern for ischemia. Pt was seen by hand service who recommended hand elevation and discontinuing dopamine. Pulses remained intact, good cap refill. Given the progressive quadriplegia and his worsening disease, it was decided by the family that he would not want the tracheostomy after discussion with Dr. [**Last Name (STitle) 3274**], outpatient oncologist, as well as with the primary ICU team. He was transitioned to a focus on comfort measures. Patient expired at 8:55 PM on [**2181-5-20**], autopsy was offered and declined. Medications on Admission: 1. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) 17 grams dose PO DAILY (Daily): hold for loose stools. 2. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 3. oxycodone 40 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q12H (every 12 hours). Disp:*60 Tablet Extended Release 12 hr(s)* Refills:*0* 4. oxycodone 5 mg Tablet Sig: Four (4) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*120 Tablet(s)* Refills:*0* 5. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for N/V. 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): hold for loose stools. 7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: [**12-24**] Tablet, Chewables PO QID (4 times a day) as needed for heartburn. 8. senna 8.6 mg Tablet Sig: Two (2) Tablet PO three times a day: hold for loose stools. 9. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 10. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 13. lactulose 10 gram/15 mL Solution Sig: Fifteen (15) cc PO twice a day as needed for constipation: hold for diarrhea or loose stools. Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Small cell lung cancer Vocal cord paralysis Respiratory failure Discharge Condition: expired Discharge Instructions: N/A Followup Instructions: N/A Completed by:[**2181-5-20**]

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icd9cm

[ [ [] ] ]

[ "96.72", "38.97", "96.01" ]

icd9pcs

[ [ [] ] ]

9368, 9377

6170, 7810

322, 367

9484, 9493

5701, 6147

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4985, 5106

9340, 9345

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7836, 9317

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395, 1814

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4700, 4969

26,915

186,861

51037

Discharge summary

report

Admission Date: [**2160-7-12**] Discharge Date: [**2160-7-19**] Date of Birth: [**2080-9-25**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 905**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: endotracheal intubation History of Present Illness: 79 yo male with h/o vascular dementia, htn, hypothyroidism who was recently admitted to [**Hospital1 18**] s/p multiple falls thought to be mechanical [**1-18**] dementia. He was transferred back to [**Hospital1 106020**] home [**7-8**] but was then sent to [**Hospital1 18**]-[**Location (un) 620**] after he was noted by NH staff be be acting out of character and being physically abusive towards staff. He was diagnosed with PNA at [**Hospital1 18**]-[**Location (un) 620**] but was then transferred to [**Hospital1 18**] when the [**Hospital1 11851**] refused to take him back before he had a psychiatry evaluation. . Psychitary evaluated patient in the ED and patient was pleasant and cooperative. Psych felt he likely had delerium presumed secondary to PNA, superimposed on his baseline dementia, and recommended discharged back to [**Hospital1 11851**]. . However, while in the ED, the patient became transiently tachypneic and hypoxic to the 70's with with good pleth per ED report. DDimer was found to be mildly elevated at 571 however patient refused a CTA. He received lovenox in the ED and was admitted to medicine on [**2160-7-12**] for further management. . On the medicine floor, his hypoxia was thought to be PE vs pna vs potential mucous plugging. However, a CXR obtained at [**Hospital1 18**] had no evidence of pneumonia. He did not receive further lovenox but sedation was considered for CTA. He was continued on Levofloxacin started at [**Hospital1 18**] [**Location (un) 620**]. Admission otherwise complicated by suboptimal blood pressures with SBPs in 150s and patient was started on hydralazine. transferred to the MICU for hypotension. Past Medical History: Vascular dementia AOx1 at baseline HTN Mitral valve regurgitation hypothyroidism depression vertigo Social History: retired hairdresser remote tob, remote ETOH (was heavy in past), - drugs, lives in nursing home ([**Hospital1 11851**]) as of early [**6-21**]. Family History: Mother: alzheimers, Father: MI, twin sister died in childhood. Physical Exam: VS: 97.7 150/90 78 20 97% RA Gen: NAD HEENT: PERRLA, EOMI, bilateral cataracts, OP clear, MMM CV: RRR, [**1-22**] holosystolic murmur Resp: CTAB Abd: soft, NT/ND, +BS, no masses Ext: +2 DP and radial pulses, no edema Neuro: unable answer questions about recent history Pertinent Results: [**2160-7-12**] 09:45AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG Admission Labs: [**2160-7-14**] WBC-5.4 RBC-4.28* Hgb-13.6* Hct-39.7* MCV-93 MCH-31.7 MCHC-34.2 RDW-13.5 Plt Ct-258 Neuts-84.8* Lymphs-11.1* Monos-3.2 Eos-0.7 Baso-0.2 BLOOD Plt Ct-258 BLOOD PT-12.1 PTT-24.7 INR(PT)-1.0 Glucose-80 UreaN-18 Creat-0.8 Na-142 K-3.7 Cl-106 HCO3-25 AnGap-15 Calcium-8.9 Phos-4.1 Mg-2.4 TSH-10*T4-6.8 [**2160-7-13**] 11:00AM CK(CPK)-95 cTropnT-<0.01 [**2160-7-15**] 10:17AM BLOOD Type-ART pO2-339* pCO2-43 pH-7.42 calTCO2-29 Base XS-3 [**2160-7-13**] CXR PA/Lat:No active pulmonary disease. [**2160-7-13**] EKG: Sinus rhythm. Right bundle-branch block. Compared to the previous tracing of [**2160-7-4**] no significant diagnostic change. [**2160-7-15**] CTA: 1. No pulmonary embolus. 2. No inflammatory process, mass or lymphadenopathy. 3. Thick walled esophagus. Suggest endoscopy or barium swallow. [**2160-7-15**] CT Head: No significant change since [**2160-7-4**] with no acute intracranial abnormalities. Moderate degree of small vessel ischemic changes. Brief Hospital Course: In summary, on the medicine floor, pt hypoxia was thought to be PE vs pna vs potential mucous plugging. However, a CXR obtained at [**Hospital1 18**] had no evidence of pneumonia. He did not receive further lovenox but sedation was considered for CTA. He was continued on Levofloxacin started at [**Hospital1 18**] [**Location (un) 620**]. Admission otherwise complicated by suboptimal blood pressures with SBPs in 150s and patient was started on hydralazine. On the morning of [**7-15**], the patient was found unresponsive to sternal rub by nursing staff at ~ 10am; a CODE BLUE was called. Vitals afebrile, SBP 70-80s, HR 90-100s, O2 90s. The patient had been doing well at 8AM, received his AM medications, including 10 mg of IV hydralazine. SBPs had been stable overnight in the 130s-160s prior to dosing. During the CODE BLUE, supplemental O2 was placed, patient was placed in Trendelenburg, and IVF were started. FSBG was 144. O2 saturations remained in the high 90s on supplemental O2 but patient remained somnolent and had minimal chest wall exertion; he was intubated for airway protection. Following 500 cc of NS, SBP rose to 100s. Following 750 cc NS total, SBPs rose to 130s. EKG showed sinus tachycardia without obvious ischemic pattern. Following intubation for airwary protection, once SBPs 100s-130s, patient was coughing, uncomfortable with airway, but also showed extensor posturing and had intermittent repetitive movements of his RUE. He received 1 mg of ativan with resolution of repetitive motor activity but continued intermittent posturing. SBPs remained stable >130 and patient was transferred to the ICU for further management. ICU Course: Upon fluid resuscitation, the patient's rapid response to minimal IVF suggested hypovolemia or neurocardiogenic causes of AMS. Hypotension was most likely secondary to hydralazine given this AM although had otherwise been tolerating this medication. Obtundation resolved with fluid resuscitation and was presumably secondary to cerebral hypoperfusion in the setting of hypotension. Further IVF were held as BP stabilized and antihypertensives were also held as hydralazine IV was likely the cause of his earlier hypotension and subsequent CODE BLUE. Patient was extubated in MICU and tolerated transition well. Patient has baseline dementia secondary to vascular disease, and 1:1 sitter was present once the patient was extubated. . Upon transfer to the MICU, posturing on exam with repetitive movements was concerning for seizure activity. Also the patient was rigid and hyperreflexic on right concerning for UMN injury more likely subacute or acute than chronic as these changes would likely not appear immediately following insult. CT head was without evidence of ICH or herniation. In the MICU, patient had no more episodes of seizure activity or posturing. . The patient's O2 saturation was 98-100% s/p extubation. Patient had history of transient hypoxia ED with excellent oxygenation on floor since admission. PE was ruled out via CTA. No significant A-a gradient from recent ABG. Hypoxia likely secondary to mucous plugging as PNA was not evident on chest imaging. Levofloxicin was continued for PNA diagnosed at OSH day # [**3-22**] therapy in ICU, although no evidence of PNA on imaging at [**Hospital1 18**]. Patient was advanced to a full mechanical diet in MICU. Heparin SC and briefly IV famotidine (during intubation) were administered for prophylaxis. Full work-up of hypotension was performed. Hb was stable on ABG at time of code. CBC showed a drop in HCT (35.7-->41.9) since admission to ICU but repeat HCT showed 43.8 did not suggest a source of bleeding. No fever, normal WBC count, clear source of infection to suggest sepsis as a cause of hypotension. Blood cultures and urine were sent to be followed pending transfer to floor. EKG did not reveal ischemic changes; three sets of cardiac enzymes were negative. LFTs and pancreatic enzymes were normal, which did not suggest an intraabdominal process. TSH was elevated, and T4 was sent to evaluate hypothyroidism. Pt was transferred back to the floor where HTN was treated with Metoprolol 25mg [**Hospital1 **] until the patient obtained a bed at his nursing home. Medications on Admission: Levothyroxine 50 mcg PO DAILY Hexavitamin 1 Cap PO DAILY Bisacodyl 10 mg PO DAILY PRN Modafinil 50 mg PO Daily Paroxetine 20 mg PO DAILY Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. 4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 6. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Modafinil 100 mg Tablet Sig: 0.5 Tablet PO QDay (). 8. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 10. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) ml Injection Q1H (every hour) as needed. Discharge Disposition: Extended Care Facility: [**Hospital 11851**] Healthcare - [**Location (un) 620**] Discharge Diagnosis: Community aquired Pneumonia Delerium Dementia Hypotensive episode requiring intubation for airway protection Discharge Condition: Stable, saturating well on room air, at baseline mental status. Discharge Instructions: You were admitted to the hospital for low blood oxygen saturation and a high heart rate. While in the hospital, you became unresponsive when your blood pressure became low and were resuscitated with intravenous fluids and were intubated. You were then tranferred to the medical ICU for one day. You did well in the ICU and when your blood pressure was stable. You were then extubated and were tranferred back to the floor. On the floor your blood pressure was controlled with metoprolol 25mg [**Hospital1 **] and the levoquin continued for your pneumonia. During your stay, you were also evaluated by psychiatry in the ED, who felt you to be pleasant and cooperative. Psych felt you likely had delerium presumed secondary to PNA, superimposed on his baseline dementia, and recommended discharged back to [**Hospital1 11851**]. Please finish your course of levoquin as perscribed. You have been started on a new medication for elevated blood pressure. Please continue to take and have you blood pressure monitored daily while at the nursing home. Please do not take the metoprolol if your systolic blood pressure is less than 110. Please call your PCP if you develop new shortness of breath, chest pain, fevers, or worsened confusion. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11771**], M.D. Phone:[**Telephone/Fax (1) 26488**] Date/Time:[**2160-9-23**] 11:30 [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

