ChanBeDu/relevant_section_length · Datasets at Hugging Face

28,712

162,069

46182+58884

Discharge summary

report+addendum

Admission Date: [**2190-3-26**] Discharge Date: [**2190-3-31**] Date of Birth: [**2105-9-13**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 443**] Chief Complaint: Chest discomfort, shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 84-year-old female with CAD s/p CABG in [**9-18**] (LIMA-LAD, SVG-OM1), CHF, ESRD on HD, DMII, PAF who is transferred from outside hospital for cardiac catheterization. . The patient recently presented to [**Hospital3 **] with a CHF exacerbation and developed worsening renal failure requiring initiation of hemodialysis. She was discharged to rehab and developed chest discomfort, epigastric discomfort and progressive shortness of breath. She represented to [**Hospital1 **] where she admitted to the ICU. She had evidence of moderate CHF on CXR and was also in atrial fibrillation. She was started on a diltiazem drip which was discontinued with metoprolol tartrate PO for rate control. Her oxygen saturation was 94-97% on 5 liters of O2. Dr. [**Last Name (STitle) 4469**] was worried that the CHF could be related to ongoing ischemia and transferred the patient to [**Hospital1 18**] for cardiac catheterization. . Vital signs on transfer were afebrile, BP 149/46, HR 65 SR, RR 21, SaO2 94-97% on 5 liters. . On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for current absence of chest pain. Reports dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema. Past Medical History: 1. coronary artery disease: s/p CABG x2v, LIMA-LAD, SVG-OM1, ETT - per Dr. [**Last Name (STitle) 4469**] fall of [**2189**] with infero-apical ischemia and normal LVEF 2. diastolic congestive heart failure - EF 65% 3. Pulmonary hypertension - PA pressure 56mmHg 4. hypertension: 5. diabetes mellitus type II: 6. end-stage renal disease: on hemodialysis, s/p recent tunneled catheter 7. hyperlipidemia: 8. h/o breast cancer: s/p R mastectomy 9. h/o rheumatic fever: 10. hypothyroidism s/p thyroidectomy: 11. peptic ulcer disease: 12. s/p hysterectomy: 13. chronic anemia 14. degenerative joint disease 15. paroxysmal atrial fibrillation - with RVR 16. chronic low back pain 17. GERD Social History: The patient lives in a nursing home, prior to [**Month (only) 404**] lived in [**Location 5110**]. Sister [**Name (NI) 2048**] [**Telephone/Fax (1) 98209**]. -[**Name2 (NI) 1139**] history: Prior history, quit -ETOH: None -Illicit drugs: None Family History: Positive for CKD. Daughter has DM, CAD. Mother and sister have CAD. Although negative for premature coronary artery disease. Physical Exam: Admission exam: GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: JVP of 10cm. CARDIAC: Promenant PMI located in 5th intercostal space, midclavicular line. RR, normal S1, loud S2. II/VI SM at LLSB increased with inspiration. No lifts. No S3 or S4. LUNGS: Diffuse rales in bilateral lung fields. R tunnel cath in place. ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 1+ PT 1+ Left: DP 1+ PT 1+ Pertinent Results: Transthoracic Echo [**2190-3-27**]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with normal global and regional biventricular systolic function. Moderate diastolic LV dysfunction. Mild mitral regurgitation. Mild pulmonary hypertension. CXR [**2190-3-26**]: There are median sternotomy wires. Right-sided dual-lumen central venous catheter with distal tip at the cavoatrial junction. Cardiac silhouette is within normal limits. There is increased opacity at the right lung base with obscuration of the right hemidiaphragm and costophrenic angle, most likely in keeping with a moderate-sized pleural effusion. There is blunting of the left costophrenic angle, in keeping with a mild subpleural effusion. There are increased linear opacities, vascular distention and parahilar opacities in keeping with moderate CHF. No evidence of pneumothorax. [**2190-3-29**] 07:15AM BLOOD WBC-8.8 RBC-2.98* Hgb-8.1* Hct-27.1* MCV-91 MCH-27.3 MCHC-30.0* RDW-17.5* Plt Ct-461* [**2190-3-29**] 07:15AM BLOOD Plt Ct-461* [**2190-3-29**] 07:15AM BLOOD Glucose-71 UreaN-32* Creat-2.7* Na-135 K-3.8 Cl-96 HCO3-28 AnGap-15 [**2190-3-29**] 07:15AM BLOOD Calcium-8.4 Phos-2.5* Mg-2.0 [**2190-3-27**] 06:05AM BLOOD calTIBC-229* Ferritn-335* TRF-176* [**2190-3-27**] 06:05AM BLOOD PTH-116* [**2190-3-26**] 10:47PM BLOOD Glucose-89 UreaN-36* Creat-2.8* Na-133 K-4.4 Cl-96 HCO3-33* AnGap-8 [**2190-3-26**] 10:47PM BLOOD WBC-9.6 RBC-3.31* Hgb-8.8* Hct-29.5* MCV-89 MCH-26.5* MCHC-29.8* RDW-16.5* Plt Ct-348 Brief Hospital Course: Ms. [**Known lastname **] is an 84 year old woman with past medical history of DM, HTN, CKD, hyperlipidemia and CAD s/p CABG x2 LIMA->LAD,SVG->OM1 who initially presented to an outside hospital with chest discomfort and shortness of breath. She was transferred here for possible cardiac catherization as her symptoms were thought to be ischemic in nature. #.Acute on Chronic Diastolic Congestive Heart Failure: Ms. [**Known lastname **] was admitted to the hospital with an acute exacerbation of her congestive heart failure. She was noted to have diffuse crackles in both lungs and 1+ pitting lower extremity edema on admission. A transthroacic echo was done on [**2190-3-27**] which revealed Diastolic dysfunction with EF of >55%. She underwent multiple hemodialysis treatments with removal of fluid and subsequent improvement of her symptoms. # Coronary Artery Disease: Patient is s/p CABG x 2 - SVG-OM and LIMA-LAD. Her chest discomfort was thought to be anginal in nature, however it was believed that this was likely due to her atrial fibrillation and RVR and more related to demand ischemia rather than acute plaque rupture. The decision was made to medically manage her coronary artery disease, and she was discharged on metoprolol for rate control, hydralazine for afterload reduction and isosorbide mononitrate for anginal symptom control. # ESRD currently on Hemodialysis She was started on Hemodialysis at [**Hospital3 **] and was transferred with a right sided tunneled IJ Quinton catheter in place. She was followed by the Nephrology team and received regular Hemodialysis during hospitalization. There is still potential for recovery of her renal function in the future, though she will need dialysis for the near future. She has had a Chest Xray and a PPD was placed on [**2190-3-30**] in preparation for outpatient hemodialysis. She will need an outpatient nephrologist. PPD will need to be read on [**4-1**] or [**4-2**]. # Paroxsymal atrial fibrillation: The patient initially presented in atrial fibrillation with RVR at an outside hospital, where she was placed on diltiazem drip. On transfer she was still in atrial fibrillation and rate controlled with metoprolol, also on amiodarone for rhythm control. She converted to normal sinus rhythm during hospitalization. She was also started on warfarin because her CHADS score was 4. Her metoprolol dose was decreased in the setting of low heart rate. # Hypertension: Patient's BP has been elevated throughout her stay here 150/50-160/60. She was re-started on her home dose hydralazine which was further increased to 50mg TID for better blood pressure control prior to discharge. Her chronic kidney disease is likely secondary to longstanding hypertension. # Right sided flank pain: Patient complained of intermittent band like pain, localized mostly under her Right breast. This pain was reproducible, and the patient was noted to have bruising in that area. Rib films showed no displaced fracture. # Diabetes Mellitus. She was on Insulin sliding scale regimen in the hospital and she had good glycemic control. She will be placed back onto her diet-controlled regimen upon discharge. # Anemia Patient has chronic anemia in the setting of End Stage Renal Disease. She was continued on her home iron suppements. # Hyperlipidemia: Simvastatin was changed to pravastatin due to potential interaction of simvastatin with amiodarone. # Peptic Ulcer Disease. She was continued on famotidine 20mg PO daily. # Hypothyroidism s/p Thyroidectomy Patient was continued on home dose Levothyroxine. Medications on Admission: Ativan 0.5mg PO qhs Zocor 40mg PO daily Protonix 40mg PO daily Allopurinol 200mg PO daily Hydralazine 25mg PO daily Tylenol PRN Ferrous sulfate 325mg PO daily Aspirin 81mg PO daily Amiodarone 100mg PO daily Synthroid 25mcg PO daily Toprol XL 25mg PO daily Imdur 90mg PO daily Maalox PRN Levaquin 250mg daily for 5 days (to be continued until [**2190-3-28**]) . MEDICATIONS: at transfer Levoxyl 25mcg PO daily Ferrous sulfate 325mg daily Lorazepam 0.5mg qHS PRN Amiodarone 100mg PO daily Aspirin 81mg PO daily Allopurinol 100mg PO daily Protonix 40mg PO daily Diltiazem gtt - 15mg per hour Metoprolol tartrate 25mg PO BID Simvastatin 40mg PO daily Levalbuterol hydrochloride 1.25mg QID PRN inhaled Heparin SQ TID Nitroglycerin SL PRN Bumex 4mg PO or IV - as directed Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Acute on Chronic Diastolic Congestive Failure End stage renal disease on Hemodialysis Coronary Artery Disease diabetes Mellitus Type 2 Paroxysmal Atrial Fibrillation Anemia of chronic Disease Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: You had an episode of congestive heart failure that responded to hemodialysis treatment that was able to remove excess fluid. We adjusted your medicine to keep your blood pressure under better control. We decided that we would not do a cardiac catheterization because we [**Male First Name (un) **] not want to make your kidneys worse with IV contrast (dye). You may be able to get a cardiac catheterization when your kidneys improve. . Medication changes: 1. Zocor was changed to Pravastatin 2. Protonix was changed to famotidine 3. Amiodarone was increased to 200 mg daily 4. Hydralazine was increased to 50 mg three times a day . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Primary Care: [**Last Name (LF) **],[**First Name3 (LF) **] S. Phone: [**Telephone/Fax (1) 8506**] Date/Time: please make an appt to see Dr. [**First Name (STitle) 1557**] when you get out of rehabilitation . Cardiology: [**Last Name (LF) **],[**First Name3 (LF) **] W. Phone: [**Telephone/Fax (1) 4475**] Date/time: Friday [**4-16**] at 1:30pm. Name: [**Known lastname 15670**],[**Known firstname 15671**] Unit No: [**Numeric Identifier 15672**] Admission Date: [**2190-3-26**] Discharge Date: [**2190-3-31**] Date of Birth: [**2105-9-13**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3780**] Addendum: Pt has acute on chronic diastolic congestive heart failure. An ACE or [**Last Name (un) **] was not prescribed at discharge because of her ESRD. Discharge Disposition: Extended Care Facility: [**Hospital1 49**] - [**Location (un) 50**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3782**] MD [**MD Number(2) 3783**] Completed by:[**2190-3-31**]

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Discharge summary

report

Admission Date: [**2119-4-12**] Discharge Date: [**2119-4-19**] Date of Birth: [**2062-3-20**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / House Dust Attending:[**First Name3 (LF) 983**] Chief Complaint: hemoptysis Major Surgical or Invasive Procedure: pulmonary angio History of Present Illness: 55 yo F w/ RCC (dx [**2118**]) with mets to lung and bone s/p L nephrectomy, XRT to R femur and tibia, cryodebridement (LUL/lingula) and electrocautery ablation x2, IL-2 therapy c/b toxic encephalopathy and shock, who is transferred from [**State 91250**] Center with hemoptysis. . Per husband, she was in her usual state of health until this morning when she experienced hemoptysis. Patient p/w [**1-23**] cup full of hemoptysis x3 that started in the morning. She did not have f/c, n/v, changes in bowel patterns, cough, sob. She went to OSH where she was intubated electively w/ double barrel ET tube. At the OSH her labs were notable for: na 141, k 4.1, cl 102, BUN/Cr 17/1.3, Ca 9.6, Albumin 3.8, ALT/AST 25/12, AP 156, t bili 0.3, wbc 7.9, hct 42, plt 2777, inr 0.9. She was transferred to [**Hospital1 18**]. . At [**Hospital1 18**] ED, initial VS wer: HR 70, BP 137/65, O2 100 on CMV 18 RR, 350 TV, 5 PEEP. On exam patient was guaiac neg. She was started on fentanyl/propofol gtt. Labs were notable for: WBC 7.1, Hgb 12.2, HCT 37.6, Plt 239, Na 139, K 4.5, Cl 108, HCO3 , BUN 16, Cr 1.2, Glu 85, PTT 23.6, INR 1, Trop. ABG on 40% FiO2, RR 14, TV 400 7.4/41/146 (R lung ventilation only). CXR showed double-barrel ET tube w/ limb terminating in distal L main stem bronchus, volume loss of L hemithorax. IP and IR were contact[**Name (NI) **]. She was transferred to IR for embolization of L bronchial artery. IV access: 2 20g. Patient full code. . Of note, patient has known LUL endobronchial lesion seen in CT chest, s/p rigid bronchoscopy, flexible bronchoscopy ([**11/2118**]) that showed complete obstruction of the LUL bronchus by mucous plug covering endobronchial tumor. At that time, she underwent cryodebridement and electrocautery ablation restoring near to 100% patency of the left upper lobe bronchus and lingular bronchus, and distal airways patent. She further underwent rigid flexible bronchoscopy of the left upper lobe on [**2119-3-10**] with cryodebridement and balloon dilation, along with therapeutic aspiration of secretions. Residual 50% LUL proper obstruction, 80% lingular obstruction. Her most recent CT from [**2119-4-6**] showed increase in size of all metastatic lesions, including numerous bilateral pulmonary nodules and left hilar mass and increased size of two right kidney lesions, concerning for metastatic disease. She has had a ~30 pound weight loss over 6months. . On arrival to the MICU, pt intubated and sedated. Past Medical History: # Renal cell carcinoma: - c/b right femur fracture and XRT to the lytic lesions on the right femur and tibia. - lung mets: LUL endobronchial lesion s/p cryodebridement and electrocautery ablation [**2118**] restoring near to 100% patency of the left upper lobe bronchus and lingular bronchus, and distal airways patent. [**2119-3-10**] with cryodebridement and balloon dilation, along with therapeutic aspiration of secretions. Residual 50% LUL proper obstruction, 80% lingular obstruction. - s/p high dose IL-2 13/14 doses on week 1 and [**11-5**] on week 2 course was complicated by toxic encephalopathy and shock requiring pressor support. - plan was to enroll in clinical trial of gemcitabine (IV chemo theray week x2 ) and sunitinib ( 37.5 mg 2 weeks on and 1 week off) # Allergies # GERD # s/p Cholecystectomy Social History: walks w/ a cane, works as an accountant, married and lives w/ husband. - Tobacco: + 1ppd many years, quit 20 years ago - Alcohol: none - Illicits: none Family History: She has a brother with oral cancer. No other known kidney cancer or other cancers in the family. Physical Exam: Admission exam General: Intubated, sedated, arousable HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Right side clear, Left side w/ absent breath sounds. Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: + foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: PERRL, sedated, arousable, opens eyes, follows commands, down going toes, normal toes, no clonus. . Discharge exam T 98.6 HR 75 BP 145/85 RR 20 99%ra GEN: NAD, hoarse voice, breathing comfortably SKIN: no rashes or lesions CV: RRR, no MRG, normal S1/S2 Pulm: rhonchi b/l, expiratory wheezes, loudest in RUL; crackles in b/l lung bases ABD: BS+, S/NT/ND. No HSM Pertinent Results: Admission labs [**2119-4-12**] 02:30PM BLOOD WBC-7.1 RBC-4.26 Hgb-12.2 Hct-37.6 MCV-88 MCH-28.5 MCHC-32.3 RDW-13.7 Plt Ct-239 [**2119-4-12**] 02:30PM BLOOD Neuts-77.5* Lymphs-15.7* Monos-3.4 Eos-2.5 Baso-0.9 [**2119-4-12**] 02:30PM BLOOD PT-10.8 PTT-23.6* INR(PT)-1.0 [**2119-4-12**] 02:30PM BLOOD Glucose-85 UreaN-16 Creat-1.2* Na-139 K-4.5 Cl-108 HCO3-21* AnGap-15 [**2119-4-12**] 06:44PM BLOOD ALT-6 AST-12 CK(CPK)-30 AlkPhos-101 TotBili-0.3 [**2119-4-12**] 02:30PM BLOOD cTropnT-<0.01 [**2119-4-12**] 06:44PM BLOOD CK-MB-2 cTropnT-<0.01 [**2119-4-12**] 06:44PM BLOOD Calcium-8.6 Phos-4.3 Mg-1.9 Discharge labs [**2119-4-19**] 05:58AM BLOOD WBC-7.7 RBC-3.52* Hgb-9.7* Hct-31.1* MCV-88 MCH-27.6 MCHC-31.3 RDW-13.7 Plt Ct-333 [**2119-4-19**] 05:58AM BLOOD Glucose-80 UreaN-12 Creat-1.1 Na-141 K-3.3 Cl-106 HCO3-27 AnGap-11 [**2119-4-19**] 05:58AM BLOOD Calcium-8.7 Phos-2.5* Mg-1.9 Imaging: CXR [**4-12**]: IMPRESSION: Substantial new volume loss in the left lung status post placement of double-lumen endotracheal and orogastric tubes. Right lung remains clear. IR procedure [**4-12**]: IMPRESSION: Unsuccessful cannulation of bronchial arteries due to extreme angles at their origins. No evidence of active contrast extravasation. CXR [**4-13**]: The unilateral left lung intubation device is in place. The left subclavian line tip is at the level of mid SVC. There is interval improvement of the atelectasis with currently better aerated left upper lung and central position of the mediastinum. Bilateral pleural effusions are noted, with no appreciable change in the left perihilar mass. Multiple nodules are better appreciated on the cross-sectional imaging obtained on [**2119-4-6**]. Right lower lung opacity might reflect area of atelectasis. Minimal interstitial edema is better seen in the right perihilar area. There is no evidence of pneumothorax. CXR [**4-14**]: As compared to the prior study obtained at 8:42 p.m. on [**4-13**], [**2119**], there is minimal interval change on the current radiograph, but there is definitive interval increase in right pleural effusion and right lower lung opacity that might reflect aspiration or hemorrhage. CXR [**4-15**]: The patient was extubated. There is interval progression of pulmonary edema. Known left mass and multiple pulmonary nodules are redemonstrated, partially obscured by pulmonary edema and newly appeared bibasal areas of atelectasis and pleural effusion [**4-16**]: FINDINGS: In comparison with the study of [**4-15**], there is some improved level of inspiration with decrease in the bilateral opacifications. CXR [**4-17**]: In comparison with the study of [**4-16**], there are slightly lower lung volumes, but otherwise little change. No definite focal area of consolidation or vascular congestion. Left IJ catheter extends to the cavoatrial junction or possibly the upper portion of the right atrium. BAL [**4-14**] micro results: Time Taken Not Noted Log-In Date/Time: [**2119-4-14**] 9:54 am BRONCHIAL WASHINGS BRONCHIAL WASHINGS. GRAM STAIN (Final [**2119-4-14**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2119-4-16**]): 10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora. ACID FAST SMEAR (Final [**2119-4-15**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED [**4-17**] C dif screen: negative Brief Hospital Course: 55 yo F w/ RCC (dx [**2118**]) with mets to lung and bone s/p L nephrectomy, XRT to R femur and tibia, cryodebridement and electrocautery ablation x2, IL-2 therapy c/b toxic encephalopathy and shock, who presented from OSH with hemoptysis s/p double lumen ET tube intubation for airway protection transferred to [**Hospital1 18**] for further evaluation. . # Hemoptysis, likely due to endobronchial lesion. Patient with known RCC metatastatic to the lungs w/ prior bronch notable for endobronchial tumor of LUL as well as progression on [**4-6**] CT (incr. precarinal lymph node, left hilar nodal mass, upper lobe anterior segment nodule, right lung apex nodule). Unable to perform a IR embolectomy due to difficult anatomy and no visible blush was seen on angiogram. She was intubated with double lumen tube and eventually ventilated with double ventilators (AC on right and PCV on left) with some recruitment (FiO2 decr to 50%). Flexible bronchoscopy on [**4-13**] showed complete obstruction to level of Left main bronchus, but no active bleeding, w/ some blood tinged fluid suctioned throughout the day. On HD2, patient developed sepsis physiology (see below). IP performed rigid bronchoscopy on [**4-14**] which showed purulent secretions (though cultures would not grow anything back), LUL that was completely occluded. She underwent debridment and electrocautery of LUL bronchus, which was opened, no active bleeding, but notable for old clots. Electrocautery applied to lingula w/o success. Her HCT remained overall stable 28 - 34. No further bleeding was noted. Upon ventilation, of Left lung s/p electrocatery and debridement, significant recruitment was achieved. After this procedure, she had no more hemoptysis the remainder of the hospitalization. # Hypoxic respiratory failure. Post. obstructive PNA/Volume overload/Hematemesis. On HD#1 was noted to have fevers, 103F Tmax with decreased UOP and hypotension. She was started on Vancomycin/Cefepime ([**4-13**]) for post obstructive PNA and Flagyl was added [**4-14**]. With aggressvie volume resuscitation, UOP improved as did her pressures. Frank purulence was visualized on bronchoscopy as above. Although her bronchial washings grew commensal flora only (2 days on ABx), treatment was continued due to clinical presentation consistent w/ PNA. She will complete an 8 day course, initially on vanc/cefepime/flagyl for 6 days, then switched to levoquin/flagyl for 2 days. Pt. was extubated on [**4-15**] with en episode of flash pulmonary edema. Did not tolerate BiPAP but responded well to IV lasix. At time of transfer to floor, LOS +2.2L. Pt. was on RA upon transfer to floor with minimal stridor on exam. On the floor, she continued to improve, with intermittent nebulizer treatments for wheezing on exam. She was started on a prednisone taper for laryngeal edema [**2-23**] intubation. # Stridor. Noted grade III subglottic edema during ETT exchange on [**4-14**] w/ IP. Received IV solumedrol in OR. On [**4-15**] post extubated, was found to have signifiant stridor, received racemic epinephrine and additional dose of IV solumedrol. On [**4-16**] changed to PO prednisone; she was sent out on a prednisone taper. # RCC. Discussed with Dr. [**Last Name (STitle) **], outpatient oncologist. Given recent events, pt reportedly did not quialify for drug trial initially suggested by her oncologist. However, an off label of a different study drug was suggested by Dr. [**Last Name (STitle) **], to be started once patient is able to return home (will be mailed to her) . # CKD: S/p nephrectomy. Baseline Cr seems to range 1.2-1.5. Improved with aggressive hydration to 1.0. . # Hypertension: pt developed significant hypertension on the floor, likely as a result of prednisone. She has a history of HTN, and has previously been on HCTZ, but did not tolerate this well so on admission had no HTN therapy. She was started on lisinopril and amlodipine, w/ close PCP f/u, given that her prednisone will be tapered and expect her HTN to come down from that alone. Pt instructed to get BP cuff and check daily, and educated about signs/symptoms of hypotension. . # Communication: Husband HCP - [**Telephone/Fax (1) 91251**]; [**Telephone/Fax (1) 91252**] # Code: Full (confirmed) . ==== TRANSITIONAL ISSUES # Will need close monitoring of blood pressures, given she was quite high in house, but prednisone will be coming off Medications on Admission: ALBUTEROL SULFATE 90 mcg HFA Aerosol Inhaler - 2 HFA(s) inhaled every four (4) hours as needed for SOB, wheeze OXYCODONE - 5 mg Capsule - [**1-23**] Capsule(s) by mouth three times a day ACETAMINOPHEN - (OTC) - 500 mg Tablet - [**1-23**] Tablet(s) by mouth DIPHENHYDRAMINE HCL - (OTC) - 25 mg Capsule - Capsule(s) by mouth DOCUSATE SODIUM 100 mg prn FAMOTIDINE 10 mg Tablet prn Discharge Medications: 1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 3. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) Inhalation every four (4) hours as needed for shortness of breath or wheezing. 4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for pain. 5. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for pain. 6. famotidine 10 mg Tablet Sig: One (1) Tablet PO once a day as needed for heartburn. 7. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day as needed for constipation. 8. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 2 days: [**2119-4-20**]. Disp:*4 Tablet(s)* Refills:*0* 9. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 days: last day is [**2119-4-20**]. Disp:*1 Tablet(s)* Refills:*0* 10. prednisone 10 mg Tablet Sig: take three (3) tabs daily on [**4-20**]. Take two (2) tabs daily on [**4-21**] and [**4-22**]. Take one (1) tab daily on [**4-23**] and [**4-24**]. Then stop. Tablet PO . Disp:*9 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: - Hemoptysis secondary to lung metastases from renal cell carcinoma - Post-obstructive pneumonia - Hypertension, likely related to prednisone Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms [**Known lastname **], It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted for coughing up blood. This was found to be from a lung metastases from your cancer. For this, you were intubated, and had a procedure done to stop the bleeding. You tolerated this well. You had high blood pressures during this admission. This is probably from the prednisone [steroid] you are on. You are being sent home on blood pressure medications. Because your will taper the prednisone down over the next few days, we want to be careful that your blood pressure does not get too low. Measure your blood pressure daily (buy a blood pressure cuff at your pharamcy). Stop lisinopril and amlodipine (blood pressure meds) if the top number is less than 100. If you feel lightheaded or dizzy, also stop the medications. You will need to see your PCP to [**Name9 (PRE) 702**] on blood pressure control. The following changes were made to your medications ** START prednisone taper [steroid] ** START levoquin [antibiotic]. Take 1 pill tomorrow. ** START flagyl [antibiotic]. Take tonight, and then 3 times (every 8 hours) tomorrow ** START lisinopril [blood pressure medication] ** START amlodipine [blood pressure medication] Followup Instructions: Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD Specialty: Hematology/Oncology Location: [**Hospital1 18**] - DIVISION OF HEMATOLOGY/ONCOLOGY Address: [**Apartment Address(1) 85559**], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 13016**] We are working on a follow up appointment with Dr. [**Last Name (STitle) **] in the next week. You will be called at home with the appointment. If you have not heard within 2 business days or have questions, please call [**Telephone/Fax (1) 13016**]. Name: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 91253**], MD Specialty: Family Practice When: Tuesday [**4-25**] at 11am Location: [**Location **] FAMILY PRACTICE Address: 13 RAILROAD SQUARE, [**Location **],[**Numeric Identifier 91254**] Phone: [**Telephone/Fax (1) 91255**]

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icd9cm

[ [ [] ] ]

[ "88.44", "38.97", "96.71", "33.24", "33.22", "32.28" ]

icd9pcs

[ [ [] ] ]

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Discharge summary

report

Admission Date: [**2108-3-22**] Discharge Date: [**2108-4-3**] Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 17813**] Chief Complaint: seizures Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a [**Age over 90 **] year old woman with a recent cardiopulmonary arrest of unknown etiology and seizures who has been transferred from [**Hospital1 **] [**Location (un) 620**] for further management of suspected status epilepticus. This history was obtained from discussion with her son [**Name (NI) 333**] and from review of the medical record. On [**2108-2-18**] she was found down at her residence and was noted to be bradycardic, hypotensive, hypothermic, and lethargic. She was transported to an ED at Upstate [**Location (un) **] Hospital in NY where she had a cardiopulmonary arrest and was intubated and resuscitated. The intubation was difficult and she was found to have a mediastinal mass (multinodular goiter with papillary microcarcinoma, which was removed). She had a complicated hospital course with hospital-associated pneumonia, lung collapse s/p bronchoscopy, sepsis, corneal abrasion/chemosis, perioperative anemia from blood loss, and then confusion. She was started on quetiapine initially for suspected ICU-related delirium. However, she started showing clinical signs of seizures (sudden behavioral arrest, blank stare, eye deviation to the left and down) which resolved with low dose of lorazepam. Despite reportedly unremarkable head imaging, she was thought to potentially has PRES (unclear what the blood pressure measurements were at the time). She was started on Levetiracetam 750 mg [**Hospital1 **] for seizure prevention. An EEG done at that time reportedly suggested potential epileptiform foci but no seizures were seen. She was discharged to a rehab but per her family did not return to her prior highly functional baseline mental status. On [**2108-3-21**], she was even more lethargic than usual and did not respond promptly to sternal rub. She was observed as having right face and right shoulder twitches with associated bowel/bladder incontinence which ceased with diazepam 2.5 mg given twice. She had a normal blood sugar of 81 at that time and otherwise normal vital signs after the episode. She was transferred to [**Hospital1 **] for further management where she was given two loading doses of Fosphenytoin 500 mg with some improvement in the focal motor activity. Neurology was consulted there and recommended increasing Levetiracetam to 1000 mg [**Hospital1 **] and continuing Phenytoin. She had an unremarkable NCHCT. She was found to have a UTI and was started on Ceftriaxone on [**3-21**]. She was thought to potentially have pneumonia as well, but chest imaging did not reveal an infiltrate so this was stopped. An EEG was obtained which potentially showed frequent left parasagittal epileptiform discharges, so she was transferred to [**Hospital1 18**] for further care. Prior to transfer per her son, he [**Name2 (NI) 15598**]'t notice any more motor activity but she was not very arousable (she would only briefly open her eyes to voice). Past Medical History: [] Neurologic - Seizures (s/p cardiac arrest, ? hypoxic brain injury), Recent ? Posterior Reversible Leukoencephalopathy Syndrome (clinical diagnosis at onset of seizures) [] MSK - Left hip fracture (s/p ORIF) [] Cardiovascular - Recent cardiac arrest, HTN, HL, reportedly CAD [] Pulmonary - Recent hypoxic respiratory failure [] Endocrine - Multinodular goiter with papillary carcinoma (s/p resection, discovered during difficult intubation) [] Ophthalmologic - Corneal abrasion/chemosis Social History: Until recently living independently, driving. Now at [**Hospital3 4103**] on the [**Doctor Last Name **]. No tobacco, ETOH, or illicit drug use. Family History: Ovarian cancer (mother) Physical Exam: General: NAD, lying in bed comfortably. Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions Neck: Supple, no nuchal rigidity, no meningismus Cardiovascular: RRR, no M/R/G Pulmonary: Equal air entry bilaterally, no crackles or wheezes Abdomen: Soft, NT, ND, no guarding Extremities: Warm, no edema, palpable radial/dorsalis pedis pulses Skin: No rashes or lesions Neurologic Examination: - Mental Status - Alert, Oriented to self and year, but no year or city. She follows commands. - Cranial Nerves - [II] PERRL 3->2 brisk. VF full to threat. [III, IV, VI] Tracks to the left but has difficult crossing midline to the right. [V] Corneals present bilaterally. [VII] No facial asymmetry at rest. [XII] Tongue midline. - Motor - No tremor or asterixis or myoclonus currently. She has full strength on the left side of her body, with decreased strengh on the right, but moving at least against gravity. - Sensory - Response to noxious all four extremities. - Reflexes =[Bic] [Tri] [[**Last Name (un) 1035**]] [Quad] [Gastroc] L 2 2 2 2 2 R 2 2 2 2 1 Plantar response extensor bilaterally. - Gait - Unable to assess. Brief Hospital Course: Neuro: Mrs. [**Known lastname 110651**] was very sleepy while in the ICU, and her EEG was showing PLEDs. She was started on keppra and dilantin. Her PLEDs improved, and her mental status continued to slowly improved. Upon transfer to the floor, she had no further clinical seizures. Her mental status was improving daily, and she was back to having full conversations on the day of her discharge. we stopped her dilantin and increased the keppra in order to create a balance between her level of drowsiness and seizure control. We decided not to treat the actual PLEDs, as she was clinically improving. CV/Resp: She did not have any further acute issues during her stay. We continued her anti-hypertensive medications. FEN/GI: She was initially too sleepy to eat on her own and therefore was placed on tube feeds. She took her own tube out on [**4-1**], and as she was awake enough, we decided not to replace it and allow her to PO. We advanced her diet to soft + thin liquids based on the recommendations of speech therapy, and she tolerated it well. She needs to continue to work on her diet, and she needs supplmentation with ensure. ID: She received 7 days of ceftriaxone for her UTI, she was afebrile, and had no further complications. We kept her foley in because she developed a bed sore, and we did not want the area to become wet. The foley can come out once the area has healed. Medications on Admission: Transfer Medications: LEV 1000 [**Hospital1 **] NovoLog sliding scale Lovenox 40 SC Mag PRN PHT 100 q8h CTX 1g daily, ASA 325 Nexium 20 [**Hospital1 **] APAP 650 q6h prn Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. levetiracetam 100 mg/mL Solution Sig: 1000 (1000) mg PO BID (2 times a day). 5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Seizures Discharge Condition: Condition: good Mental status: Alert, oriented to self and year, fluctuates in terms of orientation to day/city. Ambulatory: currently bed bound. Discharge Instructions: Dear Mrs. [**Known lastname 110651**], It has been a great pleasure taking care of you. You were admitted to our neurology/epilepsy service because you were having seizures after you had your cardiac arrest. Your EEG did show that you were having a lot of epileptic discharges, you were placed on two medications, and we only kept you on one of them, which was enough to control the seizures. You also had a urinary tract infection which we treated. Your mental status continued to improve dramatically. You required a feeding tube through your nose initially, but you were able to start eating by mouth soon after and therefore did not need it anymore. Followup Instructions: Our neurology clinic will contact you for a follow up appointment.

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icd9cm

[ [ [] ] ]

[ "89.19", "96.6" ]

icd9pcs

[ [ [] ] ]

7232, 7329

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262, 268

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28085

Discharge summary

report

Admission Date: [**2163-12-27**] Discharge Date: [**2164-1-4**] Date of Birth: [**2088-3-6**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 898**] Chief Complaint: sob Major Surgical or Invasive Procedure: Bronchoscopy History of Present Illness: 75yoW with pmh sig for RCC s/p L nephrectomy, 50 pack year smoking history, presented to [**Hospital1 **] [**Location (un) 620**] with sob and right side flank pain, found to have hilar mass and multi liver lesions. She was transferred to [**Hospital1 18**] for further evaluation. On arrival to [**Hospital1 **] [**Name (NI) 86**], pt stated sob improved and r flank pain [**2166-1-18**] and like "a dull cramp" without radiation. Past Medical History: PMH: HTN, TCC, RAS, L. maxillary sinus tumor, TAH/BSO Social History: pos smoker - quit 1 yr ago, 50 pack year hx pos drinker Daughter is contact- [**Name (NI) 6480**] [**Telephone/Fax (1) 68301**] Family History: non contributary Physical Exam: T 98 BP 140/80 P 70 RR 14 O2sat 98% 2Lnc NAD No JVD RRR nl s12 no mrg Lungs with decr bs on right, no rales Abd soft nt nd nabs LE wwp min edema Pertinent Results: CT torso: 8X6 CM hilar mass, mult liver lesions ======================== [**2164-1-2**] 06:00AM BLOOD WBC-8.5 RBC-4.11* Hgb-12.3 Hct-37.3 MCV-91 MCH-29.8 MCHC-32.9 RDW-13.9 Plt Ct-192 [**2164-1-2**] 06:00AM BLOOD Neuts-66.4 Lymphs-25.2 Monos-5.7 Eos-1.9 Baso-0.8 [**2164-1-2**] 06:00AM BLOOD PT-12.8 PTT-28.2 INR(PT)-1.1 [**2164-1-2**] 06:00AM BLOOD Glucose-90 UreaN-19 Creat-1.3* Na-131* K-4.1 Cl-93* HCO3-28 AnGap-14 [**2164-1-2**] 06:00AM BLOOD ALT-36 AST-64* LD(LDH)-1230* AlkPhos-230* TotBili-0.3 [**2163-12-29**] 06:45AM BLOOD GGT-70* [**2164-1-2**] 06:00AM BLOOD Calcium-9.9 Phos-2.1* Mg-2.4 ========================= ECHO: There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). There is no aortic valve stenosis. No aortic regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a moderate sized pericardial effusion. No right ventricular diastolic collapse is seen. There is brief right atrial diastolic collapse. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. ========================= CT ABDOMEN WITHOUT IV CONTRAST: Large pericardial effusion similar to last examination. There is a right small-to-moderate loculated pleural effusion and tiny left pleural effusion. Additionally, bronchiectasis and consolidation is present in the anterior portion of the right lower lobe. Coronary vascular calcifications are present. The multiple liver lesions, spleen, adrenals, right kidney, pancreas, stomach and small bowel loops are unchanged. The left kidney is surgically absent, and there is a wide-mouthed (5cm) incisional hernia over the left posterior flank. The right renal artery stent is again noted. Small nonpathologically enlarged lymph nodes are unchanged. CT PELVIS WITH IV CONTRAST: Bladder, distal ureters, small bowel loops are normal. The sigmoid colon has scattered diverticula. Cecum and right colon are airfilled but normal. There is no free fluid, lymphadenopathy, or free air. In the right lateral vastus muscle, there is an intramuscular lipoma that is incompletely imaged, measuring 20 x 44 mm. BONE WINDOWS: A bone island is present in the right iliac bone. There are degenerative changes in the pubic symphysis, and spine. ========================== CXR: Again seen is prominence of the right mediastinal and hilar region with increased interstitial markings in the right upper lobe. There are right greater than left pleural effusions with volume loss at both bases. Brief Hospital Course: 75y/o WF w/ TCC s/p L nephrectomy is being called out from the CCU after an admission for SOB. She was originally admitted to BIDN on [**12-27**] with flank pain and SOB and was found to have hilar masses and liver lesions. At [**Hospital1 18**], she was initially managed on the floor where ECHO showed no tamponade but CT chest showed partial collapse of the L bronchus by her hilar mass as well as a pericardial effusion. She was prepped for bronchoscopy with probable stent placement but desaturated during preparation for the bronch and was transfered to the MICU for further management on [**1-2**]. . In the ICU, she was treated symptomatically with morphine for her SOB with improvement and possible pericardiocentesis and tissue biopsy were discussed with the family. However, in light of her over all poor prognosis, discussion was initiated with palliative care at the request of both the daughter and the patient. Plans now exist for the patient to be transfered home with hospice services on [**1-4**]. She denies any complaints currently outside of some lower back pain and mild dyspnea which is much improved since admission. She is comfortable with avoiding vital signs and blood draws for the remainder of her admission but elected to continue taking her home medications. Home hospice companies were contracted and supplies delivered to the home. Standard home hospice prescriptions (pain meds, bowel regimen, anxiolytics, and antisecretory agents) were filled out and faxed to the hospice per their protocol. She was d/c home on the day after call-out to the floor with home hospice services. Medications on Admission: norvasc metoprolol plavix lasix Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 2. Hospice medications per facility protocol 3. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*2* 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. Disp:*30 Suppository(s)* Refills:*2* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 7. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). Disp:*10 Patch 72 hr(s)* Refills:*2* 8. Oxygen per nasal canula prn patient comfort 9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): please remove for 12hrs in any 24hr period. Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] & Hospice Discharge Diagnosis: Primary: Metastatic cancer of unknown primary Pleural effusion Pericardial effusion . Secondary: HTN Renal artery stenosis Discharge Condition: Stable: tolerating PO intake and stable SpO2 on supplemental O2 Discharge Instructions: Please call your PCP or return to the ER with shortness of breath, chest pain, yellowing of skin, or other concerning symptoms. . Followup Instructions: Please call your primary care physician for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 702**] appointment as needed ([**Last Name (LF) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 19980**]) Completed by:[**2164-1-4**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6427, 6486

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274, 289

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1188, 3751

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43114

Discharge summary

report

Admission Date: [**2175-6-9**] Discharge Date: [**2175-6-20**] Date of Birth: [**2105-9-26**] Sex: M Service: MEDICINE Allergies: Gluten Attending:[**First Name3 (LF) 5037**] Chief Complaint: altered mental status, fevers Major Surgical or Invasive Procedure: 1. Lumbar puncture [**2175-6-10**] 2. Intubation [**2175-6-10**] 3. picc-line placement [**2175-6-12**] History of Present Illness: 69-year-old Haitian speaking male h/o ESRD s/p kidney transplant in [**2168**], Chronic Hep C, HIV on HAART (last CD4 220 [**2175-6-7**]), h/o DVTs on coumadin, who was brought in by ambulance after his cousin found him laying in bed unresponsive shaking his right arm. Prior to this, his VNA called him and he was not answering questions appropriately. She then called his cousin and HCP, to let him know. His cousin then came to the patient's house and found him as above. He immediately called 911. Of note, the cousin spoke to the patient the day prior in the late afternoon and found him to be answering questions appropriately. In the outpatient, he has been having difficulty obtaining an appropriate INR as his seroquel dosing and has had VNA help him with INR checks. . In the ED, initial vs were: 100.5 92 152/92 16 95% RA. alert and oriented x 0. Finger stick 97. T max: 101.3 in ED. CT head negative for bleed. Labs notable for an INR of 5.6. WBC of 5.2 with a left shift. He was given 1 liter NS, 2 grams CTX, 1 gram vancomycin. 1 gram of ampicillin was ordered, but not given. EKG notable for no ischemic changes. Prior to transfer to the floor, VS: 101.3 96 122/89 16 100 RA. . On the floor, patient was immediately noted to be having a seizure where both eyes deviated to the right with tonic flexion of right arm. Neuro was consulted immediately. When he was clear, he reportedly stated he had a bad taste in his mouth. He was given acyclovir, ampicillin and a total of 3 mg IV ativan, with brief improvement in his seizures, however seizures continued to return. He was then transferred to the MICU for closer monitoring. . Upon arrival to the MICU, his IV infiltrated, and no peripheral access was found. He continued to have seizures with temporary relief with 1 mg ativan. A femoral line was placed and he was keppra loaded with 750 mg IV x 1 and given 10 mg IV vitamin K. . Review of systems: Unable to obtain due to mental status. Past Medical History: 1. End-stage renal disease secondary to hypertension, status post kidney transplant in [**2168**] with deceased donor transplant, currently on azathioprine and sirolimus. 2. Chronic hepatitis C without history of treatment. 3. Hepatitis B core antibody positive and surface antibody positive. 4. Celiac sprue. 5. Positive PPD in [**2168-4-11**] and status post INH therapy per patient, but unclear in [**Name (NI) **]. 6. Osteopenia/osteoporosis. 7. Anxiety. 8. Hypertension. 9. Status post left parietooccipital hemorrhagic stroke in [**2167**], complicated by seizures. 10. History of DVT x2 with lifelong anticoagulation with Coumadin. 11. HIV diagnosed while hospitalized for PCP pneumonia in [**Name9 (PRE) 547**] [**2174**]. He has been on Truvada, renally dosed and raltegravir since [**2174-7-12**]. Social History: Patient is originally from [**Country 2045**] and has lived alone recently; He denies tobacco, alcohol or illicit drug use. Family History: Noncontributory. Physical Exam: ADMISSION: Vitals: T:100.1 BP: 188/77 P: 93 R: 17 O2: 93% RA General: Not oriented, intermittently alert HEENT: Sclera anicteric, dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Tachycardic, sinus rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . DISCHARGE: Pertinent Results: ADMISSION LABS: [**2175-6-9**] 01:00PM PT-52.0* PTT-54.2* INR(PT)-5.6* [**2175-6-9**] 01:00PM PLT COUNT-308 [**2175-6-9**] 01:00PM NEUTS-78.3* LYMPHS-12.1* MONOS-7.8 EOS-1.7 BASOS-0.1 [**2175-6-9**] 01:00PM WBC-5.2# RBC-3.32* HGB-9.7* HCT-28.4* MCV-86 MCH-29.1 MCHC-34.0 RDW-15.5 [**2175-6-9**] 01:00PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2175-6-9**] 01:00PM cTropnT-<0.01 [**2175-6-9**] 01:00PM LIPASE-71* [**2175-6-9**] 01:00PM ALT(SGPT)-7 AST(SGOT)-4 CK(CPK)-337* ALK PHOS-36* TOT BILI-0.0 [**2175-6-9**] 01:00PM GLUCOSE-105* UREA N-21* CREAT-2.3* SODIUM-134 POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-25 ANION GAP-12 [**2175-6-9**] 03:35PM rapamycin-12.4 [**2175-6-9**] 09:11PM PT-54.8* PTT-52.9* INR(PT)-5.9* [**2175-6-9**] 09:11PM WBC-5.8 RBC-3.30* HGB-9.4* HCT-27.8* MCV-84 MCH-28.5 MCHC-33.8 RDW-15.2 . DISCHARGE LABS: [**2175-6-20**] WBC 7.5 Hgb 7.8 Hct 22.5 plt 381 [**2175-6-20**] PT: 33.5 PTT: 39.1 INR: 3.3 [**2175-6-20**] Na: 134 K: 3.9 Cl: 103 HCO3: 25 BUN: 22 Cr: 1.8 . STUDIES: CT HEAD W/O: 1. No acute intracranial process. 2. Focal encephalomalacia in the left parieto-occipital region, likely from prior hemorrhage. 3. Stable periventricular hypoattenuation, possible small vessel ischemic disease or HIV-related leukoencephalopathy. . CXR [**6-9**]: Stable right upper lobe scarring. No acute findings. . MRI [**6-10**]: 1. Moderate to severe changes of small vessel disease and brain atrophy. 2. Chronic blood products in the left parietal lobe likely indicative of prior hemorrhage or ischemia. 3. No evidence of acute infarcts, mass effect or hydrocephalus. . EEG [**2175-6-11**]: This is an abnormal video EEG telemetry due to the slow and disorgnaized background wtih nearly continuous generalized delta frequency slowing with superimposed mixed alpha and theta frequency activity and frequent brief periods of generalized suppression. This pattern is consistent with a moderate diffuse encephalopathy most commonly seen with medication effect, metabolic disturbance, or infection. The mixed alpha and beta frequency activity is suggestive of a medication effect. In addition, the occasional bifronto-central sharp discharges are indicative of an underlying cortical irritability. However, no clear electrographic seizures were seen. . EEG [**2175-6-12**]: This is an abnormal video EEG telemetry due to the slow and disorganized background with bursts of generalized delta frequency slowing consistent with a moderate encephalopathy. There were also periods of prolonged mixed alpha and beta frequency activity suggestive of a medication effect. Encephalopathies are most frequently associated with toxic/metabolic disturbances, infections, and medication effects. In addition, there were occasional sharp and spike and slow wave epileptiform discharges seen in the right frontal region or the frontal regions bilaterally, indicating underlying cortical irritability and epileptogenic potential. However, no clear electrographic seizures were seen. . EEG [**2175-6-13**]: This is an abnormal continuous EEG due to the presence of frequent periods of rhythmic 0.5-1 Hz generalized delta slowing with embedded frontocentral sharp waves lasting up to 12 seconds. In addition, there were frequent generalized interictal sharp discharges seen often with a bifronto-central and occasionally with a right fronto-central predominance. Together, these patterns are suggestive of a generalized cortical irritability. In addition, there was one electrographic seizure seen at 11 a.m. without an associated clinical change, as described above in the Continuous EEG section. Otherwise, the background consists of alternating periods of a faster theta/alpha frequency activity and a slower [**2-12**] Hz delta activity, as described above, which represents a moderate to severe diffuse encephalopathy commonly seen with medication effect, metabolic disturbance, or infection. . EEG [**2175-6-14**]: PENDING EEG [**2175-6-15**]: PENDING EEG [**2175-6-16**]: PENDING . CXR [**2175-6-13**]: Stable right upper lobe nodule. . L shoulder x-ray [**2175-6-19**] Note MRI is more sensitive to evaluate the tendinous and ligamentous structures. The visualized left lung and ribs are unchanged and grossly normal. The visualized AC joint is grossly normal. The humeral head is slightly high riding, which is suggestive of rotator cuff pathology. Moderate degenerative changes of the glenohumeral joint with joint space narrowing, mild glenoid sclerosis, tiny inferior humeral head osteophytes. No definite fracture. No dislocation. IMPRESSION: 1. Moderate glenohumeral joint degenerative changes. 2. Mild high riding humeral head, which suggests rotator cuff pathology. . CT head w/o contrast: [**2175-6-19**] 1. No acute intracranial hemorrhage or major vascular territorial infarct. 2. Chronic microangiopathic ischemic disease. . Echo [**2175-6-20**] The left atrium is normal in size. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: No PFO, ASD, or cardiac source of embolism seen. Normal global and regional biventricular systolic function. . MICRO and OTHER STUDIES: Serum toxo: IgG positive, IgM negative Serum and CSF crypt Ag: negative Serum RPR: negative Serum CMV viral load: undetectable C diff: negative CSF HSV: NEGATIVE CSF [**Male First Name (un) 2326**] VIRUS: NEGATIVE CSF HHV6: NEGATIVE . Aspergillus negative 0.1 Beta glucan negative <31 pg/mL . STOOL CX [**2175-6-12**]: NEGATIVE C. DIFF [**2175-6-12**]: NEGATIVE C. DIFF [**2175-6-16**]: NEGATIVE Brief Hospital Course: HOSPITAL COURSE: Pt is a 69 yo M h/o HIV on HAART, ESRD s/p renal transplant, Hep C, DVTs on coumadin with elevated INR p/w status epilepticus and fever. Pt was seen by neurology, started on antiepileptics and admitted to the MICU for closer monitoring. He was intubated for airway protection and for MRI. Pt was started on Vanc/CTX/Ampicillin and Acyclovir to cover for meningitis. LP was initially not able to be done given elevated INR. MRI without contrast showed old left parietal blood, but no new infarct. On HOD#1, LP was done and showed few WBCs and slightly elevated protein, with negative Cryptococcal Ag, Toxo, and HSV; CSF cultures ultimately did not indicate bacterial or fungal infection. He was placed on AEDs with Keppra and monitored by neurology. ID was consulted given concern for meningitis especially in this gentleman with immune suppression. Several CSF studies were sent, which were unrevealing. He was extubated in the MICU, and transferred to the medicine floors for further care. He was more oriented, with mental status slowly improving throughout remainder of hospital course. EEG did show possible seizure focus in right posterior lobe, but patient remained clinically free of events. . ACTIVE ISSUES: ============== # Status Epilepticus: DDx for onset included meningitis, encephalitis given fevers, vs. new infarct, hemorrhage. Given the temporal nature of his seizures with the altered taste, deviation to right highly concerning for HSV infection though this came back negative. Opportunistic infections such as toxoplasmosis or cryptococcus were also considered, but were negative. CSF studies were not indicative of PML and MRI was not suggestive of PRES. Patient does have an old left parietal infarct though this is unlikely to be a seizure focus, contrast imaging of his head was not performed given renal impairment so visualization of other intracranial pathology (new small infarct or enhancing lesions) could not be fully evaluated. LP was done on HOD 1 and showed slightly elevated WBC to 14 and 5 RBCs and protein but otherwise unrevealing. Viral encephalitis is most likely etiology though would not expect seizures solely from this. Because seizure threshold can also be lowered by immunomodulators and psychiatric medications; azathioprine/ rapamycin were initially held and seroquel was discontinued. Patient had several clinical seizures and 1 non-convulsive seizure seen on EEG, and his Keppra dose was increased to 750mg q12h. Prior to transfer to the floor, he was not having any seizure activity and his mental status was improved. On the medicine floors, he was monitored on EEG, which showed possible seizure focus in the right posterior lobe. At time of discharge, patient remained clinically stable and will follow with neurology as an outpatient for further management. # Toxic metabolic encephalopathy: Likely secondary to encephalitis (most likely viral) as above. [**Month (only) 116**] also be [**Doctor Last Name 688**] and waxing in setting of delirium and peri- and post-ictal states. He was treated initially with vancomycin, ceftriaxone and acyclovir to cover for bacterial meningoencephalitis and HSV encephalitis though these were subsequently discontinued after studies came back negative. Patient was also initially intubated for airway protection and successfully extubated when mental status improved. He had an NGT placed for tube feeds. Through the remainder of the hospital course, patient became more alert and oriented to person/ place; able to follow simple commands and communicate with healthcare providers through an interpreter. Of note, patient did have new onset left upper extremity weakness (see below). . # CKD, s/p renal transplant in [**2168**]: Cr remained at baseline of around 1.8-2.0. Renal transplant team was following patient. His rapamycin levels were elevated at 14 (goal [**7-19**] one year after transplant) and rapamycin was held with daily levels checked. His azathioprine was also briefly held given concern for myelosupression and then restarted on [**2175-6-17**]. Per renal transplant, he restarted rapamycin at 1mg daily on [**2175-6-16**]. Rapamycin levels should be checked every 2-3 days and faxed to renal transplant clinic ([**Telephone/Fax (1) 697**]) where patient will be followed as an outpatient. . # Anemia: Hct 28.4 on admission, which is slightly down from baseline in the low 30s. Hct trended down to 19.6 on HD 5 and he received 1U RBCs with appropriate response to 24. He had no signs of active bleeding, iron studies were not suggestive of [**Doctor First Name **] and more consisted with ACI. His stools were guaiac negative. Myelosuppression was also likely contributing given immunosuppressive agents s/p renal transplant and HIV. Reticulocyte count was consistent with this. His azathioprine and rapamycin were initially held to aid in marrow recovery. His HCT drifted downwards to 22.1 at time of discharge with no signs of active blood loss or hemolysis. Labs should be checked as an outpatient with transfusion parameters to maintain Hct > 21. . # DVTs: patient has recent history of DVTs for which he is on coumadin. He had elevated INR on admission (5.2) which was attributed to elevated seroquel levels. He was given vitamin K and coumadin was held, heparin drip was started for bridging. His coumadin was restarted after his HCT remained stable (as above) at 2mg daily. INR was again supratherapeutic at 3.3 prior to discharge with subsequent discontinuation of coumadin. PT/INR should be checked daily with resumption of coumadin to maintain an INR of [**3-16**]. . # Left arm weakness: After acute illness, patient was noted to have isolated left deltoid weakness on exam. Per comprehensive neurologic exam, there was also a questionable decrease in left triceps and upper extremity extensiors raising concern for possible CNS pathology. Stat CT head w/o contrast showed no acute pathology and echo w/ bubble showed no PFO. As further imaging would not impact management, repeat MRI head/ neck was not pursued. Left arm weakness may also be related to rotator cuff injury from fall prior to admission although patient had no complaints of discomfort. Shoulder xray showed some elevation of the humeral head which may be consistent with musculoskeletal etiology. Further evaluation and management per outpatient providers. . # Femoral line complication: Pt had femoral line placed on left, but artery was cannulated. Vascular surgery was consulted. Line was removed once INR <1.8. Pressure was applied, pulses remained intact, no hematoma and no bruit. He remained stable for the remainder of the hospitalization. . # HIV: Last CD4 count 220. Continued HAART. CSF studies were not able to be sent for HIV viral load and LP was not repeated given clinical improvement. He was continued on HAART, and will have follow-up with ID as an outpatient. . # Leukopenia: Most likely [**3-15**] marrow suppression from immunosuppressants. Has multiple other reasons to be leukopenic including HIV vs. infection. No clear source of infection. Sirolimus & Azathioprine was initially held, and restarted on [**6-16**] and [**6-17**] respectively once leukopenia had resolved. . # Respiratory distress: Initially intubated for airway protection in setting of seizures, s/p extubation on [**2175-6-13**]. On the medicine floors, he had good O2 sats on room air. . # Eosinophilia: Differential checked [**2175-6-14**] with peripheral eos 8.1%. Pt had mild transaminitis earlier in his course that has since resolved. Only new medication is Keppra. He did not have a rash, and LFT's were mildly elevated, but downtrended. Should have follow-up to assess for resolution. . # Loose stools: Puting out large amounts from rectal tube in the MICU and continued on transfer to medicine floors. C. diff x 2 was negative and stool cultures from [**6-12**] were negative. Prior to discharge, rectal tube removed. . # HTN: on clonidine, amlodopine, and metoprolol as outpatient. Given nicardipine on admission per neuro recs, which was subsequently discontinued. Patient became increasingly hypertensive as sedation was weaned and was restarted on amlodipine and clonidine, and labetolol was added instead of home metoprolol. His SBP was relatively well controlled at ~140s at time of transfer to floor. His BP continued to be well-controlled during this stay on the medicine floors. He was discharged on Amlodipine, Clonidine per prior home doses, and started on Labetalol. . # Nutrition: Placed on TF's while in the MICU which were continued after extubation given profound weakness. Speech & swallow evaluated the pt, and recommended diet of pureed solids and thin liquids with supplemental tube feeds until PO intake improved. Patient should have repeat swallow evaluation and calorie count at LTAC to determine when Dobbhoff can be removed. # Hep C: Reportedly never been treated - check viral load . # GERD: Protonix held while in ICU, and given Lansoprazole. Once tolerating po's, pantoprazole was restarted at home dosing. . # Anxiety: On seroquel as outpatient, but thought to be interacting with INR and possible lowering the seizure threshold. This has been held since admission. Pt should follow-up with physicians at rehab for further management. . TRANSITION OF CARE: =================== 1. CODE: FULL 2. Follow-up: - Neurology - Renal transplant 3. Medical management: - several adjustments to medications made as described - please monitor rapamycin levels every 2-3 days; fax to [**Telephone/Fax (1) 697**] - hold coumadin until PT/INR [**3-16**] - monitor Hct and transfuse to maintain Hct > 21 4. Outstanding tasks: - reassess need for nutritional supplementation with calorie count; repeat speech/ swallow evaluation 5. Barriers to rehospitalization: - PT/OT to maximize strength and independence in ADL Medications on Admission: AMLODIPINE 5 mg Tablet by mouth daily AZATHIOPRINE - 50 mg Tablet daily CLONIDINE - 0.2 mg Tablet TID EMTRICITABINE-TENOFOVIR [TRUVADA] - 200 mg-300 mg Tablet - 1 Tablet(s) by mouth every 48 hours METOCLOPRAMIDE - 5 mg Tablet by mouth three times daily METOPROLOL TARTRATE 50 mg Tablet - [**2-12**] Tablet(s) by mouth twice a day MIRTAZAPINE - 15 mg Tablet - 1 Tablet(s) by mouth at bedtime For insomnia, depresion and to stimulate appetite. PANTOPRAZOLE- 40 mg Tablet, Delayed Release -1 Tablet daily QUETIAPINE [SEROQUEL] - 50 mg Tablet - 1 Tablet(s) by mouth at bedtime RALTEGRAVIR [ISENTRESS] - 400 mg Tablet - 1 Tablet(s) by mouth q 12 hours SIROLIMUS [RAPAMUNE] - 2 mg daily SULFAMETHOXAZOLE-TRIMETHOPRIM - 400 mg-80 mg Tablet - 1 Tablet(s) by mouth one time per day to prevent infection WARFARIN - 2 mg Tablet - take up to 2 Tablet(s) by mouth daily or as directed CALCIUM CARBONATE - (Prescribed by Other Provider) - Dosage uncertain CALCIUM CARBONATE-VITAMIN D3 [OS-CAL 500 + D] - 500 mg (1,250 mg)-400 unit Tablet - 1 Tablet(s) by mouth once a day CHOLECALCIFEROL (VITAMIN D3) [DELTA D3] - 400 unit Tablet - 1 Tablet(s) by mouth DAILY (Daily) CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - 1,000 mcg Tablet - 2 Tablet(s) by mouth one time per day DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth take up to 1 tab [**Hospital1 **] FOOD SUPPLEMENT, LACTOSE-FREE - Liquid - 1 can by mouth 1-2 times daily MULTIVITAMIN - Capsule - 1 Capsule(s) by mouth once a day MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth daily Discharge Medications: 1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. labetalol 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 3. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. 5. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day. 6. multivitamin Tablet Sig: One (1) Tablet PO once a day. 7. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. sirolimus 1 mg Tablet Sig: One (1) Tablet PO Q6AM (). 9. azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 11. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours). 12. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 14. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day: Please hold until INR < 3. Target PT/INR [**3-16**]. 15. simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Primary: 1. Seizures 2. Fevers 3. Toxic metabolic encephalopathy 4. Anemia 5. Leukopenia 6. CKD s/p renal transplant Secondary: 1. HIV 2. Hypertension 3. history of DVT's 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. [**Last Name (Titles) 19781**], It was a pleasure taking care of you during this admission. You were admitted with seizures and fever. You were intubated during the seizures to protect your airway and this tube was pulled out once your medical condition had stabilized. You were able to breath well on your own and come off oxygen. You were treated initially with antibiotics given concern for infection in the brain, but a sampling of the spinal fluid showed that this was not infected. You were also seen by neurology and started on an anti-seizure medication. An MRI of the brain showed no new changes. You had an EEG to monitor for seizure activity, and this showed an area of focal slowing in the right poterior brain. You also had an echocardiogram which showed no abnormalities. By the time of discharge, your mental status was improving. You did have weakness of your left shoulder which was likely caused by injury to your arm from a fall, but may have been caused by a small stroke. Due to your severe illness, you still required supplemental nutrition via a dobboff tube which will be removed once you are eating better. The following medications were changed during this admission: - STOP Seroquel 50mg by mouth at night - STOP Metoprolol tartrate 50mg 0.5 tablet twice daily - STOP Metoclopramide 5mg three times daily - HOLD your coumadin 2mg daily: you will need to have your PT/INR monitored daily until your INR is [**3-16**] - HOLD your multivitamins while you are still using tube feeds as supplementation - DECREASE your sirolimus to 1mg daily: you will need to have your levels measures every 2-3 days to ensure that you are on the correct dose - START keppra 750mg [**Hospital1 **] - START Labetalol 300mg by mouth three times daily - START simvastatin 10mg daily Please continue all other medications you were taking prior to this admission. Followup Instructions: Please follow-up with the following appointments: Department: [**Hospital3 249**] When: WEDNESDAY [**2175-7-12**] at 10:40 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15675**], MD [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: NEUROLOGY When: [**Hospital Ward Name **] [**2175-7-7**] at 9:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 31415**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: TRANSPLANT CENTER When: TUESDAY [**2175-8-1**] at 9:00 AM With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Fax: [**Telephone/Fax (1) 697**] [**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]

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52908

Discharge summary

report

Admission Date: [**2110-1-8**] Discharge Date: [**2110-1-12**] Date of Birth: [**2046-8-31**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3256**] Chief Complaint: fever Major Surgical or Invasive Procedure: [**First Name3 (LF) **] History of Present Illness: EAST HOSPITAL MEDICINE ATTENDING ADMISSION NOTE Date: [**2110-1-10**] Time: 23:45 The patient is a 62 y/o M with PMHx of paranoid Schizophrenia, COPD, colon cancer in remission s/p colectomy with liver wedge resection, recurrent biliary obstruction s/p >30 ERCPs in past 7 years (with plan for repeat [**Month/Day/Year **] next week) presents to the ED with fever. Patient reports fever to 101 at home today. Also with nausea (no vomiting) and generalized weakness. He denies any abdominal pain or diarrhea. No change in color of skin or urine. He endorses dysuria. He also reports one month of URI symptoms, was diagnosed with acute sinusitis by his PCP last week and was taking a three week course of amoxicillin, which he said improved his symptoms. He also endorses mild SOB at rest, which is worse with movement. His chronic cough is unchanged. He denies chest pain, orthopnea, pnd or LE edema. He requires ERCPs every 3-4 months for removal of biliary sludge. In [**2108-7-29**], he required ICU for cholangitis and septic shock (on pressors). Regarding patient's schizophrenia, he endorses racing thoughts but denies any SI or HI. In ED: 100.5 98P 123/76 16 99%RA; he was given Unasyn and tylenol. Labs showed elevated tbili 2.0, ruq u/s done (read pending). [**Year (4 digits) **] was consulted. His blood pressures dropped shortly after being admitted and he was transferred to the ICU, where his antibiotics were broadened to zosyn and he received IVFs, neosynephrine and levophed, which were weaned off at 2pm [**2110-1-9**]. He remained hemodynamically stable off of pressors and IVFs for >24 hours and was subsequently transferred to the medical floor for further monitoring. On the floor, he reported no pain, n/v, diarrhea, cp, sob. He endorsed insomnia and requested something to help him sleep. Review of Systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies visual changes, headache, dizziness, sinus tenderness, neck stiffness, rhinorrhea, congestion, sore throat or dysphagia. Denies chest pain, palpitations, orthopnea, dyspnea on exertion. Denies shortness of breath, cough or wheezes. Denies nausea, vomiting, heartburn, diarrhea, constipation, BRBPR, melena, or abdominal pain. No dysuria, urinary frequency. Denies arthralgias or myalgias. Denies rashes. No increasing lower extremity swelling. No numbness/tingling or muscle weakness in extremities. No feelings of depression or anxiety. All other review of systems negative. Past Medical History: - Colon Cancer metastatic to liver s/p left colectomy, s/p left liver lobe segmentectomy, s/p chemotherapy; currently in remission. - Recurrent biliary obstruction due to 5-FU. Per recent PCP note, the patient reports that he has ERCPs every 3-6 months to remove biliary sludge. - COPD - Schizophrenia - GERD - Macular degeneration - right temporal adnexal carinoma s/p removal and skin graft repair by derm - s/p Appendectomy - s/p Cholecystectomy Social History: Lives alone, spends time with sister on weekends. Quit tobacco 3 years ago, 40 pack year history. No alcohol or illicits. On disability. Family History: Mother deceased from colon cancer. Father had melanoma. Physical Exam: VS: ; pain /10 GEN: No apparent distress HEENT: no trauma, pupils round and reactive to light and accommodation, no LAD, oropharynx clear, no exudates CV: regular rate and rhythm, no murmurs/gallops/rubs PULM: Clear to auscultation bilaterally, no rales/crackles/rhonchi GI: soft, non-tender, non-distended; no guarding/rebound EXT: no clubbing/cyanosis/edema; 2+ distal pulses; peripheral IV present NEURO: Alert and oriented to person, place and situation; CN II-XII intact, [**5-3**] motor function globally DERM: no lesions appreciated Pertinent Results: [**2110-1-8**] 05:30PM GLUCOSE-112* UREA N-14 CREAT-1.1 SODIUM-137 POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-27 ANION GAP-14 [**2110-1-8**] 05:30PM ALT(SGPT)-131* AST(SGOT)-149* ALK PHOS-289* TOT BILI-2.0* [**2110-1-8**] 05:30PM LIPASE-51 [**2110-1-8**] 05:30PM ALBUMIN-4.4 [**2110-1-8**] 05:30PM WBC-7.5 RBC-4.49* HGB-14.0 HCT-38.6* MCV-86 MCH-31.2 MCHC-36.3* RDW-12.9 [**2110-1-8**] 05:30PM NEUTS-89.0* LYMPHS-5.6* MONOS-3.9 EOS-1.4 BASOS-0.2 [**2110-1-8**] 05:30PM PLT COUNT-146* [**2110-1-8**] 05:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-TR [**2110-1-8**] 05:30PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 TRANS EPI-<1 [**2110-1-8**] 05:30PM URINE MUCOUS-RARE [**2110-1-8**] RUQ U/S: read pending [**2110-1-8**] CXR: Emphysema, possible nodule in the left lower lung. Recommend non-emergent CT to assess further. No signs of pneumonia or CHF. [**2110-1-8**] 5:30 pm BLOOD CULTURE #1. Blood Culture, Routine (Preliminary): ESCHERICHIA COLI. FINAL SENSITIVITIES. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ 8 S AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Aerobic Bottle Gram Stain (Final [**2110-1-9**]): Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 630PM [**2110-1-9**]. GRAM NEGATIVE ROD(S). Brief Hospital Course: Mr. [**Known lastname **] is a 63yo M with PMH of colon cancer s/p colectomy and liver wedge resection, in remission, paranoid schizophrenia, emphysema, recurrent biliary obstruction s/p >30 ERCPs, admitted with fever and hyperbilirubinemia from likely biliary obstruction and cholangitis. # Cholangitis: Shortly after admission, patient became hypotensive with SBP in the 70s, not responsive to several IVF boluses. Most likely septic shock given fevers and possible source of biliary tract given elevated transaminases and Tbili. DDx for shock etiologies include hypovolemic, hemorrhagic or cardiogenic. Pt appears dry, but without obvious fluid loss this is less likely. Pt has anemia, but no obvious source of bleeding. Cardiogenic less likely given lungs clear, JVP flat, and no evidence of peripheral edema. CVO2 71, lactate 0.8. Given obstructive picture, cholangitis is most consistent with his presentation: fevers, elevated bilirubinemia, right upper quadrant abdominal pain. Patient was transferred to the ICU, given several more IVF boluses and he was started on neosynephrine. CVL was placed and patient was transitioned to levophed with good response. Patient's antibiotics were broadened to Zosyn for gram negative and anaerobic coverage for abdominal sources. The following morning patient was taken for [**Known lastname **] which showed biliary sludge, no frank purulence. Bile duct was cleared and stent was placed. Patient was weaned off pressors several hours later and blood pressure remained stable for the remainder of his ICU stay. On [**1-10**], 1 of 2 blood cultures from [**1-8**] grew gram negative rods. Sensitivities to cefepime, ceftriaxone, tobramycin and gentamicin were documented and thus, the patient was switched to ceftriaxone and then to cefpodoxime (high dose) with a plan for 14 day total course of antibiotics. # Biliary obstruction: Pt with rising bilirubin in setting of fevers (as above). Pt has had >30 [**Month (only) **]'s in the past, requiring multiple dilatations, most recently ~ 4 months prior. Patient was taken for [**Month (only) **] on [**2110-1-9**]: Multiple balloon sweeps distal to the stricture extracted copious amounts of debris, sludge and stone fragments. Stent was placed in bilary tract. LFTs and Bili trended down s/p [**Date Range **]. Repeat [**Date Range **] recommended in 3 months. # Shortness of breath: Pt reported mild SOB on evaluation initially in the ED. DDx includes pulmonary edema vs. PNA vs. PE vs. anxiety. Despite fluids, unlikely pulmonary edema given lungs clear. PNA possible given recent fevers, but without cough or infiltrate on CXR, this is less likely. PE possible, though not tachycardic, and no chest pain so cardiac etiology is unlikely. Pt was mildly anxious at the time as well, and seemed to improve with reassurance. Pt maintaining O2 sats without worsening symptoms. Shortness of breath resolved on transfer from ICU. # Anemia: Normocytic. Pt has no acute signs of bleeding. Pt has received multiple fluid boluses prior to most recent Hct. Plts mildly low, though pt has had thrombocytopenia previously from likely liver dysfunction. Recommend continued work up as an outpatient. #Acute sinusitis: Suspect fever due to biliary process as opposed to sinus disease given patient's subjective improvement of symptoms while on amoxicillin. Amoxicillin held while on unasyn/zosyn and then ceftriaxone, then cefpodoxime. Continued saline nasal spray. # Emphysema: Continued Advair and prn nebs. # Schizophrenia: Continued home meds, however propranolol was acutely held due to hypotension. # Lung nodule: seen on CXR, will need non-emergent evaluation with CT as an outpatient. Medications on Admission: Albuterol HFA Alprazolam 0.25mg qhs prn Amoxicillin 500mg TID x 3 weeks Advair 500/50 [**Hospital1 **] Gabapentin 800mg [**Hospital1 **], 1200mg qhs Miralax daily Propranolol 10mg [**Hospital1 **] Ranitidine 150mg [**Hospital1 **] Risperidone 1.5mg daily, 3mg qhs Actigall 300mg TID Ziprasidone 40mg [**Hospital1 **] Discharge Medications: 1. cefpodoxime 200 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*40 Tablet(s)* Refills:*0* 2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**12-30**] Inhalation every 4-6 hours as needed. 3. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for anxiety. 4. Advair Diskus 500-50 mcg/dose Disk with Device Sig: One (1) Inhalation twice a day. 5. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 6. gabapentin 400 mg Capsule Sig: Three (3) Capsule PO HS (at bedtime). 7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 8. propranolol 10 mg Tablet Sig: One (1) Tablet PO twice a day. 9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. risperidone 0.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 11. risperidone 3 mg Tablet Sig: One (1) Tablet PO at bedtime. 12. Actigall 300 mg Capsule Sig: One (1) Capsule PO three times a day. 13. ziprasidone HCl 40 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Discharge Disposition: Home Discharge Diagnosis: Cholangitis E. coli bacteremia Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with signs and symptoms of cholangitis, which you have had before. You were transfered to the ICU for treatment of this. You improved with an [**Month/Day (2) **], which you have had done before. You are being discharged on antibiotics for your infection. Please take these antibiotics for 10 more days. All of your other home medications are the same. Followup Instructions: On Tuesday, please call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] a follow up appointment in the next two weeks. Also on Tuesday, please call ([**Telephone/Fax (1) 2233**] (Gastroenterology) to [**Telephone/Fax (1) **] an [**Telephone/Fax (1) **] in 3 months. Department: PSYCHIATRY HMFP When: TUESDAY [**2110-2-4**] at 2:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 28258**], MD [**Telephone/Fax (1) 1387**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 551**] Campus: EAST Best Parking: Main Garage

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icd9cm

[ [ [] ] ]

[ "51.87", "38.93" ]

icd9pcs

[ [ [] ] ]

11497, 11503

6286, 9972

309, 334

11584, 11584

4154, 5141

12130, 12790

3517, 3575

10339, 11474

11524, 11563

9998, 10316

11734, 12107

3590, 4135

5185, 6263

2208, 2872

264, 271

362, 2189

11599, 11710

2894, 3344

3360, 3501

30,501

141,910

32659

Discharge summary

report

Admission Date: [**2129-6-14**] Discharge Date: [**2129-6-21**] Date of Birth: [**2049-3-23**] Sex: M Service: MEDICINE Allergies: Ambien Attending:[**First Name3 (LF) 898**] Chief Complaint: s/p open [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] in splint, dyspnea. Major Surgical or Invasive Procedure: Achilles tendon lengthening procedure. History of Present Illness: Patient is a 80 M with hx of Mod-severe COPD with hypoxemia, pulm HTN, PVD, CRI now s/p achilles tendon lengthening procedure who has been persistently hypoxic following procedure. This is likely a continuation of his chronic state. He is being admitted to the MICU for monitoring overnight. The patient was followed in NY for his COPD. Per records, he has been recommeneded to wear o2 20-24 hours daily. Pre-op today, his o2 sat was 80% on RA. In records he has ranged from 80-92% on RA in the past. Post op he intially desatted to the low 80s on a nonrebreather. Throughout the day, he was weaned to nasal cannula, but has been falling to the 70s while sleeping. This is most likely what he does at home, but we will admit him to the MICU to watch his sats overnight. The patient feels well on admission the MICU team. He is satting in the mid-high 80s on 3L NC. Patient got 80cc/hr of LR intraop. he recieved 1mg morphine and 1 percocet post op. Past Medical History: 1. Chronic Lung disease with Pulm htn and low DLCO: Spirometry FEV-1 85% of predicted FVC 123%, FEV1 108%, ratio 87%, TLC 111%, DLCO 23%, pormovement with broncodilator 2.Peripheral [**Last Name (NamePattern4) 1106**] disease: s/p bypass in legs, and on coumadin 3.Pulmonary [**Last Name (NamePattern4) 1106**] disease 4.Chronic hypoxemia - on chronic O2 5.Renal insufficiency. 6.Ulcerative colitis 7.Hypertension 8.Seizure disorder 9.Peripheral edema associated with his PVD 11.Hypertension 12. Achiles contraction Social History: 90 pack years smoking, quit 15 years ago, denies ETOH. Family History: DMII, CAD Physical Exam: Vitals: T: 94.2 BP: 107/61 P: 73 RR: 13 O2Sat: 96 on face mask Gen: HEENT: Clear OP, MMM NECK: Supple, No LAD, No JVD CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops LUNGS: CTA, BS BL, No W/R/C ABD: Soft, NT, ND. NL BS. No HSM EXT: No edema. dopplerable pulse left LE, rt leg in cast SKIN: No lesions NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**2129-6-14**] 10:22AM GLUCOSE-125* UREA N-20 CREAT-1.4* SODIUM-144 POTASSIUM-4.2 CHLORIDE-110* TOTAL CO2-26 ANION GAP-12 [**2129-6-14**] 10:22AM estGFR-Using this [**2129-6-14**] 10:22AM CALCIUM-8.5 PHOSPHATE-5.1* MAGNESIUM-2.3 [**2129-6-14**] 10:22AM WBC-5.9 RBC-3.62* HGB-10.0* HCT-33.7* MCV-93 MCH-27.7 MCHC-29.8* RDW-14.6 [**2129-6-14**] 10:22AM PLT COUNT-229 [**2129-6-14**] 10:22AM PT-13.5* PTT-26.0 INR(PT)-1.2* Brief Hospital Course: [**2129-6-17**] . Assessment:Pt is a 80 y/o M with COPD/emphysema here with increased hypoxia postop secondary to aspiration PNA s/p Achilles tendon surgery. . Plan: . Hypoxia: This patient has a long standing history of COPD and an oxygen requirement at home. PFT results from [**2129-6-17**] show no exacerbation of underlying emphysema/COPD/pulm HTN. Given interval change of LLL opacities on CXRs from [**6-8**] to [**6-15**], and decreased BS/egophony on physical exam, and increased oxygen requirements, hypoxia is likely attributed to an aspiration PNA s/p surgery, also possibly involving sedation from perioperative opiages. It is less likely that he is in CHF given he looks euvolemic/hypovolemic on exam, although did receive IVFs during surgery. No PEs noted on CTA. He has no shunt on TTE/bubble study. No levofloxacin given the new black box warnings on tendon/ligament tears, and patient is s/p achilles tendon lengthening procedure. Patient was covered for apsiration PNA w/ PO cefpodoxime, to be continued for a two week course until [**2129-6-28**]. He was transitioned from a ventimask to a high flow nebulizer, and finally to NC. He was satting 85-96% on [**3-13**] L NC. He will need follow-up in pulmonary clinic. He was continued on inhaled steroids and given incentive spirometry. He was transfered to the floor. On the floor, spiriva was added as per pulmonary, and patient was in excellent condition, saturating at 97% on 3L NC, with 40% venti mask use at night. . S/p Achilles tendon repair: patient stable s/p procedure. He was given tylenol and Ultram for post op pain. Podiatry is aware of his transfer to the floor and will follow him. . CRI: Patient had elevated Cre up to 1.7, and had an episode of oliguria requirng a straight-cath that returned 250 ccs of fluid. Bladder scan revealed no obstruction or residual fluid. He was given maintenance IVFS, and returned back to baseline of 1.2 by [**6-17**]. . Peripheral [**Month/Year (2) **] Disease: Continued coumadin and plavix. . Ulcerative Colitis: stable , continued on asachol. . HTN: stable, continued on HCTZ 12.5 daily, lisinopril 10mg daiy, and Amlodipine 5mg daily FEN: low sodium diet (thin liquids/soft solids/supervised feedings), lytes daily. . Ppx: heparin SC, coumadin, Tylenol for pain, Bowel reg . CODE: full . Medications on Admission: -Coumadin [**1-9**] daily -Asacol 1600mg TID -Lyrica 100 TID -Norvasc 5mg daily -Iron 325 daily -Zestril 10mg daily -Prilosec 20mg daily -Plavix 75mg daily KCl 20meq daily -Folic Acid -HCT 12.5 daily -FORMOTEROL FUMARATE -SIMVASTATIN 20mg daily -GATIFLOXACIN eye drops -TAMSULOSIN 0.4 daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four (4) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 9. Lyrica 100 mg Capsule Sig: One (1) Capsule PO tid (). 10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 12. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 14. Lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 16. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 18. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. 19. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 20. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 21. Oxygen Patient requires 3-4 L Nasal Cannula during the day for O2 saturations in the low 90's and a 40% Venti Mask when sleeping at night. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: 1.Chronic obstructive pulmonary disorder 2.Peripheral [**Location (un) 1106**] disease 3.Pulmonary [**Location (un) 1106**] disease 4.Chronic hypoxemia - on chronic O2 5.Renal insufficiency. 6.Ulcerative colitis 7.Hypertension 8.Seizure disorder 9.Peripheral edema associated with his PVD 10.Hypertension 11. Achiles contraction Discharge Condition: Patient is stable, moving from bed to chair as it is difficult for him to walk status post his achilles tendon surgery. He is on non-weightbearing status for his Right Leg. His Oxygen saturation most recently was 97% on 3 L nasal cannula, still requires a 40 percent venti mask at night to maintain saturation. Discharge Instructions: -You were diagnosed with an aspiration pneumonia. Please continue your antibiotic (cefpodoxime) for two weeks, until [**2129-6-28**]. -If you experience any loss of consciousness, severe chest pain, severe dizziness, severe headaches, or begin to cough up blood, please contact your primary care physician (Dr. [**Last Name (STitle) 6481**] and return to the hospital. Followup Instructions: 1. Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 16550**] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 4775**] Date/Time:[**2129-6-30**] 9:45 2. Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB) Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2129-10-5**] 1:00 3. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2129-10-5**] 1:45 4. Please call Podiatry for a follow-up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1140**]. Podiatry may have already set up an appointment, but please call to check. Set up an appointment within 1 week if possible. ([**Telephone/Fax (1) 76104**] Completed by:[**2129-6-21**]

[ "492.8", "V15.82", "443.9", "507.0", "556.9", "416.8", "345.90", "799.02", "V46.2", "584.9", "E878.8", "585.9", "736.71", "997.3", "285.21", "727.81", "403.90" ]

icd9cm

[ [ [] ] ]

[ "83.85" ]

icd9pcs

[ [ [] ] ]

7531, 7603

2969, 5284

358, 398

7976, 8291

2512, 2946

8708, 9541

2007, 2018

5626, 7508

7624, 7955

5310, 5603

8315, 8685

2033, 2493

227, 320

426, 1379

1401, 1919

1935, 1991

11,590

135,372

2410

Discharge summary

report

Admission Date: [**2157-4-2**] Discharge Date: [**2157-4-8**] Date of Birth: [**2083-8-18**] Sex: F Service: NEUROLOGY Allergies: Allopurinol / Ethambutol / Colchicine / Efavirenz Attending:[**First Name3 (LF) 5018**] Chief Complaint: aphasia, right-sided weakness Major Surgical or Invasive Procedure: None History of Present Illness: 73 year old woman with multiple medical problems including ESRD (On HD qMWF), CAD, CHF, HIV (CD4 198), DM2, Hyperlipidemia, and Hep C who presents to the ED this morning with speech difficulty and right facial weakness. The patient herself is unable to provide a history at this time. According to family, the patient woke up this morning around 5:30AM. She was last seen well yesterday evening. upon awakening this morning, she apparently tried to call another relative to report that something was wrong. During that phone call, however, her speech was unintelligible. The family went to the house to check on her and found her ambulating with non fluent, nonsensical speech. She followed occasional commands, but appeared "confused". Her daughter noted a right facial droop. EMS was called and she was brought to the ED. Neurology consult was called at 8:30 AM and I was present at the bedside within at 8:35AM. According to the family, she has had occasional diarrhea over the last week. Otherwise, she has been healthy. She had her regularly scheduled dialysis yesterday. She was recently admitted to the medicine service [**Date range (1) 12431**] for fever. She was felt to have a viral infection, all cultures were negative. Past Medical History: PMH: 1. ESRD on HD MWF 2. CAD -s/p MI [**6-6**] s/p stent [**2154**]. 3. CHF-last echo [**2157-3-9**] EF 40%, depressed LVSF, global hypo, moderate AR 4. Hx of pulmonary edema requiring intubation [**5-6**] 5. HIV on [**Month/Year (2) 2775**], most recent CD4 198, started on Bactrim [**3-9**] 6. DM2, diet controlled 7. HTN 8. Hyperlipidemia 9. Spinal TB 10. Gout 11. Anemia 12. Hep C 13. ? hx of stroke in past. Fell yrs ago and was told that she suffered a "minor stroke". Symptoms unknown. No residual. Social History: Pt lives alone and gets around with a walker. She cooks for herself. Her daughter comes over daily to help her take her meds. She denies tobacco, EtOH, IVDA, herbals/vitamins. She has 6 kids. Family History: She has a son with DM and CAD Physical Exam: Right homonymous hemianopia Fluent aphasia Right-sided weakness Pertinent Results: [**2157-4-2**] 08:30AM BLOOD Triglyc-157* HDL-68 CHOL/HD-5.4 LDLcalc-266* LDLmeas-241* [**2157-4-7**] 09:35AM BLOOD %HbA1c-5.7 [Hgb]-DONE [A1c]-DONE Brief Hospital Course: The patient was admitted to the neurology ICU given her hypotension and position-dependent exam, with fluctuating right-sided weakness. She stabilized her pressures on pressor support for the first few days and was then transferred to the floor on HD #3 off pressors. At this point, her global aphasia had resolved to a fluent aphasia and her right side had recovered its strength. Her vascular risk factors include hyperlipidemia, for which she will continue on lipitor and zetia. HbA1c was 5.7. TTE was unremarkable for cardioembolic source. MRA neck showed no stenoses. The patient was started on aggrenox, as she had a drug-eluding stent in [**2154-6-4**] and no history of angina. Cardiology agreed with this plan and discontinuation of plavix. She was followed by renal for hemodialysis and suffered no complications. She will be seen in stroke clinic for follow-up. Her NG tube should be continued until she is fully able to eat enough to meet her nutritional needs. On video swallow, she had no esophageal difficulty but was slow to swallow. For this reason, the NG tube was continued, even as her diet was advanced to nectar/puree, until she is able to eat enough on her own. Medications on Admission: ASA 325 Plavix 75 Sevelamer 800 TID Lipitor 80 Zetia 10 Lamivudine 100 qd Zidovudine 100 TID Metoprolol SR 100 qd Nevirapine 200mg [**Hospital1 **] Captopril 50 [**Hospital1 **] Vit B Cmplx Bactrim DS TIW Discharge Medications: 1. Atorvastatin 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 2. Ezetimibe 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 3. Lamivudine 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 4. Zidovudine 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO TID (3 times a day). 5. Sevelamer 800 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a day): Hold while patient not taking po. 6. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Hospital1 **]: One (1) Cap PO DAILY (Daily). 7. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Hospital1 **]: One (1) Tablet PO TIW () as needed. 8. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) Injection TID (3 times a day). 9. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: One (1) Injection ASDIR (AS DIRECTED): sliding scale. 10. Nevirapine 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 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. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 hr [**Last Name (STitle) **]: One (1) Cap PO BID (2 times a day). 13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Last Name (STitle) **]: as below ML Intravenous DAILY (Daily) as needed: 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift . 14. Aluminum Hydroxide Gel 320 mg/5 mL Suspension [**Last Name (STitle) **]: Ten (10) cc PO three times a day as needed for for serum phosphate >6. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Left middle cerebral artery infarct Discharge Condition: Fluent aphasia. Mild right-sided weakness. Right facial droop. Right homonymous hemianopia. Discharge Instructions: You were admitted to the neurology service after suffering a left middle cerebral artery stroke, which has affected your language and made your right side weak. Your speech should improve over the course of the next 6 months and your strength has already begun to improve. Your plavix was discontinued and you were started on aggrenox; should you experience headache with this medication, it should be taken with tylenol for a couple of weeks as your body adjusts to it. You should also continue to take lipitor and zetia for your high cholesterol. Please keep all appointments and take your medications as prescribed. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2157-5-3**] 12:15 Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**] Date/Time:[**2157-6-8**] 1:00 [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**] Completed by:[**2157-4-8**]

[ "403.91", "070.70", "274.9", "583.9", "433.30", "424.1", "433.10", "250.00", "585.6", "042", "428.0", "070.54", "434.11" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.93" ]

icd9pcs

[ [ [] ] ]

5784, 5854

2690, 3881

339, 346

5934, 6028

2517, 2667

6695, 7156

2386, 2417

4137, 5761

5875, 5913

3907, 4114

6052, 6672

2432, 2498

270, 301

374, 1623

1645, 2158

2174, 2370

27,464

156,999

3234

Discharge summary

report

Admission Date: [**2177-8-24**] Discharge Date: [**2177-8-30**] Date of Birth: [**2124-4-21**] Sex: M Service: CARDIOTHORACIC Allergies: Neurontin / Prozac Attending:[**First Name3 (LF) 165**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: tube thoracostomy left History of Present Illness: Mr. [**Known lastname 4020**] is a 53 year-old gentleman who underwent a CABGx3 on [**7-28**] with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**] at [**Hospital1 18**]. He had an uneventful post-op course and was discharged on [**Last Name (un) **]-operative day 4. He has been followed since for a superficial sternal wound infection and peripheral edema requiring increased doses of lasix. He presented to the emergency department with shortness of breath and chest pain that worsens with coughing. Past Medical History: CAD s/p MI ([**2175**]) and multiple overlapping DES to LCx ([**2176-8-5**]) HTN Hyperlipidemia--no LDL, HDL available at [**Hospital1 18**] GERD DM2--no A1C available Nocturia Hepatitis C--no viral load available Chronic back pain s/p laminectomies, rod placement d/t injury--on chronic methadone COPD--no PFTs available Arthritis Bipolar Social History: Social history is significant for the presence of current tobacco use: he has smoked [**1-15**] PPD x "all my life". There is a history of alcohol abuse in the past; he has been sober x 8 years. He admits to using 4 lines of cocaine 2 days ago. Family History: There is a family history of premature coronary artery disease in his grandmother and aunt. Physical Exam: At the time of discharge, Mr. [**Known lastname 4020**] was awake, alert, and oriented. His heart was of regular rate and rhythm. His lungs were clear to ausculation bilaterally. His abdomen was soft, non-tender, and non-distended. His mediastinal incision was clean, dry, and intact and his sternum was stable. His vein harvest site at his knee was open but without erythema or pus. His harvest sites were otherwise clean. He had trace edema in his extremities. Pertinent Results: [**2177-8-29**] 05:41AM BLOOD WBC-6.2 RBC-3.10* Hgb-8.9* Hct-27.5* MCV-89 MCH-28.6 MCHC-32.2 RDW-15.9* Plt Ct-302 [**2177-8-29**] 05:41AM BLOOD Glucose-90 UreaN-23* Creat-0.9 Na-136 K-4.3 Cl-95* HCO3-35* AnGap-10 [**Known lastname **], [**Known firstname 7167**] [**Hospital1 18**] [**Numeric Identifier 15114**]TTE (Focused views) Done [**2177-8-25**] at 1:29:35 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] [**Street Address(2) 15115**] [**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2124-4-21**] Age (years): 53 M Hgt (in): 69 BP (mm Hg): 122/64 Wgt (lb): 250 HR (bpm): 72 BSA (m2): 2.27 m2 Indication: H/O cardiac surgery. ?Pericardial effusion. ICD-9 Codes: 428.0, 786.05 Test Information Date/Time: [**2177-8-25**] at 01:29 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) 4082**], MD Test Type: TTE (Focused views) Son[**Name (NI) 930**]: Cardiology Fellow Doppler: Limited Doppler and color Doppler Test Location: West Echo Lab Contrast: None Tech Quality: Suboptimal Tape #: 2008W058-0:00 Machine: Vivid [**7-22**] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: 3.7 cm <= 4.0 cm Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *6.4 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 35% to 40% >= 55% Findings This study was compared to the prior study of [**2177-7-26**]. LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: RA not well visualized. LEFT VENTRICLE: Normal LV wall thickness. Moderately dilated LV cavity. Mild-moderate regional LV systolic dysfunction. RIGHT VENTRICLE: RV not well seen. AORTIC VALVE: Aortic valve not well seen. No AR. MITRAL VALVE: Trivial MR. TRICUSPID VALVE: Tricuspid valve not well visualized. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Left pleural effusion. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is mild to moderate regional left ventricular systolic dysfunction with severe hypokinesis of the basal half of the inferior and inferolateral walls. The remaining segments contract normally (LVEF = 35-40 %). The aortic valve is not well seen. No aortic regurgitation is seen. Trivial mitral regurgitation is seen. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2177-7-26**], the left ventricular cavity size is smaller and a large left pleural effusion is now present. The other findings are similar. Brief Hospital Course: Upon admission, an CXR was taken of Mr. [**Known lastname **] chest, revealing a large left pleural effusion. A chest tube was placed, which drained 2.5 liters of serosanguinous fluid. He was placed on IV lasix. Vancomycin was started for sternal erythema. Left EVH site was found to be open with purulent drainage. This was cultured. Abx therapy was broadened to include cipro and flagyl. His vein harvest site improved greatly. Pt. has remained stable and is ready for discharge home. He should follow-up in the wound clinic in 1 week. Medications on Admission: methadone 40 mg TID diazepam 5mg TID PRN pain aspirin 81mg daily docusate sodium 100mg [**Hospital1 **] clopidogrel 75mg daily prilosec 20mg daily ipratropium-albuterol 2 puffs Q6hours dilaudid 2mg q6hours PRN pain flomax 0.4mg daily cymbalta 60mg daily atorvastatin 20mg daily insulin glargine 50 units SQ [**Hospital1 **] rosiglitazone 4mg daily humalog insulin sliding scale toprol XL 50mg 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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2* 4. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 7. Rosiglitazone 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 10. Methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble PO three times a day. Disp:*90 Tablet, Soluble(s)* Refills:*0* 11. Diazepam 5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed. Disp:*60 Tablet(s)* Refills:*0* 12. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 13. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 15. Insulin Glargine 100 unit/mL Solution Sig: as pre-hospital Units Subcutaneous twice a day: Insulin as before re-admission per Dr. [**First Name (STitle) **]. Disp:*1 vial* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Fluid overload L Pleural effusion Discharge Condition: good Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Followup Instructions: Please see your primary care provider ([**First Name5 (NamePattern1) 8254**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 15118**]) in [**1-15**] weeks. Dr. [**First Name (STitle) **] in [**3-18**] weeks Wound check in 1 week [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2177-9-1**]

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icd9cm

[ [ [] ] ]

[ "34.04", "38.93" ]

icd9pcs

[ [ [] ] ]

8127, 8178

5097, 5642

304, 329

8256, 8263

2127, 4269

8412, 8768

1530, 1623

6091, 8104

8199, 8235

5668, 6068

8287, 8389

4318, 5074

1638, 2108

245, 266

357, 888

910, 1252

1268, 1514

16,727

157,755

4593

Discharge summary

report

Admission Date: [**2158-9-1**] Discharge Date: (pending) Date of Birth: [**2098-9-17**] Sex: F Service: MEDICINE HISTORY OF PRESENT ILLNESS: At the time of admission, the patient was a 59-year-old woman with a history of alcoholism, cirrhosis, possible seizure disorder, depression and a possible history of cerebrovascular accident. She presented to the emergency room with nausea, vomiting and hematemesis. The patient reported that she was going to bed on the night of admission when she developed these episodes of vomiting of bright red blood. She had one more episode of hematemesis and then called EMS. On presentation, the patient denied having any abdominal pain, history of retching or peptic ulcer disease. At that time, she also denied alcohol use. She denied melena, tarry stools and bright red blood per rectum. The patient also denied any history of gastrointestinal bleed in the past. Because of the patient's condition, further history was unobtainable at the time of admission. PAST MEDICAL HISTORY: 1. Longstanding alcoholism and cirrhosis with patient on spironolactone. 2. Status post apparent cerebrovascular accident in [**2152**] or [**2153**] with possible right hemiparesis: The patient later reported having been in rehabilitation for one and a half years. 3. Apparent seizure disorder: The patient was prescribed Tegretol in the past, although she had not been taking it consistently secondary to alcohol abuse. 4. Chronic obstructive pulmonary disease. 5. G5P3, status post cesarean sections: The patient had children ages 40, 35 and 31. 6. Depression. MEDICATIONS ON ADMISSION: Outpatient medications included Zoloft, folate, thiamine and spironolactone. ALLERGIES: The patient had an allergy to sulfa. SOCIAL HISTORY: As noted above, the patient had a longstanding history of alcohol abuse. She also had a history of tobacco abuse. She had three children, ages 40, 35 and 31. PHYSICAL EXAMINATION ON ADMISSION: The patient's vital signs in the emergency room per the emergency room notes were as follows: a heart rate of 92, a blood pressure of 138/26, respirations of 18 and an oxygen saturation of 99% on room air. Per the emergency room notes, the physical examination revealed the following: The patient was vomiting bright red blood. On HEENT examination, the head was normocephalic and atraumatic without any jugular venous distention. The heart revealed a normal S1 and S2 without any murmurs, rubs or gallops. The chest was clear to auscultation bilaterally. The abdomen was soft, nontender and nondistended. There was no costovertebral angle tenderness. The patient refused a rectal examination and guaiac test. On examination of the extremities, no lower extremity edema was noted. The skin was warm with 2+ dorsalis pedis pulses bilaterally. LABORATORY DATA ON ADMISSION: The CBC revealed a white blood cell count of 4200, hemoglobin of 12.4, hematocrit of 36.5 and MCV of 95 with a platelet count which was quite low at 76,000. Prothrombin time was 14.9, partial thromboplastin time was 31.5 and INR was 1.5. Chem 7 revealed a sodium of 144, potassium of 6, chloride of 106, bicarbonate of 20, BUN of 19, creatinine of 0.8 and glucose of 120. The alcohol level was 189. NASOGASTRIC LAVAGE AND ENDOSCOPY: The patient underwent nasogastric lavage in the emergency room, which revealed a significant amount of blood. Thus, the patient was taken for endoscopy. An esophagogastroduodenoscopy revealed clotted blood in the whole esophagus with no evidence of active bleed. No [**Doctor First Name **]-[**Doctor Last Name **] tears or ulcers were noted. Clotted blood was also seen in the whole stomach. A single, cratered, nonbleeding ulcer with marked edema was found in the antrum near the pylorus with a visible vessel. Epinephrine was injected for hemostasis and electrocautery was applied for hemostasis as well. No duodenal ulcers were noted. Otherwise, the esophagogastroduodenoscopy was normal to the second part of the duodenum. HOSPITAL COURSE: Because of concerns about airway protection, the patient had been intubated prior to endoscopy. Following endoscopy and cauterization of her ulcer, she was admitted to the medical intensive care unit. Extubation was delayed by difficulty weaning the patient off the ventilator. The patient was extubated on [**2158-9-5**]. Her intubation had been complicated by ischemia sustained at the patient's upper lip during the intubation process. Consequently, the patient developed an ulcer at her upper lip. The patient's post extubation course was complicated by agitation and changing mental status. Often, the patient was poorly arousable. Psychiatry was consulted and felt that, most likely, the patient's mental status was the result of delirium, possibly due to alcohol withdrawal as well as possible electrolyte abnormalities. The patient had several spikes in her temperature; there was no known source for the fever. Throughout much of the [**Hospital 228**] medical intensive care unit course, she had persistent fevers without a known source. A sputum culture later grew out coagulase positive Staphylococcus aureus and a culture taken from one of the patient's arterial lines grew out coagulase negative Staphylococcus. Also, a chest x-ray during this time revealed possible right middle lobe pneumonia as well as possible bibasilar pneumonia. The patient's sputum culture was found to be sensitive to oxacillin and thus the patient was initially started on oxacillin. However, as the patient's line culture subsequently was found to be resistant to oxacillin, the oxacillin was later discontinued in favor of vancomycin. The patient was kept n.p.o. secondary to her inability to swallow reliably. On [**2158-9-8**], the patient was called out of the medical intensive care unit. Her hematocrits were followed serially and found to be stable. However, the patient did exhibit thrombocytopenia and, for this reason, subcutaneous heparin was discontinued. It was felt that the patient's possible leukocytopenia and her definite thrombocytopenia were due to malnutrition secondary to alcoholism. The patient continued to exhibit a fair amount of agitation. The psychiatric consultation team recommended that, by this point, it was less likely that the patient was still withdrawing from alcohol and more likely that the patient was withdrawing from Ativan, as she had received a fair amount of Ativan in the unit for her agitation. Thus, the patient was gradually tapered off Ativan for a time. The patient underwent a video swallow study on [**2158-9-11**], which revealed that the patient had difficulty swallowing solid foods as well as thin liquids. Thus, the patient's diet was ordered to be that of pureed solids, pudding thick liquids only and p.o. medications which were crushed thoroughly. The patient's meals were supervised by nursing. In terms of the patient's upper lip lesion, the patient was followed by the plastic surgery service, who recommended dressing changes as well as Orabase and bacitracin gel applications. The patient frequently refused the above mentioned dressings and often took them off. Thus, the patient was continued on the bacitracin and Orabase ointments only. The plastic surgery service later recommended following up on an outpatient basis. Regarding the patient's pulmonary status, she did quite well after being released from the unit. She consistently saturated well on room air and her chest x-rays showed overall improvement in her lung congestion. The patient's mental status began to slowly and gradually improve, especially following discontinuation of the Ativan. Haldol was used for agitation instead. The patient was not put on any kind of seizure prophylaxis initially, as the patient had been seizure-free for the duration of her hospitalization and the exact nature of her past seizures was ambiguous. However, on [**2158-9-13**], the patient spiked a fever to 101.5??????F and, on the following day, she exhibited apparent seizure activity in front of her nurse [**First Name (Titles) **] [**Last Name (Titles) 19493**]. The seizure lasted for less than 30 seconds and was followed by an apparent post ictal status in which the patient slumped over in her chair with her eyes closed; she was slowly responsive. For this reason, the patient was loaded with Dilantin per the recommendations of the neurology consultation team. Also, the psychiatry service subsequently recommended switching back to the use of Ativan rather than Haldol, as Haldol would decrease the patient's seizure threshold. Also, on [**2158-9-14**], the patient underwent a CT scan of the head, which revealed a right occipital parietal hemorrhage without herniation. Her INR was 1.5 and thus she was given vitamin K to correct this. The patient was also given fresh frozen plasma to help reverse her partial thromboplastin time of 45. Subsequently, the patient underwent a stroke workup. An MRI of the head was obtained. The neurology team felt that it was possible that the patient had an underlying tumor that might have been responsible for the patient's intracranial bleed. This matter will not be resolved for another four to eight weeks following the initial presentation of the bleed, when follow up imaging can better assess the resolving insult. Also, an MRA of the head was performed, which revealed no interval change in hematoma versus the head CT scan, which initially found the bleed. The MRA of the head was also negative for vascular malformation, although small arteriovenous malformations could not be ruled out. The intracranial circulation was deemed by the radiology service to be patent. A transthoracic echocardiogram was obtained. A transesophageal echocardiogram was deferred because of the patient's thin body habitus and because of the fact that she had a history of difficult intubations. The transthoracic echocardiogram was negative. No vegetations or sources of thrombi were evident. Also, the patient underwent an electroencephalogram on [**2158-9-15**], which revealed a decreased seizure threshold, extremely frequent high voltage bursts of sharp and slow wave activity in the right posterior quadrant and in the right posterior temporal, parietal and occipital areas. The electroencephalogram findings were consistent with low seizure threshold. This was not deemed to be epilepsy but rather correlated with a poor outcome following the patient's intracranial bleed. The patient was maintained on fosphenytoin and later switched to p.o. Dilantin. A urine culture from [**2158-9-13**] grew out vancomycin-resistant enterococcus. Sensitivities were sent and are currently pending. Of note, none of the patient's urinalyses surrounding this culture were positive, suggesting that perhaps the culture had been a matter of colonization or an aberrant laboratory result. Subsequent urine cultures were sent and are currently pending. Nonetheless, the patient was moved to isolation, where she remained afebrile. By [**2158-9-19**], [**2158-9-20**] and [**2158-9-21**], the patient's mental status had been improving significantly such that, on the morning of [**2158-9-21**], she was alert and oriented times three. She was remarkably more alert, oriented and engaged than in days previously. She spoke appropriately in most cases, although she did continue to exhibit some degree of confabulation as noted by the psychiatric team consultant. Because of the patient's improving mental status, her nutritional situation was reassessed. Earlier, because of the patient's relatively poor p.o. intake and her poor swallowing ability, it had been felt that she would most likely require PEG tube placement in the near future for eventual placement in a rehabilitation facility. However, given the patient's continued mental status improvement, it is currently felt that she might be able to attain adequate nutrition by p.o. intake alone. Thus, the nutrition service had been consulted and had begun a calorie count at this time. ASSESSMENT AND PLAN: The following is a problem by problem assessment and plan as noted on the morning of [**2158-9-21**], which is the end of my term on the [**Doctor Last Name **] service: 1. INTRACRANIAL BLEED: As noted above, an MRA of the head was obtained and found to be essentially normal, aside from the intracranial hemorrhage, which had not changed since initial imaging. The neurology service has been consulted and feels that, while an MRA of the neck will eventually be useful, it is not necessarily urgent and could conceivably be obtained on an outpatient basis. Also, as noted above, the patient's transthoracic echocardiogram was essentially negative for any obvious thrombi or vegetations. The patient will need follow up for imaging of her head in approximately four to eight weeks to evaluate for a possible underlying lesion, which might have caused the bleed. The neurology team will continue to follow up. 2. SEIZURE DISORDER: The patient has had no seizure activity for the past week. Her fosphenytoin has been changed to p.o. Dilantin as of today. Also, neurology recommends increasing the Dilantin dose and this will be done. Dilantin levels as well as ammonia levels will be followed. 3. GASTROINTESTINAL: The patient's hematocrit has been, for the most part, stable. There is no current evidence of bleeding. We will continue administration of Protonix. 4. FLUID, ELECTROLYTES AND NUTRITION: As above, the patient has become more alert lately and has also increased her p.o. intake. Thus, the patient may be able to eat entirely by p.o. intake and may not require PEG tube placement. 5. INFECTIOUS DISEASE: As noted above, the patient has a positive vancomycin-resistant enterococcus culture from [**2158-9-13**], although all urinalyses have been thus far negative for signs of urinary tract infection. The patient remains afebrile. Vancomycin was discontinued earlier this week, as was the levofloxacin, of which she received a seven day course. The patient's urine cultures have been sent and sensitivities on the original vancomycin-resistant enterococcus positive culture are pending. 6. CARDIOVASCULAR: The patient is hemodynamically stable. 7. PSYCHIATRY: The psychiatry team is following the patient. Today, the patient correctly spelled the word "world" backwards, suggesting that her attention is significantly improved as she was completely unable to do this only a few days ago. Ativan will be used on a p.r.n. basis for agitation. 8. ACCESS: The patient has a PICC line in place. 9. PHYSICAL THERAPY/OCCUPATIONAL THERAPY: The patient has some cognitive and attention deficits as well as some visual field deficits on the left side of both eyes, status post intracranial bleed. The patient would nonetheless benefit from rehabilitation. 10. DERMATOLOGY: The patient will continue to receive Orabase and bacitracin gel to her lip lesion. She will follow up with the plastic surgery service on an outpatient basis. 11. PROPHYLAXIS: We will continue to use Protonix as well as pneumoboots. DISPOSITION: The patient would benefit from placement in a rehabilitation facility. NOTE: This summary covers the hospitalization of this patient up to the morning of [**2158-9-21**]. [**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**] Dictated By:[**Last Name (NamePattern1) 1550**] MEDQUIST36 D: [**2158-9-21**] 18:11 T: [**2158-9-28**] 08:48 JOB#: [**Job Number 19494**]

[ "287.5", "531.00", "303.00", "707.0", "571.2", "291.0", "780.39", "263.9", "496" ]

icd9cm

[ [ [] ] ]

[ "96.04", "38.93", "96.6", "96.72", "96.34", "44.43" ]

icd9pcs

[ [ [] ] ]

1691, 1819

4110, 15687

206, 1068

2918, 4092

1090, 1664

1836, 2018

21,645

163,525

4689

Discharge summary

report

[** **] Date: [**2105-2-21**] Discharge Date: [**2105-3-2**] Date of Birth: [**2023-5-29**] Sex: F Service: MEDICINE Allergies: Penicillins / Aspirin / Nsaids Attending:[**First Name3 (LF) 30**] Chief Complaint: Mental status changes, hypotension, GI bleed Major Surgical or Invasive Procedure: Endoscopy History of Present Illness: Ms. [**Known lastname 19784**] is an 81 yo female with PMH significant for Hepatitis C, hepatic enchephalopathy, h/o LGIB, who is being transferred to the MICU for BRBPR and mental status changes. Of note, the patient was recently discharged from [**Hospital1 18**] on [**2-16**] for RIJ thrombus and now on Coumadin. She presents today from nursing home with concern for vaginal bleeding vs. rectal bleeding per ER notes. She was also noted to have mental status changes and diaphoretic. A creole interpreter was called but the patient did not respond. Her eyes opened but no verbal response. . In the ED her initial vitals were T 98.3 BP 138/51 AR 60 RR 18 O2 sat 100% on 5L. . Upon transfer to [**Hospital Ward Name **] 2, the patient was hypotensive with BP~80/44. She was not arrousable and not responding to facial touching. She also had some rectal bleeding on exam. She received a 500cc bolus and her BP improved to 92/44 and then 134/65. The patient was given a 2nd unit of pRBCs, taken to CT, and then transferred to the MICU for closer monitoring. . Patient was recently discharged from [**Hospital1 18**] on [**2-16**] after she presented with high ammonia levels and R arm swelling. She was found to have a RIJ thrombus and was started on a heparin gtt and transitioned to Coumadin at time of discharge. INR was therapeutic when she was discharged. In regards to her ammonia levels, the patient has a history of hepatic encephalopathy and per OMR there is some concern that she is not receiving her lactulose at the NH. . Per the patient's daughter, Ms. [**Known lastname 19784**] had been doing well yesterday. Her behavior is very different from her baseline. No report of fevers or chills. Past Medical History: -Hepatitis C:c/b cirrhosis and grade I varices, hepatic encephalopathy -HTN -History of CVAs -DM -COPD -History of GI bleeding requiring transfusion years ago and more recently in [**11-20**] -osteoporosis -glaucoma -CAD - ? can't find more information about this in OMR. do see ECHO in [**2103**] with diastolic dysfunction -dementia -? sick sinus syndrome with bradycardia Social History: lives at nursing home. Is Creole speaking originally from [**Country 2045**]. No tobacco or EtoH. In USA for 35 years not married. HCP is daughter [**Name (NI) **] [**Name (NI) 19781**] Family History: No family hx of liver disease. Grandmother with HTN. Physical Exam: Vitals: T , BP 1/, HR , RR , O2sat % on L NC wt kg General: Awake, drowsy, female with HEENT: NC/AT, no scleral icterus noted. no facial edema. Lungs: crackles at bilateral bases. bilateraly wheezing Cardiac: RRR, nl. S1S2, 3/6 systolic murmur Abdomen: + BS. soft, NT/ND Extremities: +1 LE edema bilaterally. R arm more edematous than left. Skin: dry Neurologic: -mental status: Able to say she is in the hospital for a swollen arm. -Able to move upper extermeities, L>R Pertinent Results: [**2105-2-21**] 12:15PM WBC-6.2 RBC-2.47* HGB-7.2* HCT-22.1* MCV-90 MCH-29.1 MCHC-32.5 RDW-17.6* [**2105-2-21**] 12:15PM NEUTS-77.3* LYMPHS-18.6 MONOS-2.8 EOS-1.0 BASOS-0.3 [**2105-2-21**] 12:15PM PLT COUNT-167 [**2105-2-21**] 12:15PM PT-31.0* PTT-50.7* INR(PT)-3.2* [**2105-2-21**] 12:15PM CK(CPK)-154* [**2105-2-21**] 12:15PM cTropnT-0.06* [**2105-2-21**] 12:15PM CK-MB-4 [**2105-2-21**] 12:15PM GLUCOSE-174* UREA N-21* CREAT-1.3* SODIUM-143 POTASSIUM-4.8 CHLORIDE-106 TOTAL CO2-31 ANION GAP-11 . [**2105-2-27**] CXR - The left PICC line was inserted in the meantime interval with its tip projecting at the level of cavoatrial junction. The NG tube was removed. The cardiomegaly is moderate, persistent. Mild engorgement of the bilateral hilar vessels is consistent with volume overload. There are no consolidation or masses. Small bilateral pleural effusions cannot be excluded. . [**2105-2-24**] EGD: 2 cords of grade I varices were seen in the lower third of the esophagus. The varices were not bleeding. Excavated Lesions Multiple superficial acute non-bleeding ulcers ranging in size from 10mm to 15mm were found in the antrum. Otherwise normal EGD to third part of the duodenum . [**2105-2-23**] Echo: EF>60%, Mild mitral regurgitation with normal morphology. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. No definite cardiac source of embolism identified. . Cxray ([**2-21**]): Early interstitial edema and pulmonary vascular redistribution. Retrocardiac opacity likely represents atelectasis although consolidation cannot be excluded on this single view. . CT head ([**2-21**]): 1. No acute intracranial process detected. 2. Slight increase in mucosal thickening of the left sphenoid sinus consistent with chronic sinus disease. . [**Month/Day (4) **] on Discharge: [**2105-3-2**] 08:58AM BLOOD WBC-4.5 RBC-2.86* Hgb-8.3* Hct-25.0* MCV-87 MCH-29.1 MCHC-33.3 RDW-16.9* Plt Ct-105* [**2105-3-2**] 08:58AM BLOOD Plt Smr-LOW Plt Ct-105* [**2105-3-2**] 08:58AM BLOOD Glucose-166* UreaN-26* Creat-1.4* Na-144 K-4.2 Cl-110* HCO3-30 AnGap-8 [**2105-3-2**] 08:58AM BLOOD Calcium-8.0* Phos-3.5 Mg-2.4 [**2105-2-23**] 03:23AM BLOOD TSH-3.0 [**2105-2-28**] 07:37PM BLOOD Type-ART pO2-107* pCO2-36 pH-7.48* calTCO2-28 Base XS-3 Brief Hospital Course: Ms. [**Known lastname 19784**] is an 81yo Creole speaking female with PMH of Hepatitis C, hepatic enchephalopathy, h/o LGIB, recently d/ced from [**Hospital1 18**] on coumadin for RIJ thrombus who initally presented from NH on [**2-21**] with hypontension, transferred to MICU w/BRBPR and mental status changes. Now called out to floor, mental status improved following lactulose, being treated with ceftriaxone for UTI, HCT stable, EGD with no acute bleeding, plan for colonoscopy as an outpatient. . #Fever- Started on [**2105-2-27**], most likely due to viral syndrome. She was evaluated with blood cultures, urine cx, stool culture and chest xray, none of which showed any evidence of acute bacterial infection. She was treated symptomatically with tylenol and oxycodone as needed for discomfort. . #wheezing, dyspnea - most likely due to combination of COPD exacerbation due to viral illness and mild degree of diastolic heart failure, CXR on [**2-27**] showed mild engorgement of bilateral hilar vessels and possible small effusions. She was started on a 3 day prednisone taper on [**2105-3-2**] with plan for 30 -> 20 -> 10 then d/c. In addition she was treated with albuterol nebs q2hours and atrovent nebs q 6 hours. In addition, she was given an extra dose of IV lasix 60mg prior to discharge to help with her dyspnea. . #Acute renal failure -Baseline Creatinine likely around 1.1, currently with mild renal failure in the setting of likely overall volume overload with a possible element of diastolic heart failure. She was treated with usual lasix 60mg po daily and also given one time dose on lasix 60mg IV x1 prior to discharge. . # Mental status changes: On [**Date Range **], she was encephalopathic, most likely [**2-14**] hepatic encephalopathy vs. UTI, currently back to baseline and stable. Urine culture with possible urinary tract infection, treated with ceftriaxone for a 7 day course, last dose given [**2105-3-2**]. She was back to her baseline mental status prior to discharge. She was continued on a bowel regimen and lactulose three times per day. . # GI bleed: Per medical records she had BRBPR on examination in the ED with Hct~22 ( baseline Hct is between 28-30), also developed gross melena - stat Hct check demonstrated Hct 27 --> 24.9. On transfer out of MICU, HCT relatively stable at 21 with no additional episodes of BRBRP or melena in ICU. EGD with grade I non-bleeding varices and non bleeding ulcers in gastric antrum. Transfused 4 units total during this [**Month/Day/Year **]. She was treated with IV and then oral protonix [**Hospital1 **]. A PICC line was placed for access. He daughter will be contact[**Name (NI) **] by the gastroenterology fellow in the upcoming week to schedule an appointment for an outpatient colonoscopy. In the meantime, hematocrit should be checked at least several times per week to monitor hematocrit. . # RIJ thrombus: Patient presented with RUE edema during recent [**Name (NI) **] and was found to have a RIJ clot on CTA. She was started on a heparin gtt and then transitioned to Coumadin, INR~2.9 on [**Name (NI) **]. Coumadin was stopped during this [**Name (NI) **] given active bleeding. It was not restarted on discharge given likely slowly oozing from GI tract. . # Hepatitis C: prior complications of varices and encephalopathy. She was continued on lasix and nadolol, lactulose titrate to 4 BM/day. She was followed by the liver service during her hospitalization. . # Hypertension: continue outpatient regimen of amlodipine now that HCT/BP stable. Her isosorbide mononitrate was stopped in an effort to discontinue unnecesary medications. . # Access: very poor access, PICC line was left in place on discharge and can be discharged at the nursing facility once she is improved. . # Code: Full (verified with daughter) . #Communication: Daughter [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 19781**] H: [**Telephone/Fax (1) 19790**]; W:[**Telephone/Fax (1) 19791**] Medications on [**Telephone/Fax (1) **]: iron daily lactulose 60ml TID protonix 40mg daily nadolol 40mg daily isosorbide 30mg daily lisinopril 5mg daily- d/c'd recently fluticasone 2puffs [**Hospital1 **] tramadol 25mg [**Hospital1 **] colace aricept 5mg qhs xalatan eye drops qhs ipratropium q6hrs guafenasin calcium carbonate TID prn prilosec 20mg daily humalog insulin SS amlodipine 10mg daily furosemide 60mg daily alphagan eye drops serevent 50mcg q12hrs Discharge Medications: 1. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 2. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Nadolol 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 6. Insulin Regular Human 100 unit/mL Solution Sig: as directed according to sliding scale Injection ASDIR (AS DIRECTED). 7. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every 6 hours). 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation every six (6) hours. 11. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever. 13. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) neb Inhalation Q2 hours. 14. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. 15. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 16. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 18. Prednisone 20 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses: give on [**2105-3-3**]. 19. Prednisone 10 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses: please give on [**2105-3-4**]. Discharge Disposition: Extended Care Facility: Roscommon Discharge Diagnosis: Primary Diagnoses: Encephalopathy Gastrointestinal bleeding NOS Non-bleeding gastric ulcers Fever NOS Right IJ thrombosis Acute exacerbation of COPD - likely viral illness . Secondary Diagnoses: COPD Dementia Type II DM HTN CVA Diastolic heart failure Discharge Condition: Fair Discharge Instructions: You were admitted to the hospital because you had low blood pressure and were also having blood in your stool. You were given blood transfusions to replace the blood you lost. In addition, you had an endocopy which showed that you have esophageal varices and some non-bleeding ulcers in your stomach. You were treated with an acid blocker pantoprazole for the ulcers. You were also treated with ceftriaxone for a urinary tract infection. You were seen by the liver doctors during your [**Name5 (PTitle) **]. They will contact you to schedule an outpatient colonoscopy to look for sources of bleeding. . You also had confusion on [**Name5 (PTitle) **], thought to be due to your liver disease. You were given lactulose and your symptoms improved. . You also had fevers, body aches, sore throat and cough most likely due to a viral illness. You had blood cultures, urine cultures, stool cultures and a chest xray which did not show any evidence of bacterial infection. . Please take all medications as directed. . Please call your doctor or return to the hospital if you experience any concerning symptoms including increased bleeding in the stool, high fevers, chest pain, increasing shortness of breath, fainting or any other concerning symptoms. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] within 1-2 weeks of discharge from the nursing facility. Her number is [**Telephone/Fax (1) 250**]. You will be contact[**Name (NI) **] by the GI office for an appointment for an outpatient colonoscopy.

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icd9cm

[ [ [] ] ]

[ "38.93", "45.13", "99.04" ]

icd9pcs

[ [ [] ] ]

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331, 343

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47493

Discharge summary

report

Admission Date: [**2135-10-3**] Discharge Date: [**2135-10-28**] Date of Birth: [**2057-5-1**] Sex: F Service: SURGERY Allergies: Penicillins / Iodine; Iodine Containing / Codeine / Darvocet-N 100 / Vancomycin / Lactose Attending:[**First Name3 (LF) 3376**] Chief Complaint: Colon Mass Concerning for Colon Cancer Major Surgical or Invasive Procedure: 1. OR [**10-3**]: R. hemicolectomy, parastomal hernia repair with surgisys 2. [**10-7**]: central venous line placement at bedside 3. OR [**10-12**]: Ex Lap for Ex lap, LOA, SBR, washout 3. OR [**10-14**]: washout, ileocolostomy, repair parastomal hernia, closure w/surgisis, JPx3 History of Present Illness: The Pt is a 78 yo F with a prior history of bladder cancer treated with cystectomy and ileal loop diversion who presents with a colonic mass in the setting of a parastomal hernia Past Medical History: - CML on Gleevac since [**2131-3-17**]. History of lyphoma treated 35 yrs ago - H/o bladder cancer s/p cystectomy with ileal loop reconstruction. - Recurrent UTI's in setting of bladder cancer, s/p left nephrectomy - Chronic anemia(Fe and B12 deficient in past)-had been on Aranesp up until recent surgery - S/p and hernia repairs - Chronic Pain Syndrome- on neurontin - S/p recent Left knee replacement [**3-23**] - Hypothyroidism - GERD Social History: Mrs. [**Known lastname 100416**] is married for 58 years to a supportive husband. She has worked in the past as an actress. They recently moved to a housing community in [**Location (un) 2624**]. No tobacco use. Occasionally will have glass of wine or cocktail. Family History: Significant for a sister who died of lung cancer. Mother with a history of syphilis, coronary artery disease, and stroke. Her father died of coronary artery disease, diabetes, and stroke. Brief Hospital Course: Primary: Parastomal hernia Post-op fever Post-op ileus Post-op oliguria Post-op anemia . Secondary: bladder ca s/p resection w/ileal loop, L. nephrectomy, chronic anemia, ventral hernia repairs, CML, chronic pain syndrome, s/p L. TKA [**3-23**], hypothyroidism, GERD The patient is a 78-year-old woman with a complicated past medical history that includes bladder cancer, a cystectomy and an ileal conduit in the right lower quadrant. She has had multiple abdominal surgeries and a large portion of her abdominal wall is mesh except where the ileal conduit was placed and surrounding this is a large parastomal hernia. The patient was anemic and colonoscopy could not be completed because of the hernia but a virtual colonoscopy was performed suggesting a mass in the ascending colon. The patient had a preoperative CEA level that was elevated at approximately 75. On physical exam, she had a palpable mass in the right lower quadrant hernia sac which contained the right colon. On [**10-3**], she underwent a right colectomy and parastomal hernia repair through her right lower quadrant flank incision for a presumptive R colon cancer. Clinically she was slowly improving until on the evening of the 25th, she developed new enteric drainage through the site of a previous drain in the parastomal hernia space. She was taken back the operating room for exploration. Ischemic necrosis of 2 feet of her ileum was discovered upon entry to the abdomen. This was resected and her abdomen was washed out. The fascia of the abdomen was left open with packs and the pt transeferred to the ICU. she was kept intubated and paralyzed and blood pressure was supported intermittently with pressors and fluid resuscitation. She was returned to the OR after 48hours for washout and at this time the fascia was closed with surgasis mesh and drains were placed. She returned to the ICU and over the next several days was successfully weaned from ventilatory support. At the time of reexploration, she was covered broadly for perforation as gross soilage was encountered with daptomycin, fluconazole, meropenem, and flagyl. She completed a 10 day course of antibiotics and at the time of discharge has been stable off all antibiotic therapy for several days without fever or other sign of infection. Her operative cultures grew only coag negative Staph, Enterococcus and strep viridans. Nutritional supplimentation with TPN was begun postoperatively day #2 following fascial closure. She was managed on goal TPN until the day prior to discharge when TPN was discontinued as PO intake had somewhat improved. calorie counts were also improving and the patient has been able to maintain a minimum amout of coloric intake with the addition of boodt shakes tid to her diet. she has tolerated PO well and had good return of ostomy function. The ostomy itself appears quite healthy without edema or erythema. He abdominal exam remain benign and three closed suction drains left at the time of surgery were removed. The last of these - at the site of the peristomal hernia - fell out 4 days prior to discharge and some serous drainage has expressed from the wound since that time. However, no local signs of wound infection or abdominal pain or systemic infectious symptoms have been noted. During the course of her recovery she also complained of some R knee pain at the site of a prior total joint replacement. This was evaluated clinically and radiographically by the orthopaedic service who felt that there was no evidence of joint-space infection. At the time of discharge, Mrs [**Known lastname 100416**] is tolerating a regular diet. Her abdominal incisions are intact and healing well. Both urostomy and ileostomy are functioning well. She is free of infectious symptoms and has completed an appropriate antibiotic course Medications on Admission: neurontin 800HS, dilaudid 2prn, ambien 10'prn, prilosec 20', levoxyl 100' Discharge Medications: 1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for knee pain. 2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 6. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. 7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H () as needed. 8. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 9. Neurontin 800 mg Tablet Sig: One (1) Tablet PO at bedtime. 10. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Location (un) 5481**] TCU Discharge Diagnosis: Primary: Parastomal hernia Post-op fever Post-op ileus Post-op oliguria Post-op anemia . Secondary: bladder ca s/p resection w/ileal loop, L. nephrectomy, chronic anemia, ventral hernia repairs, CML, chronic pain syndrome, s/p L. TKA [**3-23**], hypothyroidism, GERD Discharge Condition: Stable Tolerating a regular diet. Requires encouragement for PO intake. Adequate pain control with oral medication Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomitting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomitting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to amubulate several times per day. . Incision Care: -Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. ##NOTE - Pt has idfficulty IV access and if PICC is needed in the future, this should be done with flouroscopy guidance only## Followup Instructions: 1. Please follow-up with Dr. [**Last Name (STitle) 1120**] ([**Telephone/Fax (1) 3378**] in [**2-19**] weeks. 2. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3919**], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2135-12-19**] 10:30 3. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2135-12-19**] 10:30 4. Please follow-up with Oncology regarding restarting Gleevec.

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icd9cm

[ [ [] ] ]

[ "45.73", "45.93", "45.74", "46.93", "38.93", "99.15", "45.62", "46.42", "54.62" ]

icd9pcs

[ [ [] ] ]

6826, 6881

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388, 671

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310, 350

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Discharge summary

report

Admission Date: [**2139-6-17**] Discharge Date: [**2139-7-15**] Date of Birth: [**2088-7-19**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4691**] Chief Complaint: s/p Motorcycle crash Major Surgical or Invasive Procedure: [**2139-6-22**] Tracheostomy [**2139-6-29**] Craniotomy and resection of colloid cyst [**2139-7-3**] Cyst gastrostomy and G-J tube placment History of Present Illness: 51 year old male driver s/p motorcycle crash with loss of consciousness at the scene requiring intubation; + EtOH. He was found to have left frontal SAH, left parafalcine SDH, right rib fractures, right scapular fracture and lung contusions. He was transported to [**Hospital1 18**] for further care. Past Medical History: PMH: Diabetes, HTN, Dyslipidemia PSH: Right Craniotomy for benign tumor resection Social History: ETOH Abuse Family History: Noncontributory Physical Exam: Upon admission: Gen: WNWD [**Male First Name (un) 4746**] intubated with cervical collar in place. Neurologic examination: GCS E=1, V=1T, M= 5 = 7T Mental status: Intubated - coming off of sedation / No eye opening to voice or noxious stim. Pupils equal and round [**1-26**] bilaterally / conjugate gaze without eye contact or tracking of examiner. + corneals bilaterally. No battles, no raccoon's signs / no hemotympanum or CSF rhinorrhea/otorrhea noted. NCAT. Localizes bilateral upper extremeties L slightly greater than R. Appears to be more purposeful with LUE and LLE as well. No commands. W/d's LLE greater than RLE. Pertinent Results: [**2139-7-1**] 04:31AM BLOOD WBC-15.9* RBC-3.10* Hgb-8.9* Hct-28.5* MCV-92 MCH-28.7 MCHC-31.2 RDW-12.4 Plt Ct-371 [**2139-7-1**] 05:40AM BLOOD Glucose-133* UreaN-28* Creat-1.0 Na-139 K-4.4 Cl-103 HCO3-26 AnGap-14 [**2139-7-1**] 05:40AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.3 [**2139-6-17**] 04:15PM BLOOD ASA-NEG Ethanol-239* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Imaging: [**7-9**] CXR: Left infrahilar consolidation is stable and there is continued enlargement of the cardiac silhouette with a probable small bilateral effusions. [**2139-7-5**] LE DVT Study: Negative for clot. [**2139-7-2**] P/Op HEAD CT: IMPRESSION: Interval reduction of the large pneumocephalus noted previously with small persistent pneumocephalus. Right frontal subarachnoid and probable small subdural hematoma, slightly smaller than the prior examination. No new hemorrhagic foci. [**2139-6-30**] P/Op HEAD MRI: 1. Intraventricular hemorrhage- close f/u with non-contrast CT to assess stability/progression; mildly increased from prior MR but stable from recent CT of [**2139-6-29**]- in the occipital horns. 2. Persistent dilatation of the lateral ventricles related to the previous obstruction from the colloid cyst. 3. Moderate amount of pneumocephalus bifrontally as well as in the left temporal [**Doctor Last Name 534**] and moderate amount of fluid in the sphenoid, mastoid air cells being new compared to the prior study. [**2139-6-17**] TRAUMA CT SCAN: TORSO 1. Right adrenal hemorrhage with associated small hemoperitoneum. 2. Right middle lobe pulmonary contusion. Bibasal atelectasis. 3. Multiple rib fractures and right scapular fracture/ 4. Distended stomach. Consider NGT decompression. 5. Large pancreatic cystic lesions in the setting of chronic pancreatitis likely represent pseudocysts though clinical correlation is advised. Recommend correlation with prior studies if available. MRI may be performed to further assess. 6. Abdominal varices. Recommend clinical correlation for portal venous HTN and cirrhosis. HEAD: 1. Acute subarachnoid hemorrhage in the left frontoparietal region towards the vertex. 2. Acute small left parafalcine subarachnoid hematoma. No midline shift. 3. Hyperdensity at the level of the foramen of [**Last Name (LF) 2044**], [**First Name3 (LF) **] represent colloid cysts. Craniotomy and a surgical tract is seen likely associated with this. Plan: Brief Hospital Course: He was admitted to the Trauma service and transferred to the Trauma ICU where he remained vented and sedated. He underwent tracheostomy on [**6-22**] secondary to failure to wean. On [**6-23**] he was noted with right upper extremity swelling and underwent an ultrasound which revealed partial nonocclusive thrombus in one of the paired right brachial veins and occlusive thrombus in the right basilic vein. Anticoagulation was initiated. Neurosurgery was consulted for his head injuries and for the colloid brain cyst noted on CT and MRI imaging. He was taken to the operating room on [**6-29**] for craniotomy and resection of colloid cyst. On [**7-1**] Infectious Disease was consulted for persistent fevers and leukocytosis. He was cultured and underwent a BAL and was treated for pneumonia with Vancomycin, Cipro, and cefepime. He was eventually weaned off of the ventilator and transferred to the regular nursing unit. He began working with Physical and Occupational therapy who were recommending rehab after his acute hospital stay. On [**2139-7-3**] he was then taken to the operating room for pancreatic cyst gastrostomy and placement of gastrojejunal feeding tube. His tube feeds were started and increased to goal. On [**2139-7-7**] he was noted to have increased secretions, tachypneic and to have an elevated WBC count and falling hematocrit. He was transferred back to the Trauma ICU and underwent another BAL and an EGD. His antibiotics were changed to treat the pneumonia; Vancomycin, Flagyl and Cipro were started. These will continue for another 7 days post discharge. He was evaluated on [**7-13**] by Speech and Swallow for Passy Muir valve for which he was able to tolerate for short periods. Because his mental status has waxed and waned it was difficult to assess his swallowing. He is currently much more awake and it is being recommended that he have ongoing Speech evaluation once at rehab to determine his readiness for an oral diet. For now he will remain NPO and continue with tube feedings. Medications on Admission: Januvia, Glimeperide Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ML's PO BID (2 times a day). 2. Oxycodone 5 mg/5 mL Solution Sig: [**4-5**] ML's PO Q3H (every 3 hours) as needed for pain. 3. Ciprofloxacin 500 mg/5 mL Suspension, Microcapsule Recon Sig: Seven [**Age over 90 1230**]y (750) MG Suspension, Microcapsule Recon PO Q12H (every 12 hours) for 7 days. 4. Tobramycin 300 mg/5 mL Solution for Nebulization Sig: Three Hundred (300) MG inhalation Inhalation [**Hospital1 **] (2 times a day) for 7 days. 5. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3 times a day): hold for HR <60; SBP <110. 6. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) GM Intravenous Q 12H (Every 12 Hours) for 7 days. 7. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) MG Intravenous Q8H (every 8 hours) for 7 days. 8. 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. 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Neb Inhalation every six (6) hours as needed for wheeze. 10. Levetiracetam 100 mg/mL Solution Sig: 1,000 MG PO BID (2 times a day). 11. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5,000 Units Injection TID (3 times a day). 12. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb Inhalation Q6H (every 6 hours) as needed for wheeze. 14. Dulcolax 10 mg Suppository Sig: One (1) supp Rectal once a day as needed for constipation. 15. Protonix 40 mg Susp,Delayed Release for Recon Sig: Forty (40) MG PO once a day. 16. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 17. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML's PO Q8H (every 8 hours): Apply to tongue with swab. 18. Neomycin-BacitracnZn-Polymyxin 3.5-400-5,000 mg-unit-unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day): Apply ointment topically to road rash ares [**Hospital1 **]. Discharge Disposition: Extended Care Facility: Rehab Hospital Of [**Doctor Last Name **] Discharge Diagnosis: s/p Motorcycle crash Colloid brain cyst Subarachnoid hemorrhage Subdural hematoma Rib fractures Right lung contusion Right scapular fracture Pancreatic pseudocyst Pneumonia Discharge Condition: Hemodynamically stable, tolerating a regular diet, pain adequately controlled. Followup Instructions: Follow up in 4 weeks with Dr. [**Last Name (STitle) **], Trauma Surgery for evalaution of your rib fractures and to determine if the tracheosotmy and feeding tube can be removed. Follow up in 4 weeks with Dr. [**Last Name (STitle) **], Orthopedics for your scapula fracture; call [**Telephone/Fax (1) 1228**] for an appointment. Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **] to be seen in 4 weeks. You should have a non-contrast head CT prior to your appointment and an MRI of the brain with and without contrast. Completed by:[**2139-7-15**]

[ "998.89", "263.9", "331.4", "250.00", "868.01", "305.01", "E878.8", "041.04", "272.4", "401.9", "807.08", "805.2", "866.01", "518.5", "285.1", "E816.2", "852.02", "577.2", "811.00", "852.22", "997.31", "861.21", "742.4" ]

icd9cm

[ [ [] ] ]

[ "38.93", "33.24", "96.72", "31.1", "33.23", "01.59", "96.6", "02.12", "45.13", "43.19" ]

icd9pcs

[ [ [] ] ]

8228, 8296

4049, 6078

335, 479

8513, 8593

1645, 2251

8616, 9219

960, 977

6151, 8205

8317, 8492

6104, 6128

992, 994

275, 297

507, 810

2260, 4026

1008, 1091

1155, 1626

1115, 1140

832, 916

932, 944

11,516

193,566

17858

Discharge summary

report

Admission Date: [**2190-3-31**] Discharge Date: [**2190-4-4**] Date of Birth: [**2164-11-8**] Sex: M Service: SURGERY Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 148**] Chief Complaint: Upper GI bleeding Major Surgical or Invasive Procedure: Esophagogastroscopy. History of Present Illness: 25 year old man with PMHx significant for uncontrolled DM I, ESRD on hemodyalisis, history of [**Doctor First Name **]-[**Doctor Last Name **] tears, UGI bleeds that presented to [**Hospital 8641**] Hospital on [**3-29**] with a 1 day history of hematemesis. EGD there revealed esophagitis and a visible vessel in the 2nd part of duodenum which may have been sclerosed on [**3-18**] (bicap'd and injected). 3 clipps were applied. Patient was hypertensive with bps in 220/110s and was treated with beta blockade and nitropaste. Hematocrits were stable on [**3-30**] but subsequently dropped overnight and was transfused 2 units of PRBCs (for a total of 6 units at [**Location (un) 8641**] that admission). He was subsequently transferred on [**2190-3-31**] to [**Hospital1 18**] for further management. Past Medical History: DM, HTN, ESRD on hemodyalisis, retinopathy, neuropathy, tricuspid regurgitation, UGI bleed [**2190-3-15**] and others, [**Doctor First Name **]-[**Doctor Last Name **] tears, gastroparesis, chronic back pain, seizure disorder. Social History: Smokes marijuana daily. Lives with mother. Unemployed Family History: non-contibutory Physical Exam: On Admission Temperature 98.5 heart rate 97SR blood pressure 206/102 respiratons 18 O2 aturation 100 % on room air. Alert and oriented. No acute distress. Sclerae anicteric. PERRL. Regular rate and rhythm. S1 S2 normal. VI/VI SEM. Clear to auscultation bilaterally. No wheezing Abdomen soft, minimal epigastric tenderness Extremities warm and well perfused. 2+ edema. Fistula in L UE. Moving all 4 extremities. No clubbing, cyanosis. Pertinent Results: [**2190-4-3**] 09:31AM BLOOD WBC-10.6 RBC-3.80* Hgb-12.1* Hct-33.8* MCV-89 MCH-31.9 MCHC-35.8* RDW-16.2* Plt Ct-286 [**2190-4-2**] 05:00PM BLOOD WBC-7.3 RBC-3.72* Hgb-11.6* Hct-32.9* MCV-88 MCH-31.1 MCHC-35.2* RDW-15.9* Plt Ct-276 [**2190-4-3**] 09:31AM BLOOD Plt Ct-286 [**2190-3-31**] 05:56PM BLOOD PT-12.2 PTT-22.6 INR(PT)-1.0 [**2190-4-2**] 04:00AM BLOOD Fibrino-324 [**2190-4-3**] 01:34PM BLOOD K-6.1* [**2190-4-3**] 09:31AM BLOOD Glucose-131* UreaN-21* Creat-5.2*# Na-139 K-5.5* Cl-100 HCO3-28 AnGap-17 [**2190-3-31**] 05:56PM BLOOD Glucose-284* UreaN-27* Creat-4.6* Na-139 K-4.9 Cl-98 HCO3-26 AnGap-20 [**2190-3-31**] 05:56PM BLOOD ALT-19 AST-23 LD(LDH)-206 AlkPhos-186* Amylase-53 TotBili-0.2 [**2190-4-3**] 09:31AM BLOOD Calcium-8.3* Phos-7.2* Mg-1.8 [**2190-3-31**] 05:56PM BLOOD Albumin-3.5 Calcium-8.8 Phos-6.6* Mg-2.2 [**2190-3-31**] 05:56PM BLOOD PTH-1375* RADIOLOGY Final Report CT ABD W&W/O C [**2190-4-2**] 12:01 PM CT ABD W&W/O C; CT PELVIS W/CONTRAST Reason: r/o gastrinoma.pt is ESRD on HD. Field of view: 32 Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 25yo M with recurrent GI bleeds / ulcers. REASON FOR THIS EXAMINATION: r/o gastrinoma.pt is ESRD on HD. CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: Recurrent gastrointestinal bleeding and ulcers. Evaluate for gastrinoma. COMPARISON: No previous studies. TECHNIQUE: Axial multidetector CT images of the abdomen were obtained without contrast and then with 150 cc of intravenous Optiray in arterial, portal venous, and delayed phases. Delayed images of the pelvis were also obtained. ABDOMEN CT WITH AND WITHOUT CONTRAST: There are no abnormalities at the visualized lung bases. There are no briskly enhancing lesions in the pancreas or in the gastrinoma triangle. There are no focal liver lesions. The gallbladder, spleen, adrenal glands, and kidneys appear unremarkable. Small bowel and colon appear normal in caliber without evidence of wall thickening. There is no mesenteric or retroperitoneal lymphadenopathy. There is no free fluid. Arterial calcifications are noted, unusual for the patient's age. PELVIS CT WITH INTRAVENOUS CONTRAST: Diverticula are present in the sigmoid colon, without evidence of acute diverticulitis. Vas deferens calcifications are suggestive of diabetes. The bladder, prostate, and rectum appear unremarkable. There is no pelvic or inguinal lymphadenopathy. There is no free fluid. BONE WINDOWS: There are no suspicious lytic or sclerotic bone lesions. IMPRESSION: 1. No evidence of a gastrinoma. 2. Sigmoid diverticulosis without evidence of acute diverticulitis. Brief Hospital Course: Patient was transferred to the [**Hospital1 18**] for further evaluaiton and management. He was admitted to the Trauma/Surgical intensive care unit and made NPO. IV fluids were started. Appropriate laboratory studies were obtained. GI service was consulted for a possible EGD. Patient was started on protonix [**Hospital1 **], and 2 large bore IVs were placed. Renal team was consulted for management of hemodialysis. Gastrin, calcium, PTH levels were sent. Overnight, patient remained hemodynamically stable and had no decrease in hematocrit with no evidence of acute bleeding. EGD was performed and showed a healing ulcer in the second part of the duodenum with previously applied clips, erythema and congestion in the antrum and stomach body compatible with mild gastropathy, erythema and congestion in the gastroesophageal junction and lower third of the esophagus compatible with esophagitis, erosions in the antrum and stomach body, successful hemostasis from previous clipping, and no bleeding in stomach or duodenum. Serial hematocrits continued to be stable. Patient was subsequently transferred to the floor on [**4-2**]. He remained hemodynamically stable. He was dialyzed on home schedule and prn for fluid overload and hyperkalemia. However, on [**4-3**] patient binged on excessive amounts of food against medical advice and had blood sugars in the critical range. Insulin was given and sugars gradually went down through the course of the evening and morning. Patient continued to be noncompliant with his diet and was instructed that we would monitor his sugars throughout the day on the 26th at which time he would be released late in the afternoon if they remained under control. However, the patient did not wish to stay and left against medical advice later that morning. He did have instructions to follow up with his gastroenterologist as well as endocrinologist for further management of his diabetes. Medications on Admission: lasix, sensapar, renagel, desipramine, dilantin, zoloft, fantenyl patch, scopolamine patch, xanax, ambien, insulin, protonix, neurontin, lopressor, lisinopril, norvasc, keppra. Discharge Medications: 1. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 2. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Cinacalcet 60 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO BID (2 times a day). 7. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Alprazolam 0.5 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day as needed. 9. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Duodenal ulcer, upper GI bleed. Discharge Condition: Stable to home. Discharge Instructions: having worsening pains, fevers, chills, nausea, vomiting, shortness of breath, chest pain, or if there are any questions or concerns. Patient to take antibiotics and other medications as directed. Patient not to drive or operate heavy machinery while on any narcotic pain medication such as percocet as it can be sedating. Patient to take colace to soften the stool as needed for constipation as narcotic pain medication can cause this issue. *** Patient's home medications, dosing, and frequency were not available and patient was unable to provide information. PATIENT SHOULD RESTART HOME MEDICATIONS AS PERSCRIBED. **** The only new medication being started is protonix. Followup Instructions: Please follow up with your gastroenterologist in [**Location (un) 8641**]. Please follow up with your Diabetes doctor and your primary care doctor. PATIENT LEFT AMA EARLY IN THE DAY BEFORE HIS SUGARS WERE STABILIZED Completed by:[**2190-4-4**]

[ "532.40", "357.2", "250.43", "585.6", "403.01", "397.0", "780.39", "250.63" ]

icd9cm

[ [ [] ] ]

[ "45.13", "39.95" ]

icd9pcs

[ [ [] ] ]

7810, 7816

4606, 6535

296, 319

7892, 7910

1982, 3036

8636, 8882

1489, 1506

6762, 7787

3073, 3115

7837, 7871

6561, 6739

7934, 8613

1521, 1963

239, 258

3144, 4583

347, 1151

1173, 1402

1418, 1473

31,779

119,869

33836

Discharge summary

report

Admission Date: [**2106-1-12**] Discharge Date: [**2106-1-20**] Date of Birth: [**2042-8-9**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1257**] Chief Complaint: Fever, anemia Major Surgical or Invasive Procedure: EGD arterial line placement History of Present Illness: Dr. [**Known lastname 31624**] is a 63 year old gentleman with a PMH significant for esophageal cancer s/p resection with a recent admission from [**Date range (1) 78207**] for PE s/p IVC filter placement with hospital course complicated by hypovolemic/septic shock, UGIB from anastamosis site, Candidemia, lacunar infarcts, NSTEMI, AF with RVR, CoNS bacteremia now admitted to the MICU for fever and a hematocrit drop. With regard to the patient's recent hospitalization, he was initially admitted on [**12-7**] with dyspnea found to have mulitple segmental and subsegmental PEs in the superior segment of the RUL and RML. He was subsequently transferred to MICU [**Location (un) **] for hypotension in the setting of large volume UGIB, which on EGD was found to be due to a large bleeding ulcer at the site of prior anastamosis that was clipped, and he ultimately was transfused 17 units PRBCs with a discharge hct of 37. He was also found during admission to have fungemia speciated as [**Female First Name (un) 564**] albicans treated with micafungin, ambisome, and then flucanzole with a course that completed on [**1-9**], as well as CoNS bacteremia treaed with vancomycin for 14 days (completed on [**1-8**]). During this hospitalization, his course was also complicated by ARF, NSTEMI with a TnT peak 3.17, MB peak 97, and AF with RVR treated wtih metoprolol and amiodarone. With regard to PE management, the patient had an IVC filter placed and was discharged without systemic anticoagulation. Today, the patient was noted to be febrile to 103 for which he received levofloxacin, and a 12 point hct drop over from 10 days prior, and was transferred to [**Hospital1 18**] for further evaluation. . In the [**Hospital1 18**] ED, initial VS 99.6 84 124/64 18 98%RA. The patient was noted to have a hct of 22 and was guaiac positive, and received 1 unit PRBC transfusion. He also had a CTAP that demonstrated bibasilar opacities (L>R) without intraabdominal fluid collections or bowel obstruction. The patient received pip/tazo and was admitted to the MICU for further management. . Currently, the patient is resting comfortably without complaints. Denies CP/SOB, f/c/s, n/v/d, abd pain, palpitations. . ROS: As above, otherwise negative. Past Medical History: Esophageal Cancer s/p resection Bowel obstruction Tracheo-esophageal fistula Left vocal cord paralysis Depression s/p ECT (following [**2091**] surgery) Anxiety . PAST SURGICAL HISTORY: Esophagectomy at [**Hospital1 112**] in [**2091**] complicated by stricture and tracheal esophageal fistula s/p dilation x2 and Y-stent for the TEF on [**2103-6-24**], exploratory laparotomy/LOA/biliary diversion with G and J Tube placement [**2103-7-9**], Repair of TE fistula w/intercostal flap [**2103-8-20**], Roux-n-Y gastrojejunostomy (esophageal conduit) with intra thoracic anastomosis, small bowel resection, J-tube on [**2103-10-8**], Exploratory laparotomy and lysis of adhesions and reduction of small bowel hernia and repair of diaphragm [**2105-8-28**], ex lap + LOA + revision of diaphragmatic repair and J-tube placement [**2105-9-10**]. Social History: former General Surgeon at [**Hospital1 112**], lives w/ wife and 2 small children ages 5 and 7. Tobacco - none. EtOH - none. No IV, illicit, or herbal drug use. Family History: non-contributory Physical Exam: Admission: VS: 99.8 94 106/63 23 91%RA Gen: Elderly male in NAD, chronically ill appearing HEENT: MM dry. CV: Nl S1+S2 Pulm: Bibasilar crackles, bronchial breath sounds at left base Abd: S/NT/ND. gtube in place Ext: 2+ pitting edema R>L. 2+ dp/pts bilaterally Neuro: Responds to questions, follows commands. . Pertinent Results: [**2106-1-12**] 12:30AM RET AUT-2.6 [**2106-1-12**] 12:30AM PT-16.1* PTT-27.8 INR(PT)-1.4* [**2106-1-12**] 12:30AM PLT COUNT-281 [**2106-1-12**] 12:30AM NEUTS-87.1* LYMPHS-8.2* MONOS-3.9 EOS-0.6 BASOS-0.2 [**2106-1-12**] 12:30AM WBC-8.2 RBC-3.03*# HGB-8.2*# HCT-25.2*# MCV-81* MCH-27.0 MCHC-33.3 RDW-16.5* [**2106-1-12**] 12:30AM CALCIUM-8.2* PHOSPHATE-3.5# MAGNESIUM-2.1 [**2106-1-12**] 12:30AM cTropnT-<0.01 [**2106-1-12**] 12:30AM ALT(SGPT)-18 AST(SGOT)-22 ALK PHOS-109 [**2106-1-12**] 12:30AM estGFR-Using this [**2106-1-12**] 12:30AM GLUCOSE-131* UREA N-28* CREAT-1.3* SODIUM-135 POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-25 ANION GAP-14 [**2106-1-12**] 12:42AM LACTATE-1.4 [**2106-1-12**] 01:30AM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 [**2106-1-12**] 01:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [**2106-1-12**] 01:30AM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.027 [**2106-1-12**] 02:10AM PLT COUNT-258 [**2106-1-12**] 02:10AM NEUTS-88.6* LYMPHS-6.6* MONOS-4.1 EOS-0.5 BASOS-0.2 [**2106-1-12**] 02:10AM WBC-8.2 RBC-2.82* HGB-7.7* HCT-24.7* MCV-82 MCH-27.1 MCHC-33.3 RDW-16.5* [**2106-1-12**] 06:00AM HGB-7.3* HCT-22.4* [**2106-1-12**] 10:36AM PT-15.2* PTT-26.2 INR(PT)-1.3* [**2106-1-12**] 10:36AM PLT COUNT-289 [**2106-1-12**] 10:36AM WBC-9.7 RBC-3.36* HGB-9.2*# HCT-27.7* MCV-83 MCH-27.5 MCHC-33.3 RDW-16.5* [**2106-1-12**] 10:36AM HAPTOGLOB-409* [**2106-1-12**] 10:36AM ALBUMIN-2.7* CALCIUM-7.9* PHOSPHATE-3.8 MAGNESIUM-2.0 [**2106-1-12**] 10:36AM ALT(SGPT)-16 AST(SGOT)-20 LD(LDH)-162 ALK PHOS-103 TOT BILI-2.1* DIR BILI-0.8* INDIR BIL-1.3 [**2106-1-12**] 10:36AM GLUCOSE-104* UREA N-25* CREAT-1.2 SODIUM-134 POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-22 ANION GAP-12 [**2106-1-12**] 05:59PM HCT-25.6* [**2106-1-12**] 11:21PM HCT-24.0* . . EGD: Well healing ulcer anterior to gastro-jejunostomy site in conduit without high risk features. No blood in stomach. Given no source of subacute hematocrit drop recommend NG placement and rapid prep for colonoscopy with anesthesia present in AM prior to discussion regarding anticoagulation. . . Colonoscopy: No clear lesion or source of bleeding identified. Diverticula. No blood in colon. Due to stool in colon small lesions may have been missed. Please remain in ICU and discussion regarding anticoagulation with primary team. . . Blood, urine, and fungal cultures all NGTD. . . ECHO: [**1-18**]: The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] There is no ventricular septal defect. The right ventricular cavity is dilated with depressed free wall contractility. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic valve abscess is seen. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . Brief Hospital Course: 63 year old gentleman with a PMH significant for esophageal cancer s/p resection with a recent admission from [**Date range (1) 78207**] for PE s/p IVC filter placement with hospital course complicated by hypovolemic/septic shock, UGIB from anastamosis site, Candidemia, lacunar infarcts, NSTEMI, AF with RVR, CoNS bacteremia admitted to the MICU for fever and a 10 pt hematocrit drop who now has had cessation of his bleeding. . #. Upper GI bleed/acute anemia: Patient was anemic on admission at 25.2. He was transfused 4 units on [**2025-1-11**] with an appropriate increase in Hct. No evidence of active bleeding clinically. However, given high risk of repeat bleeding and after discussion with the patient will hold off on therapeutic anticoagulation. He was placed on an IV PPI [**Hospital1 **] which was transitioned to PO. He underwent an EGD on [**1-12**] which was unremarkable. He underwent a conolonscopy on [**1-14**] which was poor prep, however had no obvious source for bleeding. The patient's HCT remained stable for the duration of his hospital course. . #. Recent Fevers: On admission he was pan-cultured and ruled out for C.diff. His PICC line was pulled and the tip was cultured. He was emprically started on vanc/meropenem (given prior BCx of [**1-17**] Lactobacillus sensitive to imipenem). He finished a 5 day course of antibiotics and had been afebrile for > 2 days without an obvious source so his antibiotics were stopped. Cx with no growth at the time of discharge. He remained afebrile for the course of his admission. It was believed that the fevers were related to patient's significant LE clot burden. . #. VTE: Severe clots in all of the deep veins of both the right and left lower extremities. The clots were noted to extend from as high in the groin and common femoral vein as can be scanned to below both popliteal bifurcations. Has SVC/IVC filter. No therapeutic anticoagulation given bleeding risk; this was extensively discussed with the patient and his family. . # MR/TR/Hx of NSTEMI: Re-peat ECHO showed Moderate to severe (3+) mitral regurgitation and moderate to severe [3+] tricuspid regurgitation. Patient was placed on ACE-I and lasix. During prior admission, patient had been placed on hydralazine and imdur with a goal toward afterload reduction. However, given that his renal failure has resolved, these medications were discontinued in favor of an ACE-I. The patient's EF was 50-55% on ECHO, but given his degreee of MR, likely much lower than this. . #. Atrial Fibrillation: He was continued on amiodarone and metoprolol. During prep for colonscopy he went into an SVT which responded to fluid. The patient's amio dose was changed from 400 mg to 200 mg on [**2106-1-20**] as per Cardiology recommendation during prior admission. . #. Hypothyroid: He was continued on levothyroxine. . #. Access: No IV access right now and difficult to get central given clots. Will leave without access and put in I/O line if needed. . Code: Full . Contact: [**Known lastname **],[**First Name3 (LF) **] [**Telephone/Fax (1) 78208**] Medications on Admission: white petrolatum-mineral oil 56.8-42.5 % Ointment TID fentanyl 25 mcg/hr Patch 72 hr [**Telephone/Fax (1) **]: One (1) Patch 72 hr fluconazole 200 mg Tablet [**Telephone/Fax (1) **]: Two (2) Tablet PO once a day, finished [**2106-1-9**] metoprolol tartrate 25 mg Tablet daily metoprolol tartrate 12.5 mg QHS hydralazine 10 mg Tablet [**Month/Day/Year **]: Three (3) Tablet PO Q8H amiodarone 400 mg daily through [**2105-1-20**], then 200 mg daily lansoprazole 30 mg Tablet PO daily Seroquel 25 mg Tablet [**Month/Day/Year **]: 0.5-1 Tablet PO PRN anxiety polyethylene glycol 3350 17 gram/dose daily isosorbide dinitrate 20 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO TID vancomycin 750 mg IV daily, finished [**2106-1-8**] Synthroid 50 mcg Tablet daily Discharge Medications: 1. amiodarone 200 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily). 2. fentanyl 25 mcg/hr Patch 72 hr [**Month/Day/Year **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 3. metoprolol tartrate 25 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO QAM (once a day (in the morning)). 4. metoprolol tartrate 25 mg Tablet [**Month/Day/Year **]: 0.5 Tablet PO QHS (once a day (at bedtime)). 5. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 6. levothyroxine 50 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 7. lisinopril 5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY (Daily). 8. furosemide 20 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY (Daily). 9. Seroquel 25 mg Tablet [**Last Name (STitle) **]: 0.5-1 Tablet PO once a day as needed for anxiety. 10. polyethylene glycol 3350 17 gram/dose Powder [**Last Name (STitle) **]: One (1) packet PO once a day. 11. trazodone 50 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Primary Diagnosis: Anemia Secondary to GI bleeding Secondary Diagnosis: Esophageal Cancer, Deep Venous Thrombosis, Mitral Regurgitation Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Dr. [**Known lastname 31624**], You were admitted to the hosptial because of concern for bleeding in your bowel. You underwent an endoscopy and colonoscopy which did not demonstrate any evidence of active bleeding. You were given several units of blood in order to help raise your blood counts. You were also experiencing fevers when you presented to the hospital. We did not discover any evidence of infection which may explain these fevers. It is likely that the fevers are a result of the blood clots in your legs. . You will continue to undergo physical and occupational therapy once you are discharged from the hospital. . Please START the following medications upon discharge from the hospital: Lasix 10 mg daily Lisinopril 2.5 mg daily . Please STOP the following medications: Hydralazine Imdur . If you experience any concerning symptoms after discharge, please call your primary care doctor or return to the emergency room. Followup Instructions: Please follow-up with the physician on staff [**Name9 (PRE) **]. When you leave [**Hospital1 **], please call your primary care doctor within 1-2 days to schedule a follow-up appointment.

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icd9cm

[ [ [] ] ]

[ "97.03", "45.23", "45.13" ]

icd9pcs

[ [ [] ] ]

12860, 12930

7822, 10908

317, 347

13110, 13110

4050, 7799

14253, 14444

3686, 3704

11718, 12837

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13023, 13089

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187,516

45243+58795

Discharge summary

report+addendum

Admission Date: [**2185-12-28**] Discharge Date: [**2186-1-13**] Date of Birth: [**2123-4-21**] Sex: M Service: CARDIOTHORACIC Allergies: All allergies / adverse drug reactions previously recorded have been deleted Attending:[**First Name3 (LF) 922**] Chief Complaint: Chest pressure/nausea Major Surgical or Invasive Procedure: [**2186-1-4**] Coronary artery bypass grafting x4 with left internal mammary artery to left anterior descending coronary artery; reverse saphenous vein single graft from aorta to first diagonal coronary artery; reverse saphenous vein single graft from aorta to first obtuse marginal coronary artery; reverse saphenous vein single graft from aorta to the distal right coronary artery. [**2186-12-28**] Cardiac Cath History of Present Illness: 62 year old male who is transferred from OSH for NSTEMI. He had nausea yesterday and then today developed a sensation of chest pressure. He felt lightheaded and dizzy and went to outside hospital. He had a positive troponin there and received Lovenox, Plavix, aspirin. He also developed a complete heart block. On arrival here, he is in normal sinus rhythm. His chest pressure has resolved. The complete heart block may have been a reperfusion rhythm or from a primary conduction disturbance. He was seen by the cardiology fellow - they will admit to the CCU. He is now being referred for cardiac catheterization for further evaluation. Past Medical History: Diabetes Dyslipidemia Hypertension Chronic Hepatitis C cirrhosis, genotype 1a, diagnosed [**2164**]'s, reportedly [**2-1**] to blood transfusion Hodgkin's Lymphoma s/p chemo, radiation, and BMT 22 years ago Bone Marrow transplant Osteoarthritis of the knees hypothyroidism s/p splenectomy s/p cholecystectomy s/p hip fixation Social History: Race:African American Last Dental Exam:6 months ago, upper partial Lives with:wife Occupation:Employed as a police officer, last worked [**2185-2-28**] prior to knee surgery. Tobacco: Prior smoking x2 years socially, quit 30 years ago ETOH:Drinks 2-3 beers and 2 drinks of hard liquor daily Family History: non-contributory Physical Exam: Pulse:100 Resp:16 O2 sat: 100/RA B/P Right:182/86 Left:195/90 Height:6' Weight:104 kgs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] no [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] JVD Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] no MRG Abdomen:Soft[x] non-distended [x] non-tender[x] +BS [x] Extremities: Warm [x], well-perfused [x] Edema-none Varicosities: None [x] Neuro: Grossly intact, MAE-follows commands, nonfocal exam Pulses: Femoral Right: cath site Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit no Pertinent Results: [**2186-1-4**] Echo: Prebypass: No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild regional left ventricular systolic dysfunction with hypokinesis of the apex, apical and mid portions of the inferior and inferoseptal walls. Overall left ventricular systolic function is mildly depressed (LVEF= 45%). Right ventricular chamber is normal. RV function is mildly depressed.There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the results at the time of the study. Postbypass: Patient is in sinus rhythm. Patient is receiving an infusion of phenylephrine. LVEF= 45%. RV function is mildly depressed. Mild mitral regurgitation and mild aortic regurgitation persist. Aorta is intact post decannulation. [**2185-12-28**] Cath report: 1. Selective coronary angiography of this right-dominant system revealed three-vessel coronary artery disease. The LMCA was short with mild plaquing. The LAD was heavily calcified with a near-ostial 70% tubular stenosis. D1 had a proximal tubular 65% in a large vessel. The mid-LAD appeared possibly intramyocardial. The LCX was heavily calcified and had a proximal 60% stenosis before giving rise to a large OM2. OM2 had 60% stenoses in the main vessel prior to and separately after a branch vessel (the brnach having its own 60% stenosis at the origin). The AV groove LCX had a 50% stenosis just after OM2. The RCA was heavily calcified (with calcification of the right coronary cusp) and had a near-ostial 70% stenosis before proximal 70%, mid 75% tubular, and distal diffuse 40% stenoses. 2. Limited resting hemodynamics demonstrated mildly elevated left-ventricular filling pressures with an LVEDP of 13 mmHg, and systemic arterial hypertension with a central aortic pressure of 155/78 mmHg. No gradient was seen across the aortic valve on left-heart pullback. 3. Left ventriculography was deferred given mild renal insufficiency. [**2185-12-29**] CT ABD/CHEST: 1. Ground-glass opacity involving most of the right upper lobe corresponding to the abnormality on radiograph is with other smaller foci as above is most likely related to pneumonia or pneumonitis(including aspiration). The differential diagnosis is broad but includes asymmetrical pulmonary edema given hx of recent MI. Would recommend a repeat radiograph or CT after appropriate treatment in six weeks. 2. No concerning arterial enhancing lesions displaying washout noted within the liver. Small non-specific arterial enhancing foci within the right lobe are likely perfusional can be followed up with a repeat CT or MRI in 6 months. 3. Single right and [**2-2**] left hypervascular adrenal lesions. These are most concerning for possibility of multifocal pheochromocytomas and correlation with serum markers is recommended. Additionally, given the multifocality, the patient should be evaluated for possible syndromic associations (such as MEN 2). Differential includes hypervascular lipid poor adenomas or hypervascular metastases but the latter is less likely given the lack of any primary tumor noted within the abdomen or chest. Recommend endocrine evaluation of adrenal nodules. 4. Mild-to-moderate atherosclerotic calcification within the intrathoracic and intra-abdominal aorta as detailed above. There is no significant calcification within the ascending aorta for pre-operative CABG planning. Brief Hospital Course: 62yoM with HTN, DLP, DM presenting with symptomatic bradycardia in the 30's in the setting of third degree heart block with ventricular escape rhythm and presenting with NSTEMI whose hospital course included cardiac cath showing triple vessel disease requiring Cardiac surgery evaluation and subsequent CABG. During pre-op evaluation, found to have adrenal lesions concerning for metastatic disease versus pheochromacytoma. ============= [**Hospital 662**] HOSPITAL COURSE: [**2185-12-28**] - [**2186-1-4**] ================ # Coronary Artery Disease/CAD: Patient presented with NSTEMI and had cardiac catherization on [**2185-12-28**] showing multivessel disease. Cardiac surgery was consulted for CABG evaluation. Patient was medically managed with aspirin, statin and [**Last Name (un) **]. Plavix was held in preparation for surgery. Given heart block, beta-blockaged was also held. . # Heart Block: Prior to presentation to [**Hospital1 18**], patient was reportedly in 3rd degree heart block. Upon arrival to [**Hospital1 18**], he was in normal sinus rhythm. Patient was monitored on telemetry during his hospitalization. AV nodal blockade was held given this history. . # Adrenal nodules: As part of pre-op evaluation, cardiac surgery requested a CT abdomen given history of hepatitis C. On CT, adrenal nodules were found with specific concern for pheochromacytoma versus metastatic disease. Endocrine was consulted for work-up for pheo. Serum and urine labs were sent showing...... Prior to surgery, patient was started phenoxybenzamine if lesions are in fact pheo. . # Chronic Hepatitis C: Hepatology was consulted prior to surgery for any pre-operative recommendations. No changes were made to management. On CT, right liver lesion was noted. Radiology recommended follow-up CT in 6 months. . # HTN: Poorly controlled during admission prior surgery. Anxiety appeared to contribute slightly to hypertension. Patient was started on hydralazine and phenoxybenzamine with better control of BP. . # DM: Patient's blood sugars were not controlled during admission with last A1c 9.8. Endocrine recommended changing insulin regimen to..... with better control of blood sugars thereafter. =================== SURGICAL SERVICE: [**2186-1-4**] - [**2186-1-13**] =================== On [**1-4**], Dr. [**Last Name (STitle) 914**] performed coronary artery bypass grafting surgery. For surgical details, please see operative note. #CARDIAC: Experienced episode of paroxysmal atrial fibrillation on postoperative day three. Converted back to normal sinus rhythm within 24 hours. Given history of complete heart block, EP was consulted and recommended that Amiodarone be avoided. Rate control and management of his atrial tachycardia should be with beta blockade only. He was started on Warfarin and dosed for a goal INR between 2.0 - 2.5. There was no indication for permanent pacemaker but EP followup will be required as an outpatient with Dr. [**Last Name (STitle) **]. Prior to discharge, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Heart monitor was arranged. No further episodes of atrial fibrillation were noted for the remainder of his hospital stay. INR at discharge was subtherapeutic at 1.1, and arrangements have been made with Dr. [**Last Name (STitle) **] to monitor Warfarin as an outpatient. . #PULMONARY: Extubated within 24 hours. At discharge, room air saturations were 100%. . #NEURO: Awoke from surgery neurologically intact. No neurologic complications noted. . #RENAL: Stable renal function postoperatively. Responded well to diuretics. Discharge creatinine was 1.1. . #ID: Required several days of intravenous Cefazolin for leg thigh cellulitis. White count peaked at 16K. Over several days, the erythema and white count improved. At discharge, he will remain on a [**10-13**] day course of PO Keflex. White count at discharge was 12.7K. . #HEME: Required PRBC's early postop to maintain hematocrit near 30%. Discharge hematocrit was 29%. . #DISPO: Cleared for discharge to home on postoperative day nine. Medications on Admission: DILTIAZEM HCL - 300 mg Capsule, Sust. Release 24 hr - 1 Capsule(s) by mouth in AM DILTIAZEM HCL [DILT-XR] - 240 mg Capsule,Degradable Cnt Release 1 Capsule(s) by mouth once a day FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth in AM INSULIN ASP PRT-INSULIN ASPART [NOVOLOG MIX 70-30] - 100 unit/mL (70-30)Solution - 30units in AM // 40units in PM LEVOTHYROXINE [LEVOTHROID] - 50 mcg Tablet - 1 Tablet(s) by mouth daily METFORMIN - 1,000 mg Tablet - 1 Tablet(s) by mouth twice daily OXYCODONE-ACETAMINOPHEN [PERCOCET] - 5 mg-325 mg Tablet - 1 - 2 Tablet(s) by mouth every four (4) hours as needed for Pain VALSARTAN [DIOVAN] - 320 mg Tablet - 1 Tablet(s) by mouth daily ZOLPIDEM - 10 mg Tablet - 1 Tablet(s) by mouth at bedtime ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily MULTIVITAMIN [MULTIPLE VITAMINS] daily Plavix - last dose:[**2185-12-28**] 75mg, [**2185-12-27**] 300mg 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:*1* 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 5. 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* 6. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): please have PCP check LFTs after two weeks of therapy. Disp:*30 Tablet(s)* Refills:*1* 7. potassium chloride 10 mEq Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO once a day for 2 weeks. Disp:*28 Tablet Sustained Release(s)* Refills:*0* 8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day: Take 40mg QD x 2weeks then decrease dose to 20mg QD. Disp:*45 Tablet(s)* Refills:*1* 9. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 10. Keflex 500 mg Capsule Sig: One (1) Capsule PO three times a day for 10 days. Disp:*30 Capsule(s)* Refills:*0* 11. insulin NPH & regular human 100 unit/mL (70-30) Suspension Sig: 30 units QAM and 40units QPM units Subcutaneous QAM and QPM: 30mg QAM/40mg QPM. 12. warfarin 2 mg Tablet Sig: as directed Tablet PO once a day: Atrial Fibrillaion- target INR 2-2.5 Take 5mg on [**1-13**] then as directed by Dr [**Last Name (STitle) **]. Disp:*100 Tablet(s)* Refills:*1* Discharge Disposition: Home With Service Facility: [**Hospital1 **] vna Discharge Diagnosis: Coronary Artery Disease and Myocardial Infarction s/p Coronary Artery Bypass Graft x 4 Past medical history: Diabetes Dyslipidemia Hypertension Chronic Hepatitis C cirrhosis, genotype 1a, diagnosed [**2164**]'s, reportedly [**2-1**] to blood transfusion Hodgkin's Lymphoma s/p chemo, radiation, and BMT 22 years ago Bone Marrow transplant Osteoarthritis of the knees Hypothyroidism Past Surgical History s/p splenectomy s/p cholecystectomy s/p hip fixation Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage Leg Left - Mild erythema or drainage; eccymotic medially from SVH site to thigh w/ large area of firmness at medial aspect of knee. Edema 1+ firm pedal edema bilat 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) 914**] on [**2186-1-31**] at 1:15pm Appointment with PCP Dr [**Last Name (STitle) **] on [**2186-2-9**] at 10am ****Will need follow up CT abdomen to f/u liver lesions*** Please come in [**Hospital Ward Name 121**] 6 on tuesday [**2186-1-17**] at 11:00AM for a wound check on your left leg with [**First Name8 (NamePattern2) 96690**] [**Last Name (NamePattern1) **]. Cardiologist: Dr [**Last Name (STitle) 2357**] on [**2186-2-15**] 3:00PM **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 check on [**1-14**] call results to Dr [**Last Name (STitle) **] @ [**Telephone/Fax (1) 133**] for coumadin dosing. Completed by:[**2186-1-17**] Name: [**Known lastname 2069**],[**Known firstname 63**] W Unit No: [**Numeric Identifier 15353**] Admission Date: [**2185-12-28**] Discharge Date: [**2186-1-13**] Date of Birth: [**2123-4-21**] Sex: M Service: CARDIOTHORACIC Allergies: All allergies / adverse drug reactions previously recorded have been deleted Attending:[**First Name3 (LF) 1543**] Addendum: Finalized only by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6339**], PA-C DC summary written by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 15354**], PA-C Discharge Disposition: Home With Service Facility: [**Hospital1 **] vna [**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**] Completed by:[**2186-1-17**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

16676, 16886

6670, 7128

365, 780

13955, 14277

2869, 6647

15200, 16653

2119, 2137

11685, 13381

13476, 13563

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7145, 10725

14301, 15177

2152, 2850

304, 327

808, 1446

13585, 13934

1811, 2103

54,177

114,373

40583

Discharge summary

report

Admission Date: [**2117-3-17**] Discharge Date: [**2117-3-18**] Date of Birth: [**2063-1-18**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2777**] Chief Complaint: SVC syndrome with facial and upper extremity swelling Major Surgical or Invasive Procedure: [**2117-3-17**]: SVC stent attempt, migrated, failed retrieval [**2117-3-17**]: IVC filter placed to prevent further stent migration History of Present Illness: 54-y.o. male with stage 4 NSCLC c/b SVC syndrome presented for outpatient SVC stent placement for SVC syndrome. Past Medical History: Stage 4 NSCLC c/b SVC syndrome (please refer to oncology progress notes for full oncologic history), asthma, osteoarthritis. Past Surgical history: [**2116-6-22**]: VATS with RUL biopsy and wedge resection of right lung mass Social History: Patient is of Italian heritage; his father is first generation and his mother emigrated to the U.S. Single with no children. Lives with his parents in [**Location (un) 932**]. Worked as an engineering technician in a company that makes auto remote sensors. -Cig smoking 1.5 ppd X 38 years. -Drinking beer for "fun" in the past. -Denies history of substance abuse. Family History: His sister died of brain cancer at 32 yo. Maternal Grandmother died of liver cancer at 69 yo. Maternal uncle died of livercancer at 72 yo. Another maternal uncle died of an aneurysm. His father has HTN, HL. His mother has [**Name (NI) 2320**]. Physical Exam: At time of discharge: T 97.9 P 65 (sinus rhythm) BP 104/69 RR 14 O2sat 98% Awake, alert, NAD. Improved facial/upper extremity swelling Heart RRR Lungs without respiratory distress Abdomen soft, NT, ND R groin without bleed/hematoma Palpable bilateral radial/DP/PT art Pertinent Results: [**2117-3-18**] 02:23AM BLOOD WBC-8.5 RBC-3.85* Hgb-11.9* Hct-34.0* MCV-88 MCH-30.8 MCHC-35.0 RDW-13.5 Plt Ct-169 [**2117-3-18**] 02:23AM BLOOD PT-14.3* PTT-28.5 INR(PT)-1.3* [**2117-3-18**] 02:23AM BLOOD Glucose-124* UreaN-10 Creat-0.9 Na-134 K-3.9 Cl-101 HCO3-26 AnGap-11 Brief Hospital Course: On [**2117-3-17**], the patient presented for outpatient placement of SVC stent for SVC syndrome. Please refer to operative note for details of the procedure. In short, he underwent balloon angioplasty of the SVC and during stent placement, the stent migrated to the heart, requiring emergent vascular surgery consult. The stent was snared endovascularly but could not be extracted, so it was positioned at the IVC bifurcation and an IVC filter was placed to prevent migration to the heart. The patient was admitted post-procedure to the CVICU for monitoring overnight. He was started on heparin gtt anticoagulation, transitioned to enoxaparin injections and oral warfarin. The remainder of his admission was eventful and on [**2117-3-18**] he was discharged home in good condition. Medications on Admission: albuterol nebs q6h prn, advair 100-50 disk 1 puff inh [**Hospital1 **], folate 1', ipratropium 1 inh q6h prn, dexamathasone 4 mg [**Hospital1 **] 3 days prior to chemo, lorazepam 1 mg [**Hospital1 **], zofran prn, oxycodone 10 q6h prn, prochlorperazine 5 q6h prn, spiriva', ambien 10 qhs prn, colace prn, senna prn, nicotine patch prn Discharge Medications: 1. warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM: adjust dose to reach target INR [**2-12**]. Disp:*60 Tablet(s)* Refills:*2* 2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation four times a day as needed for shortness of breath or wheezing. 3. Advair Diskus 100-50 mcg/dose Disk with Device Sig: One (1) puff Inhalation twice a day. 4. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig: One (1) puff Inhalation four times a day as needed for shortness of breath or wheezing. 5. enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) mg Subcutaneous [**Hospital1 **] (2 times a day): continue as directed until goal INR [**2-12**] is reached with warfarin. Disp:*14 syringes* Refills:*0* 6. lorazepam 1 mg Tablet Sig: One (1) Tablet PO twice a day. 7. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every six (6) hours as needed for nausea. 8. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 9. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:*10 Tablet(s)* Refills:*0* 10. prochlorperazine maleate 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 11. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for sleep aid. 12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day: take while taking narcotics. Disp:*60 Capsule(s)* Refills:*2* 13. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day: take while taking narcotics. Disp:*60 Tablet(s)* Refills:*2* 14. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Stage 4 non small cell lung cancer with superior vena cava syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Division of Vascular and Endovascular Surgery Discharge Instructions Medications: ?????? You are being started on blood thinners called lovenox(injection) and coumadin(pill). You will take the lovenox injection twice daily, and the coumadin pill once daily. You will have a frequent blood test called an INR. This will tell us how "thin" your blood is. When this number is greater than 2, you will be told to stop your lovenox injections and just take the coumdin. Dr. [**Last Name (STitle) **] will be checking your INR level and telling you how to adjust your coumadin dose. Your first blood test should be monday, [**3-22**]. . ?????? 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 to expect when you go home: It is normal to have some swelling of the legs: ?????? Elevate your leg above the level of your heart (use [**2-12**] 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 ?????? It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and 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: ?????? 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 ?????? Call and schedule an appointment to be seen in [**3-14**] weeks for post procedure check and ultrasound What to report to office: ?????? 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 vascular office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call 911 for transfer to closest Emergency Room. What is warfarin? Warfarin is the generic name for Coumadin?????? (brand or trade name). Warfarin belongs to a class of medications called anticoagulants, which help prevent clots from forming in your blood and or keep grafts open. Why am I taking warfarin? You are taking warfarin because you have a medical condition that puts you at risk for forming dangerous blood clots, or to keep open vessels that have stents and or vessels that allow blood to flow for ischemic leg symptoms. How do I take warfarin? Warfarin is taken once daily at the same time every day, preferably in the evening, with or without food. If you miss a dose of warfarin, take the missed dose as soon as possible on the same day. If you forget, do not double up the next day! Write the day of your missed dose on your calendar and let your health care provider know at your next visit. Why is warfarin use monitored so carefully? Warfarin is a medication that requires careful and frequent monitoring to make sure that you are being adequately treated, but not over- or under-treated. If you have too much warfarin in your body, you may be at risk for bleeding. If you have too little warfarin in your body, you may be at risk for forming dangerous blood clots. Medications, food and alcohol can also interfere with warfarin, making close monitoring even more important. What is INR? INR, which stands for International Normalized Ratio, is a blood test that helps determine the right warfarin dose for you. The INR tells us how much warfarin is in your bloodstream and is a measure of how fast your blood clots. A high INR means you are more likely to bleed (your blood does not clot very fast). A low INR means you are more likely to form a clot (your blood clots very fast). All patients will have an INR goal depending on their medical condition(s), yours is [**2-12**]. What are the possible side effects of warfarin? The major side effect of warfarin is bleeding (especially when your INR is too high). Here are some symptoms of bleeding to look for and to report to your health care provider: [**Name10 (NameIs) 33276**] bruising or bruises that won't heal Bleeding from your nose or gums Unusual color of urine or stool (including dark brown urine, or red or black/tarry stools) What do I need to know about drug interactions with warfarin? Many drugs can potentially interfere with warfarin and may cause your INR to change, putting you at risk for bleeding or a clot. These drugs include prescription medications, over-the-counter medications (like aspirin, ibuprofen, naproxen), and dietary and herbal supplements. They should be avoided unless otherwise directed by health provider. [**Name10 (NameIs) **] should take your Aspirin as directed. What role does my diet play? The amount of vitamin K in your diet may affect your response to warfarin. Certain foods (like green, leafy vegetables) have high amounts of vitamin K and can decrease your INR. You do not have to avoid foods high in vitamin K, but it is very important to try to maintain a consistent diet every week. What about alcohol? Alcohol use also may affect your response to warfarin. Excessive use can lead to a sharp rise in your INR. It is best to avoid alcohol while you are taking warfarin. Safety Tips Carry a wallet ID card and/or wear an emergency alert bracelet Tell all health care providers (physicians, nurses, pharmacists, dentists, etc.) that you are taking warfarin, especially if you have any planned surgeries or procedures. Alert your health care provider if you are pregnant or become pregnant while taking warfarin. Plan ahead when traveling by having enough warfarin and arrange for follow-up blood tests. It is also important to keep your diet consistent. Avoid any sport or activity that may result in a serious fall or injury. Use a soft-bristled toothbrush to protect your gums. Use an electric razor if you are prone to cut yourself when shaving. Call if you have any questions regarding your new medication Followup Instructions: Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**0-0-**] Date/Time:[**2117-3-25**] 9:00 Provider: [**Name10 (NameIs) 16570**],[**Name11 (NameIs) **] HEMATOLOGY/ONCOLOGY-SC Date/Time:[**2117-3-25**] 9:00 Provider: [**Name10 (NameIs) 8111**] [**Name11 (NameIs) 8112**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2117-3-25**] 10:00 Please call Dr. [**Last Name (STitle) 23782**] office for follow up in the next few weeks. [**Telephone/Fax (1) 2625**] Your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] will be following your INR. Please go to his office Monday [**3-22**] in the morning to have your INR drawn. His staff will call you with directions on how to adjust your coumadin dose, and when to stop lovenox. Completed by:[**2117-3-18**]

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icd9cm

[ [ [] ] ]

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icd9pcs

[ [ [] ] ]

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5096, 5096

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Discharge summary

report

Admission Date: [**2126-9-6**] Discharge Date: [**2126-9-25**] Date of Birth: [**2054-11-1**] Sex: M Service: MEDICINE Allergies: Penicillins / Codeine / Dalmane Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: fevers, rigors Major Surgical or Invasive Procedure: pacemaker extraction pacemaker extraction via re-do sternotomy History of Present Illness: Mr [**Name13 (STitle) **] is a 71yo man who has a pacemaker and bioprosthetic mitral and aortic valve replacements who presented with rigors and a fever to 103.2 with mental status changes on [**2126-9-5**]. He was found to have pacemaker endocarditis and 6/6 bottles of blood cultures were positive for staph aureus. . In the ED, initial vitals were 147/61 103.2 89 18 91%RA 97% on 2L Labs and imaging significant for WBC of 14.2, drug screen at OSH was negative, UA was positive only for albumin, ketone, blood. Creatinine is 1. Bicarb 28. LFTs wnl. PFTs mild obstruction. Echo-EF 55%. Patient given rifampin, ceftriaxone, vancomycin, gentamicin and 1L of NS for hypotension, which improved his blood pressures. He did have his pacer interrogated which revealed underlying SB 50's. PMT noted on device, V paced 98%. Lactic acid 2.6. Trop 2.29. CSF normal. CXR wnl. Vitals on transfer were BP 88-92/58-67 HR89-112 RR16 . On arrival to the floor, patient endorsed CP over the pacemaker site, SOB, abdominal pain, constipation x 3 days, rare non-productive cough. He also endorses a reecent history of myalgias, especially in his calves. Past Medical History: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: CABG x4 ([**2124-10-19**] at [**Hospital3 **]) with saphenous vein graft to OM ramus PLV and LIMA to LAD, -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: Symptomatic sinus bradycardia--s/p dual chamber PPM [**2119-12-13**], with pocket revisions in [**2119**] and [**2120**]; Guidant Insignia PPM 3. OTHER PAST MEDICAL HISTORY: -aortic valve replacement with a 21 mm [**Doctor Last Name **] pericardial tissue heart valve, and mitral valve replacement with a [**Street Address(2) 70723**]. [**Male First Name (un) 923**] bioprosthesis. -Hep C, chronic, no cirrhosis -History of cocaine use; history of IVDU -Lung cancer, s/p resection of L upper lobe -Multiple cysts removed -Spine surgery, metal rods in place -Asthma -stroke Social History: The patient lives by himself in an apartment as part of a group home. He is an ex-smoker- 2ppd x60y, quit seven years ago. History of IVDU (30 years ago) and cocaine abuse (25years ago). He no longer drinks alcohol but used to abuse alcohol. Works at Salvation Army as drug counselor now Family History: Mother-deceased of MI at age 65. Grandma deceased of MI. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM: VS: T=99.7 BP= 111/70 HR= 95 RR=18 O2 sat= 98% 2L NC GENERAL: NAD. Oriented x2 (not to date). 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 flat. CARDIAC: RR, normal S1, S2. systolic murmer II/VI heard best at apex. No S3 or S4. tender to palpation over pacer pocket on left anterior chest. LUNGS: CTAB, no crackles, wheezes or rhonchi. No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. ABDOMEN: Soft, no distension. mild tenderness to palpation. No HSM or tenderness. EXTREMITIES: Positive clubbing. No cyanosis, edema. SKIN: No stasis dermatitis, ulcers, or xanthomas. Large scar down spine beginning around L2. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ NEURO: slight pronator drift on left. strength and gait normal. CNII-XII intact. DISCHARGE PHYSICAL EXAM: VS: Tm 99.5 Tc 98.6 134/70 (134-156/73-93) 103 (85-103) 18 99%RA GENERAL: NAD. Alert. CARDIAC: RRR, normal S1, S2. systolic murmur III/VI heard best at apex. No S3 or S4 CHEST: healing incision from clavicle to umbilicus, c/d/i. No ecchymosis. Right sided pacer pocket with staples in place, non-erythematous, dry, no discharge. LUNGS: CTAB ABDOMEN: normoactive bowel sound, NTND EXTREMITIES: no peripheral edema, 2+ peripheral pulses. Pertinent Results: ADMISSION LABS: . [**2126-9-7**] 07:48AM BLOOD WBC-7.6 RBC-3.58* Hgb-10.8* Hct-30.6* MCV-85 MCH-30.1 MCHC-35.4* RDW-13.6 Plt Ct-68* [**2126-9-7**] 07:48AM BLOOD Plt Ct-68* [**2126-9-7**] 07:48AM BLOOD Glucose-159* UreaN-22* Creat-0.8 Na-138 K-3.5 Cl-104 HCO3-23 AnGap-15 [**2126-9-8**] 05:30AM BLOOD CK(CPK)-66 [**2126-9-10**] 04:30AM BLOOD ALT-15 AST-20 LD(LDH)-299* AlkPhos-52 TotBili-0.8 [**2126-9-7**] 07:48AM BLOOD Calcium-8.7 Phos-1.4* Mg-1.9 . PERTINENT LABS AND STUDIES: [**2126-9-7**] 07:48AM BLOOD VitB12-545 Folate-10.8 [**2126-9-10**] 04:30AM BLOOD CRP-253.6* [**2126-9-7**] 07:48AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2126-9-8**] 05:30AM BLOOD CK-MB-3 cTropnT-0.10* [**2126-9-8**] 01:30PM BLOOD CK-MB-3 cTropnT-0.10* [**2126-9-11**] 05:40AM BLOOD ESR-100* [**2126-9-6**] 09:25PM URINE Blood-LG Nitrite-NEG Protein-300 Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM [**2126-9-19**] 12:37PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2126-9-19**] 12:37PM URINE Eos-NEGATIVE [**2126-9-19**] 12:37PM URINE Hours-RANDOM UreaN-211 Creat-49 Na-61 K-29 Cl-67 [**2126-9-19**] 04:45AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.9 Iron-21* [**2126-9-19**] 04:45AM BLOOD calTIBC-176* Ferritn-290 TRF-135* [**2126-9-18**] 04:39PM BLOOD Hapto-263* [**2126-9-7**] 07:48AM BLOOD VitB12-545 Folate-10.8 [**2126-9-19**] 04:45AM BLOOD CRP-107.3* [**2126-9-14**] 12:40PM BLOOD freeCa-1.14 [**2126-9-18**] 04:39PM BLOOD Albumin-2.8* [**2126-9-20**] 04:30AM BLOOD ESR-109* . Culture data (organism and susceptibilities) [**2126-9-5**] (at [**Hospital3 **]) STAPHYLOCOCCUS AUREUS Target Route Dose RX AB Cost M.I.C. IQ ------ ----- ------------------ ------ -- ------ --------- -----CEFAZOLIN S <=4 CLINDAMYCIN SERUM X S 0.5 ERYTHROMYCIN SERUM X S <=0.25 LEVOFLOXACIN SERUM X S <=0.5 OXACILLIN SERUM X S <=0.25 TETRACYCLINE SERUM X S <=1 TRIM/SULFA SERUM X S <=0.5/9.5 VANCOMYCIN SERUM X S 1 . All Blood Cultures since [**2126-9-6**] are negative C. diff cultures negative x4 Urine cultures negative . [**2126-9-10**] CTA Coronary Arteries 1. Retained one larger and one small object in the right subclavian vein as described in detail. Please review the addition volume rendering images for better localization of this finding. 2. Status post CABG with patent bypasses. 3. Status post left upper lobectomy. 4. Extensive venous collaterals in the anterior mediastinum with some of them located right underneath the sternotomy. 5. Small bilateral pleural effusion. 6. Status post aortic and mitral valve replacement. Extensive mitral annulus calcification. 7. Several pulmonary nodules. Followup of this patient given the presence of the nodules, several mediastinal lymph nodes and prior lobectomy should be obtained in three months with conventional chest CT. Right middle lobe subpleural opacity most likely represents atelectasis, but pleural plaque would be another possibility and can be also reassessed on the subsequent study. . TEE (Complete) Done [**2126-9-11**] The left atrium is dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. A bioprosthetic mitral valve prosthesis is present. There is a large vegetation 1.3 cm x 1.3 cm on the posterior annulus of the mitral bioprosthetis. No mitral regurgitation is seen. There is no mitral stenosis. The mean mitral gradient is 5mm of Hg. Moderate to severe [3+] tricuspid regurgitation is seen. IVC is dilated (2.9cm) with preserved respiratory variation although small. There is systolic flow reversal at the hepativ veins. There is no pericardial effusion. . [**2126-9-15**] CT Head No Contrast No acute intracranial process. If clinical concern for stroke is high, MRI is more sensitive. . [**2126-9-18**] ECHOCARDIOGRAM The left atrium is mildly dilated. The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. Trace aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. The gradients are higher than expected for this type of prosthesis. There is echodense thickening of the posterior annulus of the mitral bioprosthesis measuring 1.3 cm x 1.1 cm. No mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. IMPRESSION: Preserved left ventricular systolic function with normally functioning aortic bioprosthesis. There is focal echodense thickening of the posterior annulus of the mitral bioprosthesis with gradients higher than expected for this type of prosthesis. Given the history of mitral bioprosthesis endocarditis on recent TEE dated [**2126-9-11**], a healed vegetation cannot be excluded. . CXR [**2126-9-15**] FINDINGS: The patient is status post median sternotomy, aortic valve replacement, as well as left upper lobe resection. Cardiomediastinal contours are similar to the prior exam. Interval resolution of congestive heart failure and associated decrease in size of right pleural effusion with residual small pleural effusion remaining. Left pleural effusion is small and similar to the prior study. IMPRESSION: Resolution of congestive heart failure and improved right pleural effusion. CT Thorax [**2126-9-19**] Air and fluid collection with enhancing walls as discussed in the suprasternal notch. This finding is suspicious for early abscess formation. No evidence to suggest osteomyelitis. Communication with the right sternoclavicular joint is not excluded. Right pleural effusion with adjacent compressive atelectasis. Interval removal of retained pacemaker fragment in the right subclavian vein. Extensive vascular calcification within the common and external iliac arteries. In combination with the extensive streak artifacts from the vertebral column hardware, evaluation of lumen is difficult. If there is clinical concern for significant stenosis MRI can help better evaluate the vasculature. . DISCHARGE LABS: [**2126-9-25**] 05:40AM BLOOD WBC-9.8 RBC-3.26* Hgb-9.4* Hct-27.9* MCV-86 MCH-28.9 MCHC-33.8 RDW-14.8 Plt Ct-325 [**2126-9-25**] 05:40AM BLOOD Glucose-123* UreaN-15 Creat-2.0* Na-136 K-3.6 Cl-98 HCO3-26 AnGap-16 [**2126-9-25**] 05:40AM BLOOD Calcium-8.7 Phos-4.1 Mg-2.1 Brief Hospital Course: 71M PMH CAD-CABG and bioprosthetic MVR/AVR, DM, HTN, HLD, lung cancer s/p resection, Hepatitis C, and dual-chamber PPM implanted in [**2118**] for symptomatic sinus bradycardia, followed by pocket revisions in [**2119**] for infection and [**2120**] due to painful location, who presented to [**Hospital6 1597**] with mental status changes on [**2126-9-5**], and was found to have fever to 103 with 6/6 bottles with Staph Aureus, and an 8mmx8mm vegetation on the RV lead seen on TEE, now transferred for further care and lead extraction, s/p lead extraction, with atrial lead initially retained. The patient required re-do sternotomy for removal of the wire, which was done on [**9-11**]. A MV vegetation was seen on TEE done intraoperatively. The patient will have antibiotics for 6 weeks and then consideration for MVR. Hospital course was complicated by [**Last Name (un) **]. . ACTIVE ISSUES # MSSA Bacterial Endocarditis: The patient initially presented with sepsis to the OSH, but was hemodynamically stable throughout his hospitalization at [**Hospital1 18**]. His cultures here were consistently negative--blood, urine, sputum, the pacemaker leads-- but grew MSSA at the OSH. The source of the infection was not clear. He was initially treated with pacemaker removal with the EP service, but unfortunately, the atrial lead was friable and broke off and was lodged in the chest. He required re-do sternotomy by the cardiac surgeons for removal of the lead. His wounds from the sternotomy and the pacemaker extraction remained clean, dry and intact with no erythema throughout his hospitalization. ID was consulted and the patient was treated with Vancomycin, which was transitioned to Cefazolin, and Gentamicin and Rifampin for synergy. He did have nightly fevers in the 2 weeks subsequent to his surgery despite blood cultures remaining negative and treatment with the antibiotics. It was thought that his fevers may have been drug fever but resolved spontaneously. Out of concern for his nightly fevers, the patient was pan-scanned and a small sub-sternal fluid collection was visualized. The cardiac surgeons, ID and orthopedic surgeons all discussed the possibility of incision and drainage but the fluid collection was thought to be small and not a source of infection. He also developed a transient leukocytosis which resolved and he was consistently tachycardic in the 90-110 range during his hospitalization. The patient did have some wound-associated discomfort but refused opioid medication due to his history of heroin abuse. He preferred to use tramadol throughout the hospitalization. The patient will need LFTs checked on Rifampin. He may need MVR and replacement of the pacemaker in the future after he completes the antibiotics. He will need repeat echo in 1 week. . # Diarrhea: the patient developed diarrhea after initiation of antibiotics. He was treated empirically for c. diff with Flagyl. This was transition to PO Vanc given that pt had ongoing fevers without clear source. However, he had four negative c.diff cultures so treatment was discontinued. Pt continued to have occasional diarrhea. We opted not to treat with anti-motility agents given that no clear cause of diarrhea was identified. He may benefit from pro-biotic treatment. . # Acute Kidney Injury: the patient's creatinine was 0.8 at baseline and trended up as he was initiated on gentamicin. It peaked at 2.0 which we attributed to gentamycin toxicity in setting of contrast dye-induced nephropathy. His gentamycin was stopped, and his lasix, losartan and spironolactone were held. His creatinine remained stable at 2.0. Lasix, losartan, and spironolactone should be resumed once his Cr <1.5. . # Chest Pain associated with surgery: the patient had some minor pain associated with his surgical wounds. He was treated with tramadol, per his preference. . . CHRONIC ISSUES: # Normocytic Anemia: the patient's hematocrit is in the 27-30 range. Recommend outpatient follow up. Iron studies and hemolysis labs were obtained. The picture was not consistent with hemolysis. . # Coronary artery disease: the patient is s/p CABG. His EF is preserved (55%). He was maintained on a BB (switched from home atenolol to metoprolol). Continued on a statin, his LFTs were within normal limits. His ASA was continued. His lasix was held in the setting of [**Last Name (un) **]. . # Hepatitis C: chronic, no cirrhosis. LFTs within normal limits. . # Diabetes: maintained on ISS. His HgbA1c was 6.5. . ISSUES OF TRANSITIONS IN CARE: CODE: full code EMERGENCY CONTACT: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 96666**], C [**Telephone/Fax (1) 96667**] [**Doctor Last Name **] C. [**Telephone/Fax (1) 96668**] # pt will need close follow up with cardiology regarding possible replacement of pacemaker, mitral valve replacement. He will need repeat ECHO in 1 week. # He will need weekly labs to monitor LFTs while on rifampin, along with CBC. # His creatinine will need to be closely monitored as well. Lasix, spironolactone, and losartan should be resumed once creatinine <1.5. # Pt found to have normocytic anemia that should be worked up further as an outpatient. Medications on Admission: -metformin, -tramadol 50mg qhs prn pain, -Lasix 40mg qam and 20mg qpm -atenolol 100mg qday -trazodone 400mg qday, -aspirin 325 mg qday, -Neurontin 600mg QID Discharge Medications: 1. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*90 Tablet(s)* Refills:*0* 2. trazodone 100 mg Tablet Sig: Four (4) Tablet PO at bedtime. 3. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO QID (4 times a day). 4. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain/fever. Disp:*60 Tablet(s)* Refills:*0* 7. rifampin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours) for 31 days: Course will be complete on [**10-24**]. Disp:*0 Capsule(s)* Refills:*0* 8. cefazolin 10 gram Recon Soln Sig: Two (2) gram Injection Q8H (every 8 hours) for 31 days: Course will be complete on [**10-24**]. Disp:*0 gram* Refills:*0* 9. Outpatient Lab Work frequency: weekly CBC with diff BMP LFT's Fax to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**] 10. ferrous sulfate 300 mg (60 mg iron) 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. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: primary diagnosis: endocarditis of the pacemaker, coronary artery disease, bradycardia, diabetes, hypertension secondary diagnoses: hepatitis C, hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Last Name (Titles) **], You were admitted to the hospital because you had an infection in the wires of your pacemaker. You were treated with antibiotics and you also had your pacemaker removed. You required a surgery to get the pacemaker out. One of the antibiotics caused kidney dysfunction but this was stable at the time of discharge and we expect it to get better quickly. Please note the changes to your medications: - START Cefazolin 2g IV q8h for 6 weeks starting [**Date range (3) 96669**] - START Rifampin 300mg po q8h for 6 weeks starting [**Date range (3) 96669**] - STOP Atenolol - START Rosuvastatin - START Losartan - START Metoprolol - START Spironolactone - DECREASE Lasix from 40mg every morning and 20mg every evening to 20mg in the morning and the evening - INCREASE tramadol 50mg, you may take this every 4 hours as needed for pain. - CONTINUE Gabapentin, Trazadone, Aspirin, Metformin Please be sure to follow up with your physicians. Followup Instructions: Department: CARDIAC SURGERY When: [**2126-10-1**], 1:15 With: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 170**], staples will be removed Building: LM [**Hospital Unit Name **] [**Location (un) 551**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Name:[**Name6 (MD) **] [**Name8 (MD) **], MD Specialty: Cardiology Address: [**Hospital3 **] [**Apartment Address(1) 3882**], [**Hospital1 **],[**Numeric Identifier 53049**] Phone: [**Telephone/Fax (1) 73509**] When: We put a call into the office but it is closed until Monday so wewere unable to schedule a follow up. Please call the above number to schedule a follow up within the next two weeks. Completed by:[**2126-9-25**]

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icd9cm

[ [ [] ] ]

[ "37.77", "37.89", "37.79", "34.03" ]

icd9pcs

[ [ [] ] ]

18616, 18682

11915, 15771

314, 379

18886, 18886

4352, 4352

20031, 20778

2717, 2889

17317, 18593

18703, 18703

17135, 17294

19037, 19443

11621, 11892

2929, 3869

18835, 18865

1654, 1962

19472, 20008

260, 276

407, 1546

4368, 11605

18722, 18814

18901, 19013

1993, 2394

15787, 17109

1568, 1634

2410, 2701

3894, 4333

68,234

142,568

3312

Discharge summary

report

Admission Date: [**2108-12-14**] Discharge Date: [**2109-1-1**] Service: NEUROLOGY Allergies: Sulfonamides Attending:[**First Name3 (LF) 2569**] Chief Complaint: Acute Left Face, Arm, Leg Weakness Major Surgical or Invasive Procedure: * None History of Present Illness: PER ADMITTING RESIDENT: 86 F w/ hx CHF, HTN, AF, on coumadin, COPD, aortic stenosis, presented to [**Hospital3 15402**] Hosp with dyspnea. While being treated there, at about 6:55 am, she developed sudden onset L-face, arm, and leg weakness, that was severe. A code stroke was called, and she was given IV tPA, and subsequently transferred to [**Hospital1 18**], where strength seemed to be modestly improving evidenced by some movement of the LUE, though mostly not against gravity. She remained somewhat letharic at [**Hospital1 18**] and had a repeat NCHCT with CTA. Oxygen requirements were increased to the point of being on CPAP. CXR showed [**Hospital1 65**] pulm edema and she was given an add'l 40 mg Lasix IV. Past Medical History: CHF - diastolic dysfunction (EF 70% [**2108-12-6**]) aortic stenosis AF on coumadin HTN moderate - severe pulmonary HTN by echo [**2108-12-6**] COPD asthma Gastrointestinal bleed, secondary to angiodysplasia s/p hysterectomy Social History: - oldest of fourteen children - lives independently and does her own cooking and cleaning at baseline - widowed - enjoys caring for others . HABITS - ETOH: denies - Tobacco: never smoked - Recreational Drugs: denies Family History: Non contributory Physical Exam: ON ADMISSION: T- BP- HR- RR- O2Sat [**Age over 90 **]F 115 141/75 24 88% on 2L NC Gen: Lying in bed, eyes mostly closed, letharic, but rouses and able to converse in short bursts HEENT: NC/AT, moist oral mucosa Neck: No tenderness to palpation, normal ROM, supple, no carotid or vertebral bruit. (+) JVD CV: irreg irreg, with likely murmur, though difficult to tell over lung rales, no gallops/rubs Lung: Diffuse rales bilaterally aBd: +BS soft, nontender ext: no c/c, Neurologic examination: Mental status: sleeping with eyes closed, but arouses to voice. mostly uncooperative with exam . Oriented to person, "hospital" but not exact place, but not date (states "[**Month (only) **]"). Speech is dysarthric, but she appears to understand well, follows many commands, and is able to produce speech in limited qualtities without evidence of a productive aphasia. Possible L neglect. Cranial Nerves: Pupils equally round 1 mm and min reactive to light bilaterally. BTT appears to be present B/L.. (+) L facial droop. Motor: Normal bulk bilaterally. Tone normal on R, low on L. No observed myoclonus or tremor Her RUE and RLE appear full as she is able to move them freely against gravity and provide at least some amount of resistance. In the LUE, she is able to flex fingers on command, and against the plane of gravity, able to move [**Hospital1 **] and Tri. Unable to hold up delt, though able to perform downward force. She does flex the LUE to pain. In the LLE, she wiggles toes spontaneously, and to pain is able to flex against gravity. Sensation: responds to pain with withdrawal or grimace in all 4 ext Reflexes: +2, brisk and symmetric throughout UE, 2+ and normal in the LE R toe mute, L toe upgoing Pertinent Results: Admission Labs: . WBC-13.8*# RBC-4.26 HGB-12.5 HCT-38.3# MCV-90 MCH-29.3 MCHC-32.6 RDW-14.5 UREA N-31* CREAT-1.2* SODIUM-141 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-19* ANION GAP-22* CALCIUM-9.2 PHOSPHATE-4.1 MAGNESIUM-2.0 CK-MB-NotDone cTropnT-<0.01 proBNP-1717* CK(CPK)-61 %HbA1c-6.1* PT-17.3* PTT-21.6* INR(PT)-1.6* [**2108-12-15**] 02:12AM BLOOD WBC-14.1* RBC-3.95* Hgb-11.7* Hct-35.1* MCV-89 MCH-29.6 MCHC-33.3 RDW-14.7 Plt Ct-304 [**2108-12-20**] 05:50AM BLOOD WBC-13.8* RBC-4.64 Hgb-13.3 Hct-41.5 MCV-89 MCH-28.6 MCHC-32.0 RDW-14.1 Plt Ct-235 [**2108-12-21**] 04:50AM BLOOD WBC-12.7* RBC-4.54 Hgb-13.0 Hct-40.1 MCV-88 MCH-28.6 MCHC-32.3 RDW-14.3 Plt Ct-247 [**2108-12-21**] 04:50AM BLOOD PT-19.4* PTT-26.9 INR(PT)-1.8* [**2108-12-21**] 04:50AM BLOOD Glucose-180* UreaN-24* Creat-0.8 Na-141 K-3.6 Cl-101 HCO3-33* AnGap-11 [**2108-12-18**] 08:18PM BLOOD ALT-17 AST-25 AlkPhos-62 TotBili-0.5 [**2108-12-15**] 02:12AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2108-12-14**] 09:35AM BLOOD CK-MB-NotDone cTropnT-<0.01 proBNP-1717* [**2108-12-21**] 04:50AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.1 [**2108-12-14**] 11:19AM BLOOD %HbA1c-6.1* [**2108-12-14**] 09:35AM BLOOD Triglyc-90 HDL-52 CHOL/HD-3.3 LDLcalc-102 [**2108-12-14**] 09:35AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2108-12-16**] 12:00AM URINE Blood-LG Nitrite-POS Protein- Glucose-NEG Ketone-40 Bilirub-LG Urobiln-4* pH-5.0 Leuks-LG [**2108-12-16**] 12:00AM URINE RBC-967* WBC-311* Bacteri-MOD Yeast-NONE Epi-0 [**2108-12-17**] 08:45AM URINE Hours-RANDOM UreaN-1440 Creat-153 Na-22 [**2108-12-17**] 08:45AM URINE Osmolal-765 [**2108-12-14**] 05:13PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG . IMAGING . Chest X-ray ([**2108-12-14**]): IMPRESSION: Findings compatible with moderate congestive heart failure and probable small bilateral pleural effusions. CTA head/neck [**2108-12-14**] 1. Large acute infarct in the right PCA territory. Patent carotid and vertebral arteries, including right posterior cerebral artery through its mid-distal P2 segment, without evidence of stenosis. 2. Bilateral pleural effusions and interstitial pulmonary edema, and left upper lobe focal opacity, which could be atelectasis; pneumonic consolidation is not excluded. MRI brain [**2108-12-14**] FINDINGS: There is a large area of restricted diffusion in the right PCA territory, corresponding to abnormalities seen on recent CT perfusion. The infarction extends from the medial aspect of the right cerebellar hemisphere, possibly tiny focus in the vermis and involves medial right temporal lobe, extending to the midbrain and thalamus (series 8, image 14). There is vasogenic edema, with mild mass effect on sulci, but no shift of normally midline structures or herniation. The remainder of the brain demonstrates periventricular and subcortical FLAIR hyperintensities, which could represent small vessel ischemic changes. There are no areas of susceptibility artifact to suggest presence of hemorrhage. The major vascular flow voids are maintained. CT head [**2108-12-15**] IMPRESSION: Large right PCA territory infarct and right cerebellum infarct as described above. No evidence of acute hemorrhage or shift of normally midline structures. Exam is slightly limited due to patient motion. CT head [**2108-12-16**] 1. Continued evolution of a right PCA territorial infarct with increased hypodensity in this region. No areas concerning for hemorrhage. 2. No new areas concerning for acute infarct; however, this evaluation is limited by the pronounced periventricular white matter hypodensities which appear unchanged. 3. No midline shift, and no evidence for herniation. CXR [**2108-12-17**] Nasogastric tube ends in the region of the pylorus or first portion of the duodenum. Generalized interstitial pulmonary abnormality is most commonly edema, but needs to be followed to differentiate it from interstitial lung disease acute or chronic. Heart is moderately enlarged, particularly the left atrium proximal to a heavily calcified mitral annulus, the pulmonary arteries are very large and there is some mediastinal vascular engorgement indicating biventricular decompensation as the most likely diagnosis. Small bilateral pleural effusions are unchanged since earlier in the day. Some focal opacities developing in the left suprahilar lung may represent infection, also warranting followup. No pneumothorax. TTE [**2108-12-18**] The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 10-20mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The ascending aorta is moderately dilated. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is severe mitral annular calcification. There is a minimally increased gradient consistent with trivial mitral stenosis. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Impression: severe calcification of the left side of the cardiac skeleton; minimal aortic and mitral stenosis; no definite cardiac sourse of embolus seen. CT head [**2108-12-19**] IMPRESSION: Overall, little significant interval change since examination one day prior from [**2108-12-18**] in large evolving right PCA territorial infarction and cytotoxic edema with mass effect on fourth ventricle. Relative hyperattenuating regions in the right posterior temporal lobe, unchanged in appearance, with stability more suggestive of regions of spared edematous cortex rather than petechial hemorrhagic conversion. Continued followup can be performed as indicated. EEG [**2108-12-20**] IMPRESSION: Abnormal portable EEG due to the slow and disorganized background with occasional additional focal slowing, especially in the right centro-temporal region. The first abnormality indicates a widespread encephalopathy, with medications, metabolic disturbances, and infection among the most common causes. The focal slowing was relatively [**Name2 (NI) 15403**], but encephalopathies may obscure focal findings. Focal slowing is not specific with regard to etiology, but vascular disease is a relatively common cause. There were no areas of fixed prominent delta slowing. There were no epileptiform features. The abnormal cardiac rhythm could be assessed better through routine ECG tracings. Brief Hospital Course: Ms. [**Known lastname 15404**] is a lovely 86 year-old right-handed woman with a past medical history including atrial fibrillation (on coumadin), HTN, and CHF who initially presented to [**Hospital 15405**] [**2108-12-14**] with dyspnea and develped acute weakness in the left face, arm, and leg. After a non-contrast CT of the head was performed, IV t-PA was administered. She was subsequently transferred to the [**Hospital1 18**] for further evaluation and care. She was admitted to the stroke service from [**2108-12-14**] to [**2108-12-28**]. . NEURO Upon the patient's arrival, a non-contrast CT was performed which showed a large right PCA territory infarct. The CTA showed showed patent vessels. A CT perfusion study demonstrated delayed mean transit time, reduced blood flow and reduced blood volume in the distribution of the right PCA territory inolving the posterior-inferior right temporal lobe and extending into the thalamus and midbrain. . Ms. [**Known lastname 15404**] was initially admitted to the ICU for close post-tpa monitoring. A non-contrast CT of the head was repeated following 24 hours to evaluate for any hemorrhage. The stroke was thought to be attributable to atrial fibrillation in the context of a subtherapeutic INR. . In the setting of acute stroke, the patient's outpatient regimen of imdur and verapamil were held to allow for blood pressure autoregulation with a goal SBP of 140-160. The lopressor was administered at half dose for rate control. An MRI brain showed a large area of restricted diffusion in the right PCA territory involving the right cerebellar hemisphere, right medial temporal lobe, with extension into the midbrain and thalamus. . To evaluate modifiable risk factors for stroke, lipids and glycosylated hemoglobin were measured. As the LDL was found to be 102 and she was started on simvastatin 20 mg daily. Although the HBA1C was 6.1 %, blood glucose was monitored regularly and an insulin sliding was instituted to maintain normoglycemia. Her coumadin was resumed for goal INR [**1-2**]. . Unfortunately the patient's condition worsened upon transfer to the step-down unit. The patient was no longer verbal, did not follow commands, groaned to noxious stimuli with only minimal withdrawl on the right side. She was monitored with several CT scans which showed cytotoxic edema with some mass effect on the fourth ventricle. Given the midbrain and thalamic involvement, it was thought the stroke may have been contributing to the patient's decreased level of arousal, however it also appeared an infectious process may have also been contributing. The patient also underwent a routine EEG which did not show any seizure activity. LFTs and ammonia were also within normal limits. . The patient currently does not follow commands. She moans, moves the right arm and leg spontaneously and withdraws purposefully, and withdraws to noxious stimuli in the left leg. . RESP Ms. [**Known lastname 15404**] seemed to develop increasing oxygen requirements following her arrival to the [**Hospital1 18**] ED. A chest x-ray demonstrated evidence of moderate pulmonary edema, consistent with a BNP of 1717. Accordingly, an additional dose of lasix (40 mg IV) was given with a good response. Her oxygen requirements were thought to be secondary to congestive heart failure as well as a possible aspiration pneumonia. She was maintained on a facemask delivering 40% oxygen while in the step-down unit. She was also treated with albuterol and ipratropium nebulizers. Her ABGs earlier in the hospital course appeared to be consistent with a primary metabolic alkalosis, attributed to possible volume contraction. She is currently on room air with O2 saturations in the low 90s, however does require O2 via 40% face mask at times to maintain O2 sats. . ID Ms. [**Known lastname 15404**] had a mild leukocytosis, with a peak of 14.1 and has remained stable at 12-13. On [**12-16**], she was found to have a urinalysis with positive nitrites and WBCs, and eventually grew e. coli. She was started on ceftriaxone at this time for treatment of a UTI. CXR was also concerning for possible aspiration pneumonia. As her oxygen requirements continued to be rather substantial (requiring 40% face mask) with a mild leukocytosis, her antibiotic was changed to cefepime on [**12-21**]. She completed a 10-day total course of antibiotics and her WBC has remained essentially stable over the past several days ranging from [**10-13**]. She has been afebrile with no new localizing source of infection. . CV Her input and output have been closely monitored. She has a history of diastolic dysfunction however was unable to take PO intake and appeared to be intravascularly volume depleted at the time of admission. Her home lasix was held and was given free water via IV until her NG tube was placed. Lopressor was used for rate control which has been titrated up to 50 mg q6h. She has had a difficult fluid balance, with ABG concerning for possible contraction alkalosis and CXR and O2 sats concerning for pulmonary edema. Lasix has been given as needed and standing lasix has not been resumed at this time. She has resumed anticoagulation for atrial fibrillation as above. . Nutrition The patient has been receiving tube feeds at 45 cc/hr via NG tube and tolerating this well. There have been frequent discussions with the family in regards to goals of care. After the patient's decompensation earlier in the hospital course it was unclear if her change in arousal was attributed only to her stroke or whether an underlying infectious, metabolic, or other process (seizure) was confounding her exam. Her infections had been treated and had no evidence of seizure on EEG, but still remains quite encephalopathic. Therefore, it was decided that the patient would require a PEG tube for nutritional intake. After a family meeting [**2108-12-27**] with the [**Hospital 228**] health care proxy, it was decided to proceed with PEG, and this was placed [**2108-12-31**]. . CODE STATUS After a family meeting [**2108-12-27**] with the patient's daughter and health care proxy, [**Name (NI) 15406**] [**Name (NI) 15407**] [**Telephone/Fax (1) 15408**] (c), [**Telephone/Fax (1) 15409**] (h), the patient's code status was changed to DNR/DNI. Medications on Admission: Lopressor 150 mg [**Hospital1 **] Lasix 20 mg TID Omeprazole 20 mg Qday Premarin 0.625 mg Qday Verapamil 180 mg [**Hospital1 **] Coumadin 3 mg Qday Imdur 30 mg Qday KCl 20 mEq Qday Calcium Qday Iron Qday MVI Qday . ALL: sulfa Discharge Medications: 1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Hospital1 **]: One (1) Inhalation Q4H (every 4 hours) as needed for SOB. 2. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. 3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Hospital1 **]: [**12-1**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 4. Simvastatin 10 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO DAILY (Daily). 5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 6. Senna 8.6 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a day) as needed for constipation. 7. Docusate Sodium 100 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a day) as needed for constipation. 8. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6 hours). 9. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 10. Coumadin 3 mg Tablet: 1 tablet daily, adjust accordingly for goal INR [**1-2**]. Discharge Disposition: Extended Care Facility: [**Hospital 8971**] Rehabilitation Center (at [**Hospital6 8972**]) - [**Location (un) 8973**] Discharge Diagnosis: Right PCA stroke Discharge Condition: Eyes closed, occasionally briefly open to noxious stimuli. Moans but nonverbal. Roving eye movements, pupils 3mm --> 2mm. L facial droop. Moves RUE and RLE spontaneously. Withdraws LLE to noxious stimuli. Discharge Instructions: You were admitted with left face, arm, and leg weakness and found to have a stroke. You were treated with IV TPA. You were also treated with antibiotics for a pneumonia and a urinary tract infection. You will be transferred to another hospital for further care. Followup Instructions: Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in two months. His office can be reached at ([**Telephone/Fax (1) 15319**] to schedule an appointment. [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

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icd9cm

[ [ [] ] ]

[ "43.11", "96.6" ]

icd9pcs

[ [ [] ] ]

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10410, 16716

256, 265

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18914, 19213

1513, 1531

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16742, 16970

18625, 18891

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293, 1015

2449, 3267

3302, 10387

1560, 2017

2056, 2433

2041, 2041

1037, 1264

1280, 1497

13,259

168,107

7403

Discharge summary

report

Admission Date: [**2108-4-11**] Discharge Date: [**2108-4-23**] Date of Birth: [**2026-12-30**] Sex: F Service: SURGERY Allergies: Sulfa (Sulfonamides) / Cefazolin / Aminophylline Attending:[**First Name3 (LF) 2597**] Chief Complaint: right leg pain Major Surgical or Invasive Procedure: 1) Thrombectomies of left ax-fem bypass graft 2) Thrombectomy of fem-fem bypass graft 3) Thrombectomy of right fem-peroneal bypass graft with Dacron patch 4) Angioplasty of left ax-fem distal [**Doctor Last Name **] 5) Right lower extremity angiography of right tibioperoneal trunk, angioplasty of right peroneal artery, stent placement in right tibioperoneal trunk. History of Present Illness: 81 y/o female who presented to ED for RLE pain with decreased sensation and ROM since the early AM. Pt denies trauma, pain has been increasing throughout day and is now sever in nature. Unable to palpate or doppler foot pulses, Vascular consulted and decision to go to OR for immediate intervention. Past Medical History: 1) Peripheral vascular disease 2) s/p right femoral peroneal bypass 3) s/p common femoral artery thrombectomy 4) status post left axillo bifemoral 5) status post profunda 6) status post left 7) ilioprofunda with PTFE 8) aortic insufficiency 9) HTN 10) DM2 diet controlled 11) coronary artery disease 12) status post myocardial infarction 13) status post CABG remote 14) hypothyroidism on no supplement at this time Social History: She denies alcohol, drug or tobacco use Family History: Noncontributory Physical Exam: PE vitals: 98.7 73 108/60 20 96%RA FS 161 gen: NAD HEENT: EOMI, no JVD CV: RRR PULM: clear ABD: soft, NT/ND, + bowel sounds Groin: Staples intact, no dehisence, minimal localized erythema surrounding left incision site Pertinent Results: [**2108-4-14**] 12:05AM BLOOD CK-MB-350* MB Indx-42.6* cTropnT-6.71* [**2108-4-14**] 09:08AM BLOOD CK-MB-253* MB Indx-7.1* cTropnT-9.37* [**2108-4-14**] 03:12PM BLOOD CK-MB-146* MB Indx-5.6 cTropnT-8.68* [**2108-4-15**] 06:42AM BLOOD CK-MB-37* MB Indx-3.9 cTropnT-5.97* [**2108-4-14**] 12:05AM BLOOD CK(CPK)-821* [**2108-4-14**] 09:08AM BLOOD CK(CPK)-3576* [**2108-4-14**] 03:12PM BLOOD CK(CPK)-2593* [**2108-4-15**] 06:42AM BLOOD CK(CPK)-955* ECHO [**4-14**]: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. No masses or thrombi are seen in the left ventricle. Overall left ventricular systolic function is severely depressed with inferior, lateral, mid to distal anterior and apical akinesis (multivesssel. There is no ventricular septal defect. The right ventricular cavity is mildly dilated. There is apical right ventricular free wall hypokinesis. The aortic valve leaflets are severely thickened/deformed. There is mild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild to moderate ([**1-17**]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2102-3-31**], regional wall motion abnormalities are new (c/w multi-vessel CAD). In addition, mild aortic stenosis and moderate pulmonary hypertension are present. EKG [**4-16**]: Sinus rhythm Probable incomplete left bundle branch block Consider inferior infarct, age indeterminate ST-T wave abnormalities - cannot exclude in part injury/ischemia Clinical correlation is suggested Since previous tracing of [**2108-4-14**], further ST-T wave changes present Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W. Intervals Axes Rate PR QRS QT/QTc P QRS T 84 148 116 412/452.85 7 -23 146 EKG [**4-14**]: Sinus rhythm. Compared to tracing #1 there is one millimeter ST segment elevation in the inferolateral leads suggestive of myocardial infarction/injury pattern. There is also QTc interval prolongation in those leads. Decreased limb lead voltage. Clinical correlation is suggested. TRACING #2 Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10592**] Intervals Axes Rate PR QRS QT/QTc P QRS T 79 150 106 [**Telephone/Fax (2) 27203**] -32 149 CxR [**4-18**]: IMPRESSION: Stable bilateral pleural effusions and left retrocardiac opacity which may represent areas of atelectasis and/or consolidation. No overt CHF CBC: [**2108-4-23**] 06:20AM BLOOD WBC-13.0* RBC-3.35* Hgb-10.2* Hct-29.6* MCV-88 MCH-30.4 MCHC-34.4 RDW-16.1* Plt Ct-408 [**2108-4-22**] 04:00AM BLOOD WBC-10.1 RBC-3.37* Hgb-10.3* Hct-30.0* MCV-89 MCH-30.4 MCHC-34.2 RDW-15.6* Plt Ct-394 coags/INR data: [**2108-4-23**] 06:20AM BLOOD PT-20.1* PTT-28.3 INR(PT)-1.9* [**2108-4-22**] 04:00AM BLOOD PT-24.9* PTT-35.1* INR(PT)-2.5* [**2108-4-21**] 01:30AM BLOOD PT-29.1* INR(PT)-3.0* [**2108-4-20**] 06:40AM BLOOD PT-34.3* PTT-37.1* INR(PT)-3.7* [**2108-4-19**] 07:45AM BLOOD PT-42.4* PTT-39.4* INR(PT)-4.8* [**2108-4-18**] 12:16PM BLOOD PT-67.8* PTT-39.5* INR(PT)-8.6* [**2108-4-18**] 04:31AM BLOOD PT-71.0* PTT-39.5* INR(PT)-9.1* [**2108-4-17**] 07:48AM BLOOD PT-45.4* PTT-102.5* INR(PT)-5.2* [**2108-4-16**] 05:45AM BLOOD PT-18.3* PTT-150* INR(PT)-1.7* [**2108-4-15**] 06:42AM BLOOD PT-15.4* PTT-59.7* INR(PT)-1.4* [**2108-4-14**] 03:29AM BLOOD PT-14.7* PTT-108.6* INR(PT)-1.3* [**2108-4-13**] 04:29AM BLOOD PT-13.5* PTT-26.0 INR(PT)-1.2* Chem 7: [**2108-4-23**] 06:20AM BLOOD Glucose-134* UreaN-30* Creat-0.7 Na-141 K-4.4 Cl-105 HCO3-27 AnGap-13 LFTs: [**2108-4-17**] 07:48AM BLOOD ALT-36 AST-46* LD(LDH)-775* AlkPhos-64 TotBili-0.6 Brief Hospital Course: [**Date range (1) 17857**] Pt taken from ED into OR for a right acute critically ischemic foot/limb where thrombectomies of left ax-fem bypass graft, thrombectomy of fem-fem bypass graft, thrombectomy of right fem-peroneal bypass graft with Dacron patch angioplasty of left ax-fem distal [**Doctor Last Name **], right lower extremity angiography, angioplasty of right tibioperoneal trunk, angioplasty of right peroneal artery, stent placement in right tibioperoneal trunk was completed. The patient tolerated the procedure well and was extubated in the PACU. Pt was transferred to the VICU. [**4-13**] POD#2 Pt was doing well, diet was advanced and diruesed to 1L neg as a goal. Her lopressor dose was also increased. The Right DP/PT were palpable on exam. 2 units of PRBCs were also transfused on this date. Pt experienced nausea and emesis that repsonded to compazine. [**4-14**] POD #3 Cardiac enzymes were found to be elevated(troponin peaked at 9.37), stat cardiology eval. Pt denied any COP or SOB leading up to these events. Her lopressor dose was again increased and she was transferred to the cardiac unit for care. EKG showed STE V4 V5. Pt was requiring 6L on nc. [**4-15**] POD #4 pt was diuresed for volume overload and SOB, heparin gtt was continued, BB, ASA, Plavix, statin continued. Nitro gtt was stopped. R groin site was c/d/i. [**4-16**] POD #5 Pt was feeling better, had periods of SOB with labored breathing. Pt was started on warfarin for a goal INR of [**2-18**] due to anterior/apical Akinesis. Pt was administered metolazone and lasix. [**4-17**] POD #6 SOB improved, INR jumped to supratherapuetic level->9.1, diureses continued [**4-18**] Pt transferred to VICU, dopplerable pulses to R foot [**Date range (1) 3683**]: uneventful, Physical therapy saw and worked with the patient-cleared for home, pt transferred to floor status on [**4-21**], received 1 unit of PRBC for slowly declining HcT, HcT responded appropriately [**Date range (1) 27204**]: acute isolated episode of SOB in early AM, responded well to nebulizers, O2 levels and vitals remained stable, dopplerable pulses to R foot, PICC line removed On discharge, home meds were resumed with the following exceptions: 1)lopressor dose lowered to 37.5 [**Hospital1 **] from 50, 2)isordil 10 TID, 3)Procardia held until PCP/cards f/u appointment, 4) statin at 80 from 10, 5) 1 week course of clindamycin(cephalosporin allergy), 6) coumadin dose at 2mg--INR checks to be done by VNA with call-in to PCP, (started on [**2-17**] apical akinesis) Medications on Admission: lop 50 [**Hospital1 **]; nifedipine XR 60QD; isordil 30BID; lipitor 10QD; tylenol; ASA 325QD; plavix 75QD; chlorpropamide 100QD; percocet; lasix 40" Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 7 days. Disp:*56 Capsule(s)* Refills:*0* 8. Chlorpropamide 100 mg Tablet Sig: One (1) Tablet PO once a day. 9. Klor-Con 10 10 mEq Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 10. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*1* 11. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO twice a day. Disp:*90 Tablet(s)* Refills:*2* 12. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 701**] VNA Discharge Diagnosis: 1) Ischemic right foot 2) MI Discharge Condition: Stable Discharge Instructions: Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? Take Plavix (Clopidogrel) 75mg once daily ??????**STOP** taking procardia until you see your primary care doctor(this may be re-started later). -Your metoprolol(lopressor) medication was changed to a lower dose: 37.5mg twice a day. -Your lipitor dosage was increased to 80mg every day. -Also you were started on clindamycin (an antibiotic), please take until gone. -You were started on coumadin which will require weekly INR checks to adjust dosing. You will be taking 2mg every night unless otherwise notified. -Continue all other medications you were taking before surgery. *****Tonight only: take an additional 40mg of furosemide(1 lasix pill)before going to bed***** ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [**2-18**] 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 ?????? It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and 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: ?????? 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 ?????? Call and schedule an appointment to be seen in 1 week for post procedure check and ultrasound What to report to office: ?????? 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 vascular office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call 911 for transfer to closest Emergency Room. **Please call Dr.[**Name (NI) 5695**] office and Dr.[**Name (NI) 20014**] office if you experience shortness of breath at rest. If you are having a great difficulty breathing please go directly to the Emergency Room. Followup Instructions: You have an appointment with Dr.[**Name (NI) 5695**] office on Weds [**5-2**], 2:00pm. Please call and schedule an appointment to be seen by Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 27205**] this week for adjustment of medications. Please call and see your cardiologist within 1-2 weeks from discharge. Completed by:[**2108-4-24**]

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icd9cm

[ [ [] ] ]

[ "39.90", "39.50", "38.93", "00.45", "00.41", "39.49", "99.04" ]

icd9pcs

[ [ [] ] ]

9713, 9771

5871, 8421

324, 693

9844, 9853

1812, 5848

13088, 13435

1534, 1552

8621, 9690

9792, 9823

8447, 8598

9877, 12272

12298, 13065

1567, 1793

270, 286

721, 1023

1045, 1461

1477, 1518

44,784

139,287

13429

Discharge summary

report

Admission Date: [**2165-10-14**] Discharge Date: [**2165-10-18**] Date of Birth: [**2081-11-1**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2901**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Percardial Drain Placement Atrial Flutter Ablation History of Present Illness: HISTORY OF PRESENTING ILLNESS: Mr. [**Known lastname 40743**] is a 83yo M with history of CAD s/p RCA PCI in [**6-3**], dyslipidemia and CRI who presents with sharp chest pain radiating to this back. . About two weeks PTA pt was diagnosed with pericarditis at [**Hospital1 18**] ED. At the time his ECG showed slight diffuse ST elevation, biomarkers were negative. Denies having URI or flu like symptoms prior to diagnosis of pericarditis. Over the past several days he has been experiencing worsening doe and chest pain. Pain is worse when sitting upright and is worse with inspiration. . In the ED, initial vitals were 98.4, 66, 127/80, 16, 97% RA. He had a bedside echo which showed pericardial effusion and cardiology was consulted. Formal echo was performed which preliminarily showed early tamponade physiology with invagination of RV. His pulsus was in the high teens to low 20s but he was hemodynamically stable. Vitals on transfer to the CCU were 67, 129/66, 24, 95% RA. . . On floor vitals are 116/65, 86, 20 92% RA, with pulsus of 10hgmg. Pt went into afib w/ rvr for several minutes and converted to sinus spontaneously. He was asymptomatic at the time. . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Dyslipidemia 2. CARDIAC HISTORY: - CABG: none - PERCUTANEOUS CORONARY INTERVENTIONS: RCA PCI in [**2163-5-27**] - PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: Depression CVD (L ICA 60-69% stenosis) Chronic Renal Insufficiency (baseline Cr. 1.5) Social History: SOCIAL HISTORY: Ran an eyeglass manufacturer, retired in [**2148**], works out three times/week. - Tobacco history: Never - ETOH: occ - Illicit drugs: no Family History: non-contributory to this admission Physical Exam: ON ADMISSION: VS: T= 99 BP=136/67 HR= 67 RR=12 O2 sat=92% RA, pulsus 10 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 flat JVP CARDIAC: RRR no rub appreciated. No murmurs or gallops LUNGS: CTAB ABDOMEN: Soft, NT, mildly distended. 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+ ON DISCHARGE: T:98.8 BP 132/58 HR 78 RR 16 O2 sat 97% 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 flat JVP CARDIAC: RRR no rub appreciated. No murmurs or gallops LUNGS: CTAB ABDOMEN: Soft, NT, mildly distended. 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: LABS ============== ON ADMISSION: [**2165-10-14**] 05:30PM BLOOD WBC-10.7 RBC-3.43* Hgb-11.9* Hct-35.4* MCV-103* MCH-34.7* MCHC-33.7 RDW-12.8 Plt Ct-342# [**2165-10-14**] 05:30PM BLOOD Neuts-80* Bands-0 Lymphs-7* Monos-12* Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0 [**2165-10-14**] 05:30PM BLOOD Glucose-121* UreaN-32* Creat-1.7* Na-135 K-4.2 Cl-100 HCO3-26 AnGap-13 [**2165-10-15**] 05:53AM BLOOD Calcium-8.1* Phos-4.2 Mg-2.3 DIAGNOSIS: Pericardial fluid: NEGATIVE FOR MALIGNANT CELLS. Blood, lymphocytes, and neutrophils. ON DISCHARGE [**2165-10-18**] 06:00AM BLOOD WBC-6.5 RBC-3.38* Hgb-11.5* Hct-34.2* MCV-101* MCH-34.0* MCHC-33.5 RDW-12.8 Plt Ct-403 [**2165-10-18**] 06:00AM BLOOD Glucose-94 UreaN-33* Creat-1.4* Na-137 K-4.4 Cl-105 HCO3-26 AnGap-10 [**2165-10-18**] 06:00AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.3 IMAGING ================= ECHO [**10-14**]: There is a moderate sized pericardial effusion. There is brief right atrial diastolic collapse. There is right ventricular diastolic compression, consistent with impaired fillling/tamponade physiology. Compared with the prior study (images reviewed) of [**2165-10-4**], the pericardial effusion and tamponoade are new. ECHO [**10-18**]: Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is no pericardial effusion. IMPRESSION: No residual pericardial effusion. PROCEDURES: ================== CARDIAC CATH: COMMENTS: 1. Pericardiocentesis was performed with needle entry from the subxiphoid position. The opening pericardial pressure was 20 mmHg. 2. Subsequent removal of 200 mL of pericardial fluid (all sent for studies) and confirmation by echocardiography of only a small anterior rim of pericardial fluid with the catheter positioned in the anterior pericardium. The pericardial pressure decreased to a mean of 7 mmHg. FINAL DIAGNOSIS: 1. Pericardial tamponade with improvement in pericardial pressure after removal of 200 mL of straw colored fluid. Brief Hospital Course: Mr. [**Known lastname 40743**] is a 83yo M with history of CAD s/p RCA PCI in [**6-3**], CRI, recently diagnosed with pericarditis, who presented with chest pain and worsening SOB and diagnosed with cardiac tamponade. # Pericardial Effusion/tamponade: Patient was diagnosed with pericarditis 2 weeks prior to admission. In the week leading to admission patient had worsening SOB and DOE. In the ED ECHO showed early tamponade physiology with invagination of RV, pulsus was 15-20 at that time. Patient was given several large fluid boluses with normalization of his puslus and started on colchicine and prednisone. A pericardial drain was placed with serosanginous drainage which did not show malignant cells on review by pathology. The drain stayed in place for 4 days until ECHO confirmed resolution of the effusion and the drain was removed. Patient's underlying inflammation was treated with colchicine and high dose Aspirin for a 3 day course. Omprezole was added to the patient's medication list for gastric protection while on aspirin 650 mg. . # RHYTHM: Prior to drainage patient developed afib with RVR to the 130s and frequent bradycardic episodes with rates in the 30s that would spontaneously resolve. He remained asymptomatic and hemodyanmically stable during these episodes. On the way to pericardial drain placement patient had a 6 second conduction pause with junctional escape suggesting an underlying tachy-brady syndrome. Subsequently post drainage patient developed atrial flutter, EP was consulted and recommended an ablation procedure which was successfully completed with return to sinus rhythm. . # CKD: patient had baseline creatinine of 1.7 and elevated to 1.9 at presentation, likely secondary to poor renal perfusion. He returned to baseline after pericardial drainage. . # Dislipidemia: stable, patient continued on outpatient regimen. . # Depression: stable, patient was continued on outpatient regimen. Medications on Admission: ATORVASTATIN [LIPITOR] - 40 mg Tablet - 1 Tablet(s) by mouth once a day BRIMONIDINE - (Prescribed by Other Provider; 1 gtt right eye [**Hospital1 **]) - 0.15 % Drops - one drop eye 1 gtt right eye [**Hospital1 **] BUPROPION HCL - (Prescribed by Other Provider) - 75 mg Tablet - 1 Tablet(s) by mouth twice a day DORZOLAMIDE-TIMOLOL [COSOPT] - (Prescribed by Other Provider) - 0.5 %-2 % Drops - 1 gtt OU twice a day EZETIMIBE [ZETIA] - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth once a day MULTIPLE VITAMINS AND MINERALS - (Prescribed by Other Provider) - - NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 (One) Tablet(s) sublingually every 5 minutes X 3 doses as needed for chest pain If 3rd tablet is needed, call 911. SERTRALINE - (Prescribed by Other Provider) - 50 mg Tablet - 1 Tablet(s) by mouth once a day TESTOSTERONE [ANDROGEL] - (Prescribed by Other Provider) - 50 mg/5 gram (1 %) Gel in Packet - as needed ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - 1 Tablet(s) by mouth once a day OMEGA-3 FATTY ACIDS [FISH OIL] - (Prescribed by Other Provider) - 500 mg Capsule - 2 Capsule(s) by mouth once a day Discharge Medications: 1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day): in right eye. 3. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day): right eye. 4. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day. 5. multivitamin with minerals Capsule Sig: One (1) Capsule PO once a day: as previously taking. 6. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual every 5 minutes as needed for chest pain: If 3rd tablet is needed, call 911. . 7. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 11. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*0* 12. aspirin 325 mg Tablet Sig: Two (2) Tablet PO three times a day: For 3 days. Return to home dose (1 tab daily) on Tuesday [**10-22**]. Discharge Disposition: Home Discharge Diagnosis: Pericardial Effusion Cardiac Tamponade Atrial Flutter status post ablation 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 a collection of fluid around your heart (pericardial effusion). You had a drain placed to drain the fluid around the heart. You were placed on medications to quell any inflammation and hopefully prevent re-accumulation of the fluid around your heart. Repeat imaging of your heart showed no re-accumulation of fluid around your heart after the drain was removed. Sometimes aspirin can cause irritation to the stomach and cause bleeding - if you develope light headedness, dark black stools or blood in your stool, you should call your physician or seek medical care. You also developed an abnormal heart rhythm (atrial flutter) during your admission. You underwent an ablation to resolve this and you had a normal heart rhythm on discharge. You also had some wheezing during the admission - this may very well be the sequelae to a viral infection that may have also caused your pericarditis/effusion. You have been given an inhaler to use as needed for wheezing over the next few days. If you have any shortness of breath or other concerning symptoms you should see your physician or go to the emergency room. You are being discharged home to follow-up with your outpatient cardiologist in a few weeks. You will need to take Aspirin for the next 4 days and will need to be on colchicine for about 3 months - your outpatient cardiologist may decide to change this plan at your follow-up appointment. Changes in Medication: - Start Aspirin 650mg three times a day through [**10-21**] - on [**10-22**] return to 325 mg daily (your previous dose) - Start Omeprazole 20 mg daily (protect your stomach while taking aspirin) - Start Colchicine 0.6 mg daily for 3 months - Start Albulterol inhaler 1-2 puffs every 4-6h as needed for shortness of breath or wheezing - Please continue all other medications as previously prescribed Followup Instructions: Please call your outpatient cardiologist to arrange a follow-up appointment. Name: [**Last Name (LF) 1877**],[**First Name3 (LF) **] A. Address: [**Street Address(2) 12840**],[**Apartment Address(1) 40744**], [**Location (un) 6017**],[**Numeric Identifier 12842**] Phone: [**Telephone/Fax (1) 40745**] Appointment: Thursday [**2165-10-31**] 1:15pm Department: CARDIAC SERVICES When: MONDAY [**2165-11-25**] at 1:40 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: WEST [**Hospital 2002**] CLINIC When: THURSDAY [**2166-2-20**] at 8:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

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icd9cm

[ [ [] ] ]

[ "37.26", "37.0", "88.52", "37.34" ]

icd9pcs

[ [ [] ] ]

10619, 10625

6124, 8072

317, 370

10744, 10744

4029, 4049

12793, 13969

2619, 2655

9280, 10596

10646, 10723

8098, 9257

5986, 6101

10895, 12770

2670, 2670

2214, 2312

3363, 4010

267, 279

398, 2112

4064, 5969

10759, 10871

2343, 2431

2156, 2194

2463, 2603

10,044

124,073

227

Discharge summary

report

Admission Date: [**2152-10-2**] Discharge Date: [**2152-10-11**] Service: MEDICINE ONCOLOGY HISTORY OF PRESENT ILLNESS: This is an 81-year-old female with a history of metastatic melanoma with known metastases to the liver and lung who status post resection in the 90s with recurrence in [**2146**] status post treatment with Taxol. She presented to the Emergency Room on [**2152-10-3**], with altered mental status, decreased p.o. intake, confusion and headache over several weeks, and was found to have three mass lesions in her brain on head CT. The patient was started on Decadron, as well as Dilantin. In the Emergency Room she became hypertensive and was sent to the SICU. She was maintained on Nipride GTT. In the Intensive Care Unit, the patient was weaned off Nipride and then changed to Labetalol, Hydralazine. The patient was also noted to have cellulitis on her left knee and was initially maintained on Vancomycin and later changed to Keflex. The patient was also evaluated by Radiation/Oncology, and it was decided that the patient would received a total of seven treatments of whole brain radiation therapy in conjunction with Decadron, as well as Dilantin. During her Intensive Care Unit stay, the patient had increased alertness and was more oriented, although she does have a history of baseline dementia. PAST MEDICAL HISTORY: Metastatic melanoma status post resection in [**2138**] with recurrence in [**2146**] status post treatment with Taxol. History of paroxysmal atrial fibrillation with anticoagulation in the past. Status post PCM for sinoatrial dysfunction. History of coronary artery disease status post myocardial infarction in [**2143**]. MIBI in [**2152-6-23**] showed an ejection fraction of 50%. History of hypercholesterolemia. History of hypertension, osteoarthritis, cellulitis. Status post skin graft. Peptic ulcer disease. History of bladder cancer. Chronic renal insufficiency. ALLERGIES: AMOXICILLIN, OXACILLIN AND PERCOCET, REACTIONS UNKNOWN. MEDICATIONS ON ADMISSION: Imdur 30 mg, Warfarin, Lasix 20 q.d., Calcium Carbonate 1500 q.d., Vitamin D 4000 q.d., Colace 100 mg b.i.d., Protonix 40 q.d., Dietrol 2 mg b.i.d., Labetalol 300 mg b.i.d., Lipitor 10 mg p.o. q.d. SOCIAL HISTORY: The patient is a home health aide. Husband died three months ago. She walks but recently was unable to do so. She otherwise has a very close family. FAMILY HISTORY: On maternal side there is a history of diabetes, as well as hypertension. PHYSICAL EXAMINATION: Vital signs: Temperature 96.5??????, blood pressure 161/47, pulse 74, respirations 14, oxygen saturation 98% on 2 L, 92% on room air. General: She was elderly, lying in bed. She was sometimes agitated and not following commands. She was nonverbal. HEENT: Normocephalic, atraumatic. Pupils equal, round and reactive to light. Extraocular movements intact. Dry mucous membranes. There was poor dentition. Neck: Supple. No lymphadenopathy. Heart: Regular, rate and rhythm. There was an early systolic ejection murmur, 3 out of 6. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, nontender, nondistended. Good bowel sounds. Extremities: There were bilateral skin eschars. The left knee had excoriation and was erythematous. Neurological: The patient was obtunded and not following commands. She had a limited neurologic exam. Cranial nerves II, III and IV intact. She was moving both hands with appropriate strength. No lifting of left arm off bed. Right lower extremity with decreased strength, apparently chronic secondary to polio. On the left lower extremity, she moved toes and feet. LABORATORY DATA: On admission her white count was 6.4, hematocrit 37.5, platelet count 269, neutrophils 73, 22 lymphs, 3 monos; INR 1.1, PT 12.7, PTT 27.8; sodium 138, potassium 4.3, chloride 106, bicarb 22, BUN 36, creatinine 1.8, baseline 1.4-1.5; platelet count 151; calcium 10.6, magnesium 1.9, phos 3.1, CK 116, MB 5, troponin 0.04; Albumin 4.2; TSH 2.9; urinalysis with occasional bacteria, trace ketones, 30 protein. Electrocardiogram was paced, lateral T-wave inversion, inferior T-wave inversion which new consistent with [**2152-6-23**]. Head CT showed three moderately large-sized mass lesions in the right posterior frontal, right anterior frontal lobe and left parietal lesion with significant edema. There was a small amount of peripheral density, question of hemorrhage or calcification. Chest x-ray revealed cardiomegaly, atelectasis, but no overt failure. Knee films showed no fracture and no dislocation and degenerative changes with small right knee effusion. HOSPITAL COURSE: 1. Altered mental status: This was felt to be secondary to metastatic disease to the brain. The patient was evaluated by Radiation/Oncology, and it was decided that the patient would receive a total of seven treatments of whole-brain radiation therapy. Additionally she was maintained on Decadron, as well as Dilantin. The patient had no seizure activity while in the hospital. She tolerated her Decadron well and tolerated her whole-brain radiation therapy without any complications. The patient was discharged on a Decadron taper. Her Dilantin dose was increased to a total of 300 three times a day, given that her Dilantin level [**Company 2240**].i.d. was only 8. The patient will need her Dilantin level followed as an outpatient at her next appointment. 2. Hypertension: The patient's blood pressures while in the Emergency Room were noted to be 200/100; however, once she was transferred to the floor, she maintained very good control on a combination of Clonidine, Hydrochlorothiazide and Minoxidil, Hydralazine, as well as Labetalol 400 b.i.d. The patient's blood pressures were maintained in the 140s to 160s systolic, and it was decided that this was an appropriate range given that the patient needed to have adequate perfusion in the face of increased intracranial pressure. 3. Cellulitis: The patient was initially maintained on Vancomycin, and this was later changed to Keflex. The patient did not develop any rash or other complications Keflex. Her cellulitis was improved by the time of discharge. 4. Renal insufficiency: Her creatinine remained at baseline between 1.4-1.5. 5. Coronary artery disease: The patient was maintained on enteric coated Aspirin, as well as Labetalol. The patient ruled out for myocardial infarction, and her electrocardiogram remained stable without any EKG changes. 6. FEN: The patient was maintained on a soft diet, as well as thin liquids. She tolerated this without event. Additionally her electrolytes were followed daily and were repleted as needed. Her I&Os were monitored closely. 7. Paroxysmal atrial fibrillation: The patient is paced. She was rate controlled. She was held off all anticoagulation given her metastatic disease to the brain. DISPOSITION: The patient was discharged to her home because her family wanted the patient to do so. The patient has [**12-27**] full-time nurses that will be following her once she is discharged to home. Her mental status improved greatly while the patient was in the hospital. By the time of discharge, the patient was conversive and much more alert and oriented. Her neurologic exam was significant for intact cranial nerves and the ability to move all extremities spontaneously. She did have limited movement in her arms, given that she has a history of bursitis. Otherwise, the patient's exam neurologically was much improved. CONDITION ON DISCHARGE: Stable. She was stable on room air. She could not ambulate without assistance and does need help with all bed transfers. She was tolerating a p.o. diet without problems. [**Name (NI) **] mental status had improved considerably in that she was conversant, could move her extremities spontaneously, and cranial nerves were intact. Her strength was notable for weakness throughout but was symmetric. DISCHARGE DIAGNOSIS: 1. Metastatic melanoma with metastases to the liver, lung and brain. 2. Hypertension. 3. Hypercholesterolemia. 5. Osteoarthritis. 6. Bursitis. 7. Cellulitis. 8. Chronic renal insufficiency. 9. Coronary artery disease. 10. Paroxysmal atrial fibrillation. DISCHARGE STATUS: As stated above, the patient will be discharged to home with [**Hospital 2241**] nursing care. Home Hospice has been discussed with the family, and they would like to avail this possibility as the need arises. DISCHARGE MEDICATIONS: Fluconazole nitrate powder to be applied b.i.d. as needed, Hydrochlorothiazide 25 mg 1 p.o. q.d., Minoxidil 10 mg 1 tab p.o. q.d., Hydralazine 25 mg 3 tab p.o. q.6 hours, Clonodine 0.1 mg 1 tab p.o. t.i.d., Aspirin 325 1 p.o. q.d., Pantoprazole 40 mg 1 p.o. q.d., Keflex 500 mg 1 p.o. q.12 hours for a total of 5 days, Docusate 100 p.o. b.i.d., Phenytoin 300 mg 1 p.o. t.i.d., Dexamethasone taper 8 mg p.o. q.8 hours for 3 days, then 4 mg p.o. t.i.d. for 3 days, then 4 mg p.o. b.i.d. for 3 days, then 2 mg p.o. b.i.d. for 4 days, then 1 mg p.o. b.i.d. for 7 days, then 0.7 mg 1 p.o. b.i.d. for 5 days, then 0.75 mg 1 p.o. b.i.d. for 5 days, then 0.5 mg 1 p.o. b.i.d., then Dexamethasone again 0.25 mg p.o. b.i.d. for 5 days, then Dexamethasone 0.25 mg 1 p.o. q.d. for 5 days, and then stop, Labetalol HCL 200 mg 2 tab b.i.d., Bactrim DS 1 tab p.o. q.d. for UTI prophylaxis. FOLLOW-UP: The patient is to see [**Name8 (MD) 2242**], RN, at the [**Hospital Ward Name 23**] Center on [**2152-10-23**], at 2 o'clock. She is to see Dr. [**First Name4 (NamePattern1) 2243**] [**Last Name (NamePattern1) 284**] at the [**Hospital Ward Name 23**] Center on [**2152-10-23**], at 3 o'clock. She is to see Dr. [**Last Name (STitle) 2244**] at the Hematology/Oncology Center at the [**Hospital Ward Name 23**] Building on [**10-30**] at 3 o'clock. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1736**] Dictated By:[**Name6 (MD) 2245**] MEDQUIST36 D: [**2152-10-11**] 10:51 T: [**2152-10-11**] 11:02 JOB#: [**Job Number 2246**] cc:[**Last Name (NamePattern4) 2247**]

[ "682.6", "197.0", "414.01", "197.7", "427.31", "285.22", "593.9", "401.9", "198.3" ]

icd9cm

[ [ [] ] ]

[ "38.93", "92.29" ]

icd9pcs

[ [ [] ] ]

2433, 2508

8494, 10136

7976, 8470

2047, 2246

4660, 4672

2531, 4642

133, 1345

4688, 7529

1368, 2020

2263, 2416

7554, 7955

9,800

186,995

44621

Discharge summary

report

Admission Date: [**2152-8-18**] Discharge Date: [**2152-9-4**] Date of Birth: [**2096-1-14**] Sex: M Service: MEDICINE Allergies: Levaquin Attending:[**First Name3 (LF) 297**] Chief Complaint: Nausea, Vomiting, Abd Pain Major Surgical or Invasive Procedure: Endotracheal Intubation ERCP = Endoscopic Retrograde Cholangiopancreatogram Hemodialysis History of Present Illness: 56 y.o. man with HIV presented with abd pain and hematemesis at dialysis. Pt had sudden onset of nausea and vomitting with blood streaks in emesis. Sent to the ED for further eval and found to be hypotensive to SBP in 80's and febrile to 102.6. Blood cultures were drawn and pt started on vanco, levo, flagyl. Pt also received fluids 2l NS and code sepsis was called. A right IJ presep cath was placed. Pt was also started on peripheral dopamine for his hypotension. Past Medical History: PMH: 1. HIV: diagnosed in [**2135**]. CD4 493 (18%), viral load 21,400 [**2152-3-21**]. CD4 527, VL undetectable [**1-22**]. Patient originally started on antiretroviral treatment approximately in [**2141**]. Patient reports stopping HAART in [**2150-6-16**] due to anemia. HAART restarted in early [**2150**], discontinued 2 months later in [**1-21**] when admitted for ARF and HD. Patient was having side effects of N/V/dysphoric feelings prior to cessation. Unclear why not restarted. 2. ESRD: secondary to HIV nephropathy or IgA nephropathy (per Dr.[**Name (NI) 9920**] notes). Started HD [**1-21**], fistula in L forearm [**2151-2-9**]. HD now at [**Location (un) 4265**] in [**Location (un) **] MWF. 3. CHF: Echo [**2-19**] - Aortic stenosis with valve area 1.1 cm2, mean gradient 24mmHg. Mild MR, mild AI. EF 60%. 4. Hypertension 5. Hypercholesterolemia 6. COPD 7. Type II DM: controlled with glipizide Social History: The pt. has lived with his friend, [**Name (NI) 1959**] for 25 years. He quit smoking tobacco one year ago after smoking 2ppd for 20 years. He denied use of alcohol or illicit drugs. Family History: Unknown. Physical Exam: PE: (in ED) 98.1 (102.8) -- 120s -- 110/70 -- 16 -- 97% 2LNC Gen whispering, in NAD HEENT: NCAT, PERRL, anicteric. OP with thrush, dry MM. Neck: supple, no JVD Lungs CTA b/l CV RRR nml S1S2, [**2-20**] sys murmur at LSB Abd soft, mild diffuse tndr, no rebound or guarding, naBS, neg psoas/obturator signs. Ext: no edema. Neuro: non focal. Pertinent Results: [**2152-8-18**] 11:45AM BLOOD WBC-9.3# RBC-4.55*# Hgb-15.3# Hct-46.3# MCV-102* MCH-33.7* MCHC-33.1 RDW-15.7* Plt Ct-210# [**2152-8-18**] 09:48PM BLOOD Hct-32.4* [**2152-9-3**] 12:58AM BLOOD WBC-4.0 RBC-2.36* Hgb-7.4* Hct-24.0* MCV-102* MCH-31.4 MCHC-30.9* RDW-18.1* Plt Ct-207 [**2152-9-3**] 08:41AM BLOOD Hct-22.1* [**2152-8-18**] 06:39PM BLOOD Neuts-74* Bands-12* Lymphs-11* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2152-8-18**] 11:45AM BLOOD Plt Ct-210# [**2152-8-18**] 02:30PM BLOOD PT-12.5 PTT-24.4 INR(PT)-1.0 [**2152-8-23**] 03:50PM BLOOD Fibrino-567* D-Dimer-[**2124**]* [**2152-8-19**] 10:35AM BLOOD WBC-14.2* Lymph-7* Abs [**Last Name (un) **]-994 CD3%-82 Abs CD3-814 CD4%-44 Abs CD4-441 CD8%-40 Abs CD8-393 CD4/CD8-1.1 [**2152-8-18**] 11:45AM BLOOD Glucose-178* UreaN-47* Creat-8.7*# Na-139 K-5.1 Cl-95* HCO3-27 AnGap-22* [**2152-9-3**] 12:58AM BLOOD Glucose-75 UreaN-17 Creat-3.6*# Na-144 K-3.2* Cl-110* HCO3-29 AnGap-8 [**2152-9-4**] 12:08AM BLOOD CK(CPK)-1469* [**2152-9-3**] 03:50PM BLOOD CK(CPK)-623* [**2152-9-3**] 08:41AM BLOOD CK(CPK)-251* [**2152-9-3**] 12:58AM BLOOD ALT-16 AST-31 CK(CPK)-73 AlkPhos-142* Amylase-133* TotBili-0.3 [**2152-8-18**] 11:45AM BLOOD ALT-86* AST-100* CK(CPK)-46 AlkPhos-224* Amylase-1782* TotBili-1.5 [**2152-8-18**] 11:45AM BLOOD Lipase-[**Numeric Identifier 95509**]* [**2152-9-3**] 12:58AM BLOOD Lipase-106* [**2152-9-4**] 12:08AM BLOOD CK-MB-131* MB Indx-8.9* cTropnT-5.60* [**2152-9-3**] 03:50PM BLOOD CK-MB-69* MB Indx-11.1* cTropnT-2.49* [**2152-8-18**] 11:45AM BLOOD CK-MB-NotDone cTropnT-0.13* [**2152-8-31**] 02:54AM BLOOD calTIBC-130* Ferritn-1650* TRF-100* [**2152-9-1**] 03:44AM BLOOD Triglyc-253* [**2152-8-18**] 06:39PM BLOOD Cortsol-50.6* [**2152-9-3**] 09:37AM BLOOD Cortsol-13.9 [**2152-9-3**] 12:41PM BLOOD Cortsol-27.9* [**2152-9-3**] 01:08PM BLOOD Cortsol-24.0* [**2152-8-19**] 01:38AM BLOOD Type-ART Temp-38.4 O2 Flow-2 pO2-78* pCO2-34* pH-7.40 calHCO3-22 Base XS--2 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**] [**2152-8-18**] 06:27PM LACTATE-3.5* . CT Abd Contrast ([**2152-8-18**]) 1. Unchanged appearance of a markedly dilated common bile duct and mild central intrahepatic biliary ductal dilatation. No evidence of an obstructing lesion. Correlation with liver function tests is suggested. . 2. Slight interval enlargement of retroperitoneal lymph nodes. . CT Head ([**2152-9-3**]) 1. No intracranial hemorrhage or mass effect. 2. Chronic small vessel ischemic change and lacunar infarct in the right thalamus. . ECHO ([**2152-8-22**]) The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (tape reviewed) of [**2152-6-6**], the aortic valve gradient is slightly higher, but the calculated aortic valve area is similar. . ekg [**8-31**] Normal sinus rhythm. Downsloping ST segment depressions in leads I, aVL and leads V4-V6 suggest to possibility of anterolateral ischemia. Compared to the previous tracing of [**2152-8-23**] there has been no diagnostic interval change. Brief Hospital Course: On arrival to MICU, pt had lipase of [**Numeric Identifier 961**] c/w pancreatitis. Abd CT showed chronically dilated CBD but no evidence of pancreatitis. It was thought pt may also have cholangitis given fever, and no other explanation for pancreatitis. ERCP was done and showed pus in biliary system, s/p sphinceteromy. Bld CX grew out E. coli for which pt was on levaquin for and GPCs for which vanco was added. . 12 hours after admission to MICU, pt had acute hypoxic resp failure requiring intubation. He had a brief asystolic arrest which responded to ventilation for hypoxia and atropine/epi. Etiology of resp fialure was thought to be ARDS vs. CHF. . Pt remained intubated c several unsuccessful attempts at weaning limited by desaturation when placed on PS trials of 7/0. Vancomycin, ceftriaxone, metronidazole were started and levaquin stopped for broader coverage. Pt. remained afebrile on this regimen. Tube feeds were attempted given seemingly functional gut (BS, stool) but were limited by persistently high residuals. Pt. started on PPN and scheduled for post-pyloric doboff tube placement. . Pt. had febrile episode on [**8-25**] - lines were changed, abd CT done to eval. pancreas - no evidence of necrotizing pancreatitis. Pt. pan cultured but no growth. Pt. noted to have R sided pleural effusion but was determined to be too small for thoracocentesis. Pt. fever resolved. Abx continued for 14 day course but metronidazole stopped at day 9. . Pt. continued to fail SBT; limited by hypoxia. Discussions re: trach were started with partner. Pt. also could not receive tube feeds given difficulty advancing Dobhoff tube into post-pyloric position (s/p two attempts under flouro). TPN was administered. Plan was to place PEG if tube did not advance on its own. Pt. noted to be significantly volume overloaded [**8-30**]. Plan was to try removing volume with ultrafiltration during dialysis to optimize pulmonary V/Q status + minimize shunting prior to SBT. Failing this, pt. to receive trach. This was discussed with pt's partner who agreed. PEG also discussed with partner who agreed. Pt. failed SBT immediately after dialysis; limited by desaturation and dyspnea. PEG/trach to be placed on [**9-4**]. . [**Date range (1) 57511**], pt spiked temp to 102, became hypotensive. EKG done c no change, cardiac enzymes c/w troponin leak in setting of hypotension, thought [**1-19**] infxn and lines were changed, C. Diff toxin sent, pancultured. Pt. noted to have received enalapril 3 hours prior to hypotensive episode and medication effect may have had some role. . [**9-4**] - Pt. lost endotracheal tube while being turned, developed flash pulmonary edema thought [**1-19**] to loss of PEEP, went into hypoxic PEA arrest. Coded successfully and noted to be pressor dependent with new LBBB, cardiac enzymes elevated and c/w ACS. Also noted to have dilated L pupil though head CT negative for herniation. Cardiology did not recommend heparin until seen by neurology. While awaiting neurology to see patient, patient again became hypotensive to the 50s, became bradycardic. Fluids and pressors administered but pt. went into asystolic arrest, coded, developed a wide complex tachycardia, underwent unsuccessful defibrillation followed by asystole. Code was called and pt. expired [**1-19**] asystolic arrest. Medications on Admission: Enalapril 20mg [**Hospital1 **] Atorvastatin 40mg daily protonix 40mg daily Sevelamer 800mg tid Reglan 10mg QACHS Lopressor 50mg [**Hospital1 **] ASA 325mg daily Plavix 75mg daily Fluoxetine 20mg daily Insulin Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Primary 1. Cholangitis 2. Pancreatitis 3. Acute Respiratory Distress Syndrome Secondary 1. End stage renal disease Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

[ "250.00", "577.0", "424.1", "427.5", "042", "576.1", "428.31", "287.5", "785.52", "574.51", "410.71", "038.8", "276.7", "518.81", "995.92", "403.91" ]

icd9cm

[ [ [] ] ]

[ "99.60", "39.95", "00.17", "51.85", "96.72", "51.88", "51.87", "96.04", "99.62", "99.15", "38.93", "96.6" ]

icd9pcs

[ [ [] ] ]