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icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

9100, 9184

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336, 361

9337, 9403

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9205, 9316

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2439, 2710

275, 298

390, 2059

3690, 3827

2845, 3681

2081, 2182

2198, 2344

8,712

156,710

3327

Discharge summary

report

Admission Date: [**2164-5-30**] Discharge Date: [**2164-6-1**] Service: CCU HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **] year old male with good baseline activities of daily living functions with a history of coronary artery disease, with acute myocardial infarction in [**2159**] status post successful primary intervention with left ejection fraction of 30% after myocardial infarction, who has done well since procedures with only minor recurrence of chest pain and who also has a history of colon cancer status post hemicolectomy. Over the last year, he has developed a prolonged PR interval, a right bundle branch block, left anterior fascicular block that has been noted on electrocardiograms. Prior to admission, the patient was able to walk regularly and be active, but on the day of admission at around noon, the patient had severe lightheadedness and dizziness while walking. He denied chest pain, shortness of breath, nausea, vomiting or diaphoresis at that time. The patient had significant symptoms while standing, walking and even when trying to sit upright; after the initial episode of dizziness, however, he was asymptomatic while resting in bed in a prone position. A bystander at the scene of the initial episode was savvy enough to check a pulse which was 37 at the time of onset of symptoms. In the Emergency Room, the patient had a pulse ranging from 32 to 34 with a blood pressure in the 110 to 120 over 40 to 50 range without symptoms. He had no chest pain, no shortness of breath, and no diaphoresis. The patient denies recent medication changes. He has had no recent fevers, chills, sweats, cough, prior episodes of dizziness, paroxysmal nocturnal dyspnea, orthopnea, nausea, vomiting or abdominal pain. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Colon cancer. 3. Hypertension. 4. Hypercholesterolemia. 5. Bullous pemphigus. 6. Glaucoma. 7. Cataracts. PHYSICAL EXAMINATION: His physical examination on admission was vital signs of blood pressure 113/48; heart rate 32 to 34; O2 saturation 99% on room air; respiratory rate 14. General examination was an elderly male that was alert and oriented times three in no acute distress. HEENT: Pupils were equal, round and reactive to light with accommodation. His mucous membranes were moist. Oropharynx was clear. His cranial nerves II through XII were intact. Neck: No venous pulsation, no thyromegaly. Cardiovascular examination showed bradycardia, irregular rhythm, normal S1 and S2 but no murmurs, rubs or gallops. Pulmonary examination clear to auscultation bilaterally; no wheezes. Abdomen was soft, nontender; he had active bowel sounds. Extremities cool to touch; no cyanosis, no edema, one plus radial pulse, one plus posterior tibial pulse and one plus dorsalis pedis pulses bilaterally. LABORATORY: On admission, white blood cell count 9.0, hemoglobin 14.0, hematocrit 14.1, neutrophils 74%, lymphocytes 18%, monocytes 6% and eosinophils 1%. His platelet count was 163. PT was 12.4, INR 1.1, PTT 34.3. His sodium 140, potassium 4.8, chloride 105, bicarbonate 24, BUN 53, creatinine 1.7. CK was 43, CK MB was 1. His troponin was less than 0.3 and CPK was, as I said, 43. His chest x-ray impression was: Much improved appearance compared to prior examination on [**2162-9-22**], without congestive heart failure or pneumonia. EKG showed undifferentiated second degree heart block with 2:1 conduction pattern and occasional runs of second degree Type I Wenckebach block. EKG also showed profound bradycardia. There was no evidence of ST elevation or other signs of ischemia. HOSPITAL COURSE: 1. Bradycardia: On the evening of admission, a central venous catheterization Cordis, was placed and transvenous pacing was induced at a rate of 80. This pacing was done for six to eight hours prior to the patient being sent to the Electrophysiology Laboratory where he had a permanent pacer placed on [**5-31**] without complications. The patient's pacemaker was interrogated both after the procedure and the day following procedure, which showed appropriate pacing. The patient received two days of Kefzol and was sent home with one day of p.o. Keflex for post-procedure antibiotic prophylaxis. The patient had an appropriate paced rhythm in the range of 60 to 80 throughout the remainder of his hospitalization. He was hemodynamically stable throughout the rest of his hospitalization. He had no new complaints. 2. Activity: The patient's activity is to be monitored for six to eight weeks, avoiding raising his left arm above his shoulder due to replacement from the pacemaker. The patient will have a visiting nurse which was arranged by the Care Coordinator, to visit on a daily basis, to help him with his daily functions in light of his arm restrictions. 3. Renal: The patient's creatinine elevated to 1.7 on the day of admission, which was thought to be from low p.o. intake and low ejection fraction secondary to bradycardia. Intravenous hydration followed by p.o. hydration, led to normalization of the patient's creatinine to 1.1. It was later learned that the patient had a baseline slightly inhibited renal function which was evident in his hospital course. 4. Endocrine: The patient was maintained on his maintenance dose of Prednisone at 5 mg p.o. for his diagnosis of bullous pemphigus. It was not thought that he needed any stress dose steroids as the 5 mg dose was not suppressing his pituitary access. CONDITION AT DISCHARGE: Good. DISPOSITION: The patient was discharged home. DISCHARGE DIAGNOSES: 1. Tri-fascicular heart block. DISCHARGE MEDICATIONS: 1. Plavix 75 mg q. day. 2. Cozaar 25 mg q. day. 3. Aspirin 325 mg q. day. 4. Zantac 150 mg twice a day. 5. Latanoprost 0.005%, place one drop in right eye at bed time. 6. Metoprolol 25 q. day. 7. Potassium 20 mg q. day. 8. Sertraline 50 mg q. day. 9. Lipitor 10 mg q. day. 10. Prednisone 5 mg q. day. 11. Keflex 500 mg q. eight hours times four doses. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**] Dictated By:[**Last Name (NamePattern1) 7942**] MEDQUIST36 D: [**2164-6-2**] 21:36 T: [**2164-6-4**] 12:07 JOB#: [**Job Number 15455**] cc:[**Last Name (NamePattern4) 15456**]

[ "412", "V10.05", "694.5", "426.13", "272.0" ]

icd9cm

[ [ [] ] ]

[ "37.83", "37.72" ]

icd9pcs

[ [ [] ] ]