9625, 9634

5988, 9335

294, 384

9792, 9801

2427, 5965

9857, 9867

2038, 2048

9596, 9602

9655, 9771

9361, 9573

9825, 9834

2063, 2408

228, 256

412, 886

908, 1820

1836, 2022

28,784

109,764

30333

Discharge summary

report

Admission Date: [**2194-1-2**] Discharge Date: [**2194-1-7**] Date of Birth: [**2165-8-10**] Sex: M Service: MEDICINE Allergies: Morphine / Codeine / Hydroxyzine / Chlorpromazine Attending:[**First Name3 (LF) 30**] Chief Complaint: RUQ/epigastric pain c/w prior episodes of pancreatitis - admitted to MICU with persistent tachycardia likely due to EtOH withdrawal Major Surgical or Invasive Procedure: Midline placement History of Present Illness: Patient is a 28 yo male with pmhx depression, etoh abuse/withdrawl, alcoholic pancreatitis who presents with 10/10 epigastric/RUQ pain radiating to his back. Patient reports the pain feels like severe muscle cramping/stabbing c/w prior episodes of pancreatitis after heavy drinking. The patient reports that he is currently having problems with his fiance and decided to drink [**12-4**] gallon of vodka last night. Last drink was either last night or this am, pt cannot remember. Patient also reports severe nausea and approx "30" episodes of vomiting coffee ground material over the last 6 hours (gastro-occult positive) but not frankly bloody. Patient also feels sweaty and c/o chest pain associated with retching. Denies dizziness, headache, vision changes, sob, melena, hematochezia, dysuria. Pt has not been able to void since coming to the ED. Patient has not eaten today, but reports feeling hungry. . Recent admission [**Date range (1) 31643**]/08 for abdominal pain, found to have pancreatitis secondary to ETOH; this was his 10th admission (and 12th ED visit) in 1 year for abdominal pain or alcohol related . He was treated for ETOH withdrawal though he did not have any signs/symptoms. . Initial vs in ED were T 98.6, P 128, BP 149/86, R 20, O2 sat 99% on RA, [**9-12**] pain. In the ED, patient received 8 mg dilaudid over 5 hours, 2 mg IV ativan, 5 mg IV diazepam, 5 mg po diazepam, bananna bag, zofran 4 mg x1, phenergan 25 mg x 1, 1 liter of NS with 2 grams of Magnesium. Social work and case management were contact[**Name (NI) **] and patient was put in for section 35 as he was thought to be a danger to himself given multiple alcohol-related ED visits. Past Medical History: 1) Alcohol Abuse - multiple ED visits with intoxication 2) Abdominal Pain with self-reported history of recurrent pancreatitis - though no objective evidence for such. 3) Depression and Anxiety--> reported history of prior suicide attempts 4) Anemia 5) Esophagitis - EGD [**January 2193**] 6) Drug-seeking behavior 7) possible mesenteric adenitis by CT scan Social History: Owns tile company. History of alcohol abuse. Denies history of seizure, DT. Denies tobacco and illicit drug use. Denies IVDA. Semi-professional boxer. Family History: Positive for depression and anxiety. Grandfather with lung cancer Physical Exam: VS: Temp: 99.6 BP: 145/76 HR: 140 RR: 27 O2sat 95% on RA GEN: diaphoretic, writhing in pain, uncomfortable HEENT: NCAT, PERRL, EOMI, anicteric, MM dry, op without lesions NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: CTA b/l with good air movement throughout CV: RR, tacchy, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, tender in epigastrium and RUQ, no guarding, + rebound, negative murphy'ssign, no masses or hepatosplenomegaly EXT: no c/c/e, warm, good pulses SKIN: no rashes/no jaundice NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. RECTAL: guaic positive in ED Emesis: guaic positive and black Pertinent Results: ADMISSION LABS [**1-2**]: Na 140, K 3.9, Cl 94, HCO3 22, BUN 14, Cr 0.8, Gluc 90; AG = 28 [**1-2**]: WBC 9.4, HCT 47.9, Plt 457 [**1-2**]: ALT 54, AST 53, AlkP91, TotBili 0.5 [**1-2**]: ETOH 234 [**1-2**]: osm 353 [**2194-1-2**] 09:42PM TSH-4.4* . EKG: rate 120, rhythm sinus, axis nl, nl intervals, j point elevation in v2, v3, TWI III, AVF . IMAGING: CXR: no cardiopulmonary process . CT abdomen [**2194-1-3**] 1. No CT evidence of pancreatitis or complications related to pancreatitis. 2. Fatty liver. 3. Small hiatal hernia. Brief Hospital Course: Mr. [**Known lastname 1001**] is a 28 yo old man with extensive history of ETOH use and pancreatitis who presents with epigastric pain c/w with previous episodes of pancreatitis, admitted to ICU for tachycardia and hypertension thought likely associated with ETOH withdrawal. . # Abdominal pain - His pain was mid abdominal, sharp, crampy and radiated to his back, consistent with the descriptions of previous episodes. It was felt to be likely pancreatitis as lipase elevated to 111 and c/w prior episodes. Could also be esophagitis, gastritis, PUD, GERD as patient is having guaic positive emesis. Biliary disease unlikely given nl tbili and alk phos; RUQ U/S on [**10-14**] with same presentation was negative. This could also be alcoholic hepatitis although transaminitis is mild. Patient was kept NPO, received fluid resusciitation with NS x 4L, and then kept on maintenance fluids. For pain control he received Dilaudid 1-2 mg Q1h and sedation was closely monitored (he remained alert). Nausea control was achieved with zofran and phenergan. His last ABD CT in [**December 2193**] non-conclusive [**1-4**] motion artifact, [**10-10**] showed no appendicitis or acute pancreatitis - and was repeated as his pain was very strong, with negative results. He also developed hiccups and was given thorazine which resulted in confusion that resolved. For the rest of his hospitalization in the MICU he had pain out of proportion to exam. He continued to require high doses of narcotic medications for continued reports of cramping abdominal pain with a benign exam. A pain service consult was obtained, and the patient was started on a PCA of IV dilaudid and neurontin with some improvements in his symptoms. Upon arrival to the floor, he continued to complain of extreme pain, despite having a normal abdominal exam, with no tenderness to palpation when the patient was distracted, and a normal appetite. Upon weaning him off of the dilaudid, the patient was found to have several dilaudid pills in his bedside table. Security was called to do a room and patient search which was unremarkable. Social work was consulted to attempt to set up a sober holding program for the patient until inpatient alcohol rehab became available to avoid a section 35 started in the ED. THe patient left AMA within 24hours of arrival to the floor. . # Guaic positive emesis-He had a few episodes of emesis that was dark and guiaic positive. He was given Promethazine 12.5mg IV Q6 and Ondansetron 8mg IV Q8 and Pantoprazole 40mg IV Q12. He had a midline placed for access as peripherals consistently failed due to patient movement. He was monitored on tele and had an active type and screen. His hematocrit remained stable and he ceased having dark emesis by HD#2. . # ETOH withdrawal - Patient's Ciwa score on admission was 5 and peak was 17; points for sweatiness, anxiety, n/v. He received bananna bag in ED as well as 2 mg IV ativan, 5 mg IV diazepam, 5 mg po diazepam in the ED. While he was in the MICU he was on a CIWA scale as well as 10mg valium q 6 hours standing. He recieved a large amount of valium during his first two HDs, but then was weaned. His standing q6h valium was ceased, and his CIWA scale was decreased, requiring less PRN diazepam. In addition he was on MVI, Thiamine 100mg IV, Folic Acid 1mg . # Tachycardia - He had sinus tachycardia while in the hospital, initially going up to 150. EKG was normal and this was felt to be likely secondary to fluid losses [**1-4**] to repeated vomiting and withdrawal. Other contributors are probably pain, alcohol withdrawl. Resolved with fluid rescusitation, pain management and valium. Cocaine negative. Plan was for continued maintenance fluids and occasional boluses, pain control with dilaudid, Ciwa scale with diazepam, and a TSH check (which was normal). By HD#3 his tachycardia was largely resolved, most often ranging in the 80s in NSR. . # Anion Gap acidosis: Anion gap was 28 on labs from ED; Osm gap was 12 taking into account his etoh level. Urine ketones 15, also possible pt has starvation or alcohol ketosis. Acetone negative, lactate 1.6, ASA negative. No evidence of DKA, uremia, not taking INH, methanol. Resolved with fluids within the first 12hr of hospitalization. . # Depression: Patiently currently denies desire/plans to harm himself. Continued Zoloft 50mg QD and Seroquel 800 QHS. SW consult (seen on multiple visits by SW/Psych). F/U on Section 35: cannot be initiated on weekend; if moving forward with it then must contact [**Name (NI) **] [**Name (NI) **] of legal dept (7-1888) Sunday night to let her know plans to move forward with Section 35 in the morning. Will need to send 1) affidavit 2)updated medical course from overnight and 3) written description of pt to [**Doctor First Name **] by 9am so that lawyer can go to court to request section 35. # Pruritis: Bilirubin is normal, unlikely to be cause for pruritis. Patient's skin appears dry. Recent shaving of torso hair may also contribute to pruritis. - Benadryl 25mg IV, Sarna cream given with good results. Medications on Admission: zoloft 200mg QD and seroquel 800 mg qhs. Discharge Medications: Not yet determined Discharge Disposition: Home Discharge Diagnosis: Patient left AMA Discharge Condition: Patient left AMA Discharge Instructions: Patient left AMA Followup Instructions: Patient left AMA

[ "276.52", "291.81", "577.1", "577.0", "786.8", "303.91", "698.9", "535.50", "530.10", "785.0", "276.2", "311" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9325, 9331

4120, 9191

438, 457

9391, 9409

3562, 4097

9474, 9493

2727, 2794

9282, 9302

9352, 9370

9217, 9259

9433, 9451

2809, 3543

267, 400

485, 2160

2182, 2542

2558, 2711

73,713

152,792

50316

Discharge summary

report

Admission Date: [**2149-9-8**] Discharge Date: [**2149-9-15**] Date of Birth: [**2096-10-22**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3151**] Chief Complaint: Dyspnea/Hypoxemia Major Surgical or Invasive Procedure: -Left internal jugular central venous line, placed [**2149-9-8**] -Right PICC line, placed [**2149-9-12**] History of Present Illness: Ms. [**Known lastname **] is a 52F with T1-T2 paraplegia s/p MVC, recurent UTI/PNA, and anxiety admitted with hypoxemia. She presented to [**Company 191**] waiting room for an appt with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] [**9-8**], and her routine O2 sat was 80%; BP 98/60 HR 105. At the time pt states she was not sob, no CP, and she was placed on 2L oxygen. At [**Company 191**] her O2 sat on 2L=95%, BP 118/67, HR=85 T=97.2. She typically uses 2l oxygen at night but does not usually need it during the day. Patient endorses a more "junky" cough since the week prior to admission, and now coughing up yellowish sputum but feeling well otherwise. CXR at [**Company 191**] was limited secondary to poor penetration showing left upper lung opacification improved with no new focal areas and persistent LLL opacity likely representing atelectasis/effusion but cannot exclude pneumonia. In clinic, her pOx was 93-94 on 2 L NC, with drops to 84 % without oxygen. She was sent to ED for hypoxia. . In the ED, she became hypotensive to SBP 70s, and a central line was placed. Levophed was started. Patient was given CeftriaXONE 1g for UTI, vancomycin, azithro for pneumonia, and oxycodone for pain. She was given 1500 cc NS. VS upon transfer to the MICU were T97.6 P 98 BP 88/55 --> 140/85 RR 22 O2 94%3L. Past Medical History: #T1 to T2 paraplegia status post a motor vehicle accident. #Recurrent pneumonia (followed by pulm - Last [**2149-4-9**]) - Per pulm, recurrent pneumonia likely from pulmonary toilet issues secondary to neuromuscular disease with improvement with consistent and aggressive bronchopulmonary therapy. - Prior sputum cultures + for MRSA, pan-sensitive Klebsiella, and Pseudomonas. #Recurrent UTIs in the setting of urinary retention requiring straight catheterization #COPD #Hx Pres syndrome #hepatitis C #anxiety #DVT in [**2142**] -IVC filter placed in [**2142**] #Pulmonary nodules #Hypothyroidism #Chronic pain #Chronic gastritis #Anemia of chronic disease #S/p PEA arrest during hospitalization in [**2147-10-3**] Social History: Lives at home with husband and 2 adolescent children. - Tobacco: 35-pack-years, quit several months ago, relapsed recently. - Alcohol: Denies. - Illicits: Denies. Family History: Mother passed away with lung disease. Physical Exam: Admission: Vital Signs: T 99.4 BP 137/69 HR 88 RR 13 O2 97% 3L NC CVP 10 Gen: Alert, oriented, sitting calmly in bed; patient with weak, wet prolonged productive cough HEENT: Mucous membranes dry, no lymphadenopathy or JVD Card: Normal S1, S2, no murmurs, rubs or gallops Resp: poor inspiratory effort; mild scattered rhonchi bilaterally Abd: obese, soft non-tender, non-distended Ext: 1+ pitting edema to low calf; no calf tenderness Skin: no rashes Neuro: CN II - XII grossly intact; UE strength grossly [**6-5**]; LE strength 0/5; feet slightly inverted but no evidence of lower extremity contracture/rigidity . Discharge: Unchanged from above except for the following: Vital Signs: T96.1 BP 116/70 HR 75 RR 20 O2 97% 2.5L NC GENERAL - NAD NECK - supple, no thyromegaly, no JVD, no carotid bruits, CVL in Left IJ clean and intact LUNGS - talking in full sentences, small rhonchi on R side but none on L, moderate air movement, resp unlabored, no accessory muscle use. NEURO - awake, A&Ox3. Pertinent Results: ADMISSION LABS: [**2149-9-8**] 04:31PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG [**2149-9-8**] 04:31PM URINE RBC-3* WBC-36* BACTERIA-MOD YEAST-NONE EPI-0 [**2149-9-8**] 04:31PM URINE HOURS-RANDOM CREAT-60 SODIUM-39 POTASSIUM-64 CHLORIDE-62 albumin-2.5 alb/CREA-41.7* [**2149-9-8**] 08:20PM WBC-8.3 RBC-3.04* HGB-9.2* HCT-26.6* MCV-88 MCH-30.2 MCHC-34.4 RDW-16.6* [**2149-9-8**] 08:20PM NEUTS-77.1* LYMPHS-16.3* MONOS-4.5 EOS-1.4 BASOS-0.7 [**2149-9-8**] 08:20PM PLT COUNT-177 [**2149-9-8**] 08:20PM CALCIUM-8.2* PHOSPHATE-3.5 MAGNESIUM-1.9 [**2149-9-8**] 08:20PM GLUCOSE-110* UREA N-7 CREAT-0.3* SODIUM-143 POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-32 ANION GAP-12 [**2149-9-8**] 08:27PM LACTATE-1.4 . DISCHARGE LABS: [**2149-9-14**] 06:05AM BLOOD WBC-5.4 RBC-2.93* Hgb-8.5* Hct-26.1* MCV-89 MCH-28.9 MCHC-32.5 RDW-16.1* Plt Ct-175 [**2149-9-14**] 06:05AM BLOOD Plt Ct-175 [**2149-9-15**] 11:30AM BLOOD Glucose-112* UreaN-2* Creat-0.3* Na-145 K-4.3 Cl-102 HCO3-38* AnGap-9 [**2149-9-15**] 11:30AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.9 [**2149-9-9**] 04:21AM BLOOD TSH-0.64 [**2149-9-10**] 01:50PM BLOOD Type-ART pO2-100 pCO2-72* pH-7.33* calTCO2-40* Base XS-8 [**2149-9-12**] 02:23PM BLOOD Type-ART pO2-81* pCO2-70* pH-7.40 calTCO2-45* Base XS-14 [**2149-9-13**] 10:44AM BLOOD Type-ART FiO2-94 O2 Flow-2.5 pO2-109* pCO2-76* pH-7.37 calTCO2-46* Base XS-14 AADO2-487 REQ O2-82 [**2149-9-13**] 10:44AM BLOOD Lactate-1.2 . MICROBIOLOGY: -[**9-8**] URINE CULTURE (Final [**2149-9-12**]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML. Sensitive only to meropenem and pip/tazo. -[**9-8**] Blood Cx No Growth -[**9-11**] RESPIRATORY CULTURE (Preliminary): SPARSE GROWTH Commensal Respiratory Flora. STAPH AUREUS COAG +. SPARSE GROWTH. . IMAGING: . - [**9-8**] Admission CXR:FINDINGS: This is a limited examination secondary to poor penetration. Within these limitations, left upper lobe opacification is improved with no new focal areas of opacification. There are no large effusions or pneumothorax. The cardiomediastinal and hilar contours are normal. The patient is status post bilateral humeral fixation. IMPRESSION: Extremely limited examination. Improvement in left upper lobe Opacification with no evidence of worsening effusion. - EKG: ST @ 100bpm, NA/NI, no acute ST-Twave changes, no change from prior. -[**9-12**] CTA CHEST W&W/O C&RECONS: 1. No evidence of pulmonary embolism. 2. Atelectatic changes at both lung bases, with some hypoenhancements suggesting some degree of superimposed infection as well. In the presence of tracheal secretions, aspiration is a consideration. 3. Unchanged appearance of the right paravertebral soft tissue mass adjacent to the azygoesophageal recess and posterior to the left atrium. 4. Right hilar lymphadenopathy has decreased since the prior examination. 5. Left-sided internal jugular vein catheter tip is in the region of the left brachiocephalic vein. Brief Hospital Course: Ms. [**Known lastname **] is a 51-yo woman with T1-T2 paraplegia, COPD, multiple recent admissions for pneumonia, who was admitted to the MICU with hypoxia and altered mental status found on vital signs at [**Hospital 3782**] clinic. After being on pressors for about 24hrs, she stabilized and was transferred to the regular medicine floor on [**9-11**]. . ACTIVE ISSUES: . #. Hypoxia: The patient was found to be significantly hypoxic in the ED. Her exam, CXR, leukocytosis, and increased sputum initially suggested pneumonia and she was started on broad-spectrum antibiotics. She was treated with vancomycin given coag + staph on prelim sputum Cx, ciprofloxacin for empiric pseudomonal coverage, and meropenem for UTI (see below). She was given nebulisers, and her O2 sats remained in the high 80's on 2-3L NC. Her oxygen requirements stabilized over the course of her MICU stay and she was transferred to the regular medicine floor on [**9-11**] with vitals Temp 98.8F, BP 92/56, HR 80, R 24, O2-sat 98% 4L. . On the medicine floor, the pt was feeling better and did not c/o SOB. She occasionally desatted to the 80's when feeling anxious and tearful, but otherwise remained in the 90's on 2L NC. She was initially continued on vancomycin, meropenem, and ciprofloxacin. Given persisting hypoxia since admission, CTA chest [**9-12**] was ordered which showed no evidence of pulonary embolism, and a left lower lobe consolidation and small effusion, likely representing PNA (less likely atelectasis). She had several ABG's showing normal pH but pCO2 in the 70's; the pt also had high bicarb which is likely robust compensation for chronic respiratory acidosis. On [**9-15**], pt was stable with further resolving SOB and improved lung sounds on exam, satting 98% on 2.5L NC. . #. Sepsis: The patient was hypotensive in the ED, even relative to her home [**Name (NI) **] which are already low. The initial concern was for sepsis versus hypovolemia. She was fluid responsive but did require levophed, which was weaned after about 24 hours in the MICU, after which her SBP remained in the 90's (her normal baseline). On the medical floor, pt remained hemodynamically stable. . #. Altered mental status: She had repeated episodes of somnolence and difficulty being aroused. However, these appear to be a chronic issue and precede the current episode of hypoxia and hypotension. The cause is unclear, but her numerous medications for pain and anxiety may be contributing to her underlying hypercarbia and infection. By the time of discharge, the pt's mental status was AAOx3 and mentating well without confusion. . #. UTI: The patient has a history of recurrent UTIs in the setting of straight cathing. Past cultures have grown [**Name (NI) 40097**] organisms, including Klebsiella sensitive only to meropenem. Her urine culture on this admission grew the same, and so she was treated with meropenem. She was transitioned to ertapenem for outpatient antibiotic administration. . #. PNA: The patient may have had some component of hypercarbia in setting of COPD and sedating medications at home. She was continued on her home albuterol and ipratropium. Her sputum prelim grew out coag + staph. She was treated with vancomycin as above. . INACTIVE ISSUES: . #. Depression: Reportedly increased from baseline despite home celexa. Patient was previously amenable to seeing a psychologist as an outpatient. . #. T1-T2 paraplegia with chronic pain: The patient had maintained on multiple medications at home including baclofen, clonazepam, lidocaine patch, methadone, oxybutynin, pregabalin, trazodone, oxycodone. Several of these medications were temporarily discontinued in the hospital given concern for sedation (oxycodone, clonazepam, trazodone). . #. Hypothyroidism - TSH was 0.64. The patient was continued on her home levothyroxine. . TRANSITIONS OF CARE: -A PICC line was placed on [**9-12**] to replace her left IJ CVL. -[**9-12**] CTA: Stable appearance of the soft tissue mass in the azygoesophageal recess since [**2148-2-24**]. Medications on Admission: (from recent d/c summary) 1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea/hypoxia 2. Albuterol-Ipratropium [**2-2**] PUFF IH TID 3. Baclofen 10 mg PO/NG HS 4. Baclofen 10 mg PO/NG NOON 5. Baclofen 20 mg PO/NG BREAKFAST 6. Citalopram Hydrobromide 40 mg PO/NG DAILY 7. Clonazepam 1 mg PO/NG [**Hospital1 **] 8. Docusate Sodium 100 mg PO BID 9. Levothyroxine Sodium 75 mcg PO/NG DAILY 10. Lidocaine 5% Patch 1 PTCH TD DAILY 11. Methadone 5 mg PO/NG TID 12. Oxybutynin 5 mg PO NOON 13. Oxybutynin 10 mg PO BREAKFAST 14. Oxybutynin 10 mg PO HS 15. Polyethylene Glycol 17 g PO/NG DAILY 16. Pregabalin 150 mg PO/NG TID 17. Sucralfate 1 gm PO/NG QID 18. traZODONE 100 mg PO/NG HS 19. OxycoDONE (Immediate Release) 5 mg PO TID pain Discharge Medications: 1. ertapenem 1 gram Recon Soln [**Hospital1 **]: One (1) gram Intravenous once a day for 7 days. Disp:*7 grams* Refills:*0* 2. vancomycin 1,000 mg Recon Soln [**Hospital1 **]: One (1) gram Intravenous every twelve (12) hours for 3 days. Disp:*6 grams* Refills:*0* 3. baclofen 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO QAM (once a day (in the morning)). 4. baclofen 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q DAY AT 1600 (). 5. baclofen 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO QHS (once a day (at bedtime)). 6. citalopram 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 7. clonazepam 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO three times a day: Hold for sedation or RR<12. 8. estradiol 0.01 % (0.1 mg/g) Cream [**Hospital1 **]: One (1) Vaginal twice a week: Apply to external gyn area twice a week . 9. Combivent 18-103 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) puffs Inhalation three times a day. 10. levothyroxine 112 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 11. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]: Four (4) patch Topical once a day: Apply four patches to the affected areas once a day 12 hours off and 12 hours on - No Substitution. 12. methadone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a day). 13. methenamine hippurate 1 gram Tablet [**Hospital1 **]: One (1) Tablet PO twice a day: take with Vitamin C 500. 14. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 15. oxybutynin chloride 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO once a day: Take in AM. 16. oxybutynin chloride 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day: Take in afternoon. 17. oxybutynin chloride 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO once a day: Take in evening. 18. oxycodone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO three times a day as needed for pain for 60 doses. Disp:*60 Tablet(s)* Refills:*0* 19. pregabalin 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO TID (3 times a day). 20. simvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 21. sucralfate 1 gram Tablet [**Hospital1 **]: One (1) Tablet PO four times a day. 22. trazodone 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO at bedtime as needed for insomnia. 23. Calcium 500 500 mg calcium (1,250 mg) Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 24. Surgilube Gel [**Hospital1 **]: One (1) Topical PRN as needed for straight cath. 25. heparin (porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) mL Injection TID (3 times a day). 26. ciprofloxacin 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H (every 12 hours) for 3 days. Disp:*6 Tablet(s)* Refills:*0* 27. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Hospital1 **]: One (1) Inhalation Q4H (every 4 hours) as needed for wheezing. Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Primary diagnoses: Sepsis secondary to urinary tract infection Hypoxemia Secondary diagnoses: #T1 to T2 paraplegia status post a motor vehicle accident. #Recurrent pneumonia with prior sputum cultures + for MRSA, pan-sensitive Klebsiella, and Pseudomonas. #Recurrent UTIs in the setting of urinary retention requiring straight catheterization #COPD #Hx PRES syndrome #hepatitis C #anxiety #DVT in [**2142**] -IVC filter placed in [**2142**] #Chronic pain #Anemia of chronic disease #S/p PEA arrest during hospitalization in [**2147-10-3**] 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 Ms. [**Known lastname **], It was a pleasure providing care for you here at the [**Hospital3 **] Hospital. You were admitted because you were found to have a low oxygen saturation at your urologist's office on [**9-8**]. You were taken to the emergency room, where because of low blood pressure, you were given a central venous line. You were treated in the intensive care unit, where you were given antibiotics, fluids, and breathing treatments. As your blood pressure and oxygen saturation improved, you were transferred to the regular medical floor. Your antibiotics were adjusted and you received further breathing treatments. Your condition has steadily improved, and you can be discharged to home with services. The following changes were made to your medications: NEW: 1. Ertapenem: One (1) gram Intravenous once a day for 7 days. 2. Vancomycin: One (1) gram Intravenous every twelve (12) hours for 5 days. 3. Methenamine hippurate - 1 gram Tablet: 1 Tablet by mouth twice a day, take with Vitamin C 500 (started on [**2149-9-8**] by your urologist) 4. Ciprofloxacin: One (1) 500mg tablet by mouth every twelve (12) hours for 3 days. CHANGED: -none STOPPED: - None Please keep your follow-up appointments as scheduled below. Followup Instructions: Department: [**Hospital3 249**] When: WEDNESDAY [**2149-9-24**] at 8:10 AM With: Dr. [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**] Address: [**Location (un) 830**] [**Location (un) 86**], [**Numeric Identifier 718**] Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] South [**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: WEDNESDAY [**2149-10-8**] at 11:10 AM With: [**First Name8 (NamePattern2) 1409**] [**Last Name (NamePattern1) **], NP [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: GASTROENTEROLOGY When: [**Hospital Ward Name **] [**2149-11-3**] at 1:20 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], MD [**Telephone/Fax (1) 463**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: [**Hospital3 249**] When: TUESDAY [**2150-3-10**] at 11:00 AM With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2149-9-16**]

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Discharge summary

report+addendum

Admission Date: [**2164-8-27**] Discharge Date: [**2164-9-11**] Service: Cardiology HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old woman with a history of dilated ischemic cardiomyopathy who had been in her usual good state of health. She went to a wedding on [**Hospital3 **]. Following this she had dizziness while sitting down. She had no pain. She took a sublingual nitroglycerin tablet and felt worse, diaphoretic, and went to [**Hospital **] [**Hospital **] Hospital via Emergency Medical Service. She was asymptomatic by arrival to their Emergency Room. She experienced no pain during any of this. While at [**Hospital3 **] Hospital on telemetry she had a run of wide complex tachycardia associated with hypotension to a systolic blood pressure of 80s. She was started on intravenous amiodarone and planned for transfer to [**Hospital1 188**]. She did not have recurrence of the tachycardia after the amiodarone was started. She did, however, have bradycardia to a heart rate in the 40s and hypotension again to a systolic blood pressure in the 80s. Amiodarone intravenously was given at 1 mg per minute from 1430 to 2230 on [**2164-8-26**]. Amiodarone at 0.5 mg per minute was given from 2230 until arrival at [**Hospital1 190**] at midnight when the bottle broke on transfer. She has had some increased of shortness of breath with exertion over the past two months as well as a cold which has totally resolved. She denied headache, chest pain, orthopnea, paroxysmal nocturnal dyspnea, pedal edema, abdominal pain, nausea, vomiting, dysuria or back pain. She gets short of breath at one flight of stairs but is able to work out for 10 minutes on a stationary bike. PAST MEDICAL HISTORY: (Previous medical history is significant for) 1. Coronary artery disease, status post myocardial infarction in [**2159**], complicated by cardiogenic shock. 2. Status post cardiac catheterization in [**2159**] with a normal right coronary artery, 70% proximal left anterior descending artery, 100% middle left anterior descending artery, a normal left circumflex, and diffuse second obtuse marginal. 3. Cardiac stress test in [**2162-8-27**] with large fixed abnormalities involving anterior wall, lateral wall near the cardiac apex and sputum, mild reversible abnormality of the inferior wall, marked ventricular chamber dilatation with global diffuse hypokinesis and decreased ejection fraction of 13%. 4. Hypothyroidism. 5. Status post total abdominal hysterectomy and bilateral salpingo-oophorectomy. 6. Peptic ulcer disease with a history of bleeding; last bleeding was greater than 30 years ago. 7. Paroxysmal atrial fibrillation; echocardiogram on [**2164-7-17**], revealed left ventricular ejection fraction of 10%, depressed right ventricular ejection fraction, 1+ mitral regurgitation, trace aortic insufficiency, entire intraventricular septum and anterior wall were thin, fibrotic and akinetic, apex was frankly dyskinetic; all other segments of the left ventricle were severely hypokinetic and extensive spontaneous echocontrast throughout the left ventricular cavity consistent with an old mural thrombus. 8. Glaucoma. 9. Hepatitis (unclear type). MEDICATIONS ON ADMISSION: Her medications at home include Lopressor 12.5 mg p.o. b.i.d., aspirin 81 mg p.o. q.d., Zantac 150 mg p.o. b.i.d., Lipitor 10 mg p.o. q.d., digoxin 0.125 mg p.o. q.d. (held on admission), Coumadin 3 mg p.o. q.d. (held on admission), amiodarone 200 mg p.o. on Monday, Wednesday and Friday (was admitted on intravenous amiodarone at 0.5 mg per minute), Synthroid 75 mcg p.o. q.d., Lasix 40 mg p.o. q.d., Zestril 20 mg p.o. q.d., Timoptic 0.5% OU q.h.s., Lovenox 50 mg p.o. q.12h. ALLERGIES: There were no known drug allergies. SOCIAL HISTORY: The patient is widowed. Formerly worked managing a law firm, but retired at age 55. Lives in apartment at [**Hospital1 **] Community Center in [**Location (un) 745**]. Works out on machines, 10 minutes on a stationary bike. Smoked an unclear amount from 17 until 52. Never a serious drinker. PHYSICAL EXAMINATION ON ADMISSION: On examination, the patient was comfortable, wearing lipstick, talking on the phone. Temperature 98, heart rate 54, blood pressure 103/49, respiratory rate 19, saturating 96% on 2 liters. Her eyes were anicteric. Extraocular muscles were intact. Moist mucous membranes without lesions. Neck was supple. Jugular venous distention was observed at 6 cm. On heart examination, there was a dyskinetic point of maximal impulse laterally displaced. Rate was regular, soft S4, soft holosystolic murmur at the apex. Examination of the lungs revealed crackles one-quarter of the way up. The abdomen was soft, nontender, and nondistended, normal active bowel sounds. No organomegaly by examination. Extremities revealed no edema, and 2+ dorsalis pedis pulses. LABORATORY DATA ON ADMISSION: Laboratories on admission were significant for a hematocrit of 34.1, with a MCV of 88. An albumin of 3.6. Chemistry of 9. An INR of 3.4, and digoxin level of 1.3. RADIOLOGY/IMAGING: Her electrocardiogram showed somewhat broad complex tachycardia at 130 msec, QRS of right bundle-branch block type, RS complex was absent in all precordial leads with Q waves across the precordium. Also in lead II probable AD disassociation. Her electrocardiogram on arrival at [**Hospital1 190**] showed normal sinus rhythm with a long P-R, slightly broad QRS, poor R wave progression, and a left axis. HOSPITAL COURSE: The patient was admitted with probable ventricular tachycardia or accelerated idioventricular rhythm and was referred to the Electrophysiology Service for evaluation. An addendum to this dictation is to follow. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**] Dictated By:[**Name8 (MD) 4430**] MEDQUIST36 D: [**2164-9-11**] 13:45 T: [**2164-9-11**] 19:36 JOB#: [**Job Number **] (cclist) Name: [**Known lastname 15918**], [**Known firstname 9854**] L Unit No: [**Numeric Identifier 15919**] Admission Date: [**2164-8-27**] Discharge Date: [**2164-9-11**] Date of Birth: [**2082-11-2**] Sex: F Service: Cardiology ADDENDUM: HOSPITAL COURSE: The patient underwent an electrophysiology study and ventricular tachycardia focus ablation on [**2164-8-29**]. Eight different inducible foci were ablated. The patient tolerated the procedure well. There were some residual ventricular tachycardic foci remaining and the patient was placed on Amiodarone 400 mg per day times three months and it was planned to have a biventricular automatic implantable converter and defibrillator placed on the following Monday. The patient remained on the inpatient service with no complications from her ablation, no ectopic beats on monitoring by telemetry. On [**2164-9-3**] the patient underwent AICD placement. The procedure was complicated by difficult placement of the wires with multiple attempts of placement of the leads. The patient became hypotensive during the procedure. An echocardiogram demonstrated that there was no pericardial effusion or tamponade. The patient was placed on Dopamine with good recovery of blood pressure and it was presumed that her hypotension was secondary to high dose of Fentanyl given during the procedure. The patient was transferred to the Intensive Care Unit on Dopamine drip for maintenance of blood pressure. The patient was found the following morning to be in an accelerated idioventricular rhythm with AV dissociation and that this was contributing to her hypotension with systolic blood pressures only 70-80 on 13 mcg of Dopamine. EP service was called and A pace terminated the AVR with burst pacing and pressures immediately increased to 110-120 systolic. Dopamine was then slowly weaned off over the next several days and the patient was transferred out of the Intensive Care Unit on [**2164-9-7**]. During this time the patient's hematocrit dropped from 30 down to 25.9. She was transfused with one unit of blood and her hematocrit increased to 31.6. The patient remained in stable condition until the night of [**2164-9-9**] when at 12:30 in the morning house staff was called to see Mrs. [**Known lastname **] for assistance and management of acute respiratory distress. She was found to have heart rates 100 to 110, systolic blood pressures 160's, respiratory rate in the 40's, SAO2 85% on 100% non rebreather with jugular venous pulses increased in the neck to 10 cm and crackles and rhonchi throughout with retracting and paradoxical breathing. EKG at that time showed AV dissociation, atrial rate of about 80, ventricular rate of about 100, wide left bundle branch block type with a left axis. The patient was given Lasix 60 mg, Morphine Sulfate 2 mg IV, IV Nitroglycerin drip was started. She was given another 2 mg of Morphine Sulfate and 120 mg of Lasix IV. With this, her SAO2 increased to 95% on 100% non rebreather and respiratory rate decreased now to 20 with only retracting during breathing and no paradoxical. The patient was transferred to an ICU setting for non invasive monitoring. She was continued with preload reduction with Nitrates and Morphine and diuresis. We discussed the use of mechanical ventilation intervention with her and she does not want this as previously discussed during this admission with Dr. [**Last Name (STitle) 1426**], even if likely temporary under any circumstances. Electrophysiology service was called at 2:30 a.m. on [**9-9**] and they were able to burst pace her AICD which showed immediate response in blood pressure to SVTs of 100 and it was decided to continue Amiodarone. No further Lasix was given. The patient continued to put out good urine. Later the following morning the patient was seen by the EP service fellow again. He attempted to program the ICD to detect 90 beats per minute, however, the algorithm would not permit rate less than 100 beats per minute. He changed VT detection to 100 beats per minute, programmed 19 algorithms followed by a 10 joule cardioversion. He decreased V fib detection from 320 milliseconds to 340 milliseconds, activated all SVT detection algorithms. PA and lateral chest x-ray was performed during the day showing no pneumonia, no effusion and some resolution of congestive heart failure. Electrolytes were checked and abnormalities were corrected and it was planned that if an AIVR, slow V tach returned, that Lidocaine would be used intravenously to assess class IB anti-arrhythmic efficiency. This may provide support to combine Amiodarone and Mexiletine in future if efficacious. Following these adjustments and the biventricular pacer, the patient remained stable, continued to diurese well with no further episodes of AIVR or VT. During this time afterload reduction was introduced with Captopril 6.25 mg tid. This was changed on [**2164-9-10**] to Zestril 5 mg per day and preload reduction was added with Lasix 40 mg per day. It was felt that preload and afterload reduction would help prevent the patient from decompensating into congestive heart failure so rapidly should the AIVR slow VT return. It was decided not to add any other anti-arrhythmics at this time and the ability of the AICD to defibrillate V tach, V fib would not be tested during this admission. The patient continued to do well, her respiratory status improved so that she was saturating 98% on room air. She was cleared by physical therapy for discharge to home and she will follow-up in two weeks with Dr. [**Last Name (STitle) 1426**] of cardiology and with the electrophysiology service device clinic. Appointment times remain to be determined. DISCHARGE MEDICATIONS: Lasix 40 mg per day, Zestril 5 mg per day, Protonix 40 mg per day, Amiodarone 400 mg per day times three months and then 200 mg per day, Lipitor 10 mg per day, Timoptic 0.5% one drop each eye per day, Colace 100 mg po bid, Aspirin 81 mg per day. It was elected not to start anticoagulation or beta blockade at this time and this will be followed up on her visit with Dr. [**Last Name (STitle) 1426**] in two weeks. DISCHARGE STATUS: DNR, DNI. DISCHARGE DIAGNOSIS: 1. Ventricular arrhythmia. CONDITION ON DISCHARGE: Good. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1729**], M.D. [**MD Number(1) 6268**] Dictated By:[**Name8 (MD) 502**] MEDQUIST36 D: [**2164-9-10**] 15:25 T: [**2164-9-13**] 11:20 JOB#: [**Job Number **]

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Discharge summary

report

Admission Date: [**2194-10-29**] Discharge Date: [**2194-12-12**] Date of Birth: [**2130-3-12**] Sex: M Service: MEDICINE Allergies: Aspirin / Optiray 300 / IV Dye, Iodine Containing Attending:[**First Name3 (LF) 3913**] Chief Complaint: Fatigue, dizziness Major Surgical or Invasive Procedure: Bone marrow biopsy Placement of PICC line History of Present Illness: 64 year-old male with hx of post-polio syndrome and gout who presents with fatigue and dizziness. These symptoms have been worsening x 5-6 weeks. He developed SOB with exertion over the past week though no chest pain or palpitations. Notably, he has had a few episodes of spontaneous bleeding including a nosebleed and two episodes of bright red blood per rectum. He reports subjective fevers, though no sweats or chills. He did have an episode of nausea and emesis on morning of admission. He also reports that he this morning he had a right sided frontal headache and noticed some blurry vision that has resolved. He was seen by his PCP day prior to admission who ordered labs. He was referred to the ED for a hematocrit of 10. Past Medical History: -Polio in childhood -Post-polio Syndrome -Gout -Hemorrhoids Social History: Single. Sexually active with women. Remote history of cocaine and heroin use 30 years prior. History of alcohol abuse 30 years ago. Has friends from church. Family History: No history of malignancy. Physical Exam: On admission: T: 98.1 HR: 74 BP: 121/56 RR: 16 SP02: 100% RA. General: Alert, oriented, no acute distress HEENT: Sclera pale, 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, mild tenderness in right upper quadrant, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema CN: AOx3, CN II-XII grossly intact, 5/5 strength in all 4 ext Skin: Petichiae along right medial groin. Pertinent Results: Significant labs: On admission pt WBC 2.0, h/h 3.8/10.8, plts 10 ANC 72 Fibrinogen normal at 292 PT/PTT/INR were normal, INR 1.1 Chems on admission with increased BUN at 28, Cr 1.1, rest of chems normal ALT 14, AST 15, LDH 148, AlkP 54, Tbili 1.3 CK 80 Trop negative x1 Urates negative ferritin elevated at 855 (30-400) iron elevated 252 HBsAg and IgM HBc negative [**Doctor First Name **] negative PSA 0.6 nml SPEP without any specific abnmls IgG 556 IgA 110 IgM 36 HIV negative EBV with evidence of past infxn HHV6 negative Parvovirus positive IgG negative IgM HBV and HCV VL's negative CMV VL negative The pt's assay for PNH (CD55 and CD 59) showed that he did not have PNH. REPORTS: [**2194-10-29**] BM Bx flow cytometry DIAGNOSIS: FLOW CYTOMETRY REPORT FLOW CYTOMETRY IMMUNOPHENOTYPING: The following tests (antibodies) were performed: HLA-DR, FMC-7, Kappa, Lambda and CD antigens: 2,3,4,5,7,8,10,16,19,20,23, 45 and 56. RESULTS: Three color gating is performed (light scatter vs. CD45) to optimize lymphocyte yield. B cells comprise 2% of lymphoid-gated events, are polyclonal, and do not express aberrant antigens (CD5, CD10). T cells comprise 85% of lymphoid gated events, express mature lineage antigens, and have a normal helper-cytotoxic ratio of 1.6 (usual range in blood 0.7 - 3.0). Natural killer cells are quantitatively normal (13%). INTERPRETATION: Non-specific T cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by leukemia/lymphoma are not seen in specimen. Correlation with clinical findings and morphology (see S09-[**Numeric Identifier 59908**]) is recommended. Flow cytometry immunophenotyping may not detect all lymphomas due to topography, sampling or artifacts of sample preparation. [**2194-10-29**] EKG Sinus rhythm. Non-specific inferolateral ST-T wave flattening. Compared to the previous tracing of [**2189-12-30**] no diagnostic interim change. [**2194-10-29**] CT head without contrast NON-CONTRAST HEAD CT: There are foci of curvilinear high-density along the sulci along the left superior convexity (2:25, 26), right posterior temporal/parietal region (2:20, 21), and the right occipital lobe (2:70). These findings are concerning for subarachnoid hemorrhage. No intraventricular extension nor hydrocephalus is demonstrated. No evidence for large vascular territory infarction is seen. Curvilinear ill-defined high density, which appears extra-axial along the sylvian fissure is along the expected course of the left MCA and could represent vascular calcification; thrombosis is not completely excluded (measures 47 [**Doctor Last Name **] in density) (2:[**1-27**]). No shift of normally midline structures or effacement of the basal cisterns is seen. Coarse calcification is noted within the right parietal scalp. The orbits appear unremarkable and the skull intact. The visualized paranasal sinuses and mastoid air cells are well aerated. Vascular calcifications are noted along the carotid siphons. IMPRESSION: 1. Left frontal, right parietal, and right occipital foci of high density along sulci concerning for acute subarachnoid hemorrhage. 2. High-density seen along the expected course of the left MCA is of uncertain etiology. Thrombosis and early caclifications are considerations, the former being a greater possibility. Consider CTA or MRA for assessment of vascular patency. [**2194-10-30**] CXR There is mild cardiomegaly. The lungs are grossly clear. There is no pneumothorax or pleural effusion. IMPRESSION: No evidence of pneumonia. [**2194-10-30**] CT head NON-CONTRAST HEAD CT: Foci of subarachnoid hemorrhage are less conspicuous, with only tiny residual apparent high density in the right occipital (2:22) and right posterior temporal/parietal (2:20) regions. High density along the left sylvian fissure is also less apparent, consistent also with evolving subarachnoid hemorrhage. No new focus of intracranial hemorrhage, nor interval development of intraventricular hemorrhage, hydrocephalus, edema, mass effect, or large vascular territory infarction is seen. The soft tissues, orbits, and skull appear intact. Minimal mucosal thickening is noted in the maxillary sinuses. The mastoid air cells are well aerated. Vascular calcifications are noted along the carotid siphons. IMPRESSION: 1. Decreasing conspicuity of small foci of subarachnoid hemorrhage compared to one day prior. No interval intraventricular extension, hydrocephalus, or new intracranial hemorrhage. 2. Decreased conspicuity of high density described along the sylvian fissure one day prior is consistent with also evolving subarachnoid hemorrhage. [**2194-10-31**] BM core Bx DIAGNOSIS: SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY: DIAGNOSIS: MARKEDLY HYPOCELLULAR BONE MARROW, SEE NOTE. MICROSCOPIC DESCRIPTION Peripheral Blood Smear: The smear is adequate for evaluation. Erythrocytes are decreased, and are normochromic and normocytic with mild anisopoikilocytosis (oval macrocytes, pencil cells, and rare target cells are noted). The white blood cell count appears markedly decreased. Smudge cells are noted. Neutrophils with toxic granules are noted. Platelet count appears markedly decreased. Large forms are not seen. Giant forms are not present. Differential count shows 6% neutrophils, 1% bands, 1% monocytes, 88% lymphocytes, 2% eosinophils. Aspirate Smear: The aspirate material is inadequate for evaluation due to only rare hypocellular spicules being identified and extensive hemodilution. The M:E ratio is 4.5:1 (due to limited count and hemodilution). Erythroid precursors are markedly decreased. Myeloid precursors appear markedly decreased and show full spectrum of maturation. Megakaryocytes are absent. A limited differential count (100 cells) was performed and shows: 0% Blasts, 1% Promyelocytes, 1% Myelocytes, 1% Metamyelocytes, 6% Bands/Neutrophils, 7% Plasma cells, 82% Lymphocytes, 2% Erythroid. Numerous stripped cells without discernable morphology are present. Degranulated mast cells are noted. Clot Section and Biopsy Slides: The biopsy material is adequate for evaluation, and focally interrupted by areas of hemorrhage. Overall cellularity is 5-8%. Histiocytes, plasma cells, and stromal cells comprise the major composition of marrow cellularity. Focal serous atrophy noted. Focal hemosiderin laden macrophages seen. The M:E ratio estimate is decreased. A single erythroid colony is noted, but otherwise erythroid and myeloid precursors are markedly decreased in number. Megakaryocytes are absent. A few small non-paratrabecular lymphoid infiltrates comprised of small lymphocytes are present and account for ~5% of the marrow cellularity. Clinical: Myelodysplastic syndrome (MDS), anemia, leukopenia, thrombocytopenia. [**2194-10-31**] Peripheral blood DIAGNOSIS: FLOW CYTOMETRY REPORT FLOW CYTOMETRY IMMUNOPHENOTYPING The following tests (antibodies) were performed: CD antigens 55, 59. RESULTS: Two color gating is used to identify population(s) of interest by light scatter. INTERPRETATION NOTE: The patient is severely granulocytopenic and is transfused heavily. A repeat study is recommended. Red blood cells and granulocytes were examined for phosphatidylinositol linked antigens. RBCs and granulocytes (decreased events) express expected levels of DAF (CD55) and MIRL (CD59). These findings do not support a diagnosis of paroxysmal nocturnal hemoglobinuria (PNH). Reference: [**Doctor Last Name **] and [**Last Name (un) **], Blood 87(12):5332-5340, [**2181**]. [**2194-11-2**] head CT FINDINGS: There is no new acute intracranial hemorrhage. Previously noted subarachnoid hemorrhage is no longer dense. The [**Doctor Last Name 352**]-white matter differentiation is preserved. There is no mass effect or edema in the brain. The ventricles are normal in size. A coarse calcification is again seen within the right parietal scalp. The bones, mastoid air cells and visualized paranasal sinuses are unremarkable. IMPRESSION: No new intracranial hemorrhage and no evidence of other new intracranial abnormalities. Previously noted subarachnoid hemorrhage is no longer dense. [**2194-11-3**] CT chest/abdomen/pelvis FINDINGS: CHEST CT: No lymphadenopathy is seen in the mediastinal, hilar, or axillary areas. Central line is seen with its tip at the superior vena cava. A small elongated pulmonary node is seen in the right lower lobe (series 2, image 44). Small hiatal hernia is noted. Minimal irregularities of posterior pleural surfaces are seen bilaterally. No pleural or pericardial effusion is seen. Heart is within normal limits. Linear atelectasis in the lingula. ABDOMINAL CT: Liver is of normal size and attenuation with 1.2-cm hypodense lesion at segment [**Doctor First Name 690**] - hemangioma? Gallbladder is within normal limits. No intrahepatic or extrahepatic bile dilatation is seen. Adrenals, kidneys, spleen, and pancreas are unremarkable. No mesenteric or retroperitoneal lymphadenopathy is seen. PELVIC CT: Prostate is enlarged with coarse calcifications. Bilateral inguinal hernias with fat are seen. IMPRESSION: 1. No evidence of lymphadenopathy or tumor in the anterior mediastinum. 2. Small hypodense lesion in liver. [**2194-11-6**] FINDINGS: There is no evidence of acute hemorrhage or shift of normally midline structures. The ventricles and sulci are normal in appearance. There is normal [**Doctor Last Name 352**]-white matter differentiation. The visualized paranasal sinuses are clear. IMPRESSION: No acute intracranial hemorrhage identified. [**2194-11-9**] FINDINGS: There is no intra- or extra-axial hemorrhage, masses, mass effect or shift of normally midline structures. The ventricles are mildly prominent and may reflect age-associated involutional changes. There are no acute major vascular territorial infarcts. Punctate calcifications are noted in bilateral basal ganglia, stable. The [**Doctor Last Name 352**] and white matter differentiation is well preserved. There is exuberant calcification involving the anterior portion of the falx cerebri. The osseous and soft tissue structures are unremarkable. IMPRESSION: No acute intracranial pathological process. [**11-24**]: IMPRESSION: 1. Dilated intra- and extra-hepatic bile ducts, distended gallbladder and dilated pancreatic duct with narrowing of the distal CBD and enhancing soft tissue at the ampulla. While a papillitis is possible, the appearances are worrisome for an ampullary or a duodenal lesion. Endoscopic assessment is warranted for further evaluation. 2. Calculi within the distended gall bladder, but no filling defects in the dilated CBD, to suggest choledocholithiasis. The findings were added to the critical results communication dashboard at the time of dictation. [**11-25**]: There is no evidence of acute hemorrhage, edema, mass, mass effect, or infarct. The ventricles are mildly prominent, reflecting normal changes with age, and unchanged in size and appearance compared to prior study on [**2194-11-9**]. The sulci are normal in configuration. There are scattered small calcium-dense foci within the basal ganglia, which are stable from prior exam. Prominent calcifications along the anterior aspect of the falx cerebri are unchanged since prior exam. There are no acute fractures. Included views of the mastoid air cells and paranasal sinuses are clear. [**11-27**] [**Month/Year (2) **]: [**Month/Year (2) **]: 14 fluoroscopic spot images were obtained without presence of a radiologist and submitted for review. Images demonstrate endoscopic cannulation and opacification of the biliary tree, showing dilatation of CBD. A biliary stent was placed. No filling defects or strictures seen on submitted images. . [**11-29**] ECG: Sinus bradycardia. . [**12-1**] U/S: IMPRESSION: 1. Gallbladder sludge and distention, without other signs to indicate acute cholecystitis. These findings are not diagnostic for acute cholecystitis, if further concern for acute cholecystitis consider HIDA scan. 2. Interval improvement in intrahepatic biliary ductal dilation with moderate residual central intrahepatic and CBD dilation. 3. Partly seen Choledochoduodenal stent is appropriately positioned within the CBD. The intraduodenal portion is not well seen. . [**12-7**] CT abdomen/pelvis: IMPRESSION: 1. The patient had a reaction to the IV contrast in the form of diffuse hives and probable mild laryngeal edema. Please see above note for further details. 2. Probable slight increase in the amount of intrahepatic biliary dilatation. Otherwise, no significant change since the prior study. 3. Stable appearance of borderline size fluid-filled appendix. = details on IV contrast reaction: NOTE ON IV CONTRAST REACTION: The patient received 130 mL of Optiray intravenous contrast. After the second half of the injection was given and after completion of the CT scan, the patient reported feeling warm, specially in his face. I (Dr [**First Name (STitle) **] was called to evaluate the patient. The patient's nurse, [**First Name8 (NamePattern2) 1060**] [**Last Name (NamePattern1) **], was also called as was the heme-onc fellow Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The patient developed widespread urticaria involving his entire body with edema of his eyelids and earlobes in addition. The patient was placed on oxygen and was hemodynamically monitored. He remained hemodynamically stable throughout the entire course. The patient also had some mild laryngeal edema, which did not worsen throughout his course. The patient was initially given 50 mg IV of Benadryl followed by famotadine IV. The patient also received 125 mg of Solu-Medrol IV. His blood pressure remained in the 110's/70-90s during the entire time with an oxygen saturation of 99% on 8 liters of oxygen. He was initially tachycardic to the 117 but eventually settled down into the upper 90s. The patient was able to breathe and talk throughout and after discussion with Dr. [**Last Name (STitle) **], it was decided that epinephrine would be be given. The patient was transferred to the ICU at 6:50 p.m. for continued monitoring. Pertinent labs on discharge: WBC 3.2 Hb 8.7 Hct 26.5 Plt 28 Differential: 58.5N, 28.5L, 12.0M, 0.5E, 0.2B Chem: Na 139 K 4.2 Cl 104 HCO3 28 BUN 24 Cr 0.8 Gluc 120 TBili 1.3 Lipase 56 Ca 8.7 Mg 1.5 Phos 4.4 Alb 3.2 UricAcid 3.8 Brief Hospital Course: This is a 64-year-old gentleman with a history of polio and gout who presents with fatigue and dizziness found to have aplastic anemia. #PANCYTOPENIA: patient initially presented with pancytopenia and several episodes of spontaneous bleeding with recorded platelet count at admission of 6. The initial differential dx included marrow replacement by fibrosis or tumor, myelodysplastic syndromes or various viral infections. The patient was admitted and placed on neutropenic precautions. He had been transfused 7 units of PRBC's and 3 units of platelets at the time of his transfer from the MICU to the floor. Viral serologies were also sent. EBV serologies were c/w old infection and HIV was negative. Initial chemistries showed no evidence of tumor lysis syndrome. Hematology/oncology service was consulted. . On the BMT floor, the patient's BM Bx from [**2194-10-30**] was considered non-diagnostic, and a repeat bone marrow biopsy was performed the next day which did show a hypocellular marrow consistent with aplastic anemia. Allopurinol and indomethicin can cause aplastic anemia and these medicines were discontinued and should not be restarted. The patient's viral studies did not explain the etiology, including HIV, HepB and C, parvovirus, HHV6, CMV, EBV. [**Doctor First Name **] was negative. Assay for PNH was negative. No specific etiology was found. As mentioned above, the had been taking allopurinol for gout, which could be responsible, or this could also be idiopathic. . Mr. [**Known lastname 5850**] went on to receive four cycles of ATG, with steroids before and after, x4 days. He also started cyclosporine (dose adjusted based upon level). The pt was noted to have a temp of 103.9 at the end of his first dose of ATG, treated symptomatically, and did not spike through his next 3 days of treatment. After chemotherapy, Mr. [**Known lastname 5850**] was started on a prednisone taper for one month. . Mr. [**Known lastname 5850**] was started on levaquin, acyclovir, and fluconazole prophylactically. His antibiotics were later adjusted. . #ABDOMINAL PAIN/DILATED BILIARY DUCTS: On [**11-22**], Mr. [**Known lastname 5850**] developed severe abdominal pain overnight. A CT scan showed dilation of intra/extra biliary ducts. An MRCP was confirmatory. Mr. [**Known lastname 5850**] went for an [**Known lastname **] and a stent was placed within CBD. Patient was started on vancomycin, cefepime, and flagyl for prophylaxis of intraabdominal infection; all antibiotics were subsequently weaned. . However, despite CBD stenting, Mr. [**Known lastname 5850**] continued to have abdominal pain. Repeat scans showed persistent biliary dilatation. Patient had a CT abdomen/pelvis on [**12-7**] and during this had an allergic reaction to IV contrast - see below. The following day, abdominal pain improved, his bilirubin trended down, and so the team opted to consult [**Month/Year (2) **]/GI and observe the patient before jumping to another study that might involve contrast. Patient's bilirubin continued to trend down until discharge, and his abdominal pain improved (but did not dissapate). On discharge, patient was comfortable, eating/drinking, ambulating, having regular bowel movements. Per [**Month/Year (2) **] team, he will follow-up as an outpatient for an [**Month/Year (2) **]. . #PANCREATITIS: Post-[**Month/Year (2) **]. Patient was made NPO and started on IVF and PCA. His amylase and lipase resolved and abdominal pain returned to baseline. . #HEADACHE: Patient initially reported left-sided headache with persistent visual changes. He underwent CT head which showed left frontal, right parietal, and right occipital foci of high density along sulci concerning for acute subarachnoid hemorrhage. Neurosurgery was consulted and recommended repeat head CT in 24 hours, SBP control to < 140. Repeat head CT showed improvement and neurosurgery signed off. The patient had several head CTs throughout his admission, which showed improvement in the SAH, with the last head CT showing resolution of hemorrhage. Patient continued to have persistent headaches thought to be related to cyclosporine. Medication was switched to tacrolimus without any improvement. Mr. [**Known lastname 5850**] was treated symptomatically with pain medication so that he was able to tolerate the headaches. . #RIGHT EYE RETINAL HEMORRHAGE: Ophthomology confirmed right eye retinal hemorrhage. Recommendations were to keep platelets between 30-40 and assess for acute change in vision. Optho revisted patient throughout admission; patient was told that visual impairment would eventually resolve and that he should follow-up with ophthalmology as an outpatient. . #CONSTIPATION: The patient was noted to be constipated during his admission, an issue exacerbated by a large external hemorrhoid (see below). Patient was started on a bowel regimen with good effect. . #LARGE EXTERNAL HEMORRHOID: Mr. [**Known lastname 5850**] has a known external hemorrhoid and this was very tender and active during this admission. The pt was treated symptomatically with Tuck's ointment and then steroid cream. Surgery did not recommend intervention at this time. . #HYPERTENSION: Patient was started on Valsartan during admission and achieved appropriate blood pressure control. It was held in the setting of his allergic reaction, but then restarted with good effect. . #GOUT: No active issues. Allopurinol was discontinued as above, due to concern as causative [**Doctor Last Name 360**] for aplastic anemia. . #ALLERGIC REACTION TO CT CONTRAST DYE: The patient developed flushing of head/neck, SOB, some throat tighness, hives (he felt tightening in his throat, swelling of his ears, and nursing staff noted a diffuse erythematous rash over his trunk and extremities) after receiving IV contrast during CT a/p on [**2194-12-7**]. The patient received 50mg Bendaryl, 125 mg of Solumderol, 20 mg famotidine and was transferred to ICU for monitoring overnight. The patient maintained a patent airway and remained hemodynamically stable throughout. The patient's symptoms resolved prior to transfer to ICU. In the ICU, he remained free of symptoms concerning for anaphylaxis; he was bolused 2L of IVFs for orthostatic hypotension. He was closely monitored overnight. The dose of Benadryl was reduced, and the patient was switched to PO Prednisone taper. He was called out back to BMT service. Allergy was consulted on [**12-9**] regarding use of contrast in the future - please see OMR note for full details. Patient had no further sequelae of allergic reaction following this event. He was breathing comfortably on room air at discharge. Medications on Admission: Allopurinol 150 mg daily Colchicine PRN gout pain indomethicin prn gout pain Discharge Medications: 1. Cyclosporine Modified 100 mg Capsule Sig: One (1) Capsule PO every twelve (12) hours. Disp:*60 Capsule(s)* Refills:*2* 2. Cyclosporine Modified 25 mg Capsule Sig: Three (3) Capsule PO every twelve (12) hours. Disp:*180 Capsule(s)* Refills:*2* 3. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 4. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for nausea. Disp:*60 Tablet(s)* Refills:*0* 6. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for pain. Disp:*90 Tablet(s)* Refills:*0* 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for diarrhea. Disp:*60 Tablet(s)* Refills:*2* 8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). Disp:*120 Tablet, Chewable(s)* Refills:*2* 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for heart burn. 12. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). Disp:*180 Capsule(s)* Refills:*2* 13. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal PRN (as needed) as needed for hemorrhoidal pain. 14. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical PRN (as needed) as needed for hemorrhoidal pain. 15. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 16. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary diagnoses: 1. Aplastic anemia of unknown etiology 2. Subarachnoid hemorrhage 3. Retinal hemorrhage 4. Large external hemorrhoid 5. Anaphylactoid reaction to IV contrast Discharge Condition: By the time of discharge, the pt had received a 4 day course of ATG chemotherapy with Dexamethasone before and after, and also cyclosporine and prednisone, his hematocrit and platelet count were stable, was no longer constipated, was taking good PO, vital signs were stable, was ambulating, and was medically clear for discharge. Discharge Instructions: It was a pleasure taking care of you in the hospital, Mr [**Known lastname 5850**]. When you go home please throw away your allopurinol and indomethicin as they may have caused the low blood counts that you were admitted to the hospital with. Please tell any doctors [**Name5 (PTitle) **] [**Name5 (PTitle) 59909**] that you have contact with in the future that one of these medicines may have caused you to have this reaction. You were admitted to [**Hospital1 18**] with fatigue and increased bleeding, and found to be pancytopenic, meaning all the cells in your blood were low. You were admitted and a bone marrow biopsy showed an empty marrow, meaning that the stem cells for these blood cells were very low. On presentation you also had a subarachnoid hemorrhage (a bleed in your head) and right eye blurriness from a hemorrhage in the back of your eye. These were followed and found to be stable. You were given a 4 day course of chemotherapy called ATG, and you also received steroids and an immunosuppressant called cyclosporine. You are being discharged on the steroids and the cyclosporine (take both of these medications twice a day). While in the hospital you had an allergic reaction to the IV contrast that was given to you during a CT scan; you were treated with medications to counteract this allergic reaction, and you were monitored in the ICU overnight. The allergic reaction subsided. While in the hosptital you had abdominal pain, this was treated with pain medicine and it decreased in discomfort. You will follow-up with a gastroenterologist as an outpatient regarding this pain and regarding the stent in your bile tract. After discharge please do NOT take any more of the Allopurinal or Indomethacin. You were given pentamidine on [**11-18**]. You will get your neupogen at outpatient appointments You have an appointment here in 7 [**Hospital Ward Name 1826**] on Sunday [**2194-11-13**] at 9:30a. You will need to come to have your cyclosporine level checked at this appointment. Therefore, do not take your cyclosporine that morning. You will have your blood counts drawn and may be given neupogen. Your valsartan was stopped and you were started on lisinopril Please return to the hospital if you experience fevers, chills, night sweats, bleeding problems, worsening abdominal pain, severe fatigue, changes in your vision, changes in the character of your headaches, or any other concerns. Followup Instructions: 7 [**Hospital Ward Name 1826**] on Sunday [**12-14**]. at 9:30am Provider: [**Name Initial (NameIs) 455**] 2-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F Date/Time:[**2194-12-14**] 11:30 Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS Date/Time:[**2195-2-26**] 8:00 Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2195-2-26**] 8:00 Completed by:[**2194-12-13**]

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icd9cm

[ [ [] ] ]

[ "41.31", "51.87", "99.15", "99.25", "38.93" ]

icd9pcs

[ [ [] ] ]

25247, 25253

16528, 23185

331, 375

25474, 25806

2132, 4121

28282, 28722

1413, 1440

23312, 25224

25274, 25453

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273, 293

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1469, 2113

1158, 1219

1235, 1397

8,452

172,439

4589

Discharge summary

report

Admission Date: [**2135-1-29**] Discharge Date: [**2135-2-4**] Date of Birth: [**2080-11-23**] Sex: M Service: MEDICINE Allergies: Reglan / Protonix Attending:[**First Name3 (LF) 6195**] Chief Complaint: confusion Major Surgical or Invasive Procedure: left second toe amputation. History of Present Illness: 54 year old man with DM1 complicated by gastroparesis/neuropathy, ESRD s/p renal transplant in [**2119**] now on PD, CAD s/p IMI with stent, CHF with EF 45% who presents with dehydration, L foot infection, and confusion. The patient was admitted for sepsis in [**Month (only) 359**] and d/c'd on Keflex. He had sudden onset of weakness and chills. He denied fevers cp sob or abd pain. He did have some nausea, that is normal for him following PD. He had been off plavix for 2-3 days for recent nose bleeds. In the [**Name (NI) **], pt's initial vitals were T98.6, P93, BP80/51, RR 23, O2 sat 97%. His blood sugars remained in the 70s/40s with BS 40. His blood pressures did not respond to 2x1L IVF boluses and he was started on levophed. He was cultured and then started on Ceftriaxone 1gm IV x 1, Vancoymcin 1gm IV x 1. He was later given Zosyn for pseudomonas coverage. Given his Hct drop to 21, he was type and crossed for 4 units. FAST ultrasound showed no pericardial effusion, some abdominal fluid. He had a Pt was also intubated for airway protection/unresponsiveness. During intubation, wife reported new right-sided tooth fracture. He was ventilated on 550x14, PEEP 5 with fent/midaz for sedation. A sepsis line was placed in the right IJ vein. He had elevated cardiac enzymes and lateral wall ST depressions and was given ASA 325mg PO x 1. He was given 10 mg decadron for h/o adrenal insufficiency. On exam, he had bilateral pitting edema that had been resolving, but his left 3rd toe was dusky. It had no signal on doppler or pleth and vascular was consulted. They will see him in the ICU. Prior to transfer, VS 98 132/75 (on levo) 86 14 100% (intubated). Of note, the patient had been DNI, but his wife [**Name (NI) 19490**] this in the [**Name (NI) **]. He is now full code. . In the ICU, he was intubated and sedated. . Review of systems: Unable to obtain Past Medical History: # Insulin dependent diabetes type I - complications of neuropathy, retinopathy, gastroparesis (somewhat responsive to erthromycin) # Renal transplant, [**2119**], now on PD since [**5-27**] - followed by Dr [**First Name (STitle) 805**] # CAD - 3VD, DES to OM [**3-26**], following MI (deferred placing multiple stents d/t excessive dye load in setting of renal insufficiency). # Systolic CHF: ECHO from [**1-25**]--EF 45-50%, akinesis of basal inferior wall and hypokinese of the mid and basal inferolateral wall. # Polycythemia [**Doctor First Name **] # PVD # HTN # h/o Osteomyelitis of R 5th metatarsal in [**2128**] # Eosinophilic gastritis # Stoke in [**2123**] with right hand weakness, resolved on its own Social History: Patient lives with his wife. [**Name (NI) **] is a retired auto mechanic. Per wife, no smoking, alcohol, and any illicit drug use. Family History: One sister has a congenital [**Last Name 4006**] problem. Mother and another sister with bipolar disorder on lithium. Physical Exam: Exam on admission. Vitals: afebrile, 56, 91/42, 16, 100% Gen: Sedated, intubated Eyes: No conjunctival pallor. No icterus. ENT: MM. OP clear. CV: JVP not assessable. Normal carotid upstroke without bruits. PMI in 5th intercostal space, mid clavicular line. RR. Distant S1, S2. No appreciable murmurs, rubs, clicks, or gallops. LUNGS: Mechanical breath sounds anteriorly, no obvious wheeze, rhonchi or rales ABD: NABS. Soft, ND. No HSM. Abdominal aorta was not enlarged by palpation. No abdominal bruits. Heme/Lymph/Immune: No CCE, no cervical lymphadenopathy. SKIN: R heel ulcer, L 2nd toe ulcer NEURO: Sedated, intubated Exam on discharge: VS - T 128/77 HR 73 RR 13 O2-sat % RA GENERAL - pleasant man in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2, S3 ABDOMEN - NABS, soft/NT, distended, PD catheter in place C/D/I, no rebound/guarding EXTREMITIES - warm, no c/c/e, s/p 2nd toe amputation with wound vac in place; 3rd nail bed necrotic SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**6-22**] throughout, Did not test dorsiflexion/plantar flexion, able to wiggle toes, decreased sensation in L4 distribution on Left, normal sensation to light touch and proprioception otherwise, did not ambulate patient, dressing to left foot C.D.I. Pertinent Results: [**2135-1-29**] 09:34PM TYPE-[**Last Name (un) **] TEMP-36.7 RATES-/14 TIDAL VOL-500 PEEP-5 O2-40 PO2-43* PCO2-37 PH-7.32* TOTAL CO2-20* BASE XS--6 INTUBATED-INTUBATED VENT-CONTROLLED [**2135-1-29**] 09:34PM LACTATE-1.5 [**2135-1-29**] 09:34PM O2 SAT-70 [**2135-1-29**] 09:22PM CK(CPK)-380* [**2135-1-29**] 09:22PM CK-MB-12* MB INDX-3.2 cTropnT-0.95* [**2135-1-29**] 09:22PM WBC-7.3 RBC-2.28* HGB-6.6* HCT-20.0* MCV-88 MCH-28.9 MCHC-32.9 RDW-17.7* [**2135-1-29**] 09:22PM PLT COUNT-208 [**2135-1-29**] 09:00PM ASCITES WBC-30* RBC-35* POLYS-11* LYMPHS-37* MONOS-50* MESOTHELI-2* [**2135-1-29**] 06:18PM TYPE-MIX PO2-128* PCO2-29* PH-7.32* TOTAL CO2-16* BASE XS--9 COMMENTS-GREEN TOP [**2135-1-29**] 06:18PM GLUCOSE-100 LACTATE-2.7* [**2135-1-29**] 06:18PM O2 SAT-97 [**2135-1-29**] 05:43PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017 [**2135-1-29**] 05:43PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500 GLUCOSE-100 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2135-1-29**] 05:43PM URINE RBC-[**4-22**]* WBC-[**7-28**]* BACTERIA-MOD YEAST-NONE EPI-0-2 TRANS EPI-0-2 [**2135-1-29**] 05:43PM URINE HYALINE-0-2 [**2135-1-29**] 04:15PM GLUCOSE-47* UREA N-64* CREAT-6.6* SODIUM-137 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-19* ANION GAP-22 [**2135-1-29**] 04:15PM ALT(SGPT)-14 AST(SGOT)-34 CK(CPK)-194* ALK PHOS-87 TOT BILI-0.2 [**2135-1-29**] 04:15PM cTropnT-1.0* [**2135-1-29**] 04:15PM CK-MB-5 [**2135-1-29**] 04:15PM ALBUMIN-2.8* CALCIUM-7.8* PHOSPHATE-5.0* MAGNESIUM-2.0 [**2135-1-29**] 04:15PM CORTISOL-2.5 [**2135-1-29**] 04:15PM WBC-6.2 RBC-2.45*# HGB-7.0* HCT-21.7*# MCV-89 MCH-28.8 MCHC-32.5 RDW-17.6* [**2135-1-29**] 04:15PM NEUTS-61.7 LYMPHS-31.4 MONOS-3.9 EOS-1.9 BASOS-1.1 [**2135-1-29**] 04:15PM PLT COUNT-192 [**2135-1-29**] 04:15PM PT-14.3* PTT-28.4 INR(PT)-1.2* [**2135-2-4**] 06:10AM BLOOD WBC-5.7 RBC-3.27* Hgb-9.6* Hct-29.2* MCV-89 MCH-29.4 MCHC-33.0 RDW-17.0* Plt Ct-189 [**2135-2-4**] 06:10AM BLOOD Plt Ct-189 [**2135-2-4**] 06:10AM BLOOD Glucose-141* UreaN-41* Creat-5.0* Na-138 K-3.8 Cl-104 HCO3-24 AnGap-14 [**2135-2-4**] 06:10AM BLOOD Calcium-7.4* Phos-5.4* Mg-1.9 . Pathology. SPECIMEN SUBMITTED: LEFT SECOND TOE MPJ Procedure date Tissue received Report Date Diagnosed by [**2135-1-31**] [**2135-1-31**] [**2135-2-3**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/ttl Previous biopsies: [**-4/2867**] GI BX'S. [**-4/2864**] BONE DISTAL PHALANX & RIGHT ULCER. [**-4/2841**] GI BX'S. [**-4/2816**] RIGHT 5TH BONE. (and more) DIAGNOSIS: Left second toe, MPJ: - Acute osteomyelitis. - Skin with ulceration. - Bony and soft tissue margins are viable. . Foot 1. Cortical irregularity and periosteal reaction in the shaft of the proximal phalanx of the great toe, is concerning for osteomyelitis. 2. Suspected minimally impacted fracture at the base of the middle phalanx of the left second toe. 3. Continued healing of the proximal left metatarsal shaft fracture with callus formation and obscuration of the fracture line. If clinically indicated, a lateral view targeted to the second toe (the current lateral view is of the entire foot) or alternatively a CT or MRI may help to better depcit the findings in the second digit. Brief Hospital Course: Mr. [**Known lastname 10936**] was admitted with hypotension and intubated in the ED for altered mental status, though there was some report that he had throat swelling after an injection of dexamethasone. He was admitted to the MICU intubated on a small dose of norepinephrine. His norepinephrine was weaned off and his lactate/central venous O2 were noted to worsen to 3.2 and 44% so the norepinephrine was restarted. Cardiology was consulted for rising cardiac enzyems his CK peaked at 647 and troponin 1.59. Cardiology thought that this was most likely secondary to demand and given his 3vd he would not benefit from catheterization, they recommended calling cardiac surgery to redisscuss a CABG as he had been turned down for unclear reasons in the past. He had an infected toe which grew MSSA and was amputated by vascular surgery with placement of a wound vac. He was switched from vancomycin to unasyn. His mental status improved and he was extubated 2 days after admission. He was transitioned to the regular floor where he continued to do well. The wound vac was removed and the wound was sutured closed. He received wound care, with a recommendation for dry dressings and his antibioitics were switched to augmentin for a total antibiotic course of 10 days. He was seen by physical therapy, with a plan for weight bearing while wearing a post operative shoe, and continued outpatient physical therapy. He was found to be c.difficile positive in the intensive care unit. He was not having increased stool output, and it was unclear whether this was asymptomatic carriage. Given the host context, he was treated with p.o vancomycin for this. He continued to receive peritoneal dialysis. He has follow up planned with vascular surgery as well as his primary care doctor. For his Coronary Artery disease, his simvastatin was increased to 80mg daily from 20 mg daily for cardioprotective purposes while revascularization surgery continues to be considered. He was a full code during this hospitalization. Medications on Admission: Sevelamer HCl 800 mg TID W/ [**Known lastname **] Clopidogrel 75 mg Daily Prednisone 5 mg Daily Cyclosporine 25 mg daily Metoprolol Succinate 25 mg SR daiyl Aspirin 81 mg Daily Simvastatin 80 mg Daily Calcitriol 0.5 mcg Daily Lantus 20u qAM ISS Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Cyclosporine 25 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for fungal rash. 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 7. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 9 days. Disp:*45 Capsule(s)* Refills:*0* 9. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) injection Injection QMOWEFR (Monday -Wednesday-Friday). Disp:*30 injection* Refills:*0* 10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain : please do not drink alcohol, or perform activities that require a fast reaction time while taking this medication.[**Month (only) 116**] cause sedation. Disp:*84 Tablet(s)* Refills:*0* 11. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO three times a day: with [**Month (only) 16429**]. 13. Lantus 100 unit/mL Cartridge Sig: Ten (10) units Subcutaneous qam. 14. insulin sliding scale Sig: dose depends on blood glucose level as needed. 15. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 days. Disp:*8 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 932**] Area VNA Discharge Diagnosis: Primary Toe osteomyelitis complicated by sepsis . Secondary Diabetes complicated by gastroparesis/neuropathy End Stage Renal Disease on Peritoneal Dialysis Discharge Condition: stable, good, baseline mental status, full weight bearing in post operative shoe. Discharge Instructions: You were admitted to the hospital because you had sepsis from a toe infection. The toe was amputated, and you were treated with antibiotics for the foot infection with improvement. . The following changes were made to your medications. 1. Augmentin 500mg every 12 hours for 4 days 2. Vancomycin 125mg four times a day for 9 days. 3. Simvastatin 80mg daily . Followup Instructions: Dr[**Name (NI) 11574**] office will call you to set up an appointment for the week of [**2135-2-7**]. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2135-2-7**] 8:15 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2135-3-17**] 8:40 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**] Date/Time:[**2136-1-30**] 1:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**] MD, [**MD Number(3) 6199**]

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icd9cm

[ [ [] ] ]

[ "38.93", "96.71", "54.98", "96.04", "84.11" ]

icd9pcs

[ [ [] ] ]

12057, 12120

8138, 10150

288, 319

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4856, 8115

12812, 13520

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2200, 2219

239, 250

347, 2181

3898, 4837

2241, 2957

2973, 3106

59,347

144,152

37417

Discharge summary

report

Admission Date: [**2145-1-16**] Discharge Date: [**2145-2-24**] Date of Birth: [**2085-1-26**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 301**] Chief Complaint: (L)LQ abdominal pain and leukocytosis. Major Surgical or Invasive Procedure: [**2145-1-25**]: 1. Descending colostomy. 2. Sigmoid resection. 3. Adhesiolysis. [**2145-2-12**]: ERCP for colonic stent placement for a retracting stoma [**2145-2-16**]: ERCP for colonic stent (Wallflex 105mm by 23mm stent; LOT# [**Serial Number 84111**])placement for a retracting stoma History of Present Illness: Ms. [**Known lastname 4379**] is a 59 year old female who was transferred from [**Hospital 1562**] Hospital with a left-sided diverticulitis/colitis and microperforation containing collection within the pelvis. She presented to the OSH with LLQ abdominal pain and leukocytosis. A CT on [**1-11**] and on [**1-15**] demonstrated two fluid collections in the pelvis and inflammatory stranding surrounding the sigmoid colon with small foci of gas. At the OSH, she was on bowel rest and TPN was initiated on [**2145-1-14**]. She was also on Zosyn, Levaquin and Flagyl with minimal improvement. Her hospital course was complicated by ARF secondary to intravascular volume depletion which was treated with volume resuscitation. She was transferred to the [**Hospital1 18**] for further surgical management of her sigmoid diverticulitis. Past Medical History: PMHx: HTN, Chronic back pain, Morbid obesity, Chronic constipation [**3-2**] narcotics, Immobility secondary to degenerative disk disease resulting in weak (L)LE. . PSHx: Multi-level laminectomy [**2135**] and [**2138**] followed by fusion, Repair of large incarcerated ventral hernia with mesh sublay complicated by wound infection requiring incision and drainage, debridement and VAC placement [**2143-5-17**], Pilonidal cyst excision complicated by persistent drainage [**2143-2-14**], Tubal Ligation. Social History: Widow. 45 pack-year smoking history. Quit smoking one year ago. Denies alcohol or illicit substance use. Family History: Non-contributory. Physical Exam: On Admission: Vitals: T 98.4 HR 101 BP 119/60 RR 20 Sat 95%RA Gen: lethargic appearing, NAD HEENT: Dry mucous membranes. NC/AT No scleral icterus Cardiac: RRR; no MRGC Pulmonary: CTA (B) Abdomen: Obese +BS healed midline incision TTP LLQ No rebound, No gaurding Ext: 1+pitting edema . At Discharge: AVSS/afebrile. GEN: Pleasant, obese female in NAD. HEENT: Sclerae anicteric. O-P clear. NECK: Supple. No [**Doctor First Name **]. COR: RRR; nl S1/S2 w/o m/c/r. LUNGS: CTA(B) ABD: Large midline incisional wound granulating and clean. Left abdominal stoma necrotic, which is intubated with a large clear stent that is sutured to skin. Positive flatus in bag. (L)LQ prior JP site (now discontinued) clean/intact with DSD cover. Protuberant with BSx4. Appropriately tender to palpation in area of stoma, otherwise soft/NT/ND. EXTREM: 1+/4+ pitting edema (B)LE; no c/p/c. NEURO: A+Ox3. Pleasant. Deconditioned. Pertinent Results: On Admission: [**2145-1-16**] 09:00PM GLUCOSE-156* UREA N-48* CREAT-1.9* SODIUM-148* POTASSIUM-3.3 CHLORIDE-119* TOTAL CO2-17* ANION GAP-15 [**2145-1-16**] 09:00PM CALCIUM-9.6 PHOSPHATE-1.5* MAGNESIUM-1.7 [**2145-1-16**] 09:00PM WBC-14.4* RBC-2.87* HGB-8.8* HCT-26.6* MCV-93 MCH-30.5 MCHC-32.9 RDW-15.5 [**2145-1-16**] 09:00PM PLT COUNT-365 . Prior to Discharge: [**2145-2-23**] 05:00AM BLOOD WBC-11.2* RBC-2.66* Hgb-7.9* Hct-25.1* MCV-94 MCH-29.7 MCHC-31.5 RDW-15.5 Plt Ct-396 [**2145-2-23**] 05:00AM BLOOD Plt Ct-396 [**2145-2-18**] 05:48AM BLOOD ALT-12 AST-10 AlkPhos-111* Amylase-35 TotBili-0.5 [**2145-2-24**] 07:05AM BLOOD Glucose-111* UreaN-29* Creat-1.0 Na-139 K-4.5 Cl-104 HCO3-24 AnGap-16 [**2145-2-24**] 07:05AM BLOOD Calcium-9.4 Phos-4.1 Mg-1.8 . IMAGING: [**2145-1-16**] CXR: Left PICC tip is in the proximal SVC. Cardiac size is top normal. There are low lung volumes. Aside from minimal atelectasis in the left base, the lungs are clear. . [**2145-1-19**] Renal U/S: No evidence of hydronephrosis. However, this ultrasound is extremely limited given patient's body habitus. . [**2145-1-25**] Supine Abdominal X-Ray: Limited study with gas-distended small bowel, representing ileus or early obstruction. Equivocal small free air below right hemidiaphragm may represent perforation of known sigmoid diverticulitis. . [**2145-1-25**] ABD/PELVIC CT W/CONTRAST: 1. New large amount of free intraperitoneal air, consistent with bowel perforation likely due to progression of perforated sigmoid diverticulitis. Persistent feculent perisigmoid fluid collection, better visualized on outside hospital CTs. New large gas and fluid containing collection in right mid abdomen. 2. Small bowel obstruction with probable transition point in mid abdomen. . [**2145-2-6**] KUB/upright: Contrast is seen in the hepatic flexure and transverse colon with gas seen in the descending colon. There are multiple dilated loops of small bowel measuring up to 4.9 cm with multiple air-fluid levels, but no free air is identified. It is unclear if this represents a small bowel obstruction or an ileus given that colonic gas is still present, but given the patient's history of prior SBO, this is a likely possibility and clinical correlation is recommended. Brief Hospital Course: The patient was transferred from [**Hospital 1562**] Hospital and admitted to the General Surgical Service on [**2145-1-16**] for further treatment of sigmoid diverticulitis with microperforation and acute renal failure. She was made NPO except medications, started on IV fluids, started on empiric IV Flagyl and Levaquin, and continued on Oxycontin 80mg TID plus OxyIR PRN for pain with good effect. PICC line from OSH was cleared for use, and TPN started. The patient was hemodynamically stable. . After surgery on [**2145-1-25**], the patient was admitted to the SICU, where she remained until [**2145-2-3**], afterwhich she was transferred to the inpatient floor. Hospital course as follows: . Neuro: Upon admission, the patient received home Oxycontin 80mg TID plus PRN OxyIR with good effect. Post-operatively, she received Fentanyl along with either Propofol or Midazolam for sedation. She was transitioned to Methadone and Dilaudid IV PRN once transferred to the floor for post operative pain with adequate pain control. By [**2-11**], she had been weaned off Methadone, and her pain was well controlled with Dilaudid PO PRN. She remained neurologically intact. . CV: Initially on pressors in the SICU, which were weaned off. Patient started back on home Metoprolol and HCTZ while in SICU for hypertension with good effect. The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. . Pulmonary: Post-operatively while in the SICU, the patient was transitioned from being intubated on mechanical ventilation due to pulmonary edema to nasal CPAP once the pulmonary plethora improved. Patient declined recommneded BiPAP once on the floor. Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. . GU/FEN: Upon admission, Nephrology was consulted regarding the acute renal failure felt to be secondary to intravascular volume depletion. At OSH, her creatinine went as high as 4.0; maximum creatinine at [**Hospital1 18**] was 3.0. As recommeded, the patient received aggressive IV fluid rescusitation with a goal of keeping a positive fluid balance every day over the next few days with good response. Also, she received blood transfusion to address her anemia as well as low oncotic pressure. By discharge, her creatinine was 1.0. She did require a number of doses of Lasix for secondary fluid overload when on the floor, but chronic lower extremity edema was ultimately controlled with home HCTZ. TPN was restarted, and continued throughout admission. Post-operatively, the patient was made NPO with IV fluids. While in the SICU, she briefly received tubefeeds, which were discontinued before she returned to the floor. When not NPO for procedures or tests, the patient tolerated clear liquids advanced to regular when appropriate. According to calorie counts, however, the patient did not take in adequate calories or protein enterally, thus required parenteral nutrition in the form of TPN at discharge, which was cycled. Nutrition followed the patient throughout hospitalization, working to augment the patient's nutritional status. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. . GI: On [**2145-1-25**], the patient underwent descending colostomy, sigmoid resection, and adhesiolysis (reader referred to the Operative Note for details). The Wound/Ostomy Nurse [**First Name (Titles) **] [**Last Name (Titles) 17037**]d early post-operatively, and followed the patient throughout hospitalization. Post-operatively, the stoma was retracted. On [**2145-2-12**], the patient underwent ERCP for colonic stent placement for the retracting stoma. The stoma subsequently expressed flatus and stool. On [**2145-2-16**], the patient returned for repeat ERCP for a second colonic stent placement again for retracting stoma, which was sutured in place. A bowel regimen was started. She will need to follow-up with Dr. [**Last Name (STitle) 13543**] (Surgery) as an outpatient for stoma revision and stent removal. By discharge, the stoma was passing flatus and stool. Stoma care recommendations were updated by the Ostomy Nurse. . ID: Upon admission, the patient was started on empiric IV Flagyl and a fluoroquinolone (first Levaquin, then Ciprofloxacin) for perforated diverticulitis. On [**2145-1-19**], the Cipro and Flagyl were discontinued, and changed to IV Zosyn with Vancomycin added on [**2145-1-27**]. Fluconazole was then added on [**2145-2-3**]. [**2145-1-26**] fluid and tissue cultures grew pan-sensitive enterococcus species. Antibiotic therapy was completed on [**2145-2-16**]. The patient's white blood count and fever curves were closely monitored for signs of infection. . Wound Care: The Wound/Ostomy Nurses was consulted early in the patient's admission, and followed the patient throughout her hospitalization. Their recommednations were appreciated and followed. On admission, the patient had a pilonidal cyst wound, which was draining. Wound care and pressure relief resulted in significant improvement; at discharge wound was approx. 2.2 x 1cm without depth at gluteal cleft. Post-operatively, the large midline incisonal wound intitially received saline moist-to-dry dressings, which were changed to a VAC dressing using black foam at 125mmHg on POD#17 with resultant improved wound healing and granulation. The VAC dresssing was changed every third day. Abdominal JP drain to bulb suction, with scant output, discontinued on [**2-24**]. At discharge, incisional wound, pilonidal cyst wound and stoma care continued as outlined. For transport to the rehabiliation facility, the VAC dressing was taken down, and a wet-to-dry dressing placed. . Endocrine: The patient's blood sugar was monitored throughout her stay; sliding scale insulin was administered accordingly. . Hematology: The patient's complete blood count was examined routinely. Iniitially after admission, she was transfused three units of PRBCs with a resultant hematocrit of 28.4% pre-operatively. Post-operatively on POD#6, the patient required an additional three units of PRBCs for a hematocrit of 21.1% with good response. Hematocrit by discharge was 25.1%. . Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get mobilized with assistance as early as possible. . Activity/Mobility: Post-operatively, the patient had a number of issues contributing to impaired mobility, including: morbid obesity, degenerative disc disease s/p back surgeries, degenerative joint disease of knees, post-operative status and associated deconditioning, patient reluctance, and pain. Both Physical Therapy and Occupational Therapy follwed the patient throughtout admission. Activity tolerance and mobility were slowly, but minimally improved. By discharge, the patient required assist x [**1-30**] people and a rolling walker to ambulate short distances (i.e. to chair or commode). Further rehabilition is required. . At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet with inadequate caloric intake requiring continuation of TPN, ambulating with assistance only short distances, voiding without assistance, and pain was well controlled. She was discharged to an extended care facility for rehabilitation and nursing care. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: 1. OxyContin 80mg PO TID 2. Lisinopril 20mg Po daily 3. HCTZ 25mg PO daily 4. Ibuprofen 200mg 1 tab PO BID 5. Chantix 1mg 1 tab PO BID 6. Lexapro 30mg 1 tab PO daily 7. Valium 20mg PRN leg spasm Discharge Medications: 1. Escitalopram 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for wheezing. 5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 6. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 7. Escitalopram 10 mg Tablet Sig: Three (3) Tablet PO once a day. 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4 HOURS PRN as needed for pain. 9. 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. 10. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen (17) grams in 8oz water/juice PO DAILY (Daily) as needed for constipation. 11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 13. Insulin Regular Human 100 unit/mL Solution Sig: 4-16 units Injection As directed per Regular Insulin Sliding Scale. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary: 1. Perforated diverticulitis 2. Acute Renal Failure 3. Pulmonary edema 4. Incisional Wound . Secondary: 1. Morbid Obesity 2. HTN 3. Degenerative Disc Disease Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: 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 [**6-7**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. . Monitoring Ostomy output/Prevention of Dehydration: *Keep well hydrated. *Replace fluid loss from ostomy daily. *Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. *Try to maintain ostomy output between 1000mL to 1500mL per day. *If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16mg/24 hours. . JP Drain Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *Maintain suction of the bulb. *Note color, consistency, and amount of fluid in the drain. Call the doctor, nurse practitioner, or 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. . Incisional wound and ostomy care as ordered. Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD (Surgery). Phone: ([**Telephone/Fax (1) 28786**]. Date/Time: [**2145-3-19**] at 2:15PM. Location: [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 5074**]. . Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13543**], MD (Colorectal Surgery). Phone: ([**Telephone/Fax (1) 15721**]. Date/Time: [**2145-3-23**] at 3:00PM. Location: [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**]. Call for sooner appointment. . Please call ([**Telephone/Fax (1) 84112**] to arrange a follow-up appointment with Dr. [**First Name (STitle) **] (PCP) in 4 weeks. Completed by:[**2145-2-24**]

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Discharge summary

report

Admission Date: [**2130-8-24**] Discharge Date: [**2130-9-16**] Service: SURGERY Allergies: Aspirin Attending:[**First Name3 (LF) 7760**] Chief Complaint: abdominal pain, acute abdomen, Meckel diverticulitis. Major Surgical or Invasive Procedure: Exploratory laparotomy, ileal and cecal resection and gastrostomy tube Exploratory laparotomy with abdominal wash-out Flexible bronchoscopy History of Present Illness: The patient is an 87-year-old male who presented to the [**Hospital1 **] [**Location (un) 620**] with complaints of abdominal pain. He was found to have small bowel thickening and free-fluid. Because of his physical exam findings and radiographic evidence, surgery was indicated. He had evidence of a Meckel diverticulum with surrounding small bowel wall thickening. The diagnosis of a possible perforated Meckel's versus small bowel ischemia given his atrial fibrillation were discussed with the patient. In [**Location (un) 620**], he was difficult to intubate resulting in hemorrhage from his upper airway. There was a large amount of clot that almost completely occluded his endotracheal tube, and for this reason he required tracheostomy in order to secure the airway. This was performed in [**Location (un) 620**]. Because of the concern for impending airway obstruction, he was transferred to the [**Hospital1 18**] for thoracic surgical consultation and further surgical treatment. Past Medical History: Coronary artery disease, CABG status post stent, atrial fibrillation, dyslipidemia, BPH, negative colonoscopy more than 10 years ago per patient. History of upper GI bleeding in [**2130-1-2**] secondary to esophageal ulceration/[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear Social History: No tobacco, 1 glass of wine per day. Family History: Positive for coronary artery disease in his father Physical Exam: Temperature 96.2, blood pressure 153/72, pulse 64, respiratory rate 7 (on ventilator, AC 1.00, 500x12 PEEP 5.0) Neuro: sedated HEENT: anicteric sclera. Cardiovascular regular rate and rhythm. Lungs clear bilaterally anteriorly, tracheostomy Abdomen soft, no hepatosplenomegaly, normal active bowel sounds, unable to asses tenderness due to sedation Extremities, no clubbing, cyanosis or edema. Pertinent Results: [**2130-8-24**] 10:45PM TYPE-ART RATES-/6 TIDAL VOL-540 O2-60 PO2-124* PCO2-52* PH-7.31* TOTAL CO2-27 BASE XS-0 INTUBATED-INTUBATED [**2130-8-24**] 10:45PM GLUCOSE-185* LACTATE-1.9 NA+-129* K+-4.0 CL--100 [**2130-8-24**] 10:45PM HGB-10.0* calcHCT-30 [**2130-8-24**] 10:45PM freeCa-1.05* [**2130-8-24**] 07:05PM GLUCOSE-137* UREA N-30* CREAT-1.5* SODIUM-132* POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-24 ANION GAP-14 [**2130-8-24**] 07:05PM ALT(SGPT)-11 AST(SGOT)-15 LD(LDH)-160 ALK PHOS-50 AMYLASE-33 TOT BILI-1.4 [**2130-8-24**] 07:05PM LIPASE-12 [**2130-8-24**] 07:05PM CALCIUM-7.9* PHOSPHATE-4.2 MAGNESIUM-2.2 [**2130-8-24**] 07:05PM WBC-9.4 RBC-3.18* HGB-11.6* HCT-33.0* MCV-104* MCH-36.5* MCHC-35.2* RDW-15.0 [**2130-8-24**] 07:05PM NEUTS-92.4* BANDS-0 LYMPHS-5.9* MONOS-1.6* EOS-0.1 BASOS-0.1 [**2130-8-24**] 07:05PM PLT COUNT-126* [**2130-8-24**] 07:05PM PT-19.3* PTT-44.5* INR(PT)-1.8* [**2130-8-24**] 07:05PM FIBRINOGE-489* [**8-24**] Pathology: Ileum and cecum: Ischemic bowel with Meckel's diverticulum. Resection margins viable [**8-25**] CTA Chest: FINDINGS: There is mild asymmetry with mild thickening of the right true vocal cord. Soft tissue hypodense material anterior to the vallecula and posterior to the hyoid displaces the airway towards the left side. This could represent pooling of secretion and/or edema. The cricoid, thyroid and hyoid cartilage are intact. Tracheostomy tube is in place. There is pooling of secretion superior to the tracheostomy cuff. There are increasing number of prevascular and mediastinal lymph nodes in all the stations. Individually none of them measure more than 1 cm. The aorta is normal in caliber. Cardiac size is normal. Dense coronary calcifications are in the LAD, left circumflex arteries. Mild calcification is in the aortic valve. Transvenous pacemaker leads terminate in standard position in the right atrium and right ventricle. There is a trace of pericardial fluid. There are bilateral layering small pleural effusions greater in the left side. Relaxation atelectases are in the left lower lobe. Extensive pneumonic consolidation is in the right lower lobe. A smaller peribronchial consolidation is also present in the right middle lobe. OG tube tip is in the stomach. There is a small quantity of ascites. Imaged portions of the liver, spleen, adrenal glands and right kidney are unremarkable. In the upper pole of the left kidney an exophytic hypodense lesion is too small to be characterized. A hypodense nodule in the left lobe of the thyroid measures 17 mm. There are compression fractures in lower vertebral bodies. IMPRESSION: Multifocal pneumonia. Mediastinal lymphadenopathy likely reactive. Coronary calcifications. Asymmetry with thickening of the right true vocal cord likely due to edema, but direct inspection may be helpful if warranted clinically. Edema and/or pooling secretions anterior to the vallecula displacing the airway towards the left side as described. Bilateral pleural effusions. [**8-25**] Abd Duplex U/S: FINDINGS: No comparison is available. The study is limited secondary to overlying bowel gas, but the origin of the SMA is identified and Doppler color flow demonstrates patency and normal waveform morphology with brisk systolic upstroke and normal diastolic flow. The velocity could not be obtained secondary to the inability to adequately angle-adjust. The [**Female First Name (un) 899**] could not be identified. The celiac artery was not evaluated. IMPRESSION: Patent proximal superior mesenteric artery. [**8-29**] ECHO: Findings: LEFT ATRIUM: Mild LA enlargement. No LA mass/thrombus (best excluded by TEE). RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire is seen in the RA and extending into the RV. The patient is mechanically ventilated. Cannot assess RA pressure. LEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global systolic function (LVEF >55%). No resting LVOT gradient. RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function. AORTA: Normal aortic diameter at the sinus level. Focal calcifications in aortic root. Normal ascending aorta diameter. AORTIC VALVE: Moderately thickened aortic valve leaflets. Minimally increased gradient c/w minimal AS. Mild (1+) AR. MITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild mitral annular calcification. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [[**1-3**]+] TR. Moderate PA systolic hypertension. PERICARDIUM: No pericardial effusion. Conclusions: The left atrium is mildly dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) The right ventricular cavity is mildly dilated with normal free wall motion. The aortic valve leaflets are moderately thickened. There is minimal aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Minimal aortic valve stenosis. Mild aortic regurgitation. Mild mitral regurgitation. Moderate pulmonary artery systolic hypertension. Right ventricular cavity enlargement with preserved systolic function. This constellation of findings is suggestive of an acute pulmonary process (e.g., pulmonary embolism, pneumonia, bronchospasm). [**8-29**] CTA Torso: CONCLUSION: 1. Interval increase in the bibasilar effusions and pulmonary atelectasis along with new confluent ground glass opacities in both lungs is in keeping with the known recent pulmonary hemorrhage. 2. Intrathoracic mediastinal lymphadenopathy is unchanged since the prior examination. No abdominal pelvic lymphadenopathy. 3. Atherosclerosis is present in the abdominal aorta, its branches and the coronary arteries, short segment dissection in the abdominal aorta above its bifurcation as described above. 4. Extensive stranding in the subcutaneous tissues of the chest, abdomen and pelvis most likely represents a generalized anasarca, there is presacral soft tissue thickening of unknown significance. 5. The tracheostomy tube, dual-lumen pacemaker, nasogastric tube, percutaneous gastrostomy and the postoperative pelvic drain are seen in satisfactory position. [**8-31**] Liver/GB U/S: FINDINGS: Bedside right upper quadrant ultrasound was compared to abdominal CT of [**2130-8-29**]. The exam is limited secondary to anasarca, but the gallbladder appears normal, aside from moderate distention without shadowing gallstones, pericholecystic fluid, or gallbladder wall edema. There is a right pleural effusion. There is no intra- or extra-hepatic biliary ductal dilation and no focal lesions are identified. The portal vein is patent with hepatopetal flow. The spleen measures 7.9 cm. IMPRESSION: Limited exam, moderately distended gallbladder without evidence for acute cholecystitis. [**9-5**] Liver/GB U/S: FINDINGS: The liver shows no focal or textural abnormalities. There is no biliary dilatation and the common duct measures 0.4 cm. The portal vein is patent with hepatopetal flow. The gallbladder is filled with sludge but there is no evidence of cholecystitis. No ascites is identified. The spleen measures 8.5 cm. There is a right pleural effusion identified. IMPRESSION: 1. No biliary dilatation. 2. Sludge-filled gallbladder without evidence of cholecystitis. 3. Right pleural effusion. [**9-7**] Bleeding Study: INTERPRETATION: Following intravenous injection of autologous red blood cells labeled with Tc-[**Age over 90 **]m, blood flow and dynamic images of the abdomen for 125 minutes were obtained. A left lateral view of the pelvis was also obtained. Blood flow images show normal arterial flow. Dynamic blood pool images show persistently increased tracer uptake in the stomach which might be related to inflammatory changes, or bleeding. At 80 minutes faint uptake is seen in the mid-abdominal area with rapid retrogade and some antegrade motion. This represents a bleed either in the small bowl or sigmoid colon. Exact characterization is difficult as the bleeding rate is small and subsides after 10 minutes. Patient was imaged again at 6 hours post-tracer injection and no bleeding was seen. IMPRESSION: 1. Persistent tracer uptake in the stomach suggestive of inflammation. 2. Positive bleeding identified either in the small bowel or sigmoid colon at 80 minutes post-tracer injection lasting for 10 minutes. [**9-15**] CT HEAD FINDINGS: This study is limited due to patient motion causing artifact. Given these restrictions, there is no identifiable acute hemorrhage, mass, or mass effect. The ventricles and sulci are prominent, consistent with age- appropriate involutional changes. There is mild mucosal thickening of the right sphenoid sinus air cell. The remainder of the visualized paranasal sinuses are unremarkable. There is opacification of the left middle ear cavity by soft tissue density material, which is new since previous examination, likely an inflamamtory process. There are no acute fractures identified. IMPRESSION: 1. Interval development of opacification of left middle ear cavity, likely inflammatory in origin. 2. No evidence of acute intracranial hemorrhage or mass effect. MICRO [**8-24**] Wound Swab: FLUID CULTURE (Final [**2130-8-29**]): A swab is not the optimal specimen collection to evaluate body fluids. ESCHERICHIA COLI. SPARSE GROWTH. PRESUMPTIVE STREPTOCOCCUS BOVIS. RARE GROWTH. _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- =>128 R PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [**8-25**] Blood: No Growth [**8-28**] Broncho/alveolar lavage: orophyaryngeal flora [**8-30**] Sputum: yeast [**8-30**] Urine: no growth [**9-2**] C.Diff: neg [**9-4**] Cath tip: no growth [**9-5**] Sputum: yeast Brief Hospital Course: The patient was transferred from [**Hospital1 18**]-[**Location (un) 620**] s/p tracheostomy for a difficult intubation for an exploratory lapartomy. Thoracic surgery was immediately consulted to assess for oropharyngeal bleeding. After bronchoscopy, a large clot was evacuated and the patient was brought to the OR for an exploratory laparotomy. On exploration, there were numerous blue nodules (questionable ischemic nodules) on the distal small bowel. Approximately 50 cm small bowel was resected and a G-tube was placed. The patient remained on ampicillin/cipro/flagyl postoperative. The patient did not require any pressors post-operative. On POD1, the patient had an u/s of the abdomen consistent with a patent proximal SMA. ENT was consulted for the oropharyngeal bleeding. The patent's orophayrnx was packed on POD0 and was rexamined on POD1. On ENT exam, no oropharyngeal mass was found and there was no active bleeding. ENT recommended to follow up as an outpatient. On POD1, the patient was brought back to the OR for a re-exploration and abdominal wash-out. On exam, there was no ischemic bowel present. Vascular surgery was also consulted due to a possible embolic cause of the bowel ischemia. Pathology was consistent with ischemic bowel. Neuro Post-operatively, the patient was on a propofol drip for sedation. The propofol was weaned and the patient was given dilaudid/fentanyl prn. The patient was also given ativan prn for anxiety. On POD5/4, the patient was still non-arousable s/p discontinuation of sedation. A Head CT showed no acute intracranial hemorrhage or mass effect and no CT evidence of acute ischemia. On [**9-15**], the patient had a decreased mental status. A CT HEAD showed no acute intracranial events. CV The patient has a ventricular pacemaker with a rate of 60 bpm. The patient was given lopressor prn for hypertension, but had stable blood pressures. The patient did not require pressors during this admission. On POD5/4, EP increased the HR to 80 to increase cardiac output (the patient tolerated this well). A CTA was performed on POD5/4, consistent with a patent SMA. As a result, there was no indication for SMA stenting. A transthoracic ECHO on POD [**5-5**] showed moderate pulmonary artery systolic hypertension and right ventricular cavity enlargement with preserved systolic function. No vegetations were found to be a cause of the ischemic bowel. RESP The patient was admitted with a tracheostomy requiring vent-assistance. The patient was weaned off of vent-assistance and was on a trach collar by POD3. On POD3, the patient had increased pulmonary secretions and a bronchoscopy was performed by the critical care team. The bronchoscopy was consistent with diffuse secretions. The patient was put back on pressure support and been on the ventilator for the rest of this admission. The patient was placed on a lasix drip for a short course with an improvement in respiratory status. GI The patient remained NPO until return of bowel function. TPN was started with a goal of 30kcal/kg. The patient began to have bowel movements and trophic TF were started POD7/6. On POD11/10, the patient began to have an increased Tbili and Dbili. A RUQ u/s showed a mildly distended GB, but no cholecystitis. Hepatology was consulted and recommended stopping lipids in the TPN. After stopping the lipids in the TP, there was still an isolated elevated bilirubin (normal AST/ALT). On POD12/11, the patient began to have melanotic stools and to have a decreased hematocrit. The patient was transfused for a Hct>30. GI was consulted. Lower endoscopy was deferred due to the new bowel anastomosis. Since the G-tube was not bloody, an upper GI was deemed unnecessary. On POD13/12, the patient received 4u PRBCs, 2uFFP. A GI bleeding study showed uptake in either in the small bowel or sigmoid colon. By POD15/14, the patient's hct was stable and the melanotic stools decreased. TF were held while the patient had lower GI bleeding. Trophic TF were restarted on [**9-12**] and the rate was increased. RENAL The patient had adequate urine output during this admission but continued to be edematous. The patient had a good response to lasix, but had an elevated Cr=1.4. The patient was started on a lasix drip on POD [**10-10**] with a good response, but was stopped due to elevated creatine. The patient received a HCO3 drip before and after CTA for renal protection. ID The patient was placed on amp/cipro/flagyl post-op. On POD5/4 the amp and cipro were d/c'ed and Zosyn and Vanco were added (wound swab culture was postive for E-coli). The patient had variable WBC spikes and low-grade fevers with negative cultures. Antibiotics were d/c'ed on POD14/13. HEME The patient was placed on a heparin drip postoperative for prevention of bowel ischemia. The PTT goal was 60. The heparin drip was d/c'ed after the LGIB began. The patient's hct goal was >30 due to his CAD. ENDO The patient was originally placed on an insulin drip to control his blood glucose. The patient then tolerated a sliding scale. DISPO A family meeting was held on [**9-8**]. As per discussion with the attending, Dr. [**Last Name (STitle) 6633**], the health care proxy, and the patient, no further aggressive measures are to be done for the patient. In the event that he is uncomfortable, he will be CMO. On [**9-15**], the patient had a decreased mental status. A CT Head showed no intracranial process. The patient's respiratory status declined and was then placed on AC. After a family meeting on [**9-16**], the patient was made CMO and expired shortly thereafter. Medications on Admission: coumadin 2.5' plavix 75' Flomax 0.4' Betaxolol 5' Neurontin 100' Lipitor 10' Discharge Medications: patient expired Discharge Disposition: Expired Discharge Diagnosis: patient expired Discharge Condition: patient expired Discharge Instructions: patient expired

[ "428.0", "600.00", "V45.82", "557.0", "998.2", "751.0", "786.3", "518.5", "041.4", "V44.0", "E870.8", "427.31", "782.4", "567.21", "578.9" ]

icd9cm

[ [ [] ] ]

[ "45.93", "96.6", "43.19", "99.15", "33.24", "45.72", "54.12" ]

icd9pcs

[ [ [] ] ]

18645, 18654

12839, 18478

269, 410

18713, 18730

2305, 12816

1823, 1875

18605, 18622

18675, 18692

18504, 18582

18754, 18772

1890, 2286

175, 231

438, 1429

1451, 1752

1768, 1807

4,923

134,937

21667

Discharge summary

report

Admission Date: [**2192-8-14**] Discharge Date: [**2192-9-4**] Date of Birth: [**2122-11-17**] Sex: M Service: MED Allergies: Aspirin Attending:[**First Name3 (LF) 2181**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Endogastric duodenography s/p placement of 3 bands thoracotomy, pleurodesis x2 and chest tube placement History of Present Illness: 69 y.o Spanish speaking male with hx of Etoh cirrhosis transfered from OSH with initial compaint of SOB and found to be bradycardic with HR in 40's. Found to have first degree heart block and required placement of demand pacemaker (DDDR 5370) placed on [**2192-7-2**]. Chest CT showed R sided pleural effusion with compression of R lung which was recurrent according to medical records. Pt has been admitted mult times in the past for thorocentesis. Chest tube was placed and 3 liters removed and continued to drain throughout admission at OSH. Cytology showed no malignant cells, no bacteria seen. D/c'd at OSH due to pain and constant drainage of fluid [**1-9**] liver failure. CXR after chest tube removal showed reaccumulation of smaller amounts of fluid. Also found to have R middle lobe infiltrate and started on Levoquin for ? hospital acquired PNA. Pt transfered to [**Hospital1 18**] for evaluation for TIPS procedure. Pt denies fever/chills, denies N/V/D. No change in color of BM's, denies melena. + cough, report hx of hemoptysis 2-3 times per day. No change in appetite but + loss of 30 lbs over past 2 months [**1-9**] fluid loss. Pt does complain of R sided chect pain with inspiration which has not changed since chect tube placed. Pain radiates across abdomen. Unchanged for over one week. Treated with percocet at OSH. Past Medical History: Liver failure- hx of encephalopathy, no bx seen in records DM type 2- non insulin dependent CHF Elevated PSA Pancreatitis Postive PPD Alcoholic cardiomyopathy Social History: No Tob, Hx of alcoholism, has been sober for 4 years No IVDA Lives at home with wife, son and [**Name2 (NI) 41859**] in-law. Family History: Hx of Diabetes HTN in mother Father with Asthma Physical Exam: Vitals: T: 98.3, HR: 71, O2sat: 94% RA, BP: 120/70, RR:20 Gen: pleasant, lying comfortably in bed with HOB at 20 degrees. NAD. HEENT: Pupils equal, mildly injected sclerae, anicteric, mmm, poor dentition, upper dentures, OP clear, carotids 2+ no bruits, no LAD. CV: RRR with occ extra beat, II/VI SEM at LSB. Resp: mild tachypnea, abd breathing, no use of accessory muscles, no audible wheezing, speaking in full sentences, ambulating well. R side with bronchial breath sounds at apex and decreased BS at bases. No rales or wheezing. L side clear. ABD: mild distention, soft, +BS, mild tenderness at LUQ. Unable to appreciate liver edge. No palpable spleen. Ext: warm, well perfused. 2+ radial pulses, 2+ pedal pulses. No pedal edema. Skin: no jaundice, well healed scar over R lat hemithorax. Neuro: No focal deficits, alert and oriented x3. Pertinent Results: [**2192-8-14**] 08:00PM GLUCOSE-95 UREA N-27* CREAT-1.4* SODIUM-134 POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-24 ANION GAP-14 [**2192-8-14**] 08:00PM LIPASE-37 [**2192-8-14**] 08:00PM ALBUMIN-3.5 CALCIUM-9.9 PHOSPHATE-3.7 MAGNESIUM-1.6 [**2192-8-14**] 08:00PM WBC-6.1 RBC-4.20* HGB-13.1* HCT-38.7* MCV-92 MCH-31.3 MCHC-33.9 RDW-14.3 [**2192-8-14**] 08:00PM PLT COUNT-175 [**2192-8-14**] 08:00PM PT-15.3* PTT-32.7 INR(PT)-1.5 Brief Hospital Course: Brief summary: 69 y.o male with hx of Etoh cirrhosis, CHF, and DM presents from OSH with 6 weeks hx of recurrent r sided pleural effusion and for possible TIPS placement. However, thoracentesis on [**8-15**] with pleural fluid consistent with exudates. Thorascopy on [**8-21**] for further evaluation but work up so far negative for malignancy or infection. Had pleuradesis on [**8-24**]. slightly hypoxic on [**8-25**] and cxr with increased right pleural effusion, and had an episode of coffee ground emesis ([**8-26**]) associated with hypotension and dizziness- sent to MICU. EGD showed varices and were banded. Repeated pleurosdesis on [**8-29**] and stable post procedure with significant improvement in O2 requirement and no evidence of shortness of breath. MICU COURSE: Pt transferred to MICU s/p hypotensive episode. Pt stablized BPs before endoscope. GI scope demonstrated stage 3 esophageal varices in the lower third of the esophagus, three bands were placed. Scope also revealed several small nonbleeding ulcers in stomach, as well as portal hypertensive gastropathy. Pt remained stable during and after procedure. On unit day #3, pt underwent second pleurodesis due to continued large amount of drainage from right sided chest tube. Procedure was tolerated well except for a fever that night likely associated with the inflammation of the pleurodesis itself. Pt transferred back to floor for continued management. Post MICU course, BY PROBLEM: 1) R sided pleural effusion: Cytology from OSH shows no malignant cells, few poly and no bacteria. Pt has hx of +PPD, AFB and adenosine deaminase on cytology were negative so the effusion was ruled out for tuberculous origin. Pt began to reaccumulate fluid with removal of chest tube. He had stable loculated effusion on chest xray. As he was not short of breath, and was ambulating and saturating well, he did not require further pleurodesis and was managed medically. He did continue have occasional low grade temperatures but these were felt to be related to the inflammation of the pleurodesis. 2) Etoh Cirrhosis: Pt does demonstrate significant liver failure with elevated INR and alb of 2.9. U/S of liver [**8-17**] showed normal portal flow. He was not felt to be a candidate for TIPS procedure. His diuretics were restarted after the resolution of his hypotension. 3) CV: Hx of recent pacer placement. The patient had an echo showing EF 50% and ?diastolic dysfunction. He was continued on his cardiac medication regimen and there were no cardiac related active issues. 5) Positive PPD: discussed with PCP. [**Name10 (NameIs) **] symptoms, fluid at OSH neg for AFB. [**Doctor First Name **] neg on [**8-24**]. 6) Diabetes-He was followed by [**Last Name (un) **] for the management of diabetes and did well on a regimen of repaglinide. Medications on Admission: Protonix 40 QD Corgard 10 QD Lasix 20 PO QD Glucatrol 2.5 mg PO QD Cardura 2 Qhs Aldactone 50 QD Levaquin 500 PO QD Combivent, flovent Percocet PRN Discharge Medications: 1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-9**] Puffs Inhalation Q6H (every 6 hours). Disp:*1 1* Refills:*2* 2. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 1* Refills:*2* Discharge Disposition: Home With Service Facility: Home Health Discharge Diagnosis: upper gastrointestinal bleed grade II esophageal varices in lower third of esophagus alcoholic cirrhosis alcoholic cardiomyopathy with EF > 55% first degree AV block s/p pacemaker placement recurrent right pleural effusions, s/p pleurodesis and chest tube placement Discharge Condition: good Discharge Instructions: Favor de continuar sus medicamentos con algunos cambios. Para el diabetes tiene que tomar un nuevo medicamento que se llama Prandin. If you have shortness of breath, fever greater than 100.4, shaking chills, palpitations, vomit blood or have black stool, call your doctor immediately or go to the emergency room. Followup Instructions: 1) Please make an appointment to see your primary care physician 1 to 2 weeks to follow up. Call ([**2191**] to make appointment. 2) You need to return to the hepatology clinic in 1 week for a repeat endoscopy. Call [**Telephone/Fax (1) 56990**] to make an appointment. 3) You need to return to see your pulmonary specialist in 1 week for follow up. Call [**Telephone/Fax (1) 3020**] to make an appointment.

[ "286.7", "511.8", "428.0", "584.9", "571.2", "276.2", "518.0", "456.20", "425.5" ]

icd9cm

[ [ [] ] ]

[ "34.92", "99.04", "34.24", "34.04", "34.91", "42.33", "34.21", "99.07", "38.93" ]

icd9pcs

[ [ [] ] ]

6788, 6830

3482, 6296

283, 389

7140, 7146

3026, 3459

7508, 7921

2099, 2148

6494, 6765

6851, 7119

6322, 6471

7170, 7485

2163, 3007

224, 245

417, 1757

1779, 1940

1956, 2083

79,392

153,167

41242

Discharge summary

report

Admission Date: [**2169-5-4**] Discharge Date: [**2169-5-24**] Date of Birth: [**2102-4-3**] Sex: M Service: CARDIOTHORACIC Allergies: Protamine Attending:[**First Name3 (LF) 922**] Chief Complaint: Unstable angina/periop Myocardial Infarction Major Surgical or Invasive Procedure: [**2169-5-11**] Coronary artery bypass grafting x5, left internal mammary artery to left anterior descending coronary artery; reverse saphenous vein single graft from the aorta to the first diagonal coronary artery; reverse saphenous vein graft from the aorta to the first obtuse marginal coronary artery; reverse saphenous vein single graft from the aorta to the third obtuse marginal coronary artery; as well as reverse saphenous vein graft to the distal right coronary artery History of Present Illness: 67 year old male with a complicated medical history including coronary artery disease, peripheral vascular disease, obstructive sleep apnea, and diabetes mellitus who presented to an OSH after a fall and concern for syncope. Pt was found to have critical carotid stenosis on the right and underwent CEA without complication. On pod#2 he had chest pain at rest that lasted approximately 45 minutes. Troponins were mildly elevated. BNP>1000. A repeat echo revealed slight changes in wall motion and ejection fraction. Cardiac cath was performed and revealed multivessel coronary artery disease. Mr.[**Known lastname **] was transferred to the [**Hospital1 18**] for further cardiac evaluation and possible revascularization. Past Medical History: Coronary artery disease s/p Coronary artery bypass graft x 5 post-op atrial fibrillation Past medical history: s/p Myocardial infarction age 42, [**2165**], [**2168**] and [**4-14**] Ischemic cardiomyopathy COPD-chronic bronchitis & asthma Hypothyroid Hyperlipidemia Lower Back Pain secondary ruptured discs Obstructive sleep apnea uses CPAP Peripheral vascular disease w/severe claudication Systolic and diastolic heart failure Pleural Effusion requiring chest tube [**9-10**] Diabetes Mellitus with Diabetic coma x2 s/p right carotid endarterectomy [**2169-4-28**] s/p amputaion of R 4th and 5th toes-due to infection s/p tonsillectomy Social History: Lives with:wife who has alzheimers/seizure disorder-he is primary caregiver, gets around w/scooter Occupation:retired city worker Tobacco:2ppd x many years-smoked until admission, 98pky ETOH:denies ***patient is unable to read*** ***Extremely Hard of Hearing*** Family History: Non-contributory Physical Exam: Pulse:72 Resp:18 O2 sat: 95 on RA B/P Right: 132/53 Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs scattered wheezes Heart: RRR [x] Irregular [] Murmur 2/6 systolic murmur Abdomen: Soft [x] obese, non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema none Varicosities: None [x], chronic venous changes on bliateral lower extremities Neuro: Grossly intact [x] Pulses: Femoral Right:1+-no hematoma Left:1+ DP Right:dopp Left:dopp PT [**Name (NI) 167**]:dopp Left:dopp Radial Right:[**2-5**]+ Left:[**2-5**]+ Carotid Bruit Right: none Left:none Pertinent Results: [**2169-5-11**] Echo: PRE-CPB: The left atrium is moderately dilated. Moderate spontaneous echo contrast is present in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is mildly depressed (LVEF=40-45 %). The right ventricular cavity is mildly dilated with normal free wall contractility. There are complex (mobile) atheroma in the distal aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. No thoracic aortic dissection is seen. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild to moderate ([**2-5**]+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. POST-CPB: The right heart chamber has decreased in size to a normal range. The LV systolic function remains mildly depressed, estimated EF = 45%. The mobile atheroma in the distal arch remains unchanged. There is no evidence of aortic dissection. [**5-11**] Vein mapping: Patent left and right greater saphenous veins from the ankle to the saphenofemoral junctions with the measurements as indicated above. [**2169-5-22**] 05:19AM BLOOD WBC-7.1 RBC-3.23* Hgb-10.3* Hct-30.3* MCV-94 MCH-31.9 MCHC-33.9 RDW-15.8* Plt Ct-349 [**2169-5-21**] 05:08AM BLOOD WBC-7.7 RBC-3.36* Hgb-10.7* Hct-31.4* MCV-94 MCH-31.9 MCHC-34.1 RDW-15.9* Plt Ct-330 [**2169-5-23**] 05:25AM BLOOD PT-20.8* INR(PT)-1.9* [**2169-5-22**] 05:19AM BLOOD PT-25.0* PTT-37.7* INR(PT)-2.4* [**2169-5-21**] 05:08AM BLOOD PT-26.5* PTT-37.5* INR(PT)-2.5* [**2169-5-20**] 03:06AM BLOOD PT-27.6* PTT-36.4* INR(PT)-2.7* [**2169-5-19**] 12:23PM BLOOD PT-34.6* INR(PT)-3.5* [**2169-5-19**] 03:35AM BLOOD PT-51.6* INR(PT)-5.5* [**2169-5-19**] 02:06AM BLOOD PT-49.7* PTT-39.7* INR(PT)-5.3* [**2169-5-18**] 01:57AM BLOOD PT-20.5* PTT-34.3 INR(PT)-1.9* [**2169-5-17**] 03:12AM BLOOD PT-14.4* PTT-31.2 INR(PT)-1.2* [**2169-5-16**] 01:00PM BLOOD PT-13.6* PTT-28.2 INR(PT)-1.2* [**2169-5-14**] 12:50AM BLOOD PT-15.4* PTT-37.3* INR(PT)-1.3* [**2169-5-13**] 08:42PM BLOOD PT-14.9* PTT-37.9* INR(PT)-1.3* [**2169-5-12**] 02:10AM BLOOD PT-16.9* PTT-39.9* INR(PT)-1.5* [**2169-5-11**] 10:19PM BLOOD PT-17.3* PTT-49.9* INR(PT)-1.5* [**2169-5-11**] 06:20PM BLOOD PT-18.9* PTT-51.1* INR(PT)-1.7* [**2169-5-11**] 04:44PM BLOOD PT-18.6* PTT-34.6 INR(PT)-1.7* [**2169-5-10**] 04:40AM BLOOD PT-14.6* PTT-31.0 INR(PT)-1.3* [**2169-5-4**] 11:35PM BLOOD PT-14.2* PTT-27.6 INR(PT)-1.2* [**2169-5-22**] 05:19AM BLOOD Glucose-91 UreaN-28* Creat-0.9 Na-134 K-4.5 Cl-98 HCO3-31 AnGap-10 [**2169-5-21**] 05:08AM BLOOD Glucose-80 UreaN-27* Creat-0.9 Na-135 K-4.6 Cl-100 HCO3-31 AnGap-9 [**2169-5-24**] 04:45AM BLOOD WBC-8.6 RBC-3.07* Hgb-9.8* Hct-29.0* MCV-95 MCH-31.8 MCHC-33.6 RDW-15.6* Plt Ct-368 [**2169-5-24**] 04:45AM BLOOD Plt Ct-368 [**2169-5-24**] 04:45AM BLOOD Glucose-134* UreaN-32* Creat-0.9 Na-134 K-4.5 Cl-97 HCO3-32 AnGap-10 [**2169-5-24**] 04:45AM BLOOD PT-19.3* INR(PT)-1.8* Brief Hospital Course: As mentioned in the HPI, Mr. [**Known lastname **] was transferred to [**Hospital1 18**] for surgical management. Upon admission he received medical management and underwent surgical work-up. He also awaited Plavix wash-out prior to surgery. Aortic Insufficiency was noted on echo and dental consult was obtained in the event that the valve would be replaced. The patient had dental extractions on [**2169-5-8**]. On [**5-11**] he was brought to the operating room where he underwent a coronary artery bypass graft x 5. Please see operative report for surgical details. He did develop profound hypotension following Protamine, and this will be listed as an allergy for the future. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. The patient remained intubated, on vasopressor support for several days in the CVICU. He did develop post-op atrial fibrillation and was started on amiodarone and coumadin. He was maintained on an insulin drip in the immediate post-op period for his diabetes. Lasix drip was initiated for diuresis. He converted to sinus rhythm prior to discharge and was maintained on PO amio and anti-coagulated on coumadin. INR became supra-therapeutic, and coumadin was held. Chest tubes and pacing wires were discontinued without complication. Vasopressors were finally weaned off and Beta blocker was initiated. The patient was transferred to the telemetry floor for further recovery. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 13 the patient was ambulating freely, the wound was healing and pain was controlled with Tylenol. The patient was discharged to [**Location (un) 89825**]Nursing and Rehab in [**Location (un) 5450**], NH in good condition with appropriate follow up instructions. Medications on Admission: Medications at home:Albuterol Sulfate MDI-2 puffs every 4-6hours prn,Atenolol 25 mg daily, lipitor 80 mg daily, Citalopram 20 mg daily, Glyburide 10 mg daily with breakfast, Levothyroxine 300 micrograms daily, Lisinopril 10 mg daily, Metformin 1000 mg twice daily, NTG SL 0.4 mg prn, Potassium Chloride 20 mEQ daily, plavix 75 mg daily, lasix 40mg daily, Meds on transfer: aspirin EC 81mg daily atenolol 25mg daily lipitor 80mg daily budesonide inhaler 180 mcg 2 puffs twice daily celexa 20mg daily colace 100mg twice daily lasix 40mg twice daily insulin sliding scale duo-neb 4 times daily imdur 30mg daily synthroid 300mcg daily lisinopril 10mg daily Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain or fever. 5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 6. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezes. 9. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 10. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 11. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 12. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: 400mg daily x 1 week then 200mg daily until further instructed. 14. glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 16. warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): MD to dose daily for goal INR 2-2.5, dx: afib. Take 2.5 mg on [**5-24**] for INR 1.8. 17. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): per attached insulin sliding scale. 18. furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: 80mg [**Hospital1 **] x 7 days, then decrease to 40mg [**Hospital1 **] until re-assessed by clinician. 19. metolazone 5 mg Tablet Sig: One (1) Tablet PO once a day for 7 days: Give 30 minutes prior to Lasix dose. 20. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 7 days: Check K three times/week and hold for K>4.5. Discharge Disposition: Extended Care Facility: tba Discharge Diagnosis: Coronary artery disease s/p Coronary artery bypass graft x 5 Past medical history: s/p Myocardial infarction age 42, [**2165**], [**2168**] and [**4-14**] Ischemic cardiomyopathy COPD-chronic bronchitis & asthma Hypothyroid Hyperlipidemia Lower Back Pain secondary ruptured discs Obstructive sleep apnea uses CPAP Peripheral vascular disease w/severe claudication Systolic and diastolic heart failure Pleural Effusion requiring chest tube [**9-10**] Diabetes Mellitus with Diabetic coma x2 s/p right carotid endarterectomy [**2169-4-28**] s/p amputaion of R 4th and 5th toes-due to infection s/p tonsillectomy Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema- [**2-5**]+ bilaterally Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] 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: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2169-6-13**] 2:15 Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) **] in [**5-9**] weeks Cardiologist: Dr. [**Last Name (STitle) 39975**] on [**6-23**] at 10:40 AM **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for atrial fibrillation Goal INR 2-2.5 First draw [**2169-5-25**] Then please do INR and Potassium checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by MD Please arrange for coumadin/INR follow up prior to d/c from rehab Completed by:[**2169-5-24**]

[ "244.9", "410.41", "458.29", "443.9", "285.9", "523.42", "428.0", "428.43", "V70.7", "276.1", "427.32", "E934.5", "272.4", "327.23", "305.1", "424.1", "250.00", "493.20", "414.01", "278.00" ]

icd9cm

[ [ [] ] ]

[ "96.6", "39.61", "36.14", "23.09", "36.15" ]

icd9pcs

[ [ [] ] ]

11133, 11163

6375, 8235

318, 798

11817, 12062

3255, 6352

12985, 13820

2509, 2527

8940, 11110

11184, 11246

8261, 8261

12086, 12962

8281, 8618

2542, 3236

234, 280

826, 1551

11268, 11796

2230, 2493

8636, 8917

7,253

182,255

2930

Discharge summary

report

Admission Date: [**2172-7-30**] Discharge Date: [**2172-8-4**] Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 800**] Chief Complaint: Fatigue, Digoxin Toxicity Major Surgical or Invasive Procedure: None History of Present Illness: In brief, the patient is a [**Age over 90 **]yo female with a hx of Afib on digoxin who was referred by VNA for bradycardia. HR was 30s. Of note, the pt maintained her blood pressure despite profound bradycardia. Mrs. [**Known lastname **] does say that she was feeling tired prior to arrival but denied dizziness, syncope, and chest pain. She denies recent illness, diarrhea, dysuria, shortness of breath and cough. She says that she has been in her normal state of health recently; she has 24 hour health aides who helps her with all of her meals and gives her her medications. Per one of the NPs who cares for her, she has been eating less recently but did not seem otherwise ill. There was a concern for at UTI over a week ago because blood was found in her diaper; it was later determined that blood was likely from a lesion but patient completed course of Cipro. . Labs drawn in the ED revealed hyperkalemia (potassium 8.2) and acute renal failure (creatinine on admission 3.1 from 1.5 most recent baseline in [**Month (only) 547**].) In the ED, she got 2 amp D50, 30 g kayexalate, 10u reg insulin, 2 albuterol neb, 1 mg atropine, 2 vials digibind, 1 amp bicarb. Renal and toxicology both provided recommendations. Upon transfer to the floor, vital signs 96.4, HR 36, BP 122/54, RR 19 94% on 2L NC. Transient decrease in BP to 90/70 that resolved without intervention. . Patient was initially admitted to the ED, where her heart was initially in a junctional rhythm in the 20s and 30s but converted spontaneously to NSR in the 80s, where she has since remained. There, her potassium decreased to 4.8 from 8.2, her creatinine improved from 3.1 to 2.7 after 1 L IVF and her dig level down to 1.2. Patient was given 5 mg Vitamin K twice to correct a elevated INR. . Upon transfer to our team, Mrs. [**Known lastname **] reports feeling tired, but denies any pain. Past Medical History: 1. Atrial fibrillation 2. Diastolic heart failure 3. Hypertension 4. COPD 5. Seasonal allergies 6. Urinary incontinence Social History: Patient lives at home in [**Location (un) **]. Has [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] care coordinator and NP who are very [**Name8 (MD) 14107**] NP[**MD Number(3) 14104**] to see patient once/week. Patient was married for 60 years; husband died in [**6-8**]. Can get around in wheelchair, but can only pivot when standing alone. Two sons- one lives in [**Name (NI) 12000**] and the other in NH. No smoking, EtOH, or other drug use. Family History: Mother with [**Name2 (NI) 14105**] heart disease contracted during WWI died from complications at age 68. Father with ??????[**Name2 (NI) **] heart?????? Physical Exam: Exam on admission to the floor, [**2172-7-31**] Gen: Lovely elderly-appearing female in NAD, appears to be struggling to stay awake during interview, but is not at all confused. [**Month/Day/Year 4459**]: Some clouding over sclera and cornea, balding CV: Irregular rhythm, Systolic murmurs over RUSB ([**3-7**]), LLSB ([**4-4**]), apex (2-3/6) Pulm: Poor air movement but clear to auscultation Abd: Distended, tympanic. +BS. No tenderness to palpation, no guarding, no rebound. GU: Foley in place Ext: cool extremities, 1+ pulses Skin: R and L dorsal hands with large ecchymoses, which pt states are new today; no rashes; scattered petechiae Neuro: AOx3, CN grossly intact, moving all extremities, coord grossly intact Pertinent Results: [**2172-7-30**] 02:40PM BLOOD Digoxin-3.7* [**2172-7-31**] 03:48AM BLOOD Digoxin-1.2 [**2172-7-31**] 08:30PM BLOOD Digoxin-2.1* [**2172-8-1**] 07:15AM BLOOD Digoxin-1.8 [**2172-7-30**] 02:40PM BLOOD Calcium-9.6 Phos-6.2*# Mg-2.7* [**2172-8-1**] 07:15AM BLOOD Calcium-8.3* Phos-4.8* Mg-2.3 [**2172-7-30**] 02:40PM BLOOD cTropnT-0.03* [**2172-7-30**] 02:40PM BLOOD ALT-528* AST-1096* CK(CPK)-35 AlkPhos-91 TotBili-1.9* [**2172-7-31**] 03:48AM BLOOD ALT-463* AST-715* CK(CPK)-26* AlkPhos-79 TotBili-1.2 [**2172-8-1**] 07:15AM BLOOD ALT-335* AST-331* LD(LDH)-252* AlkPhos-80 TotBili-1.5 [**2172-7-30**] 02:40PM BLOOD Glucose-113* UreaN-56* Creat-3.1*# Na-136 K-8.2* Cl-93* HCO3-32 AnGap-19 [**2172-7-30**] 07:35PM BLOOD Glucose-67* UreaN-56* Creat-3.0* Na-141 K-6.6* Cl-98 HCO3-30 AnGap-20 [**2172-7-30**] 11:15PM BLOOD Glucose-70 UreaN-55* Creat-3.0* Na-146* K-5.5* Cl-100 HCO3-37* AnGap-15 [**2172-7-31**] 03:48AM BLOOD Glucose-88 UreaN-53* Creat-2.7* Na-146* K-4.8 Cl-100 HCO3-37* AnGap-14 [**2172-7-31**] 08:30PM BLOOD Glucose-147* UreaN-47* Creat-2.3* Na-143 K-3.7 Cl-101 HCO3-37* AnGap-9 [**2172-8-1**] 07:15AM BLOOD Glucose-83 UreaN-41* Creat-2.1* Na-144 K-3.6 Cl-101 HCO3-35* AnGap-12 [**2172-7-30**] 02:40PM BLOOD PT-62.0* PTT-40.5* INR(PT)-7.1* [**2172-7-31**] 03:48AM BLOOD PT-64.7* PTT-45.1* INR(PT)-7.4* [**2172-7-31**] 08:30PM BLOOD PT-38.9* PTT-40.2* INR(PT)-4.1* [**2172-8-1**] 07:15AM BLOOD PT-22.4* PTT-37.6* INR(PT)-2.1* [**2172-7-30**] 02:40PM BLOOD WBC-9.9# RBC-4.80 Hgb-14.3 Hct-46.8 MCV-97 MCH-29.9 MCHC-30.7* RDW-15.8* Plt Ct-112* [**2172-7-31**] 03:48AM BLOOD WBC-7.8 RBC-4.21 Hgb-12.7 Hct-41.1 MCV-98 MCH-30.2 MCHC-31.0 RDW-16.1* Plt Ct-102* [**2172-8-1**] 07:15AM BLOOD WBC-9.1 RBC-4.64 Hgb-13.6 Hct-44.8 MCV-97 MCH-29.3 MCHC-30.3* RDW-16.0* Plt Ct-116* [**2172-8-3**] 05:55AM BLOOD WBC-6.5 RBC-4.11* Hgb-12.4 Hct-39.8 MCV-97 MCH-30.2 MCHC-31.1 RDW-15.9* Plt Ct-77* [**2172-8-3**] 05:55AM BLOOD PT-19.7* PTT-34.7 INR(PT)-1.8* [**2172-8-3**] 05:55AM BLOOD Glucose-95 UreaN-32* Creat-1.6* Na-144 K-3.3 Cl-99 HCO3-39* AnGap-9 [**2172-8-3**] 05:55AM BLOOD ALT-208* AST-117* AlkPhos-71 TotBili-1.1 [**2172-8-3**] 05:55AM BLOOD Calcium-8.2* Phos-3.5 Mg-1.9 [**2172-8-1**] 07:15AM BLOOD Digoxin-1.8 [**2172-8-4**] 06:20AM BLOOD WBC-8.1 RBC-4.21 Hgb-12.8 Hct-40.7 MCV-97 MCH-30.5 MCHC-31.5 RDW-15.6* Plt Ct-79* [**2172-8-4**] 06:20AM BLOOD Glucose-115* UreaN-31* Creat-1.5* Na-144 K-3.2* Cl-98 HCO3-41* AnGap-8 [**2172-8-4**] 06:20AM BLOOD ALT-158* AST-69* AlkPhos-71 [**2172-8-4**] 06:20AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.9 [**2172-8-3**] 12:50PM BLOOD Hapto-61 Brief Hospital Course: Pt is a [**Age over 90 **]yo female with a hx of Afib on digoxin, CHF who presented to ED with digoxin toxicity, profound hyperkalemia, and acute renal failure, who presented with complaints of fatigue but otherwise asymptomatic. . #) Digoxin Toxicity: Patient presented with Dig level 3.7. The etiology is thought to be due to poor po intake over last week causing renal failure, with possible UTI (asymptomatic.) Of note, patient was afebrile with normal white count. She was given 1 L IVF in the ED and received 2 vials of Digibind; and admitted to the ICU, where her heart was initially in a junctional rhythm in the 20s and 30s but converted spontaneously to NSR in the 80s. On discharge from the ICU to the floor, she was in atrial fibrillation in the 100s, she remained in afib but with rate in 70s-80s. Digoxin continued to trend down to normal. Digoxin was stopped with no plan to restart as outpatient. Metoprolol and Lasix were originally held. Lasix was restarted at full home dose and Metoprolol was restarted at half home dose. . #) Hyperkalemia: Pt's potassium on presentation was 8.2. It resolved with interventions to normal values. Most likely secondary to digoxin toxicity and acute renal failure. No EKG changes characteristic for hyperkalemia during admission. . #)Acute on chronic renal failure: Pt presented with Cr 3.1 that appeared to be elevated from new baseline 1.5 in [**Month (only) 547**]. Etiology unclear, but patient presented with initially concerning U/A positive for protein and hyaline casts. ARF was likely a pre-renal component as creatinine improved after fluids and with encouraged PO intake. Of note, UPEP negative. Patient did not receive more fluids on the floor (after 1 L IVF in ED/ICU) out of concern for oxygen requirement in the setting of CHF. Lasix was originally held but restarted once Cr was improving. Discharge Lasix dose was 80 po qd ( home dose.) . #) Elevated INR: Patient presented with INR 7.8 that decreased with fluids and 2 doses of Vit K 5mg PO. There was no concern for active bleeding- patient was hemodynamically stable and HCT was at her baseline. Coumadin intially held but restarted once the patient was INR 2.1. Patient was discharged on 2 mg daily Coumadin with INR on [**2172-8-4**] 2.2, with instructions to followup INR and Coumadin adjustment according to home schedule. This should be followed closely as she is being sent home on antibiotics for her UTI. . #) Transaminitis of unclear etiology: AST and ALT were intially elevated but quickly resolved over several days. This was most likely due to transient ischemia from poor forward flow in the setting of bradycardia. . #) Thrombocytopenia: Patient has history of thrombocytopenia in 100s-120s, which dropped to 70s during stay. This was thought to be likely due to poor synthetic liver function. DIC labs were negative and all other cell lines were normal. She was not given any heparin products while in house so it cannot be due to HIT. The patient was scheduled for an outpatient hematology appointment. . #) Atrial fibrillation: Patient has known hx afib, now in afib with rate stable in 70s. Metoprolol and Digoxin initially held; Metoprolol restarted at half home dose prior to discharge with plans to hold Digoxin permanently. Coumadin also initally held but restarted prior to discharge. . #) UTI: Patient was asymptomatic with U/A on [**2172-8-1**] showing many WBCs with large leukocytes. Foley removed. Patient began treatment with 10 day course of Augmentin, culture pending. Day 1 [**2172-8-1**], plan to stop [**2172-8-10**]. . #) Shortness of Breath: Patient required 2L during admission, de-sating to 80s when O2 was removed. This is a new O2 requirement for the patient. She had a CXR that did not suggest pneumonia and did not have a white count or fever during her stay and so we were not concerned for infectious cause. Likely due to atelectasis given mimimal activity in hospital, perhaps with component of some fluid overload given that Lasix was held for a few days at start of admission. Of note, her lungs were clear on exam and she did not have any other signs of fluid overload: no lower extremity edema. Of note, her bicarbonate slowly increased from 30 on admission to 41 on day of discharge. An ABG was not performed, as her clinical picture and respiratory status continued to improve, but this lab should be followed up by her PCP. [**Name10 (NameIs) **] was sent home on 2L/min O2. Medications on Admission: Lasix 80 mg 1 tab daily Claritin 10 mg 1 tab daily Nystatin topical [**Numeric Identifier 4856**] units/g as directed [**Hospital1 **] Toprol XL 25 mg 1 tab once daily digoxin 126 mcg 1 tab once daily VHC 2.25 60 mL [**Hospital1 **] Coumadin 2 mg 1 tab once daily Colace sodium 100 mg 1 cap [**Hospital1 **] Prilosec 20 mg 1 cap once a day Detrol LA 2 mg 1 cap [**Hospital1 **] Klor-Con 10 20 mEq 1 tab [**Hospital1 **] Discharge Medications: 1. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Q 24H (Every 24 Hours). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. Nystatin 100,000 unit/g Cream Sig: One (1) unit Topical twice a day: as directed. 5. Detrol LA 2 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 7. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 8. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 6 days. Disp:*12 Tablet(s)* Refills:*0* 9. Home O2 machine Patient needs home O2 machine at flow 2L/min. 10. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Digoxin Toxicity Hyperkalemia Supratherapeutic INR Acute on Chronic Renal Failure Transaminitis Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital because your digoxin levels were very high. Your nurse at home noticed this and brought you to the emergency room. In the emergency room, your heart rate was very slow because you had too much digoxin in your blood. We gave you a medication to bind the digoxin in your blood and that brought the levels of digoxin down and made your heart beat faster. We also treated your potassium, which was very high as a side effect of high digoxin. Your digoxin and potassium were normal when you left. We think that your digoxin was high because you have not been eating and drinking enough recently which made your kidney function worse. When the kidneys aren't working the level of digoxin can get dangerously high. It is going to be very important that you eat and drink well to stay healthy when you go home. . Your INR, which is a measure of how your blood is clotting, was also too high when you arrived at the hospital. This is also likely because you were not eating and drinking well and so your Coumadin became too high. We stopped your Coumadin here and your INR started coming down. When you left your INR was 1.8 which is actually less than therapeutic goal (your goal is [**3-4**],)on Coumadin 2mg daily. You should follow your INRs at home and have your PCP adjust your Coumadin dose accordingly. . Also, when you arrived at the hospital, we found that your kidneys were not working well. Your kidney function improved with IV fluids and when you left it was back to your baseline in [**2172-4-30**] (Creatinine 1.6.) Your PCP should check your kidney function soon to make sure that is it completely improved. . Because your heart was so slow when you came, we stopped your metoprolol, digoxin and lasix. When all of your blood tests started coming back normal, we restarted your Lasix 80 mg daily. We also restarted your Metoprolol (Toprol XL), but we are giving you HALF your home dose: 12.5 mg daily. . Your platelets were low while you were here. You have had low platelets for awhile, but they were even lower during this past hospitalization. This is not an emergency but should be followed up by your primary care doctor. . Finally, we checked your urine while you were here and found that you had a urinary tract infection. We started treating you with Augmentin (an antibiotic.) . In summary: The changes that we made to your medications were: STOP Digoxin. STOP Klor-Con CHANGE Toprol XL 25 mg daily to Toprol XL 12.5 mg daily. START Augmentin twice daily until [**8-10**] (this is for a urinary tract infection) DECREASE Detrol LA to 1 cap ONCE a day You will go home on 2 mg daily of Coumadin, and follow up your INRs as previously. Finally, we are sending you home with oxygen. We think that you now require oxygen because of atelectasis- this means there is some collapse in your lungs from being in the hospital and staying still for so long. Please use the oxygen to make sure you are breathing well. Followup Instructions: Please call your PCP office on Wednesday morning, [**8-5**] to make an appointment: Dr. [**Last Name (STitle) **]. [**Telephone/Fax (1) 608**]. Please have your CBC, electrolytes (in particular your potassium and creatinine) and INR checked on Thursday [**8-6**]. Your coumadin may need to be changed. You should also have your heart rate and blood pressure checked Thursday. Your PCP will decide whether to increase your Toprol XL dose back to your previous doses. Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2172-8-19**] at 1 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13999**], 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 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]

[ "790.92", "276.7", "995.29", "496", "599.0", "427.31", "428.32", "585.9", "428.0", "403.90", "E942.1", "584.9", "287.5" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12248, 12305

6300, 10754

239, 246

12465, 12465

3697, 6277

15624, 16548

2786, 2942

11224, 12225

12326, 12444

10780, 11201

12641, 15601

2957, 3678

174, 201

274, 2143

12480, 12617

2165, 2292

2308, 2770

5,397

159,333

48426+48427

Discharge summary

report+report

Admission Date: [**2145-3-8**] Discharge Date: [**2145-3-11**] Date of Birth: [**2093-3-26**] Sex: M Service: [**Hospital1 212**]-MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old male with a history of insulin dependent diabetes mellitus who came in with a three day history of nausea, abdominal pain, shortness of breath, and decreased p.o. intake. The patient states that he left his insulin at work three days prior to admission and thus has not been able to take any insulin. The patient also reasoned that since he had no insulin, he would limit his p.o. intake over the last three days and since then has had progressive nausea, abdominal pain, tachypnea, and shortness of breath. He denies any fever, diarrhea, chest pain, cough, URI symptoms, or dysuria. On review of systems, the patient noted a 100 pound weight loss over the past year due to decreased p.o. intake. The patient has never had a colonoscopy. The patient also complained of some mid epigastric discomfort after eating. In the Emergency Department, the patient was noted to have a blood sugar of 572. Arterial blood gas revealed 7.04/12/139. He was given 2 liters normal saline, 1 amp of bicarbonate, and 10 units of intravenous insulin. PAST MEDICAL HISTORY: Diabetes mellitus times six years, Charcot foot. MEDICATIONS: Insulin 35 units of NPH in the a.m. and 15 units of regular and 25 units of NPH and 10 units of regular in the p.m. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives at the [**Company 3596**]. He has positive tobacco use of one pack per day times 35 years and positive alcohol use with a 16 pack approximately three times a week. PHYSICAL EXAMINATION ON ADMISSION: Blood pressure was 130/60, heart rate 108, temperature 97.5, respirations 20, oxygen saturation 98% on room air. HEENT revealed anicteric sclerae, extraocular movements intact, pupils equal, round, and reactive to light, and dry mucous membranes. The lungs were clear to auscultation bilaterally. The heart examination revealed hyperdynamic, regular rate and rhythm, tachycardia, and no murmurs, rubs, or gallops appreciated. Abdominal examination revealed mild epigastric discomfort, no rebound, no guarding, no hepatomegaly. Examination of the extremities revealed 2+ distal pulses bilaterally. There was no lower extremity edema. Neurologically, the patient was alert and oriented times three. Strength was [**5-8**] throughout. LABORATORY DATA: White blood cell count was 16.1, hematocrit 49.7, platelets 337,000. Chemistries revealed sodium 135, potassium 5.5, chloride 89, bicarbonate 7, BUN 27, creatinine 1.9, glucose 625, anion gap 39. LDH was 462, CK 110, AST 38, ALT 20, alkaline phosphatase 139, amylase 107, lactate 3.0, calcium 9.4, albumin 4.7, lipase 88. PTT was 28.6, INR 1.4. Urinalysis revealed positive ketones, 1 white blood cell, no bacteria, nitrate negative. Chest x-ray revealed no gross infiltrate. Electrocardiogram revealed sinus tachycardia at 113, normal axis, normal intervals, left ventricular hypertrophy, Q waves in V3-V6 that were old, no acute ST changes. Toxicology screen revealed no alcohol detected. SUMMARY OF HOSPITAL COURSE: The patient was admitted to the Medicine Service in the Intensive Care Unit. He was treated with intravenous fluids and insulin. The patient was subsequently changed to subcutaneous insulin and transferred to the regular medicine floor. The patient started tolerating full p.o. without incident. Because the patient complained of some odynophagia upon admission, an upper GI series was ordered which showed some gastroesophageal reflux disease. Please see the official report for details in the CCC. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSIS: Diabetic ketoacidosis. DISCHARGE MEDICATIONS: Regular Insulin 6 units subq. q.a.m. and 6 units subq. q.p.m., NPH Insulin 24 units subq. q.a.m and 20 units subq. q.p.m. with glucometer sticks and glucometer strips, Ranitidine 150 mg p.o. b.i.d., insulin needles, and Nystatin Swish and Swallow 10 cc p.o. q.i.d. DISCHARGE FOLLOWUP: The patient will follow up in the [**Hospital 191**] Clinic with Dr. [**Last Name (STitle) **] in two weeks time. After discharge, the patient's weight loss over the past year will be further evaluated on an outpatient basis. The patient was also instructed to follow up with the [**Hospital **] Clinic and the [**Hospital 8183**] Clinic. The patient was given the phone numbers for these clinics and will make appointments for each as soon as possible. [**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. Dictated By:[**Last Name (NamePattern1) 27618**] MEDQUIST36 D: [**2145-3-11**] 13:06 T: [**2145-3-11**] 17:32 JOB#: [**Job Number **] Admission Date: [**2145-3-8**] Discharge Date: [**2145-3-12**] Date of Birth: [**2093-3-26**] Sex: M Service: [**Hospital1 212**] ADDENDUM: Patient remained in the hospital overnight and was discharged on [**2145-3-12**] because his blood sugars were elevated in the range of 200s to 300. DISCHARGE MEDICATIONS: 1. Regular insulin 6 units subcutaneous q.a.m. and 6 units subcutaneous q.p.m. Regular insulin sliding scale at lunchtime. NPH insulin 24 units in the a.m., 24 units in the p.m. 2. Ranitidine 150 mg po b.i.d. 3. Nystatin swish and swallow 10 cc po q.i.d. [**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. Dictated By:[**Last Name (NamePattern1) 27618**] MEDQUIST36 D: [**2145-3-12**] 10:08 T: [**2145-3-12**] 10:08 JOB#: [**Job Number **]

[ "783.21", "276.5", "V15.81", "250.11", "305.01", "305.1", "530.81", "577.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5171, 5681

3809, 3833

3218, 3724

4144, 5148

185, 1254

1733, 3189

1277, 1496

1513, 1718

3749, 3787

63,030

162,596

34070

Discharge summary

report

Admission Date: [**2139-10-25**] Discharge Date: [**2139-10-28**] Date of Birth: [**2059-12-9**] Sex: M Service: ORTHOPAEDICS Allergies: Vicodin Attending:[**First Name3 (LF) 8587**] Chief Complaint: Left periprosthetic femur fracture Major Surgical or Invasive Procedure: [**2139-10-27**]: ORIF left femur History of Present Illness: 79 M had mechanical fall at home while using walker. Fell on left hip. Transferred from [**Hospital 1562**] Hospital. Found to have a fracture around his prior left THA. Past Medical History: CHF (EF=30% in [**2137**]), CAD s/p CABG x 4, Afib s/p biventricular pacer placement, hyperlipidemia, DM-2, s/p b/l THR, PVD s/p multiple [**Year (4 digits) 1106**] bypass procedures of RLE for foot gangrene (done by [**Hospital1 18**] [**Hospital1 1106**] group), COPD, h/o MRSA colonization Social History: Lives with wife [**Name (NI) **] Smokes x 35 y., quit '[**20**] Family History: n/c Physical Exam: Upon Admission: VS: AVSS Gen: NAD, Alert and oriented x 3 HEENT: NCAT, anicteric, mmm CV: RRR, S1S2, no murmurs Chest: CTAB, no adventitious sounds heard Abd: Soft, NTND RLE - Palpable DP and PT pulses. Skin is intact. No deformities LLE - DP and PT pulse found by doppler. Skin is intact. NVI - TA/[**Last Name (un) 938**]/Gastroc. SILT. Compartments soft Pertinent Results: [**2139-10-25**] 04:05PM BLOOD WBC-6.9 RBC-5.35 Hgb-15.7 Hct-44.8 MCV-84 MCH-29.4 MCHC-35.2* RDW-16.1* Plt Ct-90* [**2139-10-27**] 07:20AM BLOOD WBC-9.0 RBC-5.24 Hgb-15.0 Hct-44.0 MCV-84 MCH-28.6 MCHC-34.1 RDW-16.2* Plt Ct-94* [**2139-10-27**] 03:56PM BLOOD WBC-6.0 RBC-4.58* Hgb-12.9* Hct-38.4* MCV-84 MCH-28.1 MCHC-33.6 RDW-15.9* Plt Ct-135* [**2139-10-27**] 08:52PM BLOOD WBC-4.7 RBC-4.58* Hgb-13.2* Hct-38.5* MCV-84 MCH-28.9 MCHC-34.4 RDW-16.0* Plt Ct-125* [**2139-10-28**] 01:46AM BLOOD WBC-6.9 RBC-4.40* Hgb-12.6* Hct-36.5* MCV-83 MCH-28.5 MCHC-34.4 RDW-16.2* Plt Ct-137* [**2139-10-28**] 04:34AM BLOOD WBC-8.9 RBC-4.36* Hgb-12.2* Hct-36.4* MCV-84 MCH-28.0 MCHC-33.6 RDW-16.2* Plt Ct-165 [**2139-10-25**] 04:05PM BLOOD PT-13.9* PTT-41.3* INR(PT)-1.2* [**2139-10-25**] 06:25PM BLOOD PT-13.9* PTT-40.1* INR(PT)-1.2* [**2139-10-27**] 03:56PM BLOOD PT-14.8* PTT-42.5* INR(PT)-1.3* [**2139-10-27**] 08:52PM BLOOD PT-15.2* PTT-42.4* INR(PT)-1.3* [**2139-10-28**] 04:34AM BLOOD PT-14.6* INR(PT)-1.3* [**2139-10-25**] 04:05PM BLOOD Glucose-118* UreaN-39* Creat-1.7* Na-143 K-5.6* Cl-106 HCO3-28 AnGap-15 [**2139-10-25**] 06:25PM BLOOD Glucose-111* UreaN-39* Creat-1.8* Na-143 K-4.1 Cl-105 HCO3-26 AnGap-16 [**2139-10-26**] 06:50AM BLOOD Glucose-132* UreaN-35* Creat-1.8* Na-145 K-4.2 Cl-106 HCO3-31 AnGap-12 [**2139-10-27**] 07:20AM BLOOD Glucose-178* UreaN-47* Creat-2.5* Na-143 K-4.3 Cl-103 HCO3-24 AnGap-20 [**2139-10-27**] 03:56PM BLOOD Glucose-158* UreaN-58* Creat-2.9* Na-141 K-4.2 Cl-106 HCO3-24 AnGap-15 [**2139-10-27**] 08:52PM BLOOD Glucose-200* UreaN-59* Creat-2.6* Na-144 K-4.1 Cl-109* HCO3-24 AnGap-15 [**2139-10-28**] 01:46AM BLOOD Glucose-207* UreaN-65* Creat-2.8* Na-142 K-4.2 Cl-109* HCO3-24 AnGap-13 [**2139-10-28**] 04:34AM BLOOD Glucose-200* UreaN-66* Creat-3.0* Na-139 K-4.3 Cl-106 HCO3-23 AnGap-14 [**2139-10-27**] 08:19AM BLOOD CK(CPK)-1445* [**2139-10-27**] 08:52PM BLOOD CK(CPK)-2413* [**2139-10-28**] 01:46AM BLOOD CK(CPK)-2124* [**2139-10-27**] 08:19AM BLOOD CK-MB-9 cTropnT-<0.01 [**2139-10-27**] 08:52PM BLOOD CK-MB-12* MB Indx-0.5 cTropnT-<0.01 [**2139-10-28**] 01:46AM BLOOD CK-MB-10 MB Indx-0.5 cTropnT-<0.01 [**2139-10-25**] 04:05PM BLOOD Calcium-9.0 Phos-3.7 Mg-2.5 [**2139-10-26**] 06:50AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.4 [**2139-10-27**] 07:20AM BLOOD Calcium-8.9 Phos-5.8*# Mg-2.5 [**2139-10-27**] 03:56PM BLOOD Calcium-8.2* Phos-6.2* Mg-2.4 [**2139-10-27**] 08:52PM BLOOD Albumin-3.0* Calcium-7.6* Phos-6.0* Mg-2.2 [**2139-10-28**] 01:46AM BLOOD Calcium-7.6* Phos-5.3* Mg-2.7* [**2139-10-28**] 04:34AM BLOOD Calcium-8.6 Phos-5.2* Mg-3.3* [**2139-10-27**] 01:29PM BLOOD Glucose-205* Lactate-2.0 Na-138 K-4.3 Cl-103 [**2139-10-27**] 02:56PM BLOOD Glucose-164* Lactate-2.8* Na-139 K-3.8 Cl-106 [**2139-10-27**] 04:06PM BLOOD Lactate-2.5* [**2139-10-27**] 09:00PM BLOOD Lactate-1.5 [**2139-10-27**] 11:35PM BLOOD Lactate-1.7 [**2139-10-28**] 01:56AM BLOOD Lactate-2.0 [**2139-10-28**] 04:43AM BLOOD Lactate-2.7* [**2139-10-28**] 05:37AM BLOOD Lactate-8.5* [**2139-10-27**] 01:29PM BLOOD freeCa-1.17 [**2139-10-27**] 02:56PM BLOOD freeCa-1.11* [**2139-10-27**] 09:00PM BLOOD freeCa-1.14 [**2139-10-28**] 01:56AM BLOOD freeCa-1.12 [**2139-10-28**] 04:43AM BLOOD freeCa-1.19 XR left femur [**10-25**]: IMPRESSION: Cortical disruption along the medial aspect of the left femur along the mid shaft of the femoral component of left total hip arthroplasty that is highly suspicious for an obliquely oriented fracture. KUB [**10-27**]: IMPRESSION: Multiple distended central loops of small bowel, suggestive of ileus or early small-bowel obstruction. PMIBI [**10-26**]: IMPRESSION: 1. Predominantly fixed severe defect involving the apex, and moderate defects involving the distal anterior wall, the inferior wall and the septum. No reversible ischemic defects. Fixed defect in distal anterior wall worsening since [**2138-6-4**]. Pronounced left ventricular enlargement with global hypokinesis with LVEF = 22% Brief Hospital Course: Mr. [**Known lastname 22807**] was seen in the ED and found to have a left femur fracture around his prior left THA. He was admitted to the orthopaedic surgery service. A medical consult was called to assess pre-op risk and for medical co-management. A stress TTE was obtained and cardiology was also consulted for medical clearance. He was taken to the OR in the afternoon of [**2139-10-27**]. He underwent ORIF of his left femur fracture. He tolerated the procedure well, but had episodes of hypotension intraoperatively. He was taken to the trauma ICU for post-operative care. He was on a drip of neosynephrine. At approximately 2AM on [**10-28**] he began having runs of ventricular tachycardia and continued hypotension. His pressor requirements went up and he was started on an amiodarone drip for rate control. His runs of VTach increased in length and frequency and an attempt to shock him back into rhythm took place. He did not respond to shocking and his blood pressure continued to decline. He was pronounced dead at 5:50 AM on [**2139-10-28**]. Medications on Admission: Amiodarone 400qam, Lyrica 75 qPM, Januvia 100', torsemide 20'', zocor 40', Niferex 150 (iron/vit c), KCl 20'', Glipizide 10'', Coreg CR 40', Plavix 75', Pepcid 20'', ASA 325', Seroquel 125 qhs, Colace Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Cardiac arrest Left periprosthetic femur fracture s/p ORIF Secondary Diagnoses: CHF, Atrial fibrillation, CAD, Hyperlipidemia, Diabetes Mellitus, PVD Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None Completed by:[**2139-10-28**]

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icd9cm

[ [ [] ] ]

[ "79.35" ]

icd9pcs

[ [ [] ] ]

6666, 6675

5323, 6386

309, 344

6869, 6879

1357, 5300

6932, 6968

958, 963

6637, 6643

6696, 6756

6412, 6614

6903, 6909

978, 980

6777, 6848

235, 271

372, 543

995, 1338

565, 860

876, 942

28,382

103,765

27106

Discharge summary

report

Admission Date: [**2154-10-17**] Discharge Date: [**2154-10-19**] Date of Birth: [**2105-7-28**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3326**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 49 year old female with hx metastatic renal cell carcinoma on sutent s/p gemzar chemotherapy on [**10-14**] presented to clinic with dizziness and malaise. She was found to be hypotensive to the 80s, and tachycardic at 112, pale but mildly jaundiced which was an acute change. She was also initially hypothermic at 94. She was then brought to the ED were rectal temp was 98, BP 100/60s, and tachy 100-110s. Received IVF. Denied pain. Found to be in acute liver failure. A CTA was performed which showed no PE but with increased vascular resistance in the R M/L lobes, known R mediastinal mass with mass effect on SVC, worsening collapse of entire R lung and finally R pleural effusion. Recently she has been admitted for a presumptive pna on levo/flagyl dc'd on [**9-16**] with completion of her antibiotics on [**2154-9-21**]. She denied further symptoms at that time. C/o increased WOB and fever for last 2 days, that has worsened to dyspnea at rest. Increasingly weak for last 7 days and cannot ambulate for more than a few feet, eating fatigues her. Denies any other localizing symptoms - no cough, chest pain, fever, abdominal pain, diarrhea, rashes or headaches. Confirms poor food intake for last several days. Past Medical History: Depression Renal Clear Cell Carcinoma, [**Last Name (un) 19076**] grade [**2-3**] s/p right radical nephrectomy with venacavotomy, with pulmonary metastases, s/p multiple chemotherapeutic regimens most recently C3D1 of gemzar/sutent on [**10-14**] Peridontal disease Bartholin cysts Social History: Divorced, 2 adult kids, quit tobacco at age 30 after 1ppd x 10 years, social EtOH, lives in [**State 1727**]. Sister lives in [**Name (NI) 86**] area. Son, [**Name (NI) 916**] lives in [**Location 86**]. Daughter lives in [**Location **]. Family History: colon ca mother age 80, [**Name2 (NI) 3685**] in maternal aunts, older age Physical Exam: 96.8 79/61 HR 90 RR 36 SpO2 50% on nonrebreather Gen: obvious increased work of breathing, speaking in short sentences HEENT: periocular pallor, perioral cyanosis, MM dry, open mouth breathing CV: tachycardic, regular rhythm, no m/g/r Pulm: no breath sounds right side, left side with good air movement, no wheeze/rale/rhonchi Abd: +BT, soft, nontender Ext: Cool, poorly perfused with mild cyanosis Pertinent Results: [**2154-10-17**] 04:20PM TYPE-ART O2 FLOW-4 PO2-23* PCO2-37 PH-7.15* TOTAL CO2-14* BASE XS--17 INTUBATED-NOT INTUBA COMMENTS-NASAL [**Last Name (un) 154**] . [**2154-10-17**] 12:05PM WBC-9.8# RBC-3.75* HGB-11.7* HCT-37.9 MCV-101*# MCH-31.3 MCHC-30.9* RDW-16.9* NEUTS-90.0* BANDS-0 LYMPHS-8.9* MONOS-0.7* EOS-0.3 BASOS-0.2 HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL . [**2154-10-17**] 12:05PM ALT(SGPT)-150* AST(SGOT)-511* LD(LDH)-674* ALK PHOS-166* TOT BILI-4.5* DIR BILI-2.7* INDIR BIL-1.8 . [**2154-10-17**] 12:05PM UREA N-31* CREAT-1.2* SODIUM-138 POTASSIUM-6.2* CHLORIDE-96 TOTAL CO2-13* ANION GAP-35* . [**2154-10-17**] 01:30PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.021 BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-8* PH-5.0 LEUK-NEG RBC-[**11-19**]* WBC-[**3-4**] BACTERIA-FEW YEAST-NONE EPI-[**3-4**] GRANULAR-[**3-4**]* HYALINE-21-50* . [**10-17**] CTA - IMPRESSION: 1. No evidence of aortic dissection or central/segmental pulmonary emboli. Subsegmental branches within the right middle and right lower lobe are incompletely opacified due to increased vascular resistance. 2. No significant interval change since prior exam of the known large invasive right mediastinal mass, adjacent mass effect on the SVC, and development of collateralization. 3. Moderate increase in size to a loculated right pleural effusion with fissural component. New small left pleural effusion. Mild amount of adjacent linear and dependent atelectasis. . [**9-9**] CT Abd/Pelvis IMPRESSION: 1. Increased size and mass effect of metastatic lesion in the mediastinum/right hilum which now almost completely occludes the SVC with increased collateralization. The right main pulmonary artery is also significantly compressed. 2. Increased right pleural effusion, partly loculated. 3. Other pulmonary lesions have increased in size. Brief Hospital Course: 49 F with met RCC presents with SOB found to have near total collapse/occulusion of her right lung [**2-1**] tumor progression. Have discussed futility of care, and she's confirmed a CMO status. . # SOB - No PE evident on CTA, CT with evidence of tumor progression and collapse of most of right lung with minimal perfusion and pleural effusions. Initially began antibiotics and fluid resuscitation. Discussed ultimate poor outcome with patient, and that if intubated it is unlikely she would be successfully extubated. And that intubation needed to be soon given her poor oxygenation. Pt chose to be CMO at this point and requested we contact her family to come in, which we did. Was started on a morphine gtt which helped with her dyspnea. Her family arrived and she was continued on CMO status until her death on [**2154-10-19**]. . # Acid/base- Metabolic Acidosis- 31 Gap acidosis, with Elevated lactate, also with inappropriate respiratory compensation, thus likely respiratory alkalosis, with mixed metabolic alkalosis given the anion gap difference is 20, and change in bicarb is 17. Given D5 3amps bicarbonate. Patient then decided to be CMO, so stopped attempted to aggressively treat her acid-base abnormalities. No labs were drawn the last day of her life given her CMO status. . # ARF - Likely prerenal in the setting of hypotension, low fluid intake. Bolused with IVF, then transitioned to CMO. Was not treated with further IV fluids. Expired [**2154-10-19**]. . # Increased LFTs- New lab abnormality, no evidence of malignancy on recent CT, likely associated with worsening SVC syndrome, hepatic congestion, or possible new metastases. Did not pursue further work-up on admit given CMO status. . # Hypothyroidism- Held synthroid given CMO status. Expired [**2154-10-19**]. . Expired [**2154-10-19**] due to cardiopulmonary arrest in the setting of widely metastatic lung cancer. Medications on Admission: Venlafaxine 150 mg Daily Levothyroxine 75 mcg Daily Docusate Sodium 100 [**Hospital1 **] Senna 8.6 mg [**Hospital1 **] Prilosec 20 mg QD Albuterol 90 mcg q6h Ipratropium Bromide 17 mcg Inhaler Discharge Medications: Expired [**2154-10-19**] Discharge Disposition: Expired Discharge Diagnosis: Metastatic Lung Cancer Discharge Condition: Expired [**2154-10-19**] Discharge Instructions: Expired [**2154-10-19**] Followup Instructions: Expired [**2154-10-19**]

[ "459.2", "584.9", "276.4", "518.0", "799.02", "197.2", "244.9", "V10.52", "570", "518.81", "197.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6824, 6833

4631, 6531

337, 343

6899, 6925

2683, 4608

6998, 7025

2172, 2248

6775, 6801

6854, 6878

6557, 6752

6949, 6975

2263, 2664

278, 299

371, 1590

1612, 1897

1913, 2156

21,699

195,644

51713+51714

Discharge summary

report+report

Admission Date: [**2144-4-26**] Discharge Date: [**2144-5-11**] Service: MEDICINE-[**Location (un) 259**] CHIEF COMPLAINT: Hypoxia. HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **] year-old male with a recent admission for pneumonia who was admitted from a rehab after he was found unable to urinate for the three days prior to admission. The patient reportedly has a history of traumatic bladder catheterization requiring blood transfusions. A pelvic ultrasound done on the day of admission at his nursing home reportedly demonstrated a distended urinary bladder containing approximately 950 ml of urine, so the patient was sent to the emergency department. While in the Emergency Room the department of urology placed a Foley without difficulty; only 300 cc of urine were drained at that time. Of note, at the time the urologists arrived at the bedside, the patient had spontaneously voided in his bed. Subsequent to the Foley catheter placement, the patient dropped his oxygen saturation to the Foley catheter placement, the patient dropped his oxygen saturation on a 100% nonrebreather face mask, and he also developed a temperature to 102.1 degrees. He was therefore admitted to the Medicine Service. According to the patient's daughter, the patient denied shortness of breath or chest pain at this time. PAST MEDICAL HISTORY: 1) Ischemic stroke in [**2137**] complicated by memory loss and left sided weakness. 2) Prostate cancer status post bilateral orchiectomy in [**2126**]. 3) Compression fracture at L4. 4) Osteoporosis. 5) Zenker's diverticulum.. 6) History of C. difficile colitis. 7) Hemorrhoids with occasional rectal bleeding. 8) Hypertension. 9) Iron deficiency anemia. ALLERGIES: The patient has no known drug allergies but purportedly develops altered mental status when given Trazodone or Risperidone. MEDICATIONS ON ADMISSION: 1) Sodium bicarbonate 10 ml p.o. day, 2) Calcitonin nasal spray. 3) Levofloxacin 500 mg p.o. q.d. (started [**2144-4-25**]). 4) Levofloxacin 250 mg p.o. q.d. (administered [**2144-4-7**] through [**2144-4-22**]). 5) tamsulosin 0.4 mg per nasogastric tube q 12 hours. 6) Finasteride 5 mg p.o. q.d. 7) Lansoprazole 30 mg pr nasogastric tube q.d. 8) metoprolol 50 mg per nasogastric tube b.i.d. 9) Ticlopidine 250 mg p.o. b.i.d. 10) albuterol nebulizers. 11) ipratropium nebulizers. 12) Bisacodyl. 13) Docusate 100 mg p.o. b.i.d. 14) Lactulose 30 cc p.o. q 6 hours p.r.n. 15) multivitamin. 16) acetaminophen, 17) guaifenesin, 18) trazodone 12.5 mg p.o. q.h.s. p.r.n. SOCIAL HISTORY: Prior to [**2144-4-8**], the patient lived with his wife. [**Name (NI) **] denies any history of alcohol or tobacco abuse. Following his recent hospitalizations, the patient was found to be unable to continue to care for himself at home and was therefore transferred to [**Hospital1 **]. FAMILY HISTORY: Coronary artery disease. REVIEW OF SYSTEMS: According to the patient's daughter: The patient denies headache, visual changes, chest pain, shortness of breath, nausea, vomiting, diarrhea, melena, bright red blood per rectum, or dysuria. The patient did note constipation, and reportedly his last bowel movement was several days prior to admission. ON INITIAL PHYSICAL EXAMINATION: The patient's temperature was 102.1, heart rate 109, blood pressure 132/70, respiratory rate 22, and oxygen saturation 95 percent on 4 liters of oxygen by nasal cannula. Patient was elderly, only Farsi speaking, cachectic, and lying in bed. Normocephalic, atraumatic. Extraocular movements intact. Sclerae were anicteric, and the patient had bilateral temporal wasting. Regular rate and rhythm with frequent ectopy, and a systolic ejection murmur was best heard at the left upper sternal border. His oropharynx was dry. Patient had left sided rhonchi on limited pulmonary examination. Patient's abdomen was soft, nontender, nondistended, and there were normal active bowel sounds. His hands were cool and his feet were warm, and there was no peripheral edema. Patient was alert to person, [**Hospital1 **], and his sensation was intact to light touch. He was found to have 5 out of 5 strength of all four lower extremities. ON INITIAL LABORATORY EVALUATION: The patient's white count was 18,000, hematocrit 29.5, and platelets 192,000. Differential of his white count demonstrated 92 neutrophils, 4.7 lymphocytes, 2.7 monocytes, and 0.2 eosinophils. His PT was 13, PTT 26.2, and INR 1.1. Serum chemistries demonstrated 132, potassium 5.5, chloride 98, bicarbonate 27, BUN 30, creatinine 1.6, glucose 135, calcium 7.5, magnesium 1.9, and phosphate 3.1. Initial urinalysis demonstrated trace protein, negative nitrite, negative leukocyte esterase, no white blood cells, and no bacteria. Electrocardiogram demonstrated normal sinus rhythm at 98 beats per minute, left axis, prolonged QRS, right bundle branch block with bifascicular block, poor wave progression, Q waves in leads 2, V1, and V2. Compared with an electrocardiogram dated [**2143-4-16**], the QRS complex was wider, but there were no acute ischemic ST segment changes. On initial chest x-ray, the patient was found to have low lung volumes, bibasilar atelectasis, and mild elevation of the left hemidiaphragm. HOSPITAL COURSE BY SYSTEMS: 1) Infectious diseases: The patient was on levofloxacin on admission. According to the physician at the rehabilitation hospital at which the patient had been living, this antibiotic had been started when the patient complained of dysuria prior to admission to the hospital. This antibiotic was continued for four additional days for empiric coverage of a urinary tract infection and then discontinued. On hospital day three, the patient was started on Vancomycin. This antibiotic was added when it was discovered that the patient had received only a seven day course of Vancomycin during his prior hospitalization as treatment for a presumed MRSA pneumonia. (In d/w the attending from the patient's past admisison, however, it was felt that 7d would be sufficient as it was not clear that there was a true PNA and he may have only had a tracheobronchitis). The patient received Vancomycin from [**4-28**] through [**5-8**] dosed by levels. He was also started on metronidazole during the same time that the patient received Vancomycin in order to provide coverage for aspiration pneumonitis. Following initiation of his antibiotics, the patient defervesced and remained afebrile except as noted below. He tested negative of C. difficile during this hospitalization. 2) Pulmonary: As noted, the patient was treated for MRSA and aspiration pneumonia during this hospitalization. Despite these antibiotics, the patient had persistent opacification (left greater than right) on his chest radiographs. The patient was started on nebulizers, mucolytics, and chest physical therapy, but he continued to have significant left sided opacification on his chest x-ray. The presumed etiology of these opacifications was that the patient had persistent mucous plugging of his airways that was caused by global deconditioning and weakness that caused the patient top lack the strength necessary to clear his own oral secretions. A bronchoscopy was therefore done on [**2144-5-4**] with significant suctioning of mucous plugs on the right greater than on the left. This procedure was complicated by a transient need for intubation given the drop in the patient's oxygen saturation into the mid 70s, but the patient was quickly extubated with the return of his oxygen saturation to its baseline. Within several days of this bronchoscopy, the patient again had significant left sided opacification on his chest radiograph that was again thought to be consistent with persistent mucous plugging. The above mentioned medical measures were continued, and at the time of discharge the patient was maintaining an oxygen saturation in the mid 90s on a 50 percent face tent. Also of note, the patient was febrile for the 24 hours following his bronchoscopy; his fever was thought to be most likely secondary to a post bronchoscopy fever and not an acute infectious process. 3) Nutrition: At the time of admission, the patient was receiving nutrition by tube feeds through a Dobbhoff feeding tube that had been placed under fluoroscopy during the prior admission. On [**4-29**], his tube clogged, and therefore, it was again replaced under fluoroscopy on [**4-30**]. The tube clogged again on [**5-8**] and was again replaced under fluoroscopy on [**5-9**]. At the time of discharge, the patient was tolerating tube feeds without difficulty through this Dobbhoff. Also of note, the patient had three swallowing evaluations during this hospitalization. During each of these evaluations, the patient took no more than two bites of custard. While he did not demonstrate overt signs of aspiration during these evaluations, he has been noted in the past to have silent aspiration on video swallowing studies. It was felt that the patient, even if he were able to swallow,would not be able to meet his nutritional requirements by oral feedings alone, so he was continued on his tube fees by his Dobbhoff at the time of discharge. He should continue to receive nutrition in this fashion until he demonstrates on a swallowing evaluation that he can tolerate oral feedings without any evidence of aspiration. 4) Gastrointestinal: The patient had mild to moderate abdominal distention throughout this hospitalization. During the last week of his hospitalization, a KUB was done that demonstrated a normal bowel gas pattern and some stool in the rectal vault. Given these findings, the patient was given several enemas with good result. He had only mild abdominal distention at the time of discharge. His abdomen was soft throughout his hospitalization. Also of note, the patient had liver function tests tested during his hospitalization; they were normal. 5) Cardiovascular: The patient was aggressively hydrated on admission. He subsequently was found to have mild pulmonary edema and pleural effusions on chest radiographs, so he was given furosemide as needed with good effect. He remained on his metoprolol for hypertension as well as intermittent episodes of supraventricular tachycardia. At the time of discharge, the patient was medically stable. He was maintaining oxygen saturations in the mid 90s on a 50 percent face tent. DISCHARGE CONDITION: Stable. DISCHARGE DISPOSITION: DISCHARGE DIAGNOSES: 1. MRSA pneumonia. 2. Aspiration pneumonia. 3. Persistent mucous plugging. 4. Supraventricular tachycardia. DISCHARGE MEDICATIONS: 1. Finasteride 5 mg per nasogastric tube q.d. 2. Metoprolol 50 mg per nasogastric tube b.i.d. 3. Ipratropium nebulizer q 6 hours. 4. Multivitamin 1 cap p.o.q.d. 5. Calcitonin 200 IU intranasal q.d. 6. Acetaminophen 650 mg per nasogastric tube q 4 hours p.r.n. pain. 7. Guaifenesin 10 ml per nasogastric tube q 6 hours. 8. Senna 1 tablet per nasogastric tube b.i.d. 9. Docusate liquid 100 mg per nasogastric tube b.i.d. 10. Simethicone 80 mg per nasogastric tube t.i.d. 11. Albuterol nebulizer q 6 hours. 12. Acetocystine 1 to 10 ml nebulizer q 6 hours administered with albuterol. 13. Lansoprazole oral solution 30 mg per nasogastric tube q.d. 14. Metoclopramide 10 mg per nasogastric tube t.i.d. 15. Saw [**Location (un) 6485**] 160 mg per nasogastric tube b.i.d. [**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D. [**MD Number(1) 7855**] Dictated By:[**Name8 (MD) 2507**] MEDQUIST36 D: [**2144-5-11**] 11:41 T: [**2144-5-11**] 11:37 JOB#: [**Job Number 25208**] Admission Date: [**2144-4-26**] Discharge Date: [**2144-5-18**] Service: [**Location (un) 259**] MEDICINE ADDENDUM: This is a discharge summary addendum to a previously dictated discharge summary. This addendum covers the dates of hospitalization from [**2144-5-11**] through [**2144-5-18**]. While the initial plan was for the patient to be discharged to the [**Hospital **] [**Hospital **] Hospital on [**Last Name (LF) 766**], [**2144-5-11**], he spiked a fever to 102 on that afternoon. Given this new development, a fever workup was pursued and a family meeting was arranged for the following afternoon. On [**2144-5-12**], a meeting was held. This meeting was attended by Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) 217**], Dr. [**Last Name (STitle) **], and Dr. [**First Name (STitle) 2505**]. In addition, representatives from the nursing staff, Department of Case Management, and Department of Social Work were also present. The patient's family was represented by his daughter, son in-law, and son. By the end of the meeting, it was determined that the family wished to continue to pursue aggressive medical care for their father. They felt that were he able to receive adequate nutrition, he would stand a good chance at being rehabilitated to his prior level of functioning. The plan at that time was, therefore, to pursue aggressive pulmonary rehabilitation at [**Hospital1 **], for a period of time ranging between one to two weeks, followed by subsequent reassessment of the patient's clinical status. The patient was, therefore, arranged to be discharged to [**Hospital1 **] on the day following this family meeting. On [**2144-5-13**], the family requested that the patient be evaluated by Dr. [**Last Name (STitle) **] from the Department of Gastroenterology for PEJ tube placement. Dr. [**Last Name (STitle) **] felt that the patient was a candidate for PEJ tube placement if he were to be afebrile. The patient was, therefore, restarted on vancomycin and metronidazole as empiric coverage for possible MRSA and aspiration pneumonia. Later that afternoon, the patient had an episode of desaturation into the mid 70s on a 100% nonrebreather face mask; chest physical therapy was performed and a large mucous plug was retrieved. The patient subsequently returned to his baseline oxygen saturation of the mid 90s on a 50% face tent. A chest x-ray done at that time showed no significant changes from prior radiographs. Also at this time, the patient's code status was changed to DNR, CPR not indicated, intubation acceptable if cleared with the family first. On [**2144-5-14**], the patient was clinically stable, and he went to the [**Hospital Ward Name 516**] for PEJ placement. Given the patient's tenuous pulmonary status, however, the Department of Anesthesia was reluctant to sedate the patient because of his significant pleural effusions. On the following day Interventional Pulmonology, therefore, performed a left-sided thoracentesis under ultrasound guidance and drained off 1 liter of transudative pleural fluid. Chest x-ray performed after this procedure demonstrated marked improvement in the radiographic appearance of the left lung. Later that afternoon, the patient underwent successful PEJ placement. On [**2144-5-16**], the patient remained intermittently febrile, and it was noted that a sputum culture from his bronchoscopy on [**2144-5-4**] was growing out Stenotrophomonas maltophilia. Given that the patient was intermittently febrile, he was, therefore, started on Bactrim for treatment of his Stenotrophomonas. His tube feeds were initiated by his PEJ tube and he was tolerating these feeds without difficulty. At the time of discharge, the patient's cell counts and serum chemistries were stable. DISCHARGE CONDITION: Stable. DISCHARGE DISPOSITION: [**Hospital **] [**Hospital **] Hospital. DISCHARGE DIAGNOSIS: 1. Methicillin-resistant Staphylococcus aureus pneumonia. 2. Aspiration pneumonia. 3. Persistent mucus plugging. 4. Supraventricular tachycardia. 5. Left thoracentesis. 6. PEJ placement. DISCHARGE MEDICATIONS: 1. Fenasteride 5 mg per PEJ tube q.d. 2. Metoprolol 50 mg per PEJ tube b.i.d. 3. Ipratropium nebulizer q. six hours. 4. Multivitamin one capsule per PEJ tube q.d. 5. Calcitonin 200 IU intranasal q.d. 6. Acetaminophen 650 mg per PEJ tube q. 4-6 hours p.r.n. pain. 7. Guaifenesin 10 milliliters per PEJ tube q. six hours. 8. Senna one tablet per PEJ tube b.i.d. 9. Docusate liquid 100 mg per PEJ tube b.i.d. 10. Simethicone 80 mg per PEJ tube t.i.d. 11. Albuterol nebulizer q. six hours. 12. Acetylcysteine [**2-14**] milliliter nebulizer q. six hours administered with Albuterol. 13. Lansoprazole oral solution 30 mg per PEJ tube q.d. 14. Metoclopramide 10 mg per PEJ tube t.i.d. 15. Saw [**Location (un) **] 160 mg per PEJ tube b.i.d. 16. Metronidazole 500 mg per PEJ tube t.i.d. through [**2144-5-23**]. 17. Vancomycin 1 mg IV dosed for level less than 15 through [**2144-5-23**]. 18. Bactrim Double-Strength one tablet per PEJ tube b.i.d. through [**2144-5-23**]. 19. Lidoderm 5% patch 12 hours on, 12 hours off per patient's preference. FOLLOW-UP: The patient was instructed to follow-up with his primary care physician following his discharge from the hospital. At the time of discharge, the patient was medically stable and maintaining oxygen saturation in the mid 90s on a 50% face tent. [**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D. [**MD Number(1) 7855**] Dictated By:[**Name8 (MD) 2507**] MEDQUIST36 D: [**2144-5-17**] 03:15 T: [**2144-5-17**] 15:33 JOB#: [**Job Number 58174**]

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Discharge summary

report

Admission Date: [**2185-9-28**] Discharge Date: [**2185-11-18**] Service: CARDIOTHORACIC Allergies: Morphine Sulfate Attending:[**First Name3 (LF) 1505**] Chief Complaint: Worsening shortness of breath with mild to moderate exertion Major Surgical or Invasive Procedure: [**2185-10-4**] CABGx3. Vein grafts to left anterior descending, obtuse marginal one and two. (Left internal mammary artery without flow) [**11-5**] Explor Lap/ open CCY and GJtube placement [**11-8**] Permacath HD line placed [**11-9**] Tracheostomy w takeback for bleeding History of Present Illness: 84 year old male with history of MVP, moderate MR, mild AI, TR, mild pulmonary hypertension on recent Echo complaining of worsening shortness of breath. He underwent a cardiac catheterization at [**Hospital6 5016**] that showed three vessel disease. He was then transferred to [**Hospital1 18**] for further cardiac evaluation and referral for cardiac revascularization. Past Medical History: CAD, with +ETT MI [**19**] years ago Hyperlipidemia OA/osteoporosis Chronic sinusitis Rheumatoid arthritis MVP with moderate MR CRI Social History: Lives at home with wife, denies alcohol or tobacco use (quit 40 years ago) Family History: Noncontributory Physical Exam: 84 year old male in NAD status post cardiac catheterization lying in bed HEENT- PERRL CVS- S1/S2 no m/r/g Pulm- B/S CTA ABD-S/NT/ND Vascular- no carotid bruits, varicosities. Left groin hematoma with distal pulses present, groin hematoma expanding on admission Pertinent Results: [**2185-10-1**] 05:57PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.015 [**2185-10-1**] 05:57PM URINE Blood-MOD Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM [**2185-10-1**] 05:57PM URINE RBC-[**4-29**]* WBC-[**10-9**]* Bacteri-FEW Yeast-NONE Epi-0 [**2185-9-28**] 07:43PM WBC-14.8* RBC-2.56* HGB-7.8* HCT-24.1* MCV-94 MCH-30.6 MCHC-32.5 RDW-16.9* [**2185-9-28**] 07:43PM GLUCOSE-148* UREA N-23* CREAT-1.5* SODIUM-140 POTASSIUM-5.2* CHLORIDE-112* TOTAL CO2-17* ANION GAP-16 [**2185-9-28**] 09:21PM TYPE-ART PO2-154* PCO2-25* PH-7.43 TOTAL CO2-17* BASE XS--5 [**2185-9-28**] 10:03PM ALT(SGPT)-13 AST(SGOT)-15 LD(LDH)-168 CK(CPK)-53 ALK PHOS-54 TOT BILI-0.4 CT ABDOMEN W/O CONTRAST [**2185-9-28**] 8:53 PM REASON FOR THIS EXAMINATION:r/o retroperitoneal hematoma IMPRESSION: 1. No evidence for retroperitoneal hematoma. 2. Right inguinal hernia containing a small section of small bowel at its proximal most aspect. No evidence for bowel obstruction or ischemia. 3. Diffuse atherosclerotic disease throughout the aorta. CAROTID SERIES COMPLETE [**2185-9-29**] 10:49 AM Reason: PRE-OP CABG assess for stenosis HISTORY: 84-year-old man preop CABG, assess for stenosis. Right IJV line. FINDINGS: The cervical portions of the carotid and vertebral arteries were examined with duplex ultrasound bilaterally. Wall thickening is present in the right carotid artery. The peak systolic velocities of the right internal, common, and external carotid arteries are 72, 47 and 43 cm/sec respectively. The right ICA-CCA ratio is 1.53. Mild wall thickening is seen in the left carotid artery. The peak systolic velocities of the left internal, common, and external carotid arteries are 64, 61 and 46 cm/sec respectively. The left ICA-CCA ratio is 1.04. There is appropriate antegrade flow in the left vertebral artery. The right vertebral artery could not be visualized. Overall, visibility on the right was less clear than on the left. This nonvisualization most likely related to technical factors. If there is concern for a vertebral artery stenosis on the right (i.e., the patient has symptoms referable to the posterior circulation of the brain), then a follow-up study or an alternative study (such as a CTA or MRA) could clarify. IMPRESSION: Minor wall thickening in the carotid arteries with no significant carotid stenosis (evaluated as less than 40% stenosis bilaterally). Cardiology Report ECHO Study Date of [**2185-9-29**] Conclusions: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular ejection fraction is preserved (LVEF 60%), although the inferior and posterior walls appear hypokinetic. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. CT HEAD W/O CONTRAST [**2185-10-7**] 9:41 AM Reason: S/P CABG, NOW UNRESPONSIVE, NEURO CHANGES, EVAL FOR STROKE, BLEED FINDINGS: The patient is intubated. There is generalized cerebral atrophy. There is no intracranial hemorrhage, abnormal extra-axial fluid collection, mass effect or midline shift. The ventricles are symmetric, and the cisterns are patent. Minimal fluid or focal thickening is present in the sphenoid and right maxillary sinus, possibly related to endotracheal intubation. IMPRESSION: No intracranial hemorrhage or mass effect. Cardiology Report ECG Study Date of [**2185-9-28**] 7:47:46 PM Baseline artifact. Sinus rhythm. Borderline low limb lead voltage. Marked left axis deviation consistent with left anterior fascicular block. Right bundle-branch block. Probable underlying inferolateral myocardial infarction. Non-specific ST-T wave changes consistent with ischemia, etc. No previous tracing available for comparison. Clinical correlation is suggested. [**Known lastname **],[**Known firstname **]:[**Hospital1 18**] Radiology Detail - CCC Record #[**Numeric Identifier 65676**] FINAL REPORT INDICATIONS: 84-year-old man with coronary artery disease status post coronary artery bypass graft surgery with rising creatinine, lactate, and leukocytosis. COMPARISONS: [**2185-10-28**]. TECHNIQUE: Axial non-contrast CT images of the abdomen and pelvis were obtained with oral contrast, and sagittal and coronal reconstructions were also performed. CT OF THE ABDOMEN WITHOUT IV CONTRAST: The lung bases show a few patchy ground-glass opacities, which may represent pulmonary venous congestion. There is a nasogastric tube in the stomach, and a left-sided chest tube. There are smaller, but persistent, bilateral pleural effusions. There is also a tiny pneumothorax on the left. There is new ascites surrounding the liver. The gallbladder is distended, with pericholecystic fluid seen. The wall cannot be seen on this non-contrast study. The liver is unremarkable. The pancreas, adrenal glands, and spleen are within normal limits. There are unchanged bilateral renal cysts. The left kidney again demonstrates an atrophic appearance, compared to the right side. There is no mesenteric or retroperitoneal lymphadenopathy, or free air. The stomach and small bowel are within normal limits. Again noted is thickening of the splenic flexure of the colon and descending colon and sigmoid. The distribution of the thickening raises possibility of ischemic colitis. CT OF THE PELVIS WITHOUT INTRAVENOUS CONTRAST: Again noted is a nonobstructing right-sided inguinal hernia. There is a Foley catheter in the bladder. The sigmoid demonstrates wall thickening with slight stranding. The aorta and iliac vessels are calcified. There is no pelvic or inguinal lymphadenopathy. BONE WINDOWS: Again noted are marked degenerative changes of the lumbar spine, but no suspicious lytic or blastic lesions. IMPRESSION: 1. New gallbladder distention and pericholecystic fluid, as well as perihepatic ascites. These findings are suspicious for acalculous cholecystitis in this clinical setting, but correlation with clinical factors and an ultrasound, if clinically indicated, is advised. 2. Colitis of the descending and sigmoid colon. This distribution raises the question of ischemic colitis. Findings were discussed with Dr. [**Last Name (STitle) 65677**] at 12:20 on [**2185-11-5**]. THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1507**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: SUN [**2185-11-13**] 12:55 AM Procedure Date:[**2185-11-5**] [**Known lastname **],[**Known firstname **]:[**Hospital1 18**] Radiology Detail - CCC Record #[**Numeric Identifier 65676**] FINAL REPORT INDICATION: 84-year-old man with mental status changes. Unresponsive. Status post CABG. TECHNIQUE: Non-contrast head CT. COMPARISON: None. FINDINGS: The patient is intubated. There is generalized cerebral atrophy. There is no intracranial hemorrhage, abnormal extra-axial fluid collection, mass effect or midline shift. The ventricles are symmetric, and the cisterns are patent. Minimal fluid or focal thickening is present in the sphenoid and right maxillary sinus, possibly related to endotracheal intubation. IMPRESSION: No intracranial hemorrhage or mass effect. THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**] Brief Hospital Course: Mr. [**Known lastname 7280**] was transferred to the [**Hospital1 18**] from an OSH after undergoing cardiac catheterization which revealed three vessel disease (90% stenosed LCx, 80% stenosed LAD, 100% occluded RCA, EF 42%). Due to the severity of his disease the cardiac surgery team was consulted for cardiac revascularization. Upon arrival at the [**Hospital1 18**] a left groin hematoma was noted on physical exam, with intact distal pulses. Initially the patient was stable. He then became hypotensive with SBP in the 60's. The patient was quickly resuscitated with fluid boluses and was transferred to the CSRU for observation. The patient was conscious throughout and EKG's did not show any signs of ischemia. CT Abd/Pelvis did not demonstrate any retroperitoneal bleeding. The patient was then transfused four units of PRBC's. Pre-op carotid ultrasound did not show any hemodynamically significant stenosis. On hospital day (HOD) 2 the patient was transferred to the floor while awaiting his MVR/CABG. He was placed on a Nitroglycerin drip for coronary vasodilation. Echo showed LVEF of 60% and 3+ MR. His preop urinalysis was suspicious for infection. A urine culture was obtained that revealed coagulase negative staphylococcus sensitive to levaquin. He was subsequently placed on Cipro for seven days. Preoperatively the patient exhibited some confusion and restlessness. He was easily orientable, however on HOD 4 a 1:1 sitter was ordered. Mr. [**Known lastname 7280**] was usually oriented to person only and required prompting for further orientation. On HOD 5 He was given 10mg Vitamin K x2 doses for an INR of 1.7. On the morning of HOD 6 Mr. [**Known lastname 65678**] INR was 1.3 and he underwent CABGx3 (SVG to LAD, SVG to OM1, SVG to OM2) No MVR was performed. His left internal mammary artery was found to have no flow. Postoperatively he was taken to the cardiac surgery intensive care unit for monitoring. On post operative day one Mr. [**Known lastname 7280**] was very agitated when his propofol was weaned, however he was hypotensive when sedated. He was placed on Haldol for agitiation, and propofol titrated to maintain sedation without hypotension. CT scan of the head was performed and did not show any intracranial hemorrhage or mass effect. Extubated on POD #5 with some postop Afib. Sputum culture showed MRSA. He was transferred to the floor on POD #7. On POD #10, he began to complain of abd. tenderness. CT scan of abdomen was done and general surgery consult obtained. This revealed colonic thickening with stranding consistent with an ischemic process. He was kept NPO and remained on abx per gen. [**Doctor First Name **]. Over the next several days his diet was advanced. On [**10-18**], a PICC line was placed and on [**10-20**] he was on a full liquid diet. On [**10-24**], he had some respiratory distress and was transferred back to the CSRU. Over the next several days, a Swan was replaced, bronchoscopy was done, TEE done, and a repeat CT of the abdomen. He required pressors and was reintubated on [**10-26**]. GI consult was obtained, and he concomitantly started CVVHD on [**10-28**]. Pressure support wean was started, and he was weaned from his IV pressor support. He was extubated on [**11-3**], and re-intubated on [**11-4**] for respiratory distress.The following day, his WBC started to rise significantly and blood cultures showed VRE. He became somewhat acidotic, and general surgery performed urgent exploratory laparatomy with cholecystectomy and GJ tube placement. He was slow to wake from this second general anesthetic. On [**11-8**], a permacath was placed for hemodialysis. The following day, tracheostomy was done and the patient was also taken back to the OR for bleeding at the trach site.The trach tube was replaced at that time. He was weaned from pressure support on the ventilator to trach collar over the next 48 hours and remains on trach collar now. He appears to respond to commands appropriately, but is withdrawn and somewhat depressed. On exam [**11-17**], his belly is soft, BS are coarse, and there is scant bloody drainage when the trach is suctioned. GJ tube became obstructed last week and the patient went to interventional radiology for definitive intervention on the tube on [**11-17**]. Both tubes are patent, but a Dobhoff tube was placed, and can be removed once at rehabilitation and patency of g-j tube confirmed. (stopped [**11-17**]) Medications on Admission: Plavix 75mg (stopped [**2185-9-27**]) Benacor 20mg qd Atenolol 12.5mg qd Folic acid 1mg qd flexeril 10mg qd ultram 50mg qd mvi qd methotrexate 6 tabs each week Discharge Medications: 3. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2* 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*qs qs one month* Refills:*2* 8. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). Disp:*qs qs one month* Refills:*2* 1. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2* 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 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. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*qs qs one month* Refills:*2* 6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). Disp:*qs qs one month* Refills:*2* 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID (4 times a day) as needed. 10. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) mg Intravenous Q12H (every 12 hours): thru [**11-19**]. 12. Prevacid 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO once a day. 13. Linezolid 600 mg/300 mL Parenteral Solution Sig: Six Hundred (600) mg Intravenous Q12H (every 12 hours): thru [**11-19**]. 14. Cefepime 1 g Recon Soln Sig: Five Hundred (500) mg Intravenous Q24H (every 24 hours): thru [**11-19**]. 1. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2* 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 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. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*qs qs one month* Refills:*2* 6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). Disp:*qs qs one month* Refills:*2* 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID (4 times a day) as needed. 10. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) mg Intravenous Q12H (every 12 hours): thru [**11-19**]. 12. Prevacid 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO once a day. 13. Linezolid 600 mg/300 mL Parenteral Solution Sig: Six Hundred (600) mg Intravenous Q12H (every 12 hours): thru [**11-19**]. 14. Cefepime 1 g Recon Soln Sig: Five Hundred (500) mg Intravenous Q24H (every 24 hours): thru [**11-19**]. 1. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2* 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 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. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*qs qs one month* Refills:*2* 6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). Disp:*qs qs one month* Refills:*2* 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID (4 times a day) as needed. 10. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) mg Intravenous Q12H (every 12 hours): thru [**11-19**]. 12. Prevacid 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO once a day. 13. Linezolid 600 mg/300 mL Parenteral Solution Sig: Six Hundred (600) mg Intravenous Q12H (every 12 hours): thru [**11-19**]. 14. Cefepime 1 g Recon Soln Sig: Five Hundred (500) mg Intravenous Q24H (every 24 hours): thru [**11-19**]. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: CAD MI approximately 40 years ago hyperlipidemia OA CRI moderate MR/MVP mild AI, TR, pulmonary hypertension Discharge Condition: good Discharge Instructions: Shower, wash incisions with mild soap and water and pat dry. No lotions, creams or powders to incisions. Call with fever, redness or drainage from incision, or weight gain more than 2 pounds in one day or five pounds in one week. No lifting more than 10 pounds. No driving until follow up with surgeon. Followup Instructions: Follow up with Dr. [**Last Name (STitle) 5017**] in [**11-21**] weeks ([**Telephone/Fax (1) 65679**] Follow up with Dr. [**Last Name (STitle) **] in [**11-21**] weeks ([**Telephone/Fax (1) 65680**] Follow up with Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 1504**] Completed by:[**2185-11-18**]

[ "518.81", "427.31", "790.7", "584.5", "575.0", "560.9", "599.0", "519.09", "414.01", "V09.0", "482.41", "428.0", "998.12", "424.0", "575.11", "411.1", "403.91" ]

icd9cm

[ [ [] ] ]

[ "39.95", "51.22", "00.14", "33.24", "36.13", "00.13", "31.74", "99.15", "96.04", "31.1", "97.02", "96.6", "43.11", "96.72", "88.72", "38.95", "39.61", "38.93" ]

icd9pcs

[ [ [] ] ]

19936, 20015

9704, 14159

292, 571

20167, 20174

1551, 2318

20526, 20842

1237, 1254

14369, 19913

20036, 20146

14185, 14346

20198, 20503

1269, 1532

192, 254

2346, 9681

599, 973

995, 1129

1145, 1221

31,881

107,314

32217

Discharge summary

report

Admission Date: [**2175-1-2**] Discharge Date: [**2175-1-5**] Date of Birth: [**2131-2-27**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: overdose Major Surgical or Invasive Procedure: Endotracheal intubation . History of Present Illness: 43 yo M with Bipolar and suicidal ideations attempted suicide w/ OD on clomipramine (TCA), fluoxetine, Topamax, and Ativan. Unknown doses. All pills mashed up in oatmeal and eaten. Unknown time of ingestion (per ED note ?around 4PM). Pt wrote a suicide letter prior ingestion. Pt was found stuporous at home by a friend, was brought to [**Name (NI) **] by EMS. . In the ED, his VS were 97.8, 79, 84/61, 16, 100%NRB. His MS worsened and he was intubated for airway protection. An EKG showed a QRS of 96. He received once charcoal (50 grams) PO. A bicarb drip was started at 250cc/h. He was admitted to the ICU for further management. Past Medical History: Bipolar disorder Social History: Used marijuana x20yrs but quite marijuana, cigarettes and EtOH in [**2173-10-1**]. Since then, he has had 3 suicide attempts, the last one now. His psychiatrist Dr. [**First Name (STitle) **] has recently been in contact with Dr. [**Last Name (STitle) 75327**] ([**Hospital1 18**] psychiatrist) for planned ECT on Monday. Family History: non-contributory Physical Exam: VS: Temp: 98.7 BP: 102/78 HR: 95 RR: 17 O2sat: 96% on MMV 500x15, FiO2 0.6, PSV 15/5 GEN: Intubated/sedated HEENT: Dilated, slowly reactive pupils, anicteric, ET tube in place NECK: supple, no jvd RESP: CTA b/l anteriorly CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses EXT: no c/c/e, warm, good pulses SKIN: no rashes/no jaundice NEURO: Intubated and sedated. Moves spontaneously all extremities. Pertinent Results: [**2175-1-2**] 08:40PM WBC-6.4 RBC-4.34* HGB-13.6* HCT-40.5 MCV-93 MCH-31.4 MCHC-33.7 RDW-13.1 [**2175-1-2**] 08:40PM PLT COUNT-285 [**2175-1-2**] 08:40PM GLUCOSE-102 UREA N-23* CREAT-1.2 SODIUM-140 POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-22 ANION GAP-17 [**2175-1-2**] 08:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-POS [**2175-1-2**] 08:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-7.0 LEUK-NEG . ABG: pH 7.38 pCO2 42 pO2 344 HCO3 26 . UA negative . EKG: NSR at 88, nl axis, QRS 96 (repeat EKG: QRS 90), NSSTW changes . Brief Hospital Course: 43 yo M with bipolar, suicidal ideations attempted suicide w/ OD on clomipramine (TCA), fluoxetine (SSRI), Topamax, and Ativan. . 1. Intentional toxic ingestion: Intentional overdose on multiple psychiatric medications. Urine and serum tox screens positive only for TCAs. Unclear amount and time-course of ingestion. Required intubation for worsening mental status. Toxicologist contact[**Name (NI) **] in the [**Name (NI) **]. Received charcoal and bicarb drip. QRS interval <106 since arrival. Intubated overnight with goal pH 7.5. Extubated on HD2 without incident. He was transferred to the medical floor on HD3 for observation. He remained alert and oriented x 3 with clear sensorium. He did develop a metabolic acidosis on HD3, which was transient and resolved with IVF with bicarb. . 2. Psych: H/o Bipolar d/o. Given suicide attempt, he was observed by 1:1 sitter. Safety food tray. Psychiatry was consulted. Pt was medically cleared on HD4 and is being transferred to an inpatient psychiatric unit. . Medications on Admission: Clomipramine Lorazepam Fluoxetine Topamax . 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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). . Discharge Disposition: Extended Care Facility: [**Hospital1 **] 4 Discharge Diagnosis: Primary diagnosis: 1. TCA overdose 2. Bipolar disorder . Discharge Condition: Vital signs stable. Alert and oriented x 3. Denies suicidal ideation. . Discharge Instructions: You were admitted to the hospital for a drug overdose in the setting of a suicide attempt. You were admitted to the ICU for close monitoring and were intubated for one day. You were then observed on the regular medical floor and cleared medically for transfer to an inpatient psychiatric unit for further treatment. . Once back at home, if you develop thoughts of wanting to hurt yourself or end your life, chest pain, shortness of breath, or persistent fever> 101, you should return to the ED. . Followup Instructions: You should follow up with your primary care provider and your psychiatrist. . [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "305.23", "969.4", "V15.82", "E950.4", "518.81", "305.03", "966.3", "296.80", "969.0", "780.09", "E950.3" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

3928, 3973

2518, 3529

321, 349

4074, 4148

1881, 2495

4693, 4895

1407, 1425

3624, 3905

3994, 3994

3555, 3601

4172, 4670

1440, 1862

273, 283

377, 1011

4013, 4053

1033, 1051

1067, 1391

44,748

162,861

50830

Discharge summary

report

Admission Date: [**2194-10-15**] Discharge Date: [**2194-10-19**] Date of Birth: [**2126-8-9**] Sex: M Service: CARDIOTHORACIC Allergies: IV Dye, Iodine Containing Contrast Media Attending:[**Known firstname 4679**] Chief Complaint: Lung Nodules Major Surgical or Invasive Procedure: [**2194-10-15**] VATS Left Upper Lobectomy History of Present Illness: Mr [**Known lastname 25068**] returns to Thoracic [**Hospital **] Clinic for follow-up of a newly discovered 14 mm LUL pulm nodule w/ associated mediastinal lymph nodes that were FDG avid on PET [**2194-8-9**]. He recently had a CT head and EBUS w/ mediastinal LN biopsy [**2194-9-17**]. The CT head had a ? cerebellar anomaly and EBUS biopsies were negative for malignancy. He is still asymptomatic and denies F, C, SOB, N, V, CP, weight loss. Given the questions of possible cerebellar anomaly on CT head and Warthin's tumor or pleomorphic adenomas on PET scan, a MRI head to was conducted to evaluate. We therefore scheduled a left VATS, wedge resection and possible upper lobectomy. Past Medical History: CAD, SCC upper arms s/p excision, GERD, erectile dysfunction, spinal stenosis, OA, nephrolithiasis, cervical radiculopathy, anxiety, thrombocytopenia Social History: Cigarettes: [ ] never [ ] ex-smoker [x] current Pack-yrs:_60_ quit: ______ ETOH: [x] No [ ] Yes drinks/day: _____ Drugs: Exposure: [ ] No [ ] Yes [ ] Radiation [ ] Asbestos [ ] Other: Marital Status: [x] Married [ ] Single Lives: [ ] Alone [ ] w/ family [x] Other: wife [**Name (NI) **] pertinent social history: fought in [**Country **] war, currently working at BU at a desk job, hoping to gain full-time employment Family History: Mother - died of cervical cancer Father - died of lung cancer Physical Exam: On Discharge: GEN: NAD, AOx3 CV: RRR, occasional PVC's, nl S1 and S2 PULM: CTAB, no crackles or wheezes. Wound: Left incisons were c/d/i and not oozing. No erythema, swelling or evidence of infection. There was a soft resloving hematoma around the axillary incisions. ABD: Soft, NT, ND EXT: No c/c/e. Pertinent Results: [**2194-10-17**] 04:30AM BLOOD WBC-10.7 RBC-3.96* Hgb-13.0* Hct-38.2* MCV-97 MCH-32.8* MCHC-33.9 RDW-12.3 Plt Ct-165 [**2194-10-16**] 07:15AM BLOOD WBC-10.5 RBC-4.37* Hgb-14.1 Hct-43.2 MCV-99* MCH-32.3* MCHC-32.7 RDW-12.1 Plt Ct-133* [**2194-10-15**] 03:00PM BLOOD WBC-15.2* RBC-4.11* Hgb-13.7* Hct-40.2 MCV-98 MCH-33.4* MCHC-34.1 RDW-12.4 Plt Ct-130* [**2194-10-17**] 04:30AM BLOOD Glucose-119* UreaN-14 Creat-0.8 Na-137 K-4.2 Cl-106 HCO3-24 AnGap-11 [**2194-10-17**] 12:24AM BLOOD Glucose-137* UreaN-13 Creat-0.7 Na-139 K-3.8 Cl-105 HCO3-23 AnGap-15 [**2194-10-15**] 03:00PM BLOOD Glucose-137* UreaN-12 Creat-0.7 Na-141 K-4.2 Cl-109* HCO3-22 AnGap-14 [**2194-10-17**] 08:51AM BLOOD CK(CPK)-319 [**2194-10-17**] 12:24AM BLOOD CK(CPK)-457* [**2194-10-17**] 08:51AM BLOOD CK-MB-5 cTropnT-<0.01 [**2194-10-17**] 12:24AM BLOOD CK-MB-7 cTropnT-<0.01 [**2194-10-17**] 04:30AM BLOOD Calcium-8.5 Phos-2.4* Mg-2.6 [**2194-10-17**] 12:24AM BLOOD Calcium-8.6 Phos-2.3* Mg-2.1 [**2194-10-15**] 03:00PM BLOOD Calcium-7.9* Phos-3.3 Mg-1.7 [**2194-10-15**] CXR: Lung volumes are low. Single mediastinal drain tube is present on the left side. Bilateral lower lung opacities are likely atelectasis. Patient is status post left upper lobectomy. Subcutaneous air along the left lateral chest wall and axilla is attributed to the postop changes. There is no pneumothorax. Pleural effusion, if any, is minimal on the left side. The heart size is top normal. Mild prominence of mediastinal contour is likely from low lung volumes. [**2194-10-16**] CXR: IMPRESSION: Small left apical pneumothorax after chest tube removal. [**2194-10-16**] CXR: Bilateral low lung volumes are noted with crowding of bronchovascular markings. Plate-like atelectasis is again noted within the right lung base. Additionally, there is increased opacification at the right medial lung base which may represent crowding of bronchovascular markings. Cardiac silhouette is top normal but may be exaggerated by low lung volumes. Emphysematous changes are noted along the left hemithorax. Trace left pleural effusion cannot be excluded. Brief Hospital Course: The patient was admitted to the Thoracic Surgery Service following a Left VATS Upper Lobectomy on [**2194-10-15**], which went well without complication (reader referred to the Operative Note for details). After a brief, uneventful stay in the PACU, the patient arrived on the floor NPO, on IV fluids and antibiotics, with a foley catheter, and ***for pain control. The patient was hemodynamically stable. In the evening of POD 1, the patient went into rapid a fib with RVR (HR in 140's) . He was asymptomatic and all other vital signs were stable. However, the arrythmia was not responding to 3 doses of 5 mg IV push lopressor and one dose of 10 mg IV push diltiazem. His blood pressure at that point lowered to about 90/60 and he was transferred to the unit for a dlitiazem drip and blood pressure monitoring. He converted to sinus rhythm several hours later and stayed there thereafter (HR in 80's) with ocassional PVC's. He was taken off the diltiazem drip later that morning. His blood pressure remained stable through out. He went back to the floor on POD3, did well and went home on POD 4. His PCP was notified of the events to ensure proper follow up. Neuro: Post- operatively, the patient received percocet PO which was then switched to oxycodone and tylenol seperately with good effect and adequate pain control. CV: The patient remained more or less stable from a cardiovascular standpoint- please refer to CV events as mentioned above. Vital signs were continously monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirrometry were encouraged throughout hospitalization. GI/GU/FEN: Post-operatively, the patient was allowed to eat a regular (cardiac healthy) diet, which was well tolerated. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. ID: The patient's white blood count and fever curves were closely watched for signs of infection. Wound care involved changing chest tube site dressings as needed. 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 on POD 4, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: isordil 40''', atenolol 50', pepcid 20'', simvastatin 40 or 20' (does not recall dose), aspirin 325', hydrocodone, oxycodone, flexeril, clonopin prn Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 2. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 4. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every [**2-26**] hours as needed for pain. 5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 7. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 8. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. isosorbide dinitrate 40 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO Q8H (every 8 hours). 10. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 11. atenolol 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 7 days. Disp:*28 Tablet(s)* Refills:*0* 12. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet Sublingual every five minutes for fifteen minutes as needed for angina. Disp:*25 tablets* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Lung Nodules Atrial Fibrillation with Rapid Ventricular Response Exacerbation of Cervical radiculopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure of taking care of you during your stay at [**Hospital1 18**]. You were admitted following a VATS Left Upper Lobectomy. Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience: -Fevers > 101 or chills -Increased shortness of breath, cough (it is normal to cough up blood tinge sputum for a few days) or chest pain -Incision develops drainage -Chest tube site: remove dressing 48 hours after removal and cover site with a bandaid until healed. -Should chest tube site begin to drain, cover with a clean dry dressing and changes as needed to keep site clean and dry Atenolol Take 25 mg three times per day, as directed, for the next week. After this time, pending approval of your primary care physician, [**Name10 (NameIs) **] may switch back to your home regimen of atenolol 50 mg by mouth daily. Pain -Acetaminophen 650 mg every 6 hours as needed for pain. Do not take more than 4000 mg acetaminophen per day. -Ibuprofen 400 mg every 6 hours as needed for pain -Oxycodone 5-10 mg every 4-6 hours as needed for pain -No driving while taking narcotics -Take stool softners with narcotics Activity -Shower daily. Wash incision with mild soap & water, rinse, pat dry -No tub bathing, swimming or hot tubs until incision healed -No lotions or creams to incision site -No lifting greater than 10 pounds until seen -Walk 4-5 times a day for 10-15 minutes increase to a Goal of 30 minutes daily 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. Followup Instructions: Please follow up with Dr. [**First Name (STitle) **] in clinic in 2 weeks. Call [**Telephone/Fax (1) 2348**] to confirm appointment date and time. You should arrive 30 minutes early for a chest x-ray before your appointment. Please follow up with your Primary Care Physcian in 1 week to continue to monitor your current medical issues as well as to discuss with him the new development of atrial fibrillation. Completed by:[**2194-10-19**]

[ "162.3", "300.00", "305.1", "530.81", "287.5", "V10.83", "723.4", "427.31", "607.84", "278.00", "715.90", "414.01", "724.00" ]

icd9cm

[ [ [] ] ]

[ "32.41", "38.91" ]

icd9pcs

[ [ [] ] ]

8459, 8465

4307, 7082

320, 365

8613, 8613

2190, 4284

10500, 10943

1787, 1850

7282, 8436

8486, 8592

7109, 7259

8764, 10477

1865, 1865

1880, 2171

268, 282

393, 1085

8628, 8740

1107, 1258

1665, 1771

69,587

158,288

38587

Discharge summary

report

Admission Date: [**2181-7-5**] Discharge Date: [**2181-8-3**] Service: UROLOGY Allergies: Zocor / Erythromycin Base / Bactrim / Sulfa (Sulfonamide Antibiotics) / Invanz / Latex / Adhesive / Midazolam / Fluconazole Attending:[**First Name3 (LF) 4533**] Chief Complaint: Bladder Cancer Major Surgical or Invasive Procedure: [**2181-7-5**], Dr. [**First Name (STitle) **], Robot-assisted laparoscopic cystoprostatectomy, bilateral pelvic lymph node dissection, and ileal conduit urinary diversion [**2181-7-13**], Dr. [**First Name (STitle) **], 1. Exploratory laparotomy, drainage of fungal abcess and urine in peritoneum 2. Revision of ureteroileal anastomosis on the left and a reinforcement of the anastomosis on the right. 3. Endoscopic exam of inside of ileal loop, placement of bilateral ileal conduit to ureter to kidney stents. 4. Reclosure of abdomen. [**2181-7-12**]: Interventional radiology 1. Nephrostogram. 2. Right percutaneous nephrostomy catheter placement. [**2181-7-25**]: Interventional radiology 1. Bilateral retrograde ureterogram, ileal loopogram. 2. Left percutaneous nephrostomy catheter placement. History of Present Illness: 87M pmh CaP s/p brachy [**2169**] w/ [**2-28**] gross hematuria w/ w/u osh, CT A/P negative, no cytology reports, [**3-28**] cystoscopy and TURBT unk location adenoCA ?muscle invasion, [**2181-5-15**] Dr. [**First Name (STitle) **] visit, slides reviewed Adenocarcinoma, moderately differentiated, extensively invading muscularis propria. Past Medical History: prostate cancer brachytherapy in [**2169**] at [**Location (un) 68753**]Hospital; bilateral hip replacement in [**2175**]-[**2176**];pacemaker in [**2178**]; urethral sling for incontinence placed and subsequently removed in [**2179**]; and ureteral laser lithotripsy in [**2181**]. DM, HTN He reports continuous urinary incontinence for which he wears pads. He's had toruble with recurrent proteus UTI's. He denies bowel or rectal problems. Social History: He lives alone in a house adjacent to another daughter and grandson. [**Name (NI) **] has a 60 pack-year smoking history. Physical Exam: AFVSS abdomen: soft, non-tender, non-distended, urostomy pink/patent with stents in place and NGT in urostomy, b/l nephrostomy tubes draining clear yellow urine, JP [**Last Name (un) **] with sanguinous discharge c/w urine ext: w/w/p, no c/c/e Pertinent Results: [**2181-8-3**] 04:56AM BLOOD WBC-9.6 RBC-3.36* Hgb-9.6* Hct-30.6* MCV-91 MCH-28.6 MCHC-31.4 RDW-16.2* Plt Ct-478* [**2181-8-3**] 04:56AM BLOOD Glucose-173* UreaN-11 Creat-0.6 Na-134 K-3.8 Cl-102 HCO3-23 AnGap-13 [**2181-8-2**] 06:31AM BLOOD ALT-124* AST-119* AlkPhos-444* TotBili-0.4 [**2181-8-1**] 01:02AM BLOOD GGT-470* [**2181-7-31**] 06:12AM BLOOD Albumin-2.2* Calcium-7.9* Phos-2.8 Mg-1.9 [**2181-8-2**] 06:31AM BLOOD Ferritn-752* [**2181-7-22**] 05:31AM BLOOD Triglyc-121 [**2181-7-17**] 07:00AM BLOOD TSH-4.8* [**2181-7-29**] 06:11AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE [**2181-7-24**] 05:33AM BLOOD CRP-216.1* [**2181-7-29**] 06:11AM BLOOD HEPATITIS C - RIBA-Test [**2181-8-1**] 02:15PM ASCITES WBC-540* RBC-25* Polys-40* Lymphs-26* Monos-0 Macroph-33* Other-1* [**2181-8-1**] 02:15PM ASCITES TotPro-4.0 Creat-0.6 Albumin-1.6 [**2181-8-3**] 09:31AM OTHER BODY FLUID Creat-PND [**2181-8-1**] 2:15 pm PERITONEAL FLUID PERITONEAL FLUID. GRAM STAIN (Final [**2181-8-1**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count. FLUID CULTURE (Final [**2181-7-30**]): ENTEROBACTER CLOACAE. >100,000 ORGANISMS/ML.. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. ENTEROCOCCUS SP.. GROWING IN BROTH ONLY. REPORTED BY PHONE TO DR. [**Last Name (STitle) **] ([**Numeric Identifier 85788**]) ON [**2181-7-27**] AT 10:37AM. ENTEROCOCCUS SP.. GROWING IN BROTH ONLY. REPORTED BY PHONE TO DR. [**Last Name (STitle) **] ([**Numeric Identifier 85788**]) ON [**2181-7-27**] AT 10:37AM. 2ND MORPHOLOGY. PROTEUS MIRABILIS. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. REPORTED BY PHONE TO DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Numeric Identifier 85788**]) ON [**2181-7-27**] AT 10:37AM. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROBACTER CLOACAE | ENTEROCOCCUS SP. | | ENTEROCOCCUS SP. | | | PROTEUS MIRABILI | | | | AMPICILLIN------------ <=2 S <=2 S =>32 R AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- 32 R <=1 S CEFTAZIDIME----------- =>64 R <=1 S CEFTRIAXONE----------- =>64 R <=1 S CIPROFLOXACIN---------<=0.25 S =>4 R GENTAMICIN------------ <=1 S 8 I MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- 64 I <=16 S 32 S PIPERACILLIN/TAZO----- =>128 R <=4 S TETRACYCLINE---------- =>16 R <=1 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S =>16 R VANCOMYCIN------------ 1 S <=0.5 S ANAEROBIC CULTURE (Final [**2181-8-1**]): UNABLE TO R/O OTHER PATHOGENS DUE TO OVERGROWTH OF SWARMING PROTEUS SPP.. FUNGAL CULTURE (Final [**2181-8-1**]): [**Female First Name (un) **] ALBICANS. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. Brief Hospital Course: [**2181-7-5**], Dr. [**First Name (STitle) **], Robot-assisted laparoscopic cystoprostatectomy, bilateral pelvic lymph node dissection, and ileal conduit urinary diversion Patient was admitted to Urology after undergoing Robot-assisted laparoscopic cystoprostatectomy, bilateral pelvic lymph node dissection, and ileal conduit urinary diversion. No concerning intraoperative events occurred; please see dictated operative note for details. The patient received perioperative antibiotic prophylaxis. The patient was transferred to the ICU in stable condition. On POD#1, he was extubated without complication and transferred to the floor. On POD#3, his pain was controlled with IV pain medications and he was eventually transitioned to PO pain medications as his diet was advanced over the next several days. Also on POD3 his NGT was removed. As his JP output had decreased, it the JP was then removed on POD 4. With return of bowel function by POD5, his diet was advanced from sips to clears. By POD6 he was adavanced to a house diet, was ambulating out of bed, and his stents were d/c??????d. His intraop ucx showed [**Female First Name (un) **], and another ucx was sent. He was started on fluconazole. His wbc was 14 from 11, Cr 1.1. He developed diarrhea, but c was dif neg. By POD7 - [**2181-7-12**]: Interventional radiology 1. Nephrostogram. 2. Right percutaneous nephrostomy catheter placement. Patient was noted to have decreased urostomy output, going from 1800 to 800 over 24hrs. A foley placed, but no change was observed. His Creatinine went from Cr 1.3->1.7-2.1, and his wbc was 18, and his hct was slightly decreqased at 28. He continued on fluc, received 2U prbc. A CT A/P showed R hydroureter w/ mild hydro and pelic fluid collection around conduit, but no abscess identified. Therefore a R PCN was placed, with a decreased in Cr from 1.7->1.6. Shortly therafter, he noted shortness of breath without desaturation - and no documented desats. Therefore, lasix was administered with good result. CXR showed mild b/l pleural eff. To r/o PE, a v/q scan was obtained which was neg. A medical cosnult was then obtained, which rec an ECHO which showed: mild AS stenosis EF>60%. Ultimately, the decision was made to return to the OR to explore his abdomen. POD 8/0: [**2181-7-13**], Dr. [**First Name (STitle) **], 1. Exploratory laparotomy, drainage of fungal abcess and urine in peritoneum 2. Revision of ureteroileal anastomosis on the left and a reinforcement of the anastomosis on the right. 3. Endoscopic exam of inside of ileal loop, placement of bilateral ileal conduit to ureter to kidney stents. 4. Reclosure of abdomen. Pod9/1 - 19/11 He initially did wwell postoperatively, however he continued again to have increasing output from his JP over the next 10 days despite the revised anastomoses. Numerous gentle manipulations of the stents were performed in the urostomy to faciliatate urostomy drainage, without success. The right PCN produced copious yellow urine, leading us to believe that the left anastomsis might still be leaking. Additionally, he develped some profuse diarrhea, with one episode of bright red blood per rectum. C diff was again sent, and found to be negative. GI was consulted for guiac positive stools and continued hematocrit drop. He was started on [**Hospital1 **] PPI, milk of magnesia, and sucralfate, and all medications that could increase the propensity to bleed were stopped. He recieved 4U pRBC over this time, and his stools eventually normalized and his hematocrit stabilized without further need for blood. During this time his albumin was found to be low, and his appetite was poor. Nutrition was consulted, and the nutrition team rec placement of a PICC line and starting TPN. He received TPN for ~1.5 weeks while we encourgaed PO and provided nutritional supplements. Phsyical therapy followed and helped with ambulation. Our ostomy nurse helped him with wound and ostomy care. After receioving TPN for approximately 6 days, his LFTs were noted to slowly rise and were carefully monitored. POD20/12/0 - Given his continued high JP output (~1.5L/day), which was felt to be secondary to a anastomotic leak, the patient was taken to IR suite for a tube(stent) study and loopogram. This revealed persistent left ureteral-ileal leak, therefore L PCN was placed, JP exchanged, and Urine and wound cultures were sent. POD21/13/1 - 24/16/4 - His LFT's continued to rise despite all hepatotoxic medications being d/c'd. They continued to remain elevated even as TPN was weaned to off. Our infectious disease team was again consulted and fluconaczole was switched to micafungin, also to reduce hepatotoxicity. Urine and wound cultures from the IR suite were found to be positive for: 2 sp enterococcus, proteus and yeast. The infectious disease service reccomended that Unasyn was added to micafungin. Additionaly, on POD 22, patient spiked a temperature to 101.2, and repeat blood and urine cultures were sent and showed again yeast and enterococcus. CXR was obtained and was negative. Urine culture was noted to be positive for yeast as well as proteus. Per infectious disease, Ciprofloxacin was added to treat the proteus infection, to which it was sensitive. POD25/17/5 - 29/21/9 - Patient's WBC remained generally within normal limits at the end of his hospitalization. His JP drain output also remained low (~100-200 cc per day). Test of the JP fluid for creatinine on the day of discharge was still consistent with urine (16.9), so the decision was made to d/c him to rehab with the JP drain in place. It will be re-evaluated at his followup appointment with Dr. [**First Name (STitle) **] on [**8-8**]. Consultation of the hepatobiliary service for his elevated liver enzymes resulted in paracentesis and drainage of ~750cc of ascitic fluid. The etiology of his ascites/cirrhosis remains unlcear, however their final reccomendation was to avoid fluconazole in the future. On final consultation, the infectious disease service reccomended continuing all antibiotics (micafungin, unasyn, and ciprofloxacin) until his followup appointment with them on [**2181-8-14**]. At the time of discharge, the patient was tolerating a good PO diet, and having regular bowel movements and passing flatus. He was afebrile, and all vital signs were stable. His pain was controlled primarily with tylenol, and rare breakthrough narcotic medication. He was able to ambulate with assist with his nurse and physical therapy. He was having good urostomy and b/l nephrostomy output. His lower wound had been opened (~2 inches at the inferior aspect of the wound, and was being packed wet to dry with saline soaked guaze twice a day,a nd remained free of purulent exudate or erythema. His staples were removed, and his incisions were otherwise clean, dry, and intact with steri strips applied. Discharge Medications: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. 2. Ampicillin-Sulbactam 3 gram Recon Soln Sig: Three (3) Recon Soln Injection Q6H (every 6 hours): Continue through [**2181-8-14**]. Disp:*360 Recon Soln(s)* Refills:*2* 3. Micafungin 100 mg Recon Soln Sig: One Hundred (100) Recon Soln Intravenous Q24H (every 24 hours): Continue through [**2181-8-14**]. Disp:*3000 Recon Soln(s)* Refills:*2* 4. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 14 days. Disp:*28 Tablet(s)* Refills:*0* 5. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO DAILY (Daily). 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 7. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 9. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itchiness. 11. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 12. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 16. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 17. Sarna Anti-Itch 0.5-0.5 % Lotion Sig: One (1) Topical four times a day as needed for itching. 18. Insulin Regular Human 100 unit/mL (3 mL) Insulin Pen Sig: sliding scale Subcutaneous QAC and QHS. Discharge Disposition: Extended Care Facility: [**Hospital3 1122**] Center - [**Hospital1 3597**] Discharge Diagnosis: Bladder cancer Discharge Condition: Stable Discharge Instructions: -Please resume all home meds -avoid tylenol as it is bad for your liver -Do not drive while taking narcotic pain medication -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication, discontinue if loose stool or diarrhea develops -You may shower, but do not immerse incision, no tub baths/swimming -Small white steri-strips bandages will fall off in [**5-25**] days, you may remove at that time if irritating, your JP drain will be evaluated by Dr. [**First Name (STitle) **] at your follow-up appointment --If you have fevers > 101.5 F, vomiting, or increased redness, swelling, or discharge from your incision, call your doctor or go to the nearest ER -Please refer to visiting nurses (VNA) for management of the ileal conduit. - You are being discharged without your enalapril (blood pressure medication). Please see your primary care provider when you are returned to home for blood pressure and kidney function check and to restart your enalapril. Followup Instructions: Please call Dr.[**Name (NI) 24219**] office ([**Telephone/Fax (1) 33927**] for follow-up on [**2181-8-8**]. On [**2181-8-8**] you will need to have LABS drawn so that they will be ready for your appointment with ID on [**2181-8-14**] (CBC w/ diff, Chem 7, LFTs - please have this done when you see Dr. [**First Name (STitle) **] in clinic that day) Please call Infectious disease clinic @ [**Telephone/Fax (1) 457**] this week to confirm your f/u appointment for [**2181-8-14**]. You will be on antibiotics through [**2181-8-14**]. You will also need to make arrangements for f/u with GastroEnterology for [**2181-8-14**] as well. You may do this at [**Hospital1 18**] or with your own GI specialist in [**Hospital1 **] MA..Dr. [**Last Name (STitle) 17562**].

[ "198.82", "188.8", "997.5", "112.2", "458.29", "998.59", "584.9", "401.9", "250.00", "567.29", "995.92", "038.9", "518.5" ]

icd9cm

[ [ [] ] ]

[ "40.3", "56.52", "38.93", "87.74", "99.15", "56.51", "54.91", "54.12", "57.71", "54.62", "55.03" ]

icd9pcs

[ [ [] ] ]

15344, 15421

6479, 13329

343, 1158

15480, 15489

2413, 6360

16560, 17327

13352, 15321

15442, 15459

15513, 16537

2149, 2394

289, 305

1186, 1526

6443, 6456

1548, 1994

2010, 2134

6392, 6407

4,949

180,710

46412

Discharge summary

report

Admission Date: [**2198-9-6**] Discharge Date: [**2198-9-11**] Date of Birth: [**2144-5-29**] Sex: F Service: MEDICINE Allergies: Tetracycline Attending:[**First Name3 (LF) 2159**] Chief Complaint: shortness of breath, bilateral eye swelling, and fever Major Surgical or Invasive Procedure: none History of Present Illness: 54yoW with h/o atypical thrombotic microangiopathy/TTP on chronic plasmapheresis, CKD, obesity, HepB and HepC, presenting with shortness of breath, bilateral eye swelling, and fever. She was admitted [**7-24**]/-[**2198-7-29**], [**Date range (1) 25044**]/06 and [**Date range (1) 98602**]. During the [**7-/2198**] admission she was treated for coagulase negative Staph bacteremia with Vancomycin. She was then admitted with acute on chronic renal failure. ARF was attributed to vancomycin, and she antibiotics were changed to Linezolid. She was again admitted for acute renal failure. The last admission was for SOB and eye swelling. In [**7-/2198**] her right AV fistula, used for plasmapheresis, clotted. A tunnelled left IJ was placed; however, she developed a left IJ thrombosis, and this line was pulled. Upper extremity U/S [**2198-8-17**] demonstrated right subclavian and left IJ thrombus. She was treated with antibiotics for line infection and warfarin for anticoagulation. She also has a stent in the right subclavian to SVC. She was without plamapheresis access and missed her last session of plasmapheresis. . She initially presented to [**Hospital1 18**] w/ periorbital edema, disorientation, found to be hypotensive in the ED, responded to IVF. While in the MICU, the pt was was thought to be hypercapneic [**3-8**] obesity hypoventilation. In addition, she was found to be volume overloaded and aggressive diuresis was initiated. The initial periorbital edema was thought to be secondary to SVC syndrome from R SC/ L IJ thromboses. She was continued on anticoagulation, and a MVR was recommended to better categorize the clots. She was initially rx with cipro/Ceftriaxone and Linezolid for prior line infection, possible septic thrombophlebitis, but these were then tailored to Linezolid as monotherapy. She was found to have ARF in the setting of CKD, thought to be secondary to nephrotoxicity from Vancomycin. . Denies pain or difficulty breathing, cannot describe the inciting event that brought her to the hospital. Does not have dyspnea, but has no 02 requirement at home. Complaining of nausea, no vomiting. Past Medical History: Acute on Chronic Renal Failure, [**2198-8-4**], thought [**3-8**] Vancomycin Atypical Thrombotic Microangiopathy since [**2187**] CKD, baseline Cr 2.0-recent ARF with increaced Cr to 5.0 Steroid induced osteoporosis Obesity HTN Hep B and C (past IV drug use) h/o heart murmur L radius fracture, ([**7-10**]) Cataract surgery, L eye 2 mo ago, R eye 2 yrs ago Migraines Social History: Divorced, lives alone. Has two sisters and aunt for social support. Unemployed since [**2187**]. Has one daugher in [**Hospital1 1474**]. Smoking-40yr smoking hx-currently <1ppd, but formerly more. Prior IVDA, last used heroin 10 years ago. Currently on Methadone maintenance. Family History: Father died from unkown malignancy at age 78 Mother had uterine ca-died at age 81 Siblings in good health No FH of kidney or blood dz, no hx of heart disease Physical Exam: Vitals: 135/78 HR 86 RR 18 02 98%4L GEN: Obese woman sitting in bed. Breathing comfortably. HEENT: mild scleral icterus, PERRL (left pupil sluggish), oropharynx clear, no lymphadenopathy CV: RRR, 3/6 systolic murmur at LLSB radiating to LUSB and apex LUNGS: right base with occ crackles, left base with coarse BS, otherwise clear to ausc bilaterally. ABD:obese, hypoactive BS, non-tender EXT:[**3-9**]+ edema pitting to knee, hemosiderin changes, warm with [**2-5**]+ DP pulses NEURO: A&0x3, CN II-XII intact. Pertinent Results: [**2198-9-6**] 11:20AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-POS [**2198-9-6**] 11:20AM URINE HOURS-RANDOM UREA N-305 CREAT-104 SODIUM-23 [**2198-9-6**] 03:44PM PT-18.9* PTT-150* INR(PT)-1.8* [**2198-9-6**] 06:48PM PTT-150* [**2198-9-6**] 08:40AM TYPE-ART TEMP-37.7 PO2-57* PCO2-59* PH-7.30* TOTAL CO2-30 BASE XS-0 COMMENTS-AXILLARY [**2198-9-6**] 07:49AM GLUCOSE-118* UREA N-22* CREAT-3.4* SODIUM-139 POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-26 ANION GAP-15 [**2198-9-6**] 07:49AM CALCIUM-6.2* PHOSPHATE-3.9 MAGNESIUM-1.8 . Imaging: CXR [**9-6**]: Mild pulmonary edema. Interval removal of a left central venous catheter. . L hand XRAY [**9-7**] (pt has distal radius fracture): Interval callus formation with fracture lines still visible with approximate neutral angulation of the distal margin of the radius . CXR [**9-10**]: PA AND LATERAL VIEWS OF THE CHEST: Venous stent is again demonstrated and unchanged in position. The pulmonary vasculature appears less engorged compared to the previous study. Lungs are grossly clear. No pleural effusion is seen. No evidence of pneumothorax. IMPRESSION: Interval improvement in pulmonary vascular congestion. Brief Hospital Course: 54 yo female with h/o of atypical thrombotic microangiopathy/TTP on chronic plasmapheresis, CKD, obesity, HepB and HepC, recently treated for bacteremia/ line infections, who initially presented with SOB and periorbital swelling, found to be severely volume overloaded with L IJ and R SC clots. . 1. Heme- LIJ and RSC vein thrombosis - the patient was continued on anticoagulation with heparin bridge to coumadin with a target INR of [**3-9**], which was achieved on [**2198-9-11**] with an INR of 2.0. The patient is well known to Dr. [**Last Name (STitle) 1366**], who followed her throughout her admission, recommended that an MRV be done to establish sites of future access for plasmapheresis, however the patient exceeded the size requirement for the MR machine and was also not willing to undergo the procedure at the level of sedation necessary for following commands. Dr. [**Last Name (STitle) 1366**] also feels that the patient can be discharged without plasmapheresis access for now and can follow up with weekly labs to monitor for TTP relapse. . 2. [**Doctor First Name **]/TTP- the patient is on chronic plasmapheresis for chronic smoldering atypical TTP. She remained stable throughout admission and plasmapheresis was held per recommendation of Dr. [**Last Name (STitle) 1366**] given poor access and recent line infections . 3. Acute on chronic renal failure- the patient's baseline creatinine was 1.9 back in [**2198-1-4**], and with aggressive diuresis with metolazone and bumetanide, the patient's creatinine trended down to baseline by discharge. . 4. ID- the patient was febrile while in MICU, but was afebrile once she was transferred to the floor with no leukocytosis. She was treated with empiric antibiotics for a possible PNA secondary to physical exam findings and CXR, as well as a previous line infection, and possible septic thrombophlebitis, given LIJ and RSC clots in the setting of bacteremia. The last positive blood culture was on [**8-14**]--> 2/4 bottles positive for CNS and peptostreptococus. She was started on Linezolid and has completed 4 weeks at time of discharge. She will be discharged on oral Linezolid for 2 more weeks, for a total of 6 weeks of antibiotic treatment. . 5. Left radial fracture- cast removed, x-ray shows interval callus formation, neutral angulation, and the patient continues to have soft tissue swelling and mild pain. The patient was started on alendronate, Calcium and Vitamin D supplementation. Should follow up with ortho as an outpatient. . 6. Hep B/Hep C- viral loads checked in [**5-/2198**], Hep B undetectable, Hep C > 8 million. Currently stable. The patient will need liver follow-up as outpatient. . 7. Hypertension- BP meds initially held secondary to hypotension, resumed Metoprolol and Amlodipine on [**9-9**] given BP stability which were well-tolerated. . 8. Anemia- secondary to [**Doctor First Name **]/TTP. Hct was stable throughout admission. . 9. Elevated bicarb - the patient is likely having a contraction alkalosis. Labs should be rechecked in Plasmapheresis [**Doctor First Name **]. . 10. Access- R femoral line was pulled on [**9-11**] prior to discharge with the plan to have permanent access placed for future plasmapheresis as per Dr. [**Last Name (STitle) 1366**]. . . Medications on Admission: Metoprolol 50mg [**Hospital1 **] Amlodipine 5mg daily Methadone 20mg daily Bumex 2mg daily Klonopin 1mg [**Hospital1 **] Coumadin 5mg daily Discharge Medications: 1. Methadone 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Oxazepam 30 mg Capsule Sig: [**2-5**] Capsules PO at bedtime as needed. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every Monday). Disp:*4 Tablet(s)* Refills:*2* 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Tablet, Chewable(s)* Refills:*2* 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 11. Bumetanide 2 mg Tablet Sig: 1.5 Tablets PO once a day: Please take in the morning. Disp:*45 Tablet(s)* Refills:*2* 12. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day for 14 days: Please take all of this medication. Disp:*28 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: venous thrombi with severe volume overload Discharge Condition: Stable, ambulating, afebrile Discharge Instructions: 1. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight increases more than 3 lbs. Adhere to 2 gm sodium diet . 2. Please take all medications as prescribed. - Please take your antibiotics, Levofloxacin 500mg daily and Flagyl 500mg three times daily for 2 weeks from time of discharge. Please be sure you finish all of this medication. - Please take your diuretics, Bumex 3mg daily and Metolazone 5mg daily. - We have added Alendronate 70mg weekly (on Monday) as well as calcium and Vitamin D supplements, started for your fracture. - Please take your Coumadin 5mg daily. You will need to get your INR checked weekly, this is very important to monitor so that you don't have an increased risk of bleeding. Additionally, please start your other outpatient medications as prior to admission, Aspirin, Oxazepam, Methadone maintenance, Metoprolol and Norvasc. . 3. Please return to the hospital if you have significant swelling, shortness of breath, chest pain or dizziness. Followup Instructions: 1. Please follow up with the Plasmapheresis [**Name8 (MD) **] and Dr. [**Last Name (STitle) 1366**] on [**2198-9-18**] at 9:15am. 2. Please follow up in [**Hospital3 **] with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11180**] on [**Last Name (LF) 2974**], [**9-14**] at 1:30pm, [**Hospital Ward Name 23**] Building, [**Location (un) **].

[ "443.89", "486", "585.9", "496", "584.5", "278.00", "E930.8", "518.81", "070.54", "996.62", "733.09", "070.32", "401.9", "451.89", "E932.0", "276.7" ]

icd9cm

[ [ [] ] ]

[ "00.14" ]

icd9pcs

[ [ [] ] ]

10000, 10006

5149, 8423

327, 333

10093, 10124

3915, 5126

11174, 11539

3210, 3369

8613, 9977

10027, 10072

8449, 8590

10148, 11151

3384, 3896

233, 289

361, 2504

2526, 2895

2911, 3194

20,296

178,739

21299

Discharge summary

report

Admission Date: [**2132-11-13**] Discharge Date: [**2132-11-21**] Date of Birth: [**2068-2-16**] Sex: M Service: VSU CHIEF COMPLAINT: Acute onset of painful, cold, right leg. HISTORY OF PRESENT ILLNESS: This is a 54 year old male with known peripheral vascular disease who underwent a right fem- popliteal bypass graft in [**2132-3-20**], now here complaining of significant leg pain times two weeks, now with increasing intensity which is describes as a [**9-28**]. He also has noted onset of coolness of the foot and mottling of the skin today. The patient had been on Plavix which he discontinued two months ago. Patient was initially evaluated in the emergency room and he was begun on intravenous heparin at a bolus of 6200 units and infusion started at 1400 units per hour with monitoring of coags. Morphine sulfate was administered to the patient for analgesic control. The patient was seen by the Vascular Service in the emergency room. Patient was prepared for emergent arteriogram with possible surgical exploration. PAST MEDICAL HISTORY: Is significant for tobacco use and peripheral vascular disease, hypertension. PAST SURGICAL HISTORY: As indicated in the history of present illness. The bypass graft that was done was a PTFE. The patient has had an open cholecystectomy and a Dupuytren contracture repair. He denies any drug allergies. MEDICATIONS ON ADMISSION: Lopressor 25 mg B.I.D, aspirin which he does not take on a regular basis and Plavix 75 mg daily which he stopped several weeks ago. SOCIAL HISTORY: Denies alcohol use but has excessive tobacco use. PHYSICAL EXAMINATION: Vital signs: 98.2, 80, 174/80, 16, 97 percent oxygen saturation on room air. General appearance: Alert male with moderate distress. HEENT examination was unremarkable. Lungs were clear to auscultation bilaterally. Heart was regular rate and rhythm. Abdominal examination was benign. Extremity examination showed left lower extremity was warm with palpable pulses and 1 plus ankle edema. The right lower extremity was with erythema to the knee, was cool with 2 plus edema with diminished sensation and weak flexion extension of the ankle and toes. The pulse examination shows palpable radial pulses bilaterally 2 plus, femoral pulses on the right were 1 plus and distal to the right femoral artery pulse all remaining extremity pulses on the right side were absent. On the left his popliteal, posterior tibial and dorsalis pedis pulses were palpable 2 plus. HOSPITAL COURSE: The night of admission the patient underwent a retrograde left common femoral artery access and had an AngioJet of the right femoral-[**Doctor Last Name **] graft, followed by angioplasty of the proximal and distal anastomosis and angioplasty of the popliteal artery. Infusion of 2 mg of tPA and placement of a thrombolysis infusion catheter into the right fem-[**Doctor Last Name **] graft was done at the end of the procedure. The findings were normal aorta and iliacs. The common femoral was occluded. There is a patent profunda femoris. The graft was occluded. There was thrombus and plaque in the popliteal and peroneal arteries with a stenosis of greater than 50 percent present in the mid popliteal artery. The anterior tibial and posterior tibial were occluded. There was a reconstitution of the posterior tibial artery distally. The peroneal was the main run-off vessel to the foot. Stenosis was present and moderately severe at the distal anastomosis. The patient tolerated the procedure well, was continued on tPA infusion and was transferred to the Surgical Intensive Care Unit for continued monitoring and care. The patient remained hemodynamically stable. Aspirin and Plavix were started on [**11-14**]. Intravenous heparinization with tPA was continued for a goal PTT of 60 to 80. Regular vascular checks were continued and his coagulations and hematocrits were monitored and fibrinogen levels were monitored q 4 hours. Adjustments in tPA and heparin were made at that time. The patient did well overnight and returned to the angio suite on [**2132-11-14**]. At that time he underwent a right leg run- off with angioplasty of the knee, popliteal and distal anastomosis of the fem-AK-[**Doctor Last Name **] graft and profunda femoris. There was an angioplasty of the native posterior tibial with rheolytic AngioJet thrombectomy of the right profunda femoris artery. The femoral artery was closed with Perclose. Patient tolerated the procedure and returned to the Vascular Intensive Care Unit for continued monitoring and care. Patient had required intravenous nitroglycerin during the angio procedure for systolic hypertension. This was weaned off by the time he was transferred to the Vascular Intensive Care Unit. The examination showed a groin with serosanguineous drainage but no hematoma and the right foot was warm. Extremity was warm and there was a biphasic DP signal and a monophasic PT signal. Patient did have some ST changes during the procedure. He was treated with nitroglycerin and Lopressor and electrocardiogram was examined. There were no ischemic changes noted. Serial enzymes times one were obtained. Post angio total CPK was 4100. The MB and troponin levels were flat. The patient did well overnight in the Vascular Intensive Care Unit. He remained hemodynamically stable. His examination remained unchanged. There was no groin hematoma. The ST changes resolved with the Lopressor. He was continued on Lopressor, aspirin and Plavix. Coumadinization of 7.5 mg at bedtime was instituted. Intravenous heparinization was continued during the conversion period. His Foley was discontinued. The patient was transferred to the regular nursing floor on [**2132-11-15**]. [**Hospital **] hospital course otherwise was unremarkable except for some mental status changes which occurred on hospital day number 4. Psychiatry was consulted. They felt that the mental status changes were secondary to delirium which was multifactorial in etiology. The patient underwent a chest x-ray which was unremarkable for acute pulmonary process or infiltrates. A head CT was done which was negative for any intracranial bleed or mass. The patient was continued on Haldol for agitation. His narcotics were minimized as necessary and he was begun on vitamin B12. Over the next 48 hours his mental status improved. By hospital day nine patient remained without complaint but was very much interested in returning to rehabilitation for continued therapy. The remaining hospital course was unremarkable. The patient's heparin was discontinued on [**2132-1-31**]. The patient's INR was greater than 2.0 and therapeutic. Discharge planning was instituted. At the time of discharge the patient was stable. Mental status was cleared. Vascular examination was with a warm foot with a triphasic DP and PT bilaterally. DISCHARGE DIAGNOSES: 1. Ischemia of the right extremity secondary to graft occlusion secondary to thrombus status post thrombectomy angioplasty and tPA. 2. Post procedure delirium, resolved. 3. History of alcohol use. 4. History of nicotine abuse. Patient was placed on nicotine patch. DISCHARGE MEDICATIONS: 1. Plavix 75 mg daily. 2. Aspirin 325 mg daily. 3. Nicotine 14 mg patch q 24 hours. Patient to follow up with the primary care physician regarding continuation of smoking cessation program. 4. Metoprolol 75 mg q.i.d. 5. Oxycodone/acetaminophen 5/325 tablets one to two q 4 to 6 hours PRN for pain. 6. Vitamin B12 100 mcg daily. 7. Pentamidine 20 mg tablets B.I.D 8. Coumadin 75 mg at bed time. INR should be monitored at least twice a week. The goal INR is 2.0 to 3.0. These results should be called to Dr.[**Name (NI) 7446**] office. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 6039**] Dictated By:[**Last Name (NamePattern1) 2382**] MEDQUIST36 D: [**2132-11-20**] 18:05:51 T: [**2132-11-20**] 18:56:47 Job#: [**Job Number 56331**]

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1638, 2505

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1598+1599+55298

Discharge summary

report+report+addendum

Admission Date: [**2176-3-14**] Discharge Date: Date of Birth: [**2137-9-14**] Sex: F Service: MICU GREEN HISTORY OF PRESENT ILLNESS: The patient is a 38 year old HIV positive Haitian American woman with a history of seizures and possible CNS toxoplasmosis who presents with a chief complaint of fevers, chills, lethargy and diarrhea. The patient has had the diagnosis of HIV since [**2165**] and her course has been complicated by opportunistic infections including abnormal Pap smears, vulvar and peroneal condylomata, esophageal Candidiasis, disseminated Zoster, HSV keratitis and possible CNS toxoplasmosis with multiple subcortical ring enhanced lesions since on CT since [**2171-9-3**] and a positive Toxoplasmosis IgG titer. She has had these infections despite having CD-4 counts greater than 220 at all times. Her most recent CD-4 count is 1800 with a viral load of 320,000. The patient was doing well and was in her usual state of health until approximately 2:00 p.m. on [**3-13**] when her husband noted her to be complaining and shaking cold. The patient felt more and more tired throughout the afternoon and by early evening was unable to get out of bed, was complaining of severe skin and muscle pain over her entire body. Approximately 2:00 a.m. on the day of admission, the patient's husband tried to get her out of bed and found her unable to move and minimally responsive. At this point, he noted she had been grossly incontinence of watery brown stool with scant streaks of blood and was complaining of extreme thirst. At this point, emergency medical services were called. In the ambulance, the patient was noted to be short of breath and noted to have no palpable blood pressure or measurable oxygen saturation. In the Emergency Department at [**Hospital1 69**], the patient's initial vital signs were stable with a temperature of 100.0, blood pressure of 148/76, respiratory rate of 26, pulse of 113, oxygen saturation of 98% on 4 liters. Over the next hour, her blood pressure dropped to the 60's/30, she was resuscitated with 4 liters of normal saline, given right femoral central line through which a Dopamine drip was started. At that point, the patient was transferred to the Medical Intensive Care Unit for further management. PAST MEDICAL HISTORY: 1. HIV. The patient has a history of reasonable CD-4 counts, all greater than 220 but a recently very high viral load and a history of significant opportunistic infections over the past five years, as noted in the History of Present Illness. Because of the patient's unexpectedly high CD-4 count, she has been worked up for lymphoproliferative disease including studies for HTLV-1 which have been negative. She is scheduled to follow-up with Dr. [**Last Name (STitle) **] of the [**Hospital1 346**] Hematology Service in the future. 2. CNS lesions with the question of toxoplasmosis. The patient presented in [**2171-9-3**] with change in mental status. CT and magnetic resonance scans showed bilateral frontal and temporal ring enhancing hypodense lesions in the subcortical areas, toxoplasmosis IgG antibody was positive though the patient refused brain biopsy. She was treated presumptively with ................ and sulfadiazine for presumed toxoplasmosis. Sulfadiazine was changed to Clindamycin after an episode of acute renal failure in [**2162**]. 3. Seizures. The patient presented with a staring seizure and altered mental status without tonoclonic movements in [**2172-8-3**]. Imaging at that time showed stable central nervous system lesions as described earlier. The patient again refused brain biopsy and was discharged on a regimen of oral Dilantin. 4. Back pain with a history of compression fractures of her L1 vertebral body. 5. Depression. The patient has been on longstanding Zoloft. 6. Hypocalcemia of unknown significance with an idiopathic low parathyroid hormone level. 7. History of a cesarean section 13 years ago. 8. History of tuberculosis exposure from her husband in [**2172**]. She was PPD negative, underwent a three month course of INH with B6 treated at [**Location (un) 8599**]Hospital and had a subsequent PPD test that was also negative. 9. History of recurrent otitis media. MEDICATIONS ON ADMISSION: 1. Dilantin 600 mg p.o. in the morning and 500 mg p.o. in the evening. 2. Neurontin 400 mg p.o. b.i.d. 3. Cleocin 300 mg p.o. t.i.d. 4. Zoloft 100 mg p.o. q. day. 5. Bactrim DS one tablet q. day. 6. ................. 150 mg p.o. b.i.d. 7. Zerit 40 mg p.o. b.i.d. 8. ................. 400 mg p.o. q. day. 9. .................. 400 mg p.o. q. day. 10. Acyclovir 800 mg p.o. b.i.d. 11. Daraprim 500 mg p.o. q. day. 12. Leucovorin 10 mg p.o. q. day. ALLERGIES: She has no known drug allergies. SOCIAL HISTORY: The patient lives with her second husband who is also HIV positive. The patient is not sure whether she or her husband contracted the virus first and believes it was contracted via heterosexual contact. She has one daughter now 13 years old. She has never smoked. She does not use alcohol though admits to prior social use in the past and she has never used intravenous drugs. She immigrated from [**Country 2045**] approximately 10 years ago. PHYSICAL EXAMINATION: Vital signs showed a temperature of 99.2, blood pressure 106/58 on 19 mcg/min of Dopamine and 60 mcg/min of Neo-Synephrine, pulse of 139, oxygen saturation of 93% on 100% nonrebreather and respiratory rate in the 30's. The patient was obese, ill appearing woman in acute distress, responsive to voice and alert and oriented to person, place and date. Her pupils were equal, round and reactive to light. She had no scleral icterus. Her neck was exquisitely tender but supple. Her lungs showed coarse rhonchi bilaterally and audible loose secretions in all lung fields. Her heart was regular and tachycardiac to the 120's, no murmurs were heard and the patient had a hyperdynamic point of maximal impulse. Her abdomen was obese with numerous striae, nondistended, soft, diffusely tender but without rebound. Her extremities were exquisitely tender over all muscle groups, particularly her shoulders and her skin was diffusely tender to the touch. Hands and feet were cold with weak peripheral pulses. LABS: White count of 27.0 with 58% polys, 17% bands, 17% lymphocytes. Hematocrit of 36.9 and a platelet count of 186. PT was 15.2, PTT 25.3, INR 1.5. Sodium 134, potassium 4.8, chloride 104, bicarbonate 9, BUN 19, creatinine 1.1, blood glucose 99. Lactate level was initially 5.6 and rose to 12.5 by her transfer to the Medical Intensive Care Unit. Liver function tests showed an ALT of 37, an AST of 29, CK of 144 with an MB fraction of 3, alkaline phosphatase of 117, amylase of 106 and total bilirubin of 1.5. Calcium 6.6, phosphate 4.8, magnesium 1.0 and albumin was 2.9. Urinalysis was negative and serum tox and urine tox screens were negative and a Dilantin level was 6.8 which corrected to 10.0. Initial arterial blood gases gave a pH of 7.32, PCO2 of 21, PO2 60. Radiologic studies including a chest x-ray which showed patchy opacification of the left base and a clear right lung, chest CT which showed a left lower lobe and left lingular consolidation, no effusion or edema and increased axillary mediastinal lymphadenopathy compared to a prior chest CT. Abdominal CT showed focal segmental dilatations of the distal duodenum and proximal jejunum, edema of the ascending and transverse colon and retroperitoneal lymphadenopathy and a head CT also obtained on admission showed no change in the subcortical lesions compared with the prior head CT from [**2174-5-3**]. It also was remarkable for soft tissue density in the right maxillary and bilateral ethmoid sinuses. Microbiology, stool studies for Cryptosporidium, Giardia, Cyclosporin, ..................., fecal culture, Campylobacter, E. coli, .................. and Clostridium difficile were pending. Fecal leukocytes were negative and ova and parasites were pending. Blood cultures obtained in the Emergency Department were 4/4 bottles positive for Gram positive cocci in pairs and chains by the time of admission to the Medical Intensive Care Unit. A cryptococcal serum antigen was pending. HOSPITAL COURSE: 1. Infectious Disease. The patient presented in severe sepsis with hypotension on near maximal pressors, eventually 400 of Neo, 15 of Levo and 0.08 of vasopressin with tachycardia with chills, fever to 102, severe myalgias and bloody diarrhea. There was a clear left lower lobe infiltrate on chest x-ray and chest CT and positive blood cultures, 4/4 bottles for Gram positive cocci which eventually speciated out to Strep Pneumococcus sensitive to penicillin and Ceftriaxone. The patient was initially started on [**3-14**] on penicillin, Ceftriaxone, intravenous Flagyl and Bactrim plus Solu-Medrol in case of PCP. [**Name10 (NameIs) **] initial stool studies were negative for C. diff, negative for fecal leukocytes, Cryptosporidium, Giardia, Cyclosporin, Microspora, Salmonella, Shigella, Campylobacter, E. coli or ................. On [**3-15**], the patient underwent a bronchoscopy. BAL fluid was negative for PCP, [**Name10 (NameIs) 9269**] fast bacilli and legionella but was positive for sparse Pseudomonas and Enterobacter which were thought to be colonizer rather than pathogen. Repeat blood cultures from [**3-16**] were negative and remain negative to date. On [**3-18**], the patient had an outbreak of vesicular lesions on her face which were swabbed and came back positive for ASV-1. The patient was started on intravenous Acyclovir which was changed to her home regimen of 800 mg p.o. Acyclovir b.i.d. on [**3-27**]. On [**3-18**], the patient's coverage was tailored to high dose penicillin 4 million units q.4h. intravenous and between [**3-18**] and [**3-25**] the patient remained afebrile and was weaned off of pressors. On [**3-20**], the patient was started on Vancomycin and Levofloxacin for broader coverage and concern for resistant Pneumococcus and by [**3-23**] the penicillin and Levofloxacin were discontinued and the patient was maintained on Vancomycin. On [**3-25**] through [**3-27**] the patient had a recurrence of temperature spikes to 102 Fahrenheit and a recurrence of low blood pressures requiring pressors along with bloody perfuse diarrhea. The diarrhea resolved over 24 hours, the blood cultures obtained on the 23rd, 24th, 25th were negative and remain negative to date including fungal isolators. Out of concern for Gram negative sepsis, the patient was started on 160 mg intravenous q.8h. of Gentamycin and also started on p.o. Flagyl which was discontinued on [**3-29**] after three C. diff toxin assays came back negative. The [**Hospital 228**] hospital course has also been significant for a coag negative Staph line infection, blood cultures through her right femoral line on [**3-20**] were positive for coag negative Staph. The spine was re-sited to the right internal jugular and after the patient's recurrent fevers on [**3-25**] and [**3-26**] the right internal jugular vein was re-sited to the right subclavian and the right IJ tip also grew out coag negative staph. By [**3-28**], the patient's recurrent temperature spikes and low blood pressure were resolving. The patient was off pressors and afebrile and it was thought that the patient had been febrile due to her line infections rather than to C. diff infection or Gram negative sepsis. The plan is to discontinue the Gentamycin on [**Last Name (LF) 1017**], [**3-31**] if the cultures remain negative and to continue Vancomycin until seven days after her positive line tip culture from [**3-26**], i.e., [**4-2**]. Of note, on [**3-26**], the patient was started on Daraprim and Clindamycin at her home doses for her usual suppressive regimen for toxoplasmosis. 2. Pulmonary. The patient's initial chest x-ray and chest CT suggested a focal left lower lobe process. Initially her respiratory status was tenuous, she was saturating 92 to 93% on 100% nonrebreather. She was tachypneic and had a profound metabolic anion gap acidosis with a Lactate level as high as 12, bicarbonate level of 9 and arterial blood gases of 7.32, 21, 60. On [**3-14**] in the evening, the patient had a generalized tonoclonic seizure (see neurological below) and in the post ictal period arterial blood gas showed pH of 6.97, PCO2 38, PO2 of 137. At that point, the patient was intubated for airway protection and for management of her lactic acidosis. The patient was initially on assist control ventilation with a tidal volume of 800, rate of 18, FIO2 of 70% and a PEEP of 5. On [**3-20**], the patient was changed to pressure control ventilation for increased plateau pressures and decreasing lung compliance. The patient was initially on an inspiratory pressure of 30, PEEP of 10, FIO2 of 60% and a respiratory rate of 22, pulling tidal volumes of 300 to 400. Chest x-ray at this time showed worsening bilateral fluffy infiltrates and PAO2/FIO2 ratio of less than 200, suggesting evolution of adult respiratory distress syndrome. By [**3-26**] the patient's lung volume had improved with better tidal volumes on lower pressures. The patient's chest x-ray showed clearing of the right lung field and the patient was changed to assist control ventilation with a tidal volume of 400, rate of 25, PEEP of 7.5, FIO2 of 40% and plateau pressors in the 27 to 31 range. Over the next few days, sedation was weaned and the patient was ultimately judged to be ready for pressor support, to which she was switched on [**3-28**] with pressor support of 15 and PEEP of 5. On [**3-29**] the patient was weaned to a pressor support of 10 and PEEP of 5. 3. Cardiovascular. The patient was initially severely hypotensive on support with Neo-Synephrine, Dopamine, Vasopressin. Dopamine was quickly weaned off because of tachycardia. An echocardiogram on [**3-15**] showed an ejection fraction of 40% with marked biventricular hypokinesis, no significant valvular abnormalities. On [**3-20**], Swan Ganz catheter was placed to assess the patient's fluid status. Initial numbers showed a wedge pressure of 20, cardiac output of 4.2 and a systemic vascular resistance of 990. The wedge pressure decreased to 12 with diuresis. The cardiac output increased to 6.8 when Levophed was started. The patient did better and pressors were weaned off by [**3-23**]. Between [**3-25**] and [**3-27**] in the setting of the patient's recurrent temperature spikes the patient had recurrence of hypotension and Levophed was restarted to a level of 5 mcg/min but the patient improved and was able to be weaned off of Levophed by [**3-28**]. Of note, during the [**Hospital 228**] hospital stay, despite aggressive fluid resuscitation initially and again on [**3-26**] and 25, no symptoms or signs of congestive heart failure were noted either on chest x-ray or on clinical examination. 4. GI. The patient presented with bloody diarrhea initially with negative stool studies as described under Infectious Disease and it was decided that the patient's diarrhea was a result of sepsis rather than a GI infection. Over the first several days of her hospital stay, the patient had increase in her liver function tests. By [**3-20**] her total bilirubin was 3.6, her AST was 204, her ALT was 191 and her alkaline phosphatase was 172. A right upper quadrant ultrasound obtained on [**3-20**] was negative for biliary pathology and HEP serologies obtained on the same date were negative for Hepatitis B and Hepatitis C. It was decided that the patient's liver abnormalities were due to her initial hypotension. On [**3-26**], the patient had recurrence of severe guaiac positive diarrhea in association with her temperature spikes. Stool studies at that time showed an asmotic gap of 30, suggestive of a secretory diarrhea and it was suspected that the patient might have infection. However, three C. diff toxin assays were negative and it was then thought that the patient's diarrhea might have been due to advancing her bowel regimen in the setting of advancing tube feeds. Her guaiac positive status was thought to be due to her coagulopathy from DIC (see Heme below). The patient's diarrhea resolved after 24 hours and there has been no recurrence since early in the morning of [**3-28**]. 5. Endocrine. The patient was started on steroids early in her stay for possible PCP and initially had very high blood sugars causing brisk asmotic diuresis. She was initially on a regular insulin sliding scale but when her blood sugars became unmanageable she was switched to an insulin drip sliding scale on which she was maintained on [**3-28**] at which point she was switched to a subcutaneous sliding scale. Her sugars over the past 24 hours have been in the 150 range on this sliding scale. The patient was suspected to be adrenally insufficient due to hyperthermia and persistent hypotension and on [**3-20**] she received two doses of Dexamethasone 10 mg. On the morning of [**3-21**] she underwent a troponin test which showed an a.m. cortisol of 2, a 30 minute post stimulation cortisol of 9.3 and a 1 hour post stimulation cortisol of 8.0 indicative of severe adrenal insufficiency and the patient was started on 100 mg q.8h. of intravenous Solu-Cortef. Over the weekend of [**3-23**] and 22, the patient's Solu-Cortef was weaned to 50 mg q.8h. and then 30 mg q.8h. Stress doses were restarted on [**3-27**] in the setting of the patient's hypotension and fevers and the wean from stress doses was started on [**3-27**]. On [**3-21**], thyroid function tests were obtained which showed a low TSH and low Free T4 indicative of thick euthyroid syndrome. In consultation with the Endocrine Service, it was decided not to replete the patient's thyroid hormone in this setting. 6. Neurological. The patient has a known seizure disorder and has been on p.o. Dilantin for several years. Her Dilantin level on admission was subtherapeutic at 10.0 corrected and she was begun on an equivalent dose of intravenous Dilantin on admission. On [**3-14**], as her first dose of intravenous Dilantin was going in the patient underwent a generalized tonoclonic seizure with repetitive clonic movements of her upper extremities and it was in the immediate postictal period that she was intubated for combination metabolic and respiratory acidosis. She was continued on intravenous Dilantin and her level was supra therapetuic by [**3-18**] at which time her Dilantin was held and it continued to be held through [**3-28**] when her level had fallen to 15.3 corrected. Her Dilantin was then restarted at 200 mg intravenous q.8h. Her most recent level on [**3-29**] was 15.2 corrected. 7. Fluids, electrolytes and nutrition. The patient underwent aggressive fluid resuscitation on presentation and was soon total fluid body overloaded. Diuresis was attempted on [**3-23**] to [**3-25**] with effective diuresis of approximately 4 liters of fluid but on [**3-25**] the patient had recurrence of fever spikes and hypotension and required fluid boluses. When the patient's hypotension resolved by [**3-28**] diuresis was resumed with a current goal of negative 500 cc to 1 liter/day. The patient's initial Lactic acidosis resolved over the first 48 hours of her stay and since that point the patient has had a mild metabolic alkalosis thought to be due to her intermittent diuresis with Lasix. The patient's tube feeds were begun on [**3-20**]. The patient has been tolerating them well at her goal tube feed rate of 70 cc/hr. 8. Heme. The patient's platelet level dropped dramatically over her first several days in the unit to a low point of 12 by [**3-20**]. At that point, DIC screen showed a fibrin degradation level of greater than 1280 and the D-Dymer level of greater than [**2174**] and the patient was judged to be in DIC. She was transfused 2 units of platelets and 2 units of FFP with a steady rise in her platelet level since and her most recent platelet level is 237. Of note, her INR also was elevated into the 3 range while she was in DIC but has since recovered and she never had an abnormal PTT. 9. Lines. The patient has a right subclavian central line, day number 4, a left axillary line day 15, endotracheal day 15 and a Foley catheter. 10. Prophylaxis. The patient has Venodyne and is on Prilosec 40 mg q. day. 11. Code status. The patient remains full code. 12. Communication. The team has been in close contact with the patient's primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9270**] of the [**Hospital 9271**] Community Health Center as well as other Dimmck staff and the patient's family has visited frequently with frequent updates from the team. CONDITION AT TIME OF DICTATION: Guarded. DIAGNOSIS: At the time of this dictation; 1. HIV. 2. Resolving Pneumococcal sepsis. 3. Adult respiratory distress syndrome, resolving. 4. Renal insufficiency. DISCHARGE MEDICATIONS: At the time of this dictation; 1. Ativan drip at 4 mg/hr. 2. Morphine drip at 3.5 mg/hr. 3. Tube feeds at 70 cc/hr. 4. Vancomycin 1.5 grams q.12h. intravenous day #[**2-7**] and the last positive line culture. 5. Daraprim 15 mg q. day, day #3. 6. Clindamycin 300 mg q.8h., day #3. 7. Flagyl 500 mg p.o. q.8h. p.o. 8. Gentamycin 160 mg q.8h. intravenous, day #4. 9. Acyclovir 800 mg b.i.d., day #12. 10. Prilosec 40 mg p.o. q. day. 11. Vitamin C 500 mg p.o. q. day. 12. Zinc sulfate. 13. Regular insulin sliding scale. 14. Tums. 15. Neutra-Phos. 16. Dilantin 200 mg q.8h. intravenous. 17. Solu-Cortef 70 mg q.8h. intravenous. [**Name6 (MD) 9272**] [**Name8 (MD) 9273**], M.D. [**MD Number(1) 9274**] Dictated By:[**Name8 (MD) 9275**] MEDQUIST36 D: [**2176-3-29**] 16:12 T: [**2176-3-29**] 21:59 JOB#: [**Job Number 9276**] Admission Date: [**2176-3-14**] Discharge Date: Date of Birth: Sex: F Service: ADDENDUM TO HOSPITAL COURSE: (Date of this addendum is [**2176-4-18**]) 1. PULMONARY: The patient continued to do well on low levels of pressure support and was extubated on [**4-4**]. Over the course of the next two days, the patient's oxygen saturation continued to be stable on oxygen by nasal cannula. However, on approximately [**4-6**] or [**4-7**], the patient became increasingly more tachypneic and had episodes of decreased oxygen saturation. The patient's tachypnea gradually continued. Serial arterial blood gases were followed quite Lclosely. Initially, the patient's oxygenation PAO2 remained adequate, and CO2 was not elevated. Serial chest x-rays revealed worsening bilateral pulmonary infiltrates. Consideration of bronchoscopy was given, but given the patient's poor oxygenation status, this was not attempted. On [**4-10**], because of increasing tachypnea and decline oxygen saturation, the patient was given a brief trial of BiPAP which she did not tolerate well. As a result, the patient was reintubated. On the day of intubation, the patient underwent a bronchoscopy which was, by gross examination, unremarkable. BAL cultures revealed 1+ PMNs, but no organisms. Later, cultures for bacteria, [**Month (only) **]-fast bacterial fungus, Legionella, PCP were all found to be negative. Subsequent cultures later grew out [**Female First Name (un) 564**] albicans which was felt to be most likely a contaminant, as this is a very typical cause of pneumonia. Over the course of the next several days, the patient's pulmonary status declined significantly. PAO2 and oxygen saturations declined. The patient was tried on multiple ventilation modes including AC and pressure control. The patient's pulmonary status progressed to the point where she was requiring quite high levels of pressure control into the 30s, along with very high PEEPs, along with 100% FIO2. The patient was found to have a metabolic acidosis, but because of extremely poor pulmonary function could not adequately ventilate to correct her acidosis, even given very high respiratory rates and high pressure control settings. The patient's compliance progressed to the point where it was found to be below 10. The etiology of the patient's worsening pulmonary function remained unclear. The patient was considered a candidate for either an open lung biopsy or a VATS procedure, but the patient's pulmonary status was too tenuous during this period to consider this. On [**4-13**], the patient's oxygenation and overall ventilatory status began to improve. Gradually, her FIO2 and PEEP settings were weaned down, as were her pressure controls. The patient tolerated pressure support trials well and was extubated on [**4-17**]. At the time of this dictation, the patient had a maximum oxygen saturation on oxygen by nasal cannula. Subsequent BAL cultures were found to be positive for parainfluenza. The patient was felt to have likely acute respiratory distress syndrome secondary to an underlying parainfluenza respiratory infection. 2. CARDIOVASCULAR: While her pulmonary status was very poor, in the setting of her very high fevers, the patient continued to have a baseline tachycardia of approximately 100 to 120. During the course of her severely worsening pulmonary status, the patient had transient episodes of hypertension. The etiology of these episodes remained unclear. They were somewhat responsive to intravenous fluid boluses. The differential diagnosis of these episodes of hypertension included the patient's sedation drugs, the subcutaneous Octreotide or an infectious etiology of unknown origin. As the patient's pulmonary status improved, the episodes of hypotension resolved. At the time of this dictation, the patient was hemodynamically stable without tachycardia or hypertension. 3. INFECTIOUS DISEASE: The patient completed a 14-day course of vancomycin for her coag-negative Staphylococcus line sepsis. She was continued on her acyclovir for her disseminated herpes simplex virus; as well as her clindamycin and Daraprim for toxoplasmosis coverage. During the first week of [**Month (only) 116**], the patient continually spiked very high temperatures from approximately 103 to 105. In addition to her fevers, the patient continued to have severe voluminous watery diarrhea, approximately 1.5 liters to 2 liters per day. For these fevers with diarrhea in the setting of worsening pulmonary status, the patient received an exhaustive Infectious Disease workup. An Infectious Disease consultation was obtained. Numerous blood, urine, and stool cultures were obtained, all of which were found to be negative. As stated above, a BAL culture performed on [**4-10**] was negative for bacteria, Legionella, PCP, [**Name10 (NameIs) **] [**Name11 (NameIs) 9277**] bacteria. As stated above, extensive multiple stool cultures were obtained including Clostridium difficile and other enteric bacterial pathogens; all of which were negative. Stool AFB was negative. Stool was sent on multiple occasions for Cyclospora, Isospora, Microspora, and cryptosporidia; all of which were negative. On [**4-4**], on the recommendation of Gastroenterology (please see below), the patient was begun on empiric intravenous Flagyl for Clostridium difficile colitis despite multiple negative Clostridium difficile cultures. She was given this for three days without improvement. The patient was also empirically restarted on vancomycin for which she received three days for empiric treatment of line sepsis. On [**4-8**], these antibiotics were discontinued because of the lack of positive cultures or any clinical benefit. Stool viral cultures as well as Giardia cultures were also negative. Despite this extensive workup, no infectious etiology was found to account for the patient's clinical condition. Because of the lack of a clear diagnosis, the patient was referred for pan, head, abdominal, and chest CT scan on [**4-9**]. On chest CT, a left basilar infiltrated was found to be improved with new bilateral patchy diffuse opacification, left greater than right. Enlarged AP prevascular, peritracheal, and precarinal nodes were noted since last examination. Thickening of the ascending colon was noted as was seen on previous CT scans. Head CT revealed diffuse areas of low attenuation of the left basal ganglia, internal capsule, periventricular area, but these were without interval change. Subsequently, duodenal biopsies from the patient's endoscopic procedures were found to be negative for cytomegalovirus. The patient underwent a flexible sigmoidoscopy on [**4-5**] which was unremarkable. On [**4-10**], following intubation, the patient underwent esophagogastroduodenoscopy and colonoscopy. Mild colitis was noted on colonoscopy, but otherwise it was felt to be an unremarkable examination. As stated above, cytomegalovirus biopsies of the duodenum were negative. The patient was found to have mild grade II candidal esophagitis. For this, the patient was begun on intravenous fluconazole. Over the course of this time with her copious stool output, the patient pearl fragments were found in the patient's stool. As a result, she was felt to not be absorbing her HIV prophylactic medications for toxoplasmosis. These were later discontinued. In the setting of the worsening of the patient's pulmonary function, she was empirically treated for PCP for approximately two days. She was given one dose of intravenous pentamidine but tolerated this poorly. The patient was then begun on Bactrim intravenously. The patient was initially not started on intravenous Bactrim because of a concern of a Bactrim allergy, but a careful review by pharmacy of the [**Hospital 228**] hospital course demonstrated that she did tolerate this. The patient also had her steroids changed to Solu-Medrol 60 mg IV q.8.h. for empiric coverage of the antiinflammatory effects of PCP [**Name Initial (PRE) **]. When the patient's BAL cultures were negative for PCP, [**Name10 (NameIs) 9278**] were discontinued. Over the course of the next several days, the patient gradually defervesced when her pulmonary status improved. At the time of this dictation, the patient's only antibiotics including IV fluconazole and IV acyclovir. Because of the patient's quite high fevers, and lack of any positive culture data, and lack of response to any antimicrobial therapy, noninfectious causes were considered in the differential including possible hematopoietic malignancy. Consideration of an abdominal lymph node or bone marrow biopsy were considered, but given the patient's overall very/very tenuous clinical condition, this was deferred to a later time. 4. GASTROINTESTINAL: As stated above, during the first two weeks of [**Month (only) 116**], the patient continued to have copious, approximately 1.5 liters to 2 liters, of watery diarrhea per day. Culture workup as above was negative. On [**4-5**], the patient underwent a flexible sigmoidoscopy which was unremarkable. On [**4-10**], the patient underwent esophagogastroduodenoscopy and colonoscopy with biopsies. Mild colitis was noted. Biopsies were negative for cytomegalovirus. Mild esophageal candidiasis was noted as above. The patient was given several days of therapy with subcutaneous Octreotide with some clinical resolution of her diarrhea. However, when the patient's pulmonary status was very/very tenuous, this was discontinued secondary to concerns of precipitating hypertension. Over the course of the next several days, the patient's diarrhea seemed to resolve without clear explanation of why this occurred. AS stated above, the patient was not felt to absorb any p.o. medication and all of her medications were changed to intravenous. 5. ENDOCRINE: The patient was continued on Solu-Cortef for adrenal suppression. In the setting of her worsening pulmonary function during the second week of [**Month (only) 116**], she was changed back to Solu-Medrol, initially for presumptive coverage of PCP. [**Name10 (NameIs) 2772**], when PCP from the BAL culture was found to be negative, the patient was continued on high-dose Solu-Medrol because of a possible correlation in the improvement of her overall clinical function. At the time of this dictation, the patient's steroids were tapered. A central neuroendocrine etiology to account for the patient's fevers and overall clinical condition was considered. However, serial TSH and thyroid studies were negative. On urine studies, the patient had no evidence of diabetes insipidus. During the patient's clinical decompensation she experienced marked hyperglycemia requiring the use of an insulin drip. At the time of this dictation, this was now discontinued. 6. RENAL: During the first two weeks of [**Month (only) 116**], the patient continued to have very high daily ins-and-outs. Her creatinine remained within normal limits. She continued to have enormous outputs of urine, sometimes as high as 8 liters per day. As stated above, urine studies were not indicative of diabetes insipidus. During the course of her pulmonary decompensation, the patient developed a severe metabolic acidosis of unclear etiology. As stated above, it was extremely difficult to keep the patient adequately ventilated because of her poor lung compliance. The patient remained profoundly acidotic for several days because she could not be adequately ventilated. As her overall clinical condition and the patient's pulmonary status improved, the patient's acidosis resolved. 7. FLUIDS/ELECTROLYTES/NUTRITION: Initially, the patient was started on tube feeds in the first week of [**Month (only) 116**], but the patient had continued problems with nausea and vomiting. Because of this, the patient was begun (and has continued to remain) on total parenteral nutrition as per Nutrition. 8. COMMUNICATIONS/DISPOSITION: Because of the lack of clear etiology for the patient's clinical deterioration and overall condition, and given the extensive negative workup and declining status, the patient's code status was readdressed by her primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9279**]. After lengthy discussion with the patient's husband, the patient was made DNR. However, following recovery of the patient's overall clinical condition and the potential for possibly renewed workup and even a diagnosis, the patient's code status was changed back to full, and this was the case at the time of this dictation. Throughout the [**Hospital 228**] hospital course, the patient's clinical condition was discussed at length and all questions were answered by the medical and nursing staff with the patient's husband. 9. NEUROLOGY: As stated above, a head CT performed on [**4-9**] was without new lesion or interval change. The patient was continued on intravenous Dilantin with careful monitoring of her levels. [**Last Name (LF) 9273**],[**First Name3 (LF) 9272**] 11-811 Dictated By:[**Last Name (NamePattern1) 9280**] MEDQUIST36 D: [**2176-4-18**] 14:33 T: [**2176-4-20**] 11:52 JOB#: [**Job Number 9281**] Name: [**Known lastname 1234**], [**Known firstname 1235**] [**Doctor First Name 1236**] Unit No: [**Numeric Identifier 1237**] Admission Date: [**2176-3-14**] Discharge Date: [**2176-4-22**] Date of Birth: [**2137-9-14**] Sex: F Service: HOSPITAL COURSE: 1. Pulmonary: Over the last few days of her hospitalization, the patient continued to have an excellent oxygen saturation and have a normal respiratory rate on minimal amounts of O2. 2. Infectious Disease: The patient remained afebrile. She will complete a two week course of fluconazole for esophageal candidiasis. Her Aciclovir was changed to po suppressive doses for Herpes. 3. Gastrointestinal: Over the last few days of her hospitalization, the patient gradually increased her po intake. Her total parenteral nutrition was discontinued. She was maintained on PR anti-emetics. 4. Endocrine: On the day of discharge the patient was changed to po prednisone. She was instructed to complete a very slow taper. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: Discharged to [**Hospital1 1238**]. DISCHARGE DIAGNOSES: 1. Sepsis, multiple courses of sepsis. 2. Adrenal insufficiency. 3. Acute respiratory distress syndrome. 4. Liver failure. 5. Viral bronchitis. 6. Fevers. 7. Infectious diarrhea. 8. HIV. 9. Disseminated Herpes. 10. Esophageal candidiasis. FOLLOW UP: The patient will follow up with her primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 1239**] [**Last Name (NamePattern1) 1240**], [**Telephone/Fax (1) 1241**]. Dr. [**Last Name (STitle) 1240**] will coordinate any modifications of the patient's steroid therapy, as well as reinitiating her HIV medications. [**Name6 (MD) 1242**] [**Name8 (MD) 1243**], M.D. [**MD Number(1) 1244**] Dictated By:[**Last Name (NamePattern1) 1245**] MEDQUIST36 D: [**2176-4-22**] 11:00 T: [**2176-4-23**] 11:19 JOB#: [**Job Number 1246**]