5591, 5624

5647, 6351

3645, 5498

1952, 3628

5514, 5570

115, 1763

1785, 1929

48,425

144,643

39302

Discharge summary

report

Admission Date: [**2139-10-27**] Discharge Date: [**2139-11-20**] Service: SURGERY Allergies: Celebrex Attending:[**First Name3 (LF) 148**] Chief Complaint: Cholangiocarcinoma Major Surgical or Invasive Procedure: [**2139-10-27**]: 1. Staging laparoscopy. 2. Pylorus-preserving Whipple's pancreaticoduodenectomy. 3. Open cholecystectomy. 4. Jejunostomy tube. 5. Placement of CyberKnife gold fiducial seeds for radiation therapy. History of Present Illness: 87M w/hx of HTN, CAD, who presented to PCP with abnormal LFTs, 14 lb wt loss- MCRP concerning for biliary malignancy. Pt reports initially developing pruritis on his bilateral arms and chest 6 weeks ago. He saw his PCP who referred the patient to dermatology. He was seen by a dermatologist, and the physician noted possible jaundice on exam?, and LFTs were ordered and found to be elevated. The pt again saw his PCP, [**Name10 (NameIs) **] his LFTs remained elevated. The pt had an Abd CT and then and MRCP, which was concerning for biliary malignancy. The pt does report a 14 lb weight loss over the past 10 weeks, and reports a decreased appetite. The patient underwent ERCP on [**2139-9-28**]. The procedure was notable for a single stricture of malignant appearance of 2-3cm at the lower CBD, with moderate post-obstructive dilation. A sphincterotomy was performed, with placement of a plastic stent in the CBD for decompression. During his last admission, patient was evaluated by Dr. [**Last Name (STitle) **] and he was offered to have a surgical resection. Patient was scheduled for elective Whipple procedure. Past Medical History: -HTN -CAD (s/p PCI [**2127**]) -left carotid stenosis -prostate CA s/p XRT/TURP -legally blind ([**First Name8 (NamePattern2) **] [**Last Name (un) **]) -left nephrectomy (per pt, 60 yrs ago, secondary to retained stone) -left inguinal liposarcoma excised [**2138**] Social History: Pt lives in an [**Hospital3 **] facility in [**Hospital3 **]. Pt reports drinking 2oz of liquor daily (usually vodka). He denies tobacco use currently, pt smoked pipes >12 yrs ago. Family History: Positive for heart disease. No history of cancer. Physical Exam: On Discharge: VS: 97.2, 88, 124/58, 20, 94% RA Gen: NAD CV: RRR, sinus tachycardia with activities Lungs: Diminished bilateraly on bases Abd: Bilateral subcostal incision with steri strips and c/d/i. RLQ JP x 2 to gravity drainage in ostomy bag. LLQ J tube with dry dressing and c/d/i. Extr: Warm, no c/c/e Pertinent Results: Pathology Examination SPECIMEN SUBMITTED: BILE DUCT MARGIN, GALLBLADDER, JEJUNEM, WHIPPLE SPECIMEN, PORTAL LYMPH NODES. Procedure date Tissue received Report Date Diagnosed by [**2139-10-27**] [**2139-10-27**] [**2139-11-2**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/ttl DIAGNOSIS: I. Portal lymph nodes (A-D): Three lymph nodes with no carcinoma seen (0/3). II. Gallbladder, cholecystectomy (E-J): A. Chronic cholecystitis with cholesterolosis and mural fibrosis. B. Cholelithiasis, pigment type. C. No carcinoma seen. III. Bile duct margin (K): Segment of bile duct with focal periductal glandular complexity; no definite carcinoma or dysplasia seen. IV. Jejunum (L-O): Small intestinal segment, within normal limits. V. Whipple specimen (P-AQ): A. Adenocarcinoma of the extrahepatic biliary tree (cholangiocarcinoma), moderately differentiated, see synoptic report. B. Six of twenty-two regional lymph nodes (periampullary and peripancreatic nodes), involved by adenocarcinoma ([**7-28**]). C. Adenocarcinoma is present within < 1 mm of the retroperitoneal pancreatic surface. D. Periampullary pancreatic duct with focal high grade intraepithelial neoplasia (slide AH), see synoptic report. E. Duodenal and jejunal segments, within normal limits. Distal Extrahepatic Bile Duct Resection Synopsis Includes Local / Segmental Resections and Pancreaticoduodenectomy Specimens Staging according to American Joint Committee on Cancer Staging Manual -- 7th Edition, [**2138**] MACROSCOPIC Specimen Type: Common bile duct. Other Organs Received: Duodenum, Pancreas (head and neck), Ampulla, Gallbladder, Other (Specify): jejunum. Procedure: Pancreaticoduodenectomy (pylorus-sparing). Tumor Site: Common bile duct: Intrapancreatic. Tumor Size Greatest Dimension: 1.0 cm. Additional dimensions: 1.0 cm x 0.8 cm. MICROSCOPICP: Histologic Type: Adenocarcinoma (not otherwise specified). Histologic Grade: Moderately differentiated. Extent of Invasion TNM Descriptors: N/A. Primary Tumor (pT): pT3: Tumor invades the gallbladder, pancreas, duodenum or other adjacent organs without involvement of the celiac axis or superior mesenteric artery. Regional Lymph Nodes (pN): pN1: Regional lymph node metastasis. Lymph Nodes Number examined: 25. Number involved: 6. Distant metastasis: PMX: Cannot be assessed. MARGINS: Segmental Resection Margins: Margins uninvolved by invasive carcinoma: Distance of invasive carcinoma from closest margin: Specify margin: <1 mm (posterior retroperitoneal). Proximal Margin: Uninvolved by invasive carcinoma. Distal Margin: Uninvolved by invasive carcinoma. Pancreatic Retroperitoneal Margin: Involved by invasive carcinoma (tumor present 0-1 mm from margin, slide Y), see note. Bile Duct Margin: Uninvolved by invasive carcinoma. Distal Pancreatic Margin: Uninvolved by invasive carcinoma. Lymphatic/Vascular Invasion: Present, extensive. Perineural Invasion: Present. Additional Pathologic Findings: Dysplasia (associated with invasive lesion). Comments: Tumor is present within lymph node parenchyma less than 1 mm from the inked retroperitoneal pancreatic margin. Clinical: Cholangiocarcinoma of the bile duct. [**2139-10-28**] EKG: Sinus rhythm. Left axis deviation. Consider left anterior fascicular block. Precordial T wave abnormalities. Since the previous tracing of [**2139-10-19**] ST-T wave abnormalities have improved. Limb lead voltage is somewhat less. [**2139-10-30**] EKG: Sinus rhythm. Left axis deviation. Left anterior fascicular block. There is a late transition with anterior and anterolateral ST-T wave changes consistent with possible prior anterior myocardial infarction. Additional non-specific lateral ST-T wave changes. Compared to the previous tracing ST-T wave changes are more marked and diffuse. [**2139-10-27**] CHEST PORT: IMPRESSION: AP chest compared to [**10-19**]: Lung volumes are generally lower, suggesting that bilateral infrahilar consolidation is probably atelectasis. Small left pleural effusion is new. There is no pleural effusion on the right or any indication of pneumothorax. Right IJ line ends at the junction of the brachiocephalic veins or upper SVC. ET tube and nasogastric tube are in standard placements. A 37 mm long straight metallic linear opacity projecting to the left of the neck is also present on subsequent study 4:43 a.m. on [**10-28**]. We will resolve whether this is technical artifact or foreign body and advise the clinical service accordingly. [**2139-10-31**] CHEST PORT: FINDINGS: Frontal chest radiograph is compared to the prior study from [**10-30**]. The heart is enlarged. Mediastinum is within normal limits. There is dense left lower lobe consolidation with moderate left-sided pleural effusion. There is mild congestive failure. These have increased since prior study. Multiple leads project over the chest. The right IJ catheter is no longer seen and may have been removed. [**2139-11-2**] KUB: IMPRESSION: 1. No evidence of free air to suggest perforation. 2. Air-filled loops of large and small bowel are seen with distention of the small bowel concerning for postoperative ileus, though early partial small- bowel obstruction cannot be excluded. [**2139-11-4**] CT ABD: IMPRESSION: 1. Imaging findings most suggestive of focal ileus involving portion of the pancreaticobiliary limb and proximal jejunum about duodenojejunal anastomotic site and near J-tube entrance. No fluid collection is noted about the blind-ending portion of the hepaticobiliary limb nor is there any extraluminal enteric contrast. A moderate amount of simple appearing ascites is present. Oral contrast within the distal esophagus and stomach also suggests underlying esophageal/gastric ileus or dysmotility. 2. Interval development of small bilateral simple pleural effusions with adjacent regions of lower lobe compressive atelectasis. 3. Mild edema involving the base of the cecum of unclear etiology with no other findings of enteritis or colitis. [**2139-11-8**] CT ABD: IMPRESSION: Interval increase and still small amount of air and fluid in the region of termination of the JP drains. No discrete collections or abscesses identified. Thickening of the adjacent hepaticojejunostomy bowel loops may be secondary to underdistension. No evidence of small-bowel obstruction. [**2139-11-9**] CHEST PORT: FINDINGS: As compared to the previous radiograph, there is mild improvement of the pre-existing retrocardiac atelectasis. Otherwise, the radiograph is unchanged. Moderate cardiomegaly with enlargement of the left ventricle. Mild residual pulmonary edema. Minimal left pleural effusion. No newly occurred focal parenchymal opacities. Nasogastric tube in unchanged position. [**2139-11-11**] CHEST PORT: FINDINGS: In comparison with the study of [**11-10**], there is little overall change. Again, there are low lung volumes with atelectatic changes and effusion at the left base in the retrocardiac region. No definite vascular congestion or acute focal pneumonia. [**2139-11-11**] 9:55 am STOOL CONSISTENCY: LOOSE **FINAL REPORT [**2139-11-11**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2139-11-11**]): REPORTED BY PHONE TO [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], R.N. ON [**2139-11-11**] AT 2305. CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. (Reference Range-Negative). A positive result in a recently treated patient is of uncertain significance unless the patient is currently symptomatic (relapse). Brief Hospital Course: The patient with history of biliary malignancy was admitted to the General Surgical Service for elective Whipple procedure. On [**2139-10-27**], the patient underwent Pylorus-preserving Whipple's pancreaticoduodenectomy, open cholecystectomy, jejunostomy tube placement and placement of CyberKnife gold fiducial seeds for radiation therapy, which went well without complication (reader referred to the Operative Note for details). After a surgery patient was transferred in ICU secondary to respiratory distress and hypotension. On POD # 1 patient was extubated, he self discontinued NGT, and hypotension was improved with IV fluid. On POD # 2, patient was stable, continued on face mask. On POD# 4, IV fluid was discontinued, patient was weaned from face mask to nasal cannula (6L), and diuresed with Lasix IV. On POD # 5, patient was transferred on the floor on 6L n/c, diet was advanced to clears, CVL and Foley were discontinued. The patient was hemodynamically stable. Neuro: The patient received Morphine IV with good effect and adequate pain control after surgery. When tolerating oral intake, the patient was transitioned to oral pain medications - Oxycodone. Currently patient taking PO Tylenol prn for pain control. On POD # 22 patient was triggered for acute mental status change. Patient was lethargic, but easy arousal, VS were within normal limits, and patient returned to his baseline without any interventions. This is was a single incident and patient continue to be stable from neurological stand point until discharge. CV: After transfer from ICU patient's blood pressure was stable. Patient had several episodes of tachycardia, especially with activities, which were treated IV Lopressor with good respond. On POD # 12, patient developed persistent sinus tachycardia with HR 120s, did not improved with IV Metoprolol, patient was transferred into ICU. In ICU patient converted in sinus rhythm, he was continued on small doze of beta-blocker. Patient remained stable from cardiac stand point, he was transferred back on the floor on POD# 15. On the floor patient's cardiac status was continued to be monitored with telemetry unit, patient continue to have episodes of tachycardia and PVCs without any symptoms, patient was restarted on his home medications when tolerated PO. On POD # 22, patient was triggered for episode of tachycardia and mental status change, patient returned back to his baseline without any interventions. Patient's Atenolol was increased for better rate control and his cardiac statu remained stable prior discharge. Pulmonary: Patient was extubated on POD # 1, and after extubation was required BIPAP. BiPAP was discontinued on POD # 3, and patient was transferred on 6L nasal cannula. On POD # 5, patient was transferred on the floor. He was started on aggressive IS, pulmonary toilet and physical therapy. On POD # 8, patient was weaned down to 3 L n/c and his O2 Sats were stable 96-98%. On POD # 12, patient was triggered for persistent tachycardia and tachypnea, he was transferred into ICU. In ICU patient continued on aggressive pulmonary regiment including: IS, chest PT, and nebulizers. Patient was transferred on the floor on POD #15, on the floor he continued to wean off supplemental O2. Patient was required several doses of Lasix to remove excess of fluid. On POD # 18, patient's supplemental O2 was weaned off, he continued to receive nebulizer treatments, IS and chest PT. Patient's pulmonary status continue to improve on discharge. GI/GU/FEN: Post-operatively, the patient was made NPO with IV fluids. Diet was advanced to clear liquids on POD # 5, patient vomited and was made NPO again. On POD # 6, KUB was obtained and demonstrated ileus, NG tube was placed to low suction. Nutritional consult was obtained for tube feed and TPN recommendations. On POD # 8, patient was started on TPN and troph tube feed. JPs amylase was sent and result of output was high ([**Numeric Identifier 86924**] - JP#1, [**Numeric Identifier 86925**] -JP#2), patient was continued on Octreotide IV for treatment of pancreatic leak. Patient was continued on TPN for six days and on POD # 14 TPN was discontinued. Patient's TF was advanced to goal on POD # 15, repeat abdominal CT scan was negative for ileus or SBO. On POD # 16, patient's abdomen was more distended and TF was held. On POD # 17, TF was restarted and patient tolerated well. Electrolytes were routinely followed, and repleted when necessary. On POD # 22 patient was advanced to clear liquid diet, his TF was started to cycle. Patient was evaluated by Speech and Swallow and cleared to have a diet without restrictions. Patient was discharged home on cycled TF and liquid diet with instructions to advance his diet as tolerating and starting to wean off TF. ID: The patient's white blood count and fever curves were closely watched for signs of infection. Patient remained afebrile during hospitalization. WBC was elevated after surgery secondary to atelectasis, when pulmonary function improved, WBC went down to normal limits. After initiation of tube feed, patient developed frequent, loose stool. Stool was sent for c-diff and was found to be positive. Patient was started on IV Flagyl. Patient's Flagyl was changed to PO prior discharge, patient will continue on Flagyl for 14 days total. Patient's urine and blood were negative for infection during hospitalization. On Wound was examined routinely and no signs or symptoms of infection were noticed. Endocrine: The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. Hematology: The patient's complete blood count was examined routinely; no transfusions were required. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a clear liquid diet and TF up to his goal, ambulating with assist, voiding without assistance, and pain was well controlled. Patient was evaluated by Physical Therapy, and they recommended to discharge patient in Rehab. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Atenelol 25mg', Vit B12 100mcg', asa 325', amlodipine 10mg' Discharge Medications: 1. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 2. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 5 days: stop on [**11-25**]. 3. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) neb Inhalation q6h (). 4. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 5. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for peri area. 6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 8. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every six (6) hours as needed for fever or pain. 9. insulin regular human 100 unit/mL (3 mL) Insulin Pen Sig: 4-12 units Subcutaneous before meals and bedtime. 10. atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. 11. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. Discharge Disposition: Extended Care Facility: [**Hospital1 **] Cape & Islands Discharge Diagnosis: 1. Cholangiocarcinoma. 2. Post operative hypotension 3. Ileus 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: 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 [**6-15**] 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. JP Drain Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *Keep ostomy bag firmly attached to your skin. *Note color, consistency, and amount of fluid in the drain. Call the doctor, nurse practitioner, or VNA nurse if the amount increases significantly or changes in character. *Be sure to empty the drain frequently. Record the output, if instructed to do so. *You may shower; wash the area gently with warm, soapy water. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 1231**] Date/Time:[**2139-12-11**] 10:00 [**Hospital Ward Name 23**] 3, [**Hospital Ward Name **] . Please follow up with your PCP [**Last Name (NamePattern4) **] [**3-11**] weeks after discharge Completed by:[**2139-11-20**]