[ "780.39", "038.2", "112.84", "996.62", "518.5", "276.2", "042", "054.9", "286.6" ]

icd9cm

[ [ [] ] ]

[ "45.24", "96.72", "33.24", "45.23", "99.15", "45.13" ]

icd9pcs

[ [ [] ] ]

36297, 36362

36383, 36632

21076, 22062

4271, 4773

35548, 36275

36644, 37239

5263, 8244

155, 2288

2310, 4245

4790, 5240

47,450

113,346

9083

Discharge summary

report

Admission Date: [**2108-4-24**] Discharge Date: [**2108-5-10**] Date of Birth: [**2030-11-10**] Sex: M Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 4748**] Chief Complaint: Excruciating right foot pain Major Surgical or Invasive Procedure: [**2108-4-25**] 1. Angiogram: Abdominal aortogram, Serial arteriogram of the right lower extremity, Angioplasty of right above-knee popliteal artery, angioplasty of right superficial femoral artery, StarClose closure of left common femoral arteriotomy. [**2108-4-27**] 1. Angioscopy 2. Right superficial femoral artery to distal anterior tibialis artery bypass with nonreversed cephalic vein. History of Present Illness: Patient is a 77 year old male seen on day of admission by Dr [**Last Name (STitle) 1391**] in clinic who told patient to come to ED for hospital admission. He reports right foot pain starting back in [**Month (only) 404**] when podiatrist diagnosed him with plantar faucitis and prescribed unknown medication which made the patient nauseous prompting discontinuation. The pain persisted while living in [**State 108**] for the winter causing difficulty ambulating while playing golf. He takes Advil regularly with some relief and reports that hanging leg off bed, dependency, improves symptoms. On [**4-19**] worsening pain and concern for toe infection prompted podiatry visit where paronychia of the right hallux nail was noted, started on Levaquin antibiotic and told to meet with Dr [**Last Name (STitle) 1391**] in consult. Patient reports increasing in pain over last week sharp, achy in nature. He reports no fever, chills however has nausea and emesis 3-4x per week. Past Medical History: PMH: DMII requiring insulin, HTN, hyper cholesterol, Thrombocythemia, history of shingles. PSH: Fracture left elbow [**2055**], Appendectomy, Ulnar nerve repair left elbow, carpal tunnel repair, right inguinal hernia. All: Penicillin for which he has anaphylaxis Social History: Posting 1PPD tobacco hx quit 40 year ago, EtOH 1 vodka/day, no ilicit drugs. Married with 5 children, retired registrar at [**University/College 31355**]now gold coach. Physical Exam: on Admission 99.2 HR:65 BP:124/46 Resp:17 100%ra GEN: NAD, AA0x3, clean well groomed man Neuro: CNII-X11 grossly intact, equal motor strength CV: RRR, possible carotid bruits, Notable systolic murmur PUl: CTA, no respiratory distress Abd: Apear distended-reports baseline, soft, NT, ND, umbilical hernia noted. Ext: Upper radial pulses palpable ......Fem.....[**Doctor Last Name **].....DP....PT Lt.....Palp....Dop....Palp..Dop Rt.....Palp....Dop....none...DopFaint Right foot notable cold to touch, decreased hair growth in lower extremities bilaterally, Rt first phalanx with mild swelling erythema of lateral toe nail bed with minimal purulent discharge. Pertinent Results: On addmision 137 100 43 -------------<213 4.1 24 2.5 102 28.7 > 11.3< 474 35.1 PT: 14.4 PTT: 38.3 INR: 1.2 On Discharge [**2108-5-10**] 141 105 85 --------------<111 4.4 24 3.9 Ca: 8.5 Mg: 2.2 P: 4.6 96 39.3 > 9.4 < 346 28.7 Imaging: [**2108-4-28**] Renal Ultrasound 1. No hydronephrosis 2. Parvus tardus waveform on the left kidney can represent a more proximal stenosis. 3. Complex 1.9 cm cyst arising from the upper pole of the left kidney, likely a hemorrhagic or proteinaceous cyst. [**2108-4-25**] Arterial non-invasive studies Severe outflow arterial disease in the right lower extremity. Disease is likely located at the right superficial femoral artery as well as distal to it. 2. Mild outflow arterial disease in the left lower extremity. Disease is likely located distal to the popliteal artery. Micro WOUND CULTURE (Final [**2108-4-27**]): CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH. URINE CULTURE (Final [**2108-5-4**]): YEAST. >100,000 ORGANISMS/ML. Blood Culture, Routine (Final [**2108-4-30**]): NO GROWTH. Brief Hospital Course: The patient was admitted to the Dr[**Name (NI) 1392**] Vascular Surgical Service for evaluation and treatment. On [**2108-4-25**] the patient underwent angiography and on [**2108-4-27**] he underwent Angioscopy and Right superficial femoral artery to distal anterior tibialis artery bypass with nonreversed cephalic vein. (Please refer to Operative Notes for details). The patient tolerated the procedure well. After a brief, uneventful stay in the PACU, the patient arrived to the VICU NPO, on IV fluids and antibiotics, narcotic medication for pain control. The patient was closely monitored throughout out his hospital stay which can be summarized by following systems: Neuro: The patient received IV narcotic medication with good effect and adequate pain control. When tolerating oral intake, the patient was transition ed to oral pain medications. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. GI:Post-operatively, the patient initially NPO with IVFs. Patient had nausea with diet advancement for which he was closely monitor. He was encouraged to maintain his PO intake in spite of decrease appetite at time. He was tolerating a regular diet prior discharge. was advanced appropriately and was well tolerated. Post-operatively, GU/FEN: Post-operatively, the patient initially was on IVFs and foley in place. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed and repeated when necessary. Due to an increase in Creatinine and the patients baseline stage III CKD caused by DM, nephrology was consulted to help manage acute on chronic kidney insufficiencies. Patient suffered from acute on chronic renal insufficiency during his hospital stay which prolonged the hospital course and for which he is deconditioned. On renal ultrasound, there was no evidence of hydronephrosis. The patient creatinine, fluid balance and electrolytes were closely monitored, his antibiotics and hydroxyurea medication were appropriate changed or adjusted and his renal insufficiency improved over time. He did not require hemodialysis.His Creatinine plateau ed at 6.1 and at time of discharge is 3.9. Due to renal insufficiency patient required prolonged use of a foley catheter which was definitively discontinued on [**2108-5-9**] at midnight. On day of discharge he was unable to void and was straight cathed for 375cc. On discharge he is due to void at 6pm. If patient unable to void please bladder scan patient and consider foley placement and follow-up with a urologist. Of note, his home dose Atenolol was discontinue per Nephrology consult as desired SBP goal is >120 to facilitate renal perfusion. When re-ignition of beta-blocker is deemed appropriate, it is advised that his PCP consider metoprolol as oppose to Atenolol as it is cleared more effectively from the kidneys. He will need to follow up with long term kidney physician [**Last Name (NamePattern4) **]. [**First Name (STitle) 10083**] at [**Last Name (un) **] as well as with his PCP. ID: The patient's white blood count and fever curves were closely watched for signs of infection. He was started on broad spectrum antibiotics Vanc/levo/Flagyl with admission which was changed to Bactrim post operatively on [**5-1**] and subsequently changed to Cipro [**5-3**] secondarily to Cipro ability to falsely elevate creatinine. He is being discharged on 7 days PO Cipro to complete course. 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; the patient received 4 non reactive blood transfusions during this hospitalization. He was noted to have leukocytosis on admission and with his history of thrombocythemia, hematology was consulted to facilitate proper management. His hydroxyurea was decreased from 5x/week to 2x/week secondary to renal insufficiency. He is to follow with his long term hematologist Dr [**Last Name (STitle) 17881**] on discharge. Prophylaxis: The patient received subcutaneous heparin, asa, Plavix and venodyne boots on non affected leg were used during this stay; was encouraged ambulate when appropriate with the assistance of physical therapy. At the time of discharge, the patient had improved significantly. From a surgical perspective he was doing very well but was deconditioned secondary to recovering renal insufficiency. He has been afebrile with stable vital signs, tolerating a regular diet, ambulating minimally with much assistance, patient is due to void and may require foley and urology fup if unable and his pain was well controlled. At time of discharge the patient, physicians, physical therapist and nursing staff agreeded that he was safe for discharge to a rehabilitative center. The patient received discharge teaching and follow-up instructions with understanding verbalized and was in agreement with the discharge plan. Medications on Admission: Insulin Before Breakfast Humalog 5 and NPH 25, Before Dinner: Humalog 5 and NPH 20, Cilostazol 100mg [**Hospital1 **], Hydroxyurea 500mg 5x/wk, hydrocholrothiazide 25mg Q otherver day with 2pill (50mg) Q other day alternating, Pravachol 20mg QHS, Viagra 100mg PRN, Diovan 160mg', enalapril 20mg [**Hospital1 **], Atenolol 25mg', Prazosin 12mg in am and 10mg in pm, Actos 30 mg', Vitamin D 1000 Unit Fish oil, Asairin 325mg', Glucosamine 500mg [**Hospital1 **],Philostazol 100mg [**Hospital1 **], Levaquin 500mg daily since [**4-19**]. Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 30 days. 3. Insulin and sliding scale Breakfast Dinner Humalog 5 Units NPH 25 Units Humalog 5 Units NPH 20 Units Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Regular Regular Regular Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-70 mg/dL Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol Proceed with hypoglycemia protocol 71-119 mg/dL 0 Units 0 Units 0 Units 0 Units 120-159 mg/dL 2 Units 2 Units 2 Units 2 Units 160-199 mg/dL 4 Units 4 Units 4 Units 4 Units 200-239 mg/dL 6 Units 6 Units 6 Units 6 Units 240-279 mg/dL 8 Units 8 Units 8 Units 8 Units 280-319 mg/dL 10 Units 10 Units 10 Units 10 Units 320-359 mg/dL 12 Units 12 Units 12 Units 12 Units 4. Pravastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule 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 Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 9. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Until patient appropriately euvolemic. 10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 11. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): to affected areas. 12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for Constipation. 13. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for Pain: Do not drive while taking this medication. 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 15. Prazosin 5 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO 2X/WEEK (TU,FR). 17. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 18. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. Discharge Disposition: Extended Care Facility: [**Hospital 31356**] health care center-[**Location (un) **] Discharge Diagnosis: 1) Right lower extremity critical limb ischemia with rest pain 2) Acute on Chronic kidney failure 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: Division of Vascular and Endovascular Surgery Lower Extremity Bypass Discharge Instructions ACTIVITIES: - ambulate essential distances untill FU with Dr. [**Last Name (STitle) 1391**] - Ace wrap leg from foot-knee when ambulating, to prevent swelling - Your operated leg is expected to have some swelling and will resolve over time - Elevate leg when sitting - no driving till FU - may shower, pat dry your incisions, no tub baths WOUND: - Keep wound dry and clean, call if noted to have redness, excess draining, swelling, or if temp is greater than 101.5 - Your staples have been removed and replaced with steri strips. Leave seri strips in place, they will come off on [**Last Name (un) 1292**] own or will be removed at FU. Ok to use dry guaze dressin if need for ozzing. - Pleaese use heal protection (waffle boot) on both legs while in bed - Use ace wrap foot to knee while ambulating to prevent swelling DIET: - Diet as tolerated eat a well balanced meal - Your appetite will take time to normalize - Prevent constipation by drinking adequate fluid and eat foods [**Doctor First Name **] in fiber, take stool softener while on pain medications MEDICATIONS: - Continue all medications as directed - Please follow up with your PCP regarding restarting beta blocker- It is recommended that you take Metoporol inplace of Atenolol for purposes of renal clearance. Ask your PCP to address. - Take your pain medications conservatively - Your pain will get better over time FU APPOINTMENTS: - keep all FU appointments - Call Dr.[**Name (NI) 1392**] office for FU appointment. Phone [**Telephone/Fax (1) 1393**] - Follow-up with your Nephrologist Dr. [**First Name (STitle) 10083**] at [**Last Name (un) **] - Follow-up with your hematology Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17881**]. ([**Telephone/Fax (1) 31357**] - Follow-up with your Primary Care Physician Followup Instructions: 1) Please follow-up with Dr [**Last Name (STitle) 1391**] in 3 weeks. Call [**Telephone/Fax (1) 1393**] to schedule an appointment. 2) Follow-up with your Nephrologist Dr. [**First Name (STitle) 10083**] at [**Last Name (un) **] 3) Follow-up with your hematology Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17881**]. ([**Telephone/Fax (1) 31357**] 4) Follow-up with your Primary Care Physician Completed by:[**2108-5-10**]

[ "V58.67", "585.3", "584.9", "250.40", "440.22", "403.90", "238.71", "272.4", "E878.2" ]

icd9cm

[ [ [] ] ]

[ "39.50", "00.41", "88.48", "39.29", "88.42" ]

icd9pcs

[ [ [] ] ]

12236, 12323

4000, 9248

302, 698

12465, 12465

2879, 3977

14572, 15020

9833, 12213

12344, 12444

9274, 9810

12648, 14549

2200, 2860

233, 264

726, 1708

12480, 12624

1730, 1997

2013, 2185

31,336

136,378

53104

Discharge summary

report

Admission Date: [**2176-9-23**] Discharge Date: [**2176-9-27**] Date of Birth: [**2096-8-10**] Sex: F Service: ORTHOPAEDICS Allergies: Sulfa (Sulfonamide Antibiotics) / Cephalexin / Allopurinol And Derivatives / Lasix Attending:[**First Name8 (NamePattern2) 1103**] Chief Complaint: L femur fracture Major Surgical or Invasive Procedure: [**2176-9-23**]: s/p ORIF L femure periprosthetic fracture History of Present Illness: Patient's knee hurts above her L TKA. She fell, had an ORIF last year for locking plate. Recently, she had persistent and increasing discomfort and pain in her left knee. There was a history of a fall at home, at which time around [**2176-7-26**] she came to our ED and had her left hip evaluated. Since then, her left knee has been hurting more. CT scan ordered by Dr. [**Last Name (STitle) 7111**] at the [**Hospital6 14475**] performed in late [**Month (only) **] demonstrated a nonunion with sclerotic margins of the fracture in the left distal femur. Patient presents for a revision as the Synthes locking plate is broken. Plan is to remove the plate and perform a retrograde intramedullary nailing of the femur. Past Medical History: 1. Urinary tract infection was active and treated during hospitalization 2. Myocardial infarction in [**2172-8-29**], with two bare metal stents placed in the right coronary artery. EKG changes consistent with a more remote AMI were found in early [**2154**]. 3. DM2. HbA1c was 6.0 % during this admission. High blood glucose had been noticed in the early to mid-nineties, and control has been variable over the intervening years. 4. Diverticulosis 5. Depression/Anxiety (diagnosed in [**2159**], and not active during this admission). 6. Hypertension was diagnosed prior to [**2156**], and is well controlled. 7. Previous gastritis, erosions and ulcer in [**2154**]. 8. Osteoarthrits, and subsequent bilateral total knee replacement. 9. Chronic cystitis, on nitrofurantoin suppression 10. Chronic Kidney Disease. GFR was 30 at the beginning of admission, and 54 at discharge. Creatinine low of 1.1 during admission, but baseline may be more like 1.5. 11. Breast cancer in [**2156**], treated with right total mastectomy, adjuvant radiotharpy and chemotherapy (cyclophosphamide, methotrexate, 5FU - four cycles, complicated with neutropenia and mucositis), including tamoxifen. Was T2-N0-M0, poorly differentiated infiltrating carcinoma. Inactive since [**2156**]. 12. Cirrhosis, suspected of being non-alcoholic steatohepatitis. 13. Neutropenia has been a recurrent problem, first being found in [**2156**] during chemotherapy. This has been a problem again during [**2171**], and has been attributed to Kephlex. The medical student also notes rifamin and isoniazid treatment in [**2150**] for tuberculosis, along with cytotoxic chemotherapy in [**2156**], colchicine treatment in [**2156**] and intermittantly since [**Month (only) 1096**] [**2170**], in the context of chronic liver and kidney disease). 14. Tuberculosis was the cause of a one-and-a-half year admission to a sanitorium at the age of thirteen, and was treated with rifampin and isoniazid in [**2150**]. 15. B12 deficiency has been found upon previous admissions. Social History: Mrs [**Known lastname **] lives at home with husband, and both are now retired. She worked as a receptionist at the [**Hospital1 2025**], and then in the office of a shoe company, when working. They have six children, one of which is a nurse [**First Name (Titles) **] [**Last Name (Titles) 18**], and she lives on the same street in [**Location (un) 3146**]. She has not smoked, nor taken alcohol during her life. Family History: Both of Mrs[**Known lastname 109398**] parent died of tuberculosis when she was two, and she was an only child. More remote family history has not been taken. Her six adult children are well. Physical Exam: Well appearing in no acute distress Afebrile with stable vital signs Pain well-controlled Respiratory: CTAB Cardiovascular: RRR Gastrointestinal: NT/ND Genitourinary: Voiding independently Neurologic: Intact with no focal deficits Psychiatric: Pleasant, A&O x3 Musculoskeletal Lower Extremity: * 2 femoral incision healing well with staples * Scant serosanguinous drainage * Thigh full but soft * No calf tenderness * 5/5 strength * SILT, NVI distally * Toes warm Pertinent Results: [**2176-9-27**] 05:37AM BLOOD WBC-5.0 RBC-2.88* Hgb-8.7* Hct-26.1* MCV-91 MCH-30.3 MCHC-33.4 RDW-16.1* Plt Ct-122* [**2176-9-26**] 06:01AM BLOOD WBC-6.2 RBC-2.64* Hgb-8.0* Hct-24.3* MCV-92 MCH-30.2 MCHC-32.7 RDW-16.2* Plt Ct-118* [**2176-9-25**] 03:57AM BLOOD WBC-8.8 RBC-2.99* Hgb-9.0* Hct-26.0* MCV-87 MCH-30.1 MCHC-34.7 RDW-16.2* Plt Ct-138* [**2176-9-24**] 04:19AM BLOOD WBC-7.0 RBC-2.72* Hgb-8.3* Hct-23.1* MCV-85 MCH-30.4 MCHC-35.8* RDW-15.8* Plt Ct-110* [**2176-9-23**] 12:32PM BLOOD WBC-11.1*# RBC-3.23* Hgb-9.9* Hct-28.1* MCV-87 MCH-30.5 MCHC-35.2* RDW-15.6* Plt Ct-161 [**2176-9-24**] 04:19AM BLOOD PT-14.6* PTT-27.5 INR(PT)-1.3* [**2176-9-23**] 04:58PM BLOOD PT-13.9* PTT-24.8 INR(PT)-1.2* [**2176-9-27**] 05:37AM BLOOD Glucose-216* UreaN-31* Creat-1.5* Na-135 K-4.7 Cl-104 HCO3-24 AnGap-12 [**2176-9-26**] 06:01AM BLOOD Glucose-298* UreaN-36* Creat-1.7* Na-133 K-5.1 Cl-104 HCO3-23 AnGap-11 [**2176-9-25**] 03:57AM BLOOD Glucose-228* UreaN-38* Creat-1.7* Na-134 K-5.2* Cl-105 HCO3-21* AnGap-13 [**2176-9-24**] 04:19AM BLOOD Glucose-250* UreaN-33* Creat-1.5* Na-136 K-5.3* Cl-108 HCO3-20* AnGap-13 [**2176-9-23**] 04:58PM BLOOD Glucose-214* UreaN-29* Creat-1.4* Na-138 K-5.5* Cl-111* HCO3-20* AnGap-13 [**2176-9-23**] 12:32PM BLOOD Glucose-167* UreaN-29* Creat-1.4* Na-138 K-5.5* Cl-108 HCO3-23 AnGap-13 [**2176-9-26**] 06:01AM BLOOD Calcium-8.3* Phos-3.2 Mg-2.0 [**2176-9-24**] 04:19AM BLOOD Calcium-7.8* Phos-4.1 Mg-1.8 [**2176-9-23**] 04:58PM BLOOD Calcium-7.4* Phos-4.2 Mg-1.7 Brief Hospital Course: The patient was admitted to the orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. Postoperative course was remarkable for the following: 1. ICU - Patient was sent tot he ICU after surgery for intra-operative blood loss of 1750cc and was given 4u PRBCs. 2. Post-op anemia due to blood loss - On POD 1, Patient was given as additional i1 for Hct 23.1 -> 26.9. On POD 3, Hct 24.4, asymptomatic -> 1u PRBCs. 3. LLE US - Patient c/o L calf tenderness. LLE ultrasound negative for DVT. Otherwise, pain was initially controlled with a PCA followed by a transition to oral pain medications on POD#1. The patient received lovenox for DVT prophylaxis starting on the morning of POD#1. The foley was removed on POD#2 and the patient was straight cathed x 1 after 8 hrs, then voiding independently thereafter. The surgical dressing was changed on POD#2 and the surgical incision was found to be clean and intact without erythema or abnormal drainage. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity. Ms. [**Known lastname **] is discharged to rehab in stable condition. Medications on Admission: albuterol, alendronate, norvasc, allopurinol, anastrozole, gabapentin, insuln, omeprazole, percocet, timolol drop, zolpidem, aspirin Discharge Medications: 1. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous Q24H (every 24 hours) for 3 weeks. Disp:*21 syringe* Refills:*0* 2. aspirin, buffered 325 mg Tablet Sig: One (1) Tablet PO twice a day for 3 weeks: AFTER COMPLETING LOVENOX, take as directed with food. Disp:*42 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:*2* 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. timolol maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic once a day. 7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed. 8. anastrozole 1 mg Tablet Sig: One (1) Tablet PO once a day. 9. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days: End date: [**2176-9-29**]. 10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 12. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 13. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 14. insulin glargine 100 unit/mL Solution Sig: Twenty Two (22) units Subcutaneous at bedtime: Home dose. 15. Humalog 100 unit/mL Solution Sig: Sliding scale Subcutaneous four times a day: Adjust as needed. 16. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for Pain. Disp:*50 Tablet(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital3 9475**] Care Center - [**Location (un) 3146**] Discharge Diagnosis: Left periprosthetic fracture Post-op anemia due to blood loss 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: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as colace) as needed to prevent this side effect. Call your surgeons office 3 days before you are out of medication so that it can be refilled. These medications cannot be called into your pharmacy and must be picked up in the clinic or mailed to your house. Please allow an extra 2 days if you would like your medication mailed to your home. 5. You may not drive a car until cleared to do so by your surgeon. 6. Please keep your wounds clean. You may shower starting five (5) days after surgery, but no tub baths or swimming for at least four (4) weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out at your follow-up visit in three (3) weeks after your surgery. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment in three (3) weeks. 8. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, motrin, etc). 9. ANTICOAGULATION: Please continue your lovenox for three (3) weeks to help prevent deep vein thrombosis (blood clots). After completing the lovenox, please take Aspirin 325mg TWICE daily for three weeks. [**Male First Name (un) **] STOCKINGS x 6 WEEKS. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four (4) week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed at your follow-up visit in three (3) weeks. 11. VNA (once at home): Home PT/OT, dressing changes as instructed, and wound checks. 12. ACTIVITY: Weight bearing as tolerated on the operative extremity. Mobilize. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: LLE WBAT Mobilize frequently Treatments Frequency: Dry sterile dressing daily as needed for drainage Wound checks Ice and elevation TEDs Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**] Date/Time:[**2176-10-15**] 1:40 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2176-10-21**] 2:00 Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4012**], MD Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2176-10-22**] 10:40 Completed by:[**2176-9-27**]

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icd9cm

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[ "78.05", "78.55", "78.65" ]

icd9pcs

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9521, 9607

5911, 7686

374, 435

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463, 1188

9728, 9872

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3266, 3685

42,020

197,606

35578

Discharge summary

report

Admission Date: [**2150-4-27**] Discharge Date: [**2150-5-25**] Date of Birth: [**2098-3-21**] Sex: F Service: SURGERY Allergies: Ciprofloxacin Er Attending:[**First Name3 (LF) 148**] Chief Complaint: Abdominal pain and fever Major Surgical or Invasive Procedure: Pancreatic pseudocyst gastrostomy [**2150-4-30**]. History of Present Illness: 52 yo F with a past medical history of Crohn's disease and recent post-ERCP pancreatitis c/ pseudocyst formation was transferred to the [**Hospital1 18**] from an OSH with abdominal pain and fevers to 102. The pt was previously admitted to [**Hospital1 18**] from [**Date range (2) 80978**] with post-ERCP pancreatitis complicated by pancreatic necrosis and pseudocyst formation. Her course was complicated by C. diff associated diarrhea, and she was discharged on PO Flagyl and PO Vancomycin as well as TPN with a small amount of PO intake. The patient presented to [**Hospital **] Hospital on [**2150-4-20**] with persistent abdominal pain, fevers, and shortness of breath. Broad spectrum antiobiotics were started for presumptive infected pancreatic necrosis. She underwent a CT scan which demonstrated persistent pancreatic collections. She continued to spike fevers to 102 and experience respiratory decompensation requiring ICU care at [**Hospital **] Hospital. She was transferred to [**Hospital1 18**] SICU for further management. Past Medical History: PMH: - ERCP pancreatitis with estimated 50% pancreatic necrosis - restless leg syndrome - Crohns disease - B/L ovarian cancer [**2141**] s/p TAH/SBO and chemotherapy - GERD PSH: - s/p cholecystectomy - s/p appendectomy - s/p TAH/BSO (chemotherapy) - s/p L nephrectomy for ovarian metastases Social History: No cigarettes; occasional alcohol. She does not drink coffee. Lives with husband; retired from the VA where she worked as a nursing assistant Family History: Father died of CA of the esophagus. Three healthy siblings. Physical Exam: On Admission: . Temp 102.6 HR 107 BP 130/62 95%5L GENERAL: NAD, ill-appearing; alert and responsive. HEENT: Sclerae anicteric. Mucous membranes moist,intact. HEART: Tachycardic, no murmurs appreciated. LUNGS: Diminished breath sounds at bases; faint crackles at bases ABDOMEN: Well-healed RUQ and vertical midline scars present. Soft, distended, diffusely tender to palpation without guarding or peritoneal signs. EXTREM: No peripheral edema. . On Discharge: T 98.7 HR 88 BP 121/76 RR 18 96%RA GENERAL: NAD, AOx3 HEENT: No scleral icterus. HEART: RRR, no MRG LUNGS: CTA bilaterally ABD: soft, nontender, nondistended Extremities: No cyanosis, clubbing or edema Pertinent Results: [**2150-4-27**] 05:52PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-0.2 PH-6.5 LEUK-MOD [**2150-4-27**] 05:52PM URINE RBC-[**5-20**]* WBC-[**2-12**] BACTERIA-MOD YEAST-FEW EPI-[**10-30**] [**2150-4-27**] 04:45PM GLUCOSE-135* UREA N-15 CREAT-0.7 SODIUM-129* POTASSIUM-3.8 CHLORIDE-93* TOTAL CO2-29 ANION GAP-11 [**2150-4-27**] 04:45PM ALT(SGPT)-20 AST(SGOT)-30 LD(LDH)-297* ALK PHOS-135* AMYLASE-447* TOT BILI-0.2 DIR BILI-0.1 INDIR BIL-0.1 [**2150-4-27**] 04:45PM LIPASE-114* [**2150-4-27**] 04:45PM ALBUMIN-2.5* CALCIUM-7.8* PHOSPHATE-2.8 MAGNESIUM-1.7 [**2150-4-27**] 04:45PM WBC-14.8* RBC-2.72* HGB-7.7* HCT-24.0* MCV-88 MCH-28.4 MCHC-32.2 RDW-14.6 [**2150-4-27**] 04:45PM NEUTS-92.2* LYMPHS-4.4* MONOS-2.2 EOS-0.9 BASOS-0.2 [**2150-4-27**] 04:45PM PLT COUNT-532* [**2150-4-27**] 04:45PM PT-16.5* PTT-31.2 INR(PT)-1.5* . CT ABD/PELVIC W/CONTRAST & CTA W & W/O CONTRAST & RECON: 1. No evidence for pulmonary embolus or acute aortic syndrome, although evaluation of the subsegmental pulmonary arteries is limited by suboptimal contrast bolus timing. 2. Small bilateral pleural effusions, with adjacent bibasilar consolidation, which could reflect an element of atelectasis, although pneumonia is not excluded. Additional area of ground-glass opacity with nodular center is seen at the right apex. This could represent infection or pulmonary infarct. However, malignancy such as bronchoalveolar cell carcinoma is not excluded, and followup to resolution is recommended. 3. Large pancreatic pseudocyst within the pancreatic bed. There is minimal residual normal pancreatic tissue identified. 4. New fluid collection within the right mid abdomen, inferior to the tip of the liver. 5. Status post left nephrectomy. 6. Thickening and fibrofatty proliferation involving the terminal ileum. These changes are consistent with chronic Crohn's disease. There may also be inflammatory changes involving the sigmoid colon/rectum. . CTA CHEST W&W/O C&RECONS, NON-CORONARY: 1. No pulmonary embolism. 2. Interval progression of moderate bilateral pleural effusion. Unchanged moderate bibasilar atelectasis. 3. New foci of ground-glass opacities in the prebronchovascular distribution and new foci of consolidation within both lung apices. The differential diagnoses include infectious and inflammatory etiologies. . CT ABDOMEN W/CONTRAST: 1. Interval decrease in size of the large pancreatic pseudocyst within the pancreatic bed and interval decrease in the size of pseudocyst located in the right upper quadrant area. 2. New fluid accumulation anterior to the body of the stomach. It is unclear if this might be post-surgical in nature, status post cyst gastrotomy. 3. No vascular compromise is noted including no pseudoaneurysm and no vascular thrombosis. 4. New mild right hydrouretronephrosis, unclear consequence. Heterogeneous enhancement of the right kidney could be seen in setting of pyelonephritis; please correlate with urinalysis/urine culture. This was called to Dr. [**Last Name (STitle) 21822**] at 4:30pm, [**2150-5-9**]. 5. Slight interval increase in the left pleural effusion and slight interval improvement in bibasal atelectasis. . [**2150-5-19**] CT ABDOMEN/PELVIS W/CONTRAST: 1. Interval decrease in the size of large pancreatic pseudocyst within the pancreatic bed and interval decrease in the size of pseudocyst located in the right upper quadrant area. No new focus of fluid collection is noted. 2. No vascular compromise is noted including no pseudoaneurysm and no thrombosis. 3. Slight decrease in the bibasilar atelectasis. 4. Unchanged small left pleural effusion. . [**2150-5-21**] PA CXR: Interval removal of a right-sided catheter. Progressed left pleural effusion and associated opacities, likely atelectasis. Brief Hospital Course: The patient was transferred from the ICU at [**Hospital1 14579**] in [**Location (un) 8973**] to [**Hospital1 18**] SICU with fevers, abdominal pain and respiratory decompensation for further evaluation and management. The patient was NPO with a foley catheter, PIV, and RICC line in place. An A-line and CVL were placed. Present PICC line discontinued; tip sent for culture. Infectious Disease consulted upon admission. Pancultures repeated. IV antibiotics continued/updated. The patient was hemodynamically stable. [**4-27**]: admitted to SICU, CVL and A-line placed, 1 unit PRBC, no PE [**4-28**]: started micafungin, ECHO, restarted TPN [**4-29**]: triggered for tachy 180s after albuterol treatment; given Lopressor 5mg x3 doses, discontinued albuterol nebs, and switched to xopenex nebs with resultant normalization of heart rate. [**4-30**]: To OR for cyst-gastrostomy, admitted to SICU thereafter [**5-1**]: self-extubated, TPN restarted, KVO, micafungin changed to fluconazole [**5-3**]: triggered on floor with desats, transferred to SICU, CT chest, intubated, A-line placed [**5-4**]: IP consulted for (L) pleural effusion; declined tap, Lasix 20mg x1 [**5-5**]: vanco trough 30, so evening dose held, recruitment maneuvers, bronchoscopy secretions without plug, attempted vent wean, but failed T-piece, Cr 1.2 (1.1), FeNa=1.2, d/c'd Zosyn switched to Levaquin, 5% albumin x1, Lasix held, urine eos neg, PEEP incr 7 (5) [**5-6**]: failed SBT, back on vent [**9-14**], held vanco/decreased dose, FeNa not c/w prerenal, Lasix, diuresis -2L [**5-7**]: urine greenish sediment, discontinued PO&IV vancomycin, discontinued Levaquin, TEE, extubated, sips [**5-8**]: discontinued NGT, NPO, discontinued (L) SCL CVL, placed (R) SCL CVL, increased fluconazole to 600, CT abdomen [**5-9**]: Started on sips, continued on [**Hospital 80979**] transferred to floor. [**5-10**]: Diet advanced to clears with good tolerability, IV fluid rate decreased to 25mL/hr, foley discontinued, TPN continued [**5-11**]: Diet advanced to fulls with good tolerability, IV fluids discontinued, continued on TPN [**5-12**]: Beta-glucan sent, ambulated frequently [**5-13**]: Chest/Abdominal CT performed, Tolerated fulls, continued on TPN [**5-14**]: Made NPO for TEE performed today - no endocarditis, diet then advanced to lactose-restricted regular with Boost supplement, Reglan started [**5-15**]: Calorie counts started. Several fevers greater than 101; CVL discontinued with tip sent for culture. [**5-16**]: TPN discontinued. CVL tip positive for GPCs. IV Vancomycin added to Flagyl and Fluconazole. [**5-17**]: Continued with fever 102; daily blood cultures started. [**5-18**]: Continued with fever greater than 101. Daily blood cultures continued. received 1 unit PRBC for HCT 23.7 with post-transfusion increase to 26.1. Flagyl discontinued. [**5-19**]: Continued with fever greater than 101. Daily blood cultures continued. Abdominal/pelvic CT with contrast revealed interval decrease in size of pseudocyts without new fluid collections. [**5-20**]: Temperature decreased. Continued on antibiotics. Tolerating diet. Stool for C.diff sent. [**5-21**]: Triggered for SVT with Heart rate 170-180; CXR, EKG, enzymes, and labwork performed. Cardiology was consulted. Treated with IV Lopressor x3 followed by Adenosine 6mg IV single dose with return to SR. Continued on low dose Lopressor. Remained hemodynamically stable. No further episodes during hospitalization. [**5-22**]: Follow-up EKG with NSR. Patient stable. No events. [**5-23**]: Tolerating diabetic, lactose-free diet. Remained stable from cardiac standpoint. Glucose monitoring/insulin administration teaching underway; [**Last Name (un) **] following. [**5-24**]: Vancomycin discontinued; continued on PO Fluconazole. Hemodynamically stable. At the time of discharge on [**2150-5-25**], the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular lactose-free, diabetic diet, ambulating, voiding without assistance, and pain was well controlled. She will be discharged home with [**Date Range 269**] Services and home Physical Therapy. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Lomotil, Requip 1mg qhs, Zoldipem 5mg PO QHS PRN, Omeprazole 20mg PO daily. Discharge Medications: 1. Ropinirole 1 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4HOURS as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*2* 5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation four times a day as needed for wheeze. Disp:*1 HFA* Refills:*2* 6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 7. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*100 Cap(s)* Refills:*2* 8. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:*135 Tablet(s)* Refills:*2* 9. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours): Thru [**2150-6-12**]. Disp:*40 Tablet(s)* Refills:*0* 10. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous at bedtime. Disp:*1 vial* Refills:*2* 11. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 13. Humalog 100 unit/mL Solution Sig: 1-7 units Subcutaneous As directed per the Humalog Insulin Sliding Scale. Disp:*1 vial* Refills:*2* 14. Insulin Syringe-Needle U-100 1 mL 30 x [**4-25**] Syringe Sig: One (1) syringe per injection Miscellaneous as directed. Disp:*1 box* Refills:*2* 15. Lancets,Ultra Thin Misc Sig: One (1) lancet Miscellaneous as directed. Disp:*1 box* Refills:*0* 16. Alcohol Pads Pads, Medicated Sig: One (1) pad Topical as directed. Disp:*1 box* Refills:*0* 17. One Touch Ultra Test Strip Sig: One (1) strip In [**Last Name (un) 5153**] as directed QID. Disp:*100 strips* Refills:*0* Discharge Disposition: Home With Service Facility: [**Last Name (un) 269**] of Southeastern Mass. Discharge Diagnosis: 1. Pancreatic pseudocyst. 2. Fungemia. 3. Type 2 Diabtes Mellitus 4. Single episode SVT Discharge Condition: Stable. Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**4-19**] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD (covering for Dr. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 476**] Date/Time:[**2150-6-8**] 11:15; Location: [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**]. Please call ([**Telephone/Fax (1) 71666**] to schedule a follow-up appointment with Dr. [**Last Name (STitle) 1789**] (PCP) in [**1-13**] weeks. Follow-up issues: Diabetes/Insulin management, single episode SVT while hospitalized started on low dose Lopressor, standard post-operative follow-up. Completed by:[**2150-5-25**]

[ "518.5", "999.31", "511.9", "555.9", "117.9", "V10.43", "997.1", "577.2", "250.00", "333.94", "530.81", "518.0", "997.39" ]

icd9cm

[ [ [] ] ]

[ "96.72", "38.91", "52.4", "96.04", "99.15", "38.93", "33.23", "88.72" ]

icd9pcs

[ [ [] ] ]

12917, 12994

6497, 10769

300, 353

13126, 13136

2680, 6474

15143, 15726

1917, 1979

10896, 12894

13015, 13105

10795, 10873

13160, 14615

14631, 15120

1994, 1994

2456, 2661

236, 262

381, 1427

2008, 2442

1449, 1742

1758, 1901

17,232

109,145

6709

Discharge summary

report

Admission Date: [**2158-11-14**] Discharge Date: [**2158-12-7**] Date of Birth: [**2091-4-21**] Sex: M Service: [**Hospital1 212**] HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 67-year-old man who came to the [**Hospital1 69**] on the [**4-14**] for cardiac catheterization. During that catheterization, he was found to have a patent LIMA, LAD and SBG times two and patent stents. After catheterization, further patient had history of hematuria and pneumaturia with a possible anastomosis between his GI and urinary system. He had seen a doctor on the [**3-26**] for this problem and his INR was found to be 4 so his Coumadin was held, however the next day he noted some red urine with clots. Over the week prior to admission, he had complaints of pain with urination and bloody urination. On the 28th, the day prior to admission, the patient noted air in his urine and also flecks of darker material and pus or white material in the urine. The patient denied any fever or chills. Had not had any changes in his bowel movements. He has no history of urinary tract infections. He does have a history of positive renal stones and has had ureteral stents placed 10 years prior to admission. The patient had some nausea, but no vomiting prior to admission. PHYSICAL EXAMINATION: On admission blood pressure in the 100 to 110 range over 60s. Temperature 98.3 F, heart rate 76 and respiratory rate of 20. In general the patient was alert and oriented times three in no apparent distress. Head, eyes, ears, nose and throat: The patient had pupils that were equal, round and reactive bilaterally. Extraocular motions were intact. Chest: He had a few rales at the left base, no rhonchi, no wheezing. Decent air exchange. Cardiovascular system: He had distant heart sounds, slight murmur, no gallops, no rubs. Abdomen was soft, not distended. He had some mild suprapubic tenderness. Normal rectal tone, no gross blood, nontender prostate, stage I sacral ulcer, no groin cellulitis. Extremities: He had lower extremity muscle wasting, no cyanosis, clubbing or edema. Legs were warm. In the left distal pulses were not palpable. Skin was warm and dry. He had moist mucous membranes. PAST MEDICAL HISTORY: 1. The patient has end stage renal disease. He is on hemodialysis on Monday, Wednesday and Fridays. 2. He had coronary artery bypass surgery in [**2151**]. 3. He also has a history of five myocardial infarctions. 4. He had cardiac catheterization in [**2158-4-17**] with stent placement. 5. He has a history of congestive heart failure with an ejection fraction listed between 15 and 25%. 6. History of hypertension. 7. Patient has diabetes type 2 requiring insulin for control. 8. He has peripheral vascular disease status post aortobifemoral bypass. 9. Patient has a history of atrial fibrillation and flutter with an episode of ventricular tachycardia in [**2158-3-17**] for which he had electrophysiology treatment with ablation and a defibrillator pacer placed. 10. Hypercholesterolemia. 11. Diverticulitis. 12. Splenectomy. 13. Ventral hernia repair times four. 14. Tonsillectomy and adenectomy. 15. Left leg internal fixation. 16. Peripheral sensory neuropathy. MEDICATIONS ON ADMISSION: 1. Toprol. 2. Imdur. 3. Digoxin. 4. Neurontin. 5. NPH insulin. 6. Humalog insulin. 7. Nephrocaps. 8. Coumadin. 9. Coreg. 10. Lisinopril. 11. Phos-Lo. 12. Zantac. 13. Dulcolax. ALLERGIES: 1. Amiodarone. 2. Tetracycline. 3. Seldane 4. Procainamide. 5. Shellfish. 6. Steri-Strips. LABORATORIES ON ADMISSION: The patient had a white count of 15 with 71 polys, no bands, hematocrit of 40. His Chem-7 was essentially normal. His urine showed gross infection with greater than 1,000 white blood cells, large blood, many bacteria. HOSPITAL COURSE: The patient was admitted to the hospital and started on antibiotic treatment for his urinary tract infection which was suspected to be entero vesicular fistula given his history of diverticulitis. Urology was consulted. A CT Scan just after admission showed sigmoid diverticulitis with sigmoid vesicular fistulas. The patient was started on Levaquin, Flagyl and Ampicillin. Due to the extremely long hospitalization and transfer to the Surgical Service and then back to the Medical Service, the rest of the dictation summary will be by system to give a concise review of hospital occurrences. 1. GI / GU SYSTEMS: As mentioned in the HPI, the patient was admitted with a enterovesical fistula and started on triple antibiotic coverage. The patient was seen by the Urology Department and Surgical Colorectal Surgery Department as well as by Infectious Disease. Initially, it was deemed more appropriate to treat the patient with medial therapy i.e. triple antibiotic coverage to decrease inflammation in the colon and bladder area. He had a Foley catheter placed which on several occasions was clogged and had to be readjusted. Following medical treatment, the patient was transferred to the Surgical Service on [**11-23**] where he underwent a diverting colostomy with Hartmann pouch of the distal segment and his bladder was oversewn. A suprapubic catheter was placed. Due to the contaminated nature of the surgery and the fact that the patient had an abscess within his abdominal cavity as shown on CT Scan, only his fascia was closed and the skin and subcuticular layer were left open to heel by secondary intention. Please refer to the [**11-23**] operative note by Dr. [**Last Name (STitle) 1888**] for full details of the surgery. Following surgery, the patient underwent a complicated medical course with a prolong stay in the SICU and eventual transfer to the floor. It should be noted that the patient's preoperative mortality morbidity was estimated to be 50% due to his complicating medical conditions. As the patient improved, he was transferred back to the Medical Service on [**11-30**] for fine tuning of his urine, endocrine and cardiac systems. He was maintained on triple coverage antibiotics of Flagyl, Levaquin and Vancomycin until [**12-6**] when there were no further signs of infection and patient was doing well clinically. It should be noted that postoperatively, the patient had some hypotension and there was fear of sepsis so he was pan cultured and aggressive antibiotic treatment continued, however all of the cultures with exception of urine culture returned as negative. On [**12-6**], the patient had an abdominal CT Scan which showed no abscess within the abdominal cavity and only the open abdominal wound left from surgery. The patient will have the suprapubic catheter in place until follow up with Dr. [**Last Name (STitle) 1888**]. He gradually developed stools through his ostomy and good gas flow. 2. CARDIOVASCULAR: As mentioned before, the patient has extensive cardiac disease. While in the hospital, he was monitored on Telemetry which showed no significant events. His pacer defibrillator was interrogated after surgery and was found to be in normal working order. He was kept on Carvedilol for blood pressure and cardiac status. His aspirin was restarted during hospital stay after surgery and Coumadin was restarted for the patient's atrial fibrillation. During the time of surgery and during the postoperative period, the patient was anticoagulated with heparin. 3. PULMONARY: The patient has an extensive tobacco history. During his hospitalization his pulse oximetry saturations were within normal limits. There was some mild congestive heart failure clinically on x-rays due to his fluid status, but this was corrected with dialysis. It should also be the patient had a methicillin-resistant Staphylococcus aureus positive nasal swab for which he was placed on isolation. 4. RENAL: As mentioned, the patient has end stage renal disease and he receives tri-weekly hemodialysis. In the GI / GU section the patient's enterovesical fistula was discussed. During the week of [**11-26**], the patient's fluid status was deemed to be that he was retaining quite a bit of fluid. He underwent daily dialysis for several days during which 2 to 3 kilograms were taken off per day. This gradually improved the patient's fluid status back to his baseline and a more appropriate dry weight. The patient's antibiotics were renally dosed while in hospital. The patient was also noted to have reasonable urinary output from his suprapubic catheter after surgery and no signs of obstruction of this portal. The suprapubic catheter will be kept in place until follow up with Dr. [**Last Name (STitle) 1888**] to serve as a pressure outlet in order to not distend the bladder which had recently been oversewn. 5. INFECTIOUS DISEASE: As mentioned previously, the patient was found to have a methicillin-resistant Staphylococcus aureus positive nasal swab. He is also status post splenectomy. Some hypotension in the SICU after surgery led to a concern for sepsis as well as a high white blood count that maxed at 19. The patient was maintained on triple antibiotic coverage including Flagyl, Levaquin and Vancomycin. He was pan cultured. The cultures were found to have no growth with the exception of the urine culture. All of his antibiotics were dosed at renal levels. Antibiotics were stopped on the [**12-5**] as the patient had been afebrile, white count returning to baseline and clinically improving and a sufficient course of antibiotics had been met. 6. ENDOCRINE: The patient had been admitted on NPH insulin and Humalog sliding scale. The consultation with the Josalin diabetic doctors recommended changing the patient to a longer acting Lantus insulin for once a day basal coverage and maintaining the Humalog sliding scale. After surgery, the patient was switched back to his Lantus insulin at a lower dose and gradually increased to 40 units q.h.s. and maintained on Humalog sliding scale for meals and coverage throughout the day. The patient checks his own blood sugars and is quite familiar with his insulin regimen and its management. 7. HEMATOLOGY: The patient has received Epogen for hemopoietic stimulus. His hematocrits remained stable, although relatively low probably due to chronic myelosuppression. 8. NEUROLOGY: The patient has a peripheral neuropathy. He also noted that he had numbness in his left 3rd through 5th digits which is chronic for him. After his operation, the patient was noted to have some postoperative hallucinations which were believed to be secondary to his epidural catheter and anesthesia. He gradually cleared from these and returned to [**Location 213**] mental status. 9. MUSCULOSKELETAL: The patient noted that he occasionally gets weakness and numbness in his left arm where is AV fistula is following hemodialysis, but this gradually improves within hours. It should also be noted that on the [**12-6**] when the patient was undergoing Physical Therapy and sitting up in a chair with a strapper on his chest, he noted to start to have left chest wall pain associated with palpation of his midthoracic ribs on the left, breathing and movement. A chest x-ray was taken on the [**12-7**] to rule out rib fracture. 10. DERMATOLOGY: The patient had some bilateral heel blisters when he was transferred back to Medicine and undergoing large volume hemodialysis. He was gradually improved with preventative measures such as air mattress and soft cushioning under the heels. The patient was also instructed on how to work with his ostomy bag by the ostomy nurse. In terms of his abdominal surgical wound, the patient was instructed on the wet to dry packing and t.i.d. dressing changes. To watch for signs of infection such as erythema or discharge. DISPOSITION: The patient will be discharged to rehab because of his decreased physical conditioning. It should be noted that at home, he was not quite very mobile and used a motorized wheelchair. However, when Physical Therapy worked with him at the end of his hospitalization, the patient had trouble standing and pivoting. It was agreed that some rehab would be beneficial to him. The patient was also set up with a new internist at the [**Hospital1 1444**] by the name of Dr. [**First Name (STitle) **] [**Name (STitle) 24596**]. He will see this doctor [**First Name (Titles) **] [**Last Name (Titles) 3816**], [**12-19**] at 3:30 PM in the [**Last Name (un) 469**] building. DISCHARGE DIAGNOSES: 1. Enterovesical fistula status post diverting colostomy and Hartmann pouch with bladder oversewn. 2. End stage renal disease on hemodialysis. 3. Coronary artery disease status post coronary artery bypass graft and MIs. 4. Congestive heart failure with low ejection fraction. 5. Diabetes mellitus type 2 on insulin. 6. Hypertension. 7. Peripheral vascular disease. 8. Atrial fibrillation flutter status post pacer defibrillator. 9. Hypercholesterolemia. 10. Diverticulitis. 11. Splenectomy. 12. Ventral hernias. 13. Peripheral sensory neuropathy. DISCHARGE MEDICATIONS: 1. Carvedilol 3.125 mg p.o. b.i.d., hold for systolic pressure less than 90 or heart rate less than 60. 2. Calcium Acetate two tablets p.o. q. AC. 3. Fentanyl patch 50 mcg per hour, apply every 72 hours. 4. Lantus or Glargine insulin 40 units q.h.s. 5. Sliding scale Humalog insulin per patient dosing. 6. Protonix 40 mg a day. 7. Warfarin 5 mg a day. 8. Neurontin 200 mg twice a day. 9. Percocet one to two tabs every four to six hours p.r.n. pain. 10. Dulcolax suppositories as needed. Please note the patient is to follow up with Dr. [**First Name (STitle) **] [**Name (STitle) 24596**] as mentioned above. He is to follow up with Dr. [**Last Name (STitle) 1888**] of the Surgery Department within two weeks of discharge. He is to call for an appointment for that at which time his surgical wounds and suprapubic tube will be addressed. If there are any concerns prior to that, he should call Dr.[**Name (NI) 25573**] office. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 15868**] Dictated By:[**Last Name (NamePattern1) 2215**] MEDQUIST36 D: [**2158-12-7**] 15:43 T: [**2158-12-7**] 16:44 JOB#: [**Job Number 25574**] cc:[**Name8 (MD) 25575**]

[ "596.1", "599.0", "V45.81", "403.91", "413.9", "250.00", "428.0", "567.2", "427.31" ]

icd9cm

[ [ [] ] ]

[ "37.26", "57.6", "46.10", "37.22", "88.55", "57.17", "39.95", "45.76" ]

icd9pcs

[ [ [] ] ]

12437, 12994

13017, 14260

3262, 3570

3824, 12416

1320, 2234

181, 1297

3585, 3806

2256, 3236

40,094

187,522

34666

Discharge summary

report

Admission Date: [**2148-12-23**] Discharge Date: [**2149-1-2**] Date of Birth: [**2096-2-3**] Sex: M Service: SURGERY Allergies: IV Dye, Iodine Containing Contrast Media Attending:[**First Name3 (LF) 695**] Chief Complaint: IVC stenosis Major Surgical or Invasive Procedure: [**2148-12-23**] Exploratory laparotomy, extensive lysis of adhesions, Donor cava to recipient caval anastomosis, intra op US x2 History of Present Illness: Per Dr.[**Name (NI) 1369**] preoperative note as follows: 52-year-old male who underwent orthotopic deceased donor liver [**Name (NI) **] on [**2147-10-8**] complicated by hepatic artery thrombosis resulting in retransplantation on [**2147-11-23**] using an infrarenal hepatic artery conduit a Roux-en-Y hepaticojejunostomy. He subsequently has developed the onset of ascites and lower extremity edema in [**Month (only) 216**] and [**2148-8-1**]. An ultrasound on [**2148-8-14**] demonstrated ascites with normal flow in the right and left portal veins. The main hepatic vein, right and left hepatic veins also remain patent with antegrade flow. He had splenomegaly. Liver biopsy on [**9-4**] demonstrated zone 3 congestion with sign of serial dilatation and minimal associated atrophy. On [**9-27**] an IVC gram and hepatic venogram was performed with balloon dilatation. He was noted to have moderate stenosis in the upper IVC at the level of hepatic vein confluence. He had collateral drainage from the lower IVC. The right hepatic venogram demonstrated minimal to mild stenosis at the confluence with the IVC. Post hepatic vein balloon dilatation resulted in minimal improvement angiographically and in pressure measurements. A repeat procedure was performed on [**2148-11-8**] for persistent ascites. Again he had IVC stenosis at the level of the hepatic vein confluence that was unchanged. He had a right hepatic venogram that demonstrated mild stenosis at its confluence with the IVC. There was minimal angiographic and pressure improvement after hepatic vein balloon dilatation. There was mild improvement after dilatation of the IVC. Due to his persistent ascites he is now brought to the operating room for possible cava- caval anastomosis between the donor and recipient cava and side-to-side portacaval shunt. He has provided informed consent. Past Medical History: 1. UC 2. cirrhosis [**1-2**] PSC s/p OLT [**2147-10-8**] and re-[**Month/Day/Year **] [**2147-11-23**] for hepatic artery thrombosis [**2148-12-23**] Exploratory laparotomy, extensive lysis of adhesions, Donor cava to recipient caval anastomosis, intra op US x2 3. CKD 4. Hypertension 5. Migraines Social History: He had a tattoo back in college. No transfusions. No IV drug use. No recreational drug use. No tobacco. He has had rare alcohol use in the last 15 years, social in the past. He lives with his wife and his teenage son; aged 17. He has a grown daughter aged 29, who lives nearby. Family History: Significant for a father who had liver disease, it is unclear whether he also had primary sclerosing cholangitis. No other family history. Physical Exam: On discharge: Vitals- 99.0, 87, 118/61, 20, 97%RA Weight 95 kg GEN: NAD, A+O x3 CV: RRR, No MRG, normal S1/S2 RESP: CTAB, no crackles or wheezing Abd: soft, mildly distended, very mild tenderness to deep palpation, +BS, horizontal incision with staples with very mild SS drainage from the center and otherwise C/D/I. Two old drain sites with a suture each. Ext: persistent 2+ pitting edema but improved from before, warm, palpable DP pulses bilaterally. Pertinent Results: [**2149-1-2**] 06:33AM BLOOD WBC-4.2 RBC-2.97* Hgb-8.6* Hct-25.9* MCV-87 MCH-28.9 MCHC-33.1 RDW-16.3* Plt Ct-180 [**2149-1-2**] 06:33AM BLOOD PT-13.1* PTT-29.4 INR(PT)-1.2* [**2149-1-2**] 06:33AM BLOOD Glucose-116* UreaN-27* Creat-2.0* Na-142 K-3.6 Cl-105 HCO3-28 AnGap-13 [**2149-1-2**] 06:33AM BLOOD ALT-23 AST-24 AlkPhos-114 TotBili-1.0 [**2149-1-2**] 06:33AM BLOOD Albumin-2.8* Calcium-8.0* Phos-3.4 [**2149-1-2**] 06:33AM BLOOD tacroFK-7.4 [**2149-1-2**] 06:33AM BLOOD WBC-4.2 RBC-2.97* Hgb-8.6* Hct-25.9* MCV-87 MCH-28.9 MCHC-33.1 RDW-16.3* Plt Ct-180 [**2149-1-1**] 06:30AM BLOOD WBC-4.5 RBC-3.18* Hgb-9.0* Hct-26.6* MCV-84 MCH-28.5 MCHC-34.0 RDW-16.4* Plt Ct-155 [**2148-12-31**] 05:50AM BLOOD WBC-5.1 RBC-3.24* Hgb-8.9* Hct-27.3* MCV-84 MCH-27.5 MCHC-32.7 RDW-15.8* Plt Ct-160 [**2148-12-30**] 06:30AM BLOOD WBC-6.2 RBC-3.35* Hgb-9.4* Hct-27.6* MCV-83 MCH-28.1 MCHC-34.0 RDW-16.1* Plt Ct-130* [**2148-12-28**] 07:10AM BLOOD WBC-4.2 RBC-3.69* Hgb-10.3* Hct-30.7* MCV-83 MCH-27.8 MCHC-33.4 RDW-15.5 Plt Ct-112* [**2148-12-27**] 06:45AM BLOOD WBC-4.4 RBC-3.70* Hgb-10.3* Hct-31.0* MCV-84 MCH-28.0 MCHC-33.3 RDW-15.9* Plt Ct-95* [**2148-12-26**] 09:37AM BLOOD WBC-3.1* RBC-3.69* Hgb-10.3* Hct-30.6* MCV-83 MCH-27.9 MCHC-33.6 RDW-16.1* Plt Ct-73* [**2148-12-26**] 01:58AM BLOOD WBC-3.9*# RBC-3.60* Hgb-10.2* Hct-29.7* MCV-82 MCH-28.5 MCHC-34.5 RDW-16.1* Plt Ct-91* [**2148-12-25**] 02:13AM BLOOD WBC-18.4* RBC-3.54* Hgb-9.9* Hct-29.5* MCV-83 MCH-28.0 MCHC-33.6 RDW-16.5* Plt Ct-154 [**2149-1-2**] 06:33AM BLOOD PT-13.1* PTT-29.4 INR(PT)-1.2* [**2149-1-1**] 06:30AM BLOOD PT-13.5* PTT-27.9 INR(PT)-1.3* [**2148-12-31**] 05:50AM BLOOD PT-14.1* PTT-29.0 INR(PT)-1.3* [**2148-12-30**] 06:30AM BLOOD PT-13.2* PTT-28.5 INR(PT)-1.2* [**2148-12-29**] 06:20AM BLOOD PT-13.1* PTT-28.4 INR(PT)-1.2* [**2149-1-2**] 06:33AM BLOOD Glucose-116* UreaN-27* Creat-2.0* Na-142 K-3.6 Cl-105 HCO3-28 AnGap-13 [**2148-12-31**] 05:50AM BLOOD Glucose-111* UreaN-34* Creat-2.0* Na-141 K-3.3 Cl-106 HCO3-28 AnGap-10 [**2148-12-27**] 06:45AM BLOOD Glucose-136* UreaN-42* Creat-1.9* Na-135 K-3.2* Cl-104 HCO3-25 AnGap-9 [**2148-12-26**] 01:58AM BLOOD Glucose-165* UreaN-42* Creat-1.9* Na-137 K-3.5 Cl-106 HCO3-26 AnGap-9 [**2148-12-25**] 02:13AM BLOOD Glucose-180* UreaN-44* Creat-2.1* Na-137 K-4.2 Cl-106 HCO3-28 AnGap-7* [**2148-12-24**] 11:19AM BLOOD Glucose-195* UreaN-43* Creat-2.1* Na-142 K-3.4 Cl-106 HCO3-23 AnGap-16 [**2149-1-1**] 06:30AM BLOOD ALT-26 AST-28 AlkPhos-129 TotBili-1.0 [**2149-1-2**] 06:33AM BLOOD ALT-23 AST-24 AlkPhos-114 TotBili-1.0 [**2148-12-30**] 06:30AM BLOOD ALT-31 AST-28 AlkPhos-128 TotBili-1.8* [**2148-12-27**] 06:45AM BLOOD ALT-50* AST-44* AlkPhos-94 TotBili-2.2* [**2148-12-25**] 02:13AM BLOOD ALT-63* AST-95* CK(CPK)-323* AlkPhos-69 TotBili-2.4* [**2148-12-24**] 11:19AM BLOOD ALT-63* AST-117* AlkPhos-53 TotBili-2.1* [**2148-12-24**] 02:03AM BLOOD ALT-50* AST-108* AlkPhos-55 TotBili-4.0* [**2148-12-23**] 06:02PM BLOOD ALT-26 AST-60* [**2149-1-2**] 06:33AM BLOOD Albumin-2.8* Calcium-8.0* Phos-3.4 [**2149-1-1**] 06:30AM BLOOD Albumin-2.8* Calcium-8.0* Phos-3.1 Mg-1.7 [**2148-12-30**] 06:30AM BLOOD Albumin-2.4* Calcium-7.7* Phos-3.8 Mg-1.9 [**2148-12-27**] 06:45AM BLOOD Albumin-2.3* Calcium-7.1* Phos-3.4 Mg-2.1 [**2148-12-25**] 02:13AM BLOOD Albumin-2.9* Calcium-8.0* Phos-2.7 Mg-2.1 [**2148-12-26**] 01:58AM BLOOD Albumin-2.5* Calcium-7.2* Phos-2.9 Mg-2.0 [**2148-12-24**] 02:03AM BLOOD Albumin-2.9* Calcium-8.4 Phos-4.0 Mg-2.0 [**2148-12-24**] 05:57PM BLOOD Cortsol-37.5* [**2148-12-24**] 05:30PM BLOOD Cortsol-31.7* [**2148-12-24**] 04:47PM BLOOD Cortsol-23.5* [**2149-1-2**] 06:33AM BLOOD tacroFK-7.4 [**2149-1-1**] 06:30AM BLOOD tacroFK-4.7* [**2148-12-31**] 05:50AM BLOOD tacroFK-4.8* [**2148-12-30**] 06:30AM BLOOD tacroFK-4.8* [**2148-12-29**] 06:20AM BLOOD tacroFK-7.2 [**2148-12-28**] 07:10AM BLOOD tacroFK-9.7 [**2148-12-27**] 06:45AM BLOOD tacroFK-15.8 ASCITES ASCITES ANALYSIS WBC RBC Polys Lymphs Monos Eos Mesothe Macroph [**2149-1-1**] 12:56 510* 6825* 32* 8* 3* 1* 2* 54* PERITONEAL FLUID [**2148-12-27**] 08:47 1200* 3750* 80* 7* 0 3* 10 [**2148-12-23**] Intra op abd US widely patent left middle and right hepatic veins in the donor liver. Slight narrowing is identified at the confluence of the donor cava with the recipient cava characterized by slight flow velocity increases. The study was then continued posterior to the displaced liver which demonstrated blind-ending vena cava with no thrombosis. The second cava could not be easily depicted on the study. There appears to be slight narrowing at the junction between the donor liver vena cava and the native vena cava associated with aliasing and turbulence of blood flow. [**12-24**] Abd duplex CONCLUSION: Right and middle hepatic veins are patent with relatively slow velocities. Left hepatic vein could not be imaged and the inferior vena cava could only be imaged at the cavocaval anastomosis and distal to the anastomosis. Proximal to the anastomosis, the IVC could not be successfully imaged and may be narrowed based on one CFI image (Im 21), but this could not be confirmed by pulsed Doppler. [**2148-12-26**] KUB IMPRESSION: Dilatation of small bowel loops with air in the rectum, compatible with ileus. [**2148-12-28**] KUB Impression: Ileus or early obstruction, follow up is recommended Brief Hospital Course: Mr. [**Known lastname 699**] was admitted on [**2148-12-23**] and he underwent exploratory laparotomy, extensive lysis of adhesions, donor cava to recipient caval anastomosis, intra op US x2 for IVC stenosis at the level of the hepatic vein confluence. Surgeon was Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. Please refer to operative note for details. There were no complications but he did require pressor support to persistent hypotension post-op. He was transferred to the floor on POD 2 after being sucessfully weaned off pressors. Neuro: Post-operatively, the patient received morphine IV with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications which also provided a good effect. CV: On POD 2 the patient no longer needed pressor support and thus was transferred to the floor. He remained cardiovascularly stable for the rest of his stay here. Vital signs were routinely monitored. Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. His diet was advanced when appropriate, which was tolerated well. He was also started on a bowel regimen to encourage bowel movement. Foley was removed on POD#6. He underwent two diagnostic and therapeutic paracentesis taps (POD 4 and POD 8). The first tap showed elevated WBC (but no growth) and thus he was given one dose of vancomycin and a 1 week course of zosyn. The second tap was clean. He was agressively treated with lasix to remove excess fluids. He was also wearing compression stockings throughout his stay. Both abdominal JP drains were removed prior to his discharge. Intake and output were closely monitored. ID: As described above, the patient was treated with one dose of vancomycin and one week of zosyn for SBP prophylaxis. He was sent out on a daily dose of ciprofloxacin. The patient's temperature was closely watched for signs of infection and he was afebrile throughout his stay. Prophylaxis: The pt's platelet count was initally low, but after a HIT profile came back negative and platelet count improved, the patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. [**Last Name (un) **]: the pt continued to receive the usual immunosuppresants- MMF and prograf by level. At the time of discharge on POD#10, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Medications on Admission: atenolol 25', plavix 75', famotidine 20', MMF 500'', Bss', FK [**1-2**], topiramate 25'', ASA 81', lasix 60', loratadine 10', calcium-vitamin D3 500-400'' Discharge Medications: 1. Cipro 500 mg Tablet Sig: One (1) Tablet PO once a day: sbp prophylaxis. Disp:*30 Tablet(s)* Refills:*2* 2. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 3. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 9. topiramate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*56 Tablet(s)* Refills:*0* 11. tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every 12 hours). 12. Calcium-Vitamin D Oral 13. multivitamin Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: h/o liver [**Month/Day (2) **] c/b IVC stenosis at the level of the hepatic vein confluence Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call the [**Month/Day (2) 1326**] Office [**Telephone/Fax (1) 673**] if you have any of the listed warning signs -check your weight every day and record -you may shower -do not lift anything heavier than 10 pounds -continue to elevate your legs above heart level when at home. Avoid sitting with legs down for long periods Followup Instructions: Paracentesis Wed [**1-8**] time to be scheduled. [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **] to call you with time. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2149-1-8**] 2:20 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2149-1-3**]

[ "E878.2", "997.79", "572.3", "287.5", "568.0", "403.90", "789.59", "585.9", "995.93", "560.1", "459.2", "E878.0", "996.82" ]

icd9cm

[ [ [] ] ]

[ "39.1", "50.11", "54.91", "54.59" ]

icd9pcs

[ [ [] ] ]

12877, 12883

8950, 11622

311, 442

13019, 13019

3612, 8927

13525, 13994

2980, 3121

11828, 12854

12904, 12998

11649, 11805

13170, 13502

3136, 3136

3151, 3593

259, 273

470, 2347

13034, 13146

2369, 2668

2684, 2964

24,900

153,828

29231

Discharge summary

report

Admission Date: [**2172-10-28**] Discharge Date: [**2172-11-1**] Date of Birth: [**2122-6-10**] Sex: M Service: MEDICINE Allergies: Amiodarone / Bacitracin / Morphine / Percocet / Oxycodone Attending:[**First Name3 (LF) 613**] Chief Complaint: Bright red blood per rectum, hypotension Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 50 year old male with past medical history significant for CRF on HD s/p cadaveric transplant now on HD, DM, restrictive lung disease/ intersitial pulmonary fibrosis, bilateral BKAs, and metastatic calcaphylaxis, who presents from [**Hospital 100**] Rehab after being found to be sitting "in pool of blood," with systolic blood pressure in the 70's. Last night, patient had a rectal tube that was d/c'd, and 20 cc of blood was noted. He was also found to have MRSA cultured from a wound (leg?) and was started on vanco yesterday, per transfer note from Dr. [**Last Name (STitle) 16232**]. In the ED, his blood pressures were noted to be 56-81 systolic over 40-50 diastolic. He was given 1 gram of vancomycin, 500 mg levofloxacin, 1.5 L of NS, and 1 unit of PRBCs. GI was consulted and plans were made for immediate flex [**Last Name (STitle) 65**]. Patient had recent admission on [**2172-10-3**] (discharged to rehab [**2172-10-19**]) for mental status changes, fevers, and hypotension, and no clear infectious source was identified. His mental status changes were felt secondary to his numerous pain medications that are renally cleared, and his mental status cleared, with Dilaudid, Neurontin, and Ibuprofen for pain control. It was felt that his blood pressure was not accurrately able to be measured. During that stay, PICC and hemodialysis lines were placed. He had previously been admitted in [**8-/2172**] and underwent left BKA and right first toe amputation for gangrenous infection. Past Medical History: - ESRD, s/p cadaveric transplant for presumed chronic glomerulonephritis - Metastatic calciphylaxis - s/p BKA - Interstital pulmonary fibrosis - Restrictive lung disease - Gout - Diabetes Mellitus - s/p prior left AV fistula - Hypertension - Hyperlipidemia - Atrial fibrillation noted during prior admissions. Social History: Lives by himself, divorced; no EtOH or tobacco. Family History: Non-contributory Pertinent Results: [**2172-10-28**] Sigmoidoscopy - Ulcers in the rectum at 15cm; Ulcer in the rectum at 10cm; Otherwise normal sigmoidoscopy to sigmoid colon upto 40cm. Brief Hospital Course: Patient is a 50 year old male with history of ESRD s/p cadaveric transplant on HD, DM, metastatic calciphylaxis, who presents with bright red blood per rectum and hypotension, in setting of recently diagnosed MRSA wound infection. A flex [**Month/Day/Year 65**] was performed on the day of admission that showed multiple superficial ulcers but also a single large ulcer with visible vessel that started bleeding after deploying endoclip. A total of 8 clips and 20cc of epinephrine was used to control hemostasis. He received 2 units of FFP but did not require PRBC's. He did not have any further bleeding. The team and ICU attending doctor, Dr. [**Last Name (STitle) **], had extensive discussion with both the family and patient. The patient was able to clearly state that he did not want any further interventions, did not hemodylasis, and wanted to be DNR/DNI and comfort measures only. Family was tearful but understood his wishes which he expressed to them as well. Social work assisted with meeting with the family. His pain was agressively treated. He was transferred out to the medical floor on [**2172-10-31**]. He passed away at 6:50am on the morning of [**2172-11-1**], prior to being seen by the medical attending on the floor. The family was notified and agreed to an autopsy. Medications on Admission: 1. Etidronate Disodium 400 mg daily 2. Senna 8.6 mg [**Hospital1 **] 3. B Complex-Vitamin C-Folic Acid 1 mg Daily 4. Aspirin 325 mg DAILY 5. Simvastatin 40 mg daily 6. Cinacalcet 30 mg QOD 7. Allopurinol 100 mg Please dose with dialysis. 8. Prednisone 5 mg DAILY 9. Ipratropium Bromide neb Inhalation Q6H as needed. 10. Albuterol Sulfate 0.083 % every 6 hours as needed. 11. Trazodone 50 mg HS 12. Fluconazole 200 mg Q24H Please continue until [**2172-10-22**]. 13. Ibuprofen 400 mg Q8H 14. Docusate Sodium 100 mg [**Hospital1 **] 15. Acetaminophen 650 mg Q6H 16. Gabapentin 300 mg DAILY 17. Pantoprazole 40 mg Q24H 18. Ondansetron Q8H as needed. 19. Hydromorphone 0.5 mg Injection Q3H 20. Dilaudid 1mg q3hrs Discharge Medications: The patient passed away at 6:50am on [**2172-11-1**]. Discharge Disposition: Expired Discharge Diagnosis: Metastatic calcaphylaxis ESRD Diabetes mellitus Discharge Condition: The patient passed away at 6:50am on [**2172-11-1**]. Discharge Instructions: The patient passed away at 6:50am on [**2172-11-1**]. Followup Instructions: The patient passed away at 6:50am on [**2172-11-1**]. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "403.91", "V42.0", "585.6", "286.9", "250.00", "275.49", "578.9", "569.41", "V49.75" ]

icd9cm

[ [ [] ] ]

[ "48.23", "39.98" ]

icd9pcs

[ [ [] ] ]

4672, 4681

2533, 3835

359, 365

4772, 4827

2358, 2510

4929, 5106

2321, 2339

4594, 4649

4702, 4751

3861, 4571

4851, 4906

279, 321

393, 1907

1929, 2240

2256, 2305

3,202

181,207

16589

Discharge summary

report

Admission Date: [**2117-11-16**] Discharge Date: [**2117-11-25**] Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 1631**] Chief Complaint: R hip fracture Major Surgical or Invasive Procedure: open reduction, internal fixation of R hip fracture History of Present Illness: [**Age over 90 **]yo male hx [**First Name9 (NamePattern2) 47038**] [**Doctor First Name **], HTN, CAD, osteoporosis, depression admitted [**11-16**] from [**Hospital 100**] Rehab with R femur fx which he reportedly sustained while attempting to xfer from bed to WC. Pt has had R hemiplegia since "childhood accident." Denied CP, SOB prior to fall. No LOC, head trauma. Past Medical History: polycythemia [**Doctor First Name **] pernicious anemia gout HTN R hemiplegia 2/ childhood accident CAD s/p MI [**6-18**] macular degeneration depression w/delusional psychosis hard of hearing osteoporosis hx occult GI bleed; colonoscopy [**2107**] found no source R hip fx [**2-/2108**], unclear if had THR at that time Social History: resident of [**Hospital 100**] Rehab since [**7-19**] legal guardian is [**Name2 (NI) 802**] [**Name (NI) 17**] [**Name (NI) 47039**] ([**Telephone/Fax (3) 47040**]) Family History: NC Physical Exam: VS 150/68 68 16 100%RA Gen thin, appropriate for age HEENT NCAT, EOMI, MMM Neck no tenderness, FROM Chest CTA B/L Heart RRR Abd soft, NT/ND, NABS, erythema and flaking skin in RLQ extending to groin Perineum +scrotal hematoma unchanged from earlier today [**Name8 (MD) **] RN Extr RLE shortened, externally rotated with obvious deformity; 2+DP B/L; cap refill 2 sec; no open skin wounds; contractures of RUE Pertinent Results: [**2117-11-16**] 07:10PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020 [**2117-11-16**] 07:10PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2117-11-16**] 07:10PM URINE RBC->50 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0 [**2117-11-16**] 05:19PM K+-4.8 [**2117-11-16**] 05:18PM GLUCOSE-106* UREA N-34* CREAT-1.2 SODIUM-141 POTASSIUM-5.0 CHLORIDE-104 TOTAL CO2-26 ANION GAP-16 [**2117-11-16**] 05:18PM WBC-17.4* RBC-7.62* HGB-17.2 HCT-56.5* MCV-74* MCH-22.5* MCHC-30.4* RDW-14.7 [**2117-11-16**] 05:18PM NEUTS-86.8* LYMPHS-7.2* MONOS-4.0 EOS-2.0 BASOS-0.1 [**2117-11-16**] 05:18PM HYPOCHROM-3+ MICROCYT-2+ [**2117-11-16**] 05:18PM PLT COUNT-639* [**2117-11-16**] 05:18PM PT-14.4* PTT-35.6* INR(PT)-1.3 [**2117-11-18**] 06:00PM BLOOD WBC-21.2* RBC-4.49*# Hgb-11.1*# Hct-35.7*# MCV-80* MCH-24.8*# MCHC-31.1 RDW-15.5 Plt Ct-646* [**2117-11-18**] 08:57PM BLOOD WBC-21.1* RBC-4.91 Hgb-13.2* Hct-38.9* MCV-79* MCH-27.0 MCHC-34.0 RDW-17.7* Plt Ct-492* [**2117-11-19**] 12:06AM BLOOD Hct-38.7* Plt Ct-521* [**2117-11-19**] 08:00AM BLOOD WBC-23.6* RBC-4.98 Hgb-13.3* Hct-39.5* MCV-79* MCH-26.6* MCHC-33.6 RDW-17.2* Plt Ct-597* [**2117-11-19**] 10:56PM BLOOD WBC-23.5* RBC-4.63 Hgb-12.4* Hct-36.8* MCV-80* MCH-26.8* MCHC-33.7 RDW-18.3* Plt Ct-713* [**2117-11-20**] 04:04AM BLOOD WBC-15.6* RBC-4.03* Hgb-10.6* Hct-32.5* MCV-81* MCH-26.4* MCHC-32.7 RDW-17.8* Plt Ct-492* [**2117-11-21**] 03:36AM BLOOD WBC-13.0* RBC-3.70* Hgb-9.9* Hct-30.5* MCV-82 MCH-26.8* MCHC-32.6 RDW-18.4* Plt Ct-498* [**2117-11-22**] 05:42AM BLOOD WBC-13.7* RBC-4.29* Hgb-11.4* Hct-35.8* MCV-83 MCH-26.5* MCHC-31.8 RDW-18.7* Plt Ct-467* [**2117-11-23**] 05:11AM BLOOD WBC-13.0* RBC-4.14* Hgb-10.9* Hct-33.6* MCV-81* MCH-26.3* MCHC-32.4 RDW-18.5* Plt Ct-515* [**2117-11-24**] 05:27AM BLOOD WBC-10.8 RBC-3.68* Hgb-9.8* Hct-30.0* MCV-82 MCH-26.7* MCHC-32.7 RDW-18.6* Plt Ct-516* [**2117-11-25**] 04:22AM BLOOD Hct-32.4* [**2117-11-19**] 10:56PM BLOOD Neuts-86.1* Lymphs-6.4* Monos-7.2 Eos-0.2 Baso-0.1 [**2117-11-19**] 10:56PM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+ Microcy-2+ [**2117-11-18**] 05:25PM BLOOD PT-16.5* PTT-46.2* INR(PT)-1.7 [**2117-11-18**] 06:00PM BLOOD PT-15.4* PTT-43.4* INR(PT)-1.5 [**2117-11-18**] 06:00PM BLOOD Plt Ct-646* [**2117-11-18**] 08:57PM BLOOD PT-15.7* PTT-52.0* INR(PT)-1.6 [**2117-11-18**] 08:57PM BLOOD Plt Ct-492* [**2117-11-19**] 12:06AM BLOOD PT-14.7* PTT-37.1* INR(PT)-1.4 [**2117-11-19**] 12:06AM BLOOD Plt Ct-521* [**2117-11-19**] 08:00AM BLOOD PT-16.5* PTT-56.7* INR(PT)-1.7 [**2117-11-19**] 08:00AM BLOOD Plt Ct-597* [**2117-11-19**] 10:56PM BLOOD Plt Ct-713* [**2117-11-20**] 04:04AM BLOOD PT-17.8* PTT-49.8* INR(PT)-2.0 [**2117-11-20**] 04:04AM BLOOD Plt Ct-492* [**2117-11-21**] 03:36AM BLOOD PT-17.3* PTT-54.8* INR(PT)-1.9 [**2117-11-21**] 03:36AM BLOOD Plt Ct-498* [**2117-11-22**] 05:42AM BLOOD PT-16.8* PTT-38.7* INR(PT)-1.8 [**2117-11-22**] 05:42AM BLOOD Plt Ct-467* [**2117-11-23**] 05:11AM BLOOD Plt Ct-515* [**2117-11-24**] 05:27AM BLOOD Plt Ct-516* [**2117-11-18**] 05:25PM BLOOD Fibrino-268 [**2117-11-20**] 04:04AM BLOOD Fibrino-600*# [**2117-11-18**] 06:00PM BLOOD Glucose-94 UreaN-11 Creat-1.1 Na-143 K-4.1 Cl-107 HCO3-27 AnGap-13 [**2117-11-18**] 08:57PM BLOOD Glucose-111* UreaN-27* Creat-0.9 Na-138 K-4.5 Cl-112* HCO3-17* AnGap-14 [**2117-11-19**] 12:06AM BLOOD UreaN-27* Creat-1.0 [**2117-11-19**] 08:00AM BLOOD Glucose-115* UreaN-27* Creat-0.9 Na-136 K-4.6 Cl-108 HCO3-20* AnGap-13 [**2117-11-19**] 10:56PM BLOOD Glucose-108* UreaN-22* Creat-0.8 Na-135 K-4.6 Cl-108 HCO3-19* AnGap-13 [**2117-11-20**] 04:04AM BLOOD Glucose-112* UreaN-21* Creat-0.8 Na-137 K-4.2 Cl-111* HCO3-19* AnGap-11 [**2117-11-21**] 03:36AM BLOOD Glucose-133* UreaN-22* Creat-0.8 Na-140 K-3.6 Cl-112* HCO3-19* AnGap-13 [**2117-11-22**] 05:42AM BLOOD Glucose-108* UreaN-32* Creat-0.9 Na-140 K-4.0 Cl-110* HCO3-20* AnGap-14 [**2117-11-23**] 05:11AM BLOOD Glucose-115* UreaN-32* Creat-0.8 Na-143 K-3.4 Cl-110* HCO3-22 AnGap-14 [**2117-11-24**] 05:27AM BLOOD Glucose-101 UreaN-35* Creat-0.8 Na-146* K-3.1* Cl-113* HCO3-25 AnGap-11 [**2117-11-19**] 01:03PM BLOOD CK(CPK)-1571* [**2117-11-19**] 10:56PM BLOOD CK(CPK)-1200* [**2117-11-20**] 04:04AM BLOOD ALT-14 AST-54* LD(LDH)-227 AlkPhos-46 TotBili-2.2* [**2117-11-19**] 12:06AM BLOOD CK-MB-12* cTropnT-0.01 [**2117-11-19**] 01:03PM BLOOD CK-MB-18* MB Indx-1.1 cTropnT-0.02* [**2117-11-19**] 10:56PM BLOOD CK-MB-17* MB Indx-1.4 cTropnT-0.02* [**2117-11-18**] 06:00PM BLOOD Calcium-8.9 Phos-2.9 Mg-2.0 [**2117-11-19**] 12:06AM BLOOD Mg-1.3* [**2117-11-19**] 08:00AM BLOOD Calcium-7.4* Phos-2.5* Mg-1.9 [**2117-11-19**] 10:56PM BLOOD Calcium-7.6* Phos-2.8 Mg-1.8 [**2117-11-20**] 04:04AM BLOOD Calcium-6.7* Phos-2.6* Mg-1.7 [**2117-11-21**] 03:36AM BLOOD Albumin-2.1* Calcium-7.4* Phos-2.7 Mg-2.2 [**2117-11-22**] 05:42AM BLOOD Calcium-8.0* Phos-2.5* Mg-2.4 [**2117-11-23**] 05:11AM BLOOD Calcium-8.2* Phos-2.2* Mg-2.2 [**2117-11-24**] 05:27AM BLOOD Calcium-7.8* Phos-2.7 Mg-2.1 [**2117-11-19**] 01:03PM BLOOD Cortsol-19.0 [**2117-11-19**] 01:03PM BLOOD Cortsol-24.6* [**2117-11-19**] 01:03PM BLOOD Cortsol-27.0* [**2117-11-18**] 04:46PM BLOOD Type-ART pO2-97 pCO2-37 pH-7.38 calHCO3-23 Base XS--2 [**2117-11-18**] 06:54PM BLOOD Type-ART Temp-36.6 Tidal V-550 PEEP-5 FiO2-100 pO2-240* pCO2-60* pH-7.17* calHCO3-23 Base XS--7 AADO2-428 REQ O2-73 Intubat-INTUBATED [**2117-11-18**] 07:35PM BLOOD Type-ART Tidal V-800 FiO2-100 pO2-298* pCO2-55* pH-7.18* calHCO3-22 Base XS--8 AADO2-375 REQ O2-65 Intubat-INTUBATED Vent-CONTROLLED [**2117-11-18**] 09:09PM BLOOD Type-ART pO2-87 pCO2-48* pH-7.20* calHCO3-20* Base XS--9 [**2117-11-19**] 12:30AM BLOOD Type-ART pO2-82* pCO2-32* pH-7.39 calHCO3-20* Base XS--4 [**2117-11-19**] 04:51AM BLOOD pO2-54* pCO2-29* pH-7.38 calHCO3-18* Base XS--6 [**2117-11-19**] 06:02AM BLOOD Type-ART pO2-260* pCO2-31* pH-7.38 calHCO3-19* Base XS--5 [**2117-11-19**] 08:17AM BLOOD Type-ART Rates-15/ Tidal V-550 pO2-217* pCO2-28* pH-7.42 calHCO3-19* Base XS--4 Intubat-INTUBATED Vent-IMV [**2117-11-19**] 11:47AM BLOOD Type-ART O2 Flow-6 pO2-150* pCO2-36 pH-7.32* calHCO3-19* Base XS--6 Intubat-NOT INTUBA Comment-FM [**2117-11-19**] 01:21PM BLOOD Type-MIX pO2-45* pCO2-45 pH-7.30* calHCO3-23 Base XS--3 [**2117-11-19**] 01:24PM BLOOD Type-ART Temp-37.4 pO2-146* pCO2-39 pH-7.33* calHCO3-21 Base XS--4 [**2117-11-19**] 11:01PM BLOOD Type-ART pO2-118* pCO2-36 pH-7.34* calHCO3-20* Base XS--5 Intubat-NOT INTUBA [**2117-11-20**] 04:16AM BLOOD Type-ART pO2-141* pCO2-38 pH-7.36 calHCO3-22 Base XS--3 Intubat-NOT INTUBA [**2117-11-18**] 04:46PM BLOOD Glucose-120* Lactate-3.3* Na-129* K-4.8 Cl-105 [**2117-11-18**] 09:09PM BLOOD Glucose-161* K-4.9 [**2117-11-19**] 12:30AM BLOOD Glucose-125* Lactate-2.9* Na-133* K-4.3 Cl-107 [**2117-11-19**] 04:51AM BLOOD Lactate-2.4* [**2117-11-19**] 01:24PM BLOOD Lactate-1.4 [**2117-11-19**] 11:01PM BLOOD Lactate-1.4 [**2117-11-20**] 04:16AM BLOOD Lactate-1.0 [**2117-11-18**] 04:46PM BLOOD Hgb-8.8* calcHCT-26 [**2117-11-18**] 06:54PM BLOOD Hgb-11.6* calcHCT-35 [**2117-11-18**] 09:09PM BLOOD O2 Sat-95 [**2117-11-19**] 12:30AM BLOOD Hgb-12.4* calcHCT-37 O2 Sat-90 [**2117-11-19**] 01:21PM BLOOD O2 Sat-81 [**2117-11-19**] 01:24PM BLOOD O2 Sat-98 [**2117-11-18**] 04:46PM BLOOD freeCa-1.12 [**2117-11-18**] 09:09PM BLOOD freeCa-1.10* [**2117-11-19**] 04:51AM BLOOD freeCa-1.19 [**2117-11-20**] 04:16AM BLOOD freeCa-1.08* Hip XR [**2117-11-16**]: Fracture of the right femur below the inferior edge of the right hip prosthesis CXR [**11-16**]: Limited study with low lung volumes CT Head [**11-16**]: Study limited due to patient positioning. No large areas of hemorrhage are present, and there is no demonstrable mass effect. Please note that subtle foci of hemorrhage may be missed. Right mastoid opacification. CXR [**11-17**]: 1) Moderate left ventricular prominence. Mild left ventricular failure cannot be excluded due to supine technique. 2) Large hiatal hernia. CXR [**11-18**]: Endotracheal tube in satisfactory position, allowing for positioning of the patient. CXR [**11-19**]: 1. Central venous catheter terminates at junction of SVC and right atrium, with no pneumothorax. 2. Overdistension of endotracheal tube cuff. 3. Layering left pleural effusion and left retrocardiac opacity. CXR [**11-20**]: No pneumothorax. Persistent atelectasis in left lower lobe and probable small left pleural effusion. LUE U/S [**11-20**]: No DVT identified. Pelvis XR [**11-21**]: No fracture. Scrotal U/S [**11-21**]: 1. Normal testicles with normal flow. 2. Severe scrotal wall thickening with no air or discrete collection. UCx x2, BlCx x3: NGTD Brief Hospital Course: A/P: [**Age over 90 **]yo male with multiple medical problems, admitted for open reduction & internal fixation of R femoral fx sustained after mechanical fall. 1. S/P R hip fracture: Surgery complicated by 1L blood loss; pt received 2u pRBCs intraoperatively. Surgical site has been hemostatic, incision C/D/I. Pain controlled with IV morphine, with standing dose of Tylenol. 2. Hypotension: Pt became hypotensive to 80s systolic with labile BPs in PACU, started on neosynephrine for pressure support. Pt could not be weaned from pressors on [**Age over 90 **]#1, so was transferred to MICU for closer monitoring. Etiology was uncertain, with DDx including cardiogenic, hypovolemic, and septic shock, as well as adrenal insufficiency. He was given IV fluids; placed on stress-dose steroids; started on antibiotics until ruled out for sepsis (negative urine and blood cultures, no sign of consolidation on CXR); ruled out for MI (three sets of cardiac enzymes negative). Pressors weaned on [**Age over 90 **]#3, pt transferred to floor. Over [**Age over 90 **]#[**2-18**], pt became gradually hypertensive to the 180s systolic, and stress-dose steroids were D/C'd with return to normotensive. 3. MS/Dementia: Pt is demented and disoriented at baseline, often aggressive. [**Name8 (MD) **] RN from [**Hospital 100**] Rehab, pt often refuses food and PO meds, yells at his caretakers, shouts for help. Pt returned to his baseline MS [**First Name (Titles) **] [**Last Name (Titles) **]#1 and has remained stable. He was kept on his standing Zyprexa and Prozac, with PRN Zydis Zyprexa for agitation. 4. Anticoagulation: Given general immobiliity of pt, recent surgery, and recent fracture of long bone, pt is at very high risk for DVT. He was placed on Lovenox by orthopedics, to be continued as outpt until transition to Coumadin can be made. Pt has been guaiac positive in the past; in-house, has been negative. INR to be followed at HR. 5. GU: On [**Last Name (Titles) **]#3, pt was noted to have swollen scrotum. Pelvis XR revealed no fracture; U/S of scrotum showed no fluid collection, but marked tissue edema of scrotal wall. Pt was unable to void spontaneously, and a Foley catheter was placed. Per GU consult, scrotal enlargement likely represents tissue edema after surgery, and will likely resolve spontaneously. Until then, pt may require Foley catheter for bladder drainage. Trial of void performed [**2117-11-23**] without success, so Foley replaced p.m. [**2117-11-23**]. If no resolution, may follow up as outpt with urology. 6. CAD: Stable. Pt denied CP and SOB throughout his hospital stay. Will continue outpt doses of ASA, atorvastatin. Will consider restarting beta blocker based on BP. 7. Gout: Pt was continued on his outpt allopurinol. 8. Hyperlipidemia: Pt was continued on his outpt statin. 9. Access: Pt had R IJ catheter placed [**2117-11-16**]. 10. FEN: Regular diet as tolerated. Corrected serum Ca normal (given low albumin). 11. Code: Full after discussion with health care proxy. 12. Dispo: to [**Hospital3 **] when stable. Medications on Admission: Allopurinol Atenolol Calcitonin Erythromycin ophthalmic ointment Prozac Zyprexa Discharge Medications: 1. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig: Two Hundred (200) IU Nasal DAILY (Daily). Disp:*1 unit* Refills:*2* 2. Erythromycin 5 mg/g Ointment Sig: 0.5 inch Ophthalmic HS (at bedtime). Disp:*1 tube* Refills:*2* 3. Fluoxetine HCl 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Morphine Sulfate 0.5-4 mg IV Q4H:PRN 7. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:*120 Tablet(s)* Refills:*2* 8. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: Forty (40) mg Subcutaneous DAILY (Daily). Disp:*30 syringes* Refills:*2* 10. Coumadin 3 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - LTC Discharge Diagnosis: Primary diagnosis: R hip fracture Secondary diagnoses: polycythemia [**Doctor First Name **] pernicious anemia gout hypertension R hemiplegia 2/ childhood accident CAD s/p MI [**6-18**] macular degeneration depression w/delusional psychosis hard of hearing osteoporosis hx occult GI bleed prior R hip fracture Discharge Condition: Good, stable Discharge Instructions: 1. Please take all medications as prescribed. 2. Please keep all follow-up appointments. 3. Please return to the hospital if you experience F/C, N/V, CP, SOB, drainage from or pain at your incision site, or any other symptoms that worry you. Followup Instructions: With your physician as needed. Outpatient follow-up with urology as needed if scrotal/penile swelling and/or urinary retention do not improve. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1636**] Completed by:[**2117-11-25**]

[ "414.00", "788.20", "V43.64", "281.0", "608.86", "294.8", "458.29", "412", "821.00", "274.9", "238.4", "401.9", "E888.9" ]

icd9cm

[ [ [] ] ]

[ "96.6", "79.35", "38.93", "99.04" ]

icd9pcs

[ [ [] ] ]

14565, 14630

10336, 13414

236, 290

14985, 14999

1682, 10313

15291, 15589

1232, 1236

13544, 14542

14651, 14651

13440, 13521

15023, 15268

1251, 1663

14707, 14964

182, 198

318, 689

14670, 14686

711, 1033

1049, 1216

4,787

114,129

2545

Discharge summary

report

Admission Date: [**2126-6-30**] Discharge Date: [**2126-7-9**] Date of Birth: [**2044-1-3**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 800**] Chief Complaint: hypotension, fever Major Surgical or Invasive Procedure: none History of Present Illness: 82 M with ESRD on HD, AFib, CHF, C diff colitis, h/o klebsiella/e.coli urosepsis, MRSA bacteremia presented after noted to have systolic BPs in the 60s at dialysis. . In the ED his initial vitals were 101.9 (rectal), 103, 70/50 (138/50 in room), 24, 97%2L. He received 3L of NS while he was down there. His most recent vitals were 91, 108/64, 21, 93%2L. His lowest SBP was 108. He had a UA which was positive. He had elevated LFTs, had a RUQ US which did not show evidence of acute cholecystitis. He was given vanco, zosyn, and tylenol in the ER. He was transferred to MICU for hypotension and sepsis. . He denies any fever, chills, nightsweats, current chestpain, abdominal pain, nausea, vomitting, palpitations, focal weakness or numbness. He makes some urine and denies any dysuria, hematuria. No blood in stool. Past Medical History: - ESRD on HD T/T/S - Atrial fibrillation - h/o GI bleed, diverticulitis - C. Diff colitis - h/o 2 CVAs - h/o nephrolithiasis w/ stent and nephrostomy tube - CAD s/p MI - sleep apnea not on cpap - h/o klebsiella/E.coli urosepsis, MRSA line infection - depression - PFTs [**2117**] with mild restrictive ventilatory defect - Anemia with h/o iron deficiency Social History: Lives with wife [**Name (NI) **], daughter lives downstairs, h/o smoking [**12-21**] PPD for 50 years, quit 20 years ago, occasional beer, none recently, no drugs. Family History: NC Physical Exam: Vitals: Gen: Pleasant gentleman, AOx3, in no apparent distress, following commands. HEENT: EOM-I, MM slightly dry, OP clear, JVP not elevated Heart: S1S2 RRR, no MRG Lungs: Bibasilar crackles, no wheezes Abdomen: BS present, very minimal tenderness in RUQ, no rebound, no appreciable mass/organomegaly Ext: no edema, dopplerable pulses present Neuro: AOx3, CN III-XII grossly intact, strength 5/5 in bilateral lower extremities, sensation is intact in BLE. Pertinent Results: Blood cx negative from [**7-1**], [**7-2**], [**7-3**]. . Upon discharge, WBC was 5.4, Hct 31.3, plt 205 . [**2126-7-3**] Pelvis US - Enlarged prostate gland as described above. No evidence for abscess. . [**7-3**] CT abd/pelvis with and without oral/iv contrast . [**2126-7-1**] HIDA: Normal study. No evidence of acute or chronic cholecystitis. . [**2126-7-1**] AVF U/S: no thrombus . [**2126-6-29**] RUQ US: Distended gallbladder No [**Doctor Last Name 515**] sign No cholelithiasis, no wall thickening, no pericolecystic fluid Unlikely acute cholecystis . CXR [**2126-6-29**]: Low lung volumes, with no acute abnormalities. . [**2126-7-2**] 04:35AM BLOOD WBC-6.4 RBC-3.20* Hgb-9.8* Hct-30.0* MCV-94 MCH-30.7 MCHC-32.8 RDW-15.3 Plt Ct-178 (WBC trending down, Hct trending down) . [**2126-7-2**] 04:35AM BLOOD Glucose-109* UreaN-40* Creat-4.5* Na-141 K-3.8 Cl-104 HCO3-29 AnGap-12 (cr up from 2.7) . LFTs decreasing during admission: [**2126-7-2**] 04:35AM BLOOD ALT-67* AST-42* AlkPhos-336* TotBili-0.6 [**2126-6-29**] 10:00PM BLOOD ALT-167* AST-335* LD(LDH)-702* CK(CPK)-169 AlkPhos-607* TotBili-2.3* . [**2126-7-2**] 04:35AM BLOOD Calcium-7.9* Phos-3.2 Mg-2.3 [**2126-6-29**] 10:00PM BLOOD cTropnT-0.07* [**2126-6-29**] 10:00PM BLOOD Lipase-19 [**2126-6-29**] 10:00PM BLOOD Lactate-2.8* [**2126-6-30**] 10:31AM BLOOD Lactate-1.5 Brief Hospital Course: 82 y/o male with ESRD on HD, multiple episodes of blood stream infections (MRSA, E.coli) admitted with sepsis secondary to polymicrobial blood stream infection with ESBL E. coli and E. faecium of unclear source. . # Sepsis/polymicrobial bacteremia: E. faecium and ESBL E. coli bacteremia. Unclear source after extensive workup outlined below. He underwent extensive GI workup (concern for biliary vs peri-diverticular etiology) including negative RUQ US, HIDA scan and CT A&P without clear focus identified. GU source was pursued as well, with negative prostate US. AVG US was negative. Pt also underwent TTE (negative), xray of teeth (normal), CXR (no pna), and WBC scan (negative). Pt was placed on meropenem and vancomycin initally, switched to daptomycin given hx of VRE, and then back to vancomycin when sensitivities returned. Patient was discharged on IV vancomycin and meropenem with an end date of [**2126-7-29**] (for a total Abx course of 4 weeks). Patient is to take vancomycin 1g IV with HD. He is to take meropenem 500 mg IV q24 hours, at 9 pm every night. Upon discharge, patient cleared his nidus of infection which may have been seeding into the bloodstream. . # ESRD/HD: lytes remainded stable and pt underwent his regularly scheduled HD schedule. . # h/o CAD/PVD/CVA: asa was continued for prevention. . # h/o Afib: in afib throughout hospitalization, but rate controlled. Pt not anticoagulated secondary to h/o GI bleed. . # Anemia h/o GIB: Hct remainded at baseline. . Medications on Admission: Fluoxetine 10 mg daily Atrovent HFA 1 inh q4h prn Pantoprazole 40 mg daily Tiotropium i puff daily Tylenol prn ASA 81 mg daily Colace prn Bisacodyl prn MVI Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 8. PICC care Sodium Chloride 0.9% Flush 3 mL IV prn PICC line use 9. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous HD PROTOCOL (HD Protochol) for 19 days: end date [**2126-7-29**]. Disp:*20 QS* Refills:*0* 10. Meropenem 500 mg Recon Soln Sig: One (1) Intravenous once a day for 20 days: PLEASE GIVE AT 9 pm EVERY NIGHT (important to dose after dialysis). End date [**2126-7-29**]. Disp:*20 QS* Refills:*0* 11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. Discharge Disposition: Extended Care Facility: [**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **] Discharge Diagnosis: Primary 1. Polymicrobial blood stream infection: E. faecium and ESBL E. coli bacteremia . Secondary 1. ESRD on HD 2. History of multiple episodes of catheter related bloodstream infections 3. Hx of VRE UTI [**12-26**] 4. Atrial fibrillation Discharge Condition: good, ambulating, no supplemental oxygen Discharge Instructions: You were found to have a bloodstream infection with E. coli and E. faecium bacteria and were treated initially in the ICU. You underwent many tests to determine the cause of your bloodstream infections. Your gall bladder scan, CT scan of the abdomen and pelvis, prostate ultrasound, AV hemodialysis fistula, and cardiac echocardiogram showed no signs of infection. In addition, the x-ray of your teeth and WBC scan showed no signs of infection. . Please take your medications as prescribed. . You were placed on 2 new medications, vancomycin and meropenem, on discharge. Your vancomycin will be given with dialysis. Your meropenem will be given at 9 pm every night. Please take these medicines to clear your blood stream infection with an end date of [**2126-7-29**]. . Please seek medical attention for fevers, chills, malaise, chest pain, shortness of breath, abdominal pain, nausea/vomiting, or any other concerning symptoms. Followup Instructions: An appointment has been made with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], on [**7-17**], Wednesday, at 12:10. The phone number is [**Telephone/Fax (1) 1144**]. . An appointment has been made at ID Urgent Care for [**7-30**] at 1:30 pm. The phone number is [**Telephone/Fax (1) 457**]. . Provider [**Name9 (PRE) 5536**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2126-7-19**] 1:00 . [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**] Completed by:[**2126-7-9**]

[ "403.91", "038.42", "438.89", "995.91", "038.40", "427.31", "428.0", "285.9", "585.6" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.93" ]

icd9pcs

[ [ [] ] ]

6516, 6610

3623, 5120

331, 338

6895, 6938

2261, 3600

7918, 8575

1764, 1768

5327, 6493

6631, 6874

5146, 5304

6962, 7895

1783, 2242

273, 293

366, 1188

1210, 1566

1582, 1748

28,869

104,673

32147+57787

Discharge summary

report+addendum

Admission Date: [**2153-10-3**] Discharge Date: [**2153-10-4**] Date of Birth: [**2088-6-17**] Sex: M Service: MEDICINE Allergies: Penicillins / albuterol Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: AMS, hypotension Major Surgical or Invasive Procedure: None History of Present Illness: 65M with PMH of paraplegia s/p C5/C7 w/ suprapubic catheter, MRSA UTI, PE, DVT, and c. diff who presents with one day of altered mental status and hypotension. At [**Name (NI) 1501**], pt was noted to be feeling very tired on the morning of [**10-3**] with his usual neck pain. The staff noticed that he was more lethargic and had some abdominal distension. They changed his suprapubic cath. Approx 30 min after transfering to wheelchair, pt became unresponsive. He was returned to the bed and became responsive again immediately, was lethargic but answering questions appropriately, alert and oriented. VS were afebrile, SBP 74-84/x, HR 50-60, with exam notable for distended abdomen (nontender), possible L posterior wheeze, and thick cloudy urine from SPT. BP did not improve with oral fluids. He was given a dose of levaquin 750mg po. He was sent to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital where he presented afebrile, with eyes closed but answering questions. His urine was cloudy/white. He was diagnosed with a 7mm basal ganglia bleed by CT. He is on coumadin and was found to have a recorded INR 3.3 prior to transfer, he received 2000U profilnine iv and 500cc fluid prior to transfer. By transfer he was awake and alert. In the ED, his initial vital signs were 96.6 78 114/48 18 97% 2L Nasal Cannula. The pt c/o [**4-12**] headache and was found to be arousable by verbal stimuli. BPs ranged from 89-116/48-61. Labs were largely unremarkable. Imaging was reviewed by neurology, who felt there was no visible basal ganglia bleed on NCHCT. He had received Vit K prior to this, and once CT was reread he was started on heparin gtt to resume anticoagulation. He also received 2L fluids, ativan, and tylenol, no antibiotics were started. He was admitted to MICU for management of possible urosepsis and AMS. Vital signs on transfer were 98.9 87 110/61 16 96%. On arrival to the ICU, vitals were 113/62, 81, 11, 96%RA. He describes this morning's incident as an episode of feeling "funny" shortly after transfer from bed to wheelchair and then feeling very sleepy. He complained of neck pain similar to what he has had the last 7 years since his neck injury and headache which he gets from time to time. He denies photophobia, vision change. No CP, SOB, fever, chills, nausea, vomiting, or diarrhea. He reports that for the last few months he has been experiencing worsening fatigue and sleepiness. He has also had dizzy spells with transfers to wheelchair on and off. Other new symptoms over the last few months include memory loss, tremor in hands, and SOB lying flat. His LEs have been edematous for years since his accident. He also has redness on his sacrum. Past Medical History: MRSA/VRE UTI C. Diff Paraplegia [**1-4**] trauma at C5/C7 CVA Acute respiratory failure [**1-4**] PE, s/p IVC filter Chronic SFV thrombosis Hypoxemia PAF GERD Spinal stenosis Pleural effusion Cardiomegaly Phimosis and balanoposthitis HTN Anxiety Sacral decub OA groin cellulitis chronic back pain BPH Psychotic disorder NOS Social History: Former carpenter who had accident on the job 7 yrs ago with cervical SC injury. Married, stepson, lives in nursing home. Former smoker - quit [**7-12**] yrs ago and used to smoke 1.5ppd x 40yrs, former heavy drinker - quit 30 yrs ago, no illicit drugs. Family History: Multiple cancers - mother [**Name (NI) **], GF lung, sister [**Name (NI) **], [**Name2 (NI) 39378**] lung Aunt with CVD Physical Exam: Vitals: afebrile, 113/62, 81, 11, 96%RA General: Alert, oriented, no acute distress, appears somnolent when not participating in conversation HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: irregularly irregular, nl rate, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally with decr breath sounds at right base, no wheezes, rales, rhonchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: SPT in place, dressed, no edema or erythema, nontender. no penile redness or discharge Ext: warm, well perfused, 2+ pulses, 2+ pitting edema in [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**] Neuro: CN II-XII intact, upper extremeties tremulous with action and at rest, contractures in the hands bilaterally, increased tone in UEs. LEs with 0/5 strength, normal sensation. Cognition appears slow. Skin: stage I-II sacral decub Pertinent Results: ADMISSION LABS [**2153-10-3**] 05:41PM BLOOD WBC-6.2 RBC-4.42* Hgb-13.4*# Hct-40.3# MCV-91 MCH-30.4 MCHC-33.4 RDW-15.2 Plt Ct-134*# [**2153-10-3**] 05:41PM BLOOD PT-22.9* PTT-36.3 INR(PT)-2.1* [**2153-10-3**] 05:41PM BLOOD Glucose-101* UreaN-18 Creat-0.5 Na-141 K-4.6 Cl-106 HCO3-33* AnGap-7* [**2153-10-3**] 05:41PM BLOOD Calcium-8.0* Phos-3.9 Mg-2.4 [**2153-10-3**] 05:50PM BLOOD Lactate-1.1 DISCHARGE LABS [**2153-10-4**] 04:25AM BLOOD WBC-5.5 RBC-4.26* Hgb-12.6* Hct-37.3* MCV-88 MCH-29.5 MCHC-33.7 RDW-15.2 Plt Ct-123* [**2153-10-4**] 09:49AM BLOOD PT-13.7* PTT-130.7* INR(PT)-1.3* [**2153-10-4**] 04:25AM BLOOD Glucose-116* UreaN-13 Creat-0.5 Na-142 K-3.7 Cl-107 HCO3-27 AnGap-12 [**2153-10-4**] 04:25AM BLOOD ALT-14 AST-21 LD(LDH)-160 AlkPhos-58 TotBili-1.6* DirBili-0.2 IndBili-1.4 [**2153-10-4**] 04:25AM BLOOD Albumin-3.6 Calcium-8.0* Phos-2.9 Mg-2.3 MICRO [**2153-10-3**] URINE URINE CULTURE-PENDING EMERGENCY [**Hospital1 **] [**2153-10-3**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] [**2153-10-3**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] IMAGING [**10-3**] CXR: Semi-upright portable AP view of the chest was provided. Overlying EKG leads are present. The lungs appear clear. No signs of pneumonia or CHF. Cardiomediastinal silhouette is unchanged with normal heart size, unchanged. Bony structures are intact. IMPRESSION: Top normal heart size. Otherwise, unremarkable. [**10-3**] CT Head (Prelim read) FINDINGS: Examination is suboptimal due to patient motion. No intracranial hemorrhage, edema, mass effect, or vascular territorial infarct. Stable appearance of bilateral globus pallidus calcifications. Ventricles and sulci are age appropriate. There is no shift of the normally midline structures. Large amount of right and small amount of left external auditory canal cerrumen. Mastoid air cells and middle ear cavities are clear. Minimal mucosal thickening in the ethmoid air cells. The orbits and intraconal structures are symmetric. IMPRESSION: No acute intracranial process. Bilateral basal ganglia calcifications. Brief Hospital Course: 65M with PMH of paraplegia [**1-4**] trauma, recurrent UTI with SPT, PAF, PE who presents with 1 day of lethargy and hypotension. ACTIVE ISSUES: 1. Hypotension: Improved. Autonomic dysfunction was considered a likely contributor given patient's paraplegia and history of orthostasis. Urosepsis was also considered given UA (mildly positive in setting of suprapubic catheter) and history of MRSA and VRE UTI's. [**Hospital3 26615**] urine culture growing GNR and proteus (no sensitivities at the time of discharge), and patient was placed on ciprofloxacin. In addition, some of his medications could be contributing to his low blood pressure, such as morphine, multiple types of benzodiazepines, baclofen. Please consider tilt table test as an outpatient to further evaluate autonomic instability. Please follow up urine culture sensitivities from [**Hospital3 26615**] and pending urine and blood cultures from [**Hospital1 18**], as patient may require an antibiotic change if he grows a resistant organism. It would be important to simply his pain and anxiety medication regimen. 2. AMS: Improved. Although there was concern for an intracranial bleed at OSH, CT head here was negative. Polypharmacy in the setting of numerous sedating medications vs. infection was determined to be the most likely etiology of AMS. As an outpatient, please consider further taper of sedating medications. Patient was started on ciprofloxacin as above. 3. Atrial fibrillation: Patient was maintained on telemetry. His head CT showed no signs of intracranial bleed, and he was restarted on his home coumadin dose. His telemetry did show intermittent bradycardia to the low 50's and occasional pauses, which were asymptomatic. 4. Chronic pain: Morphine sulfate SR QID was changed to Morphine Sulfate IR QID given concern for sedation contributing to hypotension. CHRONIC ISSUES: 1. Paraplegia: Patient is s/p C5/C7 injury. His neurologic examinations were stable, and he was continued on his home muscle relaxants. 2. History of C. diff: Patient has no diarrhea at present 3. GERD: Patient was continued on omeprazole. 4. History of PE: Patient has an IVC filter and is treated with coumadin. Coumadin was restarted as above. 6. Psychosis NOS: Patient was continued on clonazepam and Prozac TRANSITIONAL ISSUES: - Follow up urine culture GNR sensitivities from [**Hospital3 26615**]. If UCx grows a resistent organism, may need to change antibiotics. - Follow up blood and urine cultures from [**Hospital1 18**] - Consider taper of sedating medications Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Bisacodyl 10 mg PO DAILY hold for loose stool 2. Morphine SR (MS Contin) 15 mg PO QID hold for oversedation or RR <12 3. Multivitamins 1 TAB PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Baclofen 10 mg PO TID hold for oversedation or RR<12 6. UTI-Stat *NF* ([**Last Name (un) **]-vitC-D mannose-inuln-[**Last Name (un) **]) 3,875 mg/30 mL Oral [**Hospital1 **] 7. Clonazepam 2 mg PO BID hold for RR<12 or oversedation 8. Psyllium 1 PKT PO DAILY hold for loose stool 9. Milk of Magnesia 30 mL PO DAILY: SUN,TUES,THURS,SAT hold for loose stool 10. Vitamin D 50,000 UNIT PO 1X/WEEK (WE) 11. Acetaminophen 650 mg PO BID 12. Gabapentin 300 mg PO TID hold for oversedation or RR<12 13. Ascorbic Acid 500 mg PO DAILY 14. Ferrous Sulfate 325 mg PO DAILY 15. Aripiprazole 10 mg PO DAILY 16. Lorazepam 1 mg PO TID hold for oversedation or RR<12 17. Docusate Sodium 100 mg PO DAILY hold for loose stools 18. Fluoxetine 20 mg PO DAILY 19. Warfarin 5 mg PO DAILY16 Discharge Medications: 1. Acetaminophen 650 mg PO BID 2. Aripiprazole 10 mg PO DAILY 3. Ascorbic Acid 500 mg PO DAILY 4. Baclofen 10 mg PO TID hold for oversedation or RR<12 5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 6. Clonazepam 2 mg PO BID hold for RR<12 or oversedation 7. Ferrous Sulfate 325 mg PO DAILY 8. Fluoxetine 20 mg PO DAILY 9. Gabapentin 300 mg PO TID hold for oversedation or RR<12 10. Lorazepam 1 mg PO TID hold for oversedation or RR<12 11. Milk of Magnesia 30 mL PO DAILY: SUN,TUES,THURS,SAT hold for loose stool 12. Multivitamins 1 TAB PO DAILY 13. Omeprazole 20 mg PO DAILY 14. Psyllium 1 PKT PO DAILY hold for loose stool 15. Warfarin 5 mg PO DAILY16 16. Ciprofloxacin HCl 500 mg PO Q12H Duration: 9 Days 17. Docusate Sodium 100 mg PO DAILY hold for loose stools 18. Morphine Sulfate IR 15 mg PO Q6H 19. Vitamin D 50,000 UNIT PO 1X/WEEK (WE) Discharge Disposition: Extended Care Facility: [**Location (un) 32944**] Village & Rehabilitation Center - [**Location (un) 32944**] Discharge Diagnosis: Hypotension UTI 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: Dear Mr. [**Known lastname **], You were admitted to the [**Hospital1 69**] for low blood pressure and altered mental status. Your symptoms were most likely due to an infection of your urine, to autonomic dysfunction related to your paralysis, or to the medications you take for pain (which can lower blood pressure). You were started on an antibiotic for your urinary tract infection and your blood pressures improved. Followup Instructions: Please follow up with the physician at your skilled nursing facility. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Name: [**Known lastname **],[**Known firstname **] A. Unit No: [**Numeric Identifier 12365**] Admission Date: [**2153-10-3**] Discharge Date: [**2153-10-4**] Date of Birth: [**2088-6-17**] Sex: M Service: MEDICINE Allergies: Penicillins / albuterol Attending:[**Last Name (NamePattern4) 3776**] Addendum: ACTIVE ISSUES: 1. Bradycardia: Patient was intermittently bradycardic. He was asymptomatic during these episodes and quickly rebounded to normal HR without intervention. He is not on nodal blocking agents. Please continue to avoid nodal agents and please refer to Cardiology for outpatient work-up of bradycardia. TRANSITIONAL ISSUES: - Please refer to Cardiology for outpatient work-up of bradycardia. Discharge Disposition: Extended Care Facility: [**Location (un) 7190**] Village & Rehabilitation Center - [**Location (un) 7190**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 593**] [**Name8 (MD) 304**] MD [**MD Number(1) 594**] Completed by:[**2153-10-4**]