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21499

Discharge summary

report

Admission Date: [**2174-8-29**] Discharge Date: [**2174-9-23**] Date of Birth: [**2102-10-23**] Sex: M Service: NEUROSURGERY Allergies: Plavix Attending:[**First Name3 (LF) 1271**] Chief Complaint: Sudden onset headache Major Surgical or Invasive Procedure: [**2174-8-30**] Suboccipital craniotomy for evacuation of Cerebellar hematoma [**2174-8-30**] External Ventricular Drain [**2174-9-5**] PICC LINE PLACEMENT [**2174-9-12**] tracheostomy [**2174-9-12**] peg placement History of Present Illness: Pt is a 71m with significant PMHX with cardiac stenting in [**2168**] and more recently [**2174-8-26**] who is on ASA 325 and a lovenox to coumadin bridge at home. Pt had onset of severe headache this morning at 11 a.m and ultimately went to local ER when he had no relief. CTH from OSH shows 3.8cm hyperdensity within right cerebellum with mass effect and effacement of the fourth ventricle with no hydrocephalus. INR at that time 1.7 and given FFP, Platelets and profiline nine. He was transfered to [**Hospital1 18**] for further care. He currently complains of headache but no word finding difficulty, facial weakness, extremity weakness or sensory changes and no visual changes. Past Medical History: poorly diabetes x 5 years arthritis of hands treated with ?steroids Social History: SH: no tobacco, occ EtOH, no street drugs or cocaine use ever from [**Country **], lived in states since [**2129**] married, has a daughter and 5 [**Name2 (NI) 7337**] Family History: FH: father and mother died from cancer no premature CAD Physical Exam: On admission: BP: 172/84 HR: 68 R 14 Awake and alert,oriented to place,self and year but not month. Follows commands. Eyes open to voice. Speech fluent. R facial droop with flatening of nasolabial fold. No pronator drift. MAE with full strength. Sensation intact to light touch. Right sided dysmetria with FTN testing. HEENT: Pupils: 2.5mm-2mm reactive EOMs Full, Visual fields full Extrem: Warm and well-perfused. On Discharge: trach/peg- thick yellow secretions, Pupils R [**3-15**] sluggish L [**3-15**] brisk, consistent commands with all four exremities/antigravity moving all extremities spontaneously with good strength Pertinent Results: CT HEAD [**8-29**] 1. Size of hemorrhage in the right cerebellum is unchanged since most recent prior, but there has been interval increase in surrounding vasogenic edema and mild increase in compression and 4 mm leftward shift of the fourth ventricle. 2. Prominence of the bilateral frontal horns of the lateral ventricles, as well as the right temporal [**Doctor Last Name 534**] are new compared to the most recent prior, worrisome for early obstructing hydrocephalus. 3. Stable effacement of the right perimesencephalic cistern. Updated findings were discussed with Dr. [**Last Name (STitle) 56711**] at 10:12pm on [**2174-8-29**]. CT HEAD [**8-30**] pre-op Enlarging 4.6 x 4.1 cm right cerebellar hemorrhage, with increasing 5-mm leftward shift of the fourth ventricle, worsening obstructive hydrocephalus, and developing descending transtentorial and tonsillar herniation. CT HEAD [**8-30**] Post-Op Post-surgical changes in the right cerebellar hemisphere with persistent leftward shift and partial compression of the fourth ventricle. Unchanged dilatation of the lateral and third ventricles. CHEST (PORTABLE AP) Study Date of [**2174-9-4**] 5:57 AM Cardiomediastinal contours are unchanged. Bibasilar opacities, left greater than right are stable consistent with aspiration/pneumonia. There are no new lung abnormalities. There is no pneumothorax or enlarging pleural effusions. ET tube and NG tube are in place in standard position. CT chest [**2174-9-7**] Bibasilar opacities are grossly unchanged. This could be due to atelectasis, superimposed infection cannot be excluded and followup is recommended. Line and tubes remain in place in a standard position. There is no pneumothorax. Bilateral pleural effusions are small. Cardiomediastinal contours are unchanged. CT head [**2174-9-8**] 1. No interval change since the prior examination. Stable ventricular size. Stable appearance to right occipital hemorrhage and suboccipital craniectomy. 2. Stable sinus opacification CT head [**2174-9-15**]: Status post ventriculostomy tube removal. Otherwise, little change since previous study. CT head [**2174-9-16**]: 1. No evidence of developing hydrocephalus. 2. Stable findings in right cerebellum including hematoma, edema and mass effect on quadrigeminal plate cistern and fourth ventricle. CT Chest [**2174-9-16**]: 1. Patchy left lower lobe air bronchogram containing opacity with some scattered tree-in-[**Male First Name (un) 239**] nodules consistent with underlying pneumonia and infectious bronchiolitis. Secretions are noted distal to the tracheostomy site with some impacted airways and bronchial wall thickening in lower lobe which may make placement at risk for recurrent episodes of aspiration pneumonia/pneumonitis. 2. Free intraperitoneal air, presumably related to recent G-tube placement. 3. Small pleural plaques, may relate to prior asbestos exposure. 4. Trace right pleural effusion with mi;d interstitial septal thickening which may suggest component of interstitial edema. CT head [**2174-9-20**]: 1. Continued evolution of right cerebellar hematoma with decreased edema and decreased effacement of the fourth ventricle. 2. Mild interval enlargement of lateral and third ventricles. Recommend continued close follow-up. Brief Hospital Course: This patient presented to an OSH for evaluation of headache on [**8-29**]. Head CT was done which showed a cerebellar hemorrhage on the right side. He was given FFP, Platelets, and Profiline 9. He was then transferred to [**Hospital1 18**] for further care. he presented to the emergency department and found to have a right facial droop and right sided dysmetria. He was admitted to the ICU where he remained stable overnight. On the morning of [**8-30**] a repeat CT of the head was obtained which showed that the cerebellar hemorrhage was enlarging. His exam deteriorated and he became lethargic and difficult to arouse so the decision was made to take him to the OR for an emergent suboccipital craniotomy for evacuation of the right cerebellar hematoma. He tolerated the procedure well and was kept intubated and brought back to he intensive care unit. A CT scan of the head was obtained post-operatively which showed expected post-operative changes as well as slight worsening of hydrocephalus. As a result of this, an external ventricular drain was placed at the bedside. Initial ICP's were in the [**5-25**] range and they remained in that area into the evening of [**8-30**]. Serial head CTs performed on the 18th and 19th continued to show expansion of the posterior fossa bleed and the patient remained intubated with a poor exam consisting of no eye opening and weak flexion to nox. stimuli in the upper extremities. Patient had a bronchoscopy on [**9-1**] for fevers and increased secretions. Preliminary results of the sputum sample were of GPC and GNR. He was started on appropriate abx. An improvement in exam was noted on [**9-2**]; with weak eye opening and command following. The decision was made to continue to provide aggressive supportive care over the weekend. He spiked a fever to 102 on [**9-4**] overnight and he was pan cultured including CSF. Sputum cultures were positive for Klebsiella. Although his neuro exam is steadily improving and CT imaging remains stable, he has a poor cough and no gag reflex. He had a non contrast CT of the head obtained on [**9-5**] which showed hydrocephalus. His ventricular drain was functioning appropriately so no changes were made to it;s settings and it remained at 10cm of water. After discussion with the family and trauma surgical intensive care unit it was determined that he would undergo Trach and PEG. It was also noted that his hematocrit was 25 down from 27 and he received 2 units of packed red blood cells. Following the transfusion his hematocrit raised to 31.6. On [**9-6**] another CT scan of the head was obtained to evaluate his ventricles which showed an interval decrease in size as well as stable appearance of his cerebellar hematoma. He was following commands on exam and per the family seemed much more interactive with them. On [**9-7**] he intermittently followed commands and was noted to be febrile to 102. As a result he was pan cultured including CSF and had a bronchoscopy from which a BAL was sent. On [**9-8**] he was planned for a Trach and PEG however this was postponed secondary to increased ICP's. Also on this date he had a non contrast head CT which was stable in appearance from prior scan and his EVD was left at 10cm of water. On [**9-9**] his exam was improved and he began consistently following commands with his upper extremities and would intermittently follow commands with his lower extremities. He also appeared more interactive. On [**9-10**], patient's staples were removed and his exam remains unchanged. EVD at 10 and draining appropriately. On [**9-11**], patient less interactive, urgent head CT ordered and was stable in comparison to previous scan. Patient's EVD was raised to 15 in the evening. A Trach and peg were placed on [**2174-9-12**]. On [**9-16**], The patient was febrile to 101.6. The patient was pan cultured, a bilateral lower extremity ultrasound was ordered to rule out deep vein thrombosis which was negative, and a chest xray to assess pneumonia. The patient was due to complete his course of two IV antibiotics: Cefepime and Vancomycin; in light of the patient continued fever a consult was placed to infectious disease. Per infectious disease the patient was started on Vancomycin for sputum with preliminary result STAPH AUREUS COAG + on [**2174-9-14**]. Cefepime was increased to 2 grams IV BID. On [**9-19**], the patient again spiked fevers despite double antibiotic coverage, we contact[**Name (NI) **] ID for further recommendations on [**9-20**]. They recommended stopping cefepime and continuing Vancomycin for a 21 day course. The ID team felt that he will continue to spike fevers for several weeks due to the continued aspiration and VAP, however he is being adequately treated and there are no concerns for other caused of fever. He was medically cleared for rehab on [**9-22**] and he was transferred on [**2174-9-23**] to [**Hospital 38**] Rehab. Medications on Admission: AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth daily ATENOLOL - 25 mg Tablet - 1 Tablet(s) by mouth qam ENOXAPARIN [LOVENOX] GLIPIZIDE - 10 mg Tablet - 1 Tablet(s) by mouth qam HYDROCHLOROTHIAZIDE - 12.5 mg Capsule - 1 Capsule(s) by mouth daily PIOGLITAZONE [ACTOS] - 30 mg Tablet - 1 Tablet(s) by mouth qam SIMVASTATIN - 80 mg Tablet - 1 Tablet(s) by mouth daily VALSARTAN [DIOVAN] - 320 mg Tablet - 1 Tablet(s) by mouth daily WARFARIN [COUMADIN] - 5mg daily ASA- 325mg daily Discharge Medications: 1. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). 6. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) [**Hospital1 **] PO BID (2 times a day). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for wheezing. 10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 11. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: One (1) PO DAILY (Daily). 12. White Petrolatum-Mineral Oil 56.8-42.5 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for irritation. 13. Acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for fevers. 14. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: 15-30 MLs PO Q6H (every 6 hours) as needed for constipation. 15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 16. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 17. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for SBP>160. 18. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-15**] Drops Ophthalmic TID (3 times a day) as needed for irritation. 19. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for wheezing. 20. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed for wheezing. 21. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for oral thrush. 22. Insulin Glargine 100 unit/mL Solution Sig: One (1) Subcutaneous once a day: See attached sheet. 23. Ticlopidine 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 24. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg Intravenous every twelve (12) hours: Continue until [**10-6**].Obtain trough prior to 4th dose. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Cerebellar Hemorrhage Obstructive Hydrocephalus Anemia requiring transfusion respiratory failure PNA Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: ?????? A friend, caregiver or family member should check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? You were on Ticlid and effient prior to your surgery. You are currently taking Ticlid however Per your cardiologist you will not be taking Effient ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. You will need to have Weekly Vancomycin trough, CBC with diff and renal function studies weekly while on Vancomycin. Vancomycin should be continued until [**10-6**]. Followup 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. [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2174-9-23**]

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icd9cm

[ [ [] ] ]

[ "38.93", "96.72", "01.59", "31.1", "43.11", "01.10", "96.6", "02.39", "33.24" ]

icd9pcs

[ [ [] ] ]