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Discharge summary

report+addendum

Admission Date: [**2183-8-29**] Discharge Date: [**2183-9-19**] Date of Birth: [**2109-11-2**] Sex: F Service: CARDIOTHORACIC Allergies: Ciprofloxacin Attending:[**First Name3 (LF) 1505**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: [**2183-9-15**] - AICD Implant (Guidant Vitality DS Model T125 DR [**Last Name (STitle) 23278**]# [**Serial Number 29806**]) [**2183-9-10**] - PTCA/Stent (Drug Eluting)of left main-left Circumflex [**2183-9-8**] - Off Pump CABGx1 (Left Internal mammary to the Left anterior descending artery. Right femoral artery false aneurysm repair. [**2183-9-3**] - Cardiac Catheterization History of Present Illness: Ms [**Known lastname 29807**] is a 73 year old woman with a history of hypertension, hyperlipidemia, CAD s/p bare metal stent [**2175**], presenting with symptoms of acute heart failure. . Ms [**Known lastname 29807**] [**Last Name (Titles) 5058**] the morning of admission ([**2183-8-29**]) at 3 am with profound shortness of breath, a sensation of fluid in her lungs, a desire to cough but an inability to do so, and the feeling that "I thought I was a goner." She pressed a panic button in her home which set off an alarm that alerted police; she was ultimately brought by ambulance to an outside hospital where she was evaluated further; and then was brought by [**Location (un) **] helicopter to [**Hospital1 18**] for concern for STEMI. . In the OSH she had lab values notable for a BNP of 449. CK of 333, CK-MB 4.3; Troponin-I was <0.04; 2nd set CK 331, CK-MB 9.7, Troponin I 2.01. She received Lasix 20 mg IV, lopressor 5 mg IV x1, nitro drip 13 mcg, Mg replacement 1 gm IV, lovenox 40 mg, aggrastat 4 mcg, ativan 1 mg x1; as well as many of her home meds: protonix, indur, and fosamax were held, but asa, lisinopril, allopurinol, plaquenil, plavix, atenolol. . The day prior to this episode, she woke up and "could hear myself wheezing" but had no trouble breathing and proceeded on with the rest of her day including working at a senior center. . Two or three weeks ago, her primary care physician became concerned about Ms [**Known lastname 29808**] renal function and high potassium. The PCP recommended that Ms [**Known lastname 29807**] go off lasix; avoid bananas, oranges and other K-containing food; and drink lots of water. Accordingly Ms [**Known lastname 29807**] bought bottled water and drank [**1-26**] 16 oz bottles of water each day (roughly 1.4-1.9 liters/day). Her PCP planned [**Name Initial (PRE) **] renal ultrasound for Ms [**Known lastname 29807**] but Ms [**Known lastname 29807**] was concerned about the cost she would incur for this so this was deferred in favor of future bloodwork, scheduled for next week. The K was originally detected in follow-up for a question of bacterial or fungal cellulitis on her foot. At her PCP's recommendation, she has since been using a "steroid-type" cream, she says, which has solved the problem. On review of systems, she 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. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1)CAD s/p silent myocardial infarction in [**2175**] 2)s/p L CEA in [**2175**] 3)Congestive heart failure 4)COPD 5)Scleroderma, complicated by Raynaud's Cardiac Risk Factors: Dyslipidemia, Hypertension Percutaneous coronary intervention, in the RCA in [**2175**] Social History: Social history is significant for a 50 pack year smoking history; she quit in [**2175**]. There is no history of alcohol abuse. Family History: Family history is notable for a mother, died at 72 of "heart problems", was diabetic; father, in his mid-60s fell off a ladder and died of ruptured aorta. Brother died of cancer (she is not sure what kind); he had CHF and a 4-vessel CABG prior; he died at age 67. 2 sons, age 50, 46, one with high cholesterol. Physical Exam: BP 126/47 127/37 HR 71 73 RR 14 21 O2 99%2L 96% 2L Gen: Elderly woman looking approximately her stated age, in NAD, resting comfortably in bed. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP not appreciated. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. Periodic extra beats. No m/r/g. No thrills, lifts. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. Ext: 2+ pitting at the ankles. Multiple varicose veins. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Carotid 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: Labs on Admission: [**2183-8-29**] 08:45PM WBC-8.0 RBC-3.24* Hgb-10.5* Hct-31.2* MCV-96 MCH-32.4* MCHC-33.6 RDW-15.0 Plt Ct-204 PT-12.7 PTT-27.9 INR(PT)-1.1 Glucose-104 UreaN-23* Creat-1.1 Na-139 K-3.7 Cl-105 HCO3-29 AnGap-9 Calcium-9.7 Phos-3.5 Mg-1.6 [**2183-8-29**] 08:45PM BLOOD CK-MB-10 MB Indx-2.8 cTropnT-0.23* CK(CPK)-351* [**2183-8-30**] 06:49AM BLOOD CK-MB-7 cTropnT-0.11* CK(CPK)-294* [**2183-8-31**] 06:40AM BLOOD CK-MB-4 cTropnT-0.10* CK(CPK)-211* [**2183-8-29**] changes but with no significant change compared with prior several EKGs from OSH. [**2183-8-29**] CXR IMPRESSION: 1. Bibasilar opacities, compatible with small layering pleural effusions and associated atelectasis on the left. 2. Mild pulmonary vascular congestion. [**2183-9-2**] ECHO TTE - The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with basal inferior aneurysm and inferolateral akinesis. The apical lateral wall may be hypokinetic but is not fully visualized. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**11-26**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. NOTE: Addendum re apical lateral wall added on [**2183-9-2**]. [**2183-9-3**] RIGHT FEMORAL VASCULAR ULTRASOUND: Grayscale and Doppler son[**Name (NI) 1417**] of the right groin puncture site demonstrate a 3.9 x 4.1 x 2.0 cm hypoechoic ovoid structure seen lateral to the vascular sheath that demonstrates contiguity with the right common femoral artery. There is internal swirling color flow within this structure consistent with a pseudoaneurysm. The neck of the aneurysm, where it meets the common femoral artery measures 3 mm in diameter. Also noted are mixed arterial and venous waveforms within the right common femoral artery and common femoral vein suggesting the presence of an AV fistula. IMPRESSION: 1. Right groin pseudoaneurysm measuring 4 x 4 x 2 cm with 3-mm neck joining the right common femoral artery. 2. Mixed waveforms within the right common femoral artery and vein suggesting AV fistula. [**2183-9-3**] Cardiac Catheterization 1. Selective coronary angiography of this right dominant system demonstrated a moderate LMCA disease. The LMCA had a 60% distal lesion with moderate calcification. The LAD was patent with a patent previously placed proximal stent. The LCx was a moderately calcified non-dominant vessel and was patent. The RCA was occluded at its origin and distal flow was supplied via left to right collaterals. 2. Resting hemodynamics revealed elevated left and right sided filling pressures with an RVEDP of 22 mmHg and a mean PCWP of 25 mmHg. The cardiac output was preserved at 2.71 l/min/m2. There was a moderate pulmonary artery systolic hypertension with a PASP of 50 mmHg. There was a severe central arterial systolic hypertension with an SBP of 180 mmHg. 3. Left ventriclulography was deferred given elevated creatinine. 4. The LMCA lesion was evaluated with a pressure wire interrogation. Baseline FFR was 0.92. The FFR was 0.76 with maximal hyperemia. FINAL DIAGNOSIS: 1. LMCA and RCA disease. 2. Moderate diastolic left ventricular dysfunction. 3. Moderate pulmonary artery systolic hypertension. 4. Severe systemic arterial systolic hypertension. [**2183-9-4**] 1. [**Doctor Last Name **] TEST FOR PREOPERATIVE ASSESSMENT OF THE RADIAL ARTERIES. IMPRESSION: There is an incomplete palmar arch in the right hand. There is a complete palmar arch in the left hand with the ulnar artery being dominant. 2. VEIN MAPPING. FINDINGS: Both greater saphenous veins were not visualized. The right lesser saphenous vein is patent and compressible with diameters ranging between 0.26 and 0.38 cm. The left lesser saphenous vein is patent and compressible with diameters ranging between 0.26 and 0.42 cm. IMPRESSION: Patent bilateral lesser saphenous veins. 3. CAROTID ULTRASOUND. FINDINGS: B-mode showed evidence of mild plaque in the bilateral internal carotid arteries. On the right side, peak systolic velocities were 92 cm/sec for the internal carotid artery, and 106 cm/sec for the common carotid artery. The right ICA/CCA ratio was 0.86. On the left side, peak systolic velocities were 134 cm/sec for the ICA and 105 cm/sec for the CCA. The left ICA/CCA ratio was 1.2. Both vertebral arteries presented antegrade flow. IMPRESSION: Less than 40% stenosis of the bilateral internal carotid arteries. [**2183-9-8**] ECHO 1. The left atrium is moderately dilated. Mild spontaneous echo contrast is seen in the body of the left atrium. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No mass/thrombus is seen in the left atrium or left atrial appendage. The left atrial appendage emptying velocity is depressed (<0.2m/s). No thrombus is seen in the left atrial appendage. 2. No spontaneous echo contrast is seen in the body of the right atrium. No atrial septal defect is seen by 2D or color Doppler. 3. Left ventricular wall thicknesses and cavity size are normal. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is an inferobasal left ventricular aneurysm. There is mild regional left ventricular systolic dysfunction with inferobasal akinesis.. No masses or thrombi are seen in the left ventricle. Overall left ventricular systolic function is mildly depressed (LVEF= 40%). The remaining left ventricular segments contract normally. 4. Right ventricular chamber size and free wall motion are normal. 5.. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 6. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis. No aortic regurgitation is seen. 7. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 8. There is transient akinesis of the mid and apical anterior segments while the LAD was clamped. Post off-pump bypass, there is restoration of the anterior wall to normal systolic function. [**2183-9-15**] ECHO The left atrium is elongated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild to moderate regional left ventricular systolic dysfunction with basal to mid infero-septal, inferior and infero-lateral akinesis to dyskinesis. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular systolic function appears depressed. There is abnormal septal motion/position. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: Ms. [**Known lastname 29807**] was admitted to the [**Hospital1 18**] on [**2183-8-29**] via med flight for further management of her heart failure and myocardial infarction. Heparin, aspirin and plavix were started and diuresis was initiated with improvement. She ruled in for a myocardial infarction by enzymes. As she had acute renal failure, her lasix was adjusted to not overwork her kidneys. Bactrim was started for a urinary tract infection. On [**2183-9-3**], Ms. [**Known lastname 29807**] [**Last Name (Titles) 1834**] a cardiac catheterization which revealed a 60% stenosed left main coronary artery, a patent stent in the LAD and an occluded RCA. An echocardiogram was obtained which revealed an ejection fraction of 45% and [**11-26**]+ mitral regurgitation. Given the severity of her disease, the cardiac surgical service was consulted for surgical management. Ms. [**Known lastname 29807**] was worked-up in the usual preoperative manner. As she lacked bilateral greater saphenous veins, vein mapping was performed. This showed absent greater saphenous veins and patent bilateral lesser saphenous veins. As she had a large right groin hematoma, an ultrasound was obtained. This revealed a pseudoaneurysm measuring 4 x 4 x 2 cm with 3-mm neck joining the right common femoral artery and mixed waveforms within the right common femoral artery and vein suggestive of AV fistula. She was transfused for low hematocrit. The vascular surgery service was consulted and recommended concomitant repair during her cardiac surgery. As she lacked conduit for bypass, a radial artery ultrasound was obtained which showed an incomplete right [**Location (un) **] arch and her left extremity to be ulnar artery dominant. Given her lack of conduit, it was decided that an off pump internal mammary artery to left anterior descending artery bypass be performed. On [**2183-9-8**], Ms. [**Known lastname 29807**] was taken to the operating room where she [**Known lastname 1834**] off pump coronary artery bypass grafting to one vessel and repair of her right femoral artery pseudoaneurysm. Please see operative note for details. Postoperatively she was taken to the cardiac surgical intensive care unit. By postoperative day one, Ms. [**Known lastname 29807**] had [**Known lastname 5058**] neurologically intact and was extubated. Beta blockade, a statin, plavix and aspirin were resumed. On postoperative day two, she was transferred to the step down unit for further recovery. Gentle diuresis was initiated. She was taken to the cath lab on [**2183-9-10**] for elective stenting of her left main coronary artery which was successfully performed. Following the procedure, Ms. [**Known lastname 29807**] developed VF arrest and asystolic episodes. She was successfully resuscitated and re intubated. She was transferred back to the cardiac surgical intensive care unit for monitoring. The electrophysiology service was consulted for evaluation and followed her closely. On [**2183-9-12**], she was extubated without complication. She had another episode of ventricular tachycardia which self resolved. A lidocaine drip was started. She gain had ventricular tachycardia which required defibrillation. Amiodarone was started and an echo was repeated which showed her LVEF to be 35-40%. She continued to be ventricularly paced for underlying bradycardia. As she continued to have several runs of ventricular tachycardia, it was decided to place an ICD. ON [**2183-9-15**], Ms. [**Known lastname 29807**] was taken to the electrophysiology lab where she [**Known lastname 1834**] placement of an AICD/pacemaker. She tolerated the procedure well and was returned to the cardiac surgical intensive care unit. She was transferred back to the step down unit of [**2183-9-16**] for further recovery. The physical therapy service worked with her daily. Amiodarone was continued. Ms. [**Known lastname 29807**] continued to make steady progress and was discharged to rehabilitation on [**2183-9-18**]. She will follow-up with Dr. [**Last Name (STitle) **], her cardiologist, her primary care physician and the [**Name9 (PRE) 29809**] service as an outpatient. Medications on Admission: Aspirin 325mg PO daily Lisinopril 10mg PO daily Allopurinol 150mg PO daily Plaquenil 200mg PO BID Plavix 75mg PO daily Imdur 30mg PO daily Fosamax Atenolol 50mg PO daily Simvastatin 40mg PO daily Prilosec 20mg PO daily Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Tablet(s) 2. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Take 400mg twice daily for a week. Starting [**2183-9-20**], take 400mg once daily for a week. Then starting [**2183-9-27**] take 200mg daily until otherwise instructed. 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 12 months: Drug eluting stent. 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 7 days. 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days. 12. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 13. Plaquenil 200 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital6 25759**] & Rehab Center - [**Location (un) **] Discharge Diagnosis: CAD s/p CABGx1 off pump s/p drug eluting stent Myocardial infarction Bare metal stent in [**2175**] VT/VF Bradycardia CVD s/p Left CEA [**2175**] s/p AICD CHF COPD Scleroderma Raynaud's Dyslipidemia HTN PVD False aneurysm of right femoral artery Discharge Condition: Stable Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Take Amiodarone as instructed. Take 400mg twice daily for a week (Started [**2183-9-13**]). Starting [**2183-9-20**], take 400mg once daily for a week. Then starting [**2183-9-27**] take 200mg daily until otherwise instructed. 8) Take lasix and potassium for 5 days and then re-evaluate. Monitor and replete electrolytes as needed and weigh patient daily. 9) Call with any questions or concerns. Followup Instructions: Follow-up with Dr. [**First Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**] Follow-up with Dr. [**Last Name (STitle) 11493**] in [**11-26**] weeks. ([**Telephone/Fax (1) 29810**] Follow-up with pcp [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17863**] in [**12-28**] weeks. ([**Telephone/Fax (1) 29811**] Call all providers for appointments. Schedule appointments: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2183-9-23**] 9:30 Completed by:[**2183-9-18**] Name: [**Known lastname 5213**],[**Known firstname 4497**] J. Unit No: [**Numeric Identifier 5214**] Admission Date: [**2183-8-29**] Discharge Date: [**2183-9-19**] Date of Birth: [**2109-11-2**] Sex: F Service: CARDIOTHORACIC Allergies: Ciprofloxacin Attending:[**First Name3 (LF) 741**] Addendum: Discharge delayed due to rehab Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Take 400mg twice daily for a week. Starting [**2183-9-20**], take 400mg once daily for a week. Then starting [**2183-9-27**] take 200mg daily until otherwise instructed. 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 12 months: Drug eluting stent. 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. 9. Plaquenil 200 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week. 11. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day for 5 days. 13. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 5025**] & Rehab Center - [**Location (un) **] Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 4294**] at ([**Telephone/Fax (1) 2092**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month. 7) Take Amiodarone as instructed. Take 400mg twice daily for a week (Started [**2183-9-13**]). Starting [**2183-9-20**], take 400mg once daily for a week. Then starting [**2183-9-27**] take 200mg daily until otherwise instructed. 8) Take lasix and potassium for 5 days and then re-evaluate. Monitor and replete electrolytes as needed and weigh patient daily. 9) Call with any questions or concerns. [**Telephone/Fax (1) 1477**] Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 2092**] Follow-up with Dr. [**Last Name (STitle) 1653**] in [**12-28**] weeks. ([**Telephone/Fax (1) 5215**] Follow-up with pcp [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5216**] in [**12-28**] weeks. ([**Telephone/Fax (1) 5217**] Follow up with Dr [**Last Name (STitle) **] in 2 weeks ([**Telephone/Fax (1) 5218**] Follow up Dr [**Last Name (STitle) **]/[**Doctor Last Name **] 1 month Call all providers for appointments. Schedule appointments: Provider: [**Name10 (NameIs) 1727**] CLINIC Phone:[**Telephone/Fax (1) 1728**] Date/Time:[**2183-9-23**] 9:30 [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2183-9-19**]

[ "584.9", "410.71", "710.1", "428.20", "496", "599.0", "428.0", "414.01", "427.41", "427.1", "997.1", "443.0", "E879.0", "442.3", "997.2" ]

icd9cm

[ [ [] ] ]

[ "88.56", "37.78", "36.15", "37.23", "00.66", "36.07", "00.45", "39.52", "00.40", "37.94" ]

icd9pcs

[ [ [] ] ]

22332, 22417

12765, 16915

300, 680

22438, 22445

5198, 5203

23576, 24350

3923, 4235

20970, 22309

18656, 18903

16941, 17162

8681, 12742

22469, 23553

4250, 5179

241, 262

708, 3475

5217, 8664

3497, 3761

3777, 3907

28,802

153,417

33638

Discharge summary

report

Admission Date: [**2200-1-22**] Discharge Date: [**2200-2-5**] Date of Birth: [**2167-6-18**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3223**] Chief Complaint: s/p Gunshot wound RLQ/Right groin Major Surgical or Invasive Procedure: [**2200-1-22**] RLE four compartment fasciotomy [**2200-1-30**] STSG to RLE medial and lateral wounds/VAC dressing [**2200-2-3**] Removal of VAC dressing [**2200-2-5**] Removal of staples from graft site History of Present Illness: Mr. [**Name13 (STitle) 77892**] is a 32 year old male who was by report found unresponsive in a park with a gunshot wound to the RLQ. He was taken to an area hospital where he was found to have right iliac vein and right external iliac artery transection. He underwent an exploratory laparotomy, repair of right external iliac artery with a Gortex jump graft and ligation of the right iliac vein. He received a total of 14 units of PRBC, 4 units FFP and 15 units platelets. He was stabilized there and transferred to [**Hospital1 18**] ED for further care. Past Medical History: Denies Social History: +EtOH on weekends, denies tobacco or recreational drug use Family History: Noncontributory Physical Exam: Upon admission: NAD RRR CTAB Abd: soft NT/minimally distended midline abdominal incision C/D/I RLQ incision with small area of open wound at bullet entrance Extr: RLE sensation and motor intact, mild foot drop vacs to medial and lateral fasciotomy sites Pertinent Results: [**2200-1-21**] 11:20PM BLOOD WBC-13.8* RBC-5.22 Hgb-16.2 Hct-44.5 MCV-85 MCH-31.1 MCHC-36.5* RDW-14.0 Plt Ct-205 [**2200-1-22**] 02:00AM BLOOD Glucose-180* UreaN-12 Creat-1.0 Na-144 K-3.0* Cl-111* HCO3-23 AnGap-13 [**2200-1-21**] 11:20PM BLOOD CK(CPK)-1701* Amylase-107* [**2200-1-22**] 02:00AM BLOOD ALT-235* AST-242* CK(CPK)-2275* AlkPhos-63 TotBili-0.9 [**2200-1-22**] 07:55AM BLOOD CK(CPK)-3518* [**2200-1-22**] 03:34PM BLOOD CK(CPK)-6224* [**2200-1-22**] 08:55PM BLOOD CK(CPK)-7139* [**2200-1-23**] 01:44AM BLOOD CK(CPK)-6679* [**2200-1-24**] 01:00AM BLOOD CK(CPK)-3469* [**2200-1-25**] 05:35AM BLOOD CK(CPK)-1506* [**2200-1-22**] 08:55PM CK(CPK)-7139* [**2200-1-22**] 07:55AM GLUCOSE-88 UREA N-11 CREAT-1.1 SODIUM-144 POTASSIUM-4.2 CHLORIDE-112* TOTAL CO2-29 ANION GAP-7 [**2200-1-22**] 02:00AM ALT(SGPT)-235* AST(SGOT)-242* CK(CPK)-2275* ALK PHOS-63 TOT BILI-0.9 [**2200-1-22**] 02:00AM WBC-10.3 RBC-4.84 HGB-14.8 HCT-40.5 MCV-84 MCH-30.6 MCHC-36.6* RDW-14.0 [**2200-1-22**] 02:00AM PLT COUNT-160 [**2200-1-22**] 02:00AM PT-15.3* PTT-31.7 INR(PT)-1.4* CHEST (PORTABLE AP) Reason: eval [**Hospital 93**] MEDICAL CONDITION: 32 year old man s/p GSW to RLQ with transection of R iliac vein, R external iliac artery s/p exlap and repair REASON FOR THIS EXAMINATION: eval AP CHEST, 8:59 A.M., ON [**1-22**]. HISTORY: Gunshot wound to the right lower quadrant. IMPRESSION: AP chest compared to [**1-21**] at 11:28 p.m. Endotracheal tube has been partially withdrawn, tip now between 2 and 3 cm above the carina. Nasogastric tube passes into the stomach and out of view. The right subclavian line tip projects over the mid SVC. Lungs are mildly diminished in volume but clear. No pneumothorax or pleural effusion. Normal cardiomediastinal silhouette. ABDOMEN (SUPINE ONLY) PORT Reason: eval [**Hospital 93**] MEDICAL CONDITION: 32 year old man s/p GSW to RLQ with transection of R iliac vein, R external iliac artery s/p exlap and repair REASON FOR THIS EXAMINATION: eval SUPINE AND UPRIGHT VIEWS OF THE ABDOMEN INDICATION: 32-year-old male, status post gunshot wound through the right lower quadrant with transection of the right iliac vein and right external iliac artery. COMPARISONS: [**2200-1-21**]. FINDINGS: The tip of a nasogastric tube projects over the left upper quadrant of the abdomen. The side port is not visualized. Multiple surgical staples overlie the midline of the lower abdomen and the midline of the right lower extremity. A tubular radiopaque density again projects over the right femoral head and appears relatively unchanged in position compared to the previous examination. Several metallic fragments are again noted to project over the right femoral head as well and along the lateral aspect of the pelvis on the right. The bowel gas pattern is overall unremarkable. Detailed evaluation of the sacrum is somewhat limited by overlying bowel gas and fecal material. Note is made of mild irregularity of the ilioischial line on the right at the level of the femoral head. Note is also made of mild irregularity involving the superior aspect of the left superior pubic ramus which appears unchanged compared to the previous examination. IMPRESSION: 1. Unremarkable bowel gas pattern. 2. Irregular margin involving the right ischium/medial acetabulum raises the possibility of underlying bony injury. Correlation with prior cross-sectional imaging, if available, is recommended. Otherwise, dedicated views of the right hip or a CT of the pelvis is recommended. 3. Multiple tiny metallic fragments again project over the right femoral head and right lateral aspect of the pelvis, similar in configuration compared to the plain films of [**2200-1-21**]. 4. Nasogastric tube, incompletely visualized. Brief Hospital Course: He was admitted to the trauma service. Upon assessment in the trauma bay he was found to have RLE compartment syndrome and taken to the operating room emergently by the vascular surgery team for 4 compartment fasciotomies. He remained intubated and was transferred to the trauma ICU post operatively; his vascular exam remained stable with palpable DP pulses. He was extubated on [**1-22**] and continued on a Dilaudid PCA with adequate pain management. His CK levels were monitored and a wound VAC was placed in the medial and lateral fasciotomy wounds. NG tube was continued due to abdominal distention and continued output. He continued to improve and the NG tube was discontinued on [**1-24**] and he was transferred to the floor. He was started on oral pain medications on [**1-25**] and was tolerating a full liquid diet. His abdominal pain/distention further improved and was started on a regular diet on [**1-26**]. His wound VAC was changed every 3 days by the vascular surgery team. He continued to work with physical therapy during his hospitalization and was ordered an AFO for his mild right foot drop. Psychiatry was consulted for anxiety, felt context appropriate given the traumatic event experienced by him. He was started on Ativan which did seem to help. There were no other acute psychiatric issues identified. He continued to do well and was taken back to the operating room on [**1-30**] by trauma surgery team for closure of his fasciotomy wounds with skin grafting with VAC. There were no intraoperative complications. His VAC was removed on [**2-3**] and on [**2-5**] his graft staples were removed. The graft was intact; the wound was covered with Xeroform and DSD. he was fitted for a compression stocking as well. His abdominal staples were removed on [**2-1**] and replaced with steri-strips. On [**2-4**] he was cleared by Physical therapy for home; case management continued to work on finding services for home but due to lack of insurance services were unable to be set up. Nursing began teaching patient regarding self wound care/dressing changes. He demonstrated a clear understanding and proper technique for managing his wounds at home. He was discharged to home with instructions for follow up with Dr. [**Last Name (STitle) **] the week after discharge for graft check. Medications on Admission: None Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 3. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). Disp:*60 Tablet Sustained Release(s)* Refills:*0* 4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q12H (every 12 hours) as needed for constipation. 5. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q3H (every 3 hours) as needed for breakthrough pain. Disp:*90 Tablet(s)* Refills:*0* 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: s/p Gunshot wound to right lower quadrant Compartment syndrome right leg Anxiety Discharge Condition: Good Discharge Instructions: Return to the Emergency room if you develop any fevers, chills, headache, dizziness, increased leg pain, swelling, redness/draiange from your surgery site and/or any other symptoms that are concerning to you. Continue to wear your compression stocking on your right leg during the day and evening. You may remove it at bedtime. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **], Trauma Surgery next week. Call [**Telephone/Fax (1) 600**] for an appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**] Completed by:[**2200-2-11**]

[ "E849.0", "E965.4", "305.1", "305.60", "958.92", "300.00" ]

icd9cm

[ [ [] ] ]

[ "86.69", "83.14", "96.71" ]

icd9pcs

[ [ [] ] ]

8558, 8564

5347, 7672

347, 555

8689, 8696

1573, 2681

9073, 9357

1266, 1283

7727, 8535

3422, 3532

8585, 8668

7698, 7704

8720, 9050

1298, 1300

274, 309

3561, 5324

583, 1144

1315, 1554

1166, 1174

1190, 1250

31,966

112,673

45639

Discharge summary

report

Admission Date: [**2156-12-1**] Discharge Date: [**2156-12-7**] Service: MEDICINE Allergies: Depakote Er Attending:[**First Name3 (LF) 898**] Chief Complaint: cough/fever Major Surgical or Invasive Procedure: 1. Central Line Placement History of Present Illness: [**Age over 90 **] y.o. man with h/o seizure, orthostatic hypotension on hydrocort, prostate ca, and chronic cough, p/w worsening cough productive of sputum x 3 days. He has difficult getting the sputum out of his lungs. He also c/o right pleuritic chest pain only with coughing or movement, as well as fever at home. Also c/o increased weakness and difficulty using his walker. Denies sub-sternal CP, abd pain. . Upon arrival to ED, he had a rectal temp of 103.4, was tachycardic to 100 and tachypneic so code sepsis was called. His initial BP was 146/57 but dropped to 88/30. A right IJ was placed and he was given 3L NS. CXR revealed left retrocardiac and LUL pneumonia. He was given CTX and Azithromycin. His is requiring 4L NC. Per his PCP (Dr. [**First Name8 (NamePattern2) 1312**] [**Last Name (NamePattern1) 1313**]) his baseline SBP is in the 90s, last office visit, 98/60. . MICU Course: Patient was initially hypotensive and placed on neosynephrine for 12 hours for blood pressure support. After adequate hydration this was weaned successfully. He was started on stres dose steroids given he is on hydrocort 10mg [**Hospital1 **] at baseline for orthostatic hypotension. This was reduced back to his home dose within 24 hours. His O2 was weaned from 4L at the time of admission to RA by the time he was transferred to the medicine floor. Creatinine trended down from 1.4 to his baseline of 1.0. Past Medical History: 1. Complex partial seizures 2. Prostate cancer, diagnosed 5 years ago. Being followed expectantly and treated with Proscar. 3. Sleep apnea with daytime sleepiness and sleep disordered breathing noted in past. Trialed on Modafanil but this caused oral buccal dyskinesias. Did not tolerate BiPap. Daytime sleepiness improved after discontinuation of Depakote. 4. History of orthostatic hypotension in remote past, on Cortef 5. Left eye cataract status post surgery 6. Ptosis on right as a result of surgery for detached retina 7. Peripheral neuropathy 8. ? Esophageal diverticulum 9. Pacemaker Social History: The pt is widowed since [**2151**]. Retired at age 70. Was on the Board of Directors at [**Hospital1 18**]. Former smoker of 10 pack years but quit 50+ years ago. Drinks one shot or cocktail nightly. Has 24 hour housekeeping and homecare assistance, driver. Walks with cane for past one year. Family History: Noncontributory. Physical Exam: VS T 102 (rectal) BP 105/38, HR 97, RR 23, 92% 4L NC Gen: ill appearing, conversant HEENT: moist discharge from b/l eyes. PERRL, OP dry. No JVD Lungs: poor air mvmt. scattered crackle on left Heart: RRR nl S1S2, no M/R/G Abd: +BS, soft, ND/NT Ext: 2+ pitting edema of ankles b/l Neuro: AAO x 3 Pertinent Results: [**2156-12-1**] 09:00PM GLUCOSE-125* UREA N-31* CREAT-1.4* SODIUM-136 POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-23 ANION GAP-15 [**2156-12-1**] 09:00PM ALT(SGPT)-21 AST(SGOT)-26 LD(LDH)-249 CK(CPK)-118 ALK PHOS-72 TOT BILI-0.9 [**2156-12-1**] 09:00PM WBC-10.7# RBC-3.72* HGB-12.6* HCT-35.9* MCV-97 MCH-33.8* MCHC-35.0 RDW-13.8 [**2156-12-1**] 09:00PM NEUTS-68 BANDS-15* LYMPHS-7* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-7* MYELOS-0 [**2156-12-1**] CXR - 1. New extensive consolidation of the left upper lobe and lingula, likely pneumonic, with small left pleural effusion. 2. No CHF. [**2156-12-2**] ECG Sinus rhythm with first degree atrio-ventricular conduction delay. Compared to previous tracing of [**2156-9-11**] no definite change. Brief Hospital Course: Mr. [**Known lastname 452**] is a [**Age over 90 **] y.o. man with seizure d/o and chronic cough p/w worsening productive cough, pleuritic chest pain, and fever up to 103.4 rectally. He was originally admitted to the MICU for a transiet pressor requirement. He was started on ceftriaxone and azithromycin antibiotic therapy for a likely left-sided pneumonia. His oxygenation status was stable throughout his hospital course. He was changed to cefpodoxime and azithromycin PO for a total 2-week course. Cardiac etiology for his pleuritic chest pain was continued but the EKG remaied unchanged and his cardiac enzymes were negative. I slightly elevated troponin was attributed to acute renal failure. . During the hospitalization he had frequent evening episodes of delirium thought to be secondary to his hospitalization and recent infection. Repeat blood and urine cultures remained negative. He was redirectable. Concern for seizure was raised but per his family and health care aid, his seizures present with tonic clonic movements or episodes of staring. He remained on his home dose of Keppra. His family requested to not use any antipsychotics. He had a 1:1 sitter and was alert and oriented at discharge. . The patient presented with an elevated creatinine to 1.4 with a baseline Cr of 1.0 to 1.2. This was believed to be . Acute renal failure: baseline cr 0.8-1.0. Admission creatinine peaked at 1.4 thought to be likely pre-renal in setting of sepsis. Creatinine trended down with hydration and was 0.7 on discharge. . He was discharged home with VNA services and physical therapy and has 24-hour caregivers at home. . # Contact: HCP, son Dr. [**First Name8 (NamePattern2) 449**] [**Known lastname 452**] ([**Telephone/Fax (1) 97313**], home. pager in system. Also [**First Name8 (NamePattern2) 11705**] [**Last Name (NamePattern1) 97314**] ([**Telephone/Fax (1) 97315**] # FULL CODE Medications on Admission: MULTIVITAMIN TAB one po qd COLACE CAP 100MG one po tid RESTASIS 0.05% Oph OU [**Hospital1 **] AZOPT 0.1% Oph OU [**Hospital1 **] ASPIRIN TAB 81MG EC daily PROSCAR TAB 5MG one po qhs KEPPRA 750 MG TAB 1 [**Hospital1 **] CORTEF 10 MG TAB (HYDROCORTISONE) One po bid- NO SUBSTITUTION [**Doctor First Name **] CAP 60MG one po bid MUCINEX 600 po bid Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO three times a day. 2. Levetiracetam 750 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours) for 8 days: Your last dose will be on [**2156-12-14**]. Disp:*8 Capsule(s)* Refills:*0* 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Brinzolamide 1 % Drops, Suspension Sig: One (1) Ophthalmic [**Hospital1 **] (). 7. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette Ophthalmic [**Hospital1 **] (). 8. Hydrocortisone 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 8 days. Disp:*32 Tablet(s)* Refills:*0* 10. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 11. [**Doctor First Name **] 60 mg Tablet Sig: One (1) Tablet PO twice a day. 12. Mucinex 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. Discharge Disposition: Home With Service Facility: [**Hospital1 **] Family & Children Services Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Pneumonia 2. Hypotension 3. Delirium SECONDARY DIAGNOSIS: - Complex partial seizures - Prostate cancer, diagnosed [**2144**] - chronic LE edema - Sleep apnea with daytime sleepiness - h/o chronic PEs, not on anticoagulation - Chronic bronchitis - History of orthostatic hypotension in remote past, on Hydrocort - Left eye cataract status post surgery - Right eye retinal detachment - Ptosis on right as a result of surgery for detached retina - Peripheral neuropathy - ? Esophageal diverticulum - Pacemaker [**3-/2156**] for sinus pauses w/syncope - h/o pericarditis Discharge Condition: Stable. Patient was tolerating room air and working with physical therapy for help with ambulation. Discharge Instructions: You were admitted to the hospital for treatment of pneumonia. We started you on antibiotics for your pneumonia, and you will complete a total 14 day course of the antibiotic cefpodoxime and azithromycin at home. These should be completed on [**2156-12-14**]. You also developed low blood pressures with this infection, and this improved rapidly with medications and with intravenous fluids. You were also slightly confused for a short time in the hospital, and this also improved as we treated your infection. . Please continue to take your medications as prescribed. . If you have fevers, shaking chills, night sweats, shortness of breath, increased cough, lower extremity swelling, chest pain, diarrhea, light-headedness, or dizziness, please seek immediate medical attention. . It will be important for you to continue to take all your medications as prescribed. The only medications that we have added are the following: - cefpodoxime and azithromycin to treat your infection Followup Instructions: - Please schedule an appointment with your Primary Care Physician [**Telephone/Fax (1) **] Dr. [**First Name (STitle) 1313**] within 1 week after your discharge - Please follow-up with your urologist [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. at your previously scheduled appointment on [**2156-12-29**] 11:00. If you need to reschedule, please call his office at [**Telephone/Fax (1) 277**]. - Please also follow-up with your neurologist [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16747**], M.D. at your previously scheduled appointment on [**2156-12-31**] 2:00. If you need to reschedule, please call his office at [**Telephone/Fax (1) 16748**]. - Please also follow-up in DEVICE CLINIC at your previously scheduled appointment on [**2157-2-21**] 11:30. If you need to reschedule, please call his office at [**Telephone/Fax (1) 59**].

[ "345.40", "356.9", "458.0", "995.91", "327.23", "038.9", "293.0", "185", "V45.01", "584.9", "486" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

7134, 7208

3749, 5653

230, 258

7842, 7944

2986, 3726

8972, 9871

2638, 2656

6048, 7111

7229, 7229

5679, 6025

7968, 8949

2671, 2967

179, 192

286, 1694

7310, 7821

7248, 7289

1716, 2310

2326, 2622

81,427

148,999

8415

Discharge summary

report

Admission Date: [**2138-5-3**] Discharge Date: [**2138-5-14**] Service: MEDICINE Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 783**] Chief Complaint: S/P VFib arrest Major Surgical or Invasive Procedure: Intubation, Central Line Insertion History of Present Illness: 87 y/o F with PMH significant for CAD s/p CABG ([**2129**]), HTN,HL, afib (on coumadin and dofetilide initially) presents from the MICU for increasing Cr (ARF) and supratherapeutic INR. Pt. initially p/w a [**1-9**] day headache to the ED triage where she went into V-fib arrest. Her SBP was in the 200s. She was defibrillated 200 J once, went into a junctional rhythm for 1 minute and then into sinus rhythm. She did not require chest compressions. She was intubated without sedation but was started on propofol shortly afterwards dur to agitation. Head CT was done which showed no acute intracranial process and neurology ruled out seizures and cooling was not needed. . Post-defib EKGs with normal sinus rhythm was neg for ischemia and echo was nl. She was given 2g Mg and cardiology thought her v-fib was a primary arrythmatic event [**1-8**] dofetilide rather than ischemia. Also, she continued to be hypertensive w/ SBPs in the 200s post arrest on 80mcg of propofol with other notable lab values being K 5.3, INR 3.6, Lactate 5.0. She was then transfered to the MICU on ventilation with the settings: 100% 400 x 18 PEEP 5. . In the MICU, her hypertension w/ SPB 200s persisted so was started on nipride gtt which dropped SBP to 40-50s hence propofol and nipride gtt was stopped. She was bolused 1L and SBP rose to >190-200. She was then placed on nimodipine and then switched to her home hypertensives: valsartan 80 mg [**Hospital1 **], Amlodipine 10 mg QD, metoprolol 25mg [**Hospital1 **] and maintained at SBP goal of 140s. . In the MICU, she was given IV Mg 1g Q6H and transitioned to amiodarone and plavix for her afib. Her course complicated by MSSA VAP with lots of respiratory distress for which she got nafcillin/vanc/cefepime, improved and was extubated and placed on Bipap for 2 days. She was made DNR/DNI (daughter is health care proxy). Respiratory distress improved with abx and was weaned from Bipap to breathing room air. . On arrival to the floor pt. has been afebrile, breathing 100% on 4L O2, comfortable. Denies fevers/chills/night sweats, SOB/chest pain, nausea/vomiting, diarrhea/constipation/melena/hematochezia, dysuria, headache, fatigue, myalgias, light-headedness. Past Medical History: HTN HLD CAD s/p PCI in [**2129**] with stents to [**Female First Name (un) **] and x3 to RCA AF on coumadin Anemia Social History: Pt. lives alone in [**Location (un) 86**] and her boyfriend/companion lives next door. Daughter lives in [**Location 3146**] and is very involved with her care. However, daughter reports pt. is very indepedent. Although pt. moved to the US from [**Country 532**] 20 years ago, pt speaks very little English- has been trying to learn. Denies EtOH and tobacco, illicits. Family History: Maternal: mother- Cardiac disease, sister-breast cancer at 87yrs Paternal: father-died at World war 2 Children: Son died of pancreatic cancer at 55yrs 10 years ago. Physical Exam: ADMISSION PHYSICAL EXAM: Tmax: 37.1 ??????C (98.7 ??????F) Tcurrent: 36.8 ??????C (98.2 ??????F) HR: 67 (51 - 67) bpm BP: 178/63(98) {178/63(-6) - 202/80(114)} mmHg RR: 18 (15 - 19) insp/min SpO2: 100% Heart rhythm: SR (Sinus Rhythm) O2 Delivery Device: Endotracheal tube Ventilator mode: CMV/ASSIST/AutoFlow Vt (Set): 400 (400 - 400) mL RR (Set): 18 RR (Spontaneous): 0 PEEP: 5 cmH2O FiO2: 100% . Physical Examination: General: Intubated, sedated HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: PEERLA, unresponsive while sedated, withdraws to pain DISCHARGE PHYSICAL EXAM: Vitals: Tm:98.4, Tc:98.2, HR:81 (60-80), BP:144/60(140-160/60-70), RR:18, O2 sat:94% on RA GEN: Comfortable in bed, NAD, alert and oriented HEENT: Atraumatic, normocephalic, No scleral icterus, MMM, oropharynx clear NECK: no thyromegaly, no tenderness CV: Regular rate and nl rhythm, nl S1/S2, no murmurs, gallops/Rubs, PULM: CTAB, non-labored breathing, no crackles/ronchi/wheezes ABD:Soft, +BS, non-tender, non-distended, no rebound, guarding EXT: Warm and well perfused, 2+ peripheral pulses, no edema or cyanosis NEURO: With Russian interpreter: Alert and oriented to self/place/date, could name days of the week forward, months of the year backwards,CN II-[**Doctor First Name 81**] grossly intact, 5/5 strength bilaterally UE and LE. Pertinent Results: [**2138-5-3**] 10:00PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.020 [**2138-5-3**] 10:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2138-5-3**] 10:00PM URINE RBC-4* WBC-1 BACTERIA-FEW YEAST-NONE EPI-0 [**2138-5-3**] 10:00PM URINE AMORPH-RARE [**2138-5-3**] 10:00PM URINE MUCOUS-OCC [**2138-5-3**] 09:20PM TYPE-ART TEMP-36.8 RATES-18/0 TIDAL VOL-400 PEEP-5 O2-100 PO2-296* PCO2-35 PH-7.39 TOTAL CO2-22 BASE XS--2 AADO2-402 REQ O2-68 -ASSIST/CON INTUBATED-INTUBATED [**2138-5-3**] 09:20PM LACTATE-1.3 [**2138-5-3**] 06:57PM GLUCOSE-140* UREA N-22* CREAT-1.3* SODIUM-137 POTASSIUM-5.0 CHLORIDE-100 TOTAL CO2-24 ANION GAP-18 [**2138-5-3**] 06:57PM CK(CPK)-106 [**2138-5-3**] 06:57PM CK-MB-4 cTropnT-0.02* [**2138-5-3**] 06:57PM CALCIUM-9.2 PHOSPHATE-3.3# MAGNESIUM-2.6 [**2138-5-3**] 03:22PM TYPE-ART TEMP-38.0 TIDAL VOL-400 O2-100 PO2-95 PCO2-47* PH-7.29* TOTAL CO2-24 BASE XS--3 AADO2-591 REQ O2-94 -ASSIST/CON INTUBATED-INTUBATED [**2138-5-3**] 02:19PM GLUCOSE-122* LACTATE-5.0* NA+-138 K+-5.0 CL--99* TCO2-22 [**2138-5-3**] 02:15PM GLUCOSE-125* UREA N-22* CREAT-1.3* SODIUM-136 POTASSIUM-5.3* CHLORIDE-100 TOTAL CO2-22 ANION GAP-19 [**2138-5-3**] 02:15PM estGFR-Using this [**2138-5-3**] 02:15PM CK(CPK)-88 [**2138-5-3**] 02:15PM CK-MB-3 cTropnT-<0.01 [**2138-5-3**] 02:15PM WBC-16.2* RBC-4.60# HGB-13.5# HCT-40.0# MCV-87 MCH-29.4 MCHC-33.8 RDW-13.3 [**2138-5-3**] 02:15PM NEUTS-44.2* LYMPHS-50.9* MONOS-3.4 EOS-0.7 BASOS-0.8 [**2138-5-3**] 02:15PM PLT COUNT-278 [**2138-5-3**] 02:15PM PT-36.0* PTT-28.8 INR(PT)-3.6* [**2138-5-3**] 02:20AM URINE HOURS-RANDOM [**2138-5-3**] 02:20AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2138-5-3**] 02:20AM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.010 [**2138-5-3**] 02:20AM URINE RBC-4* WBC-4 BACTERIA-MOD YEAST-NONE EPI-0 [**2138-5-3**] 02:20AM URINE AMORPH-M [**2138-5-3**] 02:20AM URINE MUCOUS-RARE [**2138-5-13**] 05:38AM BLOOD WBC-7.5 RBC-3.43* Hgb-10.3* Hct-30.4* MCV-89 MCH-30.1 MCHC-34.0 RDW-14.3 Plt Ct-352 [**2138-5-10**] 04:18AM BLOOD WBC-9.3 RBC-3.70* Hgb-11.2* Hct-32.2* MCV-87 MCH-30.2 MCHC-34.7 RDW-13.7 Plt Ct-296 [**2138-5-9**] 02:42AM BLOOD WBC-10.1 RBC-3.33* Hgb-10.1* Hct-28.8* MCV-87 MCH-30.3 MCHC-35.1* RDW-13.4 Plt Ct-258 [**2138-5-6**] 03:20AM BLOOD WBC-15.1* RBC-3.04* Hgb-9.2* Hct-27.0* MCV-89 MCH-30.4 MCHC-34.3 RDW-13.3 Plt Ct-198 [**2138-5-8**] 03:22AM BLOOD WBC-11.8* RBC-3.19* Hgb-9.8* Hct-27.8* MCV-87 MCH-30.7 MCHC-35.1* RDW-13.3 Plt Ct-239 [**2138-5-7**] 04:21AM BLOOD Neuts-76.1* Lymphs-17.2* Monos-5.3 Eos-1.0 Baso-0.4 [**2138-5-10**] 04:18AM BLOOD PT-61.7* PTT-38.7* INR(PT)-6.8* [**2138-5-10**] 04:18AM BLOOD Plt Ct-296 [**2138-5-10**] 01:52PM BLOOD PT-46.5* PTT-40.6* INR(PT)-4.9* [**2138-5-11**] 05:15AM BLOOD PT-23.2* PTT-30.7 INR(PT)-2.2* [**2138-5-11**] 05:15AM BLOOD Plt Ct-330 [**2138-5-12**] 05:59AM BLOOD PT-16.2* PTT-28.3 INR(PT)-1.4* [**2138-5-12**] 05:59AM BLOOD Plt Ct-335 [**2138-5-3**] 02:15PM BLOOD Glucose-125* UreaN-22* Creat-1.3* Na-136 K-5.3* Cl-100 HCO3-22 AnGap-19 [**2138-5-4**] 03:40AM BLOOD Glucose-168* UreaN-20 Creat-1.0 Na-136 K-3.4 Cl-99 HCO3-28 AnGap-12 [**2138-5-6**] 03:20AM BLOOD Glucose-122* UreaN-22* Creat-1.3* Na-137 K-4.3 Cl-101 HCO3-26 AnGap-14 [**2138-5-7**] 04:21AM BLOOD Glucose-104* UreaN-38* Creat-1.9* Na-139 K-3.9 Cl-103 HCO3-23 AnGap-17 [**2138-5-8**] 04:15PM BLOOD UreaN-48* Creat-1.8* Na-137 K-3.2* Cl-99 HCO3-27 AnGap-14 [**2138-5-9**] 05:35PM BLOOD Glucose-135* UreaN-53* Creat-2.4* Na-141 K-3.7 Cl-101 HCO3-29 AnGap-15 [**2138-5-10**] 04:18AM BLOOD Glucose-81 UreaN-49* Creat-2.6* Na-140 K-3.3 Cl-98 HCO3-28 AnGap-17 [**2138-5-10**] 01:52PM BLOOD Glucose-166* UreaN-47* Creat-2.4* Na-138 K-3.8 Cl-99 HCO3-25 AnGap-18 [**2138-5-11**] 05:15AM BLOOD Glucose-105* UreaN-42* Creat-2.3* Na-140 K-3.6 Cl-99 HCO3-26 AnGap-19 [**2138-5-13**] 05:38AM BLOOD Glucose-120* UreaN-29* Creat-2.3* Na-140 K-4.1 Cl-102 HCO3-25 AnGap-17 [**2138-5-8**] 04:15PM BLOOD Phos-2.8 Mg-2.3 [**2138-5-9**] 05:35PM BLOOD Calcium-8.3* Phos-2.6* Mg-2.2 [**2138-5-10**] 01:52PM BLOOD Calcium-8.8 Phos-2.5* Mg-2.0 [**2138-5-11**] 05:15AM BLOOD Calcium-8.0* Phos-2.2* Mg-1.9 [**2138-5-12**] 05:59AM BLOOD Calcium-8.2* Phos-2.9 Mg-2.2 [**2138-5-13**] 05:38AM BLOOD Calcium-8.2* Phos-3.6 Mg-2.1 Brief Hospital Course: #. VENTRICULAR FIBRILLATION ARREST: Initially presented with a [**1-9**] day headache to the ED triage where she went into ventricular fibrillation arrest. Her SBP was in the 200s. Was defibrillated 200 J once, went into a junctional rhythm for one minute and then into sinus rhythm without chest compressions. Was intubated without sedation but was started on propofol shortly afterwards due to agitation. Head CT was done which showed no acute intracranial process and neurology ruled out seizures and cooling was not needed. Post-defib EKGs with normal sinus rhythm was negative for ischemia and echocardiogram was normal. She was given 2g Magnesium and cardiology thought her ventricular fibrillation arrest was a primary arrythmatic event (prolonged QTc) secondary to dofetilide rather than ischemia. An electrophysiology consultation was obtained, resulting in the decision to initiate amiodarone. No focus was found on electrophysiology study and she did not arrest on the floor over the course of her hospitalization. She will follow up with her outpatient cardiologist in [**Month (only) 205**]. . #. HYPOXEMIA/RESPIRATORY FAILURE: Her MICU course complicated by methicillin sensitive staph aureus (confirmed by sputum cultures) ventilator associated pneumonia with lots of respiratory distress for which she started on nafcillin/vancomycin/cefepime. Her respiratory status improved, was extubated and placed on Bipap for 2 days, weaned off and sent to the general medical floor ([**2138-5-10**]). She was made DNR/DNI (daughter is health care proxy). On the floor, her respiratory status continued to improve with oxygyen (for a day) until she breathing room air with normal lung exam for the rest of the hospital course. Etiology was thought to be pulmonary edema and peumonia. Her sputum cultures have grown MSSA. She was initiated on cefepime and vancomycin for healthcare associated pneumonia, which was narrowed to nafcillin after her sputum grew MSSA. Initially, she was intubated for respiratory support. She was subsequently transitioned to non-invasive ventilation and later to high flow shovel mask and nasal cannula. She completed an 8 day course of antibiotics for her pneumonia. She was afebrile and on room air at the time of discharge. . #.ACUTE KIDNEY INJURY : Her [**Last Name (un) **] was thought to be due to hypoperfusion. She did not have evidence of ATN or AIN. Her urine showed hyaline casts but no wbc or rbc. FEUrea on [**5-8**] was 24%. Her urine eosinophils were negative. Her Creatinine improved to baseline of [**1-8**].3 at discharge from the MICU. On the floor, her Cr. was stable in the 2s and on discharge, it was 1.9. . #.ATRIAL FIBRILLATION: Her dofetilide was discontinued since it can precipitate ventricular fibrillation. She was started on amiodarone (initially IV then changed to PO) and was maintained in sinus rhythm. Her INR initially was supratherapeutic with a peak of 6.8 likely secondary to nutritional deficiency. She received oral vitamin K. She was then restarted on coumadin and had an INR of 1.5 at discharge. She was not bridged with heparin because her CHADS2 score is 2. Her goal INR is [**1-9**]. . #.ALTERED MENTAL STATUS DUE TO TOXIC/METABOLIC ENCEPHALOPATHY: She became slightly sedated after benzodiazepime and narcotic administration, but this resolved after 24 hours without any intervention. On the floor, she was observed to be confused as the night progressed and likely sun-downs at night as observed by nurses. She has no known history of dementia and sun-downing is likely from old age. Per her outpatient pyschiatrist, Dr. [**Last Name (STitle) 29696**], she has a history of visual hallucinations at night with confusion which is resolved with Olanzapine 2.5mg QHS. Her hallucinations and confusion at night was better with psychiatrist recommendation. At discharge, she continued to be alert and interactive and back to her baseline per family. She has been asked to follow-up with her psychiatrist if this continues to be a problem. . #.CORONARY ARTERY DISEASE: No signs of active ischemia. Continued statin, beta blocker. Investigate why on Plavix. . #HYPERTENSION: On admission, patient was very hypertensive with SBP > 200. Because she was bardycardic, there was initial concern for ruptured aneurysm/subarachnoid bleed,; however, head CT, head CTA, and MRI were all negative. Patient was initially maintained on a nicardipine drip, which was weaned off once SBPs reached 140-160. She was then restarted on amlodipine and labetalol was started as well with adequate blood pressure control. On the floor BPs continue to be stable with some fluctuations to 180 SBPs. Her metoprolol was changed to Labetolol 200mg TID and then Labetolol 400mg [**Hospital1 **] on discharge to keep the BP within goal of <140 SBP. . Medications on Admission: 1. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 3. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 4. dofetilide 250 mcg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 5. Calcium 600 with Vitamin D3 600 mg(1,500mg) -200 unit Tablet Sig: One (1) Tablet PO twice a day. 6. amlodipine 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. valsartan 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Centrum 0.4-162-18 mg Tablet Oral 10. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day as needed for anxiety. 11. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. famotidine 40 mg Tablet Sig: One (1) Tablet PO at bedtime. 13. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. Calcium 500 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO three times a day. 15. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for dizziness. 16. citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Discharge Medications: x 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 6. labetalol 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 8. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for anxiety, visual hallucinations. 9. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 10. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 11. senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day. 12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once a day as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: Ventricular Fibrillation Arrest Pneumonia Acute kidney injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were seen in the hospital for a cardiac arrest. Your heart returned to a normal rhythm after a shock. You were evaluated by cardiology. Your arrhythmia medication was changed. An outpatient cardiology appointment was made for you. You were continued on your coumadin although your level will need to be closely monitored. . You were also treated for a pneumonia and had to be intubated to help with your breathing. You were treating with antibiotics (Naficillin) for 8 days to treat the pneumonia which helped your breathing. . Over the hospital course, your blood pressure also went high with systolic blood pressures in the 200 (goal blood pressure is systolic <140). Your blood pressure medications were changed and your blood pressure control improved. . You were also noticed to be more confused with visual hallucinations in the late evenings with some difficulty to sleep at night. We talked to your outpatient psychiatrist, Dr. [**Last Name (STitle) 29696**], who confirmed a history of visual hallucinations in the past which is controlled with zyprexa just before bed so we resumed that medication. . We made the following changes to your medications: STOPPED Dofetilide STOPPED Valsartan STOPPED Metoprolol STARTED Amoidarone STARTED Amlodipine STARTED Labetolol Followup Instructions: Please follow up with the following providers: . EYE DOCTOR Dr. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], [**Telephone/Fax (1) 253**] at [**Hospital3 **] Center in the SC [**Hospital Ward Name 23**] Clinical Ctr, [**Location (un) **], [**Hospital Ward Name 516**] on TUESDAY [**2138-10-7**] at 10:30 AM . CARDIOLOGY Dr. [**Last Name (STitle) 29697**] at [**Hospital6 **] on Tuesday, [**2138-6-10**] at 4pm. . RADIOLOGY Radiology Department, [**Telephone/Fax (1) 327**] on, MONDAY [**2138-10-20**] at 1:15 PM in the SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**], [**Hospital Ward Name 516**]. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

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19927

Discharge summary

report

Admission Date: [**2149-12-23**] Discharge Date: [**2149-12-28**] Date of Birth: [**2121-3-13**] Sex: M Service: MICU ADMITTING DIAGNOSIS: Acute respiratory distress syndrome. HISTORY OF PRESENT ILLNESS: The patient is a 28 year old male with no apparent medical history who presented from the outside hospital with respiratory collapse and adult respiratory distress syndrome, sepsis of unknown etiology. The patient was feeling ill over the weekend with cough and upper respiratory infection symptoms, febrile to 102. The patient last took NyQuil and Ibuprofen. The patient's girlfriend was [**Name2 (NI) **] with the same symptoms. The patient last went to a local Emergency Department with a cough, hemoptysis, diarrhea, fatigue and chest x-ray showing right hilar fullness. The patient was diagnosed with bronchitis at that time and was given a metered dose inhaler and discontinued to home. Laboratory data at that time revealed white blood count 9.8, hematocrit 42.7, platelets 201 and white blood count had 25% bands, 57% polys. His creatinine at that time was 1.6. The patient presented again and felt very poorly today, felt very weak and continued to cough with hemoptysis, states he was staggering around his apartment. The patient also complained of severe chest pain, states relieved when the patient positioned himself prone on the floor. He returned to the outside hospital on the evening of [**12-23**] with chest x-ray now revealing diffuse left-sided air space infiltrate as well as right upper lobe infiltrate. Laboratory data were notable for white blood count of 1.0 with an ANC of 210, 16% bands, 5 polys, platelets of 92 and creatinine of 2.0. Creatinine kinase at that time was 2,852 with a troponin I of 0.07. The patient was intubated for respiratory distress and was transferred to [**Hospital6 1760**] via [**Location (un) **]. PAST MEDICAL HISTORY: None. MEDICATIONS: None regularly, took Ibuprofen yesterday. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Patient smoked tobacco and used marijuana, occasional alcohol, denies any intravenous drug abuse. Denies any cocaine. The patient spent four years in jail and had negative human immunodeficiency virus test times four, yearly tests done in prison. The patient also had a PPD placed and worked as a mechanic. FAMILY HISTORY: Non-contributory, no sudden deaths. Further history from girlfriend and mother revealed the patient had a right thigh abscess incised and drained approximately two weeks ago. LABORATORY DATA: Significant laboratory data on admission, again white blood count was 0.9, platelets 81, ANC 240, coagulation studies at that time revealed INR 2.2, creatinine kinase 2,467 with MB of 8 and troponin T of less than 0.01. His initial arterial blood gases was 7.13, 64, 48, on 10 of positive end-expiratory pressure and FIO2 of 100%. Chest x-ray showed severe pulmonary edema, left greater than right and fine test abdominal computerized tomography scan showed diffuse pulmonary infiltrate, bowel edema, ascites with aggressive volume resuscitation. Electrocardiogram showed sinus tachycardia at 136, some ST depressions in leads 2, 3 and AVF, and T wave inversions in V4 to V6 and leads 3. In the Emergency Department the patient became hypotensive and was started on Levophed and Dopamine and eventually weaned off of Dopamine. The patient also became increasingly hypoxic with increasing positive end-expiratory pressure and then eventually required 25 of positive end-expiratory pressure and pressure control of 20. The patient began showing bright red blood from the endotracheal tube which was bronchoscoped showing diffuse hyperemia and hemorrhage without localizing lesions. PHYSICAL EXAMINATION: The patient's examination revealed temperature 100.6, heart rate 108, blood pressure 65/40, respiratory rate 40, 80% on pressure control with 25 of positive end-expiratory pressure. A right subclavian had been placed. Lungs: Coarse sounds bilaterally diffusely, decreased breath sounds diffusely. Cardiovascular: Tachycardiac, normal S1 and S2, no murmurs. Abdomen was soft, hypoactive bowel sounds, nondistended. Extremities: No edema, however, decreased dorsalis pedis pulses with feet being cool, hands being cool to touch. Neurological, the patient was intubated and sedated, however, pupils were equal, round and reactive to light. Skin with multiple papular pustular lesions on lower extremities and chest. No draining appreciated. HOSPITAL COURSE: 1. Pulmonary - The patient presented with adult respiratory distress syndrome and symptoms of diffuse alveolar hemorrhage as shown on bronchoscopy. Throughout the hospitalization multiple maneuvers were tried including pronation, ventilator mode changes, alveolar recruitment, frequent deep suctioning to improve his respiratory distress, resulting in temporary improvement of his oxygenation. Although his respiratory status remained tenuous throughout this hospitalization, his ultimate cause of death was secondary to failure of his other organs. However, the patient was started on high dose steroids for approximately one day for concern of diffuse alveolar hemorrhage. The patient was volume resuscitated with blood, with his diffuse alveolar hemorrhage. Again multiple ventilator changes were made throughout this hospitalization course with a ventral hypoxia being unable to be controlled. 2. Heme and dermatology - The patient's skin lesions were seen by Dermatology on hospital day #2. These skin lesions were described as multiple erythematous plaques with dusky perforate centers found on the face, trunk and extremities. These perforate centers and plaques coalesced and biopsy was consistent with DIC. Stains on these biopsies were negative for any microorganisms. To control his bleeding, for the DIC control, he eventually required a total of 12 units of platelets, 15 units of fresh frozen plasma, 2 units of cryoprecipitate and 1 unit of packed red blood cells. 3. Cardiovascular - On hospital day #3 at 12 lead electrocardiogram revealed [**Street Address(2) 5366**] elevations in the inferolateral leads. Cardiac markers peaked at CK of 95,560, CKMB 435, troponin I of 3.39. Emergent cardiac catheterization at that time showed no cardiac disease, however, his hemodynamics revealed elevation of the right and left heart pressures with equalization of the right and left ventricular diastolic pressure. An emergent echocardiogram was performed in which no pericardial effusion or wall motion abnormalities were present. His ejection fraction at that time was normal. No further cardiac interventions were performed and ST elevations eventually resolved. A head computerized tomography was negative for any bleed, explaining the ST elevations. The patient remained on multiple vasopressors including Dopamine, Levophed, Neo-Synephrine and Vasopressin often at maximal doses throughout this hospitalization to keep his mean arterial pressures above 65. 4. Renal - The patient's acute renal failure worsened to a point where his creatinine was 5.8 with minimal urine output, hypocalcemia and hyperkalemia. A furosemide drip was maximized but a positive fluid balance of positive 24 liters over 4 days with worsening pulmonary edema and severe electrolyte abnormalities prompted renal consultation to initiation CVVH. However, repeated line clots and hypotension resulted in failure of CVVH to improve his electrolytes or pulmonary status. 5. Infectious disease - Infectious disease consultation was obtained on day #1 and antibiotics were tailored to Vancomycin, Levofloxacin and Ceftriaxone for broad gram positive and negative coverage. The next day his bronchial washings from his bronchoscopy revealed 4+ gram positive cocci in pairs and clusters and outside hospital blood cultures grew one out of four positive bottles of Staphylococcus aureus. These bronchial washings eventually grew Staphylococcus aureus. Clindamycin IVIG were started on day #2 for concern for Staphylococcal toxic shock syndrome. His bronchial washing cultures were resistant to Erythromycin, Oxacillin and Penicillin and were sensitive to Gentamicin, Levofloxacin, Rifampin, Tetracycline and Vancomycin. Further testing for influenza A, B, fungi, viruses, pneumocystic carinii, Streptococcus pyagenies, chlamydia trichomonas and Neisseria gonorrhea were negative. PCB and acid fast bacillus cultures were negative. Human immunodeficiency virus testings could not be performed due to inability to consent the patient. Repeated sputum cultures grew Methicillin-resistant Staphylococcus aureus but other cultures remained negative. He continues to be febrile during this entire hospitalization course. Overall Infectious Disease felt that is a case of community acquired Methicillin-resistant Staphylococcus aureus antipyatic susceptibility profile and risk factor of being incarcerated for four years. On hospital day #6 the patient passed away from a lethal ventricular arrhythmia. In the interim the patient also suffered from rapid atrial fibrillation on which he was controlled with Amiodarone drip. However, secondary to hypoxia, ventricular arrhythmia and multi organ system failure the patient was made comfort-measures-only by his family and passed away on hospital day #6. The family consented to autopsy and autopsy findings are to be awaited. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5587**] Dictated By:[**Name8 (MD) **] MEDQUIST36 D: [**2150-2-13**] 17:04 T: [**2150-2-13**] 18:04 JOB#: [**Job Number 53757**]

[ "482.41", "786.3", "286.6", "584.5", "038.11", "410.71", "518.5", "578.0", "785.52" ]

icd9cm

[ [ [] ] ]

[ "33.22", "37.23", "86.11", "99.29", "88.56", "96.6", "38.95", "33.24", "38.91", "96.72", "39.95", "38.93" ]

icd9pcs

[ [ [] ] ]

2363, 3744

4531, 9703

3767, 4513

228, 1894

161, 199

1917, 2019

2036, 2346

11,861

106,650

22380

Discharge summary

report

Admission Date: [**2128-2-4**] Discharge Date: [**2128-2-7**] Date of Birth: [**2105-5-5**] Sex: F Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 2297**] Chief Complaint: DKA Major Surgical or Invasive Procedure: None History of Present Illness: This is a 22 year old woman with diabetes type I since [**2120**] who presents with back pain and chest pain since this morning. She reports that the pain is like her usual back pain, is mid thoracic and equal on both sides, and does not radiate. It was severe this morning but is gradually better now. She also reports some chest pressure which was associated with shortness of breath and nausea. She vomited once in the ED waiting room and once in the ED. She reports that she was able to eat normally today and took her regular dose of glargine last night. She is not sure why her sugars are high (it was 183 this morning), but thinks they get higher when she has pain. She denies fevers but had some chills. She thinks she may be getting an upper repiratory infection. . In the ED she was found to have an elevated anion gap to 23 and a blood sugar of 390. She was hydrated with 3L NS (the third with potassium) and started on an insulin gtt at 5/hour which was rapidly weaned when her gap closed. She was given 2u regular insulin SQ and admitted to medicine. Past Medical History: - Diabetes Type I diagnosed in [**2120**] after her first pregnancy. Most recent Hgb A1C 10.4 % ([**7-/2125**]) - Hyperlipidemia -S/P MVA [**5-3**] - lower back pain since then. + back muscle spasm treated with tylenol. - Goiter - Depression - Multiple DKA admissions - G2P1Ab1, s/p miscarriage in 06/00 3rd trimester, s/p C-section in [**2122**], not menstruating secondary to being on Depo-Provera shots - Genital Herpes Social History: The patient was born and raised in [**Location (un) 669**], where she lived in house with siblings, mother, grandmother, and [**Name2 (NI) 12232**] when growing up. Currently lives in her own apartment. Attended job corp training following h.s., but presently unemployed feeling too overwhelmed between diabetes care and caring for three year old her son. She has a boyfriend. She is close to mother, sister, and [**Name2 (NI) 12232**] who live nearby. Denies abuse in childhood or adulthood. She denies tobacco, alcohol or illicit drug use. Family History: GM with Type I diabetes. Otherwise non-contributory. Relatives with "acid in blood" not related to diabetes. Physical Exam: PE: V: T97.8 P108 BP 139/87 R20 99% RA Gen: No acute distress HEENT: pupils with colored contacts. [**Name (NI) 3899**]. OP clear Resp: CTA bilaterally CV: tachy nl s1s2 no MGR Abd: Soft NTND +BS Ext: no edema Neuro: A+Ox3, but not forthcoming with history. Able to move extremities well. . Pertinent Results: [**2128-2-4**] 01:10PM BLOOD WBC-11.9*# RBC-4.90# Hgb-14.2# Hct-42.5# MCV-87 MCH-29.0 MCHC-33.5 RDW-13.3 Plt Ct-179 [**2128-2-7**] 03:57AM BLOOD WBC-7.0 RBC-4.07* Hgb-11.9* Hct-34.2* MCV-84 MCH-29.1 MCHC-34.7 RDW-13.5 Plt Ct-187 [**2128-2-5**] 06:39AM BLOOD Neuts-82.0* Bands-0 Lymphs-14.7* Monos-2.5 Eos-0.8 Baso-0.1 [**2128-2-4**] 01:10PM BLOOD Glucose-390* UreaN-14 Creat-1.0 Na-138 K-4.0 Cl-98 HCO3-17* AnGap-27* [**2128-2-7**] 03:57AM BLOOD Glucose-73 UreaN-5* Creat-0.6 Na-135 K-3.7 Cl-104 HCO3-21* AnGap-14 [**2128-2-5**] 12:01AM BLOOD CK(CPK)-69 [**2128-2-4**] 01:10PM BLOOD ALT-28 AST-40 CK(CPK)-89 AlkPhos-86 Amylase-50 TotBili-0.8 [**2128-2-5**] 12:01AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2128-2-4**] 01:10PM BLOOD CK-MB-2 cTropnT-<0.01 [**2128-2-4**] 10:24PM BLOOD %HbA1c-13.4* [Hgb]-DONE [A1c]-DONE . CXR [**2-4**]: This examination is normal without cardiomegaly, vascular congestion, consolidations, effusions, or hilar/mediastinal enlargement. No change from more satisfactory study [**2127-12-22**]. . KUB [**2-6**]: No evidence of obstruction or pneumoperitoneum. Brief Hospital Course: A/P: 22F with type I diabetes and DKA, with complaints of abdominal cramping. . #) DKA: Unclear inciting event, but no clear infection source and by history was taking her usual dose insulin and diet. However, had son that was sick at home and patient complained of abdominal cramping. Her anion gap closed while in the ED but reopened the day after admission to the MICU after having multiple loose stools and episodes of vomiting. Her insulin drip was restarted. She had a KUB to rule out obstrucion [**1-2**] to her episodes of vomiting, which was negative. Afterwards, she was started on Reglan. Her gap closed again, she was tranisitioned back to her home regimen of glargine. She will follow-up with [**Last Name (un) **] as an outpatient. We suspect that she has a viral gastrointestinal illness. . #) chest pain - Initially had complaints of chest discomfort on presentation but had no EKG changes and her cardiac enzymes were negative. She was continued on aspirin and her ACEI. . #) back pain - Longstanding by her report and by previous notes. Likley secondary to MVA. She was given dilaudid PRN for pain and tolerated it well. . #) depression - her prozac was held at her request because she felt it was making her apin worse. . #) Hypertension: her lisinopril dose was increased from 10 mg to 20 mg daily for SBPs over 140. She was discharged with a prescription for 20 mg daily lisinopril. . She was discharged home in [**Last Name (un) 2677**] condition with [**Last Name (un) **] follow-up. Medications on Admission: Glargine 29 units QHS Fluoxetine 20 mg PO DAILY Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Docusate Sodium 100 mg PO BID Tamsulosin 0.4 mg PO HS Novolog 1 unit for every 14 g carbohydrates. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Discharge Medications: 1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 4. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO once a day. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO at bedtime. 7. medications Take your insulin as directed by the [**Last Name (un) **] Diabetes Center 8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Diabetic Ketoacidosis Diabetes Mellitus Hypertension Discharge Condition: Good. Tolerating regular diet. Blood sugars normalized. Discharge Instructions: You were admitted to [**Hospital1 18**] for diabetic ketoacidosis (DKA) likely secondary to a viral gastrointestinal illness. Your blood sugars were well controlled on insulin drip and then on your regular insulin regimen. Your blood acid level also quickly returned to [**Location 213**]. Your lisinopril was increased from 10 mg daily to 20 mg daily. Continue taking this dose until seen by your doctor. You should continue to take all other medications as previously prescribed. Try to drink lots of fluids and eat full meals. Contact a physician for fever > 101.5, persistent nausea or vomiting, increasing abdominal pain, chest pain, shortness of breath, productive cough, or any other concerns. Followup Instructions: Please follow-up with your [**2128-2-9**] at 1:30 PM at [**Last Name (un) **] Diabetes, Dr. [**First Name (STitle) 4375**] [**Name (STitle) 3617**]. His phone number is [**Telephone/Fax (1) 12068**] for any concerns or to change your appointment

[ "250.13", "311", "786.59", "401.9", "008.8", "724.5", "272.4" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6595, 6601

3942, 5451

270, 277

6698, 6756

2832, 3919

7508, 7758

2394, 2505

5905, 6572

6622, 6677

5477, 5882

6780, 7485

2520, 2813

227, 232

305, 1371

1393, 1817

1833, 2378

17,171

170,233

17290

Discharge summary

report

Admission Date: [**2193-11-1**] Discharge Date: [**2193-11-8**] Date of Birth: [**2113-4-27**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Claudication Major Surgical or Invasive Procedure: [**2193-11-2**] Urgent Off Pump Coronary Artery Bypass Graft x 2 (SVG to LAD, SVG to Diag) History of Present Illness: Ms. [**Known lastname 48415**] is an 80 y/o female who has aortoiliac disease with bilateral claudication as well as buttock and thigh pain. Was undergoing a a cardiac cath which revealed iliac disease, as well and severe coronary diease, when she began to experience unstable angina. She was then emergently taken to the operating room. Past Medical History: Hypertension, Hyperlipidemia, h/o Stroke, Peripheral Vascular disease, s/p Appendectomy, s/p Cholecystectomy Social History: current smoker-1 ppd Family History: Non-contributory Physical Exam: Abbreviated secondary to unstable angina/emergency: Lungs: Course BS bilat. Heart: RRR Abd: Soft, NT/ND +BS Ext: Warm, rubor, decreased pulses bilat. Brief Hospital Course: As mentioned in the HPI, Ms [**Known lastname 48415**] was undergoing cardiac cath when she began to experience chest pain. Angina not relieved with medication and therefor was urgently taken to the operating room where she underwent a coronary artery bypass graft x 3. Please see operative report for surgical details. Following surgery she was transferred to the CSRU for invasive monitoring in stable condition. On post-operative day one she was weaned from sedation, awoke neurologically intact and was extubated. She initially required Epinephrine for hemodynamic support but was weaned off by post-op day two. She was then started on Beta blockers and diuretics. She was gently diuresed towards he pre-op weight. Vascular followed pt. for a large right arm hematoma. U/S revealed a hematoma and pseudoaneurysm at the site of catheterization in the right brachial artery. On post-operative day four her chest tubes, epicardial pacing wires and Foley catheter were removed. She was then transferred to the SDU for continued care. Her medications were adjusted for maximum hemodynamic support and electrolytes were repleted. Physical therapy followed patient for strength and mobility. Ms. [**Known lastname 48415**] underwent a second right upper extremity ultrasound to assess brachial artery flow given the necessity of brachial cannulation during her surgery. This study revealed normal flow. She was ready for discharge to home by post-operative day seven. Medications on Admission: Aspirin, Nifedipine, Lopressor, Lovastatin, Fosamax, Lisinopril, MVI, eye drops Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 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:*40 Tablet(s)* Refills:*0* 4. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QWED (every Wednesday). Disp:*4 Tablet(s)* Refills:*2* 5. Bimatoprost 0.03 % Drops Sig: One (1) Ophthalmic qhs (). Disp:*1 1* Refills:*2* 6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 1* Refills:*2* 7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). Disp:*1 1* Refills:*2* 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 10 days. Disp:*40 Capsule, Sustained Release(s)* Refills:*0* 11. Lovastatin 40 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 13. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). Disp:*14 Patch 24HR(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Coronary Artery disease s/p Urgent Coronary Artery Bypass Graft x 2 PMH: Hypertension, Hyperlipidemia, h/o Stroke, Peripheral Vascular disease, s/p Appendectomy, s/p Cholecystectomy Discharge Condition: Good Discharge Instructions: [**Month (only) 116**] shower, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns Followup Instructions: Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment Dr [**Last Name (STitle) 17996**] in 1 week ([**Telephone/Fax (1) 3183**]) please call for appointment Dr [**Last Name (STitle) **] in 1 week ([**Telephone/Fax (1) 3121**]) please call for appointment Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse ([**Telephone/Fax (1) 3633**]) Completed by:[**2193-11-8**]

[ "443.9", "411.1", "997.2", "998.12", "401.9", "414.01", "444.0", "272.4", "305.1" ]

icd9cm

[ [ [] ] ]

[ "88.48", "37.23", "99.04", "99.07", "99.05", "89.60", "88.56", "88.53", "36.12" ]

icd9pcs

[ [ [] ] ]

4479, 4534

1186, 2654

334, 426

4759, 4765

5230, 5669

979, 997

2784, 4456

4555, 4738

2680, 2761

4789, 5207

1012, 1163

282, 296

454, 793

815, 925

941, 963

48,204

110,693

33322

Discharge summary

report

Admission Date: [**2142-6-8**] Discharge Date: [**2142-6-13**] Date of Birth: [**2088-1-22**] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 165**] Chief Complaint: occasional dyspnea on exertion Major Surgical or Invasive Procedure: [**2142-6-8**] 1. Aortic valve replacement with size a 25-mm [**Last Name (un) 3843**]- [**Doctor Last Name **] Magna Ease tissue valve. 2. Ascending aortic aneurysm resection with a size 28-mm Gelweave graft. History of Present Illness: 54 year old female who has a history of bicuspid aortic valve stenosis. She states she has been feeling well with occasional mild dyspnea after climbing [**1-26**] flights of stairs. She was diagnosed in the [**2109**]'s and has been followed through the years by serial echocardiograms. She underwent cardiac catheterization in [**2137**] at [**Hospital6 **] after a syncopal event and had an echo showing a valve area of 0.6cm2. At catheterization, her peak aortic gradient only ended up being 42.5mmHG with a valve area of 1.0cm2. Her most recent echo from [**2141-11-23**] revealed a peak aortic gradient of 101 mmHG, mean of 59 mmHG, [**Location (un) 109**] of 0.7cm2 and [**12-25**]+ AI. She underwent a cardiac catheterization in [**Month (only) 547**] which showed normal coronaries and an aortic valve area of 1.04cm2. Past Medical History: Bicuspid Aortic valve/aortic stenosis Aortic insuffiency Osteopenia Migraines Left Wrist fracture Remote anemia Past Surgical History: Appendectomy Tonsillectomy/Adnoidectomy - Bleeding episode associated with this surgery Bilateral blepharoplasty Social History: Lives with:Husband Contact:[**Last Name (NamePattern4) **] (Husband) Phone #[**Telephone/Fax (1) 77351**] Occupation:dental hygienist Cigarettes: Smoked no [] yes [x] Hx:quit at age 18 Other Tobacco use:denies ETOH: 6 drinks/week Illicit drug use: denies Family History: Premature coronary artery disease- Father with an MI at age 40, subsequently had CABG. He passed away at age 69. Physical Exam: Pulse:75 Resp:16 O2 sat:99/RA B/P Right:111/77 Left: 105/74 Height:5'8" Weight:158 lbs General: WDWN in NAD Skin: Warm, Dry and intact HEENT: NCAT, PERRLA [x] EOMI [x], sclera anicteric, OP Benign. Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR, Nl S1-S2, Systolic Murmur grade III-IV/VI with I/VI diastolic murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] No Edema Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 2 Left:2 DP Right: 2 Left:2 PT [**Name (NI) 167**]: 2 Left:2 Radial Right: 2 Left:2 Carotid Bruit: radiating murmur, no bruit Pertinent Results: [**2142-6-8**] TEE: Conclusions PRE-CPB: 1. The left atrium and right atrium are normal in cavity size. No thrombus is seen in the left atrial appendage. 2. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. 3. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 4. Right ventricular chamber size and free wall motion are normal. 5. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. 6. The aortic valve is bicuspid. The aortic valve leaflets are severely thickened/deformed. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Mild (1+) aortic regurgitation is seen. 7. The mitral valve appears structurally normal with trivial mitral regurgitation. The mitral valve leaflets are elongated. 8. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results. POST-CPB: On infusion of phenylephrine briefly. AV pacing for slow sinus rhythm. Well-seated bioprosthretic valve in the aortic position with trivial paravalvular leak consistent with stitch hole, not visible post protamine. Preserved biventricular function. The aortic contour is normal post decannulation. Brief Hospital Course: The patient was brought to the Operating Room on [**2142-6-8**] where the patient underwent Aortic Valve Replacement, Ascending Aorta Replacement with Dr. [**First Name (STitle) **]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. She had a brief episode of non-sustained V-Tac and was treated with an amiodarone bolus. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 5 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home in good condition with appropriate follow up instructions. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Naproxen 220 mg PO PRN pain Discharge Medications: 1. Aspirin EC 81 mg PO DAILY if extubated 2. Furosemide 20 mg PO BID RX *furosemide 20 mg daily Disp #*5 Tablet Refills:*0 3. Metoprolol Tartrate 12.5 mg PO BID RX *metoprolol tartrate 25 mg twice a day Disp #*30 Tablet Refills:*0 4. Potassium Chloride 20 mEq PO BID Hold for K >4.5 RX *Klor-Con 20 mEq daily Disp #*5 Packet Refills:*0 5. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain RX *tramadol 50 mg every four (4) hours Disp #*40 Tablet Refills:*0 6. Naproxen 220 mg PO PRN pain Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Bicuspid Aortic valve/aortic stenosis Aortic insuffiency Osteopenia Migraines Left Wrist fracture Remote anemia Past Surgical History: Appendectomy Tonsillectomy/Adnoidectomy - Bleeding episode associated with this surgery Bilateral blepharoplasty Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage trace edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: You are scheduled for the following appointments: Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**], [**2142-6-21**] 10:15 Surgeon Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2142-7-17**] 1:15 [**Telephone/Fax (1) 170**] Cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2142-6-26**] at 10:15a Please call to schedule the following: Primary Care Dr. [**Last Name (STitle) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 8506**] in [**3-29**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2142-6-13**]

[ "733.90", "346.80", "458.29", "287.5", "E878.2", "V17.3", "441.2", "V15.82", "746.3", "997.1", "285.9", "427.1", "V45.79" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6051, 6108

4173, 5370

340, 560

6400, 6568

2841, 4150

7439, 8337

1979, 2094

5548, 6028

6129, 6241

5396, 5525

6592, 7416

6264, 6379

2109, 2822

269, 302

588, 1418

1440, 1552

1706, 1963

23,558

140,451

6406

Discharge summary

report

Admission Date: [**2121-12-19**] Discharge Date: [**2121-12-29**] Date of Birth: [**2053-8-8**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 458**] Chief Complaint: coffee ground emesis Major Surgical or Invasive Procedure: DC cardioversion x 3 History of Present Illness: 68M w/ h/o paroxysmal afib s/p cardioversion [**12-17**], discharged with INR 4.1 off coumadin, who presented to OSH on [**12-19**] w/ 5h increasing right flank pain and nausea. His flank pain began suddenly while driving home from Foxwoods casino. The patient denied trauma. . Of note, INR at time of cardioversion was 4.1, pt was discharged home with instructions not to take coumadin for 1 day, then start with half dose. He denied hematuria, CP/SOB. CT abdomen at OSH revealed right perinephric hematoma with contrast extravasation. He was transferred to [**Hospital1 18**] on [**12-19**]. Overnight, his Hct fell 35.9 -> 26 over 12 hours. INR on admission was 2.4. Cr was 1.3 (baseline 1.2). He received vitamin K, 1U PRBC, 2 bags FFP. He remained hemodynamically stable throughout. On the morning of [**12-19**], he was found to have 250cc coffee ground emesis. Per report, NG lavage did not clear. The pt was taken to angiography to assess perinephric bleeding, which was unremarkable. Repeat NG lavage afterwards, upon arrival to the [**Hospital Unit Name 153**], was negative. Past Medical History: Atrial Fibrillation: s/p DC cardioversion [**2118**], found to be back in asymptomatic afib on routine visit [**2121-10-2**], s/p cardioversion [**2121-10-17**], found to be in afib again, now s/p repeat cardioversion ([**2121-12-17**]) CAD singel vessel s/p circumflex stenting [**2114**] CHF/cardiomyopathy (global hypokinesis, EF 40-50%) HTN Prostate cancer, s/p radical prostatectomy [**2114**] MVA with scapular and rib fractures [**2103**] ? left side kidney stones (asymptomatic, discovered on USN at time of prostate resection). GERD basal cell ca (nose) s/p resection . Social History: 35pack years, quit ten years ago tobbacco. married. retired. Family History: NC Physical Exam: VS: 99.2, 144/72, 73, 22, 97% RA GEN: NAD HEENT: PERRLA, EOMI, sclera anicteric, OP clear, MMM, no LAD, no carotid bruits. No JVD. CV: RRR, soft 2/6 SEM loudest at LSB. PULM: decreased breath sounds RLL, otherwise CTAB, no r/r/w. ABD: soft, NT, ND, + BS, no HSM. EXT: warm, 2+ dp/radial pulses BL. NEURO: alert & oriented x 3 . Pertinent Results: [**2121-12-18**] 10:50PM GLUCOSE-189* UREA N-29* CREAT-1.2 SODIUM-140 POTASSIUM-4.8 CHLORIDE-107 TOTAL CO2-25 ANION GAP-13 [**2121-12-18**] 10:50PM WBC-12.9* RBC-4.19* HGB-12.3* HCT-35.9* MCV-86 MCH-29.4 MCHC-34.3 RDW-14.5 [**2121-12-18**] 10:50PM NEUTS-89.6* LYMPHS-7.2* MONOS-2.5 EOS-0.5 BASOS-0.2 [**2121-12-18**] 10:50PM PLT COUNT-240# [**2121-12-18**] 10:50PM PT-26.8* PTT-32.7 INR(PT)-2.7* MRI abdomen [**12-22**]: IMPRESSIONS: 1. Right perinephric collection with signal characteristics consistent with hemorrhage. The suggested etiology is, when also corrlelated with CT is a right upper pole angiomyolipoma (AML). A short-term followup examination is recommended to assess resolution of the perinephric fluid collection. 2. Cholelithiasis. 3. Hepatic lesions, which are likely cysts. Brief Hospital Course: ## perinehpric hematoma CT abdomen at OSH revealed right perinephric hematoma with contrast extravasation. Pt was transfered to [**Hospital1 18**] on [**12-19**] and next morning pt was found to have 250cc cofeee ground emesis. NG lavage did not clear. pt was taken to angiography to assess perinephric bleeding, which was unremarkable. repeat NG lavage afterwards, upon arrival to [**Hospital Unit Name 153**], was negative (few clots, no bleeding). His hct had dropped from baseline 36 to 28 on admission. He received a total of 3 units of PRBC's since admission, and then his hct subsequently stabilized. MRI of the abdomen suggested cause of perinephric bleed to be due to an angiomyolipoma. Urology recommended follow up CT in [**3-14**] weeks. . # GIB He initially presented with coffee ground emesis which cleared with NG lavage and was hemodynamically stable. He was maintained on a PPI. He was H. pylori negative. GI recommended that he be followed as an outpatient with colonoscopy and endoscopy. . ## atrial fibrillation On first transfer to the [**Hospital Unit Name 153**], he was initially in afib with RVR. He was refractory to 2 electrical cardioversions. He was continued on sotalol, but his dose was increased. Upper endoscopy was deferred at that time due to pt's increasing O2 requirement (due to RLL pneumonia) as well as Afib. A third cardioversion had been planned when the patient spontaneously converted to NSR. He was then transferred to the floor. Then, on [**2121-12-24**], patient again developed afib with RVR, rate unable to be controlled, and he was transferred back to ICU for diltiazem drip for rate control. . He was then electrically cardioverted successfully, was started on amiodarone, and has remained in NSR. He did not require TEE prior to the electrical cardioversions because episodes of Afib lasted less than 48 hours. His pnuemonia is being treated with Ceftriaxone. His hct has remained stable, with the GI service recommending endoscopy and colonoscopy as an outpatinet. His coumadin and aspirin have been held during this admission. He was then transferred to the cardiology service for further monitoring. The following morning ([**12-27**]) he converted again to afib with heart rates in the 110s-120s. It did not respond to lopressor 5 IVx2 or diltiazem 10mg IV x1. PO diltiazem was started [**2121-12-28**] and increased to 90mg po qid. Amiodarone was continued. The morning of [**12-29**], he converted back to NSR spontaneously after 5mg IV lopressor with HR in the 60s. His QT interval in NSR was ~430. TFTs and LFTs were normal in-house, and he will need outpatient PFTs. Pt will require twice annual lfts and tfts, as well as baseline and annual cxr, pfts, and eye exam which will be deferred to Dr. [**Last Name (STitle) 11649**]. . ## hypoxia The patient was noted to develop an oxygen requirement while in afib. His hypoxia was felt to likely be from afib, although a contribution from pneumonia was also considered. He was started on ceftriaxone on [**12-24**] for focal opacity seen on CXR. Aithromycin was added on [**12-27**] for atypical coverage but d/c'ed due to potential to prolong the QT interval. He was discharged on cefpodoxime and doxycycline with improved oxygenation to complete a 10-day course of antibiotics. - d/c on cefpodoxime, doxy . #HTN Lisinopril and lasix were continued on home doses. He remained hemodynamically stable throughout his hospital course. Medications on Admission: Medications (HOME): sotalol 80 mg b.i.d Lasix 20 mg daily, lisinopril 5 mg daily, aspirin 81 mg daily Coumadin 2.5 mg po qdaily. MVI vit c . . Medications (TRANSFER): Hydromorphone 6-10 mg PO Q2H:PRN pain Ipratropium Bromide Neb 1 NEB IH Q6H Lisinopril 5 mg PO DAILY Pantoprazole 40 mg PO Q24H Acetaminophen 650 mg PO Q4-6H:PRN T>101.4 Senna 1 TAB PO BID:PRN constipation Amiodarone HCl 400 mg PO BID first dose at 8PM on [**12-26**] Simethicone 40-80 mg PO QID:PRN gas Ceftriaxone 1 gm IV Q24H pneumonia Dolasetron Mesylate 12.5 mg IV Q8H:PRN nausea Docusate Sodium 100 mg PO BID Furosemide 20 mg PO DAILY Discharge Medications: 1. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day for 4 days. [**Month/Year (2) **]:*8 Tablet(s)* Refills:*0* 2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Take 2 tablets twice a day for 4 days, then 2 tablets once a day for 7 days, then 1 tablet once a day until directed otherwise by your doctor. [**Last Name (Titles) **]:*60 Tablet(s)* Refills:*2* 6. Diltiazem HCl 360 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO DAILY (Daily). [**Last Name (Titles) **]:*30 Capsule, Sust. Release 24HR(s)* Refills:*2* 7. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO twice a day for 4 days. [**Last Name (Titles) **]:*8 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: right perinephric hematoma, atrial fibrillation Secondary: coronary artery disease, congestive heart failure, hypertension, GERD Discharge Condition: good, stable, ambulating independently, O2 sat mid-90s on room air Discharge Instructions: You were admitted for evaluation of bleeding around your right kidney and also treated for atrial fibrillation. If you have chest pain, palpitations, lightheadedness, shortness of breath, or episodes of loss of consciousness, call your doctor or seek medical attention immediately. Do NOT take coumadin until directed to do so by your doctor. Do NOT take sotalol anymore. Take your medications as directed. Follow up with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 1988**]. Wear the [**Doctor Last Name **] of Hearts monitor and use as directed. Followup Instructions: You should follow up with your primary care physician [**Name Initial (PRE) 176**] [**2-10**] weeks. You may call Dr. [**First Name8 (NamePattern2) 951**] [**Last Name (NamePattern1) 24684**] office at [**Telephone/Fax (1) 6163**] to make an appointment. You have an appointment with your cardiologist, Dr. [**Last Name (STitle) 1911**], on [**2122-1-8**] at 3pm. You may call his office at [**Telephone/Fax (1) 902**] with any questions. Follow up with your urologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 986**], for your hematoma. You may call his office at [**Telephone/Fax (1) 24685**] for an appointment. You should have a colonoscopy, endoscopy, and pulmonary function tests done as an outpatient. Your PCP can arrange this for you. The urology service has recommended a CT/MRI in a couple of weeks to assess for resolution of the hematoma. This can be arranged for you by your PCP or your urologist.

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icd9cm

[ [ [] ] ]

[ "99.04", "88.45", "88.42", "99.07", "99.69" ]

icd9pcs

[ [ [] ] ]

8414, 8420

3371, 6821

336, 359

8602, 8671

2539, 3348

9288, 10232

2172, 2176

7479, 8391

8441, 8581

6847, 7456

8695, 9265

2191, 2520

276, 298

387, 1474

1496, 2077

2093, 2156

32,317

155,927

31807

Discharge summary

report

Admission Date: [**2175-1-12**] Discharge Date: [**2175-1-21**] Date of Birth: [**2098-6-14**] Sex: F Service: CARDIOTHORACIC Allergies: Ciprofloxacin Er / Lisinopril / Diovan Attending:[**First Name3 (LF) 1283**] Chief Complaint: Poor wound healing, admitted from wound clinic Major Surgical or Invasive Procedure: Sternal wound debridement, wire removal, omental flap closure History of Present Illness: S/p AVR/CABG on [**12-5**] c/b superficial sternal wound infection. Discharged home on Vancomycin, at followup visit wound did not appear to be healing and patient was readmitted for debridement and evaluation by plastic surgery. Past Medical History: s/p AVR/CABG, Hypertension, Hyperlipidemia, CLL, s/p T&A, s/p Umbilical Hernia repair, s/p Cholecystectomy, s/p total hip replacement, s/p varicose vein ligation, s/y hysterectomy Social History: Quit smoking 44 years years ago (15yr smoking hx). Denies ETOH. Family History: Non-contributory Physical Exam: Admission: Gen: NAD Cor: RRR, no murmur Pulm: Diminished Left base Skin: sternal incision open 5x3x1 inch with fibrinous slough in base. Yeast under breasts bilat. Discharge: VS 97.2 94SR 132/58 18 93%RA 107.2 kg Neuro: non focal Pulm: CTA bilat CV: RRR, no murmur Abdm: soft, NT/NABS Ext: warm, well perfused. no edema Skin: Sternal and abdominal incisions with staples. no erythema. JP drain x1 with serosang fluid Pertinent Results: [**2175-1-12**] 06:44PM GLUCOSE-107* UREA N-13 CREAT-0.9 SODIUM-143 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-29 ANION GAP-15 [**2175-1-12**] 06:44PM WBC-18.8* RBC-3.65* HGB-10.1* HCT-31.1* MCV-85 MCH-27.8 MCHC-32.6 RDW-15.1 [**2175-1-12**] 06:44PM PLT COUNT-308 [**2175-1-12**] 06:44PM PT-12.1 PTT-20.3* INR(PT)-1.0 [**2175-1-20**] 03:31AM BLOOD WBC-24.3* RBC-3.67* Hgb-10.0* Hct-31.9* MCV-87 MCH-27.3 MCHC-31.4 RDW-15.7* Plt Ct-300 [**2175-1-20**] 03:31AM BLOOD Plt Ct-300 [**2175-1-20**] 03:31AM BLOOD PT-13.6* PTT-27.9 INR(PT)-1.2* [**2175-1-20**] 03:31AM BLOOD Glucose-115* UreaN-20 Creat-0.9 Na-141 K-3.7 Cl-109* HCO3-25 AnGap-11 [**2175-1-19**] 05:48AM BLOOD Vanco-12.3 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname 4092**] [**Hospital1 18**] [**Numeric Identifier 74641**] (Complete) Done [**2175-1-15**] at 9:43:06 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] [**Last Name (LF) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 1426**] Plastic Surgery, PC [**Apartment Address(1) 1414**] [**Location (un) **], [**Numeric Identifier 1415**] Status: Inpatient DOB: [**2098-6-14**] Age (years): 76 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Abnormal ECG. Aortic valve disease. Coronary artery disease. H/O cardiac surgery. Pericardial effusion. ICD-9 Codes: 440.0, 424.1 Test Information Date/Time: [**2175-1-15**] at 09:43 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5209**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2007AW2-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 40% to 45% >= 55% Aortic Valve - Peak Gradient: 11 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 8 mm Hg Pericardium - Effusion Size: 0.2 cm Findings LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast in the body of the LA. No spontaneous echo contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No spontaneous echo contrast in the body of the RA. No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Mild symmetric LVH. Normal LV cavity size. Mildly depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). Minimally increased gradient c/w minimal AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular calcification. Calcified tips of papillary muscles. Trivial MR. TRICUSPID VALVE: Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: Trivial/physiologic pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The patient received antibiotic prophylaxis. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions 1. The left atrium is mildly dilated. No spontaneous echo contrast is seen in the body of the left atrium. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. 2. No spontaneous echo contrast is seen in the body of the right atrium. No atrial septal defect is seen by 2D or color Doppler. 3. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 45%). 4. Right ventricular chamber size and free wall motion are normal. 5. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 6. A bioprosthetic aortic valve prosthesis is present and well-seated. . There is a minimally increased gradient consistent with minimal aortic valve stenosis. Trace aortic regurgitation is seen. There is no paravalvular leak. 7. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 8. There is a trivial/physiologic pericardial effusion. 9. There is a moderate sized pleural effusion on both sides. 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) **] [**2175-1-15**] 11:32 Brief Hospital Course: Admitted from wound clinic on [**1-12**] and treated with IV antibiotics. Plastic surgery was consulted and on [**1-16**] she was brought to operating room for debridement with pectoral and omental flap closure. She tolerated this well and was brought to the cardiac surgery ICU after the surgery in stable condition. She stayed in the CVICU for two days then was transferred to the cardiac surgery floor for continued care. She was gently diuresed for a right pleural effusion. Beta blockade was titrated and her ACE inhibitor was restarted. She did well, her activity level was advanced with physical therapy and it was decided she was stable and ready for discharge home with VNA on [**1-21**]. Medications on Admission: Colace 100" ASA 81' Percocet 5/325 Lipitor 10' Zantac 150" Amiodarone 200' Lopressor 50" Lasix 40' Captopril 12.5''' Vancomycin 750" Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. Disp:*45 Tablet(s)* Refills:*0* 2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for chest wound. Disp:*1 bottle* Refills:*0* 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed. 5. Cefepime 2 gram Recon Soln Sig: Two (2) gms Injection Q12H (every 12 hours) for 6 weeks. Disp:*168 gms* Refills:*0* 6. Vancomycin 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous Q 24H (Every 24 Hours) for 6 weeks. Disp:*[**Numeric Identifier **] mg* Refills:*0* 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. Disp:*7 Tablet(s)* Refills:*0* 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1 weeks. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 9. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO three times a day. Disp:*45 Tablet(s)* Refills:*0* 10. Zinc Sulfate 220 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0* 12. Outpatient Lab Work Qweekly draws on wednesdays CBC with Diff, BUN, Cr, LFT, Vanco trough Results to Dr [**First Name8 (NamePattern2) 4035**] [**Last Name (NamePattern1) 976**] fax [**Telephone/Fax (1) 1419**] Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: S/P sternal debridement and omental flap closure [**1-16**] PMH: s/p AVR/CABG [**12-5**], AS, CAD, HTN, ^chol, CLL, Hernia repair, CCY, Total hip replacement, varicose vein ligation, Hyst, T&A Discharge Condition: good Discharge Instructions: keep wounds clean and dry. OK to shower, no bathing or swimming. Take all medications as prescribed. Call for any fever, redness or drainage from wounds. Followup Instructions: Dr [**First Name (STitle) **]([**Telephone/Fax (1) 1429**]pt to call for Monday AM for appt next week Dr [**Last Name (STitle) **]([**Telephone/Fax (1) 1504**]) in [**4-17**] weeks, pt to call for appt Completed by:[**2175-1-27**]

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icd9cm

[ [ [] ] ]

[ "83.82", "34.79", "34.03", "77.61", "99.04", "88.72", "86.75" ]

icd9pcs

[ [ [] ] ]

9389, 9447

6857, 7556

352, 416

9685, 9692

1457, 5321

9894, 10127

977, 995

7739, 9366

9468, 9664

7582, 7716

9716, 9871

5370, 6834

1010, 1438

266, 314

444, 676

698, 879

895, 961

25,462

120,411

16557

Discharge summary

report

Admission Date: [**2113-12-1**] Discharge Date: [**2113-12-6**] Date of Birth: [**2053-1-13**] Sex: M Service: CCU CHIEF COMPLAINT: Chief complaint is chest pain. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 37557**] is a 60-year-old gentleman with no prior medical history who was in his usual state of health until three days ago when he noted upper respiratory infection symptoms consisting of cough, rhinorrhea, and a sore throat. Then he noted the sudden onset of chest ache at 4 a.m. on [**2113-11-29**]. This chest ache was initially dull but increased with inspiration and was relieved by sitting forward. The patient was able to go back to sleep, and when he woke up at 7 a.m., he noticed that the pain was somewhat decreased in its intensity. He went to work as a carpenter (as he would do routinely), and he noticed that the chest pain was recurring and becoming more intense throughout the day. He denies an increase in the pain with exertion or any shortness of breath. He also denies any diaphoresis and denies any nausea or vomiting. That night, he reported to [**Hospital3 3583**] Emergency Department complaining of [**8-5**] chest pain. His temperature at that time was 99.6, and he was found to be in atrial fibrillation with a heart rate in the 150s. He was given Lopressor, Cardizem, and an esmolol drip with his blood pressure decreasing to 80/palpitation. He was also given sublingual nitroglycerin and aspirin with improvement of his chest pain from an intensity of [**8-5**] to [**6-5**]. He was then transferred to [**Hospital1 69**] for further management. En route from [**Hospital3 3583**] to [**Hospital1 190**], he received intravenous morphine with almost complete resolution of the chest pain. At [**Hospital1 346**], and electrocardiogram was done which showed atrial flutter and ST elevations in leads I, II, aVL, and V3 through V6. Cardiology was consulted, and the patient was initially started on heparin and Aggrastat and was admitted to the Coronary Care Unit for possible acute coronary artery syndrome. PAST MEDICAL HISTORY: None. MEDICATIONS ON ADMISSION: None. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He is a carpenter. He is divorced and lives with his girlfriend. [**Name (NI) **] has three grown up children who live nearby. He has a 40-pack-year history of tobacco, and he drinks about three beers per day. FAMILY HISTORY: His mother died of a heart attack at the age of 65. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on presentation revealed temperature was 99.8, heart rate was 90, blood pressure was 101/68, oxygen saturation was 96% on 2 liters on 6 cm of water. In general, a middle-aged male in no acute distress. Very pleasant. Head, eyes, ears, nose, and throat examination revealed pupils were equal, round, and reactive to light. The oropharynx was clear. Mucous membranes were moist. The neck revealed jugular venous pressure around 9 cm of water. Positive bulky 1-cm to 2-cm anterior submandibular lymphadenopathy; mostly on the right side. The chest was clear to auscultation bilaterally. Cardiovascular examination revealed a regular rate and rhythm. Positive soft diastolic murmur loudest at the left sternal border. No friction rub. The abdomen was soft, nontender, and nondistended. Positive bowel sounds. Extremities revealed no edema. Good dorsalis pedis pulses bilaterally. Neurologically, a nonfocal examination. PERTINENT LABORATORY VALUES ON PRESENTATION: Complete blood count revealed white blood cell count was 24.9, hematocrit was 46.4, and platelets were 325 at the outside hospital. Chemistry-7 at [**Hospital1 69**] revealed sodium was 135, potassium was 4.8, chloride was 105, bicarbonate was 19, blood urea nitrogen was 14, creatinine was 0.9, and blood glucose was 155. Creatine kinase was 114. Troponin was less than 0.3. RADIOLOGY/IMAGING: Electrocardiogram #1 at the outside hospital revealed atrial fibrillation with a heart rate of 168. ST elevations in V5 and V6. Electrocardiogram #2 at the outside hospital revealed atrial fibrillation with a heart rate of [**Street Address(2) 47000**] elevations in leads I, aVL, and V2 through V6. P-R elevation in lead aVR. Electrocardiogram #1 upon arrival to [**Hospital1 190**] revealed atrial fibrillation/atrial fibrillation with a heart rate of 93. ST elevations in leads I, aVL, V2 through V6; Q waves in leads II, III, and aVF. HOSPITAL COURSE: 1. CARDIOVASCULAR SYSTEM: (a) Rhythm: Mr. [**Known lastname 37557**] is a 60-year-old gentleman with risk factors for coronary artery disease including a long history of tobacco use, sex, age, and family history. Also with electrocardiogram with Q waves in the inferior leads consistent with old inferior myocardial infarction who presented with chest pain and ST elevations in the lateral leads; initially suspicious for lateral ischemia. The patient was initially started on Aggrastat and heparin for treatment of possible acute coronary syndrome. However, upon further questioning and examination, it became evident that the acute pain was caused by pericarditis. An echocardiogram was performed which showed atrial fibrillation which prevented the determination of the ejection fraction and a small pericardial effusion with no tamponade. Heparin and Aggrastat were stopped. The patient was started on Motrin for relief of symptomatic pain. The patient remained tachycardic and in atrial fibrillation. Therefore, he was started on diltiazem and beta blocker for rate control, and he was put on amiodarone in the hopes that he would cardiovert; however, this did not happen, so the patient underwent electrocardioversion with electricity at 200 joules. He was rapidly converted. He converted the first time and remained in a sinus rhythm for approximately 30 seconds; after which he went back into atrial flutter. Electrocardioversion was attempted three more times at 300 joules, 300 joules, and 360 joules without success. Therefore, the patient opted for fibrillation which was performed with success. The patient was then continued on amiodarone 400 mg p.o. t.i.d., and diltiazem was stopped. (b) Coronary artery disease: The patient had evidence of old inferior myocardial infarction on electrocardiogram and hypokinesis in the inferolateral walls on echocardiogram consistent with old inferior myocardial infarction. The patient was started on aspirin and Lopressor. The patient was instructed to follow up as an outpatient and discuss with is primary care physician the possibility of a stress test for further workup of his coronary artery disease. (c) Anticoagulation: In the hospital, the patient was started on heparin and Coumadin at the same time. INR on the day of discharge was 1.8. Therefore, the patient was discharged on Lovenox 100 mg subcutaneously q.d. until his INR was between 2 and 3; which is therapeutic. 2. BILATERAL PHLEBITIS: The patient developed bilateral phlebitis, and he was treated with Keflex with improvement of the phlebitis while in the hospital. MEDICATIONS ON DISCHARGE: 1. Aspirin 81 mg p.o. q.d. 2. Metoprolol 25 mg p.o. b.i.d. 3. Amiodarone 400 mg p.o. t.i.d. (for four days); then 400 mg p.o. b.i.d. (for one week); then 400 mg p.o. q.d. (for one week); and then 200 mg p.o. q.d. (for two weeks or until he sees his Electrophysiology cardiologist). 4. Coumadin 5 mg p.o. q.d. (for one month if he remains in sinus rhythm). 5. Lovenox 100 mg subcutaneously q.d. (until INR is 2 or higher than that). 6. Keflex 500 mg p.o. q.i.d. (for five days). DISCHARGE STATUS: Discharge status was to home with [**Hospital6 3429**] to administer Lovenox injections until INR is therapeutic. CONDITION AT DISCHARGE: Condition on discharge was good. DISCHARGE DIAGNOSES: Pericarditis with atrial fibrillation. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was to follow up with his primary care physician within the next two weeks who was to set him up with a cardiologist in the [**Location (un) 3320**] area where he lives. 2. The patient also to follow up with Electrophysiology cardiologist, Dr. [**Last Name (STitle) 284**], within four weeks. 3. The patient was discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8227**] Dictated By:[**Last Name (NamePattern1) 27069**] MEDQUIST36 D: [**2113-12-6**] 12:36 T: [**2113-12-9**] 09:23 JOB#: [**Job Number 47001**]

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Discharge summary

report

Admission Date: [**2113-5-17**] Discharge Date: [**2113-6-22**] Date of Birth: [**2067-9-28**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4095**] Chief Complaint: Shortness of breath, altered mental status Intubated Major Surgical or Invasive Procedure: [**2113-5-17**] Ventriculostomy placement [**2113-5-18**] Cerebral Angiogram [**2113-5-31**] Tracheostomy [**2113-6-14**] PEG placement History of Present Illness: 45yo male with history of IV drug use, endocarditis s/p MVR and PPM placement, and hepatitis C admitted to OSH with altered mental status. . The patient was admitted to [**Hospital **] Hospital on [**5-4**] requesting detoxification as he started using IV drugs again. He had not been compliant with his medications, including his coumadin. He was found to have a subclavian DVT and a left brachial arterial aneurysm, which was thought to be secondary to injection of IV drugs. Vascular evaluated the patient and recommended the patient be fully sober before any attempt at aneurysm repair. He was placed on a heparin gtt and transitioned to coumadin. He had an elevated WBC there and was febrile so he was started in azithromycin with improvement in both. However, on [**5-8**], he became agitated and left the hospital AMA. He returned to the ED on [**5-9**] and reported chest pain radiating to the left arm, headache, photophobia (no rigidity) and shortness of breath. He reported using cocaine since his discharge and denied use of EtOH. . While there, he was found to be febrile with increasing shortness of breath. TTE negative for vegetations and blood culture with no growth at the time of transfer. CXR with no clear consolidation and he was scheduled to undergo a TEE to rule out endocarditis but the patient started withdrawing right before the procedure. He was given suboxone. Later on during the hospitalization, he was found to have a dense aphasia and left hemiplegia. Neurology was consulted and felt this could be secondary to meningitis vs embolic events. CT scan demonstrated poor definition of perimesencephalic cisterns without asymmetry which was concerning for some increased intracranial pressure. There was evidence of treated AVM with no other signs of acute or evolving territorial infarct. Patient was started on a heparin gtt for presumed embolic event. . Given the concern for meningitis, he was also treated with vancomycin, ceftriaxone and gentamycin. His mental status remained altered. In addition, his respiratory status worsened requiring intubation on evening [**5-16**]. CXR did not reveal a clear consolidation and he had elevated A-a gradient so he underwent a CTA which did not reveal a PE. His mental status did not improve and his respiratory status worsened. He continued on a heparin drip. A CTA was negative for PE. He was intubated and transferred to [**Hospital1 18**] on [**5-17**] for further w/u. . On transfer to MICU [**Location (un) 2452**], vital signs were T- 98.2, BP- 127/76, HR- 62, RR- 23, SaO2- 96% (intubated). Patient was intubated and sedated. On day of admission a new right eye lateral deviation was noted on exam. Neurosurgery was urgently consulted. An stat head CT/CTA was obtained that showed SAH and likely PCA aneurysm. Past Medical History: - Streptococcus salivarius mitral valve endocarditis [**9-1**] with course complicated by severe MR, multiple septic embolic to bilateral kidneys, spleen, L parietal hemorrhage with underlying mycotic aneurysm s/p onyx embolization s/p MVR [**2112-2-4**] - IVDU x 22 yrs (cocaine, oxycodone) - EtOH Abuse - hx inguinal hernia repair [**2105**] - HCV Ab + [**2108**], viral load negative - Hypertension - Depression, anxiety - Permanent pacemaker Social History: The patient has a long history of IVDU with cocaine and oxycodone since the age of 21. He also has a past history of EtOH abuse. + Tobacco use. He worked as a land-scaper. Was most recently in rehab, previously lived with his girlfriend and her children. Pet cats in the home. HIV negative [**9-1**]. Family History: No family history of coronary artery disease, CVA or malignancy Physical Exam: Physical Exam on Admission Vitals: T- 98.2, BP- 127/76, HR- 62, RR- 23, SaO2- 96% (intubated). General: Intubated, sedated HEENT: Sclera anicteric, pupils reactive to light, non-pinpoint Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, mid-systolic click, no murmurs Lungs: Bibasilar crackles (R>L) Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: foley in place Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Unable to assess secondary to sedation. DISCHARGE EXAM: VS: 98, 146/101, 79, 22, 100% on 50% trach mass CHEST: clear to auscultation bilaterally Cardiac: RRR, no MRG Opens eyes to commands, sitting in chair Moves right side spontaneously withdraws from noxioius stimuli on right Pertinent Results: Admission Labs: [**2113-5-17**] 02:15AM PT-23.8* PTT-38.4* INR(PT)-2.3* [**2113-5-17**] 02:15AM PLT COUNT-423 [**2113-5-17**] 02:15AM CALCIUM-8.9 PHOSPHATE-4.3 MAGNESIUM-2.2 [**2113-5-17**] 02:15AM CALCIUM-8.9 PHOSPHATE-4.3 MAGNESIUM-2.2 [**2113-5-17**] 02:15AM CK-MB-22* MB INDX-9.0* cTropnT-0.66* [**2113-5-17**] 02:15AM ALT(SGPT)-31 AST(SGOT)-50* CK(CPK)-244 ALK PHOS-68 TOT BILI-0.2 [**2113-5-17**] 02:15AM GLUCOSE-122* UREA N-10 CREAT-0.7 SODIUM-133 POTASSIUM-3.5 CHLORIDE-96 TOTAL CO2-26 ANION GAP-15 [**2113-5-17**] 02:48AM LACTATE-0.8 [**2113-5-17**] 02:48AM TYPE-ART PO2-128* PCO2-35 PH-7.52* TOTAL CO2-30 BASE XS-6 [**2113-5-17**] 04:14AM URINE RBC->182* WBC-7* BACTERIA-NONE YEAST-NONE EPI-0 [**2113-5-17**] 04:14AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2113-5-17**] 04:14AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]->1.050* [**2113-5-17**] 10:30AM SED RATE-58* [**2113-5-17**] 10:34AM PT-19.3* PTT-36.5 INR(PT)-1.8* [**2113-5-17**] 10:34AM CRP-180.8* Cardiac labs: [**2113-5-17**] 02:15AM BLOOD CK-MB-22* MB Indx-9.0* cTropnT-0.66* [**2113-5-17**] 02:15AM BLOOD ALT-31 AST-50* CK(CPK)-244 AlkPhos-68 TotBili-0.2 [**2113-5-17**] 10:34AM BLOOD CK-MB-19* MB Indx-9.0* cTropnT-0.76* [**2113-5-17**] 10:34AM BLOOD CK(CPK)-211 [**2113-5-17**] 10:00PM BLOOD CK-MB-8 cTropnT-0.40* [**2113-5-17**] 10:00PM BLOOD CK(CPK)-93 [**2113-5-18**] 02:15AM BLOOD CK-MB-6 cTropnT-0.39* [**2113-5-18**] 02:15AM BLOOD ALT-24 AST-27 CK(CPK)-71 AlkPhos-59 TotBili-0.2 [**Hospital3 **]: [**2113-5-17**] 10:30AM BLOOD ESR-58* [**2113-5-17**] 10:34AM BLOOD CRP-180.8* Imaging: CXR [**5-17**] - FINDINGS: In comparison with the study of [**2112-2-12**], there is now an endotracheal tube in place, with the tip approximately 6 cm above the carina. Nasogastric tube is coiled within the stomach. Pacemaker device remains in place. Hyperlucency in the upper lungs is again seen consistent with chronic pulmonary disease. There are some areas of increased opacification in the bases bilaterally. Some of this most likely reflects redistribution of blood flow related to the upper zone emphysema. However, there may be some pulmonary vascular congestion related to overhydration. In the appropriate clinical setting, the possibility of supervening pneumonia on one or both sides would have to be considered. CT abd/pelv [**5-17**] - IMPRESSION: 1. Compared to prior examination of [**2111-9-20**], there are new infarcts in the spleen, right kidney in the lower pole and left kidney in the upper pole. A new exophytic lesion in the right lower pole is too small to characterize and while this may represent a cyst, this could also represent a developing abscess in this clinical setting. If further differentiation is needed, this could be performed with MRI. 2. Old infarcts in the spleen and right kidney are again noted. 3. Atelectasis in the lower lobes bilaterally CTA head [**5-17**] - IMPRESSION: 1. Extensive acute subarachnoid hemorrhage in the basal cisterns, bilateral sylvian fissures, and left parietal lobe. Intraventricular extension of hemorrhage with significant interval increase in size of the ventricles since the earlier study of [**2113-5-16**]. 2. No evidence of diffuse cerebral edema. 3. Known right pontine infarct, with new evolving infarct in the left occipital region, may relate to embolization from the aneurysm of the left PCA, which may be mycotic. 4. 4-mm aneurysm of the left PCA is new since earlier study of [**2111-11-5**] and, in this context, may be mycotic. A "nipple" contour abnormality in the inferior aspect of the aneurysm, consistent with the recent rupture. 5. Significant vasospasm involving the mid- through distal thirds of the basilar artery, with no appreciable flow seen in the distal basilar artery. CT head w/o contrast [**5-17**] - IMPRESSION: 1. Status post placement of right transfrontal ventricular shunt catheter, with the tip terminating in the floor of the third ventricle. No significant short-interval change in the ventricular size. 2. Extensive subarachnoid hemorrhage with intraventricular extension, stable. 3. Well-defined right pontine hypodensity concerning for evolving acute infarction, overall unchanged since the study done today at 12:27 p.m., with evolving left occipital lobe hypodensity, concerning for an evolving infarct in the setting of left PCA aneurysm, likely mycotic. CT head w/o contrast [**5-17**] - IMPRESSION: 1. No significant change from 4:26 p.m. 2. Right frontal approach ventricular shunt tip ends in the floor of the third ventricle. No interval change in ventricular size. 3. Unchanged subarachnoid hemorrhage with intraventricular extension. 4. Unchanged left occipital lobe and right pontine hypodensities are concerning for evolving infarctions. TEE [**5-19**] - 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. A patent foramen ovale is present. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. A bileaflet mitral valve prosthesis is present. The motion of the mitral valve prosthetic leaflets appears normal. The transmitral gradient is normal for this prosthesis. There is a serpiginous, highly-mobile echogenic mass, attached to the anterior mitral sewing ring and prolapsing into the ventricle with each diastole, through the minor opening of the mechanical prosthesis. It is most likely a thrombus, although an atypical-appearing vegetation cannot be excluded. Trivial mitral regurgitation is seen. The degree of mitral regurgitation seen is normal for this prosthesis. There is no pericardial effusion. CT HEAD [**5-19**] IMPRESSION: 1. Status post coiling of left PCA aneurysm and unchanged extent of subarachnoid hemorrhage with intraventricular extension. 2. Stable ventriculomegaly with ventriculostomy catheter unchanged in position within the third ventricle. 3. Right pontine hypodensity concerning for evolving infarction but unchanged from the most recent prior study of [**2113-5-17**]. CTA HEAD [**5-19**] Wet Read: Wet Read: [**Last Name (un) **] SUN [**2113-5-21**] 5:03 AM 1. Status post coiling of left PCA aneurysm. Subarachnoid hemorrhage with intraventricular extension again noted. 2. Stable ventriculomegaly with right frontal approach ventriculostomy catheter unchanged in position within the third ventricle. 3. Right pontine hypodensity concerning for evolving infarction but unchanged from the most recent prior study of [**2113-5-17**]. Hypodensitiy in left occipital region. 4. Dominant left vertebral artery and a hypoplastic right vertebral artery. 5. No definite flow limiting stenosis or aneurysm > 3 mm in the carotids and their major branches. ? basilar spasm, similar to prior exam. reformats pending. TCD [**2113-5-20**] Mildly abnormal TCD evaluation. Above normal velocities were seen in the left ACA. This may be due to focal atherosclerotic stenosis, hyperemia, or could be a precursor to vasospasm. There was no evidence of vasospasm in any vessel. Recommend repeat TCD exam on [**2113-5-22**]. TCD [**2113-5-23**] Abnormal TCD evaluation. Mildly increased velocities in the left MCA were either due to mild vasospasm or hyperemia. Above normal velocities were seen in the right MCA and the left ACA. Recommend repeat TCD exam on [**2113-5-24**]. ECHO [**2113-5-24**]: Conclusions The left atrium is mildly dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the distal inferior/infero-lateral walls only (clips 2 and 42) . Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. A bileaflet mitral valve prosthesis is present. The motion of the mitral valve prosthetic leaflets appears normal. The transmitral gradient is normal for this prosthesis. Trivial mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild focal systolic left ventricular dysfunction. Well functioning mechanical mitral valve prosthesis. Moderate pulmonary artery systolic hypertension. CTA [**2113-5-24**]: IMPRESSION: 1. Improved caliber of bilateral middle cerebral arteries, when compared to recent CTA of [**2113-5-21**], but persistently narrowed compared to remote prior CTA of [**2111-11-5**]. 2. Mild persistent narrowing of the A1 segment of both ACAs, right greater than the left, and both proximal A2 segments, consistent with persistent or recurrent vasospasm. Mild persistent narrowing of the distal basilar artery and its branches, status post balloon angioplasty, may also represent recurrent vasospasm. 3. Stable hypoattenuating regions in the right paramedian pons and left occipital pole, consistent with evolving subacute infarctions. Stable encephalomalacia in the left parietal region with associated embolization material, unchanged from [**2111**]. 4. Stable ventriculomegaly, with unchanged position of external ventricular drain in the third ventricle via right frontal burr hole. 5. Status post coiling of the left PCA aneurysm with intraventricular hemorrhage, unchanged from [**2113-5-22**]. No evidence of new hemorrhage is detected. TCD [**2113-5-25**] Mildly abnormal TCD evaluation. Above normal velocities of the right proximal MCA. No vasospasm was seen in any vessel. Recommend repeat TCD exam on [**2113-5-26**]. HEAD CT [**2113-5-25**]: IMPRESSION: 1. Small subdural hematoma along right frontal convexity is new from the most recent prior study of [**2113-5-24**]. 2. Decreased ventriculomegaly with slightly decreased intraventricular hemorrhage from [**2113-5-24**] and unchanged position of right transfrontal EVD in the third ventricle. 3. Diffuse loss of [**Doctor Last Name 352**]-white matter differentiation consistent with cerebral edema appears more pronounced in the left frontal lobe. Attention is recommended on followup. 4. Stable hypoattenuating areas in the right paramedian pons, right medial temporal lobe, and left occipital pole are consistent with evolving subacute infarctions. 5. Unchanged encephalomalacia in the left parietal region with associated embolization material, stable since [**2111**]. TCD [**2113-5-26**] Abnormal TCD evaluation. Mild vasospasm was seen in the right proximal MCA. This represents worsening compared with TCD results from [**2113-5-25**]. Insonation of the left MCA was technically limited [**2113-5-26**] CXR NG tube tip is in the stomach, is coiled, and the tip is at the fundus. ET tube is in standard position. Spacer leads are in standard position with tips in the right atrium and right ventricle. There is no evident pneumothorax. Patient has known emphysema. Bibasilar opacities have increased on the left. These are probably due to increasing atelectasis, but aspiration cannot be excluded. There is no pleural effusion. Cardiac size is normal. [**2113-5-26**] CTA head 1. Improved caliber of basilar artery when compared to the recent CTA of [**2113-5-24**]. 2. Moderate vasospasm of the M1 segment of the left MCA greater than the right MCA, increased from [**2113-5-24**]. 3. Mild persistent narrowing of the A1 and proximal A2 segments of the bilateral ACAs, unchanged from [**2113-5-24**]. 4. Stable hypoattenuating regions in the right paramedian pons, right medial temporal lobe and left occipital pole, consistent with subacute infarctions. 5. Stable encephalomalacia in the left parietal region with embolization material, unchanged from [**2111**]. 6. Status post coiling of left PCA aneurysm with stable intraventricular hemorrhage, but no residual subarachnoid hemorrhage. No new hemorrhage detected. [**2113-5-27**] CXR Compared to the study from the prior day there is no significant interval change. [**2113-5-28**] ECG Sinus rhythm. Probable prior inferior wall myocardial infarction. Slight persistent ST segment elevation in the inferior leads which could be consistent with an aneurysm or ongoing ischemia. Slight ST segment depression in leads VI-V3 suggestive of reciprocal posterior ischemia. Compared to the previous tracing of [**2113-5-24**] overall extensive ST segment elevations in the inferior leads and ST segment depressions in the anterior leads have decreased suggestive of ongoing infarction. Clinical correlation is suggested. [**2113-5-29**] CXR As compared to the previous radiograph, there is no relevant change. The pre-existing parenchymal opacity in the retrocardiac lung areas is likely to be atelectatic, given the concomitant elevation of the left hemidiaphragm. The presence of a minimal left pleural effusion cannot be excluded. No other parenchymal abnormalities, except for the hyperlucencies in the lung apices, strongly indicative of extensive pulmonary emphysema. Normal size of the cardiac silhouette. Unchanged position of the monitoring and support devices. [**2113-5-31**] CXR Comparison is made with prior study [**5-30**]. Cardiomediastinal contours are normal. Patient has known emphysema. Left lower lobe retrocardiac atelectasis is unchanged. There are no new lung abnormalities, pneumothorax or pleural effusion. Lines and tubes are in standard position. CT head [**2113-5-31**] 1. Right transfrontal EVD, unchanged in position, with unchanged size of ventricles from [**2113-5-26**]. 2. Residual intraventricular hemorrhage, slightly decreased in amount compared to prior studies. 3. Status post coiling of left PCA aneurysm with no residual subarachnoid hemorrhage. 4. No new intracranial hemorrhage. 5. Stable subacute infarctions of the right paramedian pons, right medial temporal lobe, and small infarct of the left occipital pole. 6. Left parietal encephalomalacia with embolization material, unchanged from [**2111**]. CXR [**2113-6-1**] Compared to the previous radiograph, the Dobbhoff catheter has been advanced by approximately 5 cm. The tip now projects over the proximal parts of the stomach. There is no evidence of complications. The other monitoring and support devices, and the general appearance of the lung and heart are unchanged. CXR [**2113-6-2**]: unchanged CT head [**2113-6-2**]: Stable CXR [**2113-6-3**]: New linear opacities have developed in the right mid and both lower lungs, most consistent with areas of subsegmental atelectasis. Otherwise, no relevant change since the recent study. CXR [**2113-6-5**]: As compared to previous radiograph, small atelectasis at the upper aspect of the middle lobe is completely resolved. Normal appearance of the lung parenchyma, except for the known areas of hyperlucency in both lung apices. Normal appearance of the cardiac silhouette. Normal hilar and mediastinal structures. CXR [**6-7**]: New opacification at the lung bases, confluent on the left, is probably due to atelectasis, conceivably attributable to aspiration. Hyperlucent upper lungs indicate emphysema. Heart is normal, but increased since [**6-5**] suggesting cardiac decompensation and some early edema in the lower lungs. Tracheostomy tube in standard placement. Transvenous right atrial and right ventricular leads in standard placements. Nasogastric feeding tube ends in the upper stomach. No pneumothorax. Left jugular line ends in the upper SVC. Radiology Report CHEST (PORTABLE AP) Study Date of [**2113-6-8**] 3:41 AM FINDINGS: As compared to the previous image, the tracheostomy tube and the other monitoring and support devices are constant. There are unchanged hyperlucencies in the lung apices, indicative of severe pulmonary emphysema. The crowded parenchyma at the lung bases is constant. Unchanged retrocardiac atelectasis and borderline size of the cardiac silhouette. No other changes. CXR [**2113-6-9**] 1. No pneumothorax. Increased left lower lobe collapse and right basilar atelectasis. 2. Pneumoperitoneum consistent with recent VP shunt placement. Head CT [**2113-6-9**] 1. Persistent ventriculomegaly after replacement of the EVD with a VP shunt along with transependymal CSF migration consistent with hydrocephalus. 2. Otherwise, stable appearance from the prior study, seven days ago. No evidence of new infarction or hemorrhage. CXR [**2113-6-10**] Right middle and lower lobe atelectasis have worsened. There is no good evidence for pneumonia. Left lower lobe collapse has improved, but atelectasis is still substantial. Upper lungs are clear. No appreciable pleural effusion or pneumothorax. Presumed shunt catheter traverses the right neck, chest and upper abdomen. Tracheostomy tube and left internal jugular line, as well as transvenous right atrium and right ventricular pacer leads are in standard placements. A feeding tube ends in the upper stomach. Heart size is normal. [**2113-6-13**] PICC line placement - Uncomplicated ultrasound and fluoroscopically guided double lumen Preliminary ReportPower PICC line placement via the right basilar venous approach. Final Preliminary Reportinternal length is 42 cm, with the tip positioned in the lower SVC. The line Preliminary Reportis ready to use. . [**2113-6-22**] [**2113-6-22**] 05:10AM BLOOD WBC-7.3 RBC-3.27* Hgb-8.9* Hct-28.6* MCV-87 MCH-27.2 MCHC-31.1 RDW-14.9 Plt Ct-384 [**2113-6-17**] 05:12PM BLOOD Neuts-73.0* Lymphs-18.2 Monos-7.6 Eos-0.8 Baso-0.4 [**2113-6-22**] 05:10AM BLOOD Plt Ct-384 [**2113-6-22**] 05:10AM BLOOD PT-12.3 PTT-75.9* INR(PT)-1.1 [**2113-6-22**] 05:10AM BLOOD Glucose-98 UreaN-14 Creat-0.9 Na-143 K-2.8* Cl-104 HCO3-34* AnGap-8 [**2113-6-22**] 12:27PM BLOOD Na-144 K-3.7 Cl-107 [**2113-6-20**] 06:15AM BLOOD ALT-18 AST-23 LD(LDH)-316* AlkPhos-71 TotBili-0.2 [**2113-6-22**] 05:10AM BLOOD Calcium-8.8 Phos-4.5 Mg-2.0 [**2113-6-20**] 06:15AM BLOOD calTIBC-218* Hapto-<5* Ferritn-99 TRF-168* [**2113-5-20**] 07:08AM BLOOD Triglyc-87 Brief Hospital Course: This is a 45-year-old gentleman with history of IV drug use, MVR, hepatitis C who presents with altered mental status and hypoxic respiratory distress. . # PONTINE INFARCATION AND ICH: The patient presented with altered mental status, initially concerning for meningitis. He had aphasia and left hemiplegia at the OSH prior to transfer, thought to be due to infection. Neurology consult at OSH recommended stat head CT, which was negative for intracranial hemorrhage. He was continued on heparin gtt with some improvement in his symptoms; coumadin was resumed at 15mg daily at OSH. He was treated with vancomycin and ceftriaxone for possible meningitis. On [**5-17**] at 1100 he was noticed to have right eye deviation and to be non-responsive even to pain. Code Stroke was called. He was found on imaging to have both a pontine ischemic stroke and small intracranial hemorrhage. The ischemic stroke may have been due to endocarditis leading to embolic event, particularly given the patient's open PFO. A ventricular shunt was placed to reduce ICH, supported by infusion of protamine and activated factor IX. His mental status did not substantially improve despite drainage and normalized ICH. On [**5-20**] the shunt was noted to have clotted off and TPA was infused to clear it. Also on [**5-20**] CTA revealed possible vasospasm. The patient's SBP target was increased and he was transferred to the NeuroICU for further specialized management. As hospital course progressed, it was determined that bleeding had stopped and patient was restarted on heparin drip as bridge to coumadin for mechanical mitral valve. Patient had a repeat head CT on [**2113-6-20**] that did not show much change. . # CEREBRAL SALT WASTING/HYPONATREMIA/FLUDROCORTISONE TAPER: Patient was started on fludrocortisone taper for cerebral salt wasting. On [**2113-6-22**], please taper fludrocortisone dose down to 0.1 [**Hospital1 **] for 3 days through [**2113-6-24**]. Then start 0.1QD for 3 days through [**2113-6-27**]. Then start 0.05mg QD for 3 days through [**2113-6-30**]. Then stop. . # ANTIBIOTICS FOR CULTURE NEGATIVE ENDOCARDITIS: Patient continues on vanc IV 750 mg Q12 and gentamycin 80 Q12 for endocarditis through [**2113-6-28**]. Patient will need to have creatinine checked every day. Gentamycin trough should be checked on [**2113-6-26**] and adjusted accordingly (should be less than 2). Gentamycin is being dosed at 5am and 5pm. If creatinine rises, gentamycin will need to be adjusted. Please check vancomycin trough on [**2113-6-26**]. Vancomycin has been dosed at 10am and 10pm. . # HYPOXIC RESPIRATORY FAILURE: The patient's initial respiratory failure was of unclear etiology, but was thought to be secondary to aspiration event in the setting of altered mental status. OSH ABG demonstrated elevated A-a gradient, which could be suggestive of PE but CTA was negative for pulmonary embolus. EKG with no acute ST changes. The patient was treated with vancomycin and ceftriaxone for possible meningitis. He was intubated and sedated on [**5-16**]. . # FEVERS: The patient was febrile at OSH. Work-up there included negative CT chest, CT head, TTE, and blood cultures. He was started on meningitis coverage with vancomycin/ceftriaxone/gentamycin. TEE showed valve vegetation and open PFO. Gentamicin was added to his antibiotics to cover culture-negative endocarditis. His WBC on transfer to [**Hospital1 18**] was 22.0, peaked at 42.9 on [**5-20**]. Patient continued to spike without obvious source. However, he has been afebrile for the last weeks. He continues on vancomycin and gentamycin through [**2113-6-28**] for culture negative endocarditis. Patient will need a repeat ECHO to evaluate for endocarditis on [**2113-6-28**]. . # ALTERED MENTAL STATUS: Initially concerning for infectious etiology (meningitis, endocarditis). On [**5-16**] patient was noted to have both ischemic and hemorrhagic stroke, responsible for his worsening mental status. His mental status however, continues to improve. On discharge, he will open his eyes to voice and respond to simply commands. According to neurosurgery attending, patient will likely have residual hemiparesis, diplopia, and difficulty with feeding. . # LEFT SUBCLAVIAN DVT: Patient will continue on heparin gtt bridge to coumadin for mechanical valve and will thus be anticoagulated for subclavian DVT as well. . # HEPATITIC C: Chronic. Not treated. . # CAD: Patient continues on metoprolol and statin. After heparin drip is discontinued, it may be reasonable to start ASA 81mg QD. This can be discussed with neurosurgery and patient's cardiologist/PCP. . # DEPRESSION/ANXIETY: Abilify and celexa were stopped during admission due to critical illness and change in mental status. These can be resumed at the discretion of outpatient providers. . # ANEMIA: Patient with combination of iron deficiency anemia and anemia of chronic disease. He received 1 unit of PRBCs on [**2113-6-20**] with appropriate bump in hematocrit. He should continue on iron supplementation with frequent hematocrit checks. . # ANTICOAGULATION: Patient continues on coumadin with heparin bridge. Patient's goal INR is 2.5-3.5 because of mechanical mitral valve. His coumadin may need to be uptitrated upon discharge. . # NUTRITION: Patient continues on isosource tube feeds through PEG tube. . # GOALS OF CARE: Long discussions were held with family about goals of care. As of now, patient is full code. Patient's 18-year-old daughter is the HCP but brother [**Name (NI) **] is responsible for much of the coordination of care. Palliative care was consulted during this admission; below is an exerpt: "I spoke with [**Doctor Last Name **] on the phone, who seems to have a fairly balanced perspective on the [**Hospital **] medical condition and prognosis. He describes that as a family they are "hoping for the best" while also "prepared for the worst" if things do not turn out well. They are definitely hoping for as much neurologic and cognitive recovery as possible. His medical team does expect him to have some degree of improvement, the extent of which is less clear. His brother describes that they want as much aggressiverehab as possible. He states that he knows it is possible that the pt may suffer some medical complications down the road and that if he experiences anything quite devastating like another stroke, he thinks that as a family they would opt for comfort-focused care at that point to minimize the pt's further suffering. He knows that even prior to that point, there are options for avoiding invasive or uncomfortable procedures, such as DNR/DNI. Overall appears that pt's brother has realistic expectations and hopes for the pt's future course, and is able to acknowledge that quality of life is important for guiding future decisions if the pt suffers any future major medical complications. Per the brother's and RN staff recommendations, we have not pursued further conversation with his daughter at this time due to her young age, her social situation (18 yo, graduating from high school this week, lost her mother 2 years ago and then step-father last year) and the nonurgent nature of our topic of conversation." . Transitional Issues: --Repeat ECHO on [**2113-6-28**] to evaluate for continued endocarditis --Ensure INR is between 2.5-3.5 and overlap with heparin gtt for 48 hours --Daily creatinine checks while patient is on gentamycin --Vanc IV and gent through [**2113-6-28**] for culture negative endocarditis --PEG care --Check IV vanc and gent trough on [**2113-6-26**] --Twice weekly hematocrit checks --Tube feeds as recommended by nutrition --Neurosurgery follow-up --Consider starting ASA for CAD after patient is off heparin gtt and OK with neurosurgery --Continued goals of care discussion with family and palliative care team --Taper fludricortisone as above . If any questions, please call floor [**Hospital Ward Name 121**] 7 at [**Hospital1 18**] and ask for the team that was taking care of this patient. Thanks! Medications on Admission: Home: 1. Gabapentin 300mg TID 2. Metoprolol 25mg [**Hospital1 **] 3. Magnesium oxide 400mg PO daily 4. Abilify 5mg PO qHS 5. Celexa 20mg PO daily 6. Coumadin daily On transfer from outside hospital: 1. Tylenol 1000mg q6hr prn 2. Fioricet 1-2 tabs PO q4hr prn pain 3. Aripiprazole 5mg PO qHS 4. Suboxone 2/0.5- SL [**Hospital1 **] 5. Ceftriaxone 2gm q12hr 6. Celexa 20mg PO qHS 7. Gabapentin 300mg PO TID 8. Gentamicin 100mg q8hr 9. Nicotine 21mg TD daily 10. Senna 1 tab daily prn 11. Vancomyin 1500mg IV q12hr 12. Coumadin 15mg daily (on hold) 13. Heparin gtt (on hold) 14. Guaifenesin 200mg q6hr prn 15. Lorazepam 0.5mg PO q4hr prn anxiety 16. Magnesium oxide 400mg PO daily 17. Melatonin 1mg qHS 18. Metoprolol 25mg PO BID 19. Milk of Magnesium- 30ml PO daily 20. Propofol 40mcg/kg/min IV drip Discharge Medications: 1. Acetaminophen 325 mg PO Q6H 2. Ferrous Sulfate 325 mg PO DAILY 3. Fludrocortisone Acetate 0.1 mg PO BID 4. Gentamicin 80 mg IV Q12H Last day [**2113-6-28**]. 5. Heparin IV Sliding Scale 6. Insulin SC Sliding Scale Fingerstick q6h Insulin SC Sliding Scale using REG Insulin 7. LeVETiracetam 1000 mg PO BID 8. Metoprolol Tartrate 25 mg PO BID Hold for SBP <110; HR <60 9. Pantoprazole 40 mg PO Q12H 10. Simvastatin 20 mg PO DAILY CAD 11. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 12. Vancomycin 750 mg IV Q 12H, last day [**2113-6-28**] 13. Vancomycin Oral Liquid 500 mg PO Q6H Please take through [**2113-6-28**]. 14. Warfarin 7.5 mg PO DAILY Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**] ([**Hospital3 1122**] Center) Discharge Diagnosis: Endocarditis Pneumonia Respiratory failure Stroke Vasospasm Intraventricular hemorrhage Hydrocephalus Coma Protien/calorie malnutrition C. diff colitis Fever of unknown origin malnutrition Anemia Leukocytosis Thrombocytosis Hyponatremia endocarditis Left subclavian DVT [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 75777**] hypotension altered mental status Vasospasm bactermia Cerebral salt wasting Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname 75772**], It was a pleasure taking care of you during this admission. You originally came to the hospital because you had an ischemic stroke. You subsequently had a bleed in your head and you needed a drain placed by neurosurgery to relieve the pressure. We were unable to take you off the breathing machine (respirator) and a tracheostomy was placed. You also had a PEG tube placed so that you could get tube feeds and medications. You have had multiple CT scans of your head; the most recent one did not show much difference from the one before. . You will need to follow-up with neurosurgery (Dr. [**First Name (STitle) **] in [**2-24**] weeks for a CT scan and an appointment. . You are on a heparin drip bridging you to therapeutic coumadin levels. Your goal INR is 2.5-3.5 because of your mechanical valve. You will need to continue on a heparin drip until your INR is over 2.5 for 48 hours. You will need to have your PTT checked (level of heparin) every 6 hours and adjusted so that it is between 60 and 80. . You will be discharged on keppra for seizure prophylaxis. . You were given a blood transfusion on [**2113-6-20**] for low blood counts probably because of iron deficiency anemia and anemia of chronic disease. . You were started on a medication called fludricortisone to treat low sodium levels. You will need to taper this medication very slowly. On [**2113-6-22**], please taper fludrocortisone dose down to 0.1 [**Hospital1 **] for 3 days through [**2113-6-24**]. Then start 0.1QD for 3 days through [**2113-6-27**]. Then start 0.05mg QD for 3 days through [**2113-6-30**]. Then stop. . You will continue on vanc IV 750 mg Q12 and gentamycin 80 Q12 for endocarditis through [**2113-6-28**]. You will need to have creatinine checked every day. Gentamycin trough should be checked on [**2113-6-26**] and adjusted accordingly (should be less than 2). Gentamycin is being dosed at 5am and 5pm. If creatinine rises, gentamycin will need to be adjusted. Please check vancomycin trough on [**2113-6-26**]. Vancomycin has been dosed at 10am and 10pm. . We will continue to treat you for c.diff (infection of the colon) with oral vancomycin through [**2113-6-28**] when you stop your other antibiotics. . Please see below for a list of your new medications. Followup Instructions: Department: RADIOLOGY When: THURSDAY [**2113-7-6**] at 2:15 PM With: CAT SCAN [**Telephone/Fax (1) 590**] Building: CC [**Location (un) 591**] [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: NEUROSURGERY When: THURSDAY [**2113-7-6**] at 3:15 PM With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7746**], MD [**Telephone/Fax (1) 3666**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