13415, 13512

5537, 10467

294, 511

13657, 13657

2247, 5514

15300, 15622

1519, 1577

11004, 13392

13533, 13636

10493, 10981

13793, 15277

1592, 1592

2028, 2228

233, 256

539, 1225

1606, 2014

13672, 13769

1247, 1317

1333, 1503

270

188,028

5803

Discharge summary

report

Admission Date: [**2128-6-23**] Discharge Date: [**2128-6-27**] Service: [**Hospital Unit Name 196**] Allergies: 20/20 / Iodine; Iodine Containing / Keflex Attending:[**First Name3 (LF) 2704**] Chief Complaint: Symptomatic carotid stenoses. Major Surgical or Invasive Procedure: L internal carotid artery stenosis s/p angioplasty and stenting Pacemaker and ICD lead revision History of Present Illness: 80 year old with significant carotid artery stenoses revealed by MRA. Noted to have significant L-ICA stenoses beyond the bifurcation with mild stenosis at the bifurcation. On the right hand side, moderate to severe stenosis at the bifurcation and in the proximal R-ICA. These stenoses have become symptomatic with recent ?TIA. Obstructions: Left 90%, right 60-70%. Past Medical History: 1. ICD: Biventricular ICD placed for VT indication. 2. CAD: last cath [**10/2124**]: D1 ostial 30%, LCx 30% ISRS, totally occluded RCA. 3 prior MI's. Stent to LCx in [**2118**], PTCA of LAD in [**2121**], stent to RCA in early [**2113**] (now occluded). 3. h/o LBBB 4. Desc aortic aneurysm (2.3 x 1.5 cm [**2-21**]) 5. CHF, syst and diast (EF 30%) 6. Asbestosis on home O2 7. DJD s/p R TKR 8. Mild CRI 9. s/p appy Social History: Pt is a Jehovah's witness no etoh /tob Lives with his wife in an apartment in [**Name (NI) 1474**] Family History: HTN, CAD, DM Physical Exam: V/S: afeb, 75, 108/59, 14, comfortable on RA I/O: 1738/1040 (+698), overnight -1340. Tele: No events. Gen: A/Ox3, pleasant, NAD. CV: RRR, nl s1/s2, no m/r/g. No carotid bruit. Pulm: CTAB Abd: +BS, S/NT/ND Extr: No c/c/e. Neuro: CNII-XII intact Pertinent Results: [**Known lastname 23052**],[**Known firstname 177**]:[**Hospital1 18**] Radiology Detail - CCC Record #[**Numeric Identifier 23053**] INDICATIONS: 80 year old man with carotid artery stenosis. Evaluation of the vasculature requested. TECHNIQUE: Multiplanar T1, T2, and susceptibility images of the brain were obtained. No contrast was administered. MR angiography of the circle of [**Location (un) 431**] was performed with acquisition of two- and three- dimensional time-of-flight images. MR angiography of the neck was also performed with two- and three-dimensional time- of- flight images of the major arteries. FINDINGS: On the brain images, there is no evidence of hydrocephalus, mass effect, or shift of the normally midline structures. The ventricles, cisterns, and sulci are unremarkable. There are patchy areas of increased T2 signal in the pons. There are also widespread patchy areas of increased T2 signal in the subcortical white matter of both cerebral hemispheres. These signal abnormalities are consistent with chronic small vessel ischemic infarcts. Also, in the posterosuperior right frontal cortex, there is a small area of increased T2 signal in the cortex consistent with a chronic infarction. A similar small infarct in the head of the left caudate nucleus is also observed. No susceptibility artifact is seen. The visualized vascular flow voids are present. The osseous structures, soft tissues, and sinuses are unremarkable. MR angiography of the circle of [**Location (un) 431**] shows no evidence of stenosis in the major vessels. Along the proximal right posterior cerebral artery, there is a tiny focus of increased signal intensity on the two-dimensional time-of-flight images. In the source images, there is no suggestion of an aneurysm at that site. This small focus appears to be an artifact. There is no definite evidence of an aneurysm. MR angiography of the carotid and vertebral arteries in the neck is significant for a severe stenosis beyond the bifurcation in the left proximal internal carotid artery. Only mild carotid narrowing is seen at the left carotid bifurcation. The left carotid bifurcation is more superiorly located than the right, and accordingly, three-dimensional time- of-flight images understandably did not entirely cover this area. The severe left proximal internal carotid stenosis is best visualized on the two-dimensional time- of- flight images. On the right side, on both the two- and three-dimensional time-of- flight images, a probable moderate to severe right carotid stenosis at the bifurcation, and moderate to severe right proximal internal carotid stenosis is also seen. IMPRESSION: The head MRI shows evidence of widespread patchy increased T2 signal. These are are consistent with chronic small vessel ischemic infarcts. The MR angiogram of the circle of [**Location (un) 431**] shows no definite evidence of stenosis or aneurysm. The MR angiogram of the neck is significant for a severe left internal carotid artery stenosis beyond the bifurcation, with mild stenosis at the bifurcation. On the right, there is evidence of moderate to severe stenosis at the bifurcation and in the proximal internal carotid artery. Procedure Date:[**2128-6-11**] [**Known lastname 23052**],[**Known firstname 177**]:[**Hospital1 18**] Radiology Detail - CCC Record #[**Numeric Identifier 23053**] HISTORY: 80 y/o man s/p bivalve ICD placement. R/O RV lead dislodgement. COMPARISON: [**2128-6-12**]. CHEST AP: The tip of the right ventricular lead appears to have rotated into the right atrium. The right atrial and coronary sinus leads are in unchanged position. Cardiac and mediastinal and hilar contours are stable in appearance. Pulmonary vasculature is normal. The lungs are clear. There are no pleural effusions. Osseous and soft tissue structures are unremarkable. IMPRESSION: Displacement of right ventricular ICD lead into the right atrium. Procedure Date:[**2128-6-24**] [**Known lastname 23052**],[**Known firstname 177**]:[**Hospital1 18**] Radiology Detail - CCC Record #[**Numeric Identifier 23053**] History: Defibrillator lead change. Chest, PA and Lateral: The heart is normal in size. A difibrillator is present on the left anterior chest wall, and there are two RV leads and a single RA lead. There is no pneumothorax. There are no signs of failure and there are no focal infiltrates. Nodular calcifications in the left mid lung zone are likely related to previous granulomatous disease. There is no mediastinal adenopathy. There is no effusion or bone destruction. Procedure Date:[**2128-6-26**] Brief Hospital Course: Admitted for stent placement in the left ICA. Pt. returned from cath with 1.5 mcg/kg/min of phenylephrine, successfully weaned. Pt. experienced brief bouts of non-specific bilateral radiating numbness but with consistently normal CNII-XII exam; likely transient vagal depression nature. The patient also has a biventricular ICD implanted, which was interrogated prior to the stent procedure. It was determined that the RV lead/ICD had become dislodged. The defibrillator function was disabled, leaving the device operating as an RA/LV DDD pacer. CXR indicated that the RV lead had ascended into the RA. The pacer function began to be impaired by erroneous sensing, with pacing occuring on the ST segment leading to brief aberrant NSVT runs. EP put the ICD into [**Last Name (un) **] (sense-only) mode, and the patients leads were then percutaneously resited satisfactorily as confirmed by repeat CXR. ICD function was tested and found to be satisfactory. The patient did well after carotid stenting and ICD lead revision and was subsequently discharged home with assistance in stable and improved condition. Medications on Admission: 1. Lasix 20mg po qd 2. Glucophage 500mg po bid 3. Glyburide 5mg po qd 4. Prevacid 30mg po qd 5. Lisinopril 20mg po qd 6. ASA 325mg po qd 7. Oxycodone 5mg po q4-6h:PRN pain 8. Plavix 75mg po qd 9. Simvastatin 40mg po qd 10. Digoxin 0.125mg po qd 11. Setraline 50mg po qd Discharge Medications: 1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once a day): Do not stop this medicine until speaking with Dr. [**First Name (STitle) **]. Disp:*30 Tablet(s)* Refills:*2* 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day). 3. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO QD (once a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day. 6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. 7. Glucophage 500 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day. 10. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 11. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**2-24**] hours as needed for pain. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: 1. L internal carotid artery stenosis s/p angioplasty and stenting 2. Dislodged pacemaker and ICD lead s/p revision 3. Congestive Heart Failure 4. Diabetes Mellitus Discharge Condition: stable and improved Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 2L -Contact your primary care physician should you experience any lightheadedness, dizziness, shortness of breath or chest pain. -Do Not restart your lisinopril without checking with Dr. [**First Name (STitle) **]. The visiting nurse will call his office next week after checking your blood pressure. Followup Instructions: 1. Please call to schedule an appointment NEXT WEEK with Dr. [**Last Name (STitle) 284**] at ([**Telephone/Fax (1) 5862**] to follow up for your pacemaker. 2. Contact Dr.[**Name2 (NI) 3101**] office to schedule an appointment at ([**Telephone/Fax (1) 7236**] to be seen the same day as Dr. [**Last Name (STitle) 284**]. Completed by:[**2128-7-12**]