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icd9cm

[ [ [] ] ]

[ "96.72", "00.42", "54.21", "96.6", "31.1", "88.72", "00.62", "88.41", "43.11", "02.34", "33.24", "99.10", "38.97", "02.21", "39.75" ]

icd9pcs

[ [ [] ] ]

33160, 33296

23468, 27254

357, 495

33760, 33760

5076, 5076

36274, 36790

4144, 4210

32402, 33137

33317, 33739

31565, 32379

33936, 36251

4225, 4815

4831, 5057

30741, 31539

265, 319

523, 3340

5092, 23445

33775, 33912

3362, 3809

3825, 4128

29,243

169,295

32112

Discharge summary

report

Admission Date: [**2192-9-4**] Discharge Date: [**2192-9-7**] Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 106**] Chief Complaint: Troponin elevation, transfer from [**Hospital **] hospital Major Surgical or Invasive Procedure: 1. Cardiac cath History of Present Illness: [**Age over 90 **] yo active female w/ PMH hypercholesterolemia and HTN presents from [**Hospital **] hospital with elevated troponins. Experienced chest pressure / pain x 2 weeks in setting of EKG's without acute ischemic changes. Recently underwent stress echo w/ 10 min exercise w/o sxs. Admitted to [**Location (un) **] for observation [**9-3**] and found to have troponins --> 1.98. Referred to [**Hospital1 **] for cath. Loaded 300 mg [**Last Name (LF) 4532**], [**First Name3 (LF) **] 325, heparin, integrillin. Cath findings: lad - mid vessel 50% stenosis; Lcx - luminal irregularities; RCA - distal 70% lesion, total occlusion PDA and PL. Team noted bradycardia, hypotension when pulled sheath in cath lab as well as floor --> SBP's 60's, hr 90's. Given atropine 1 mg, dopamine gtts, IVF's. Patient subsequently became confused and neurology was consulted. Past Medical History: L breast CA s/p partial mastectomy Appendectomy Hiatal hernia Osteoporosis Oophorectomy Back surgery, NOS Social History: Social history is significant for former tobacco use. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS: T 98.2, BP 111/60 , HR 108 , RR 22, 99 % on 2L NC Gen: frail elderly female in no acute distress HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of 10 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Abd: thin, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: 2+ DP Left: 2+ DP NEURO: A+O x 3; cn 2-12 grossly intact; tired and slow to answer questions, however responded appropriatly to questions. moving all extremeties voluntarily. Pertinent Results: [**2192-9-4**] 03:51PM BLOOD WBC-11.0 RBC-3.63* Hgb-11.0* Hct-33.3* MCV-92 MCH-30.4 MCHC-33.1 RDW-14.5 Plt Ct-222 [**2192-9-5**] 03:38AM BLOOD Neuts-72* Bands-3 Lymphs-20 Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2192-9-5**] 03:38AM BLOOD Hypochr-2+ Anisocy-NORMAL Poiklo-NORMAL Macrocy-2+ Microcy-NORMAL Polychr-1+ Burr-1+ [**2192-9-5**] 01:30AM BLOOD WBC-12.5* RBC-2.77* Hgb-8.5* Hct-25.1* MCV-91 MCH-30.6 MCHC-33.8 RDW-14.6 Plt Ct-163 [**2192-9-7**] 06:35AM BLOOD WBC-9.8 RBC-3.58* Hgb-11.1* Hct-32.1* MCV-90 MCH-31.0 MCHC-34.6 RDW-14.7 Plt Ct-127* [**2192-9-4**] 03:51PM BLOOD Glucose-119* UreaN-9 Creat-0.6 Na-144 K-3.0* Cl-117* HCO3-19* AnGap-11 [**2192-9-4**] 03:51PM BLOOD CK(CPK)-104 [**2192-9-5**] 01:30AM BLOOD CK(CPK)-338* [**2192-9-5**] 03:38AM BLOOD LD(LDH)-223 CK(CPK)-284* [**2192-9-5**] 05:38AM BLOOD LD(LDH)-251* CK(CPK)-410* [**2192-9-5**] 11:50PM BLOOD CK(CPK)-676* [**2192-9-7**] 06:35AM BLOOD CK(CPK)-251* [**2192-9-4**] 03:51PM BLOOD CK-MB-12* MB Indx-11.5* cTropnT-0.13* [**2192-9-5**] 01:30AM BLOOD CK-MB-14* MB Indx-4.1 [**2192-9-5**] 03:38AM BLOOD CK-MB-11* MB Indx-3.9 cTropnT-0.13* [**2192-9-5**] 05:38AM BLOOD CK-MB-14* MB Indx-3.4 cTropnT-0.16* [**2192-9-5**] 11:50PM BLOOD CK-MB-16* MB Indx-2.4 cTropnT-0.27* [**2192-9-7**] 06:35AM BLOOD CK-MB-7 cTropnT-0.25* . Cardiac catheterization PTCA COMMENTS: Initial angiography revealed severe calcification in the RCA with tortuosity and distal 70% stenosis. There was total occlusion of the PDA adn PL with right to right and left to right collaterals. A 6french [**Doctor Last Name **] 0.75, [**Doctor Last Name **] 1.0, AR1, Jr4 provided poor support. Ultimately we exchanged for a AR2 which provided moderate fair support for the procedure. Heparin and Integrilin were started prophylactically. A PT graphix intermediate crossed the lesion with much difficulty after a choice PT extra support, wisdom and whisper wire would not cross. A 1.5 x 9 mm maverick balloon would not cross and an echelon catheter was used to exchange for a stabilizer XS SS wire.With much difficulty a 1.5 x 9 mm Maverick balloon was used to dilate and then a 2.0 x 20 mm maverick was used to dilate. With the balloon across the elsion the patient had transient bradycardia, STE and hypotension which responded to IVF, atropine and dopamine. We were unable to cross the the lesion with a 2.0 x 12 mm minivison and a 2.5 x 18 mm minivision stent and during stent manipulation the wire prolapsed out of teh vessel. We were unable to recross the lesion again and the procedure was terminated. Final angiography revealed no angiographically apparent dissection, a residual 50% stenosis and TIMI grade III flow. The patient left the lab free of jaw pain, with ST segment resolution and in stable condition. . COMMENTS: 1. Coronary angiography of this right dominant system demonstrated single vessel disease. The LMCA had no angiographically apparent CAD. The LAD had mild luminal irregularities and a mid-vessel 50% stenosis. The LCx had mild luminal irregularities. The RCA had severe calcification with tortuosity and distal 70% lesion, total occlusion of the PDA and PL with right to right and left to right collaterals. 2. Resting hemodynamics revealed normal left sided filling pressures with an LVEDP of 11 mmHg. There was mild systemic arterial systolic hypertensions with SBP of 143 mmHg. 3. Unsuccessful stenting of the calcified RCA stenosis. Successful PTCA of that lesion with final residual stenosis of 50%, no angiographically apparent dissection and TIMI grade III flow. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Unsuccessful stenting of the RCA. Successful PTCA of the RCA stenosis. . Echocardiogram The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity is small. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF 70-80%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. 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 borderline pulmonary artery systolic hypertension. There is no pericardial effusion. . Femoral ultrasound [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] of the right groin demonstrate normal waveforms in the right common femoral vein and the right common femoral artery. A pseudoaneurysm is identified anterior to the vessels measures 1.3 x 1.8 x 1.5 cm. The neck of the pseudoaneurysm was not identifiable on this exam. No fluid collections or hematomas were identified. . Thrombin injection of femoral artery psuedoaneurysm Ultrasound of the right groin demonstrates a 1.6- cm lesion with turbulent flow consistent with pseudoaneurysm. The common femoral artery is patent. The right groin was prepped and draped in usual sterile fashion. Under ultrasound guidance, 22- gauge needle was advanced into the pseudoaneurysm and approximately 2 cc of thrombin was slowly injected. Occlusion of the pseudoaneurysm was demonstrated on real-time imaging. Post- procedure imaging demonstrates a patent common femoral artery with normal waveforms. Patient tolerated the procedure well without immediate complications. The attending Dr [**Last Name (STitle) **] participated in the entire procedure. IMPRESSION: Successful thrombin injection of right pseudoaneurysm. Brief Hospital Course: [**Age over 90 **] yo female w/ HTN, hypercholesterolemia pw NSTEMI from OSH w/ elevated troponins, ekg without signs of acute ischemia, and acute lethargy post cath s/p atropine. . course by problem . #CAD / NSTEMI Trop leak at [**Hospital3 7569**] w/ Trop 1.98. Underwent cardiac catheterization with failed stenting of calcified RCA stenosis. Underwent plain baloon angioplasty. Peak CK 676 post catheterization. Catherization was complicated by vagal reaction of bradycardia and hypotension during sheath removal and was started on dopamine and given atropine. On the medical floor patient experienced another bout of bradycardia, was given atropine, and transferred to the ICU for observation. She became extremely confused after 2 mg of atropine and neurology was consulted to comment on acute change in mental status. . For CAD, aspirin 325 mg, [**Hospital3 4532**] 75 mg, toprol xl 50 mg, simvistatin, and lisinopril were provided and should be continued as an outpatient. Nifedipine was discontinued, the [**Hospital3 **] dose is full instead of baby 81 mg, and both [**Hospital3 4532**] and lisinopril are new medications for her. She was scheduled to follow up with her cardiologist and PCP upon discharge. She was scheduled for VNA, home PT, and home health aid. . Catheterization was complicated also by psuedoaneurysm of the right femoral artery. Hematocrit dropped 8 points and she was transfused 2 units of blood. Vascular surgery was consulted; definitive treatment was taken via direct thrombin injection which resulted in termination of the pseudoaneurysm. She is scheduled to follow with vascular sugery in 2 weeks. . #PUMP / Rhythm Lisinopril was initiated for htn and cardioprotective effects post myocardial ischemia . #Change in mental status Initially confused s/p 2mg atropine after catheterization in setting of hypotension and bradycardia. Initial concern for drug effect of atropine, however also concerned for CVA with hypoperfusion. Neurology was consulted and patient underwent urgent head CT. No acute bleeding or midline shift was identified on CT scan. As time wore on the atropine wore off and patient regained normal mental status function at baseline. . Patient remained afebrile during hospitalization. Excluding 2 episodes of bradycardia and hypotension, she remained hemodynamically stable. Cardiac catheterization was performed with unsuccessful stenting of RCA lesion. Pseudoaneurysm was discovered and definitively treated. She was started on [**Hospital3 4532**] and lisinopril. Nifedipine was stopped. Aspirin was increased to 325 mg daily. She will follow with cardiology, her PCP, [**Name10 (NameIs) **] vascular surgery. Medications on Admission: [**Name10 (NameIs) **] 81 zocor detrol [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 75149**] prilosec nifedipine toprol xl 25 isordil 20 Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Detrol LA 2 mg Capsule, Sust. Release 24 hr Oral Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: 1. Non-ST-elevation myocardial infarction 2. Pseudoaneurysm, right groin Discharge Condition: Hemodynamically stable. Discharge Instructions: You were admitted and diagnosed with an acute myocardial infarction (heart attack). It will be important for you to take all your medications, as prescribed. Please note the following changes. 1. [**Hospital **]. In addition to aspirin, this helps to thin your blood. You should be sure to take this medication for one month. 2. Aspirin. Please take 325mg daily until you follow-up with your cardiologist. 3. Lisinopril. This medication is for blood pressure control and helps to protect the heart. Please STOP the nifedipine. In addition, you also had a small pseudoaneurysm in your right groin. Please follow-up with Dr. [**Last Name (STitle) **] in two weeks time. Followup Instructions: Please call to make a follow-up appointment with your PCP [**Last Name (NamePattern4) **] [**2-18**] weeks. In addition, you have an appointment with vascular surgery: [**9-25**] at 2pm -- Dr. [**Last Name (STitle) **] (Vascular surgery). Phone #[**Telephone/Fax (1) 1241**]. Dr.[**Name (NI) 75150**] office will call you after you return home. You should be sure to follow-up with him within 1-2 weeks.

[ "414.01", "V10.3", "285.1", "272.0", "V15.82", "458.29", "997.1", "427.89", "442.3", "293.0", "410.71", "998.12", "997.2", "401.9" ]

icd9cm

[ [ [] ] ]

[ "99.10", "37.22", "00.40", "99.04", "88.56", "00.66" ]

icd9pcs

[ [ [] ] ]

11667, 11730

8114, 10806

271, 289

11847, 11873

2382, 5938

12599, 13011

1446, 1528

11002, 11644

11751, 11826

10832, 10979

5955, 8091

11897, 12576

1543, 2363

173, 233

317, 1192

1214, 1321

1337, 1430

1,042

177,447

22569

Discharge summary

report

Admission Date: [**2167-9-29**] Discharge Date: [**2167-10-9**] Date of Birth: [**2129-5-22**] Sex: M Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 943**] Chief Complaint: recurrent ascites Major Surgical or Invasive Procedure: Transjugular intrahepatic portosysyemic shunt placement Therapeutic paracentesis Transesophageal Echocardiogram History of Present Illness: Briefly, 38 yo M with a h/o hep C cirrhosis, episode of SBP, s/p liver transplant in [**6-8**], recent admission at [**Hospital1 **] for ARF in the setting of new diuretic regimen, now transfered from an OSH for evaluation of worsening LFTs, which developed during a hospitalization for MI. AS above the pt was recently admitted to [**Hospital1 **] for ARF that developed after starting a regimen of lasix. With d/c of lasix, the pt's renal failure had largely resolved at the time of discharge from [**Hospital1 **] on [**2168-9-25**]. The day following discharge the pt had an episode of severe b/l neck pain that radiated down into his chest, associated with dyspnea. EMS was called and pt's pain continued until he was electively intubated for catheterization, given EKG with ST elevations in V1-V3. Cath revealed a proximally occluded LAD that underwent successful PCI with a vision stent placed with a good result. Pt was extubated on [**2167-9-27**]. His LFT's were elevated with AST of 345 and ALT of 127. The pt was transferred to [**Hospital1 **] and was initially admitted to the CCU to ensure cardiac stability. He is now being transfered to the hepatorenal service for further evaluation of his elevated LFTs. Presently he is denying CP/SOB/HPs/abdominal pain. He denies n/v. Had loose BMs last night. Past Medical History: 1 chronic hepatitis C -> cirrhosis - h/o ascites, encephalopathy, SBP - orthotopic deceased donor liver transplant on [**2166-6-21**] - one nodule of HCC found at time of transplant - c/b recurrent hep C after transplant - tx with interferon and ribavirin -> no response - VL 12,600,000 on [**2167-8-6**] - IFN, ribavarin d/c on [**2167-9-8**] - also c/b biliary anastamotic stricture s/p dilation and stenting - stent removed [**2167-9-2**] - liver bx [**2167-9-11**] shows recurrent, progressive hep C but no HCC - recurrent ascites 2 h/o hemochromatosis 3 DM2 4 h/o DVT and bilateral PE 5 h/o splenic infarct 6 ho STEMI ([**9-9**]) Social History: Currently living with his Mom. h/o etoh - quit in '[**60**] h/o ivdu - quit in '[**59**] Family History: non-contrib Physical Exam: Temp 98 BP 100/50 Pulse 76 Resp 20 O2 sat 100% RA Gen - Alert, no acute distress [**Year (2 digits) 4459**] - extraocular motions intact, anicteric, mucous membranes dry Neck - no JVD, no cervical lymphadenopathy Chest - diminished breath sounds R base CV - Normal S1/S2, RRR, no murmurs appreciated Abd - Soft, mildly distended, RUQ tenderness to deep palpation, normoactive bowel sounds Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally Neuro - non-focal Skin - No rash Pertinent Results: [**2167-9-29**] 08:19PM GLUCOSE-167* UREA N-42* CREAT-1.7* SODIUM-140 POTASSIUM-4.8 CHLORIDE-112* TOTAL CO2-22 ANION GAP-11 [**2167-9-29**] 08:19PM ALT(SGPT)-115* AST(SGOT)-304* LD(LDH)-322* CK(CPK)-29* ALK PHOS-342* AMYLASE-15 TOT BILI-2.2* [**2167-9-29**] 08:19PM LIPASE-9 [**2167-9-29**] 08:19PM ALBUMIN-2.1* CALCIUM-7.5* PHOSPHATE-3.5 MAGNESIUM-1.9 [**2167-9-29**] 08:19PM WBC-4.1# RBC-3.00* HGB-10.1* HCT-31.2* MCV-104* MCH-33.7* MCHC-32.4 RDW-15.6* [**2167-9-29**] 08:19PM NEUTS-64 BANDS-0 LYMPHS-20 MONOS-15* EOS-1 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2167-9-29**] 08:19PM PLT COUNT-84* [**2167-9-29**] 08:19PM PT-14.0* PTT-37.3* INR(PT)-1.2* [**2167-10-6**] 04:30AM BLOOD WBC-3.9* RBC-3.46* Hgb-11.2* Hct-33.8* MCV-98 MCH-32.4* MCHC-33.2 RDW-16.8* Plt Ct-79* [**2167-10-6**] 04:30AM BLOOD Plt Ct-79* [**2167-10-6**] 04:30AM BLOOD PT-14.4* PTT-40.1* INR(PT)-1.3* [**2167-10-6**] 04:30AM BLOOD Glucose-182* UreaN-38* Creat-1.1 Na-139 K-4.7 Cl-111* HCO3-22 AnGap-11 [**2167-10-6**] 04:30AM BLOOD ALT-138* AST-361* AlkPhos-351* TotBili-2.8* [**2167-10-6**] 04:30AM BLOOD Calcium-7.2* Phos-3.5 Mg-2.0 [**2167-10-4**] 09:11PM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.018 [**2167-10-4**] 09:11PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-0.2 pH-5.0 Leuks-NEG [**2167-10-3**] 12:00PM ASCITES WBC-248* RBC-3889* Polys-1* Lymphs-78* Monos-18* Macroph-3* [**2167-10-3**] 12:00PM ASCITES TotPro-1.8 LD(LDH)-141 Albumin-1.1 [**2167-10-3**] 11:01 am PERITONEAL FLUID GRAM STAIN (Final [**2167-10-3**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2167-10-6**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. [**2167-10-3**] BLOOD CULTURE pending [**2167-10-1**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING INPATIENT [**2167-10-1**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING INPATIENT [**2167-10-1**] Immunology (CMV) CMV Viral Load-FINAL negative ___________________ Doppler U/S [**9-30**] IMPRESSION: 1) Patent hepatic vasculature with unremarkable Doppler waveforms. 2) Coarsened, heterogeneous appearance of the transplant liver, largely new from [**2167-8-6**], significance uncertain. 3) Large amount of ascites; a site was marked in the right lower quadrant for paracentesis. 4) Splenomegaly. TTE [**9-30**] Conclusions: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is preserved except for probable mild mid anteroseptal hypokinesis. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a small pericardial effusion. Compared with the prior study (images reviewed) of [**2167-9-25**], there is now a mobile echodense structure on the ventricular side of the mitral valve that may represent vegetation. Left ventricular systolic function is now minimally depressed. TEE [**10-1**]: Conclusions: 1. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is mildly depressed. 2. Mild (1+) mitral regurgitation is seen. 3. no vegetations Duplex U/S, [**10-7**]: CONCLUSION: Fully patent TIPS with main portal velocity of 39 cm per second and intra TIPS velocities ranging from 85-143 cm per second. Brief Hospital Course: A/P: 38 yo M s/p liver transplant in [**6-8**], h/o recurrent hepatitis C transferred from OSH for eval of elevated LFTs s/p MI. . #Elevated LFTs: chronically elevated since [**9-8**]. Initially s/p tx pt's AST/ALT were normal. However, in [**8-5**] were ranging 40s to low 100s. Acute bump occured in late [**Month (only) **]. AST/ALT have remained on the high 100s to 300s since that time. As this has been a chronic change post transplant, this may be [**2-5**] to known recurrence of hep C and/or hemachromatosis. Of note, the pt's interferon therapy was discontinued a few weeks ago, but the pt had not appeared to respond to the therapy. More concerning these changes may be associated with rejection. RUQ showed patent vasculature, no e/o cirrhosis. Pt. was continued on lactulose, and his LFTs remained stable throughout his stay. Given his recurrent ascites, he was given a paracentesis taking off 3L, which recurred over the next few days, so TIPS was placed by IR. Post, TIPs, bili rose slightly, but stabilized by discharge with edema and ascites stable. Post-TIPS U/S showed TIPS patency. . #STEMI: pt symptomatically stable, VSS on tele throughout his stay without chest pain or shortness of breath. A TTE was performed which showed minimally depressed LV function and an echodense structure on the mitral valve worrisome for endocarditis. Subsequent TEE ruled this out. He was coninued on BB/asa/ticlopidine with no statin, given concurrent liver dz. . #Hyperkalemia: pt. was hyperkalemic, peaking at 5.9 in the context of ARF. He was placed on a low potassium diet and kayexylate tid with resultant decrease in his potassium. He will require close follow up as outpt. to ensure that he does not develop hyperkalemia. . #ARF: early in year, Cr 0.7, but had been trending up. Baseline prior to previous admissions 1.0-1.1. Initially presented a few weeks back with ARF in setting of increased diuretics. Cr. had been trending down to 1.3 at previous discharge. Upon current discharge, Cr returned to baseline 1.1, after peaking at 2.0. ARF thought to be prerenal vs. hepatorenal vs. contrast during cath/ FK506 toxicity. His urine lytes were consistent with prerenal ARF, and gentle fluids and transfusion of 2U helped to return his Cr to baseline upon discharge. His FK506 dose was decreased, maintaining level of [**5-11**] at trough, given his concurrent renal failure and his diuretics were held throughout his stay. His Cr returned to his baseline by discharge. Diuretics were not restarted upon discharge . #Anemia: hct drop since last d/c to present admit (31 at admission). Likely [**2-5**] to bleeding at cath site. Had hct drop to 28 prior to therapeutic paracentesis, 24 immediately afterwards and received 2U pRBCs with correction back to 33. suspect that the hct of [**5-27**] have been measurement issue. Stools were guaiac negative, and hct was stable for the last few days of his stay. . #Ascites/Pleural effusions: Diminished breath sounds with known R pleural effusions, CXR stable. Pt. with increasing ascites as has not been receiving diuretics [**2-5**] renal status. received 3.5L therapeutic tap on [**10-3**], with TIPS done by IR on [**10-6**]. Post-TIPS doppler U/S showed patent TIPS prior to discharge. . #DM2: sugars continued to be high during admission, initially with sugars into the 300s. Given recent MI, pt.'s sugars were more aggressively controlled. At discharge he was taking 16U NPH (up from 10U on admit) with an increased ISS. Medications on Admission: Asa 325mg qd lopressor 12.5mg [**Hospital1 **] ticlopidine Colace 100mg qd Protonix 40mg qd Tacrolimus 1mg [**Hospital1 **] Remeron 15 mg qhs Bactrim DS one tab qd Sliding scale insulin Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain: take 1 tab SL for chest pain. [**Month (only) 116**] repeat after 5 minutes x 2. Disp:*30 Tablet, Sublingual(s)* Refills:*0* 6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 7. Ticlopidine 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 9. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for back pain. Disp:*30 Tablet(s)* Refills:*0* 10. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 11. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO QAM (once a day (in the morning)). Disp:*30 Capsule(s)* Refills:*2* 12. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Sixteen (16) units Subcutaneous twice a day: give 16U in AM and 16U in PM. Disp:*3 bottles* Refills:*2* 13. Insulin Regular Human 100 unit/mL Solution Sig: per sliding scale units Injection four times a day: Give number of units per sliding scale. Disp:*2 qs* Refills:*2* 14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 weeks. Disp:*27 Tablet(s)* Refills:*0* 15. Lactulose (for Encephalopathy) 10 g/15 mL Solution Sig: Thirty (30) mg PO three times a day: titrate lactulose to [**3-7**] bowel movements per day. Disp:*3 qs* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Recurrent Ascites s/p liver transplant Diabetes Mellitus ________________ s/p STEMI Recurrent Hepatitis C Discharge Condition: Good, amblating, afebrile tolerating POs, satting well on RA. Discharge Instructions: please seek medical attention should you develop any of the following symptoms: increased confusion, lethargy, chest or abdominal pain, shortness of breath, bleeding from your rectum, henatemesis, decreased urine output, or increased abdominal distension. Please adhere to a strict low potassium diet (<1g/day) for now until further notified by your PCP. Take all medications as prescribed, including your tacrolimus at 0.5mg qday. Take your lactulose regularly and titrate it to >3 bowel movements per day. Take your ciprofloxacin, the antibiotic for your urinary infection twice a day for two more weeks. it is important to complete this antibiotic course. Follow up with Dr. [**Last Name (STitle) 497**] at the appt. outlined below next week. HAve your labs drawn on monday prior to that appointment. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 497**] on Wed. [**10-14**] at 11:30AM to follow up your prograf levels, bilirubin, potassium and creatinine. In conjunction with your cardiologist dr. [**Last Name (STitle) **], he may decide to start you on a statin medication for your cholesterol as you have recently had an MI. Please also attend the following appointments: Cardiology: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3265**] [**2167-10-20**] 3:00 PM. [**Street Address(2) 58548**], [**Location (un) 8973**], MA [**Telephone/Fax (1) 58549**]. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2167-10-15**] 11:40

[ "410.11", "584.9", "996.82", "276.7", "414.01", "070.54", "285.1", "250.00", "E878.0", "V45.82", "789.5" ]

icd9cm

[ [ [] ] ]

[ "39.1", "54.91", "39.79", "88.72" ]

icd9pcs

[ [ [] ] ]

12619, 12625

6734, 10231

286, 399

12775, 12839

3060, 4791

13695, 14435

2525, 2538

10467, 12596

12646, 12754

10257, 10444

12863, 13672

2553, 3041

229, 248

428, 1744

4827, 6711

1766, 2403

2419, 2509

12,800

108,207

25531

Discharge summary

report

Admission Date: [**2128-8-2**] Discharge Date: [**2128-8-12**] Service: CARDIOTHORACIC Allergies: Codeine / Shellfish / Ciprofloxacin Attending:[**First Name3 (LF) 1283**] Chief Complaint: Exertional angina and dyspnea on exertion Major Surgical or Invasive Procedure: [**2128-8-2**] CABG x 3(LIMA->LAD, SVG->OM, SVG->PDA) History of Present Illness: This is an 85 year old female with prior history of non-hodgkins lymphoma, s/p Cytoxan in [**2117**] a with recurrence in [**2123**]. Follow up examinations have found a suspicious left lower lobe finding. Cardiac workup prior to left lower lobe resection led to cardiac catheterization which found severe three vessel disease with [**1-16**]+ mitral regurgitation. She now present for surgical intervention. Past Medical History: Non-hodgkins lymphoma - s/p Cytoxan in [**2117**] and [**2123**], History of Varicella Zoster with opthalmic lesions, History of Menieres Disease, GERD, Glaucoma, History of chronic sinusitis, s/p cataract surgery, s/p TAH and BSO, s/p appendectomy, s/p bilateral breast reduction Social History: Retired RN. Lives alone but family is close. Denies tobacco and ETOH. Family History: Daughter died of MI at age 49. Physical Exam: Vitals: BP 160-170/80-84, HR 82, Resp 20 General: Elderly female in no acute distress HEENT: Oropharynx benign Neck: Supple, no JVD, no carotid bruits Chest: Lungs CTA bilaterally Heart: Regular rate, [**1-18**] holosystolic murmur Abdomen: Soft, nontender, nondistended Ext: Warm, no edema Pulses: 2+ distally Neuro: Nonfocal Pertinent Results: [**2128-8-10**] 06:10AM BLOOD WBC-10.9 RBC-3.99* Hgb-12.6 Hct-37.9 MCV-95 MCH-31.5 MCHC-33.2 RDW-13.9 Plt Ct-330# [**2128-8-10**] 06:10AM BLOOD Glucose-76 UreaN-12 Creat-0.9 Na-141 K-3.5 Cl-104 HCO3-26 AnGap-15 [**2128-8-11**] 06:28AM BLOOD Phenyto-5.5* Brief Hospital Course: Mrs. [**Known lastname 63769**] was admitted and underwent three vessel coronary artery bypass grafting by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1290**]. Of note, intraoperative transesophageal echocardiogram evaluation showed only mild mitral regurgitation, so no repair/replacement was indicated. Following the operation, she was brought to the CSRU. On postoperative day one, she was noted to be largely unresponsive with left hemiparesis. Restlessness with body tremors were also noted. A stat MRI was notable for multiple abnormal foci consistent with systemic emboli. These were found in the right cerebellar, occipital and anterior parietal lobes. The neurology service was consulted and attributed these findings to cholesterol emboli. Due to seizure activity, Dilantin was started. Anticoagulation was not recommended. Over the next several days, her neurological status slowly improved. She was eventually extubated without incident. She went on to experience paroxysmal atrial fibrillation which was initially treated with intravenous Amiodarone. She concomitantly had loose stools which were C. diff negative. Her clinical status stablized and she transferred to the step down unit on postoperative day six. She remained mostly in a normal sinus rhythm and transitioned to oral Amiodarone which will need to continue for three months postop. She tolerated beta blockade which was slowly advanced as tolerated. She worked daily with physical and occupational therapy. Her neurological status continued to improve. Acyclovir was eventually increased from her maintenance dose for a herpes zoster breakout on her right upper back. In addition, she was empirically started on Flagyl for persistent diarrhea(despite negative C. diff cultures), however she developed an additional rash on her buttocks after the first dose of flagyl, so the flagyl was discontinued. She developed a urinary tract infection for which she was started on Bactrim. A foley catheter was inserted given her mutiple episodes of incontinence that were adding to skin irritation. On insertion she was found to be retaining 1400 cc of urine, so the foley catheter was left in. She continued to make clinical improvements and was cleared for discharge to rehab on postoperative day 10. Medications on Admission: Acyclovir 800 qd, Nexium 40 qd, Lipitor 40 qd, Coreg 6.25 [**Hospital1 **], Asa 81 qd, Timolol eye gtts, Calcium, MVI, Vitamin C Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for fever or pain. Tablet(s) 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Tablet(s) 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day for 7 days: 400 mg PO daily for 1 week, then decrease to 200 mg PO daily. Tablet(s) 7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. Acyclovir 800 mg Tablet Sig: 0.5 Tablet PO 5X/D (5 times a day) for 5 days: Then decrease dose to 800 mg PO daily. 9. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day. 10. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO BID (2 times a day). 11. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: Coronary artery disease - s/p CABG Varicella Zoster Postop CVA Postop Atrial fibrillation Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. Do not lift more than 10 lbs. for 2 months. Do not drive for 4 weeks. Call our office for sternal drainage, temp>101.5 No lotions, creams, or powders on wounds. Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) 6051**] for 1-2 weeks. Make an appointment with Dr. [**Last Name (STitle) 1290**] for 4 weeks. Make an appointment with Dr. [**Last Name (STitle) 1693**] in neurology clinic for 4 weeks. Completed by:[**2128-8-12**]

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icd9cm

[ [ [] ] ]

[ "36.15", "89.60", "36.12", "99.04", "39.61", "96.6" ]

icd9pcs

[ [ [] ] ]

5560, 5634

1864, 4158

290, 346

5768, 5776

1586, 1841

6031, 6300

1191, 1223

4337, 5537

5655, 5747

4184, 4314

5800, 6008

1238, 1567

209, 252

374, 784

806, 1088

1104, 1175

16,216

117,106

25160

Discharge summary

report

Admission Date: [**2174-3-12**] Discharge Date: [**2174-4-15**] Date of Birth: [**2096-8-7**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 398**] Chief Complaint: hypoxic respiratory failure hypotension Major Surgical or Invasive Procedure: Endotracheal intubation Subclavian central line Thoracostomy tube placement History of Present Illness: 77 yo M with dementia, schizophrenia, HTN, DM presents to ED after removing his PEG tube. When he initially arrived from [**Location **] he was doing well. Enroute his vital signs were T 97.9 BP 128/70 HR 72 RR 20 O2sats 95% RA. He was sent to the ED for replacement of his PEG tube. In the ED he vomited and developed hypotension and hypoxia. His sats dropped into the 80's on room air and BP into the 80's. CXR then showed RLL/RML infiltrate. He was found to have significant bandemia and then was treated as code sepsis. He was given 3 L of NS with good response in his BP. He was continued on NRB with appropriate bump in oxygen level. He was also given Zosyn/Vanco for antibiotic coverage. He is only able to respond with yes or no answers. At this time he denies ant chest pain or abd pain. Otherwise unable to obtain history from this gentleman. I spoke to both his guardian and son who were not aware he was brought to the hospital. They said at baseline he is only able to give yes/no answers. Past Medical History: Dementia Paranoid Schizophrenia DM2 Prostate Ca Hypertension GERD Angina Bipolar d/o COPD Hearing impaired Social History: Patient lives in [**Location **] Manor nursing [**Last Name (un) **], wheelchair bound. He has one son who lives in the area. He smokes 10 cigarettes/day. Baseline ADL/IADLs unknown. - Guardian has been appointed by family in past given difficulties with relationship between son and patient re: forced psychiatric hospitalizations Family History: Noncontributory Physical Exam: T 94 BP 89/58 HR 92 RR 24 O2sats 93% NRB CVP 3 Gen: Agitated gentleman, who is tachypneic. Responds to yes/no questions but otherwise non-communitative HEENT: PERRL, dry mm, anicteric Neck: No obvious LAD Lungs: Course rhonchi bilaterally Heart: Tachy, difficult to appreciate any murmurs given lungs sounds Abd: Soft, NT, ND, hypoactive bowel sounds. Site of PEG tube with pink tissue no obvious infection Ext: No edema, 1+ DP/PT's Neuro: Only answers yes/no questions. Moving all 4 extremities. Unable to otherwise assess due to lack of cooperation. Pertinent Results: From [**Location (un) **] [**3-11**] WBC 5.2 Hct 32 plts 212 Na 138 K 4.9 Cl 101 CO2 31 BUN/Cr 45/1.1 ALT 31 AST 27 . CXR #1- Continued diffuse mild fluffy opacity in the right lung with interval development of a more focal area of consolidation in the right mid lung and interval improvement in aeration in the right lower lung. There is overall improved appearance of the left retrocardiac region with a residual streaky opacity. . CXR #2- Left subclavian in place in SVC. . ECG: NSR at 81, nl axis, nl intervals, Qwave in inferior leads, no ther acute/ischemic ST/Twave changes Brief Hospital Course: 77M schizophrenia, advanced dementia, initially presented for PEG dislodgement, subsequently complicated by sepsis, pneumothorax complicating central line placement, hypoxic respiratory failure, ventilator associated pneumonia, ultimately leading to withdrawal of care and expiration. Briefly, the pt was initially brought to [**Hospital1 18**] for replacement of feeding tube, however, his course was complicated by shock thought to be [**1-21**] sepsis. Pt underwent central line placement which was complicated by pneumothorax requiring thoracostomy tube placement. In addition, pt's course was also complicated by hypoxic respiratory failure requiring intubation, ultimately further complicated by ventilator associated pneumonia. Multiple attempts to wean towards extubation failed as a result of 1) asystolic arrest, 2) tachypnea to 40s-50s, 3) agitation and discomfort. Given extended endotracheal intubation time, discussion was had with guardian who felt that this was not according to pt's wishes. In addition, guardian refused further invasive procedures as pt's clinical status continued to decline. However, guardian felt uncomfortable initially with moving towards comfort measures due to an isolated statement made by the pt in the distant past. Nevertheless, following a court hearing, it was decided by all parties including pt's sons that pt would not have wanted continued aggressive care given his extremely poor quality of life and prognosis. Pt was made comfort measures only and extubated. He expired [**2174-4-15**]. Medications on Admission: 1. Aspirin 81 mg qday 2. Atenolol 12.5 mg qday 3. Rosiglitazone 2 mg qday 4. Ferrous Sulfate 220 mg/5mL Elixir Sig: 7.5 ml PO qday 5. Amlodipine 5 mg qday 6. Clopidogrel 75 mg qday 7. Haloperidol Decanoate 25mg IM Intramuscular Every other Wed. 8. Olanzapine 5 mg qday 9. Zantac 150 mg [**Hospital1 **] 10. Benztropine 1 mg TID 11. Haloperidol 1 mg [**Hospital1 **]:PRN 12. Ipratropium Bromide 0.02 % Q6hrs:prn 13. Albuterol Sulfate 0.083 % Q6hrs:prn 14. RISS Discharge Disposition: Expired Discharge Diagnosis: Septic Shock Pneumothorax Severe dementia Schizophrenia Hypoxic respiratory failure Probable Community acquired pneumonia Ventilator associated pneumonia Discharge Condition: Expired

[ "784.7", "287.5", "403.91", "276.0", "496", "584.5", "427.5", "507.0", "512.1", "250.00", "995.92", "276.52", "038.9", "518.81", "295.60", "293.0" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.6", "21.01", "96.72", "34.04", "99.04", "33.24", "96.05", "96.04" ]

icd9pcs

[ [ [] ] ]

5249, 5258

3189, 4739

353, 430

5455, 5465

2583, 3166

1974, 1991

5279, 5434

4765, 5226

2006, 2564

274, 315

458, 1477

1499, 1608

1624, 1958

16,179

111,762

24817

Discharge summary

report

Admission Date: [**2118-9-29**] Discharge Date: [**2118-10-6**] Date of Birth: [**2055-1-4**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 6180**] Chief Complaint: Fever and Hypotension Major Surgical or Invasive Procedure: 1. None History of Present Illness: Oncology History: Patient was originally diagnosed with Breast cancer in [**2113**]. At time of diagnosis she had a T1N0M0, ER+, PR-, her-2/NEU- lesion treated with lumpectomy and XRT. The patient had received Tamoxifen since [**2113-12-25**] without additional adjuvant chemotherapy and without known progression of disease to date as per patient's report. The patient's Tamoxifen was discontinued upon diagnosis of second primary malignancy. In late [**2117-11-24**], the patient presented with abdominal pain. A CT at that time revealed a mass in the pancreas w/extension to the Left adrenal and kidney with biopsy revealing mucinous adenocarcinoma. The patient is now s/p distal pancreatectomy, splenectomy, L adrenalectomy, L nephrectomy, and omentectomy for this lesion. She began treatment with XRT/xeloda and was then discovered to have metastatic disease for which gemcitabine/cisplatin were initiated. Most recently the patient has been receiving irinotecan and xeloda in [**2118-8-25**] in the setting of rising CA19-9 which has been followed by good response with a drop in her CA19-9 from 1549 to 439. Her last dose of Irinotecan was [**9-14**]. The patient was nearing completion of her second cycle of xeloda with her last dose taken on Tuesday [**9-27**]. She was to complete her cycle Wednesday night but was told to hold further doses given her symptoms for which she presented. Her next scheduled cycle was to begin Wednesday, [**2118-10-5**], but may be postponed given current symptoms. . The patient was reported to be in her USOH until Sunday afternoon when she developed onset of diarrhea. She was visiting friends in [**Name (NI) **] at the time and previously reported she felt well. She reports small hiking but denies insect bites, tick bites, rashes, drinking stream or [**Doctor Last Name **] water. The patient continued to have diarrhea and called her Oncologist on Tuesday for her ongoing symptoms. She was instructed at this time to hold her xeloda. The patient reported additionally decreased p.o. intake over the prior 48h. On the evening of presentation, the patient went to a hotel room to lie down. The patient was found by her partner to be somnolent. She was arousable but reported to be sleepy and unable to verbalize response. The patient was taken to [**Hospital1 18**] by taxi, with assistance. On the way to the hospital, she reports one episode of non-bloody, non-bilous vomiting. She denied on admission any ongoing fevers/chills, rashes, headaches, visual changes, chest pain, sob, cough, or abdominal pain. She denied any sick contacts. . In ED her vitals were as follows: 102.1, 105, 79/52, 18, 96% RA. Patient was noted to have altered MS, was confused and somnolent. She received cefepime 2g, vancomycin 1g, hydrocortisone 100mg, and levofloxacin 500mg iv x1. The patient's elevated INR was reversed w/ 1 U FFP for possible LP. However, the patient's MS improved w/3L NS with improvement in her blood pressure and an LP was not performed. . Interval History: Since admission to the MICU, the patient was noted to have episode of hypotension with SBP's in the 60's to 70's for which she received 2 500cc NS boluses. Patient continued to be hypotensive overnight and was additionally bolused another 500CC NS as well as 500CC LR. Patient was noted to have ongoing diarrhea and one episode of non-bilious, non-bloody vomiting overnight as well with dinner. She tolerated breakfast on the am of trasnfer to floor, but reports ongoing fatigue. She additionally reports some F/C this am but denies any additional N/V, abdominal pain. She denies any HA, neck stiffness, photophobia. She reports her mental clarity to be much improved since admission. . Allergies: Sulfas - patient reports adverse reaction to sulfa containing eye drops previously Past Medical History: PMHx: - Breast Ca, T1N0M0, ER+, PR-, her-2/NEU-, s/p lumpectomy and XRT, on Tamoxifen since [**12-25**], which was stopped with initiation of chemotherapy - Pancreatic Ca, as above - HTN - DVT - [**7-29**] - diagnosed asymptomatically by abd CT - Migraines Social History: Patient is currently retired. Previously employed as a superintendent for school district in [**State 4565**]. Patient denies etoh/tobacco/ivdu. Patient with male partner of 25 years, previously married with 2 children from previous marriage. Travel history as above to NH recently. Previously received her care with [**Doctor Last Name 21721**] in CA, referred to Dr. [**First Name (STitle) **] for 2nd opinion, the reason for which she is currently in [**Location (un) 86**]. Family History: Mother deceased brain tumor age 54 Father deceased [**Name2 (NI) 499**] ca age 64 Physical Exam: Physical Exam Vitals: Tc:97.7___ Tmx:101 ([**2118-9-28**] 21:00)____ BP:120/59___ HR:94_____ RR:15____ O2 Sat: 99% on RA Rectal Tube: 2835cc over last 24 hours . Gen: Patient is a middle aged female, appears chronically ill but not greatly malnourished, in NAD HEENT: NCAT, EOMI, PERRL. OP: MMM, no lesions Neck: No LAD, No JVD. Supple Chest: Mildy decreased BS at left base, otherwise CTA A+P Cor: mildly tachycardic, no M/R/G Abd: firm but not rigid, mild/mod tenderness diffusely but greater in LLQ without rebound or guarding. +NABS with occasional borborygymi Extrem: No C/C/E Access: left chest port, + Foley, + rectal tube Pertinent Results: Admission Labs: [**2118-9-29**]: . [**2118-9-29**] 01:25AM PLT COUNT-271 [**2118-9-29**] 01:25AM PT-21.8* PTT-27.6 INR(PT)-3.4 [**2118-9-29**] 01:25AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-2+ MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL TARGET-OCCASIONAL SCHISTOCY-OCCASIONAL BURR-OCCASIONAL TEARDROP-OCCASIONAL HOW-JOL-OCCASIONAL [**2118-9-29**] 01:25AM NEUTS-33* BANDS-8* LYMPHS-28 MONOS-24* EOS-2 BASOS-0 ATYPS-1* METAS-2* MYELOS-0 NUC RBCS-2* OTHER-2* [**2118-9-29**] 01:25AM WBC-1.7* RBC-3.37* HGB-11.5* HCT-33.8* MCV-100* MCH-34.0* MCHC-33.9 RDW-20.1* [**2118-9-29**] 01:25AM ALBUMIN-3.8 CALCIUM-8.5 PHOSPHATE-1.4* MAGNESIUM-1.4* [**2118-9-29**] 01:25AM LIPASE-9 [**2118-9-29**] 01:25AM ALT(SGPT)-10 AST(SGOT)-13 ALK PHOS-68 AMYLASE-15 TOT BILI-1.7* [**2118-9-29**] 01:25AM GLUCOSE-155* UREA N-19 CREAT-1.3* SODIUM-130* POTASSIUM-3.4 CHLORIDE-98 TOTAL CO2-20* ANION GAP-15 [**2118-9-29**] 01:43AM LACTATE-1.8 [**2118-9-29**] 02:20AM URINE GRANULAR-[**6-3**]* HYALINE-[**2-26**]* [**2118-9-29**] 02:20AM URINE RBC-[**2-26**]* WBC-[**2-26**] BACTERIA-FEW YEAST-NONE EPI-[**2-26**] [**2118-9-29**] 02:20AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-NEG [**2118-9-29**] 02:20AM URINE TYPE-RANDOM COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.026 [**2118-9-29**] 08:14AM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE EPI-<1 [**2118-9-29**] 08:14AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2118-9-29**] 08:14AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2118-9-29**] 08:14AM PT-24.6* PTT-29.1 INR(PT)-4.4 [**2118-9-29**] 08:14AM PLT SMR-NORMAL PLT COUNT-241 [**2118-9-29**] 08:14AM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-2+ MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL SCHISTOCY-1+ BURR-OCCASIONAL HOW-JOL-1+ [**2118-9-29**] 08:14AM NEUTS-39* BANDS-14* LYMPHS-25 MONOS-17* EOS-0 BASOS-0 ATYPS-3* METAS-2* MYELOS-0 NUC RBCS-2* [**2118-9-29**] 08:14AM WBC-1.9* RBC-2.90* HGB-9.5* HCT-28.8* MCV-100* MCH-32.7* MCHC-32.8 RDW-19.7* [**2118-9-29**] 08:14AM CALCIUM-7.6* PHOSPHATE-1.8* MAGNESIUM-1.9 [**2118-9-29**] 08:14AM GLUCOSE-169* UREA N-16 CREAT-0.8 SODIUM-135 POTASSIUM-3.3 CHLORIDE-109* TOTAL CO2-16* ANION GAP-13 Additional Pertinent Labs/Studies: . [**2118-10-4**] ABG - pO2-92 pCO2-22* pH-7.40 calHCO3-14* Base XS--8 [**2118-9-29**] Venous Lactate-1.8 [**2118-10-2**] Venous Lactate-1.2 [**2118-10-4**] Venous Lactate-1.4 . Trends: WBC: 8.9 <- 5.1 <- 4.9 <- 3.2 <- 1.5 <- 2.4 <- 1.9 <- 1.7 ANC: 2950 ([**2118-10-4**]) <- 1369 <- 1290 <- 590 ([**2118-10-1**]) HCT: 26.2 <- 27.4 <- 29.6 <- 31.0 <- 25.8 <- 26.2 <- 28.8 <- 33.8 INR: 6.3 <- 4.8 <- 4.2 <- 6.0 <- 3.1 <- 4.2 <- 4.4 <- 3.4 . Microbiology: [**2118-9-29**] Blood cx - No growth [**2118-10-1**] Blood cx - No growth [**2118-10-2**] Blood cx - No growth [**2118-10-3**] Blood cx - No growth . [**2118-9-29**] Stool cx - No salmonella, shigella, or campylobacter found. FEW CHARCOT-[**Location (un) **] CRYSTALS PRESENT. FEW POLYMORPHONUCLEAR LEUKOCYTES. NO OVA AND PARASITES SEEN. C. Diff negative [**2118-9-30**] Stool cx - MODERATE POLYMORPHONUCLEAR LEUKOCYTES. NO OVA AND PARASITES SEEN. [**2118-10-1**]: Stool: Negative for C. Diff [**2118-10-2**]: Stool: Negative for C. Diff [**2118-10-4**]: Stool cxs - No growth to date [**2118-10-5**]: Stool cxs - No groeth to date . [**2118-9-29**]: Urine cx - No growth [**2118-10-3**]: urine cx - No growth . Radiology: [**2118-9-29**]: Chest Pa/Lat: CHEST AP: Surgical clips are visualized over the right lateral upper chest. The right costophrenic angle has been excluded from the study. A left-sided Port-A-Cath is visualized with its tip in the proximal SVC. The heart size, mediastinal and hilar contours are unremarkable. The lungs are clear. There are no pleural effusions. The pulmonary vasculature is normal. IMPRESSION: No acute cardiopulmonary process. . [**2118-9-29**]: CT Head: FINDINGS: There is no intracranial mass effect, hydrocephalus, shift of normally midline structures or major vascular territorial infarction. The density values of the brain parenchyma are within normal limits. Surrounding soft tissue and osseous structures are unremarkable. IMPRESSION: No mass effect or hemorrhage. . [**2118-9-30**]: Port-a-cath Flow Study: 1. Flow study through the port was suggestive of either a fibrin sheath, or less likely, a small catheter leak. 2. Good flow was obtained on aspiration of the port at the end of the examination. . [**2118-10-4**]: CT Abdomen + Pelvis: The lung bases are clear. Patient has prior distal pancreatectomy, splenectomy and radical left nephrectomy. In the left upper quadrant posteriorly, there is ill-defined area of soft tissue density located just posterior to the surgical clips to the left and slightly inferior to the celiac artery axis origin. This area of tissue density measures up to 2.8 cm AP x 1.6 cm transverse. This could represent postoperative thickening but correlation with any prior imaging is advised to exclude the possibility of local recurrence. The remaining portion of the proximal pancreatic body, neck and head appear normal. No intra or extrahepatic biliary dilatation. The liver is normal in size. Multiple sub cm ovoid hypoattenuating areas mainly in the left lobe ,these may represent small cysts but are too small to characterise on CT and should be correlated with prior imaging or interval follow up as small hypovascular metastases cannot be excluded. The gallbladder and right adrenal gland are normal. The remaining right kidney is normal in size, 1.5 cm fluid attenuating cyst in the upper pole cortex. The abdominal aorta is normal in caliber. No intra-abdominal ascites. In the lateral mid abdominal mesentry, there is a 9 mm area of nodularity just anterior to and separate from the descending [**Month/Day/Year 499**] (series 3 image 48) and a 5 mm area of nodularity more superiorly (series 3, image 43). There is no abnormal large or small bowel loop dilatation. Many of the small bowel loops are mildly prominent, measuring up to 3 cm in diameter and the [**Month/Day/Year 499**] is fluid filled throughout which may be due to a current episode of enteritis. . Pelvis: A small 2 cm fluid attenuating locule in the posterior inferior pelvis. The uterus is normal in size. No pelvic mass lesions or lymphadenopathy. No concerning bone lesions demonstrated on bone window setting. . CONCLUSION: 1)Fluid filled non-thickened non-distended [**Month/Day/Year 499**] .This may be related to current episode of enteritis depending on current clinical correlation. 2) No definite evidence of metastatic disease. There are a number of findings which require correlation with prior postoperative imaging if available or otherwise interval follow.These include an ill- defined area of thickening of the posterior operative site in the left upper quadrant, two sub cm areas of nodularity in the left abdominal mesentery and sub cm hypodensities mainly in the left lobe of the liver. Discharge Labs: . [**2118-10-6**] 07:25AM BLOOD WBC-5.8 RBC-2.90* Hgb-9.5* Hct-28.9* MCV-100* MCH-32.6* MCHC-32.7 RDW-20.8* Plt Ct-458* [**2118-10-6**] 07:25AM BLOOD Neuts-46* Bands-6* Lymphs-16* Monos-23* Eos-2 Baso-0 Atyps-0 Metas-5* Myelos-2* NRBC-41* [**2118-10-6**] 07:25AM BLOOD Hypochr-OCCASIONAL Anisocy-2+ Poiklo-2+ Macrocy-2+ Microcy-NORMAL Polychr-OCCASIONAL Target-OCCASIONAL Schisto-1+ How-Jol-OCCASIONAL Acantho-2+ [**2118-10-6**] 07:25AM BLOOD Fibrinogen - Pending [**2118-10-6**] 07:25AM BLOOD Glucose-98 UreaN-3* Creat-0.7 Na-134 K-3.8 Cl-108 HCO3-15* AnGap-15 [**2118-10-6**] 07:25AM BLOOD Calcium-7.5* Phos-2.0* Mg-2.0 Brief Hospital Course: Patient is a 63 year old female with pancreatic Cancer, recently receiving treatment with her 2nd cycle of xeloda and irinotecan who presents to hospital with fever, hypotension, and altered mental status. . #. Hypotension/Diarrhea - On presentation, the patient's presentation was assessed to meet criteria for SIRS with a septic like picture on presentation. The patient was febrile, hypotensive with altered mental status in the setting of an ANC of 590. While in the ED, the patient had cultures drawn, and was initially treated with Cefepime, Vancomycin, Levofloxacin, and Hydrocortisone. Upon transfer to the MICU, the patient was maintained on therapy with cefepime and vancomycin for treatment of febrile neutropenia. The patient had received 3L NS hydration initially and was given FFP with intention to reverse the patient's elevated INR (patient on coumadin for DVT) for possible LP. However, after hydration the patient's mental status was noted to significantly improve and an LP was not attempted at this time. The patient had a lactate of 1.8 with good response in blood pressure with hydration. Overnight in the ICU on the day of admission the patient had two episodes of hypotension, with systolics in the 60's to 70's range necessitating 2NS and 2LR boluses, again with good response. It was the impression of the treating attending oncologist that the patient's presentation and diarrhea was consistent with chemotherapy induced diarrhea rather than an infectious diarrhea. For this reason, the patient was started on anti-motility agents including lomotil and questran. However, these agents had little effect initially as the patient continued to have high volume diarrhea. In the 24 hours after admission, the patient was assessed to have a GI output of about 2800cc. The patient upon transfer to the floor had a rectal tube and foley in place. However, given that the patient had an ANC < 1000 at that time, the decision was made that invasive catheters should likely be removed. As the patient has been largely incontinent of stool, it has been difficult objectively to quantify exact GI output. The patient reported that over the course of her hospital stay, she has not felt that there has been great improvement to date in the quantity of stool produced ,although she has reported increased continence. However, the day prior to discharge to receiving hospital, the patient endorses two to three liquid green bowel movements that she reports she was not even aware of until they had passed. The patient has not required fluid bolusing since trasnfer to the floor, but has been receiving constant IV hydration with NS with 20mEq KCl requiring electrolyte repletion q12hr. The patient continues to have a significant non-gap acidosis secondary to diarrhea with serum bicarbonate levels of 11 to 14 over the last three days prior to discharge. However, an ABG performed on [**2118-10-4**] as follows: pO2-92 pCO2-22* pH-7.40 calHCO3-14* Base XS--8 revealed that the patient is not acidemic and adequately compensating for her bicarbonate loss. As the patient has had a normal serum pH she has not been receiving oral or IV bicarbonate but continues to receive hydration and volume repletion with NS at 125 to 175 cc/hr. As the patient continues to have significant GI output, she will require ongoing hydration and additionally should receive electrolyte panels with repletion q12hrs until no longer needed. In an attempt to decrease the patient's GI output, in addition to lomotil and questran which were initiated on admission, the patient has serially been given Kaopectate and the day prior to discharge was started on Octreotide and Metamucil to help bulk her very liquidy green stool. The patient has now been afebrile > 48 hours, and is currently receiving still cefepime 2gm IV q8hr, now Day 8 (started [**2118-9-29**]) and Flagyl which was initiated in place of Vancomycin (now Day 4, initiated [**2118-10-3**]). As the patient has been afebrile for > 48 hours consideration may be made towards discontinuing these medications but will be left to the discretion of the receiving hospital. The patient has had multiple stool and blood cultures sent during this admission (see pertinent results) which have demonstrated mild to moderate Leukocytes in the stool but cultures, O+P and C. Diff have been negative multiple times. As the patient reported some mild LLQ tenderness a CT of the abdomen was obtained to detect any occult abscess or other infectious process. CT results demonstrated soft tissue density a the site of the patient's known prior pancreatic mass but revealed no abnormal large or small bowel loop dilatation. CT demonstrated many of the small bowel loops to be mildly prominent, measuring up to 3 cm in diameter and revealed the [**Month/Day/Year 499**] to be fluid filled throughout, thought to be related to the patient's ongoing enteritis. In the pelvis CT additionally revealed a small 2 cm fluid attenuating locule in the posterior inferior pelvis. The patient is now being transferred to receiving hospital for ongoing management of patient's diarrhea and electroylte abnormalities. . #. DVT - The patient on admission was being treated with 2.5mg po qhs of coumadin qhs for known DVT diagnosed in 08-[**2117**]. The patient's INR on presentation was 3.4 which was partially reversed with 1U FFP in anticipation of possible LP. However, as above, given reversal of somnolence with volume rescucitation alone, an LP was not performed. The patient's coumadin was held throughout her stay as she continued to have a supratherapeutic INR without coumadin, thought likely to be secondary to her poor PO intake as well as extinguishing gut flora with antibiotics. The patient's INR was 6.0 on [**2118-10-2**] for which she received 2.5mg PO Vitamin K with good effect, and reduction of her INR to 4.2 the next day. The patient in error however was given a dose of 2.5mg coumadin x1 despite a holding order the following day. Her INR was again elevated to 6.3 the day prior to discharge. As the patient's INR was greater than 5, but without any evidence of any ongoing bleeding, the patient's coumadin continues to be held and an addiitional 2.5mg PO Vitamin K was administered. The patient's INR the am of discharge was found to be 7.0. The patient was given 5mg Vitamin K SC this am with concern that previous PO doses are not being well absorbed given the patients rapid GI transit time. Of additional note, the patient has been noted previously and again this am to have occasional schistocytes on peripheral blood smear. A fibrinogen level checked previously was 543 on [**2118-10-3**] and repeat fibrinogen am of discharge, [**2118-10-6**] was 418, not consistent with DIC. The patient should continue to have her INR carefully monitored at the receiving hospital with consideration towards additional Vitamin K SC/IV for reversal of INR > 5.0 or FFP with any signs of bleeding. . #. Access - In the ICU on admission, the patient's port was noted to be not functioning properly. A flow study was performed which demonstrated fluid flow proximal to the catheter tip suggestive likely of a fibrin sheath vs. a possible catheter leak. The port was used once on the floor prior to the results of the flow study being revealed and the patient reported some burning at the port entry site with the infusion of some fluids with potassium. Therefore, the port has not been used again during this hospital course and the port should not be used any longer. The patient's port likely will have to be removed given it is not functional. Plans were to be made to have the port removed now that the patient has been afebrile > 48hours and hemodynamically stable. Upon transfer to the receiving hospital, plans will need to continue to be initiated towards port removal or alternatively attempts could be made to have an attempted snare by interventional radiology for removal of a fibrin sheath if present. The patient is aware the port is not functional and aware it will likely need to be removed. . #. Pancreatic Ca: As discussed in H+P, the patient is currently s/p distal pancreatectomy, left adrenal/nephrectomy, ometectomy treated additionally with XRT and Xeloda, follwed by gemcitabine/cisplatin, and most recently treated with xeloda/irinotecan s/p two 3-week cycles. The patient was travelling to [**Location (un) 86**] for second opinion regarding treatment options when she developed severe diarrhea and hypotension. Given the patient's apparent chemo toxicity, chemo was held currently until patient is medically stable to continue. Impression of Oncologist seeing patient at [**Hospital1 18**] is that of the two agents, the Xeloda may be more responsible for the treatment response to date and the irinotecan her current GI toxicity. Given this, considerations towards additional chemo included Xeloda alone, possibly with the addition of low dose irinotecan if tumor markers began to rise again. Alternatively, patient could additioanlly receive FOLFOX or taxotere as well. The patient is being discharged to receiving hospital currently with plans towards continuing management of diarrhea, electrolyte abnormalities as outlined above and will continue treatment planning with regards to her pancreatic Ca with her oncologist. . #. HTN - Given patient's admission for hypotension, her outpatient regimen of propranolol was held during her hospital course. Upon resolution of large GI output and decreased need for IV volume sresuscitation, consideration could be made towards reinitiating patient's antihypertesnive regimen. . #. FEN- patient was kept on a low fat, lactose free BRAT diet with supplemental pancrease given. Patient's PO intake was not optimal during hospital course, but continues to improve with resolution of her symptoms. . #. Communication: Patient's significant other, [**Name (NI) **] may be reached at [**Telephone/Fax (1) 62493**].; He is very supportive and intimately involved in the patient's care. Medications on Admission: Medications - outpatient: pancrease 1 capsule orally before meals coumadin 5 mg po qd xanax 0.25 mg [**12-26**] tab po qid prn anxiety propranolol 40 mg po bid prochlorperazine 10 mg po qid prn nausea capecitabine (xeloda) 500 mg 4 tabs qam, 3 tabs qpm x 14 days. loperamide 2 mg po prn diarrhea tylenol prn erythropoetin 20,000u sq qwk. . Meds on transfer to floor from MICU: RISS Lorazepam 0.5-1 mg IV Q4H:PRN Acetaminophen 325-650 mg PO Q4-6H:PRN Pangestyme-EC 2 CAP PO TID W/MEALS Cefepime 2 gm IV Q12H, Day 2 Cholestyramine 4 gm PO BID Vancomycin HCl 1000 mg IV Q 12H D 2 Epoetin Alfa 8000 UNIT SC Discharge Medications: 1. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 3. Epoetin Alfa 4,000 unit/mL Solution Sig: 8000 (8000) unit Injection QMOWEFR (Monday -Wednesday-Friday). 4. Cholestyramine-Sucrose 4 g Packet Sig: One (1) Packet PO BID (2 times a day). 5. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: Two (2) Packet PO BID (2 times a day). 6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q6 (). 7. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 8. Bismuth Subsalicylate 262 mg Tablet, Chewable Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for diarrhea. 9. Psyllium Packet Sig: One (1) Packet PO TID (3 times a day). 10. Lorazepam 2 mg/mL Syringe Sig: One (1) mg Injection Q4H (every 4 hours) as needed. 11. Cefepime 2 g Piggyback Sig: Two (2) grams Intravenous Q8H (every 8 hours). 12. Octreotide Acetate 50 mcg/mL Solution Sig: Fifty (50) mcg Injection Q8H (every 8 hours). Discharge Disposition: Extended Care Discharge Diagnosis: Primary: SIRS Hypotension Chemotherapy related diarrhea Pancreatic Cancer . Secondary: Breast Cancer Hypertension DVT - [**7-/2118**] Migraines Discharge Condition: 1. Fair. Patient is being transferred to receiving hospital in [**State 4565**] for ongoing management. Patient is currently afebrile, normotensive, with ongoing large liquid bowel movements and requiring frequent electrolyte repletion. Discharge Instructions: 1. Please take all medications as prescribed unless instructed otherwise by receiving hospital . 2. Please continue outpatient follow up with your oncologist in [**State 4565**] and continue to contact Dr. [**First Name (STitle) **] at [**Hospital1 18**] as desired for ongoing treatment options. . 3. Upon discharge from receiving hosptial, please return to hospital for any signs or symptoms of increasing diarrhea, dizziness, fever, intractable nausea/vomiting, bleeding or any other concerning symptoms. Followup Instructions: 1. Please continue treatment under the supervision and care of receiving hospital in [**State 4565**] . 2. Please call your oncologist upon discharge for ongoing care and treatment plans

[ "V10.3", "V58.61", "157.8", "276.2", "288.0", "E933.1", "401.9", "787.91", "276.52", "038.9", "995.93" ]

icd9cm

[ [ [] ] ]

[ "99.07" ]

icd9pcs

[ [ [] ] ]

25254, 25269

13456, 23448

302, 312

25457, 25695

5676, 5676

26251, 26441

4926, 5009

24101, 25231

25290, 25436

23474, 24078

25719, 26228

12810, 13433

5024, 5657

241, 264

340, 4135

9714, 12794

5692, 9705

4157, 4415

4431, 4910

30,437

181,115

33346

Discharge summary

report

Admission Date: [**2180-2-15**] Discharge Date: [**2180-3-23**] Date of Birth: [**2135-9-27**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5547**] Chief Complaint: Transfer from [**Hospital 1263**] Hospital with abdominal pain, nausea/vomiting, acute hepatitis, acute pancreatitis, and acute renal failure. Major Surgical or Invasive Procedure: [**2-17**]: Examination under anesthesia, exploratory laparotomy, resection of abdominal mass, supracervical hysterectomy, bilateral salpingo-oophorectomy, small bowel resection, sigmoid colectomy with descending colostomy, abdominal packing with Dr. [**First Name (STitle) 1022**] [**2-19**]: Exploratory laparotomy, removal of abdominal packing, control of mesenteric bleeding, maturation of end-descending colostomy with Drs. [**First Name (STitle) 1022**] and [**Name5 (PTitle) 1924**] [**2-28**]: Exploratory laparotomy with drainage of peritoneal abscesses, small bowel resection and 2-layer hand-sewn side-to-side anastomosis with Drs. [**First Name (STitle) 1022**] and [**Name5 (PTitle) 1924**] [**3-2**]: Exploratory laparotomy and abdominal washout with placement of [**Location (un) 5701**] bag to bridge fascial defect with Dr. [**Last Name (STitle) 1924**] [**3-5**]: Exploratory laparotomy and abdominal washout, wedge biopsy of left lobe of liver, placement of temporary polypropylene mesh to fascial defect with Dr. [**Last Name (STitle) 1924**] [**3-9**]: Reopening of recent laparotomy and abdominal washout with complicated delayed closure of abdominal fascia with placement of AlloDerm mesh measuring 128 cm2 with Dr. [**Last Name (STitle) 1924**] History of Present Illness: 44 yo G0 African American female with history signficant for uterine fibroids s/p UAE [**2180-1-13**] transferred from [**Hospital 1263**] Hospital for further management of abdominal pain from presumed necrosing fibroids, acute transaminitis, and pancreatitis of unclear etiology. Pt presented to the referring facility with persistent symptoms of abdominal pain for the past 4 weeks with associated nausea and vomiting. She had a CT scan and abdominal U/S which showed "significant enlargement of fibroids and further areas of necrosis in left superior fibroids." In addition, the patient [**Hospital 1834**] an MRI/MRCP which showed "unremarkable biliary and pancreatic ductal system and pancreatic parenchyma," per the discharge summary from the referring facility. Upon further history taking from patient, it becomes evident that patient has had a fibroid uterus for years. She reports that since the end of [**Month (only) 404**], she has had LUQ pain and was found to have pancreatitis marked by elevated enzymes at that time. She reports a workup at that time which indicated that the likely source was her enlarged uterus. She had a negative endometrial biopsy and opted for treatment with Uterine Artery Embolization on [**2180-1-13**] with hopes of decreasing fibroid size and thus releving the possible mass effect on the pancreas. Since then, she has been on a variety of medications for pain relief starting with Percocet and Vicodin, changed to Tramadol and Ibuprofen changed to Morphine recently. She reports multiple hospitalizations during the past few months for general abdominal pain. As noted above during her most recent hospitalization at [**Doctor Last Name 1263**] she was noted to have acute renal insufficiency, transaminitis,and questionable acute pancreatitis with normal MRCP all thought to be due to mass effect by large fibroid uterus. Past Medical History: Gyn hx: LMP [**2180-1-31**]; no hx abnormal bleeding; + abn pap "this year" with normal colposcopy and biopsy per pt; no hx STDs, not currently sexually active. Never had colonoscopy. Ob hx: G0 PMH: HTN, Uterine firboids, Asthma - only hospitalization as baby. [**Name (NI) **] intubations or steroids. PSH: Denies Social History: The patient lives with 2 yo daughter, and has quite a lot of family support. Works as a Nurse Practitioner [**First Name (Titles) **] [**Last Name (Titles) 77400**] shelter. Denies tobacco, alcohol, and drugs. She denies needle stick injuries and blood transfusions Family History: Father - h/o gallstones Physical Exam: 97.9 114/64 110 16 99%RA wt 166 lbs NAD RR, tachy CTA B Abd -soft, mildly tender to palpation, distended, firm mass palpable - 30 cm size, + eccymosis noted adjacent to umbilicus on L side, no ascites; no rebound, no guarding NT/NE Pelvic: deferred due to patient discomfort . At Discharge: Vitals: T-99.5, HR-92, BP-150/80, RR-16, O2 sat-100% on RA. Gen: NAD, A/Ox3 CV: RR, SR-ST no ectopy RESP: CTAB, decreased bases B/L ABD: Soft, Appropriately tender. Incision: Midline. Staples in place proximal & distal to wound opening. Vacuum dressing removed. Moist sterile gauze applied to wound bed with DSD on top. RE-apply vacuum dressing within 2 hours of removal. Extrem: +[**11-24**] pedal edema. No clots, CSM's intact. Pertinent Results: Labs from OSH: WBC 13.6 Hct 34.9 Plt 595 Na 139 K 4.9 Cl 109 Bicarb 19.6 BUN 8 *Cr 1.5 ( [**2179-12-26**] baseline Cr 0.9) *AST 210 ( [**2179-12-26**] LFT's noted to be 'normal') *ALT 204 *Amylase 250 *Lipase 134 *T bili 5.2 *D bili 3.4 *AP 116 *Lactic Acid 7.5 Albumin 1.7 PT 23.1 PTT 43.4 *INR 2.1 Fibrinogen 253 . Imaging: [**2180-2-15**] RUQ U/S: 1. No evidence of gallstones. 2. No focal hepatic lesion. 3. Large complex mass, extending from the level of the uterus to the mid to upper abdomen. This large mass is incompletely characterized on this study, and could partly represent patient's known history of extensive fibroids. . [**2180-2-16**] CT head: No acute intracranial abnormality. . [**2180-2-15**] 08:40PM BLOOD WBC-9.0 RBC-4.36 Hgb-10.8* Hct-33.9* MCV-78* MCH-24.8* MCHC-31.9 RDW-18.7* Plt Ct-214 [**2180-2-25**] 02:49AM BLOOD WBC-29.3* RBC-3.03* Hgb-8.9* Hct-26.8* MCV-89 MCH-29.3 MCHC-33.0 RDW-19.0* Plt Ct-167 [**2180-2-28**] 06:15AM BLOOD WBC-39.0* RBC-3.03* Hgb-8.8* Hct-27.2* MCV-90 MCH-28.9 MCHC-32.2 RDW-17.9* Plt Ct-444*# [**2180-3-22**] 05:09AM BLOOD WBC-12.8* RBC-3.19* Hgb-8.8* Hct-26.5* MCV-83 MCH-27.5 MCHC-33.2 RDW-17.9* Plt Ct-502* [**2180-3-22**] 05:09AM BLOOD Plt Ct-502* [**2180-3-16**] 07:11AM BLOOD PT-13.7* PTT-28.3 INR(PT)-1.2* [**2180-2-21**] 01:30AM BLOOD PT-20.9* PTT-37.9* INR(PT)-2.0* [**2180-2-15**] 08:40PM BLOOD PT-22.9* PTT-48.4* INR(PT)-2.2* [**2180-2-19**] 10:00AM BLOOD Fibrino-200 [**2180-2-17**] 04:05PM BLOOD Fibrino-74* [**2180-3-22**] 11:23AM BLOOD Glucose-100 UreaN-13 Creat-0.3* Na-137 K-3.9 Cl-100 HCO3-28 AnGap-13 [**2180-2-15**] 08:40PM BLOOD Glucose-70 UreaN-12 Creat-1.3* Na-139 K-4.8 Cl-106 HCO3-16* AnGap-22* [**2180-3-16**] 07:11AM BLOOD ALT-82* AST-91* AlkPhos-416* Amylase-31 TotBili-2.1* [**2180-2-28**] 06:15AM BLOOD ALT-66* AST-129* AlkPhos-144* TotBili-6.4* DirBili-5.1* IndBili-1.3 [**2180-2-15**] 08:40PM BLOOD ALT-148* AST-101* LD(LDH)-518* AlkPhos-109 Amylase-178* TotBili-5.7* [**2180-3-16**] 07:11AM BLOOD Lipase-82* [**2180-2-15**] 08:40PM BLOOD Lipase-336* [**2180-3-22**] 11:23AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.9 [**2180-3-20**] 05:03AM BLOOD Albumin-2.8* Iron-33 [**2180-2-15**] 08:40PM BLOOD Albumin-2.3* Calcium-9.7 Phos-4.6* Mg-2.3 [**2180-3-20**] 05:03AM BLOOD calTIBC-230* Ferritn-219* TRF-177* [**2180-2-16**] 10:10AM BLOOD calTIBC-118* Ferritn-217* TRF-91* [**2180-2-15**] 08:40PM BLOOD Hapto-45 [**2180-2-16**] 10:10AM BLOOD Triglyc-134 [**2180-2-16**] 10:10AM BLOOD TSH-0.83 [**2180-2-25**] 05:43PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE IgM HBc-NEGATIVE [**2180-2-15**] 08:40PM BLOOD HBsAg-NEGATIVE IgM HAV-NEGATIVE [**2180-2-26**] 04:06PM BLOOD Smooth-NEGATIVE [**2180-2-25**] 05:43PM BLOOD [**Doctor First Name **]-NEGATIVE [**2180-2-15**] 08:40PM BLOOD CEA-1.3 CA125-365* [**2180-2-26**] 04:06PM BLOOD IgG-1226 IgM-91 [**2180-2-15**] 08:40PM BLOOD Acetmnp-NEG [**2180-2-25**] 05:43PM BLOOD HCV Ab-NEGATIVE [**2180-2-15**] 08:40PM BLOOD HCV Ab-NEGATIVE . RADIOLOGY Final Report [**Hospital 93**] MEDICAL CONDITION: 44 year old woman with PICC placed [**3-15**] with tip in L subclavian vein REASON FOR THIS EXAMINATION: Please place picc in SVC IMPRESSION: Successful exchange of the PICC line. The new double-lumen PICC line measures 36 cm in length. The tip is in the SVC. The line is ready for use. . RADIOLOGY Final Report UNILAT UP EXT VEINS US [**2180-3-14**] 3:20 PM [**Hospital 93**] MEDICAL CONDITION: 44 year old woman with complicated hosp course. s/p GIST resection with mulp abd surgeries, known LE DVT with new LUE swelling IMPRESSION: No evidence of DVT in the left upper extremity. . RADIOLOGY Final Report CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2180-3-13**] 2:37 PM [**Hospital 93**] MEDICAL CONDITION: 44 year old woman with DVT (untreated), GIST, recent small bowel perforation, s/p extensive abdominal surgery and repair now with persistent tachycardia and hypertension REASON FOR THIS EXAMINATION: eval for pulmonary embolus IMPRESSION: 1. Status post TAH-BSO and GIST tumor removal , there are now multiple fluid collections within the peritoneal cavity-in the left anterior pararenal space, within the root of the mesentry and in the surgical resection site at the base of the bladder. 2. No pulmonary embolism is noted within the main pulmonary artery and its main branches. The evaluation for subsegmental pulmonary embolism was limited due to motion and poor bolus. 3.High density meaterial around the liver was not present on prior studies and raises the possiblity of leak. 4. Small left pleural effusion. . Pathology Examination Procedure date [**2180-3-5**] DIAGNOSIS: Liver, left lobe, wedge biopsy: 1. Marked canalicular and moderate intrahepatocellular cholestasis with numerous bile plugs and feathery degeneration of hepatocytes; mild bile ductular proliferation with scattered associated neutrophilic inflammation present (see note). 2. Mild resolving zone 3 hemorrhagic necrosis with focal hepatocyte drop-out. 3. Trichrome shows no significant fibrosis. 4. Iron stain shows no stainable iron. Clinical: Abdominal washout; closure. . Pathology Examination Procedure date [**2180-2-28**] DIAGNOSIS: Small bowel segment: 1. Inactive entero-enteric anastomosis. 2. Peritoneal fibrinous adhesions and focus of foreign body reaction, possibly to talc and contrast material. 3. No tumor. Clinical: 44 year old female s/p resection for intra-abdominal mass with abdominal compartment syndrome and multi-argen failure. . Pathology Examination Procedure date [**2180-2-17**] DIAGNOSIS: I. Soft tissue, abdominal mass, biopsy (A): Fragment of malignant gastrointestinal stromal tumor. II. Abdominal mass (B-R): 1. Malignant gastrointestinal stromal tumor, at least 28 cm in size (see note). 2. Colonic and small intestinal margins free of tumor. 3. Leiomyoma with extensive infarction consistent with embolization. III. Uterus, fallopian tubes and ovaries (S-AE): 1. Gastrointestinal stromal tumor implants on the serosal surface of the uterus and leiomyomata. 2. Leiomyomata, up to 6.5 cm in greatest dimension. 3. Endocervical polyp. 4. Proliferative endometrium. 5. Ovaries with benign serous cysts and hemorrhagic cysts bilaterally. 6. Left fallopian tube with benign serous paratubal cysts. 7. Unremarkable right fallopian tube. . Pathology Examination Procedure date [**2180-2-19**] DIAGNOSIS: Abdominal tumor: Malignant spindle cell tumor, morphologically similar to previous resection (S08-[**Numeric Identifier 56878**]). Clinical: Surgical hemorrhage. Brief Hospital Course: Ms. [**Known lastname 14748**] is a 44 yo G0 with medical history asthma, HTN, known fibroid uterus with pelvic mass thought to be enlarged fibroid uterus with necrosing fibroids (s/p embolization) per OSH records transferred to [**Hospital1 18**] with acute renal failure, acute live failure, and acute pancreatitis. Initially, she was admitted to the Gynecology service, but after consultation with the Gastroenterology and Hepatology services, the patient was transferred to the MICU on the [**Hospital Ward Name 517**]. She had an abdominal ultrasound which demonstrated no gallstones, no hepatic lesions. However, a large abdominal mass, extending from the pelvis to the upper abdomen was seen. Her bilirubin had continued to be markedly elevated in the 4-8 range. She had undergone a CT scan of the abdomen which revealed the picture of a small bowel obstruction as well as a large abdominal mass undergoing necrotic degeneration. There was no biliary dilatation. Surgery consultation was requested on [**2-17**]. Later that day, she [**Month/Year (2) 1834**] an examination under anesthesia, exploratory laparotomy, resection of abdominal mass, supracervical hysterectomy, bilateral salpingo-oophorectomy, small bowel resection, sigmoid colectomy with descending colostomy, and abdominal packing with Dr. [**First Name (STitle) 1022**]. Please refer to the operative note of [**2180-2-17**] for details. She was returned to the SICU intubated and sedated. Both intraoperatively and postoperatively, she required massive transfusion of blood products. She returned to the operative theater on [**2180-2-19**] for removal of her abdominal packs and ostomy maturation. Dr. [**Last Name (STitle) 1924**] was consulted by Dr. [**First Name (STitle) 1022**] for this procedure. Please refer to the operative notes of [**2180-2-19**] for details. Again, postoperatively, she was transferred to the SICU, intubated and sedated. Her creatinine began to normalize. She required pressor support with Levophed for a few days after this procedure. Due to a concern over failure to wean from ventilator support, she [**Date Range 1834**] a CT scan of the head on [**2-20**], which was unchanged from her prior scan on [**2-16**]. She was placed on trophic tube feedings. On [**2-22**], she was extubated. Throughout her stay, she had been on Ampicillin, Cipro and Flagyl. Due to an elevated WBC count, Fluconazole was added on [**2-22**], as her intraoperative peritoneal culture demonstrated yeast. Her Cipro and Flagyl were discontinued on [**2-23**]. Therapeutic diuresis with goals of [**11-24**] liters negative per day ensued. On [**2180-2-25**], she was transferred back to the Gynecology/Oncology service on the [**Hospital Ward Name 516**]. A consultation from the Medicine service was requested. At this point, she was tolerating a diet of clear liquids. Her WBC remained in the mid to upper 20s, and she [**Hospital Ward Name 1834**] a CT of the abdomen and pelvis to evaluate for abscesses. On [**2180-2-27**], she was found to have a left DVT, although she had been on Lovenox prophylaxis. A heparin drip was started. On review of the prior day's CT scan, free fluid and free air were noted. That evening, she returned to the operative theater with Drs. [**First Name (STitle) 1022**] and [**Name5 (PTitle) 1924**] and [**Name5 (PTitle) 1834**] an exploratory laparotomy with drainage of peritoneal abscesses and a small bowel resection and 2-layer hand-sewn side-to-side anastomosis. An IVC filter was also placed. For details of these procedures, please refer to the operative notes dated [**2180-2-28**]. She was transferred to the [**Hospital Ward Name 332**] ICU intubated and sedated with an open abdomen. Her creatinine had now reached its lowest value. On [**2-29**], her antibiotic regimen was changed to vancomycin, Zosyn, and fluconazole for sepsis. Her pathology was reported at this time as a GIST with malignant features. She required aggressive fluid resuscitation for her tachycardia and hypotension. TPN was initiated. On [**3-2**], she returned to the operating room for an abdominal washout. Closure of her abdomen was not possible due to bowel edema. Please refer to the appropriate operative note for further detail. She was returned to the [**Hospital Unit Name 153**]. Aggressive diuresis followed. On [**3-5**], she was again brought to the operating room with Dr. [**Last Name (STitle) 1924**] and [**Last Name (STitle) 1834**] an exploratory laparotomy and abdominal washout, wedge biopsy of the left lobe of the liver, and placement of a temporary polypropylene mesh to her fascial defect. The abdomen was left open, as, again, too much edema was present to close her wound. Please refer to the appropriate operative note for further details. Trophic tube feeds were re-initiated on [**3-5**], but stopped due to high residuals. On [**3-9**], Ms. [**Known lastname 14748**] was brought to the operating room with Dr. [**Last Name (STitle) 1924**] for reopening of recent laparotomy and abdominal washout, complicated delayed closure of abdominal fascia with placement of AlloDerm mesh measuring 128 cm2. Please refer to the appropriate operative note for further details. She was returned to the [**Hospital Unit Name 153**] with a VAC sponge in place in her abdominal wound, intubated and sedated. In the following days, her ventilatory support and sedation were weaned, until on [**3-12**], she was extubated. On [**3-13**], her VAC dressing was changed. Her wound was demonstrating healthy granulation tissue. She was rather tachycardic at this time, as well as quite confused. She was given Valium for concern of benzodiazepine withdrawal. Her tachycardia continued, and she [**Month/Year (2) 1834**] a CT angiogram of the chest as well as studied of the abdomen and pelvis. There was no pulmonary embolus. Several fluid collections were indentified in the abdomen and pelvis. Antibiotic therapy continued. On [**3-14**], an Oncology consultation was requested. The recommedation was for follow-up when she was significantly more stable. As she was treated with beta-blockers prior to admission, these were restarted, considering her hypertension and tachycardia. She had a PICC line placed, although it needed repositioning the following day. Her liver biopsy resulted in the pathologic finding of cholestasis. Lovenox therapy was initiated for her DVT. She was transferred out of the ICU to the medical/surgical floor. Her nasogastric tube was removed on [**3-16**]. Her diet was advanced to clear liquids 0n [**3-17**], then soft solids [**3-18**]. Her medications were changed to an oral route, with the exception of antibiotics, on [**3-18**]. Her TPN was decreased as she was encouraged to take an oral diet. . [**Date range (1) 23742**]/08-Her IV antibiotic (Zosyn) was discontinued. She was switched to Augmentin, receiving 2 days in hospital. She will continue with 1 more week. She had calorie counts completed during past 2 days. He oral intake continues to improve with decreased to no complaints of nausea. She had 21gm of Protein and 637 kcals yesterday ([**2180-3-22**]). She should continue with TPN at least through weekend until oral intake improves and remains stable. Her nutritional labwork should be checked, and TPN discontinued once indicated. She should receive fat in TPN once a week which is set for Wednesdays. . Her vacuum dressing was changed by the NP and wound care RN on [**2180-3-22**]. Please refer to Wound care/Ostomy RN note for further details. Wound measurements-19cm L, 6cm W, 2cm deep. She will require re-application of vacuum dressing with 2 hours of removal at REHAB center. Continue to manage wound per REHAB protocol. . She should continue with Lovenox until surgically stable. There were some fluid collections noted per CT scan. Collections have remained stable. Patient has been afebrile, tolerating oral intake with no N/V. Consider bridging Lovenox to COumadin in a few weeks for DVT prophylaxsis. Moniter coagulation studies as indicated. . She should see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1924**] (surgeon) on [**4-4**] in his office at [**Hospital3 **]. Please call for an appointment time. Medications on Admission: Home Medications: Albuterol 2 puffs q4 prn; Atenolol 50', HTCZ 25', Lisinopril 40', Ultram 100 1-2 tabs q6 hr prn; Mortrin 400 q6-8', Tylenol 650 q6 hr prn Meds on admission: Tylenol 650 q6 prn, Albuterol MDI, Morphine 2 mg IV q4 prn, Zofran 4 mg q6 prn Discharge Medications: 1. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. 3. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 1 months. 8. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous once a day as needed for line flush. 9. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection Fasting, before each meal, and at bedtime: Refer to Sliding scale. 10. Regular Insulin Sliding Scale Regular insulin Check blood sugars before each meal and at bedtime Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose 0-60 mg/dL Give 4 oz. Juice and 15 gm crackers 61-120 mg/dL 0 Units 121-140 mg/dL 2 Units 141-160 mg/dL 4 Units 161-190 mg/dL 6 Units 191-220 mg/dL 8 Units 221-240 mg/dL 10 Units > 240 mg/dL Notify M.D. 11. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 1 weeks. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary: small bowel obstruction Post-inflammatory hepatitis Multi-system organ failure Hypovolemia Tachycardia Malignant gastrointestinal stromal tumor Post-op wound infection Blood-loss anemia Malnutrition . Secondary: HTN, asthma, uterine fibroids Discharge Condition: Stable Tolerating a regular, high protein diet Adequate pain control with oral medication. Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Wound Care/Vacuum Dressing: -Please apply vacuum dressing within 2 hours upon arrival to REHAB to prevent bacterial colonization. -Change Vacuum dressing every three days. ***If changing ostomy appliance at the same time, careful to prevent contamination of abdominal wound with ostomy content. -Remove vacuum dressing. -Cleanse wound with Commercial wound cleanser. Pat dry with guaze. -Apply white foam first, make sure alloderm covered by white sponge. -Apply black foam (cut foam in half thickness-wise). -Apply clear adhesive. -Cut hole into center of black sponge & clear adhesive. -Adhere drainage tubing to opening in sponge. -Attach to vacuum pump. Turn on. Check for Leaks. Correct leaks as needed to maintain 125mmHg pressure to wound bed. . Monitoring Ostomy output/Prevention of Dehydration: -Keep well hydrated. -Replace fluid loss from ostomy daily. -Avoid only drinking plain water. Include Gatorade and/or other vitamin drinks to replace fluid. -Try to maintain ostomy output between 500mL to 1000mL per day. -If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with each episode of loose stool. Do not exceed 16mg/24 hours. . TPN: -Continue with current TPN formula daily, run continuously for 24 hours through weekend. -Discontinue TPN once tolerating adequate oral intake, including high protein & calorie content. -Add fats weekly on Wednesdays, total of 42g/d. -Check electrolytes daily until stable, then QOD. -Monitor LFT's, and triglycerides at least weekly, and PRN . Lovenox: -Continue with lovenox for next few weeks. -If patient continues to be surgically stable with no requirement for surgical/drainage intervention, bridge lovenox to coumadin. Check coagulation studes as indicated. Followup Instructions: 1. You have a follow-up appointment with Dr. [**Last Name (STitle) 1924**] [**Telephone/Fax (1) **] on Tuesday [**4-4**]. Please call for a time. 2. Your follow-up appointment with Dr. [**First Name (STitle) **] [**Name (STitle) **] ([**2180**] will be on [**2180-4-24**] at 11am. 3. Follow-up with your primary care doctor, Dr. [**First Name8 (NamePattern2) 6**] [**Name (STitle) **] [**Telephone/Fax (1) 77401**] in [**12-26**] weeks or as needed. Completed by:[**2180-3-23**]

[ "218.9", "171.5", "998.11", "453.8", "263.9", "286.9", "276.52", "995.92", "998.59", "038.9", "567.22", "577.0", "584.9", "997.4", "570", "285.1" ]

icd9cm

[ [ [] ] ]

[ "45.76", "50.12", "96.72", "45.62", "46.93", "54.4", "54.19", "54.3", "96.6", "38.7", "99.15", "45.91", "38.93", "46.11", "54.62", "65.61", "54.72", "68.39" ]

icd9pcs

[ [ [] ] ]

21693, 21765

11642, 19930

457, 1742

22060, 22153

5079, 5737

25066, 25547

4294, 4319

20238, 21670

8812, 8982

21786, 22039

19956, 19956

22177, 25043

4334, 4614

19974, 20120

4628, 5060

275, 419

9011, 11619

1770, 3651

5746, 8061

20134, 20215

3673, 3992

4008, 4278

1,148

149,228

3088

Discharge summary

report

Admission Date: [**2162-8-9**] Discharge Date: [**2162-8-12**] Date of Birth: [**2104-7-1**] Sex: M Service: MEDICINE Allergies: Ceftriaxone Attending:[**First Name3 (LF) 1491**] Chief Complaint: Confusion, Nausea Major Surgical or Invasive Procedure: Diagnostic Paracentesis under Ultrasound guidance Central line placement Intubation History of Present Illness: 58 Y.O. man with HCV/EtOH cirrohosis, 3 recent admissions for encephalopathy of unclear precipitant, p/w increasing somnolence, fatigue. Pt was most recently admitted on [**7-31**] and discharged on [**8-3**] for hepatic enceph. At that time, there was no clear precipitant and he was treated with more aggressive lactulose therapy. He has been very fatigued since discharge but per his wife there was no change in MS until this afternoon. He became very somnolent and disoriented and was brought in to the ED. Per his wife, he has not been complaining of increasing abdominal girth, abdominal pain, nausea, vomitting. He has been taking his lactulose, and has been stooling. Though he takes morphine chronically, his dose has been less over the last week. Denies F/C, cough, SOB, dysuria, or any other focal symptoms of infection. Has been on cipro for SBP ppx and lactulose, rifaximin. In [**Name (NI) **], pt noted to have GCS of [**4-10**], minimally responsive. He received PR lactulose without much change. Then, due to increased hypoxia (93% on NRB), pt intubated for airway protection. Past Medical History: 1.HCV cirrhosis: Contracted HCV from blood transfusion in [**2131**]. No prior treatment. Per report, has ulcers found on prior EGD. On the liver tranplant waiting list-- being seen by Dr. [**Last Name (STitle) 497**]. Several recent admits for altered AMS. INR peak 2.9 on [**2162-4-8**], with several measurements above 2.0 in the last several months. Albumin nadir 2.4 on [**2162-4-8**]. ALT levels are all below 40 over the last several months. 2. DM2: On inuslin. Diagnosed [**2160**]. 3. Rheumatoid Arthritis 4. Alcoholism. 5. Ascites. 6. Group B Strep Bacteremia [**4-8**] s/p 1 month of IV Zosyn . Social History: Lives with wife. Disabled veteran. +tobacco currently. +etoh previously. Used to drink 6-12 beers/day. Now, no drinks since [**Month (only) 958**]. Used Marihuana and intranasal cocaine in the remote past. Baseline of moderate activity. Family History: Family History: Father-alive,84 Mother died of lung cancer. Uncle and Aunt- died of cancer. Physical Exam: T=99.0---P=78---BP 140/74---RR 27---O2 94% on 2L Gen: somnolent, decerebrate posturing. HEENT: NCAT, PERRL, anicteric. OP clear with ETT in place. Neck: supple, no LAD. Lungs: CTA b/l CV: Tachy and regular, nml S1S2, no m/r/g Abd: soft, distended, NT, naBS, dullness at flanks Ext: no edema, 1+ dp pulses b/l. Neuro: decerebrate posturing. Skin: abrasion on LUE, multiple spiders on trunk. Pertinent Results: [**2162-8-9**] 07:45PM BLOOD WBC-7.4# RBC-3.99* Hgb-12.5* Hct-36.6* MCV-92 MCH-31.4 MCHC-34.2 RDW-15.1 Plt Ct-114*# [**2162-8-9**] 07:45PM BLOOD Neuts-74.4* Bands-0 Lymphs-17.5* Monos-5.5 Eos-2.2 Baso-0.4 [**2162-8-9**] 07:45PM BLOOD PT-15.4* PTT-35.0 INR(PT)-1.6 [**2162-8-9**] 07:45PM BLOOD Plt Ct-114*# [**2162-8-9**] 07:45PM BLOOD Glucose-143* UreaN-29* Creat-0.9 Na-137 K-4.9 Cl-105 HCO3-23 AnGap-14 [**2162-8-9**] 08:43PM BLOOD Ammonia-234* [**2162-8-9**] 07:45PM BLOOD Albumin-3.1* Calcium-8.3* Phos-3.0 Mg-1.9 [**2162-8-9**] 07:45PM BLOOD Lipase-101* [**2162-8-9**] 07:51PM BLOOD Lactate-2.2* K-5.0 Brief Hospital Course: In the MICU pt was given aggressive Lactulose with improvement in MS. [**Name13 (STitle) **] was extubated in the afternoon on [**8-10**], with stable O2 sats and vitals after extubation. A diagnostic paracentesis was performed on [**8-11**] which showed 622 WBCs and 12% PMNs, no evidence of SBP. Cipro was continued for SBP prophylaxis and as his MS was stable and he was afebrile and hemodynamically stable he was transferred to the floor for further care. . On the floor pt. was monitored overnight. As he was hemodynamically stable, with no further changes in mental status he was discharged with f/u by Hepatology outpatient. Medications on Admission: Lactulose titrated to 4BMs per day Morphine 15mg q4 hours MS Contin 15mg q8h Rifaximin 200mg tid Lasix 40mg PO bid Aldactone 100mg [**Hospital1 **] Protonix 40mg daily Cipro 250mg daily Insulin NPH 18U + 14U Nadolol 20mg daily Magnesium Oxide 800mg daily Discharge Disposition: Home Discharge Diagnosis: Primary: Hepatic Encephalopathy Secondary: Hepatitis C, Hepatic Cirrhosis Discharge Condition: [**Name (NI) 14658**] pt. was alert and oriented with no further change in mental status. Paracentesis showed no evidence of infection and pt. was afebrile. Discharge Instructions: Please take all medications as prescribed. Please continue your Lactulose at your normal home dose. Please call your PCP or go to the ER if you have any confusion, fatigue, abdominal pain or distention, fevers, chills, nausea, vomiting, coughing up blood, blood with bowel movements, or any other symptoms that concern you. Followup Instructions: Please call your PCP Dr [**Last Name (STitle) **] to set up an appointment in the next week. You can reach his office at [**Telephone/Fax (1) 13148**] to make an appointment. Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Where: LM [**Hospital Unit Name 7129**] CENTER Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2162-8-17**] 1:00 - Dr. [**Last Name (STitle) **] will check your hemocrit at this visit, as it was low in the hospital Completed by:[**2162-8-14**]

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icd9cm

[ [ [] ] ]

[ "38.93", "96.71", "54.91", "96.04" ]

icd9pcs

[ [ [] ] ]

4504, 4510

3562, 4199

288, 373

4628, 4788

2931, 3539

5162, 5694

2425, 2502

4531, 4607

4225, 4481

4812, 5139

2517, 2912

231, 250

401, 1507

1529, 2136

2152, 2393

47,816

144,244

46055

Discharge summary

report

Admission Date: [**2151-5-7**] Discharge Date: [**2151-5-19**] Date of Birth: [**2067-1-13**] Sex: M Service: MEDICINE Allergies: Neurontin Attending:[**First Name3 (LF) 20146**] Chief Complaint: Lethargy Major Surgical or Invasive Procedure: Pigtail drain placement History of Present Illness: 84 year old with h/o CAD s/p CABG, ESRD on hemodialysis presenting with three days of increasing lethargy, fever, decreased PO intake, and LLQ pain. Patient went to HD today and since complained of severe abdominal and back pain and he decided to come to the ED. He is a poor historian and states he cannot describe this pain further but does state it was gradual in onset started a couple of days prior to presentation. He denies chest pain, sob, fevers, chills, N/V, change in bowels, black, tarry, bloody stools, or dysuria. . In the ED, initial VS: 101.2 70 107/53 18 99% RA. He notably became tachycardic to the 120s and question of atrial fibrillation. Reportedly makes urine, however no urine on straight cath. Labs notable for lactate of 3.9 that decreased to 1.7 after 3 liters IVFs. WBC 20.1 with 5% bands. Trop elevated to 0.21 with flat CKs. CXR showed left peri-hilar opacity c/f PNA. Patient became hypotensive to the 70s while in ED and a triple lumen subclavian was placed and levophed started. Currently at 0.09. He was given vancomycin and zosyn for presumed PNA. Due to LLQ pain, a CT abdomen/pelvis was performed and para-cholecystic inflammation can't rule out cholecystitis, sigmoid diverticulitis. Transplant surgery was consulted and did not feel any surgical intervention was needed. VS prior to transfer: 76 8 97% 3L 130/65 on 0.09 mcs/kg/min of levophed. Prior to transfer, small amount of hemoptysis was noted. . Upon arrival to the MICU, patient feels well without abdominal pain. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: PAST MEDICAL HISTORY: Recent GI bleed earlier this month -> upper endoscopy showed only a hiatal hernia and colonoscopy showed extensive diverticulosis but no source of bleeding was identified Peripheral vascular disease Type II diabetes mellitus ESRD with hemodialysis Hyperlipidemia MI ([**2130**] and [**2138**]) TIA MRSA (+) (nares, [**2149-5-14**]) Enterobacteriaceae, Stenotrophomonas maltophilia, and Enterococcus faecalis bacteremia secondary to HD line infection [**2149-9-9**] . PAST SURGICAL HISTORY: [**9-/2136**] Right Fem-BK [**Doctor Last Name **] [**1-/2138**] CABG x 4 [**2-/2138**] PEG (later removed) [**2139**] Partial colectomy [**7-/2140**] Left CEA [**8-/2140**] Right CEA [**1-9**] Aortobifem and ventral hernia repair [**6-9**] Right toe amputations [**11-9**] Right inguinal hernia repair [**4-16**] Left UE AV graft (thrombectomy of graft [**4-17**] and [**1-18**]) [**2-17**] Left toe amputation [**2-17**] Right toe amputation [**8-17**] PEG (removed [**12-17**]) [**3-18**] Left CFA to AK-[**Doctor Last Name **] bypass with 8mm PTFE [**3-19**] Right hemiarthroplasty & ORIF Social History: Married, retired police officer, smokes [**3-12**] cigarettes/day when home; denies EtOH and other drug use. Family History: Non-contributory Physical Exam: ADMISSION: General: Alert, oriented, no acute distress, cachectic appearing HEENT: Sclera anicteric, mildly dry MM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Decreased breath sounds at bases, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema, multiple toe amputations bilaterally . DISCHARGE: O: 98.8, 136/78, 76, 22, 95% on RA Gen: awake, oriented X 2, NAD, but in pain HEENT: very dry MM CV: RRR, + SEM loudest at LLSB Pulm: poor inspiratory effort, mostly clear, lower fields with [**Month (only) **] BS Abd: scaphoid, non-tender, no rebound or guarding Ext: warm, + pitting edema at L ankle, + toe amputations Pertinent Results: Admission: [**2151-5-7**] 07:00PM BLOOD WBC-20.1*# RBC-3.62* Hgb-12.0* Hct-36.0* MCV-99* MCH-33.3* MCHC-33.5 RDW-16.7* Plt Ct-138* Neuts-87* Bands-5 Lymphs-3* Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2151-5-7**] 07:00PM BLOOD PT-13.2 PTT-27.2 INR(PT)-1.1 [**2151-5-7**] 07:00PM BLOOD Glucose-124* UreaN-24* Creat-2.4*# Na-140 K-3.6 Cl-92* HCO3-35* [**2151-5-7**] 07:00PM BLOOD ALT-19 AST-33 CK(CPK)-65 AlkPhos-104 TotBili-0.8 [**2151-5-7**] 07:14PM BLOOD Lactate-3.9* . Discharge: [**2151-5-18**] 08:20AM BLOOD WBC-16.2* RBC-2.24* Hgb-7.5* Hct-23.3* MCV-104* MCH-33.2* MCHC-32.1 RDW-16.7* Plt Ct-385 [**2151-5-18**] 08:20AM BLOOD Glucose-82 UreaN-18 Creat-2.5* Na-139 K-4.6 Cl-101 HCO3-28 AnGap-15 [**2151-5-16**] 07:15AM BLOOD ALT-14 AST-30 LD(LDH)-296* AlkPhos-118 TotBili-0.2 [**2151-5-18**] 08:20AM BLOOD Calcium-8.4 Phos-4.7* Mg-2.0 [**2151-5-7**] 11:16PM BLOOD Lactate-1.7 . STUDIES: CXR [**5-7**]: Markedly limited study due to positioning. There is suggestion of a possible left perihilar opacity. Correlate clinically. If indicated, consider repeat exam. . LINE PLACEMENT [**5-7**]: 1. New left central line ends at the level of the mid SVC. No pneumothorax. 2. Left basal opacity, concerning for pneumonia. . CTAP [**5-7**]: IMPRESSION: 1. Bilateral small pleural effusions with basal consolidations, concerning for pneumonia especially in the right lower lobe. 2. No drainable intra-abdominal abscess seen. Assessment of the sigmoid colon is limited by extensive streak artifacts from the prosthesis and lack of luminal contrast. If further imaging is needed, a CT pelvis with rectal contrast may be helpful. 3. Distended gallbladder, and a small amount of pericholecystic fluid. This could be secondary to n.p.o. status; however, if there is clinical concern for acute cholecystitis, an ultrasound can be obtained for further evaluation. 4. Extensive atherosclerotic disease of the aorta with narrowing of the origins of the SMA, celiac and renal arteries. . RUQ U/S [**5-8**]: FINDINGS: The gallbladder is moderately distended, with a small amount of layering sludge and two tiny echogenic gallstones. Corresponding to the abnormality seen in the prior CT study, there is a focal hypoechoic striated area along the anterior wall of the gallbladder, which may represent focal wall thickening. There was no [**Doctor Last Name 515**] sign of the time of the study. The common bile duct measures 4 mm and is normal. If there is concern for acute cholecystitis, a HIDA scan or a repeat ultrasound can be obtained for further evaluation. . [**2151-5-10**] Gallbladder scan: Normal filling of the gallbladder and emptying into the small bowel after CCK administration. . [**2151-5-11**] TTE: No obvious vegetations seen. Normal global and regional systolic function. Mild calcific aortic stenosis. Mild mitral regurgitation. Mild pulmonary hypertension. . [**2151-5-11**] CXR: Incomplete left pleural drainage may be a function of catheter placement anterior to posterior pleural collection, loculated or not. Left pleural thickening may be restrictive, responsible in part for continued left lower lobe atelectasis. Severe worsening right lower lobe atelectasis. . [**2151-5-11**] CT Chest: 1. Moderate bilateral exudative pleural effusions, layering on the right, partially loculated on the left, despite a left pleural drain. 2. Severe bilateral lower lobe atelectasis, without evidence of bronchial obstruction. Degree of visceral pleural thickening is indeterminate surrounding the largely collapsed left lower lobe, but not appreciable along the left upper lobe or the parietal pleura in the left chest. 3. Severe atherosclerotic plaque and mural thrombus in fusiform dilated descending thoracic aorta. 4. Diffuse lower esophageal wall thickening, probably esophagitis. . [**2151-5-16**]: Following removal of a left pigtail pleural catheter, a large loculated left pleural fluid collection has slightly increased in size. There is no visible pneumothorax. Exam is otherwise similar in appearance to the recent study except for worsening opacity at the right base with persistent adjacent small right pleural effusion. . [**2151-5-17**] CXR: As compared to the previous radiograph, the extensive left pleural effusion is unchanged in extent. The effusion on the right has slightly decreased, there is improved ventilation of the right lung. Unchanged size of the cardiac silhouette. Unchanged bilateral basal areas of atelectasis. No newly-appeared focal parenchymal opacities suggesting pneumonia. . MICRO: [**2151-5-7**] 7:14 pm BLOOD CULTURE **FINAL REPORT [**2151-5-11**]** Blood Culture, Routine (Final [**2151-5-11**]): STREPTOCOCCUS PNEUMONIAE. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STREPTOCOCCUS PNEUMONIAE | CEFTRIAXONE----------- 1 S ERYTHROMYCIN---------- =>1 R LEVOFLOXACIN---------- <=0.5 S MEROPENEM------------- 0.5 I PENICILLIN G---------- 4 I TETRACYCLINE---------- =>16 R TRIMETHOPRIM/SULFA---- 8 R VANCOMYCIN------------ <=1 S Anaerobic Bottle Gram Stain (Final [**2151-5-8**]): Reported to and read back by [**First Name8 (NamePattern2) **] [**Doctor Last Name **] @ 1:10 PM ON [**2151-5-8**]. GRAM POSITIVE COCCI IN PAIRS AND CHAINS. Aerobic Bottle Gram Stain (Final [**2151-5-8**]): GRAM POSITIVE COCCI IN PAIRS AND CHAINS. . [**2151-5-11**] 12:43PM PLEURAL WBC-5750* RBC-3525* Polys-97* Lymphs-1* Monos-0 Eos-2* TotProt-2.8 Glucose-6 LD(LDH)-5058 . Cytology of pleural fluid: negative for malignant cells . [**2151-5-16**] 10:10PM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2151-5-16**] 10:10PM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-0 [**2151-5-16**] 10:10PM URINE CastHy-1* URINE CULTURE (Final [**2151-5-18**]): YEAST. <10,000 organisms/ml. Brief Hospital Course: HOSPITAL COURSE: Pt is a 84 year old M with multiple medical problems presenting with three days of increased lethargy and found to be in septic shock. Source most likely pneumonia. Pt was started on Vanc/Zosyn. Blood cultures grew GPC's, which speciated to strep pneumoniae. He initially required Levophed for BP support. He was eventually transferred to the floor for further management (addressed below). Ultimately, a meeting was held to discuss goals of care, the patient was transitioned to comfort-focused measures and went home with hospice services. . # Septic Shock: Fever, leukocytosis, and hypotension on presentation to MICU. Possible sources included PNA vs. colitis vs. cholecystitis. Pt had CXR suggestive of possible consolidation, which was further supported by CT A/P. Regarding other sources, CT A/P showed no intrabdominal abscess, but some pericholecystic fluid. RUQ demonstrated edema, but patient had a negative [**Doctor Last Name 515**] sign and LFT's were normal. He was placed on Vanc/Zosyn for broad coverage, and started on Levophed. Blood cultures grew GPC's in pairs & chains. Surgery was consulted given concern for cholecystitis; however, he clinically did not appear to have cholecystitis and no surgery was indicated. Additionally, HIDA was negative. Blood cultures speciated to S. pneumonia. Antibiotics were narrowed to Ceftriaxone. Levophed was weaned off and the patient was transferred to the floor. . # Pneumonia complicated by Empyema: Repeat CXR revealed a loculated pleural effusion and Interventional Pulmonology was consulted for drainage. A pigtail catheter was placed and studies revealed an empyema. Gram stain and cultures were negative (note, patient had received many days of broad antibiotics at this time). Thoracic Surgery was consulted for consideration of VATS/decortication; however, given his multiple medical comorbidities, a more conservative approach was attempted. The patient received 4 days of tPA injected into his drain to help break up the loculations and promote drainage of the effusion. His oxygen requirement improved and leukocytosis initially trended down. Unfortunately, his effusion reaccumulated after the catheter was pulled. His leukocytosis began to rise and he became increasingly delerious. Other infectious work-up was negative. Given the likelihood of complications of an additional operative procedure to drain the effusion, and the patient's stated desire to focus on quality of life, a family meeting was held to discuss options and all agreed it was best to focus goals of care to comfort measures. . # ESRD on HD: On M/W/F schedule, which continued while inpatient. Renal was consulted and provided recommendations. Meds were renally dosed. He was continued on sevelemer, nephrocaps, and Zemplar with HD. Given the change in goals of care, the patient decided to go home with hospice and discontinue hemodialysis. . # CAD: s/p CABG ([**2138**]) and Peripheral Vascular Disease s/p stents. Continued on statin. ASA was initially held given hemoptysis (secondary to PNA), but restarted on HOD#1. Metoprolol was initially held in setting of sepsis, then restarted once hemodynamically stable. Plavix was held initially and then restarted as well. Given his change in goals of care, these medications were discontinued at discharge. . # Diabetes: Insulin dependent. HISS with QACHS finger sticks was provided. He required very little coverage. Given his change in goals of care, this was discontinued at discharge. . # Recent GI Bleed: noted on prior admission. Patient did not want extensive work up. Continued on pantoprazole while in house and his Hct remained stable. . # Goals of Care: Patient stated clearly that he wished to be DNR/DNI. He also wished to focus on pain control. Palliative Care was consulted for recommendations. He was re-started on oxycontin 10 mg [**Hospital1 **] for basal pain control. When the decision regarding the need for surgical intervention was discussed with the patient and his family they decided to change goals of care to focusing on aggressive management of his symptoms. He was discharged with home hospice services. Medications on Admission: docusate sodium 100 mg [**Hospital1 **] senna 8.6 mgqhs polyethylene glycol daily calcium carbonate 200 mg TID aspirin 81 mg daily acetaminophen 325 mg QID pantoprazole 40 mg q12 simvastatin 80 mg daily zinc sulfate 220 mg daily calcitriol 0.25 mcg daily B complex-vitamin C-folic acid 1 mg daily sevelamer carbonate 800 mg TID trazodone 50 mg qhs oxycodone 5 mg q4:prn multivitamin daily insulin lispro sliding scale metoprolol tartrate 25 mg twice a day. Nephrocaps Discharge Medications: 1. Hospice Please screen and admit to hospice 2. docusate sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 3. senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 4. polyethylene glycol 3350 17 gram/dose Powder [**Hospital1 **]: One (1) dose PO DAILY (Daily) as needed for constipation. Disp:*20 qs* Refills:*0* 5. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve [**Hospital1 **]: One (1) Tablet, Rapid Dissolve PO every six (6) hours as needed for nausea. Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0* 6. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution [**Hospital1 **]: 5-15 mg PO every four (4) hours as needed for moderate to severe pain or shortness of breath. Disp:*30 cc* Refills:*0* 7. lorazepam 2 mg/mL Concentrate [**Hospital1 **]: 0.5-2 mg PO every six (6) hours as needed for anxiety. Disp:*30 cc* Refills:*0* 8. haloperidol lactate 2 mg/mL Concentrate [**Hospital1 **]: One (1) mg PO every six (6) hours as needed for relief of agitation. Disp:*30 cc* Refills:*0* 9. acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain/fever. Disp:*60 Tablet(s)* Refills:*0* 10. oxycodone 10 mg Tablet Extended Release 12 hr [**Hospital1 **]: One (1) Tablet Extended Release 12 hr PO Q12H (every 12 hours). Disp:*60 Tablet Extended Release 12 hr(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 3005**] Hospice Discharge Diagnosis: Pneumonia and empyema Pneumoncoccal bacteremia and septic shock End stage renal disease Coronary artery disease Peripheral vascular disease Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Dear Mr. [**Known lastname 3647**], You were admitted to [**Hospital1 18**] Medicine Service for evaluation of pain and lethargy. You were found to have a pneumonia, a pleural effusion (fluid around your lungs), and bacteria in your blood. You initially spent time in the ICU then were transferred to the regular floor. You had a drain placed by Interventional Pulmonology to remove the fluid and the Thoracic Surgeons also helped with the management. The drain was not successful, and the thoracic surgeons ultimately recommended surgery. We had a family meeting and decided to focus our goals of care to comfort-oriented care, focusing on control of your pain and any other symptoms that may be bothering you. . We are making a few simplifications to your current medication regimen. You may change these as needed and per your wishes. Followup Instructions: A hospice nurse will be following up with you. Please contact him or her with any questions.