[ "427.1", "433.10", "401.9", "250.00", "996.04", "412", "413.9", "501", "428.0" ]

icd9cm

[ [ [] ] ]

[ "88.41", "37.99", "39.90", "89.59", "39.50" ]

icd9pcs

[ [ [] ] ]

8689, 8744

6259, 7368

300, 398

8953, 8974

1658, 6236

9444, 9796

1364, 1378

7689, 8666

8765, 8932

7394, 7666

8998, 9421

1393, 1639

231, 262

426, 793

815, 1231

1247, 1348

28,360

125,535

54563

Discharge summary

report

Admission Date: [**2137-10-6**] Discharge Date: [**2137-10-10**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4052**] Chief Complaint: Melena Major Surgical or Invasive Procedure: Upper Endoscopy with [**Hospital1 **]-CAP Electrocautery History of Present Illness: 85 F with dementia, mild mental retardation, and HTN, most recently on po Vanc for C. diff, sent to ER with lethagy and 1 episode of blood tinged emesis and found to have black, guaiac + stool. No BRBPR. Attempted to NG lavage x 3 but were unable to pass NGT. GI contact[**Name (NI) **] and felt that since she was hemodynamically stable this bleed was chronic, and they elected to scope her in the am rather than emergently in the ED. . In the ED she was ordered for 4 units PRBCs - so far has received 3 unit PRBCs. She has 2 PIVs. . Patient is a poor historian and history is quit limited. Denies abd pain, shortness of breath, chest pain. + nausea. Past Medical History: 1. Mild Mental Retardation 2. Dementia (type unknown) 3. Kyphoscoliosis 4. DJD/OA 5. Osteoporosis 6. Chronic LBP 7. HTN - recently Dx'd 8. C.diff colitis - on course of po vanco 250 mg po QID ([**Date range (2) 111616**]) Social History: The patient is a resident of [**Hospital3 **] facility at [**Location (un) 6927**]. She is mildy mentally retarded. She has 1 [**Last Name (LF) 21457**], [**Name (NI) 717**] [**Name (NI) **] who according to the recent discharge summary does not want to be the health care proxy. [**Name (NI) **] management has been working with Ms. [**Name13 (STitle) **] about need for health care proxy, and she is more amenable Family History: Unable to obtain from patient. Physical Exam: Vitals: T: 97.8 BP: 122/77 HR: 66 RR: 18 O2: 97% RA Gen: Confortable, NAD, undernourished HEENT: NC, AT, MMM, EOMI CV: RRR, no MRG RESP: CTAB, moving air well ABD: soft, NT, ND, BS + EXT: no c/c/e, DP's 2+ Pertinent Results: Admission Labs: [**2137-10-5**] 11:45PM WBC-12.2* RBC-1.21*# HGB-4.0*# HCT-12.3*# MCV-102*# MCH-33.4* MCHC-32.8 RDW-22.3* [**2137-10-5**] 11:45PM NEUTS-82.5* BANDS-0 LYMPHS-14.9* MONOS-1.8* EOS-0.6 BASOS-0.2 [**2137-10-5**] 11:45PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-1+ [**2137-10-5**] 11:45PM PLT COUNT-492* [**2137-10-5**] 11:45PM CK-MB-4 cTropnT-<0.01 [**2137-10-5**] 11:45PM CK(CPK)-29 [**2137-10-5**] 11:45PM GLUCOSE-132* UREA N-32* CREAT-0.6 SODIUM-147* POTASSIUM-4.4 CHLORIDE-110* TOTAL CO2-30 ANION GAP-11 [**2137-10-6**] 06:49AM TSH-2.0 [**2137-10-6**] 06:49AM VIT B12-1524* FOLATE-13.2 HAPTOGLOB-194 [**2137-10-6**] 06:49AM LD(LDH)-199 CK(CPK)-43 TOT BILI-0.4 . EGD - [**10-6**] - Blood in the stomach Blood in the second part of the duodenum Spot in the duodenal bulb (thermal therapy) Otherwise normal EGD to second part of the duodenum . CXR - [**10-6**] - Bibasilar consolidation worrisome for aspiration and/or pneumonia. . EKG - [**10-5**] - Sinus rhythm rsr' in lead V2 Since previous tracing of [**2137-6-24**], QRS voltage lower . Bedside Swallowing Eval: [**10-7**] 1. Suggest a PO diet of nectar thick liquids and pureed consistency solids. 2. Full 1:1 supervision 3. No straws. 4. Pills crushed with purees. Brief Hospital Course: 85 F with dementia, mild mental retardation, and HTN, on po Vanc for C. diff, sent to ER from Goaddard House for lethargy and 1 episode of blood-tinged emesis and found to have black, guaiac + stool. No BRBPR. Attempted to NG lavage x 3 but were unable to pass NGT. GI contact[**Name (NI) **] and EGD on [**10-6**] that revealed blood in the stomach, 2nd part of the duodenum, and duodenal bulb, s/p [**Hospital1 **]-CAP electrocautery for hemostasis which was successful. HCT 11.3 on admission now s/p 4 units packed RBCs with HCT stable at 30.2. . # GI bleed - likely upper given emesis, however, unable to NG lavage in ED despite multiple attempts. EGD showed old blood/clot in stomach and duodenum, ?slow oozing spot in bulb s/p BiCAP. S/P 4 units pRBCs. Currently hemodynamically stable. - PPI IV BID for 72 hours starting [**10-7**], now switched to po daily. To be continued indefinitely. - repeat EGD not going to be performed, as patient cannot give informed consent and HCP not calling back. GI did not feel repeat was necessary at this time as patient's HCT remained stable. - cont diet of of nectar-thickened clears and pureed foods. . # Anemia - has developed since [**6-13**], most likely 2/2 blood loss, was started on aspirin at that time for atrial fibrillation so may have NSAID induced gastritis. - transfused 4 units pRBCs, HCT stable in mid-30s - iron studies done but given history of GI bleed and normocytic anemia anemia likely [**2-8**] GI loss, retic count low - B12, folate, TSH - normal . # PNA: - CXR with infiltrate and elevated WBC to 22 - received course of IV Vanc and Zosyn - written for sputum culture -> pt. not cooperative with obtaining sample so was not able to obtain - wbc trending down . # Atrial fibrillation - currently in sinus, as out-patient - EKG - sinus - cardiac enzymes neg x 3 - holding asa in setting of bleed - restarted on diltiazem on [**10-7**] . # C diff - finished po vanco x 13 day course on [**10-9**] . # HTN - on diltiazem and ? lisinopril as out-patient - restarted Dilt [**10-7**] . # Osteoporosis - cont vit D and calcium when taking po . # FEN - NPO, IVF - when taking po should have no added sodium diet - puree w/ thin liquids - will replete lytes - have been repleting K, will need to continue to monitor and take 20mg [**Hospital1 **] . # Code status - DNR/DNI . Medications on Admission: from nursing home: - diltiazem 240 qday - prilosec 20 qday - calcium carbonate 500 [**Hospital1 **] - tylenol 500mg 2tab tid - acidoph. 1cap tid - flovastor 250 qid - liquid vanco 250mg po q6 - celexa 10 qd - fosamax 70 qweek - asa 325 qday - vit d 400u qday Discharge Medications: 1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 2. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical TID (3 times a day). 3. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day) as needed. 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO BID (2 times a day). 8. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 537**]- [**Location (un) 538**] Discharge Diagnosis: Upper GI bleed - c diff - on course of po vanco 250 mg po QID ([**Date range (2) 111616**]) - mild mental metardation - Dementia (type unknown) - atrial fibrillation - Kyphoscoliosis - DJD/OA - Osteoporosis - HTN Discharge Condition: Improved Discharge Instructions: You have had a bleed from your upper GI tract. If you should experience any dark, tarry stools or vomit up any blood or vomit that looks like coffee grounds, you should return to the hospital immediately. Please contact you physician if you experience any light-headedness, low blood pressure, blood in stools or any other symptoms that are new or of concern to you. Please take all medications as prescribed. Please do not take any aspirin or non-steroidals (NSAIDS) at this time. Followup Instructions: You will be seen by your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1266**] at the [**Hospital **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 4055**]

[ "401.9", "427.31", "E935.9", "733.00", "294.8", "486", "532.00", "317", "276.0", "285.1", "276.51", "008.45" ]

icd9cm

[ [ [] ] ]

[ "99.04", "44.43" ]

icd9pcs

[ [ [] ] ]

6708, 6779

3305, 5646

270, 328

7036, 7046

1985, 1985

7580, 7861

1707, 1740

5955, 6685

6800, 7015

5672, 5932

7070, 7557

1755, 1966

224, 232

356, 1011

2001, 3282

1033, 1257

1273, 1691

80,726

177,316

39121

Discharge summary

report

Admission Date: [**2174-2-4**] Discharge Date: [**2174-2-17**] Date of Birth: [**2129-4-22**] Sex: F Service: NEUROSURGERY Allergies: Erythromycin Attending:[**First Name3 (LF) 78**] Chief Complaint: headache Major Surgical or Invasive Procedure: [**2-5**]: Diagnostic angiogram and coil embolization of PCOM aneurysm History of Present Illness: 44 yo female w/ no significant PMHx who was taking a shower two weeks ago and developed an acute onset 10 out of 10 headache at the back of her head that traveled forward. She went to the bedroom and laid down. She noted that the pain was worse and throbbing when she stood up. The patient was bedridden for a week managing her symptoms. She saw a chiropractic who performed neck manipulation. She felt slightly better. Today she had a massage and her head "exploded" again. Massage therapist called an ambulance and pt brought to [**Hospital3 **] where CT head showed SAH. She was then transferred to [**Hospital1 18**] for further management. Past Medical History: previous ruptured pcomm aneurysm Social History: Married, resides at home. Jehovah's wittness. Family History: non-contributory Physical Exam: Exam on Admission: Vitals: T 98.1; BP 118/76; P 84; RR 16; O2 sat General: lying in bed NAD HEENT: NCAT, moist mucous membranes Neck: + meningismus Extremities: no c/c/e. Neurological Exam: Mental status: awake, alert, attentive. Fluent speech with no paraphasic or phonemic errors. Adequate comprehension. Follows simple and multi-step commands. Cranial Nerves: I: Not tested II: PERRL, 4-->2mm with light. III, IV, VI: EOMI. no nystagmus. V, VII: facial sensation intact, facial strength VIII: hearing intact b/l to finger rubbing. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: SCM [**3-30**] XII: Tongue midline without fasciculations. Motor: Normal bulk. Normal tone. No pronator drift. Full strength. Sensation: intact to light touch. Reflexes: 2+ symmetric Exam on Discharge: As above. Neurologically Intact Pertinent Results: Labs on Admission: [**2174-2-4**] 07:57PM [**Year/Month/Day 3143**] WBC-11.9* RBC-4.59 Hgb-14.2 Hct-40.4 MCV-88 MCH- Labs on Discharge: COMPLETE [**Year/Month/Day 3143**] COUNT WBC RBC Hgb Hct MCV MCH M CHC RDW Plt Ct [**2174-2-17**] 04:30AM 6.8 4.24 13.5 39.9 94 31.8 33.9 13.2 405 ------------------ IMAGING: ------------------ CTA Head [**2-4**]: CT angiography of the head demonstrates approximately 6 mm right posterior communicating artery aneurysm extending posteriorly and having a bilobed appearance. No other distinct aneurysms are identified. There is no vascular occlusion or stenosis seen. IMPRESSION: 6 to 7 mm right posterior communicating artery aneurysm with bilobed appearance pointing posteriorly. No other aneurysms seen. No vascular occlusion or stenosis identified. IMPRESSION: 1. Subarachnoid hemorrhage. 2. Right posterior communicating artery aneurysm measuring 6 mm. No vascular occlusion or stenosis seen. [**Known lastname 86671**],[**Known firstname **] [**Medical Record Number 86672**] F 44 [**2129-4-22**] Radiology Report CTA HEAD W&W/O C & RECONS Study Date of [**2174-2-14**] 1:11 PM Final Report INDICATION: 44-year-old woman with subarachnoid hemorrhage, status post aneurysm coiling and subsequent vasospasm. Please perform CT perfusion to evaluate for vasospasm. TECHNIQUE: Contiguous axial images were obtained through the brain without contrast material. Subsequently, axial perfusion CT images were obtained during infusion of Omnipaque IV contrast. Sequentially, rapid axial imaging was performed through the brain during infusion of Omnipaque intravenous contrast. Images were processed on a separate workstation with display of mean transit time, relative cerebral [**Name2 (NI) **] volume, and relative cerebral [**Name2 (NI) **] flow maps for the CT perfusion study and maximum intensity projection images for the CTA maps. COMPARISON: CTA of the head from [**2174-2-11**], CT of the head from [**2-5**], [**2173**]. Angiogram of the head from [**2174-2-5**] and CTA of the head from [**2174-2-4**]. FINDINGS: CT OF THE HEAD: Compared to the prior studies, there is almost complete resolution of the subarachnoid hemorrhage. There is unchanged hypodensity in the left basal ganglia, likely representing prominent Virchow-[**Doctor First Name **] space or old lacunar infarct. CTA OF THE HEAD: Again seen are high-attenuation artifats secondary to coiling of a left PCOM aneurysm. The previously described vasospasm of the M1 segment of the right MCA has resolved with a normal caliber of the right MCA. The left middle cerebral artery, anterior cerebral arteries, and bilateral posterior cerebral arteries are normal without evidence of vascular abnormalities. CT PERFUSION: Mean transit time, cerebral [**Doctor First Name **] volume and cerebral [**Doctor First Name **] flow images are normal. CONCLUSION: 1. The CT perfusion maps are normal without evidence of delayed transit time, reduced [**Doctor First Name **] flow or [**Doctor First Name **] volume. 2. The CTA images of the head demonstrate resolution of the right M1 MCA vasospasm. 3. Compared to prior studies, the subarachnoid hemorrhage has almost completely resolved. 4. Unchanged left basal ganglia hypodensity, likely representing a prominent Virchow-[**Doctor First Name **] space or old lacunar infarct. _____________________________________________ Final Report EXAM: Chest frontal and lateral views. CLINICAL INFORMATION: 44-year-old female with history of subarachnoid hemorrhage. COMPARISON: None. FINDINGS: PA and lateral views of the chest are obtained. The lungs are clear without focal consolidation. No pleural effusion or evidence of pneumothorax is seen. The cardiac and mediastinal silhouettes are unremarkable. IMPRESSION: No acute cardiopulmonary process. _______________________________________________________________ [**Known lastname 86671**],[**Known firstname **] [**Medical Record Number 86672**] F 44 [**2129-4-22**] Radiology Report CTA HEAD W&W/O C & RECONS Study Date of [**2174-2-11**] 4:41 PM Final Report EXAM: CTA of the head. CLINICAL INFORMATION: Patient with subarachnoid hemorrhage and status post PCom aneurysm coiling, for further evaluation to exclude vasospasm. TECHNIQUE: Axial images of the head were obtained without contrast. Following this using departmental protocol, CT angiography of the head was acquired. Comparison was made with the previous CTA examination of [**2174-2-4**]. FINDINGS: Since the previous MRI examination, the patient has undergone coiling of the aneurysm in the region of right posterior communicating artery. Artifacts are seen in this region which limits the evaluation of surrounding vascular structures. There is now mild-to-moderate right-sided middle cerebral artery vasospasm identified without occlusion or obliteration of the lumen of the artery. The vascular structures in both sylvian regions are well maintained. The left middle cerebral artery and the anterior cerebral arteries as well as the posterior circulation arteries are well maintained without vasospasm. The CT head obtained before contrast demonstrate interval decrease in subarachnoid hemorrhage. The ventricular size has also slightly decreased. Prominent perivascular space is again identified. IMPRESSION: 1. Head CT shows interval decrease in subarachnoid [**Year (4 digits) **]. A coil artifact is seen in the right paraclinoid region. 2. CT angiography of the head demonstrates interval coiling of the aneurysm. The area of the aneurysm coiling is obscured by surrounding streak artifacts. 3. Mild-to-moderate right middle cerebral artery M1 segment vasospasm is identified which appears nonocclusive. The remaining vascular structures are well maintained. _ _ _ ________________________________________________________________ [**Known lastname 86671**],[**Known firstname **] [**Medical Record Number 86672**] F 44 [**2129-4-22**] Radiology Report CTA HEAD W&W/O C & RECONS Study Date of [**2174-2-14**] 1:11 PM Final Report INDICATION: 44-year-old woman with subarachnoid hemorrhage, status post aneurysm coiling and subsequent vasospasm. Please perform CT perfusion to evaluate for vasospasm. TECHNIQUE: Contiguous axial images were obtained through the brain without contrast material. Subsequently, axial perfusion CT images were obtained during infusion of Omnipaque IV contrast. Sequentially, rapid axial imaging was performed through the brain during infusion of Omnipaque intravenous contrast. Images were processed on a separate workstation with display of mean transit time, relative cerebral [**Name2 (NI) **] volume, and relative cerebral [**Name2 (NI) **] flow maps for the CT perfusion study and maximum intensity projection images for the CTA maps. COMPARISON: CTA of the head from [**2174-2-11**], CT of the head from [**2-5**], [**2173**]. Angiogram of the head from [**2174-2-5**] and CTA of the head from [**2174-2-4**]. FINDINGS: CT OF THE HEAD: Compared to the prior studies, there is almost complete resolution of the subarachnoid hemorrhage. There is unchanged hypodensity in the left basal ganglia, likely representing prominent Virchow-[**Doctor First Name **] space or old lacunar infarct. CTA OF THE HEAD: Again seen are high-attenuation artifats secondary to coiling of a left PCOM aneurysm. The previously described vasospasm of the M1 segment of the right MCA has resolved with a normal caliber of the right MCA. The left middle cerebral artery, anterior cerebral arteries, and bilateral posterior cerebral arteries are normal without evidence of vascular abnormalities. CT PERFUSION: Mean transit time, cerebral [**Doctor First Name **] volume and cerebral [**Doctor First Name **] flow images are normal. CONCLUSION: 1. The CT perfusion maps are normal without evidence of delayed transit time, reduced [**Doctor First Name **] flow or [**Doctor First Name **] volume. 2. The CTA images of the head demonstrate resolution of the right M1 MCA vasospasm. 3. Compared to prior studies, the subarachnoid hemorrhage has almost completely resolved. 4. Unchanged left basal ganglia hypodensity, likely representing a prominent Virchow-[**Doctor First Name **] space or old lacunar infarct. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: On [**2174-2-4**] Patient presented to [**Hospital3 **] for what she described as an explosion in her head while receiving a massage. A Head CT was done and it was found that she had a SAH. She was then transferred to [**Hospital1 18**] for further management. On exam at [**Hospital1 18**] she had no neurological deficits and after repeating a scan and obtaining a CTA it was determined she likely had an aneurysm 2 weeks prior and had rebled. She was admitted and on [**2-5**] she underwent cerebral angiogram for diagostics and was found to have a posterior communicating artery aneurysm which was coiled. At post-angio check on the 13th she had severe headache. a CT Head was obtained which was stable. On the morning of [**2-7**] it was noted that following the removal of her arterial line she complained of some numbness and tingling in her left hand. anesthesia saw her and reported that this is most likely temporary and is related to irriation of the radial nerve due to the insertion of the arterial line. She remained stable in the ICU on spasm watch as of [**2174-2-8**]. She continued to complain of a slight headache while in the ICU but as of [**2-11**] her exam remained nonfocal. CTA showed vasospasm in R MCA and ACA, but patient remained nonfocal. Her [**Date Range **] pressure parameters were increased to 16-200 and she was to remain in the ICU. Her repeat imaging was without vasospasm. Her HHH therapy was backed off and she remained stable. She was transfered to the floor. She has been ambulating independantly and will be discharged home on Nimodipine to complete a 21 day course. Medications on Admission: Vitamin D Discharge Medications: 1. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4 hours) for 10 days. Disp:*120 Capsule(s)* Refills:*0* 2. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**11-27**] Tablets PO Q4H (every 4 hours) as needed for headach. Disp:*50 Tablet(s)* Refills:*0* 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*3* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Atraumatic SAH PCOM aneurysm cerebral vasospasm Discharge Condition: Neurologically Stable Discharge Instructions: Angiogram with Embolization and/or Stent placement Medications: ?????? Take Aspirin 325mg (enteric coated) once daily. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs. ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). ?????? After 1 week, you may resume sexual activity. ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate. ?????? No driving until you are no longer taking pain medications What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site *SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call our office. If bleeding does not stop, call 911 for transfer to closest Emergency Room! Followup Instructions: Please call [**Telephone/Fax (1) **] for an appointment to be seen by Dr [**First Name (STitle) **] in 4 weeks. You will need a MRI/MRA at that time, 'per [**Doctor Last Name **] Protocol'. You will need an Angiogram in 3 months ******* you will need to continue to take Nimodipine for aprox. 10 days from the date of your discharge, when you run out of the perscription is the end of your treatment with this medication. Completed by:[**2174-2-17**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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31874

Discharge summary

report

Admission Date: [**2106-8-8**] Discharge Date: [**2106-8-17**] Date of Birth: [**2038-1-6**] Sex: F Service: CARDIOTHORACIC Allergies: Lisinopril Attending:[**First Name3 (LF) 165**] Chief Complaint: SOB Major Surgical or Invasive Procedure: [**8-13**] Minimally invasive mitral valve repair. [**8-12**] tooth extraction History of Present Illness: 68 yo F transferred from MWMC after presenting with SOB and TEE showing MR. Cath with normal coronaries. Past Medical History: MR, [**Month/Day (4) 19293**], [**Month/Day (4) **], Pulm [**Month/Day (4) **], hypothyroidism, CRI (1.7), mild CHF Social History: lives with family Family History: NC Physical Exam: CV rrr Lungs CTAB Abdomen benign Pertinent Results: [**2106-8-16**] 07:40AM BLOOD WBC-8.7 RBC-3.48* Hgb-10.2* Hct-30.6* MCV-88 MCH-29.4 MCHC-33.4 RDW-15.2 Plt Ct-243 [**2106-8-15**] 03:25AM BLOOD WBC-13.0* RBC-3.61* Hgb-10.7* Hct-32.0* MCV-89 MCH-29.7 MCHC-33.5 RDW-15.4 Plt Ct-240 [**2106-8-16**] 07:40AM BLOOD Plt Ct-243 [**2106-8-13**] 06:53PM BLOOD PT-15.1* PTT-43.9* INR(PT)-1.4* [**2106-8-17**] 07:05AM BLOOD UreaN-19 Creat-1.6* K-4.9 [**2106-8-16**] 07:40AM BLOOD Glucose-129* UreaN-19 Creat-1.7* Na-132* K-4.8 Cl-102 HCO3-23 AnGap-12 Brief Hospital Course: Ms. [**Known lastname 19784**] was admitted to cardiac surgery. She was seen by dental medicine and OMFS who recommended tooth extraction which she underwent on [**2106-8-12**]. She was started on cipro for a UTI. On [**2106-8-13**] she was taken to the operating room where she underwent a minimally invasive mitral valve repair with a #26 [**Doctor Last Name **] physio ring. She was transferred to the ICU in stable condition on propofol and nitroglycerin. She was extubated on POD #1. Shw was transferred to the floor on POD #2. She did well postoperatively and was ready for discharge to rehab on POD #4. Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 7. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) Discharge Disposition: Extended Care Facility: [**Location (un) 1110**] TCU Discharge Diagnosis: MR [**First Name (Titles) 19293**] [**Last Name (Titles) **] Pulmonary [**Last Name (Titles) **] hypothyroidism CRI (1.7) mild CHF 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 driving for 2 weeks or while taking pain meidication. Followup Instructions: Dr. [**First Name (STitle) **] 4 weeks Dr. [**Last Name (STitle) 6254**] 2 weeks Dr. [**First Name (STitle) **] 2 weeks [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2106-8-17**]

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icd9cm

[ [ [] ] ]

[ "99.04", "99.07", "35.33", "23.19", "39.61" ]

icd9pcs

[ [ [] ] ]

2799, 2854

1269, 1880

278, 359

3029, 3037

755, 1246

3321, 3563

683, 687

1903, 2776

2875, 3008

3061, 3298

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235, 240

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515, 632

648, 667