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icd9cm

[ [ [] ] ]

[ "39.95", "99.10", "38.93" ]

icd9pcs

[ [ [] ] ]

16667, 16725

10522, 10522

280, 306

16909, 16909

4515, 10499

17911, 18007

3585, 3603

15188, 16644

16746, 16888

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1866, 2314

231, 242

334, 1847

16924, 17024

2358, 2825

3458, 3569

30,425

183,178

32416

Discharge summary

report

Admission Date: [**2166-11-21**] Discharge Date: [**2166-12-24**] Date of Birth: [**2113-11-16**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: transferred from OSH for consideration of CABG Major Surgical or Invasive Procedure: CABG x5 (LIMA>LAD, SVG>DIAG, SVG>RAMUS>YGRAFT>OM, SVG>PDA) [**12-12**] History of Present Illness: 53 y/o M w/ hx CAD with known unvascularized 3VD, chronic systolic HF with EF 20%, DM, hyperlipidemia, hx of CVA, asthma/COPD, with recent prolonged hospitalization at [**Hospital1 **] for inferior MI, cardiogenic shock, respiratory failure, VAP and ARF who is being transferred from OSH for consideration of CABG. The pt was admitted to [**Hospital1 498**] on [**9-8**] for IMI and resp failure. During this hospitalization, he required intermittent dopamine for cardiogenic shock and was unable to be weaned from vent. He had a cardiac cath on [**9-25**] demonstrating severe 3VD and global ventricular dysfunction and an EF 20% and no MR. Because of his other complicating medical issues, he was determined to not be a candidate for stenting or CABG. He was discharged to rehab and 2 days later he pt represented to another hospital with 9/10 CP. His EKGs were reportedly unchanged from prior, had flat cardiac enzymes and was medically managed with ACEI, lipitor, but no BB. Pt was not able to be weaned from vent so was transferred back to rehab after having a trach and PEG placed. He was either then discharged or signed out AMA from rehab. . He then presented to [**Hospital1 10478**] ED early this am with severe respiratory distress and chest pain, failed BIPAP, and required intubation. Prior to intubation, the pt had an episode of black coffee ground emesis. A NGL lavage was performed with aspiration of dark material that was guaiac positive. His Hct dropped from 36.9 --> 30.5. He had diffuse pulm infiltrates that improved with 1.5 L diuresis but briefly dropped his pressures to the 80s. . On review of symptoms, he denies any prior history of deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: # CAD with known 3VD - was not revacularized [**1-31**] complicating medical issues including not being able to quit smoking # DM # Hyperlipidemia # Hx o CVA # Asthma/COPD # Disabled [**1-31**] DM and CVA Social History: Social history is significant for the prescence of current tobacco use. Pt does use unknown amount of alcohol. Family History: NC Physical Exam: VS: T 98.9, BP 114/59, HR 71, RR 24, O2 100% on on AC FiO2 0.50 RR 16 TV 500 PEEP 5 Gen: WDWN middle aged male, intubated, sedated but able to respond appropriately to commands. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of 10 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. no m/r/g appreciated Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi. Decreased BS b/l at bases Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP Pertinent Results: EKG demonstrated sinus tachycardia @ 105 bpm, nl axis, nl intervals, [**Street Address(2) 4793**] elevation III, 0.[**Street Address(2) 1755**] depressions I, aVL, TWI I, aVL, V5-6, LBBB with no significant change compared with prior dated [**11-21**] at 4 am. . [**11-22**] cardiac cath BRIEF HISTORY: The patient is a 53 yo male transferred from an outside hospital with an NSTEMI, congestive heart failure now intubated with known severe three vessel disease and transferred for CABG. The patient is now s/p PEA arrest on [**2166-11-22**]. . INDICATIONS FOR CATHETERIZATION: Coronary artery disease, Canadian Heart Class IV, unstable. Prior MI. . PROCEDURE: Right Heart Catheterization: was performed by percutaneous entry of the left femoral vein, using a 7 French pulmonary wedge pressure catheter, advanced to the PCW position through an 8 French introducing sheath. Cardiac output was measured by the Fick method. Coronary Angiography: was performed in multiple projections using a 5 French JL4 and a 5 French JR4 catheter, with manual contrast injections. Intra-aortic balloon counterpulsation: was initiated with an introducer sheath using a Cardiac Assist 9 French 30cc wire guided catheter, inserted via the left femoral artery. Peripheral Imaging was performed. Conscious Sedation: was provided with appropriate monitoring performed by a member of the nursing staff. . HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.86 m2 HEMOGLOBIN: 9.1 gms % FICK **PRESSURES RIGHT VENTRICLE {s/ed} 52/14 PULMONARY ARTERY {s/d/m} 56/32/43 PULMONARY WEDGE {a/v/m} 30/31/28 AORTA {s/d/m} 103/73/85 **CARDIAC OUTPUT HEART RATE {beats/min} 103 RHYTHM SINUS O2 CONS. IND {ml/min/m2} 125 A-V O2 DIFFERENCE {ml/ltr} 37 CARD. OP/IND FICK {l/mn/m2} 6.3/3.4 **RESISTANCES PULMONARY VASC. RESISTANCE 191 . **ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM **RIGHT CORONARY 1) PROXIMAL RCA NORMAL 2) MID RCA DISCRETE 70 2A) ACUTE MARGINAL NORMAL 3) DISTAL RCA DISCRETE 100 4) R-PDA DISCRETE 80 . **ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM **LEFT CORONARY 5) LEFT MAIN NORMAL 6) PROXIMAL LAD DISCRETE 70 6A) SEPTAL-1 NORMAL 7) MID-LAD NORMAL 8) DISTAL LAD DISCRETE 80 9) DIAGONAL-1 DISCRETE 80 11) INTERMEDIUS DISCRETE 12) PROXIMAL CX DISCRETE 100 13) MID CX DISCRETE 100 13A) DISTAL CX DISCRETE 100 . TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 0 hour50 minutes. Arterial time = 0 hour46 minutes. Fluoro time = 7.6 minutes. Contrast injected: Non-ionic low osmolar (isovue, optiray...), vol 70 ml, Indications - Renal Anesthesia: 1% Lidocaine subq. Anticoagulation: Heparin 0 units IV Cardiac Cath Supplies Used: 4F CORDIS, MULTIPACK 8F ARROW, IABP ULTRA FIBEROPTIX CATHETER 40CC - ALLEGIANCE, CUSTOM STERILE PACK . COMMENTS: 1. Coronary angiography of this right dominant system revealed a normal LMCA, 70% proximal stenosis in the LAD, 80% distal LAD stenosis and 80% stenosis in D1. The LCX was totally occluded. The RCA had a 70% mid stenosis, 80% stenosis of the right PDA and total occlusion after the PDA. . 2. Peripheral arteriography revealed a right iliac artery that was patent and a left iliac artery with a 60% stenosis without a gradient of flow. . 3. Hemodynamics revealed low-normal systemic arterial pressures with an SBP of 103 mm Hg. The RVEDP was elevated at 14 and the PASP was 56. The PCWP was 28 mm Hg for which 40 mg IV lasix was given. . 4. An IABP was placed without complication in the left groin. . FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2 . Acute infero-posterior myocardial infarction, managed by IABP. Echo [**12-9**] The left atrium is normal in size. The left ventricular cavity size is normal. There is moderate regional left ventricular systolic dysfunction with inferior and lateral akinesis (estimated ejection fraction ?30-35%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. No vegetation seen (cannot exclude; views are technically suboptimal) Compared with the prior study (images reviewed) of [**2166-11-22**], there is no definite change. [**12-12**] PRE CPB Normal right ventricular systolic function. Significant left ventricular enlargement. Left ventricle with moderate global dysfunction and severe hypokinesis of all but the basal septal, anterior, and inferior walls. The apex is essentially akinetic. No thrombus is seen in the left ventricular apex. The left ventricular ejection fraction is about 15-20% at best. There is spontaneous echo contrast seen in the left atrium and left atrial appendage. No thrombus is seen in either of these locations. The mitral leaflets are mildly thickened and there is trace mitral regurgitation. There is no aortic regurgitation. A fibrinous echodensity is seen extending from the wall of the proximal ascending aorta to the left or non-coronary cusp of the aortic valve consistent with a fibroelastoma. There is mild tricuspid regurgitation. There is mild atheromatous disease seen in the descending thoracic aorta and aortic arch. CT ABDOMEN W/CONTRAST [**2166-12-4**] 1:44 PM ABDOMEN: Incompletely imaged small to moderate bilateral pleural effusions, (left greater than right) are associated with atelectasis. The liver, spleen, pancreas, and adrenal glands appear unremarkable. The gallbladder is present. Mild right perinephric and fat stranding is a nonspecific finding, as the kidneys enhance symmetrically, without hydronephrosis. . A gastrostomy tube balloon lies in the left upper quadrant musculature, and a moderate amount of air tracks along the musculature inferiorly. No discrete fluid collection is seen. The stomach is partially filled with contrast and there is no evidence of oral contrast extravasation into the peritoneum or into the subcutaneous tissues. . There is no free intraperitoneal air, bowel dilatation or ascites within the abdomen or pelvis. Atheromatous calcification of the distal aorta and iliac arteries is moderate, without aneurysm. . PELVIS: A Foley catheter and air is seen in the bladder. The prostate gland is unremarkable. The rectum and sigmoid colon are within normal limits. . OSSEOUS STRUCTURES: There are no suspicious lytic or blastic lesions. A sclerotic focus in the right femoral head has a nonaggressive appearance. . IMPRESSION: 1. Gastrostomy tube balloon in the left upper quadrant soft tissues with associated soft tissue air moderate air but no evidence of oral contrast extravasation or abscess. 2. Bilateral pleural effusions. . [**12-6**] Pathology . Soft tissue, posterior rectus sheath, "abdominal wall abscess" (A,B): Fibroadipose tissue and skeletal muscle with intense acute inflammation and necrosis. . Stains for micro-organisms will be performed and the results issued in a separate addendum. . Clinical: 53 year old man with abdominal wall abscess, rule out necrotizing fascitis, Specimen submitted, posterior rectus sheath. . Gross: The specimen is received fresh labeled with "[**Known firstname **] [**Known lastname 33733**]" the medical record number and "posterior rectus sheath". It consists of multiple fragments of tan soft red tissue measuring 3 x 2.5 x 1 cm in aggregate. A portion of the tissue appears necrotic with areas of cautery. The specimen is entirely submitted in A-B. . Microbiology . [**2166-12-6**] 1:00 pm TISSUE Site: ABDOMEN ABDOMINAL WALL TISSUE. . **FINAL REPORT [**2166-12-10**]** . GRAM STAIN (Final [**2166-12-6**]): REPORTED BY PHONE TO [**First Name8 (NamePattern2) 971**] [**Last Name (NamePattern1) **] @ 2225 ON [**12-6**] - FA6B. 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S). 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 1+ (<1 per 1000X FIELD): YEAST(S). TISSUE (Final [**2166-12-10**]): 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). ENTEROCOCCUS SP.. MODERATE GROWTH. [**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION. MODERATE GROWTH. LACTOBACILLUS SPECIES. MODERATE GROWTH. GAMMA(I.E. NON-HEMOLYTIC) STREPTOCOCCUS. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S PENICILLIN------------ 8 S VANCOMYCIN------------ <=1 S Urine Cx [**12-8**] Yeast >100,000 Brief Hospital Course: Pt was admitted to the CCU at [**Hospital1 18**] for further work-up and treatment of his medical condition. He ruled in for an NSTEMI with severe LV dysfunction per TTE. On [**11-22**] he experienced acute dyspnea and hypotension suffering PEA arrest. He was intubated and resuscitated with multiple rounds of epi/atropine. Dopamine was started for hypotension. His arrest was thought due to global cardiac ischemia/cardiogenic shock. He was put on broad spectrum antibiotics given leukocytosis and potential sepsis and ? aspiration. He was also thought to have an UGIB given his melena, though GI did not think his bleed was acute. He underwent cardiac cath on [**11-22**] showing severe 3VD and elevated filling pressures. IABP and swan were placed. He required PRBCs given his anemia. Pressors were eventually weaned. Balloon pump was kept in for a week. Pt kept on asa, heparin, plavix, metoprolol, statin, and isordil tid as pressures would tolerate. Pt had several episodes of tachycardia, tachypnea, and hypertension that would induce ST depressions on ant leads of ECG. These changes would dissipate with control of BP and HR. Fever, leukocytosis, question of impaired anoxic encephalopathy s/p PEA arrest, and question of GI bleed initially prevented CABG. Fever spiked [**12-4**] vanco/zosyn [**Date range (1) 69839**]. PEG from OSH, became tender and tube feeds were causing patient pain. [**12-6**] pt was taken to OR for exploration of PEG site and removal of rectus sheath abscess. VAC was placed. Fever resolved. Mild leukocytosis of 11.5 remained day of surgery. Pt was extubated on [**12-3**] for several day period and showed no signs of anoxic brain injury. He was reintubated on [**12-7**] for flash pulmonary edema and respiratory distress. Kept intubated up until CABG. On admit there was question of GI bleed, but patient was on heparin for greater than a week with out significant hct drop. Pt noted to have free air on CXR [**12-5**], but benign abd exam. PRN blood transfusions were given. Plavix was discontinued several days before surgery. On [**2166-12-12**] he underwent CABG x 5. He was transferred to the ICU on levophed, milrinone, insulin and propofol. on [**12-15**] he was extubated and reintubated for agitation. Seen by ID and pan-scanned. Thoracentesis for 700 cc performed on [**12-17**]. Extubated again on [**12-18**]. He was transferred to the floor on [**12-21**]. PICC placed on [**12-22**]. He was ready for discharge to rehab on POD #12. Medications on Admission: ASA 325mg daily lipitor 40mg daily ISS, no standing prednisone 20 mg daily bumex 1mg [**Hospital1 **] metoprolol ?mg daily flomax 0.4 mg daily prevacid 30mg daily coumadin 9mg daily flonase nasal spray [**Hospital1 **] fish oil Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day). 3. Atorvastatin 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime). 4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 5. Nicotine 14 mg/24 hr Patch 24 hr [**Last Name (STitle) **]: One (1) Patch 24 hr Transdermal DAILY (Daily). 6. Zosyn 4.5 gram Recon Soln [**Last Name (STitle) **]: One (1) Intravenous every six (6) hours for 4 weeks: started [**12-18**] - through [**2167-1-15**]. 7. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Month/Day/Year **]: One (1) Intravenous Q 24H (Every 24 Hours) for 4 weeks: started [**12-18**] - through [**2167-1-15**]. 8. Fluconazole 200 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO Q24H (every 24 hours) for 4 weeks: started [**12-18**] - through [**2167-1-15**]. 9. Carvedilol 3.125 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO BID (2 times a day). 10. Prednisone 20 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily). 11. Insulin Glargine 100 unit/mL Solution [**Month/Day/Year **]: Fifteen (15) units Subcutaneous at bedtime. 12. Insulin Lispro 100 unit/mL Solution [**Month/Day/Year **]: per sliding scale Subcutaneous four times a day. 13. Fluticasone 110 mcg/Actuation Aerosol [**Month/Day/Year **]: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 14. Lasix 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day for 1 weeks: then reassess need for diuresis. 15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal [**Hospital1 **]: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day) for 1 weeks: while on lasix. 16. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) Injection TID (3 times a day): SQ. 17. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Six (6) Puff Inhalation Q4H (every 4 hours). 18. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Hospital1 **]: One (1) Inhalation Q4H (every 4 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital1 **] [**Hospital1 **] Discharge Diagnosis: CAD now s/p CABG PMH: DM, HTN, CAD, COPD, Lipids, CVA, smoker, EtOH, VRE by rectal swab Discharge Condition: Good. Discharge Instructions: Call with fever, redness or drainage from incision or weight gain more than 2 pounds in one day or five in one week. Shower, no baths, no lotions, creams or powders to incisions. no lifting more than 10 pounds or driving until follow up with surgeon. Followup Instructions: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (Trauma Surgeon) in [**12-31**] weeks for wound check Dr. [**Last Name (STitle) **] 2 weeks Dr. [**First Name (STitle) **] 4 weeks Dr. [**Last Name (STitle) **] after discharge from rehab [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2166-12-24**]

[ "428.0", "250.00", "493.20", "584.9", "410.31", "428.22", "536.42", "518.82", "414.01", "998.59", "728.89", "285.9" ]

icd9cm

[ [ [] ] ]

[ "96.72", "39.61", "36.14", "37.61", "96.04", "96.6", "37.23", "88.56", "38.93", "54.3", "44.62", "36.15", "34.91" ]

icd9pcs

[ [ [] ] ]

17879, 17939

12899, 15388

370, 443

18071, 18079

3858, 4403

18378, 18759

2924, 2928

15666, 17856

17960, 18050

15414, 15643

7421, 12876

18103, 18355

2943, 3839

6220, 7404

4436, 6201

284, 332

471, 2552

2574, 2780

2796, 2908

13,353

177,798

5852

Discharge summary

report

Admission Date: [**2183-10-27**] Discharge Date: [**2183-11-2**] Date of Birth: [**2121-1-15**] Sex: Service: Cardiothoracic. #58 DISCHARGE DIAGNOSES: Coronary artery disease, status post coronary artery bypass graft times four. REASON FOR ADMISSION: The patient is a 62 year old female who had a history of five months of chest pain with exertion. The patient had positive ST changes in [**Month (only) 359**] on electrocardiogram and presented earlier this month for heart catheterization. The patient's catheterization showed an ejection fraction of 50%, 80% left anterior descending lesion and 80% circumflex. PAST MEDICAL HISTORY: Significant for hypertension, insulin dependent diabetes mellitus for 40+ weeks. She is status post colon resection for cancer. MEDICATIONS: Lescol 20 mg q. day. Loexepril 15 mg twice a day. Enteric coated aspirin 81 mg q. day. Prilosec 20 mg q. day. Ambien 10 q. day. Humilog 10 q. a.m. and sliding scale q. p.m. Lente insulin 24 units q. a.m. ALLERGIES: Lipitor and aspirin greater than 81 mg, causing gastrointestinal upset. REVIEW OF SYSTEMS: The patient denied cerebrovascular accident or transient ischemic attack. No history of claudication. No palpitations, no wheezing, no orthopnea. Pulse in the 70's; blood pressure 156/63; respiratory rate of 17; room air oxygen saturation of 97%. The patient is awake, alert, in no acute distress. Heart is regular rate and rhythm without murmur. Lungs were clear to auscultation bilaterally. Abdomen was soft, nontender, nondistended. Bowel sounds were present. Neck was supple without masses. Carotids had no bruits. Extremities showed palpable pulses in the dorsalis pedis and posterior tibial bilaterally without edema. White count was 8.3; hematocrit was 37.3; platelets were 191. Sodium of 136; potassium of 3.5; chloride 102; bicarbonate 26; BUN 13; creatinine .6 and glucose of 133. PT was 12.7; PTT was 26.5 and INR was 1.1. ASSESSMENT: 62 year old female with coronary artery disease. The patient was admitted for planned coronary artery bypass graft. HOSPITAL COURSE: The patient was taken to the operating room on the [**12-27**] and underwent coronary artery bypass graft times four including left internal mammary artery to the left anterior descending, saphenous vein graft to the obtuse marginal times two with endarterectomy in saphenous vein graft to posterior descending artery. There were no complications. The patient was transferred to the CSRU intubated in stable condition. On postoperative day number one, the patient was stable on a Neo drip of .3. Her chest tubes were continued. On postoperative day number two, the patient had been extubated. She was continued on Neo .75. Chest tubes were discontinued. On postoperative day number three, the patient remained on CSRU. Her Neo had been weaned off. Her chest tubes had been pulled. She was begun on her diuresis and started on a beta blocker. The patient was seen by [**Last Name (un) 3208**] staff to manage her diabetes on postoperative day number four. The patient was stable. Her heart rate was 94 and sinus. Her Lopressor was increased to 50 mg twice a day. Her Lasix was continued at 40 mg twice a day. The patient remained stable throughout the rest of her hospital stay, ambulating with physical therapy and remained afebrile. She was discharged on [**2183-11-2**], postoperative day number six in stable condition. She did complain of palpitations. Heart rhythm showed sinus rhythm with occasional premature ventricular contractions on monitor. Her electrolytes were checked which were within normal limits. The patient was voiding well and ambulating with some pain. This was controlled with oral analgesics. DISCHARGE DIAGNOSES: Coronary artery disease. Status post coronary artery bypass graft times four. Insulin dependent diabetes mellitus. Hypertension. History of colon cancer, status post colectomy. MEDICATIONS ON DISCHARGE: Metoprolol 50 mg twice a day. Insulin NPH 18 units q. a.m. and 14 units q. p.m. Iron 150 mg q. day. Protonic 40 mg q. day. Plavix 75 mg q. day. Fluvastatin 20 mg q. day. Darvocet N 100 prn. Aspirin 325 mg q. day. Lasix 40 mg twice a day. The patient was discharged and instructed to follow-up with Dr. [**Last Name (STitle) **] in two weeks. To follow-up with her primary care physician and cardiologist. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern1) 23184**] MEDQUIST36 D: [**2183-11-2**] 05:52 T: [**2183-11-3**] 18:39 JOB#: [**Job Number 23185**]

[ "414.01", "413.9", "427.69", "250.51", "733.00", "401.9", "362.01", "530.81", "V10.05" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

3763, 3941

3967, 4627

2107, 3742

1117, 2089

662, 1096

17,905

183,330

1426+55295

Discharge summary

report+addendum

Admission Date: [**2153-8-31**] Discharge Date: [**2153-9-10**] Service: MEDICINE Allergies: Toradol / Diovan / Bactrim Attending:[**First Name3 (LF) 297**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: This is a [**Age over 90 **] yo man with Parkinson's and DM who was discharged from [**Hospital1 18**] on [**2153-8-8**] s/p ORIF for right hip fracture, who was doing well at rehab ([**Hospital **] healthcare center) until 2 weeks ago when he started becoming somnolent, and was less engaged in rehab activities. Pt was seen in ED on [**2153-8-24**] because of hypoglycemia, where he was also noted to have a UTI. He was given Levofloxacin in ED and discharged on 10-day course of Ciprofloxacin. In addition, the patient was noted to have some dysphasia with an "abnormal swallowing study at rehab". . The patient was seen by GI today for work-up of dysphasia where he was noted to be somnolent, and apparently looked "awful" [**Name8 (MD) **] MD. He was sent to the ED for further evaluation. On presentation, he reported fatigue, loss of energy, confusion and anorexia. His wife reports that the Rehabilitation facility increased his Sinemet dose so that he has been receiving an extra dose in the morning. His wife also reports that the patient was reportedly fine and doing well at rehab for 1-2 days until changing roommates, at which time he became increasingly withdrawn and wanted to leave rehab. There was also a question of possible verbal abuse from roommate. He does have some mild baseline dementia per wife, but was highly functioning (driving, working in store, etc.) prior to his hip fracture. . The patient was unable to give much history. The majority of information was obtained through wife and [**Name2 (NI) 8526**]. Past Medical History: 1. HTN 2. DM II 3. Parkinsons disease 4. Colon CA s/p resection in [**2130**] 5. PVD 6. Right hip fracture s/p ORIF ([**2153-8-5**]) 7. Asthma 8. Osteoarthritis/Paget's 9. Latent Syphilis 10. Hypercholesterolemia 11. CRI (baseline Cr 1.4-1.5) 12. Anemia 13. Hearing loss 14. Parotid tumor 15. BPH, with h/o associated hematuria 16. h/o gastritis Social History: Married, does have some mild baseline dementia per wife, but was highly functioning (driving, working in store, etc.) prior to hip fracture. Distant tobacco history (stopped 27 years, smoked couple cigarettes/day), rare ETOH, no other drug use. Family History: N/C Physical Exam: Vitals: Tc 97.6 BP 137/69 HR 68 RR 22 O2 sat 98% RA Gen: tired, thirsty, oriented to person, place and year but not exact date, varying alertness HEENT: scratch on forehead, no [**Last Name (un) 8527**] appreciated PERRL, large hard non-mobile right neck mass, No LAD CV: RR, nl s1 s2, 2/6 systolic ejection murmur Pulm: Bibasliar crackles, louder on right than left Abd: +BS, NT, ND, no masses, midline scar Extrem: refused to move right low extremity Foley: dark tea color urine with dark precipitate in foley tube Neuro: CN III-XII nl, nl tone, nl sensation UE and LE, [**5-17**] strength in upper and left lower aside from RLE which pt refused to move Mini-mental status exam: somewhat somnolent and falling asleep, oriented to person, place, year but not exact date Immediate memory- [**3-15**] words Short term memory- [**1-15**] words Long term- knew sister's name Meaning of "people in glass house shouldn't throw stones"- "mind your own business" Comparison of apple to [**Location (un) 2452**]- "fruit" Able to do days of week forwards and backwards only after significant prompting Pertinent Results: ECG: SR 71, no ST abnormalities, unchanged from previous ECG Head CT: No acute intracranial hemorrhage or mass effect - no acute stroke evident CXR: no acute pathology [**2153-9-10**] 03:04AM BLOOD WBC-16.2* RBC-3.65* Hgb-10.6* Hct-31.9* MCV-87 MCH-29.1 MCHC-33.3 RDW-15.2 Plt Ct-162 [**2153-8-31**] 01:03PM BLOOD WBC-10.6 RBC-3.62* Hgb-10.9* Hct-32.4* MCV-89 MCH-30.2 MCHC-33.8 RDW-13.4 Plt Ct-187 [**2153-8-31**] 01:03PM BLOOD Neuts-82.7* Lymphs-11.1* Monos-4.4 Eos-1.6 Baso-0.2 [**2153-9-10**] 03:04AM BLOOD Plt Ct-162 [**2153-8-31**] 12:47PM BLOOD PT-13.0 PTT-33.0 INR(PT)-1.1 [**2153-9-10**] 03:04AM BLOOD Glucose-133* UreaN-19 Creat-0.9 Na-130* K-4.2 Cl-99 HCO3-23 AnGap-12 [**2153-8-31**] 12:47PM BLOOD Glucose-132* UreaN-38* Creat-1.6* Na-137 K-3.7 Cl-98 HCO3-24 AnGap-19 [**2153-9-8**] 10:33AM BLOOD CK-MB-3 cTropnT-0.08* [**2153-9-8**] 03:09AM BLOOD CK-MB-4 cTropnT-0.08* [**2153-9-7**] 08:13PM BLOOD CK-MB-4 cTropnT-0.08* [**2153-8-31**] 12:47PM BLOOD cTropnT-0.08* [**2153-8-31**] 12:47PM BLOOD VitB12-573 [**2153-9-10**] 07:56AM BLOOD Osmolal-271* [**2153-8-31**] 12:47PM BLOOD TSH-1.1 [**2153-9-8**] 01:36PM BLOOD Cortsol-15.8 Brief Hospital Course: Impression: [**Age over 90 **] yoM with Parkinson's, s/p ORIF sent from rehab for change in mental status. 1. Change in mental status/delirium: Head CT negative for acute pathology. A hypodensity present near stable parotid tumor, therefore SPEP and UPEP sent. CXR showed patchy atelectasis zt right lung base, but could not definitively rule out pneumonia, therefore pat was started on levofloxacin, to complete a 7 day course. Had previously diagnosed with UTI, also treated by levofloxacin. Serum tox and urine tox were all normal. VitB12 and TSH were normal. Electrolytes nl includign calcium. Pt was not to be given benzo, while in hospital. Changed Sinemet back to previuos dose, as it had been increased while in rehab, and this may have precipitated delirium. Continued to have patient OOB and PT. His mental status continued to improve. . 2. Chronic Anemia- Baseline Hct of 26-29. Continued to monitor for changes, without any significant change. - 3. UTI- Cipro changed to Levofloxacin given atelectasis vs possible pneumonia on CXR. This also covered UTI. - 4. Dysphagia- reported dysphagia to solids but not liquids, which would be consistent with a mechanical obstruction, although pt is not a good historian. Pt placed on clear liquids, obtained speech and swallow evaluation - 5. FEN- Initally presented with hypovolemia secondary to decreased PO intake, IV rehyrdation given in ED, and he was placed on maintenance IV fluids. Patient had poor po intake initally, stating that he ws not hungery. Continued on MVI and Vit C, FS [**Hospital1 **] with RISS while in hospital. Electrolytes repleted as needed. - 7. Hip fracture- Continued PT while in hospital - 8. Parkinson's- Given Sinemet 25/100 TID, and did not give additional dose that he had been receiving since at rehab. - 9.HTN- held HCTZ as BP were well controlled in hospital - 10.Asthma- continued Combivent, Advair, singulair . 11. Left heel pain: Patient complained of pain in L heel. Obtained xray of L foot, which was negative for patholgy. Elevated heel off bed with a pillow to decrease pressure on the heel. . 12. Prophylaxis- given Heparin SC, PPI, colace . 13. Code - CMO; Pt code status switched to CMO. On [**9-8**], pt required constant norepinephrine/vasopressin to maintain MAP. Pt. developed persistent hyponatremia; corrected partially with 3% NS. Monrning of [**9-9**]; pt. family switched code status to CMO and requested removal of ETT and pressors. Pt. expired soon after from respiratory arrest likely [**2-14**] complications related to MRSA sepsis. Medications on Admission: HCTZ 25mg QD Lisinopril 5mg QD Advair 250/50 QD Combivent Singulair 10mg QD Sinemet 25/100 TID plus an additional 1 tab 25/100 in AM Glyburide 5mg QD MVI QD Vitamin C 500mg [**Hospital1 **] Ciprofloxacin 500mg [**Hospital1 **] (received 6 days of 10 day course) Lovenox 40 SC QD Colace 100mg [**Hospital1 **] Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnosis: 1. MRSA sepsis 2. Delirium Secondary Diagnoses: 1. Diabetes Mellitus 2. Parkinson's Disease 3. PVD 4. Asthma 5. Right hip fracture s/p ORIF ([**2153-8-5**]) Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: None Name: [**Known lastname 1223**],[**Known firstname **] Unit No: [**Numeric Identifier 1224**] Admission Date: [**2153-8-31**] Discharge Date: [**2153-9-10**] Date of Birth: [**2062-1-5**] Sex: M Service: MEDICINE Allergies: Toradol / Diovan / Bactrim Attending:[**First Name3 (LF) 1225**] Addendum: Addendum to Hospital Course: - Respiratory Failure: Morning of [**9-10**], pt. noted to have marked hemodynamic instability (labile BP, HR) consistent with worsening septic shock. CXR showed worsening of bilateral infiltrates/effusions. Pt also noted to have copious secretions partially removed with suctioning. The differential diagnosis of the patient's worsening respiratory status included pulmonary embolus, worsening ARDS, mucous plugging, or a combination of these factors. Since patient was not stable (due to worsening shock) to undergo CT scan to look for PE and pretest prob. of PE was high (prolonged stasis, s/p ORIF), we decided to start pt. on heparin. Also decided to try deep suctioning if mucous plugging was responsible. However, the patient's family decided to switch the patient's code status to comfort measures only at this time. Pressors and respiratory support were stopped. The patient went into respiratory arrest and died within 30 minutes of removal of pressor support. Discharge Disposition: Expired [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 1226**] MD [**Last Name (un) 1227**] Completed by:[**2153-9-11**]

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icd9cm

[ [ [] ] ]

[ "96.04", "38.91", "03.31", "89.14", "38.93", "96.71" ]

icd9pcs

[ [ [] ] ]

9387, 9557

4785, 7338

255, 261

7928, 7937

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29,111

131,814

708

Discharge summary

report

Admission Date: [**2174-9-28**] Discharge Date: [**2174-10-3**] Date of Birth: [**2097-4-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1145**] Chief Complaint: Pericardial effusion, atrial fibrillation with RVR. Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. [**Known lastname 1924**] is a 77-year old male with minimal prior medical care for over 50 years, with no known past medical problems, who was brought to the [**Name (NI) **] this morning by his social worker because he was noted to have labored breathing. He minimizes his symptoms, and reports that he has been feeling "great" and has no complaints. Per his social worker, [**Name (NI) **] [**Name (NI) 1968**], she has noted a deterioration in his health over the last 2 weeks. Her main concern has been with his balance. He has been having trouble maintaining his balance on ambulating for several weeks. He has had several falls recently due to difficulty with his balance and has been walking with a cane for the last 3 weeks. He recalls his last fall to have been approximately 1 week ago. He denies any prodromal symptoms with this fall including no lightheadedness, LOC, chest pain, SOB, and palpitations. His social worker also notes that he has had decreased appetite with minimal PO intake for the last few days. She notes that on her visit today, he looked pale and had difficulty breathing. He denies difficulty breathing and other complaints including no chest pain, palpitations, SOB, orthopnea, LE edema and PND. . In the ED he was noted to have atrial fibrillation to 140-160s with SBP 145/65. He was given 5 mg IV diltiazem without response and started on a diltiazem gtt. He had an echocardiogram that was done by ED staff that revealed a pericardial effusion. He had a formal echocardiogram that showed a moderate pericardial effusion (2cm) and no evidence of tamponade, though limited by suboptimal study due to RVR. He is being admitted to the CCU with atrial fibrillation with difficult to control RVR on diltiazem 15 mg/hour. . On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: PAST MEDICAL HISTORY: # Cataracts s/p surgery bilaterally # Right sided hearing loss, saw an ENT who recommended head imaging, which he has refused thus far. # He has no primary care provider. [**Name10 (NameIs) **] has not seen a doctor (with the exception for his eye and hearing issues) since age 16. . PAST SURGICAL HISTORY: # Appendectomy in his teens # Right cataract surgery in [**2172**] # Left cataract surgery in [**2174-5-19**] . CARDIAC RISK FACTORS: - Diabetes - Dyslipidemia - Hypertension Social History: Social history is significant for 7 cigarettes per day x several years in his teenage years; he used to drink 2 cans of beer per day x 5 years in his 20s-30s, denies illicit drugs. Per his social worker, he had been homeless for the last 30 years, and just recently started living in an apartment alone in [**Month (only) 116**]. Family History: NC. Physical Exam: PHYSICAL EXAM AT ADMISSION: VS: T 98.4 , BP 131/58, HR 126 , RR 22 , O2 94 % on 2L Gen: Elderly male in NAD. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. Surgical pupils bilaterally. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of [**6-26**] cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Bibasilar crackles, no wheezing and rhonchi. Abd: Soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP .. PHYSICAL EXAM AT DISHARGE: Patient was in atrial fibrillation with rate of 90-100s. During activity, his rate increased to 150s. He remained asymptomatic with O2 sats in the mid 90s, in no apparent distress, respiratory or otherwise. He was alert and oriented and deemed competent to make decisions about his medical care. Pertinent Results: LABS AT ADMISSION: . [**2174-9-28**] 09:37PM URINE HOURS-RANDOM CREAT-117 SODIUM-83 [**2174-9-28**] 01:20PM URINE HOURS-RANDOM [**2174-9-28**] 01:20PM URINE UHOLD-HOLD [**2174-9-28**] 01:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016 [**2174-9-28**] 01:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-4* PH-5.0 LEUK-NEG [**2174-9-28**] 11:05AM [**Doctor First Name **]-NEGATIVE [**2174-9-28**] 11:03AM TYPE-ART PH-7.40 [**2174-9-28**] 11:03AM GLUCOSE-165* LACTATE-2.5* NA+-135 K+-3.7 CL--97* [**2174-9-28**] 11:03AM HGB-11.7* calcHCT-35 [**2174-9-28**] 11:03AM freeCa-1.09* [**2174-9-28**] 10:55AM GLUCOSE-163* UREA N-30* CREAT-1.3* SODIUM-133 POTASSIUM-3.7 CHLORIDE-96 TOTAL CO2-22 ANION GAP-19 [**2174-9-28**] 10:55AM estGFR-Using this [**2174-9-28**] 10:55AM ALT(SGPT)-23 AST(SGOT)-27 CK(CPK)-107 ALK PHOS-75 TOT BILI-1.0 [**2174-9-28**] 10:55AM LIPASE-57 [**2174-9-28**] 10:55AM cTropnT-<0.01 [**2174-9-28**] 10:55AM CK-MB-3 [**2174-9-28**] 10:55AM ALBUMIN-3.8 CALCIUM-8.8 PHOSPHATE-3.4 MAGNESIUM-2.2 IRON-18* [**2174-9-28**] 10:55AM calTIBC-202* FERRITIN-1071* TRF-155* [**2174-9-28**] 10:55AM TSH-3.2 [**2174-9-28**] 10:55AM WBC-6.1 RBC-3.55* HGB-10.6* HCT-30.6* MCV-86 MCH-29.8 MCHC-34.6 RDW-15.6* [**2174-9-28**] 10:55AM NEUTS-78.2* LYMPHS-18.3 MONOS-3.2 EOS-0.1 BASOS-0.2 [**2174-9-28**] 10:55AM PLT COUNT-139* [**2174-9-28**] 10:55AM PT-14.8* PTT-33.7 INR(PT)-1.3* .. ELECTROCARDIOGRAM AT ADMISSION: EKG demonstrated atrial fibrillation at 162 with normal axis, no LVH by voltage criteria, normal intervals, no ischemic changes. .. RADIOGRAPHIC STUDIES: . CT HEAD WITHOUT CONTRAST ([**2174-9-29**]): There is diffuse symmetric enlargement of the ventricles and sulci consistent with mild-to-moderate age-related atrophy. There is no evidence for hemorrhage, edema, mass effect, or large vascular territory infarct. The [**Doctor Last Name 352**]-white matter differentiation is preserved. Paranasal sinuses and ethmoid air cells are normally pneumatized and clear. There is a small heterogeneous lucency within the left parieto-occipital calvarium (2:24). This likely represents a hemangioma. The osseous structures are otherwise unremarkable. IMPRESSION: No evidence for hemorrhage or other acute intracranial process. . CT CHEST WITHOUT CONTRAST ([**2174-9-29**]): There is asymmetric interstitial septal thickening with some nodularity involving the entire right lung. Multiple pulmonary nodules in the lungs are also identified measuring 8 mm (series 4:100). There is bilateral atelectasis and moderate simple fluid-attenuating effusions. There are multiple mildly enlarged mediastinal lymph nodes measuring up to 12 mm(precarinal, series 4, image 96). Although evaluation is limited without contrast, there is increased soft tissue in the right hilum concerning for adenopathy such as increased soft tissue posterior to the right main bronchus (series 4:125). Calcified mediastinal and small right hilar nodes also noted. No left hilar adenopathy is identified. There are coronary artery calcifications. Study was not tailored for subdiaphragmatic evaluation, but no abnormalities are identified. Please note that the adrenal glands were not imaged. No suspicious lesions are identified in the osseous structures, which otherwise demonstrate diffuse degenerative changes. IMPRESSION: 1. Constellation of findings including asymmetric nodular right lung interstitial septal thickening, mediastinal and right hilar adenopathy, and multiple pulmonary nodules are concerning for possible malignant disease, but no definite primary tumor site is identified. Consider PET CT for further assessment, if warranted clinically. 2. Large pericardial effusion. 3. Bilateral pleural effusions. .. ECHOCARDIOGRAM ([**2174-9-28**]): The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. LV systolic function appears borderline depressed (difficult to assess to very rapid and irregular pulse). Right ventricular chamber size is normal with borderline normal free wall function. 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. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is a moderate sized pericardial effusion. Stranding is visualized within the pericardial space c/w organization. No right atrial or right ventricular diastolic collapse is seen. IMPRESSION: Moderate circumfirential pericardial effusion without tamponade. LV/RV systolic function are preserved (difficult to assess due to irregular and very rapid pulse) .. ECHOCARDIOGRAM ([**2174-9-29**]): The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. 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. The estimated pulmonary artery systolic pressure is normal. There is a moderate sized pericardial effusion. Stranding is visualized within the pericardial space c/w organization. The effusion is most prominent posterior to the left ventricle, with <1 cm anterior to the right ventricle in diastole. There are no echocardiographic signs of tamponade. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild aortic regurgitation. Dilated thoracic aorta. Moderate pericardial effusion. Compared with the prior study (images reviewed) of [**2174-9-28**] LV function appear normal (largely secondary to a lower ventricular response rate in atrial fibrillation). Aortic regurgitation is slightly more prominent, also likely secondary to longer diastolic period. Brief Hospital Course: In summary, this is a 77-year old gentleman with no prior medical history who presents with a pericardial effusion and atrial fibrillation with RVR. He was started on a diltiazem drip and admitted to the CCU for closer monitoring given his rapid ventricular rate. .. # PERICARDIAL EFFUSION: On echocardiogram, he was found to have a moderate-sized effusion (2 cm). Given his hemodynamic stability, we suspected that this was a chronic process. A repeat echo showed little interval progression. After evaluation of echo findings and symptoms, we felt that the effusion was not affecting hemodynamics in any marked way. By symptoms he was never hypotensive or showing clinical signs of tamponade. . We checked [**First Name8 (NamePattern2) **] [**Doctor First Name **] and PPD, both of which returned negative. We order a CT chest to evaluate his lung fields and possibly shed light on the etiology of the pericardial effusion. The full CT report is above; in brief, it showed interstitial septal thickening, as well as mediastinal LAD and pulmonary nodules, all highly concerning for malignancy (primary site not identified). Thus the pericardial effusion was felt to be due to metastatic cancer. . We discussed the findings with Mr. [**Known lastname 1924**] and explained to him that further work-up to diagnose and potentially treat his condition would involve tissue biospy and additional imaging. He was not interested in more work-up and expressed desire to go home. See below for more information. .. # CAD/ISCHMIA: We did not suspect ischemic disease as he had no risk factors, symptoms or EKG changes to suggest ACS. Furthermore, echocardiogram did not show any focal hypokinesis or akinesis to suggest myocardial infarction. .. # PUMP: There were so signs of fluid overload or clinical pump failure on physical exam. His echocardiogram showed a normal EF of 55-60%. .. # RHYTHM: He presented with atrial fibrillation with RVR that required a diltiazem drip in the emergency room. He converted back to sinus rhythm on the morning after admission. Unfortunately, he returned to AF intermittently throughout his hospital stay. We started him on PO metoprolol and diltiazem; however, he continued to have periods of AF with ventricular response to 90-110s while lying in bed. At time of discharge, his rate is 80-100 while lying in bed and increases to 150s when he is walking. His systolic blood pressure and oxygen sat are 120s and mid to low 90s, respectively, during these episodes. He remains asymptomatic. . We discussed starting anticoagulation, but felt that it was unnecessary and potentially harmful in this patient with a CHADS-2 score of 1 (age), potential medical non-compliance (history of homelessness), and significant fall risk (history of multiple mechanical falls in recent weeks). We started him on aspirin at a dose of 325 mg once daily. .. # HISTORY OF FALLS: History as above seemed most consistent with mechanical falls due to balance and gait problems. [**Name (NI) **] loss of consciousness or cardiac prodromal symptoms to suggest arrhythmic cause, although certainly AF could be contributing to his generalized weakness and propensity to fall. Neurologic exam was nonfocal and CT was negative for acute process. . He was seen by physical therapy who recommended rehab. However, he declined this option; in the end he left against medical advice so that he could return home. We arranged for him to have a walker as well as home PT/OT visits and VNA visits. . # LOW-GRADE FEVERS / PULMONARY INFILTRATE ON CXR: He had persistent fevers overnight with Tm of 101.6. Chest CT showed no infiltrate but did show diffuse nodules and adenopathy concerning for malignancy. Blood and urine cultures were negative and there were no localizing symptoms. White count was WNL with no bands on the differential. No source for his fevers was found, and he was not started on antibiotics. Further work-up would require tissue sample of his pericardial effusion or mediastinal lymph nodes. At time of discharge, he had remained afebrile for over 24 hours. .. # RENAL FAILURE: Urine electrolyes were consistent with prerenal azotemia. His ARF resolved with IVF boluses in ED. There were no further concerns. .. # ANEMIA: Iron, TSH, vitamin B12 and folate studies were normal. His anemia is likely secondary to marrow suppression from his underlying process, most likely a malignancy. .. # GOALS OF CARE: These were discussed with Mr. [**Known lastname 1924**] when his underlying disease remained uncertain. We explained that we would need a tissue sample to definitively diagnose the cause for his pericardial effusion and bilateral pleural effusions. We explained that this would likely provide an explanation for his presenting symptoms, namely his shortness of breath and anemia. He was also seen by physical therapy, who noted that he was too weak to go home and should be discharged to rehab. However, it was clear that Mr. [**Known lastname 1924**] wanted to return to his home and was not interested in any invasive procedures, even if these might reveal a potentially treatable cause for his symptoms. We suggested that he consider hospice care, but he did not want to leave his home for a hospice facility. . Prior to leaving, he signed an AMA form. Eventhough he returns home against medical advice, he has agreed to have VNA come visit him, as well as PT/OT, meals on wheels, and elderly services. We have provided home oxygen if he needs it during activities, although his O2 sats have been fine on RA when walking with walker. He has confirmed his code status is DNR/DNI. .. # He was given a regular diet. Subcutaneous heparin was used for DVT prophylaxis. Code status was discussed and at his request he was made DNR/DNI. Medications on Admission: None. Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed: Hold for diarrhea. 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Oxygen Oxygen via NP 2-4L prn to keep O2 sat> 90% while lying flat and with activity. O2 sat on RA decreased to 87% on RA. 5. Toprol XL 100 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:*2* 6. Diltiazem HCl 360 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: PRIMARY DIAGNOSES Atrial fibrillation with rapid ventricular response Pericardial effusion and bilateral pleural effusions .. SECONDARY DIAGNOSES History of Falls Likely metastatic lung cancer Discharge Condition: stable HR= 103 BP= 120/70's. O2 sat= 92-94% on 2L NP Discharge Instructions: You were admitted to the hospital with atrial fibrillation, a irregular fast heart rhythm. We treated this rhythm with medications to slow down your heart rate. You have a collection of fluid around your heart and lungs, called effusions. We asked you if you would agree to the removal of this fluid with a needle and you indicated you didn't want this done. You also have some nodules in your lungs that likely are cancer. You have told us that you don't want to have any more diagnostic tests or treatments. . We are sending you home and have asked a nurse to come to your house to check your blood pressure and heart rate so we know if the medicines are working. . Your medications have been changed. You have been started on METOPROLOL and DILTIAZEM, two medications to help keep you out of a fast heart rate. . Please take all of your medicines as instructed as they will help you feel better. Please call Dr. [**Last Name (STitle) 5280**] or Dr. [**Last Name (STitle) **] if you have more trouble breathing and the oxygen does not help, if you have chest pain or pressure, if you feel dizzy or weak. Followup Instructions: Primary Care: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5280**], MD Phone: [**Telephone/Fax (1) 250**]. Date/Time: [**10-13**] at 1:30pm. [**Hospital Ward Name 23**] [**Location (un) **]. Please contact [**Name (NI) **] [**Name (NI) 1968**] with any new appts or medication changes, she is the case management specialist: phone [**Telephone/Fax (1) 5281**] . Cardiology: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD. Phone: [**Telephone/Fax (1) 62**] Date/Time: [**10-10**] at 3:30pm. Please contact [**Name (NI) **] [**Name (NI) 1968**] with any new appts or medication changes, she is the case management specialist: phone [**Telephone/Fax (1) 5281**] Completed by:[**2174-10-3**]

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icd9cm

[ [ [] ] ]

[ "88.72" ]

icd9pcs

[ [ [] ] ]

17725, 17783

11141, 16936

367, 375

18020, 18075

4652, 11118

19231, 19982

3419, 3424

16992, 17702

17804, 17999

16962, 16969

18099, 19208

2879, 3055

3439, 4633

276, 329

403, 2527

2571, 2856

3071, 3403

29,190

152,652

30259

Discharge summary

report

Admission Date: [**2171-5-14**] Discharge Date: [**2171-5-29**] Date of Birth: [**2100-5-17**] Sex: F Service: SURGERY Allergies: Morphine / Paper Tape Attending:[**First Name3 (LF) 2597**] Chief Complaint: Gangrene and rest pain of the left foot Major Surgical or Invasive Procedure: [**5-14**] - Right femoral patch angioplasty and right external iliac angioplasty and stenting with 7 mm self- expanding stent and redo right-to-left femoral-femoral bypass with 6 mm PTFE graft [**6-2**] - Left above-the-knee amputation. History of Present Illness: This very ill and fragile 72-year-old lady has gangrene of multiple toes of both her feet. She previously had a femoral-femoral bypass at another institution. This graft was found to be thrombosed this morning. The reason for the thrombosis appears to be inflow obstruction in the distal external iliac artery on the right which is the donor vessel in addition to extensive common femoral artery atherosclerotic stenosis proximal to the anastomosis. Past Medical History: PMH: - PVD s/p fem-fem bypass & R SFA angioplasty - COPD - at baseline requires O2 only when she leaves the home - Dry gangrene of B/l toes - R breast ca s/p R mastectomy ([**2169**]), XRT, chemo - PNA 1-2 years ago - DM? impaired glucose tolerance [**12-21**] corticosteroids? - hyperlipidemia - CKD, baseline Cr 1.0-1.4 - HTN - CHF - diastolic, EF 50% - seizure d/o - liver disease? coagulopathy - diverticulitis - TB - PUD/GERD - short term memory loss - anemia - MRSA colonization . PSH: - R rotator cuff repair - partial colectomy for diverticulitis - fem-fem bypass & R SFA angioplasty Social History: 30-50 pack year hx of tob (quit 6 months ago), no EtOH in 25 years, but did have problems with alcohol use, no sick contacts at home. Daughter, [**First Name4 (NamePattern1) 803**] [**Last Name (NamePattern1) 72044**] is the HCP ([**Telephone/Fax (1) 72045**]); other daughter's name is [**Name (NI) **] [**Name (NI) **], [**Telephone/Fax (1) 72046**] (cell), [**Telephone/Fax (1) 72047**] (home) Family History: no lung ca, no COPD, no breast ca Physical Exam: deceased Pertinent Results: [**2171-5-29**] 02:54PM BLOOD WBC-27.1* RBC-3.91* Hgb-11.9* Hct-35.1* MCV-90 MCH-30.4 MCHC-33.9 RDW-16.5* Plt Ct-350 [**2171-5-29**] 08:39AM BLOOD PT-12.4 PTT-39.0* INR(PT)-1.1 [**2171-5-29**] 02:11PM BLOOD Glucose-128* UreaN-26* Creat-0.9 Na-135 K-4.2 Cl-104 HCO3-20* AnGap-15 [**2171-5-29**] 02:11PM BLOOD CK(CPK)-160* [**2171-5-29**] 02:11PM BLOOD Calcium-7.8* Phos-3.6 Mg-2.6 [**2171-5-29**] 03:28PM BLOOD Type-[**Last Name (un) **] pO2-39* pCO2-53* pH-7.19* calTCO2-21 Base XS--9 [**2171-5-29**] 02:18PM BLOOD Glucose-123* Lactate-3.0* K-4.1 [**2171-5-29**] 08:40AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.008 URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD URINE RBC-[**1-21**]* WBC-[**10-8**]* Bacteri-FEW Yeast-NONE Epi-0-2 Brief Hospital Course: pt admitted Broad spectrum AB started [**5-14**] - Right femoral patch angioplasty and right external iliac angioplasty and stenting with 7 mm self- expanding stent and redo right-to-left femoral-femoral bypass with 6 mm PTFE graft Intraprocedure - episodes of hypotension, dropping pressure down to as low at the 60s. She nearly died as a result of hemodynamic instability during this procedure She was extubated in the OR and transfered to the PACU in critical condition. Once recovered from anesthesia she was then transfered to the VICU. She remained in the VICU. Overall she was doing well, progressing to with PT. She was monitered throughout her stay. In the interim, her left foot has became severely ischemic and partially nonviable with demarcation of her temperature level at about the level of the knee joint. Because of her very tenuous medical status, she was advised to have an above-the-knee amputation. Because of previous operation, it was felt that she was not to be a candidate for further vascular reconstruction. It was discussed with the family to procede with a LAKA. She was pre-op'd for the below procedure [**5-23**] - Left above-the-knee amputation. She did tolerate the procedure well. There were no intra-op complications. She was extubated in the OR and transfered to the PACU in stable condition. Once recovered from anesthesia she was then transfered back to the VICU. She remained in the VICU. she was monitered carefully. Labs were corrected. [**5-28**] - transfered to the CSRU resp distress / intubation. [**5-29**] - Pt deceased. Medications on Admission: [**Last Name (un) 1724**]: zocor 20, protonix 40, trental 400", ECASA 81, combivent"", lisinopril 20, lasix 20, colace 100", gabapentin 600", dilauded 2"", vicodin 5q4, procrit 20Kqwk, bisoprolol 5 Discharge Medications: Deceased Discharge Disposition: Expired Discharge Diagnosis: Deceased Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased Completed by:[**2171-6-6**]

[ "250.00", "518.81", "428.0", "401.9", "V66.7", "486", "428.30", "276.51", "693.0", "V15.3", "038.9", "995.92", "496", "458.29", "440.24", "272.4", "V10.3", "440.31" ]

icd9cm

[ [ [] ] ]

[ "39.90", "00.40", "00.33", "96.71", "39.50", "89.60", "96.04", "39.56", "00.45", "39.49", "84.17", "00.14", "99.04", "86.11", "38.93" ]

icd9pcs

[ [ [] ] ]

4873, 4882

3010, 4592

321, 561

4934, 4944

2165, 2987

5001, 5039

2085, 2121

4840, 4850

4903, 4913

4618, 4817

4968, 4978

2136, 2146

242, 283

589, 1040

1062, 1655

1671, 2069

15,038

186,709

45284

Discharge summary

report

Admission Date: [**2189-5-16**] Discharge Date: [**2189-5-27**] Date of Birth: [**2110-1-7**] Sex: F Service: MEDICINE Allergies: Sulfonamides Attending:[**First Name3 (LF) 3233**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Intubation History of Present Illness: HPI: 79F with Hx of [**Doctor Last Name 352**] zone lymphoma (immunologic and morphologic features of Hodgkin's and NHL)currently day 22 (cycle 2) of British MOPP. She received her last chemo dose on [**2189-5-14**]. pt transferred from [**Hospital1 **] to [**Hospital1 18**] ED with SOB (88% on RA) beginning 1d PTA, associated with DOE and "weakness", and a cough productive of some yellow sputum. She denied CP, palpitations, fever, chills, abdominal pain, rashes, diarrhea, headache, or myalgias. She reported nausea and emesis x1 yesterday. A CXR showed CHF and patient had an ECHO in [**3-26**] that showed diastolic dysfunction. She was given O2 and her saturation and SOB improved. . This morning the patient had worsening SOB, CXR showed CHF and received 40 mg IV lasix with diuresis of >400 cc with improved breathing but had ABG of 7.45/33/61 so x-ferred to [**Hospital Unit Name 153**] for closer monitoring. Past Medical History: HTN DM type 2 s/p AAA repair w/ bypass graft GERD Hyperlipidemia LBP Social History: Lives alone in [**Location (un) **], originally from [**Country 2045**]. no tob or EtOH. Family History: FH: +CAD son, +DM siblings Physical Exam: (Upon transfer to [**Hospital Unit Name 153**]) VS: Tmax 101.4 84 100/52 18 93% on NRB. gen: pleasant and cooperative, resting in bed and not complaing of SOB currently, but in NAD. skin: no rashes HEENT: anicteric sclera, OP clear neck: supple, no masses, no JVD CV: RRR, nl S1&S2, II/VI SEM @ USB. chest: diffuse wet crackles > at bases, no wheezes. abd: obese, soft, NT, +bs, no hepatosplenomegaly ext: 1+ edema in all extr., LE>UE, no cyanosis or clubbing. GU: no CV tenderness. neuro: A&Ox3, normal mentation, CN II-XII intact, motor, reflexes, and sensory normal and symmetric. Brief Hospital Course: This patient was a 79 year-old female with a past medical history of malignant B-cell lymphoma (S05-[**Numeric Identifier 96750**]) and s/p two cycles of chemotherapy, type II diabetes, hypertension, remote axillo-femoral bypass graft, and anemia of chronic disease. She was initially seen at [**Hospital6 310**] and was transferred to [**Hospital3 **] on [**2189-5-16**] for further evaluation of shortness of breath that began one day prior to admission. An echocardiogram performed in [**2189-3-22**] had shown an ejection fraction of 60% and impaired left ventricular (LV) filling. A chest X-ray on admission was consistent with congestive heart failure (CHF). She was treated with furosemide but continued to require oxygen. She was transferred to the ICU for further management. Her shortness of breath (SOB) continued to worsen and CXR showed worsening bilateral pulmonary edema and increase in the size of pleural effusions. The patient was empirically started on antibiotics. A repeat echocardiogram revealed an EF of 50-55% and mild LV dysfunction. She initially improved with antibiotic therapy and diuretics however her respiratory status began to worsen again and she was febrile several days later. Blood cultures were negative. The patient agreed to have VATS; however the patient developed a pneumothorax as a result of a right subclavian central line placement. A chest tube was inserted and the VATS was postponed pending clinical improvement. She continued to worsen and required intubation on [**2189-5-26**]. The patient failed to improve and expired on [**2189-5-27**]. Medications on Admission: protonix 40mg po qd CaCO3 500mg po qid/prn nifedipine CR 90mg qd allopurinol 300mg qd trazadone 25mg qhs prednisone 40mg qd valsartan 80mg qhs acyclovir 200mg q12 atenolol 50mg qd lantus 40 SQ qhs humalog SS Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A Completed by:[**2189-9-20**]

[ "285.22", "593.9", "733.00", "287.5", "276.1", "458.9", "428.30", "518.81", "V58.67", "070.30", "780.6", "512.1", "112.0", "428.0", "250.00", "530.81", "788.5", "202.80", "V66.7" ]

icd9cm

[ [ [] ] ]

[ "96.04", "34.04", "96.71", "38.93", "99.04", "99.05" ]

icd9pcs

[ [ [] ] ]

4015, 4024

2127, 3729

292, 304

4075, 4084

4136, 4170

1470, 1498

3987, 3992

4045, 4054

3755, 3964

4108, 4113

1513, 2104

233, 254

332, 1256

1278, 1348

1364, 1454

22,836

126,848

13633

Discharge summary

report

Admission Date: [**2175-5-13**] Discharge Date: [**2175-6-7**] Date of Birth: [**2116-11-12**] Sex: M Service: MEDICINE Allergies: Percocet Attending:[**First Name3 (LF) 3266**] Chief Complaint: SOB Major Surgical or Invasive Procedure: Thoracentesis x 2, paracentesis x 2 Pleurodesis Redo TIPS History of Present Illness: 58M with EtOH cirrhosis s/p TIPS placement, hx of R hydrothorax with last EtOH use in Winter [**2174**], who s/p day 7 for a thoracentesis and paracentis. Patient presents today with SOB. He feels most comfortable when he lies on his right side. He denies any chest pain or palpitations. He initially felt better after these interventions. However he has since noted increasing abdominal distention. He denies any n/v/f/c/abd pain. . In the ED, the patient's vitals were as follows: T98 BP 125/76 HR 102 R22 O2sat 97%RA. CXR showed a very large right-sided pleural effusion increased since the [**2175-5-6**] study. The liver fellow was contact[**Name (NI) **] who recommended admission and thoracentesis in the AM. Past Medical History: 1. EtOH cirrhosis: decompensated with ascites and varices, on transplant list 2. Colonic adenoma: polypectomy in [**2171**] 3. Esophageal varices: grade 1 on last EGD in [**8-26**], s/p banding of grade II varices in [**10-25**], h/o hematemesis in the past 4. Cholelithiasis 5. Partial colectomy: at [**Hospital3 **] in [**2158**] [**2-24**] severe GI bleed after polypectomy 6. hernia repair Social History: Catholic Priest. [**Name (NI) **] children. No tobacco. Currently no EtOH. Formerly a heavy drinker (cannot quantify). Currently living with parents. Family History: no fam hx of cirrhosis/liver disease; 6 siblings, all healthy. parents both alive and healthy Physical Exam: VS: Tc 98, BP 125/76 HR 102, RR 22, SaO2 97%/RA General: chronically ill-appearing male in NAD, able to speak in full sentences, lying comfortably in BED HEENT: NC/AT, PERRL, EOMI, no scleral icterus,no LAD, MMM, OP clear Chest: decreased BS over right lung base, no RRW CV: nl rate, S1S2, II/VI HSM along LUSB Abd: soft, NT, distended, +fluid wave, no peritoneal signs Ext: no c/c/e, wwp Neuro: no asterixis, CN II-XII intact, no motor or sensory abnormality Pertinent Results: STUDIES: [**2175-5-13**] CXR: very large right-sided pleural effusion increased since the [**2175-5-6**] study. . [**2175-5-15**]: Diagnostic and therapeutic paracentesis: Approximately 2 liters of ascitic fluid removed. . [**2175-5-16**]: RUQ USN: There is wall to wall flow within the TIPS. The velocity within the main portal vein is 40 cm per second. The velocities within the proximal, middle and distal TIPS are 98 cm per second, 141 cm per second, and 231 cm per second, respectively. The appropriate reversal of flow is demonstrated within the right anterior portal vein and left portal vein. These findings are similar compared to prior study. Also noted are extensive varices within the oeft upper quadrant in the vicinity of the splenic hilum. . . [**2175-5-20**]: Two chest tubes remain in place in the right hemithorax. Additionally, two [**Doctor Last Name 1356**] clamps overlie the lower right abdominal and chest wall with the tip of one of the clamps overlying the lower of the two chest tubes. Very small lateral hydropneumothorax is identified in the upper right hemithorax corresponding to a site of previously composed of pleural fluid without definitive air within its contents on a previous exam. Interstitial pattern in the right lung is again demonstrated likely due to asymmetric interstitial edema and there are minor atelectatic changes at the right lung base. Subcutaneous emphysema has markedly increased in the right chest wall. . [**2175-5-25**] CXR PICC PLACEMENT: Uncomplicated ultrasound and fluoroscopically-guided PICC line placement via the right brachial venous approach with a tip positioned in SVC. . . [**2175-6-1**] ABD USN: Small amount of likely ascites in the right upper quadrant. No significant pocket of ascites was identified that would be suitable to mark for paracentesis by the clinical staff. . [**2175-6-2**] CXR: Small right pleural effusion has increased slightly in volume since [**5-30**] and 9 following removal of right basal pleural tube. The apical tube is unchanged in position. Consolidation in the posterior segment of the right upper lobe has recurred concerning for aspiration pneumonia. Lungs otherwise showed generalized vascular congestion. Mild edema present yesterday has resolved even though heart size has increased slightly. No pneumothorax. . . LABS: [**2175-5-13**] 07:40PM BLOOD WBC-9.4 RBC-2.72* Hgb-9.1* Hct-26.9* MCV-99* MCH-33.6* MCHC-33.9 RDW-18.7* [**2175-5-14**] 07:15AM BLOOD WBC-7.4 RBC-2.41* Hgb-8.2* Hct-23.8* MCV-99* MCH-34.2* MCHC-34.6 RDW-18.6* Plt Ct-73* [**2175-5-19**] 06:08PM BLOOD WBC-7.3 RBC-2.95* Hgb-9.9* Hct-29.5* MCV-100* MCH-33.6* MCHC-33.6 RDW-17.6* [**2175-5-25**] 04:40AM BLOOD WBC-16.1* RBC-2.67* Hgb-9.1* Hct-26.1* MCV-98 MCH-34.1* MCHC-35.0 RDW-20.4* Plt Ct-96* [**2175-5-30**] 04:54AM BLOOD WBC-6.5 RBC-2.87* Hgb-9.8* Hct-27.6* MCV-96 MCH-34.0* MCHC-35.3* RDW-20.1* [**2175-6-5**] 06:23AM BLOOD WBC-6.5 RBC-2.48* Hgb-8.1* Hct-22.9* MCV-92 MCH-32.8* MCHC-35.6* RDW-18.1* Plt Ct-59* [**2175-6-6**] 04:38AM BLOOD WBC-6.6 RBC-2.89* Hgb-9.6* Hct-27.2* MCV-94 MCH-33.3* MCHC-35.5* RDW-18.7* Plt Ct-73* [**2175-6-7**] 05:33AM BLOOD WBC-8.1 RBC-2.83* Hgb-9.6* Hct-26.9* MCV-95 MCH-33.8* MCHC-35.6* RDW-20.1* Plt Ct-82* . [**2175-5-13**] 07:40PM PT-18.1* PTT-39.0* INR(PT)-1.7* [**2175-5-13**] 07:40PM PLT SMR-UNABLE TO [**2175-5-13**] 07:40PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-2+ MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-1+ TEARDROP-1+ FRAGMENT-1+ [**2175-5-13**] 07:40PM NEUTS-74.9* BANDS-0 LYMPHS-9.6* MONOS-8.4 EOS-6.6* BASOS-0.5 [**2175-5-13**] 07:40PM WBC-9.4 RBC-2.72* HGB-9.1* HCT-26.9* MCV-99* MCH-33.6* MCHC-33.9 RDW-18.7* [**2175-5-13**] 07:40PM ALBUMIN-2.7* [**2175-5-13**] 07:40PM LIPASE-77* [**2175-5-13**] 07:40PM ALT(SGPT)-17 AST(SGOT)-43* LD(LDH)-308* ALK PHOS-115 AMYLASE-139* TOT BILI-7.1* [**2175-5-13**] 07:40PM estGFR-Using this [**2175-5-13**] 07:40PM GLUCOSE-109* UREA N-21* CREAT-1.3* SODIUM-134 POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-25 ANION GAP-11 Brief Hospital Course: A/P - 58 y/o male with EtOH cirrhosis, recurrent ascites s/p TIPS with recent revision, recurrent hepatic hydrothorax, p/w SOB. . . # hemetemesis: on [**6-3**], pt had episode of hemetemesis (1.3L bright red blood). pt refused NGT placement, his hemetemesis resolved, and on the following morning, decision was made not to attempt EGD as it would require intubation, which was felt counter to pt's goals of treatment. he received 4U PRBCs, with stabilization of his hematocrit. on [**6-6**], plan was to perform EGD purely for paliative banding, however pt's HCT had remained stable, thus no further intervention was pursued. . . # right hepatic hydrothorax: pt presented with right hepatic hydrothorax, felt [**2-24**] his chronic abdominal asicites. attempt was made to revise his TIPs, however this was felt patent, with gradient of 6mm Hg, thus pt went onto receive pleurodesis on [**5-22**]. a chest tube was placed, however, output remained significant over the course of the next 2 weeks. Fluid cultures revealed +MSSA, which was treated with a course of nafcillin. Ultimately, decision was made to remove chest tube, as it was felt that output would continue to remain significant despite maximal therapy of his liver disease. Plan was to perform serial thoracentesis as needed. . chest tubes were removed, and pt continued to have significant drain site output. multiple stiches were placed however his output continued to be 500-1000cc daily. an ostomy bag was affixed to the site of his chest tube drains. given his goals of care, no further intervention was performed. his pain was controlled with oxycontin, oxycodone, and prn morphine iv for breakthrough pain. . . # ascites [**2-24**] ESLD: pt received 2 paracentesis, with relief of his ascites. he was managed with diuretics initially, however these were held [**2-24**] hyponatremia. elevated creatinine were noted on [**5-31**] pt was noted to have rising creatinine, raising concern for hepatorenal syndrome [**2-24**] SBP, given +cultures from pleural fluid (which was draining from asictes). he was treated with a 5d course of zosyn to cover for other gut flora. subsequently, his renal function improved, and he denied any abdominal pain. . . # elevated WBC - etiology unclear, pt notes some diarrhea overnight, thus concerning for c. diff (on cipro), UA dirty [**5-22**], though UCx were negative x 2. will repeat labs this morning, with diff, check stool cultures, repeat urine culture, and blood culture, and f/u on routine daily CXR given chest tube placement. . . # hyponatremia - pt presented with Na 134, he has a h/p low sodium, felt [**2-24**] liver disease. on [**5-25**] his Na was noted to be 121, his diuretics were discontinued, he was treated with 1L fluid restriction. he was breifly treated with octreotide/midrodine and albumin given concern for hepatorenal syndrome on [**5-31**]. his Na was trending up at time of discharge (136), however diuretics were held given his h/o dropping his sodium quickly on diuretics, and concern about restarting diuretics with his low blood pressures. given his goals of care, he will be discharged off of diuretics. . . # ESLD: from alcohol cirrhosis, pt not a transplant candidate [**2-24**] ongoing alcohol consumption. he was treated with lactulose, rifaximin to prevent encephalopathy. he was discharged on nadolol 20 po qd. pt will cipro 250 mg po qd for SBP prophylaxis. given his poor prognosis from his liver dysfunction (Tbil 13.2), recurrent hydrothorax, and hemetemesis, goals of care were changed to DNR/DNI and plan was made to discharge pt to hospice. . . # anemia - baseline Hct 27-30 upon presentation. he was found to be guaic positive, with hct floating down slowly throughout his admission, for which he received multiple transfusions (9U PRBC) over ~2weeks. pt then had episode of hemetemesis on [**6-3**] as above. his HCT stablized without EGD, after 5U PRBC total, his last unit of PRBC on [**6-5**] resulted in hct 22-> 26-28. He has received a total of 13 units PRBC this admission. . . # ARF - pt presented with creatinine 1.3 (bl 0.9-1.1). on [**5-24**] and again on [**5-31**] pt had episodes of rising creatinine (peak 2.4 on [**5-31**]), which were concerning for hepatorenal syndrome given UNa<10, and failure to respond to fluid challenge. pt was treated with octreotide/midrodine/albumin, with rapid improvement in creatinine down to 1.1 on [**6-6**]. he continues to make good urine ouptut. . . # DISPO: goals of care discussion held on [**6-4**] between pt and dr. [**Last Name (STitle) **] (outpt hepatologist), plan was made to discharge pt to hospice. regarding [**Hospital **] hospice medications, please call his primary care physician [**Name9 (PRE) **],[**Name9 (PRE) **] [**Telephone/Fax (1) 41132**]. if any additional questions exists, please contact his hepatologist Dr. [**Last Name (STitle) 497**] (([**Telephone/Fax (1) 1582**]). Medications on Admission: HydrOXYzine 25 mg PO DAILY:PRN BuPROPion (Sustained Release) 100 mg PO QAM Lactulose 30 ml PO TID FoLIC Acid 1 mg PO DAILY Furosemide 40 mg PO BID Spironolactone 100 mg PO DAILY Hexavitamin *NF* one cap Oral daily Ursodiol 300 mg PO BID Discharge Medications: 1. Bupropion 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 2. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed. 3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 4. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 5. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours). 7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for Pain. 8. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One (1) Packet PO BID (2 times a day). 9. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 11. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 12. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 13. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 14. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 16. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed. 17. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q4H (every 4 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital1 656**] Family Hospice House Discharge Diagnosis: PRIMARY: hepatic hydrothorax ascites etoh cirrhosis hemetemesis (upper gi bleeding) SECONDARY: colonic adenoma esophageal varices Discharge Condition: Hemodynamically stable, afebrile, ambulating Discharge Instructions: you were admitted to the hospital with shortness of breath, this is being caused by fluid in your abdomen tracking into your lungs because of your severe liver disease. there is no further intervention available to you. you are being discharged to hospice. Followup Instructions: Please follow up with your PCP as needed. PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 41132**] Please arrange to be followed up with Dr. [**Last Name (STitle) 497**] at liver clinic as needed, ([**Telephone/Fax (1) 1582**]

[ "572.4", "585.9", "578.0", "511.8", "571.2", "584.9", "276.1", "285.1", "789.5", "276.7" ]

icd9cm

[ [ [] ] ]

[ "34.04", "34.92", "99.04", "39.50", "00.40", "88.51", "34.91", "54.91" ]

icd9pcs

[ [ [] ] ]

13124, 13191

6320, 11262

273, 332

13366, 13413

2273, 6297

13721, 13977

1681, 1777

11550, 13101

13212, 13345

11288, 11527

13437, 13698

1792, 2254

230, 235

360, 1078

1100, 1497

1513, 1665

32,260

105,611

9403

Discharge summary

report

Admission Date: [**2156-9-7**] Discharge Date: [**2156-9-17**] Date of Birth: [**2107-5-22**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Transfer from [**Hospital1 18**] [**Location (un) 620**] for worsening hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 49yoM with advanced anorectal carcinoma s/p anterior pelvic resection and colostomy, XRT and chemo with a recent admission to [**Hospital1 18**] for metastatic mets to the spine ([**8-7**]) who presented to [**Hospital1 18**] [**Location (un) 620**] on [**2156-9-2**] with 3 days of nausea, vomiting and increasing shortness of breath and dry cough. On initial evaluation at [**Location (un) 620**], O2 sats were found to be 88% on RA. Admission CXR revealed what was thought to represent b/l pneumonia so he was started on levofloxacin. WBC was elevated to 17K with 93% neutrophils at that time. A CT chest performed on [**9-3**] showed diffuse b/l reticularity, b/l lower lobe dense consolidation vs. atelectasis and b/l effusions. . Over the course of his [**Location (un) 620**] stay, O2 requirement increased daily from 2L->3L-->5L and then last evening he was placed on NRB. He received 10mg IV lasix last evening without improvement in respiratory status. Additionally, he was tranferred to the ICU and was placed on Bipap overnight with some decrease in WOB. CTA chest was ordered at [**Location (un) 620**] today to r/o PE, but pt. was unable to tolerate laying flat, less because of worsened dyspnea, more as a result of severe back pain [**3-5**] to his bony mets. Given suspiscion for PE, he was started empirically on heparin gtt prior to transfer. . Most recent ABG prior to transfer while on NRB was 7.48/29/57. . ROS: + fatigue, + anorexia, no fevers and chills. He does endorse dry mouth. No chest pain. He has been having some lower extremity edema (L>R) without orthopnea or PND. He does say he has been having shortness of breath over the past few days with cough, but not prior to this. Nausea and vomiting has improved, but not taking good PO given need for NRB/bipap. No current lower back pain. Past Medical History: PMH: # Anal/Rectal cancer, metastatic to spine T12,L1,L3,L4 and paraspinal retroperitoneal mass around L2, mets to lungs, liver # Rectal fissure # Hearing impaired, wears hearing aids . ONC HX: Diagnosed in [**3-8**] by rectal mass resection and biopsy demonstrating anal adenocarcinoma, he received chemoradiation with mitomycin and 5-FU up until [**Month (only) 958**] of this [**2154**], and had an anterior pelvic resection and pathology revealed a T3, N0 adenocarcinoma. He then received adjuvant 5-FU and leucovorin, which was completed on [**2154-9-30**]. In he noticed some new lumps above his left clavicle. He had a x-ray of the clavicle done which was unremarkable. biopsy of a left cervical node that was consistent with his anal adenocarcinoma, and he was then treated with FOLFOX and Avastin winter [**2155-8-2**]. Patient tolerated these treatments reasonably well, but did experience prolonged myelosuppresion (low plts) and due to adequate response, the treatment was stopped. Last dose in [**3-17**], cycle initiated [**2156-3-3**]. Social History: Married, lives in [**Location 620**] with wife, no children, works as Physicist, cat at home. No tobacco, social ETOH. Family History: Mother deceased [**7-8**], stroke and pancreatic ca Physical Exam: PE: T 98.9 HR 128 BP 100/65 RR 30-38 O2 sat 91-96% NRB HEENT: PERRL, dry MM Neck: Large left sided supraclavicular LN, neck supple CV: Sinus tachy, no mrg apprec. Resp: Decreased BS bibasilar, crackles mid lateral lung field (unable to sit pt. fully forward [**3-5**]) Abd: Ostomy bag with liquid brown output Ext: Nonpitting edema LLE, no palpable cord nor calf pain, RLE w/o edema, 2+ DP/PT pulses b/l Neuro: CN 2-12, strength, sensation grossly intact Pertinent Results: [**2156-9-2**] CXR at OSH: New bibasilar patchy opacities, most likely representing an underlying pneumonia. . [**2156-9-3**] CT chest from OSH: Interval increase in pulmonary metastases and hepatic metastases. Development of hilar and mediastinal lymphadenopathy. Interval development of bilateral pleural effusions, underlying atelectasis or consolidation. Interval increase in periaortic lymphadenopathy. Development of large left supraclavicular lymph node. . EKG: Sinus tachy to rate of 135, nml axis, no significant ST/T wave changes. . [**2156-9-11**] bilateral LE Doppler US: neg for DVT . [**2156-9-16**] LUE Doppler US: neg. for DVT Brief Hospital Course: The patient is a 49yoM with h/o of metastatic anorectal ca to spine, liver, lungs presents with worsening hypoxia in the setting of nonproductive cough. He was found to have probable lymphangitic spread of metastatic disease and transferred to [**Hospital1 18**] for close respiratory monitoring and possible chemotherapy. Hospital course by problem is as follows: . # Hypoxic/hypercarbic respiratory distress: In review of [**9-3**] chest CT, reticular pattern appears c/w lymphangitic spread of his disease and was likely the major precipitant in the decompensation of his respiratory status. Had been on face mask, but clinical evidence of increasing resp distress persisted(increased work of breathing, increased O2 requirement, tachycardia), and the patient was intubated on [**9-14**] for worsening respiratory distress and hypercarbia. Broad spectrum antibiotic coverage with zosyn, vancomycin, and azithromycin was initiated on admission for a question of PNA on admission CXR with leukocytosis and left shift. . # Fever: The patient spiked temperatures to 101s-102s during hospital course. There was no clear source of fevers. Infectious etiology was a possibility (e.g. VAP), but it was difficult to assess for new infiltrate on CXR and the patient was on broad-spectrum antibiotics (zosyn, vancomycin, and azithromycin) for the duration of admission. All cultures were negative to date. DVT/PE was considered with LUE swelling on exam; however Doppler US was negative for DVT. Etiolgy may be related to fever of malignancy. . # Sinus tachycardia: The patient demonstrated sinus tachycardia for the duration of admission. Etiology was most likely physiologic (tachypnea, fever, profound hypoxemia) with stable hemodynamics. There was lack of response to IVF boluses, making hypovolemia less likely. This was monitored closely for concern for development of tachyarrythmia. . # Metastatic anorectal ca: Last chemo in 2/[**2156**]. With known metastatic disease to bone, liver, lungs (worsening liver mets on [**9-3**] CT as well as hilar/mediastinal LNs). XRT in [**Month (only) 205**] performed for back pain [**3-5**] to his bony mets (low thoracic-lumbar spine). His cancer has previously been very chemosensitive, but since last treatment, appears to have rapid progression of disease given imaging as outlined above. The patient completed cycle of 5FU and G-CSF, which was tolerated well without significant side effects; however, there was little effect on metastatic disease during chemotherapy. During hospital course the patient developed a leukocytosis, most likely due to G-CSF treatment. Towards the end of his hospital course he developed a pancytopenia, likely related to the progression of his disease. . # Thrombocytopenia: The patient is chronically thrombocytopenic w/ platelet count 65K-154K in review of OMR labs, with evidence of declining platelets during admission. Heparin was held briefly for the question of HIT, but was restarted after HIT Ab panel was negative. Most likely etiology is either progression of metastatic disease versus 5FU treatment. . # ?DVT/PE: On admission the patient was started on a therapeutic heparin drip for concern of PE given hypercoagulable state, tachycardia, and tachypnea. He was unable to tolerate CTA per back pain from spinal metastases. Heparin drip was discontinued on [**2156-9-11**] after LE doppler US were negative for DVT. . # FEN: The patient had evidence of hypernatremia that responded well to free water repletion; this was likely hypovolemic hypernatremia given his poor po intake. He was maintained on TPN given the inability to take po during admission, and was started on tube feeds after intubation. . # During admission the patient was maintained on [**Last Name (LF) 32111**], [**First Name3 (LF) **] IV PPI, and heparin (gtt or sq) for prophylaxis. . # Communication: Wife is patient's HCP [**Doctor First Name **] [**Telephone/Fax (3) 32112**] . # Code: After discussion with the patient's oncologist and the ICU team regarding the lack of response to chemotherapy and the poor prognosis, the patient and his family decided to opt for comfort measures. On [**2156-9-17**], while the family was present the patient was bolused with fentanyl and was extubated to room air with a respiratory rate of 10. He became asystolic and was pronounced dead at 9:35am. Medications on Admission: Meds on admission to [**Location (un) 620**]: 1. MS Contin 10 twice a day, last dose on day of admission. 2. Zofran p.r.n. 3. Protonix 20 daily. . Medication on transfer: 1. Heparin gtt 2. Levaquin 500 mg qday (Day 1 = [**2156-9-2**]) 3. Prilosec 20 mg po qday 4. Zofran 4 mg IV q8 hr prn 5. Duonebs q 4-6 hr prn 6. Ativan 1 mg po q6 hr prn Discharge Disposition: Expired Discharge Diagnosis: Respiratory failure secondary to lymphangitic spread of anorectal carcinoma Discharge Condition: Expired

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icd9cm

[ [ [] ] ]

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42458

Discharge summary

report

Admission Date: [**2111-8-7**] Discharge Date: [**2111-8-11**] Date of Birth: [**2054-5-4**] Sex: M Service: SURGERY Allergies: Zosyn Attending:[**First Name3 (LF) 32612**] Chief Complaint: RUQ abdominal pain, N/V Major Surgical or Invasive Procedure: ERCP [**2111-8-8**] History of Present Illness: This is a pleasant 57 year-old Male with PMH significant for migratory athralgias with a diagnosis of stage IIB periampullary adenocarcinoma status-post pylorus-preserving Whipple procedure and completion of adjuvant chemotherapy with gemcitabine who presents with fevers, RUQ abdominal pain and nausea with emesis. . The patient initially presented with RUQ pain and had subsequent imaging noting pancreatic and biliary duct dilatation with a peri-ampullary pancreatic mass. Biopsy was performed and confirmed adenocarcinoma. Endoscopic U/S was performed in [**1-/2111**] and noted a 4.0 x 4.2-cm ill-defined mass in the peri-ampullary region which was heterogeneous and hypoechoic. It appeared to invade the duodenal wall. He underwent a diagnostic laparoscopy and elective pancreaticoduodenectomy (Whipple procedure) with pylorus preservation on [**2111-2-11**] with Dr. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **]. Final pathology noted T2 N1 stage IIB adenocarcinoma of the ampulla. [**6-28**] positive LNs were noted without perineural invasion. . He began on gemcitabine on [**2111-3-17**]. In his third week of cycle 1 he developed some neutropenia and his cycle was interrupted - but he ended up completing 4 cycles (day 15 was [**2111-7-3**]). Throughout his course, he had some issues with fatigue and nausea and the ocassional fever. Around the end of cycle 4 he began experiencing episodes of fevers to 101-102F with rare and non-restricting epigastric abdominal complaints and worsening fatigue. He also had ocassional nausea and emesis. His Oncologist did note an increase in his LFTs at that time. Of note, the plan was for his radiation therapy to commence on [**2111-8-10**]. . These periodic episodes of fever to 102F, fatigue and vague epigastric abdominal discomfort continued and he had some non-bloody particulate emesis with nausea. His abdominal pain is a [**8-18**] at its climax and occurs in the evenings; distributed in a band-like pattern with minimal radiation and is sharp and sometimes dull in character. Over the last several days, he notes persistent nausea, particulate and non-bloody emesis with some bilious output and lighter colored stools with darker urine. He denies melenic or hematochezia. He has had 15-20 lbs of unintentional weight loss over several months. His son recently had URI symptoms, but he denies headaches or vision changes. He has no nasal congestion, rhinorrhea or sore throat. He denies cough. He does note chills in the evenings. He has no dysuria or hematuria. He recently traveled to [**Country 6257**] to visit family. . In the [**Hospital1 18**] ED, initial VS 104.6 119 109/69 22 97% RA. Exam notable for marked scleral icterus and jaundice. Laboratory data notable for WBC 8.0, hematocrit 37.8%, platelets 205. LFTs: AST 87, ALT 223, AP 427, T-bili 6.4 and direct bili 4.6. Creatinine 0.8. Lactate 1.7. U/A was negative. A CT scan of the abdomen showed no intra- or extrahepatic bile duct dilatation and no abscess, but no PO contrast was given. He received Acetaminophen 1000 mg PO x 1, Morphine 5 mg IV x 1 and Zosyn 4.5 g IV x 1 - Zofran 4 mg IV was also given. Following Zosyn infusion, he developed periorbital swelling and lip swelling and this was discontinued with the administration of IV benadryl and IV methylprednisolone 125 mg x 1 with resolution of symptoms. Cefepime 2g IV was then provided. ERCP and General Surgery were consulted. The patient received a total of 5L of NS in the ED prior to transfer. Past Medical History: # Stage IIB periampullary adenocarcinoma s/p diagnostic laparoscopy and elective pancreaticoduodenectomy (Whipple procedure) with pylorus preservation ([**2111-2-11**]) # Migratory arthritis # Left orbital exoneration with prosthetic placement in childhood (traumatic injury) Social History: He is married and lives with his wife and son and daughter. His wife, [**Name (NI) **], is present. He lives in [**Location 6981**] near [**Location (un) 29158**]. He used to smoke a long time ago, but quit (roughyl 0.5 pack per week for 5 years over 20 years prior). He drinks a glass of wine each day with meals, but has none since the surgery. He is not currently working. He used to work as an irrigation foreman and also is a deacon for his church. Family History: no strong family history of malignancy or cardiovascular disease. Physical Exam: On admission VITALS: 97.9 76-78 110/68 18 98% RA GENERAL: Appears in no acute distress. Alert and interactive. Jaundice throughout. HEENT: Normocephalic, atraumatic. EOMI. PERRL on right; left prosthetic. Nares clear. Mucous membranes moist. Scleral icterus noted. NECK: supple without lymphadenopathy. JVD not elevated. CVS: Regular rate and rhythm, without murmurs, rubs or gallops. S1 and S2 normal. RESP: Clear to auscultation bilaterally without adventitious sounds. No wheezing, rhonchi or crackles. Stable inspiratory effort. ABD: soft, mildly tender to palpation in epigastrum and RUQ, non-distended, with normoactive bowel sounds. No palpable masses or peritoneal signs. Negative [**Doctor Last Name 515**] sign. EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses NEURO: CN II-XII intact throughout. Alert and oriented x 3. DTRs 2+ throughout, strength 5/5 bilaterally, sensation grossly intact. Gait deferred. No asterixis. . Pertinent Results: ERCP [**2111-8-8**] Impression: Evidence of pylorus-sparing Whipple anatomy was encountered. Both limbs were traversed with a duodenoscope. The incorrect limb was entered first, and marked with SPOT ink to avoid re-entering limb. The biliary limb was the entered with the duodenoscope. There was a tight angulation which the duodenoscope could not initially cross. A stiffening wire was used and the duodenoscope was able to move nearly to the area of fluoroscopically-noted hemoclips, but the limb was too long to completely navigate with a duodenoscope. The scope was then switched out for a colonoscope and the biliary limb was again entered. The surgically-placed hemoclips were noted several centemeters away from the blind end. The biliary ananastamosis was identified 2cm beyond the hemoclips. It was widely patent, draining clear bile, and there was no evidence of a a mass noted. A mild diffuse dilation was seen at the biliary tree on occlusion cholangiogram. Air bubbles were also noted, compatible with pneumobilia, as expected given the widely patent anastamosis. No filling defects or strictures were noted in the visualized biliary tree. No stent was placed because of free flow of bile and contrast, with no visible stricture or filling defect. Otherwise normal ERCP Brief Hospital Course: 57M with a PMH significant for migratory athralgias with a diagnosis of stage IIB periampullary adenocarcinoma status-post pylorus-preserving Whipple procedure ([**2111-2-11**]) and completion of adjuvant chemotherapy with 4 cycles of gemcitabine who presents with fevers, RUQ abdominal pain and jaundice with evidence of direct bilirubinemia. #Presumed Cholangitis - Patient presents with known periampullary carcinoma history and has undergone pylorus-preserving Whipple procedure. With suspicion of cholangitis, patient was placed on cipro and flagyl. ERCP performed was unremarkable, but given clinical presentation, cholangitis was high on differential. Blood cultures grew gram positive cocci, he was started on vancomycin. Speciation of the blood cultures revealed enterococci sensitive to Linezolid. He was provided with a 10-day course of Linezolid to be finished at home. # CHRONIC NORMOCYTIC ANEMIA - Chronic normocytic anemia with hematocrit in the 36-37% range at baseline without prior iron studies. Given malignancy diagnosis, normocytic anemia of chronic disease seems most likely. No suggestion of hemolysis. # PERIAMPULLARY ADENOCARCINOMA - Patient presents with known history of periampullary adenocarcinoma that was stage IIB with pylorus-preserving Whipple procedure performed in [**2-/2111**] followed by four cycles of gemcitabine therapy complicated by only episodic neutropenia. Completed therapy on [**2111-7-3**]. Planned for adjuvant radiation therapy [**2111-8-10**]. Medications on Admission: 1. Multivitamin 1 tablet PO daily 2. Senna 8.6 mg PO daily 3. Colace 100 mg PO BID 4. Protonix 40 mg PO daily 5. Compazine 10 mg PO Q6H PRN nausea Discharge Medications: 1. Ibuprofen 400 mg PO Q8H:PRN fever, pain RX *ibuprofen 400 mg 1 Tablet(s) by mouth Every 8 hours Disp #*40 Tablet Refills:*1 2. Linezolid 600 mg PO Q12H RX *Zyvox 600 mg 1 Tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0 3. Pantoprazole 40 mg PO Q24H RX *pantoprazole 40 mg 1 Tablet(s) by mouth daily Disp #*60 Tablet Refills:*2 4. Multivitamin 1 tablet PO daily 5. Senna 8.6 mg PO daily 6. Colace 100 mg PO BID 7. Compazine 10 mg PO Q6H PRN nausea Discharge Disposition: Home Discharge Diagnosis: Cholangitis, bacteremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the surgery service at [**Hospital1 18**] for treatment of your fevers. You have done well and are now safe to return home to complete your recovery with the following 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 [**6-18**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Please follow up with Dr. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **] in 6 months. Please call ([**Telephone/Fax (1) 86295**] to schedule an appointment. Please follow up with your primary care physician (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1169**], Address: [**Doctor Last Name 40418**], [**Location (un) **],[**Numeric Identifier 62441**] Phone: [**Telephone/Fax (1) 40420**]), weekly while taking Linezolid to monitor your liver function tests; two appointments have been made for you to follow-up at Dr.[**Name (NI) 91912**] office to have the liver function tests performed: [**2111-8-13**] and [**2111-8-20**]. Please arrive at the office at any time before 4:00pm on each of those days to have the test performed.

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icd9cm

[ [ [] ] ]

[ "51.10" ]

icd9pcs

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Discharge summary

report

Admission Date: [**2157-2-2**] Discharge Date: [**2157-2-4**] Date of Birth: [**2087-6-18**] Sex: F Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 2704**] Chief Complaint: Presenting on transfer for stent to Left carotid Major Surgical or Invasive Procedure: Thoracic aorta and subclavian angiography carotid (with and without cerebral) angiography PTA/stent x1 to Left Internal Carotid Artery. History of Present Illness: HPI: 69 y/o female with PMH significant for type 2 DM, CAD s/p angioplasty, and [**Hospital **] transferred from OSH for neuro eval and probable stenting of the carotid artery. Over the past two months, pt has been experiencing [**6-7**] minute episodes of slurred speech, right arm and leg weakness and confusion. The episodes come on quickly with no warning signs and resolve just as quickly with no residual deficits. Pt's daughter reports that the pt has had approximately 20 of these episodes. There was one episode in which pt choked at a restaurant and vomited which may have been due to swallowing difficulties. One day prior to admission, the pt's daughter witnessed another episdoe of slurred speech and weakness but this episode lasted 30 minutes before resolution. This caused the pt to present to the [**Hospital3 **]. An ultrasound done recently at her PCP's office showed a 99% stenosis of the left carotid artery. An MRI was also done at OSH that showed diffuse atherosclerotic disease within the intracerebral vessels. The pt comes to [**Hospital1 18**] with the films for stenting of the left carotid artery by Dr. [**First Name (STitle) **]. ROS: Pt denies chest pain, shortness of breath, abd pain, n/v/d, fevers, chills Past Medical History: 1. Type 2 diabetes mellitus 2. CAD s/p angioplasty- Pt's last cardiac cath in the [**Hospital1 18**] system was from 02/25/200. It showed a righ dominant system with two vessel branch CAD. The left main had a 20% distal stenosis, LAD with a mid and distal 30% stenosis, 40% ostial stenosis in the first diagonal, 50% ostial stenosis in the second diagonal, and a 40% ostial stenosis in the RCA. These findings were unchanged from [**2151-11-23**] except for some progression of the OM1 disease. 3. HTN 4. Diabetic neuropathy 5. S/P discectomy 6. S/P tonsillectomy 7. S/P cholecystectomy 8. S/P hysterectomy 9. DJD Social History: Pt lives with daughter, no tobacco, ETOH or illicit substance use. Family History: Father with stroke at age 57. Mother with HTN, deceased at 81. Physical Exam: temp 99.4, BP 158/78, HR 71, RR 16, O2 95% RA, BG 149 Gen: NAD, lying comfortably in bed HEENT: PERRL, EOMI, MMM, OP clear Neck: unable to appreciate JVD but appears not elevated; no bruits heard CV: RR, nl s1/s2, 2/6 systolic murmur at RUSB, cap refill <3 sec Chest: clear Abd: +BS, soft, NT, ND, no organomegaly Ext: warm, no edema, decreased sensation, pulses not palpable Neuro: CN 2-12 intact, reflexes 2+ upper ext, unable to obtain knee reflexes, sensation decreased in lower ext; strength 5/5 throughout; negative Babinski. Pertinent Results: [**2157-2-2**] WBC-8.7 Hgb-11.8* Hct-35.0* MCV-86 MCH-29.0 RDW-15.2 Plt Ct-223 [**2157-2-4**] WBC-8.4 Hgb-10.0* Hct-29.7* MCV-86 MCH-28.8 RDW-15.5 Plt Ct-179 [**2157-2-2**] PT-13.9* PTT-70.7* INR(PT)-1.2 [**2157-2-4**] PT-12.9 PTT-22.2 INR(PT)-1.0 [**2157-2-2**] Glucose-127* UreaN-16 Creat-1.2* Na-139 K-4.0 Cl-102 HCO3-28 [**2157-2-4**] Glucose-89 UreaN-24* Creat-1.8* Na-139 K-3.5 Cl-104 HCO3-27 [**2157-2-2**] Calcium-8.0* Phos-3.2 Mg-1.8 [**2157-2-4**] Calcium-8.3* Phos-3.7 Mg-1.9 [**2157-2-2**] Cholest-111 Triglyc-141 HDL-44 CHOL/HD-2.5 LDLcalc-39 LDLmeas-56 Catheterization report: Procedures: Thoracic aorta and subclavian angiography, carotid (with and without cerebral) angiography, PTA/stent x 1 [**Doctor First Name 3098**]. Hemodynamics: AO 196/70, RFA 163/106 Findings: Thoracic aorta - Type 1 arch. Subclavian artery: RSCA normal, LSCA normal. Carotid/vertebral arteries: RCCA normal. [**Country **] mild disease. [**Country **] fills the ipsilateral ACA, MCA, and contralateral ACA. The LCCA has an origin 30% lesion. The [**Doctor First Name 3098**] has a focal 99% lesion. The [**Doctor First Name 3098**] fills the ipsilateral MCA. Brief Hospital Course: A/P: 69 yr old female with hx of CAD s/p stent placement now with worsening TIA sx over the past two months and found to have 99% stenosis of the left carotid; transferred here from outside hospital for catheterization and stenting of her L ICA. 1. TIAs with 99% stenosis of the L internal carotid artery: The patient was transferred to [**Hospital1 18**] where she had a catheterization on arrival that demonstrated a 99% stenosis of the L ICA. She underwent uncomplicated stenting on the [**Doctor First Name 3098**] and was transferred to the CCU for observation overnight on a nitroprusside drip for blood pressure control. The introprusside drip was weaned off within the first few hours, and blood pressure was kept at goal of 110-150. She was walked by PT on the following morning and it was felt that she was somewhat unsteady, therefore she was kept for one more night in the hospital for observation. She also complained of one episode of slurred speech lasting only seconds on the following morning, which she thought was from a dry mouth. She was seen by the sroke service who felt that her unsteadiness of gait was related to her history of neuropathy for which she takes gabapentin. She walked with PT on the day of discharge, who felt that she was safe to go home. The stroke service did not believe her seconds of slurred speech represented any further TIA, and recommended holding her imdur to assure that her b.p. stayed above 110 systolic. She was discharged on her metoprolol 50 [**Hospital1 **], Lisinopril 40 daily, and amlodipine 5 daily. She was instructed to hold her imdur until she is seen by Dr. [**Last Name (STitle) 7047**] in a couple of days for a blood pressure check. She will be on lifelong Plavix and Aspirin. 2. Urinary retention: She had good urine output until removal of her foley catheter at which time she did not void for 8 hours. She was straight catheterized yielding only 330 cc's of urine. Her blood pressure had also dropped to 100-110 systolic, and creatinine had gone up to 1.8 (from 1.2 on admission), therefore it was felt she may have been slightly dry. She was started on NS at 100 cc/hr and recieved 500-1000 cc's prior to discharge, at which time she had spontaneously voided twice, approximately 50 cc each time. Her blood pressure had been back up to 140 for the two hours prior to discharge. She was instructed to stop taking her lasix for now, and have a chem 7 panel drawn in 3 days. The results will be sent to Dr. [**Last Name (STitle) 7047**], who will then instruct her regarding her lasix. 3. CAD: R dominant, s/p RCA stent, OM1 disease chronic. She had no evidence of cardiac ischemia. We checked a fasting lipid panel which showed an LDL at goal. We kept her on her outpatient dose of lipitor, and other medications as above. 4. DM2: We kept her on a regular insulin sliding scale while in house. 5. Diabetic Neuropathy: We continued her Neurontin. 6. FEN: She was given a cardiac/diabetic diet. She was given IVF post-angio for renal prophylaxis. Medications on Admission: 1. Imdur 120 mg daily 2. Lasix 40 mg daily 3. Potassium 20 mEq QAM and 10 mEq QPM 4. Neurontin 120 mg QAM and 60 mg QPM 5. ASA 81 mg daily 6. Zocor 20 mg QHS 7. Metformin 500 mg QAM and 1000 mg QPM 8. Norvasc 5 mg daily 9. Plavix 75 mg daily 10. Lopressor 50 mg [**Hospital1 **] 11. Colace 100 mg daily 12. Tylenol PRN 13. Pepcid 20 mg daily 14. Lisinopril 40 mg daily 15. BeneCor 40 mg daily 16. NPH insulin 36 units QAM and 48 untis QHS 17. Regular insulin sliding scale 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 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Gabapentin 300 mg Capsule Sig: Four (4) Capsule PO QAM (once a day (in the morning)). 4. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Tablet(s) 9. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 10. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). Capsule(s) 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 12. Outpatient Lab Work Please check a chem 7 panel. Please process STAT. Discharge Disposition: Home Discharge Diagnosis: TIA hypertension hyperlipidemia Discharge Condition: good Discharge Instructions: Take all of your medications as directed. Stop taking your lasix until seen by Dr. [**Last Name (STitle) 7047**] on Tuesday. Also stop taking your Imdur for now until Dr. [**Last Name (STitle) 7047**] checks her blood pressure on Tuesday and tells you it's o.k. to resume. Your goal blood pressure is 120-150s systolic. Monitor it at least a few times weekly. Call your doctors [**Name5 (PTitle) **] [**Name5 (PTitle) **] to the ER if you have any more headaches, weakness or trouble speaking. Followup Instructions: See Dr. [**First Name (STitle) **] as directed. See Dr. [**Last Name (STitle) 28688**] regularly every 3-4 months. You have an appointment with Dr. [**Last Name (STitle) 7047**] on Tuesday so that he can check your blood pressure and follow the results of your lab work. You will need to get your labs drawn on Monday (the day before your appt.). Follow up with the neurologists regarding your TIAs, call for an appointment at [**Telephone/Fax (1) 1694**]. You should have one within the next 2-3 weeks. They will schedule you for a repeat carotid ultrasound 3 months from now.

[ "715.90", "250.60", "V45.81", "272.4", "V45.82", "V58.67", "357.2", "V70.7", "414.01", "433.10", "788.20", "401.9" ]

icd9cm

[ [ [] ] ]

[ "88.41", "00.61", "00.63", "88.44", "88.42" ]

icd9pcs

[ [ [] ] ]

9055, 9061

4292, 7339

315, 453

9137, 9143

3101, 4269

9688, 10274

2469, 2534

7862, 9032

9082, 9116

7365, 7839

9167, 9665

2549, 3082

227, 277

481, 1732

1754, 2369

2385, 2453

82,554

195,385

35823

Discharge summary

report

Admission Date: [**2138-12-5**] Discharge Date: [**2138-12-13**] Date of Birth: [**2061-6-8**] Sex: M Service: CARDIOTHORACIC Allergies: Lipitor / Zocor Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2138-12-9**] Coronary Artery Bypass Graft x 3 (LIMA to LAD, SVG to DIAG, SVG to PLV) History of Present Illness: 77 y/o farmer with progressive dyspnea on exertion and chest tightness over past couple of months which have made his working difficult. Underwent cardiac cath which revealed severe three vessel disease. Transferred from OSH on [**12-5**] for surgical intervention. Past Medical History: Hypertension, Hyperlipidemia, Diabetes Mellitus, Benign Prostatic Hypertrophy, Colon cancer s/p resection and chemo, RLE gangrene, Degenerative disc disease s/p laminectomy, Kidney stone, s/p Hernia repair, Skin cancer s/p removal Social History: Quit smoking 30 yrs ago. Denies ETOH use. Family History: Non-contributory Physical Exam: At discharge: VS:T99 BP107/69 P92 RR18 Gen: No Acute Distress Chest:Lungs clear to auscultation bilaterally Heart:Regular rate and rhythm Abd:Soft, non-tender, non-distended Ext:Warm, trace edema Neuro:Non-focal Skin:Mediastinal incision clean, dry, and intact Pertinent Results: [**2138-12-8**] Vein mapping: Bilateral patent greater saphenous veins with small diameters on the right below the knee. The vein diameters on the left are better with small distal diameters near the ankle. Both lesser saphenous veins appear inadequate for conduit. [**2138-12-8**] Carotid U/S: Bilateral 1-39% ICA stenosis with minimal plaque. Normal vertebral flow. [**2138-12-9**] Echo: PREBYPASS: 1. The left atrium is moderately dilated. 2. No atrial septal defect or PFOis seen by 2D or color Doppler. 3. There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF 65%). 4. Right ventricular chamber size and free wall motion are normal. 5. The aortic root is moderately dilated at the sinus level. The ascending aorta is mildly dilated. There are complex (>4mm) atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 6. There are three aortic valve leaflets. Trace aortic regurgitation is seen. 7. The mitral valve leaflets are structurally normal. Mild to moderate ([**1-1**]+) mitral regurgitation is seen. 8. There is trace pericardial effusion. 9. Dr. [**Last Name (STitle) **] was notified in person of the results during the procedure. POSTOP: 1. Patient is on no infusions. 2. The left ventricular function remains unchanged with an EF 65%, ventricle is underfilled immediately post bypass with good filling after 500cc cell [**Doctor Last Name 10105**]. 3. The mitral and aortic regurgitation is unchanged. 4. Aortic contour is smooth after decannulation. [**2138-12-12**] 05:17AM BLOOD WBC-8.0 RBC-2.89* Hgb-8.9* Hct-26.0* MCV-90 MCH-30.7 MCHC-34.1 RDW-14.6 Plt Ct-260 [**2138-12-12**] 05:17AM BLOOD Plt Ct-260 [**2138-12-12**] 05:17AM BLOOD Glucose-116* UreaN-17 Creat-1.1 Na-137 K-4.6 Cl-101 HCO3-31 AnGap-10 [**2138-12-5**] 05:05PM BLOOD ALT-12 AST-19 LD(LDH)-182 AlkPhos-51 TotBili-0.3 Brief Hospital Course: Mr. [**Known lastname 81462**] was transferred from OSH after cath revealed severe three vessel disease. After admission he was medically managed and underwent the appropriate pre-operative work-up. On [**12-9**] he was brought to the operating room where he underwent a coronary artery bypass graft x 3. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one he was started on beta blockers and diuretics and gently diuresed towards his pre-op weight. His chest tubes and epicardial pacing wires were removed per protocol. On post-op day two he was transferred to the telemetry floor for further care. He continued to make good progress with no complications. He worked with physical therapy for strength and mobility. On post-op day four he was discharged home with the appropriate follow-up appointments. Medications on Admission: Arthrotec 75mg [**Hospital1 **], Tramadol, Omeprazole, Actos 20mg qd, Metformin 500mg [**Hospital1 **], Terazosin 10mg qd, Avodart 0.5mg qd, Pravastatin 80mg qd, Aspirin 325mg qd, Lopressor 25mg qd Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*30 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:*2* 3. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:*10 Tablet(s)* Refills:*2* 5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10 days. Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* 6. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:*45 Tablet(s)* Refills:*2* 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 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 chest pain. Disp:*40 Tablet(s)* Refills:*0* 9. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 10. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**First Name5 (NamePattern1) 5871**] [**Last Name (NamePattern1) 269**] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3 PMH: Hypertension, Hyperlipidemia, Diabetes Mellitus, Benign Prostatic Hypertrophy, Colon cancer s/p resection and chemo, RLE gangrene, Degenerative disc disease s/p laminectomy, Kidney stone, s/p Hernia repair, Skin cancer s/p removal Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lotions, creams or powders to incision until it has healed. You may shower and wash incision. 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: Follow-up with Dr. [**Last Name (STitle) 914**] in 1 month. ([**Telephone/Fax (1) 1504**] Follow-up with Dr. [**Last Name (STitle) 32255**] in 2 weeks. [**Telephone/Fax (1) 6256**] Follow-up with Dr. [**Last Name (STitle) 59121**] in [**2-2**] weeks. [**Telephone/Fax (1) 74523**] Completed by:[**2138-12-13**]

[ "401.9", "250.00", "414.01", "600.00", "413.9", "V10.83", "V10.05", "272.4", "338.29" ]

icd9cm

[ [ [] ] ]

[ "38.93", "36.15", "88.72", "36.12", "39.61" ]

icd9pcs

[ [ [] ] ]

5974, 6077

3248, 4254

302, 391

6417, 6424

1330, 3225

7201, 7513

1015, 1033

4502, 5951

6098, 6396

4280, 4479

6448, 7178

1048, 1048

1062, 1311

243, 264

419, 686

708, 940

956, 999

29,361

145,155

17273

Discharge summary

report

Admission Date: [**2150-6-28**] Discharge Date: [**2150-7-2**] Date of Birth: [**2089-12-2**] Sex: M Service: MEDICINE Allergies: Aspirin Attending:[**First Name3 (LF) 348**] Chief Complaint: Acute Pancreatitis & Gram Negative [**Hospital **] transfer from OSH. Major Surgical or Invasive Procedure: None. History of Present Illness: 60M PMH significant for chronic pancreatitis s/p multiple stenting procedures with most recent CBD stents x 3 [**2150-5-19**] presents with nausea, vomiting, diarrhea and severe abdominal pain after fatty meal. The morning of admission the patient had [**10-2**] sharp abdominal pain. Patient also experienced intermittent chills, subjective fevers. He vomited 6 times, no hematemesis. He had 2-3 episodes of diarrhea without melena, hematochezia. Last BM the morning of admission prior to arrival to ED. He states this is similar to his pancreatitis but the pain is much worse. It does not radiate to the back, nor does his classic pancreatitis pain. Patient states he has been abstinent of alcohol. Patient first admitted to [**Hospital3 **] Hospital where he received primaxin IV, dilaudid, zofran. CT abd/pelvis c/w acute pancreatitis. He was transferred to [**Hospital1 18**]. ED temp 102.3, HR 128, bp 156/94, 96% on RA. 3LNS NS, morphine 5mg iv *3. Given significant bandemia and history of complicated pancreatitis, he was transferred to the MICU for further care. Patient followed by surgery who noted absence of necrosis on OSH CT with recommendation for conservative management. In the MICU, the patient was given IVF and supportive care. [**1-24**] blood culture bottles returned positive for GNR and the patient was started on meropenem pending speciation and sensitivities. On transfer, the patient complains of epigastric -> LLQ pain relieved with dilaudid. No CP, SOB, n/v, dysuria. Currently the patient is resting comfortably with pain controlled on PCA. He is very interested in his treatment, the various IVs that are hung in his room, and his discharge disposition. His pain is constant on his Left abdomen. It is intermittent in his central abdomen. He denies chest pain, dyspnea, nausea or vomitting. Past Medical History: PMH: -Chronic pancreatitis secondary to prior EtOH abuse; s/p cyst-jejunostomy in [**2140**] for pseudocyst, then Peustow in [**2146**] w/limited efficacy, s/p biliary stents for CBD narrowing. Multiple complications in past including SMV thrombosis leading to portal HTN. Stents last changed [**2150-5-19**], most recent flare prior to this admission [**2150-6-9**]. -Hypertension -Hypercholesterolemia -Hearing loss - Wears hearing aids -Depression - Per medical records, patient denies Social History: Smokes 1ppd x 50 years. NO current EtOH. No IV drug use. Family History: Sister with stomach cancer and DM2. Father with throat cancer. Physical Exam: Vitals: Tm/Tc: 100.2 BP: 137/74 P: 81 RR: 20 O2Sat: 95% RA 24H I/O: 4L/4L Gen: Well-appearing, NAD HEENT: Sclera anicteric, PERRL, EOMI, OP clear, MM dry NECK: Supple, no JVD CV: RRR, no m/r/g LUNGS: Rhonchi at bases clearing with cough ABD: Obese, mild distention, tenderness to palpation in the epigastrum and left, normoactive bowel sounds, soft, no rebound, no guarding. Old scar on L abdomen from previous surgery. EXT: No c/c/e SKIN: No rashes NEURO: AAOx3, CN II-XII grossly intact, moving all extremities Pertinent Results: [**2150-6-28**] 11:07PM GLUCOSE-191* UREA N-6 CREAT-0.6 SODIUM-143 POTASSIUM-3.1* CHLORIDE-107 TOTAL CO2-24 ANION GAP-15 [**2150-6-28**] 11:07PM ALT(SGPT)-24 AST(SGOT)-28 ALK PHOS-96 AMYLASE-63 TOT BILI-0.3 [**2150-6-28**] 11:07PM LIPASE-70* [**2150-6-28**] 11:07PM WBC-16.8*# RBC-3.99* HGB-12.7* HCT-36.9* MCV-93 MCH-32.0 MCHC-34.6 RDW-14.0 [**2150-6-28**] 11:07PM NEUTS-66 BANDS-25* LYMPHS-3* MONOS-5 EOS-0 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 [**2150-6-28**] 04:15PM ALT(SGPT)-26 AST(SGOT)-39 CK(CPK)-70 ALK PHOS-135* AMYLASE-115* TOT BILI-0.6 [**2150-6-28**] 04:15PM LIPASE-181* [**2150-6-28**] 04:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-6.3 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2150-6-28**] 04:15PM NEUTS-51 BANDS-34* LYMPHS-6* MONOS-0 EOS-0 BASOS-0 ATYPS-0 METAS-7* MYELOS-1* PROMYELO-1* Studies: OSH CT abd/pelvis: severe pancreatitis, dilated bile ducts ECG: tachy 123, left axis, sinus, LBBB. similar to prior when admitted for pancreatitis. Discharge Labs: [**2150-7-2**] 05:35AM BLOOD WBC-5.7 RBC-3.62* Hgb-11.4* Hct-33.6* MCV-93 MCH-31.5 MCHC-33.8 RDW-13.2 Plt Ct-153 [**2150-7-1**] 05:40AM BLOOD Glucose-85 UreaN-9 Creat-0.5 Na-141 K-3.6 Cl-109* HCO3-22 AnGap-14 Brief Hospital Course: 60 year old male with history of complicated pancreatitis and heavy EtOH use who presents with fever, n/v/d, and abdominal pain after eating a fatty meal. Sx's are consistent with previous episodes of acute pancreatitis. 1. Pancreatitis: The patient was admitted to the MICU for acute necrotizing pancreatitis. He was made NPO, started on Protonix and IV Dilaudid for pain control. Upon transfer to the general medicine [**Hospital1 **] his diet was advanced to regular and pain medication changed to Dilaudid PO. He will follow up with Dr. [**Last Name (STitle) **] in 4 weeks. The patient was advised on avoiding high fat diets. 2. E-Coli Bacteremia: The patient was 2/4 bottles positive for pansensitive E-coli. He remained afebrile and stable throughout admission. He was started on Meropenem and converted to Cipro PO for a 14 day course once tolerating PO. Surveillance cultures have been no growth to date for at least 48 hours at the time of discharge. 3. Anemia: During admission the patient was at his baseline of 35, elevated to 40 during admission then returning after IV fluid administration. His hematocrit was stable and climbed throughout the admission. He was not started on iron at this time because of his bacteremia. Hyperglycemia: in response to severe pancreatitis and infection 4. Hypertension: The patient was maintained on Amlodipine once transferred to the floor. Medications on Admission: Medications on admission: Simvastatin 20 mg daily Pantoprazole 40 mg daily Amlodipine 5 mg daily Diazepam 5 mg [**Hospital1 **]:PRN, usually takes 1-2 per day Amitriptyline 200 mg daily - patient states he has stopped taking because he does not know if it helps Oxycodone-Acetaminophen 5-325 mg Q4H:PRN patient takes 3-4 per day for his chronic pancreatitis pain 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. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. 4. Diazepam 5 mg Tablet Sig: 1-2 Tablets PO once a day as needed. 5. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Hydromorphone 2 mg Tablet Sig: 2-3 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 11 days. Disp:*22 Tablet(s)* Refills:*0* 9. Acyclovir 5 % Ointment Sig: One (1) Appl Topical 5X/D () for 4 days. Disp:*qs * Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses 1. Acute Pancreatitis 2. Gram Negative Bacteremia 3. Iron-deficiency Anemia 4. Herpes Labialis Secondary Diagnoses 1. Chronic Pancreatitis 2. Hypertension 3. Hyperlipidemia Discharge Condition: Stable. Discharge Instructions: You have been admitted to the hospital with an episode of Acute Pancreatitis. While you were here, you were found to have a blood infection. Please see the medication list for changes to your home medications. 1. Ciprofloxacin by mouth twice a day for 11 days (ending Monday [**7-13**]). 2. Acyclovir Ointment applied to lips 5 times per day for 4 days. Please return to the emergency department for chest pain, shortness of breath, abdominal pain or any other medical concern. Followup Instructions: Please follow up with your Primary Care Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 48385**] within 1 week of discharge to evaluate your lip. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2150-8-6**] 1:15

[ "272.4", "790.29", "577.1", "054.9", "280.9", "305.00", "790.7", "576.9", "311", "401.9", "300.00", "577.9", "577.0", "041.85" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7287, 7293

4637, 6042

336, 344

7529, 7539

3418, 4387

8069, 8454

2805, 2869

6456, 7264

7314, 7508

6094, 6433

7563, 8046

4404, 4614

2884, 3399

227, 298

372, 2202

2224, 2714

2730, 2789

10,262

177,176

47610

Discharge summary

report

Admission Date: [**2175-4-9**] Discharge Date: [**2175-4-13**] Date of Birth: [**2126-9-26**] Sex: F Service: ICU CHIEF COMPLAINT: Respiratory distress. HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old female with a history of poorly differentiated adenocarcinoma of the lung with diffuse metastases to the liver, pelvis, and brain (status post carboplatin and Taxol radiation therapy 'Arissa') who was found to have brain metastases (status post resection) in [**2175-2-14**] who had been recently started on Navelbine salvage who presented on [**2175-4-10**] with hypotension, mild disseminated intravascular coagulation, acute renal failure, and supraventricular tachycardia. The patient's supraventricular tachycardia was responsive to adenosine, and the patient was volume resuscitated in the Emergency Department. She was treated broadly with ampicillin, levofloxacin, and Flagyl and was admitted to the Feniard Intensive Care Unit. The patient's hypotension resolved overnight and was thought largely secondary to volume depletion and possibly sepsis. At that time, she was made do not resuscitate/do not intubate by her husband. [**Name (NI) **] mental status was intermittent and confused. She was transferred to the floor where she improved for a few days. On [**4-12**], she developed agitation and further confusion; requiring Haldol. The patient was noted to develop stridor and tachycardia. Multiple nebulizer treatment were tried without affect. The patient was given Benadryl 25 mg p.o. times two and Cogentin 2 mg times two for suspected laryngeal dystonia from Haldol. The patient was given Pepcid 20 mg intravenously times one and dexamethasone 10 mg intravenously for a potential allergic reaction with no improvement. The patient was unable to speak secondary to distress. Ear/Nose/Throat was consulted and found no upper airway obstruction and normal cords. The patient was admitted to the Feniard Intensive Care Unit for a trial of [**Hospital1 **]-level positive airway pressure. PAST MEDICAL HISTORY: 1. Poorly differentiated lung adenocarcinoma diagnosed in [**2173-4-16**] with three right upper lobe lesions; treated with Taxol and carboplatin. The patient was found to have new lung nodules, liver metastases, and pelvis metastases in [**2174-5-16**]. She was given radiation therapy and then Arissa. Over the course of [**2174-9-16**] to [**2175-9-16**] the patient was found to have increasing liver function tests and noted to have worsening liver metastases. In [**2175-1-14**], she was found to have brain metastases and underwent right frontal lobe resection with two smaller metastases remaining in [**2175-2-14**]. The patient was started on Navelbine salvage. 2. Reactive airway disease and emphysema. 3. Right thyroidectomy for colloid nodule. 4. Iron deficiency anemia. 5. Gastritis with Helicobacter pylori. 6. Depression. 7. History of abnormal PAP smear. 8. History of whole body image. 9. History of axillary abscess. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Atrovent meter-dosed inhalers. 2. Haldol 0.5 mg p.o. twice per day as needed. 3. Neutra-Phos two packets p.o. three times per day. 4. Sucralfate 1 g four times per day. 5. Dapsone 4 mg intravenously twice per day. 6. Iron 325 mg p.o. once per day. 7. Vitamin K 10 mg p.o. once per day. 8. Docusate 100 mg p.o. twice per day. 9. Lidoderm patch as needed. 10. Senna one tablet p.o. twice per day. 11. Lactulose 30 cc p.o. three times per day. CODE STATUS: The patient is do not resuscitate/do not intubate. SOCIAL HISTORY: The patient has a 20-pack-year history of smoking. Occasional alcohol use. FAMILY HISTORY: Brain cancer, thyroid cancer, coronary artery disease, hypertension, and asthma. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed temperature was 98, blood pressure was 150/70, respiratory rate was 28, heart rate was 125, and oxygen saturation was 92% on 4 liters. Generally, the patient was an ill-appearing female in moderate respiratory distress. Head, eyes, ears, nose, and throat examination revealed extraocular movements were intact. Mucous membranes were dry. Neck examination revealed no lymphadenopathy. Audible stridor on expiration was heard. Cardiovascular examination revealed tachycardia. Normal first heart sounds and second heart sounds. No murmurs, rubs, or gallops. The lungs were clear with the exception of decreased breath sounds up to halfway up the right lung field and one quarter of the way up the left lung field. The abdomen was firm, distended, and nontender with normal active bowel sounds. Extremity examination revealed no edema. On neurologic examination, the patient was acutely agitated. PERTINENT LABORATORY VALUES ON PRESENTATION: Pertinent laboratory findings revealed the patient had a white blood cell count of 12.3, hematocrit was 33.1, and platelets were 163. INR was 2. Chemistry-7 revealed sodium was 144, potassium was 3.7, chloride was 109, bicarbonate was 19, blood urea nitrogen was 28, creatinine was 0.8, and blood glucose was 129. Anion gap was 17. The patient had a fibrinogen of 143. D-dimer was greater than [**2171**]. FBE was 80 to 160. ALT was 213, AST was 737, alkaline phosphatase was 497, and total bilirubin was 2.9. Calcium was 7.8, phosphate was 2.3, and magnesium was 2.6. Lactate was 12.5. Free calcium was 1.15. PERTINENT RADIOLOGY/IMAGING: On chest x-ray the patient had a large right pleural effusion with a question of left lower lobe atelectasis. IMPRESSION: The patient is a 48-year-old female with a history of poorly differentiated lung cancer with diffuse metastases to the liver, pelvis, and brain; status post carboplatin, Taxol, radiation therapy, Arissa, and metastases resection (on Navelbine salvage) who presented with hypotension, mild disseminated intravascular coagulation, acute renal failure, and lactic acidosis who now returned to the Feniard Intensive Care Unit with acute respiratory distress. HOSPITAL COURSE BY ISSUE/SYSTEM: 1. PULMONARY ISSUES: The patient with a question of acute stridor with an unchanged chest x-ray. The differential diagnosis initially included a dystonic reaction from Haldol or an allergic reaction. However, the patient did not respond to Cogentin, Benadryl, steroids, or H2 blockers; and Ear/Nose/Throat ruled out any upper airway swelling or laryngeal spasms. Thus, it was thought that the patient had a fixed obstruction; perhaps some lymph nodes or lung cancer which became clinically evident as wheezing or stridor in the setting of increased mini-ventilation from progressive metabolic acidosis. Heliox was attempted without success, and the patient was started on [**Hospital1 **]-level positive airway pressure with no real improvement in her symptoms. She was not any more responsive on [**Hospital1 **]-level positive airway pressure and required morphine for some sedation to enable her to work with the [**Hospital1 **]-level positive airway pressure. Her respiratory status did not improve clinically. 2. NEUROLOGIC ISSUES: The patient with mental status changes in the setting of diffusely metastatic breast cancer with liver involvement and hepatic encephalopathy as well as hypoxia and worsening acidosis with hypercarbia. Her mental status did not improve despite the aggressive measures in the Intensive Care Unit. 3. GASTROENTEROLOGY ISSUES: The patient with rapidly progressive liver failure; likely secondary to metastatic non-small-cell lung cancer with diffuse involvement. Progressive metabolic lactic acidosis was likely secondary to hepatic failure. 4. HEMATOLOGY/ONCOLOGY ISSUES: The patient with metastatic lung cancer diffusely spread to liver, [**Hospital1 500**], and brain. Nearing the end-stage on salvage Navelbine. The patient had ongoing evidence of disseminated intravascular coagulation. The overall prognosis, according to the patient's primary oncologist, was uniformly poor. 5. CODE ISSUES: The patient presented with progressive lung cancer diffusely metastatic which was refractory to multiple chemotherapeutic regimens, brain metastases resection, and radiation therapy. She developed worsening respiratory failure in the setting of progressive lactic acidosis, pleural effusions, respiratory acidosis, and altered mental status. After discussing the patient's uniformly poor prognosis with her oncologist, as well as her husband (who was her health care proxy), the decision was made to make the patient comfort measures only. The patient expired with family at the bedside. CONDITION AT DISCHARGE: Expired. DISCHARGE STATUS: The patient expired. DISCHARGE DIAGNOSES: 1. Respiratory failure. 2. Poorly differentiated metastatic non-small-cell lung cancer. 3. Progressive metabolic lactic acidosis. 4. Right pleural effusion. 5. Liver failure. 6. Acute renal failure. 7. Disseminated intravascular coagulation. 8. Supraventricular tachycardia. 9. Reactive airway disease. [**Last Name (LF) **], [**First Name3 (LF) **] N. 12-981 Dictated By:[**Last Name (NamePattern1) 5246**] MEDQUIST36 D: [**2175-4-13**] 11:58 T: [**2175-4-15**] 05:05 JOB#: [**Job Number 100596**] cc:[**Last Name (NamePattern4) 100597**]

[ "518.81", "197.7", "584.9", "286.6", "572.2", "511.9", "198.5", "276.2", "197.0" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

3727, 6059

8737, 9325

3085, 3615

6093, 8650

8665, 8716

149, 172

201, 2046

2068, 3058

3632, 3709

59,411

183,306

1355

Discharge summary

report

Admission Date: [**2160-10-16**] Discharge Date: [**2160-10-22**] Date of Birth: [**2095-8-2**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor First Name 2080**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Hemodialysis continued on Sat, Tues, Thursday schedule History of Present Illness: Mr. [**Known lastname **] is a 65 year old male with a PMH significant for stage 5 CKD of unknown etiology complicated by secondary hyperparathyroidism and anemia who initiated dialysis on [**2160-10-1**]. He also has a history of tobacco use resulting in COPD now with a pulmonary nodule, HTN, CAD, HLD, hyperkalemia, gout, CVA, and carotid endarterectomy. Per daughter, patient knocked on her door at 3am, saying he couldn't catch breath, she gave him an albuterol neb which initially helped but then he stated he couldn't breath so they called EMS. When EMS arrived, his RR was 33 and SBP 170, felt he was in distress and intubated in the field. Daughter reports no new fever or cough, no increasing albuterol use (though states he has been taking a 'pill' instead of using his neb machine for the last 4 weeks), no missed dialysis, but patient with some increasing edema, particularly L>R leg. . In the ED, initial vs were: T:unknown P:70 BP: 170/60 R O2 sat 100% on ventilator. On exam, lungs sounded wheezing, 1+ edema. CXR showed RML pneumonia. Potassium high at 5.7. Sent blood and urine cultures. Labs notable for creatinine of 5.1, HCT 32.7, u/a negative, serum tox 1. Patient was given methylprednisone, ceftriaxone and levofloxacin. Is on propofol. No ABG done downstairs. . On the floor, patient is intubated and sedated. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. hypertension 2. hypercholesterolemia 3. peptic ulcer disease 4. colocutaneous fistula status post low anterior resection, colostomy, and a loop ileo-ostomy [**2154**] 5. history of pneumonia - 5 months ago in [**Country 3587**], spent 10 days in hospital 6. denies history of CAD or diabetes (however, metformin was on med list in [**8-18**] in OMR) Social History: He lives with his daughter, he is retired from instructing at a driving school. He has a significant smoking history, but quit in [**Month (only) 956**]. He does not drink alcohol or use drugs. . Family History: Brother is on dialysis as a complication of DMII. Mother also had diabetes. . Physical Exam: VS - Temp , BP , HR , R , O2-sat % RA GENERAL - well-appearing man in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, LUNGS - CTA bilat, no w/r/c, decreased breath sounds at bases L>R, go aeration, repirations unlabored HEART - RRR, nl s1, s2, II/VI SEM heard best at the R and L USB, no peripheral edema ABDOMEN - soft/NT/ND, no masses or HSM, no rebound/guarding +BS EXTREMITIES - His right hand is cool compared to his left, with 1+ radial pulse on the right and 2+ radial pulse on the left. He has an AVG in his right upper arm: strong bruit present, fistula site with stitches in place, no surrounding erythema or tenderness. SKIN - no rashes or lesions LYMPH - no cervical, supraclavicular LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**5-19**] on the right, and [**6-18**] on the left Pertinent Results: [**2160-10-16**] CT chest: No filling defects are seen within the pulmonary arteries to suggest pulmonary embolism. Pulmonary arteries are well seen into the subsegmental level. Pulmonary arteries are normal in size. The aorta is normal in caliber throughout the thorax. There is mild aortic atherosclerosis as well atherosclerosis at the origin of the great vessels. Great vessels are widely patent. Coronary artery shows extensive calcifications as well. Heart size is within normal limits. . Compared to [**2160-9-24**], there is a new development of moderate-large bilateral pleural effusions, right greater than left. Pleural effusions are dependent and without evidence of loculation. There is compressive atelectasis of the lower lobes bilaterally, right greater than left and of the right middle lobe as well. Collapsed lung parenchyma does enhance normally, arguing against pneumonia, however, there are fluid-filled airways in the right lower lobe which likely reflects retained secretions. A component of aspiration cannot be completely excluded here. There is no evidence for pulmonary edema within the lung parenchyma. Scattered centrilobular emphysema is again noted. Central airways are patent, with the endotracheal tube tip a few centimeters above the carina in expected position. . Borderline enlarged right paratracheal lymph node is essentially unchanged from the prior study. AP lymph node and prevascular lymph nodes as well as upper right paratracheal lymph nodes have slightly increased in size but do not meet pathologic size criteria. This is likely reactive. Similarly, borderline right hilar lymph node measuring nearly 1 cm in short axis is possibly slightly larger than the prior study, again, likely reactive. A subcarinal lymph node is also borderline and unchanged. There is trace pericardial fluid, slightly increased from prior. . NG tube has its tip within the stomach. Visualized portions below the diaphragm show no definite abnormality. Visualized portions of the base of the neck also show no definite abnormality. . BONE WINDOWS: No suspicious lytic or sclerotic bone findings with multilevel mild disc degeneration in thoracic spine. . IMPRESSION: 1.No pulmonary embolism. 2.Marked increase in bilateral pleural effusions since [**2160-9-24**] CT, with moderate-large right pleural effusion and moderate left pleural effusion without complication to suggest infection. 3.Right lower lobe collapse, enhances normally. Therefore, has an appearance more of atelectasis than pneumonia, though there are airway secretions which could reflect aspiration. Otherwise, dependent atelectasis. No definite evidence of pulmonary edema. 4.Appropriate positioning of endotracheal tube and NG tube. [**2160-10-16**] BILATERAL LOWER EXTREMITY DEEP VENOUS ULTRASOUND: [**Doctor Last Name **] scale, color Doppler and pulsed Doppler imaging of the left and right common femoral, superficial femoral, and popliteal veins demonstrate normal venous flow, compressibility and augmentation. No intraluminal thrombus is identified. Compression and color Doppler imaging of the calf veins normal. IMPRESSION: No evidence of right or left lower extremity DVT. . [**2160-10-17**] U/S right arm. IMPRESSION: 1. Negative study for DVT. 2. Grossly patent right upper extremity hemodialysis fistula. No collections identified about the fistula. . 9/4.10 CXR: FINDINGS: The endotracheal tube and NG tube have been removed. The heart is mildly enlarged. There is bilateral lower lobe volume loss that has worsenedcompared to the study from two days prior. Old rib fractures are again seenin the left. There are small bilateral pleural effusions left greater than right. . . LABS: [**2160-10-16**] 10:46PM CK(CPK)-100 [**2160-10-16**] 10:46PM CK-MB-3 cTropnT-0.06* [**2160-10-16**] 03:47PM GLUCOSE-112* UREA N-10 CREAT-2.3*# SODIUM-140 POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-28 ANION GAP-18 [**2160-10-16**] 03:47PM CALCIUM-8.3* PHOSPHATE-2.8# MAGNESIUM-1.8 [**2160-10-16**] 09:52AM TYPE-ART RATES-/16 TIDAL VOL-50 PEEP-5 O2-40 PO2-71* PCO2-44 PH-7.40 TOTAL CO2-28 BASE XS-1 INTUBATED-INTUBATED [**2160-10-16**] 04:45AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014 [**2160-10-16**] 04:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-500 GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2160-10-16**] 04:45AM URINE RBC-0-2 WBC-[**4-18**] BACTERIA-NONE YEAST-NONE EPI-0 [**2160-10-16**] 04:45AM URINE WBCCLUMP-RARE [**2160-10-16**] 04:32AM COMMENTS-TRAUMA [**2160-10-16**] 04:32AM GLUCOSE-157* LACTATE-1.4 NA+-142 K+-5.7* CL--104 TCO2-29 [**2160-10-16**] 04:32AM HGB-10.9* calcHCT-33 O2 SAT-95 CARBOXYHB-2 MET HGB-0 [**2160-10-16**] 04:20AM UREA N-29* CREAT-5.1* SODIUM-144 POTASSIUM-5.9* CHLORIDE-107 [**2160-10-16**] 04:20AM estGFR-Using this [**2160-10-16**] 04:20AM LIPASE-16 [**2160-10-16**] 04:20AM CK-MB-3 cTropnT-0.06* [**2160-10-16**] 04:20AM CALCIUM-7.5* PHOSPHATE-5.2*# MAGNESIUM-1.8 [**2160-10-16**] 04:20AM %HbA1c-5.2 eAG-103 [**2160-10-16**] 04:20AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2160-10-16**] 04:20AM WBC-10.2 RBC-3.69* HGB-10.5* HCT-32.7* MCV-89 MCH-28.6 MCHC-32.2 RDW-15.4 [**2160-10-16**] 04:20AM PT-11.9 PTT-22.0 INR(PT)-1.0 [**2160-10-16**] 04:20AM PLT COUNT-424 [**2160-10-16**] 04:20AM FIBRINOGE-631* At dicharge: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2160-10-21**] 8.6 3.6 10.4 31.9 88 28.9 32.7 17.2* 410 . RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2160-10-21**] 151 76* 5.9* 137 4.5 101 27 14 . HgA1c ([**10-16**]): 5.2 Brief Hospital Course: 65 year old male with COPD, CHF, ESRD with recent hospitalization for initiation of dialysis who presents with acute respiratory distress likely secondary COPD flare and volume overload. Intubated prior to arrival, extubated in MICU without complication and transferred to floor with continued improvement of respiratory status. #Respiratory Distress: Mostly likely secondary to hypervolumic state and COPD flare. Due to patients severely compromised respiratory status on admission (requiring intubation prior to arriva to BIDMCl) ICU treated with course of abx (cipro, ceftriaxone) for ?HAP/HCAP/aspiration PNA. Patient extubated on [**10-16**] without difficulty. CTA ([**10-16**]) with no overt sign of PNA, antibiotics discontinued. CT also was neg for PE and LENIS neg for DVT. COPD flare was treated initially with 4d course of prednisone 40mg PO, azithromycin 500mg PO QD x5 days as well as ipratropium and albuterol nebs as needed. Patient with increased wheezing on day prior to discharge and decision made to discharge on a 7day prednisone taper. Home advair dose increaed to 500-50mg. Continued on Spiriva, as well as albuterol inhaler/nebs as needed. Regarding volume (recent EF: 45%, CKD V), patient with new bilateral pleural effusions on imaging. Patient dialyzed on Sat, Tues, Thurs schedule for removal of excess fluid with lasix administered on days not receiving dialysis. At time of discharge patient saturating 95-96% on RA at rest and 90-92% while ambulating. Patient not discharge with home oxygen. Patient discharged with services including cardiopulmonary nursing support. . # Right forearm swelling. Noticed on [**10-17**] in AM in ICU. Initial concern for possible hematoma or thrombosis. Good bruit and thrill from AV fistula. 1+ Distal pulses intact. Right arm cool to touch in comparison to left. U/S without sign of DVT or hematoma. Arm also evaluated by transplant surgery who were not to hematoma or thrombosis; dialysis continued as scheduled with [**Last Name **] problem with flow. At time of discharge stitches removed. . # Hypertension. Metoprolol 50 PO BID, Nifedipine 60mg CR PO initially held in ICU and restarted prior to floor transfer. Patient complained of dizziness on mornings of [**10-19**] and [**10-20**]. Orthostatics negative. Nifedipine dosing switched to 30mg CR PO BID to minimize deleterious effects in morning and better control BP at night. Prior to discharge, Nifedipine transitioned back to 60mg in morning to help alleviate confusion in administration of medications. Metoprolol transitioned to home XL 100mg qd. . # CKD stage V complicated by anemia: HD recently initiated on [**2160-9-29**]. dialysis T,Th,Sat continued in house. Patient continued to make 500 - 800cc of urine daily. Medications were renally dose medication. Continued sevelmer daily. Received EPO at HD. . #H/o CVA s/p CEA. At time of discharge patient on outpatient regimen of bblocker, nifedipine, statin and plavix. . Hyperlipidema. Statin continued in house. . GERD. Famatidine continued in house. Medications on Admission: Medications: # 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, dyspnea. #. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB, dyspnea. #. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). #. Nifedipine 30 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). #. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). #. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). #. Sevelamer Carbonate 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). #. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). #. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). #. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. #. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation twice a day as needed for wheezing and SOB. 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Nifedipine 30 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO once a day. Disp:*60 Tablet Sustained Release(s)* Refills:*2* 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. 10. Lasix 40 mg Tablet Sig: Two (2) Tablet PO Take on non-dialysis days. 11. Prednisone 10 mg Tablet Sig: take 4 tablets on [**10-23**], take 3 tablets on [**9-14**], take 2 tablets on [**10-3**], take one tablet on [**10-28**] Tablet PO 7 day taper. Disp:*15 Tablet(s)* Refills:*0* 12. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. Disp:*1 vials* Refills:*11* 13. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 14. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: PRIMARY COPD Exacerbation Chronic Kidney Disease Congestive Heart Failure Secondary Hypertension Discharge Condition: Mental status: clear and coherent Able to ambulate without assistance Discharge Instructions: You were admitted to [**Hospital1 18**] because you were experiencing shortness of breath. You were initially admitted to the intensive care you and were treated for a COPD flare as well as possible PNA. You were also found to have excess fluid in your lungs which was attributed to your underlying heart and kidney disease. The dialysis team performed dialysis 3x/week to remove excess fluid and manage your electrolytes. With dialysis, diuretics and medications for your COPD flare (steriods, antibiotics, nebulizer treatments, inhalers) your breathing improved and you were weaned off supplemental oxygen by the time of your discharge. You were dialyzed on a sat/Tues/Thurs schedule. You will need to continue to regularly scheduled dialysis. . CHANGES TO YOUR MEDICATIONS To help your breathing: --We increased your ADVAIR DISCUS from 250-50 formulation to 500-50 formulation. You will take one puff by mouth twice daily. --You will be discharged on a PREDNISONE TAPER, you will take 40mg on [**10-23**] (four 10mg tablets), 30mg on [**9-14**] (three 10mg tablets), 20mg on [**10-3**] (two 10tablets) and 10mg on [**10-28**]. . To help with your fluids --You will take one LASIX 80mg tablet by mouth on days NOT going to DIALYSIS Followup Instructions: You will continue to under dialysis on the Tues, Thurs, Sat schedule Department: [**Month/Year (2) **] SURGERY When: MONDAY [**2160-10-27**] at 1:30 PM With: [**Year (4 digits) **] LAB [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: [**Hospital Ward Name **] SURGERY When: MONDAY [**2160-10-27**] at 2:10 PM With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: TRANSPLANT CENTER When: THURSDAY [**2160-10-30**] at 10:40 AM With: [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2160-10-23**]

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icd9cm

[ [ [] ] ]

[ "39.95", "96.71" ]

icd9pcs

[ [ [] ] ]

15300, 15358

9540, 12578

325, 382

15500, 15500

3846, 9517

16855, 17834

2830, 2909

13750, 15277

15379, 15479

12604, 13727

15596, 16832

2924, 3827

1773, 2221

278, 287

411, 1754

15515, 15572

2243, 2598

2614, 2814

62,506

116,725

35292

Discharge summary

report

Admission Date: [**2148-2-19**] Discharge Date: [**2148-2-22**] Date of Birth: [**2115-10-6**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 905**] Chief Complaint: Alcohol intoxication Major Surgical or Invasive Procedure: None History of Present Illness: Mr [**Known lastname 7208**] is a 32 yo male with hx of ETOH abuse, tachycardia, brought in by EMS for AMS. He was found with multiple bottles of hard liquor around him and reportedly said that he wanted to drink himself to death. He was drinking about one liter of vodka per day for the past five weeks. He has a history of heavy drinking. He claims he had been sober for 3-4 years, although he was seen in [**Month (only) **] in the ED for EtOH related trauma. No clear h/o DT, but reports on seizure. He was then brought to the [**Hospital1 18**] ED for further workup. . In the ED, initial VS were 97.2 131 151/87 16 98% RA. He was somnolent, and had no evidence of trauma. PERRLA. Lungs were clear. Abd was benign. He had no stigmata of chronic liver disease. He was AOx1 and moving all extremities. There was no seizure activity or focal deficits. He was given a banana bag, 2L IVF, and 20mg IV valium. He was noted to have a serum etoh level of 574 and and osmolal gap of 16 when corrected for EtOH. He had an elevated lipase of 130, an ALT of 184, and an AST of 255. The rest of his serum and urine tox is negative. He had a lactate of 4.2 and a normal gas. Before transfer to the floor, vitals: HR 122, BP 137/80 RR15 99% RA . Upon arrival to the ICU, he was awake and alert, though somewhat sluggish. He reports shakiness, anxiety, nausea, HA, and "hallucinations" which he cannot characterize. He denied f/c, CP, SOB, abd pain, focal neurologic defects. He reports that he has had seizures from withdrawal before when he tried to detox on his own. He denies ingestion of other substances such as ethylene glycol, methanol, isopropanol. He denied SI/HI. Past Medical History: Lonstanding alcohol abuse Tachycardia - treated with atenolol for the past 10 years. Social History: Reports about 1L of hard alcohol daily. 1 PPD smoker. Denies other illicit drugs. Family History: EtOH abuse Physical Exam: vitals: 98.6 128 136/82 21 98%RA gen: dissheveled, diaphoretic, shaky, appears intoxicated heent: ncat, nontraumatic, pupils large and equal, sluggish pulm: bibasilar rales which clear with deep inspiration. o/w ctab cv: tachy, 2/6 sem at base abd: s/nt/nd/nabs, no hsm extr: no c/c/e neuro: strength 5/5 and sensation to light touch intact throughout. CN 2-12 intact. Pertinent Results: [**2148-2-22**] 06:45AM BLOOD WBC-2.9* RBC-4.47* Hgb-14.7 Hct-41.0 MCV-92 MCH-32.9* MCHC-35.8* RDW-14.5 Plt Ct-51* [**2148-2-19**] 02:55PM BLOOD WBC-6.1 RBC-4.86 Hgb-15.9 Hct-43.0 MCV-89 MCH-32.8* MCHC-37.1* RDW-14.3 Plt Ct-66*# [**2148-2-19**] 02:55PM BLOOD Neuts-80.5* Lymphs-15.1* Monos-3.8 Eos-0.1 Baso-0.5 [**2148-2-20**] 03:07AM BLOOD PT-13.5* PTT-25.3 INR(PT)-1.2* [**2148-2-22**] 06:45AM BLOOD Glucose-95 UreaN-11 Creat-0.7 Na-141 K-3.4 Cl-102 HCO3-30 AnGap-12 [**2148-2-19**] 02:55PM BLOOD Glucose-129* UreaN-9 Creat-0.7 Na-139 K-3.4 Cl-91* HCO3-32 AnGap-19 [**2148-2-20**] 03:07AM BLOOD ALT-133* AST-192* AlkPhos-72 Amylase-47 TotBili-0.8 [**2148-2-22**] 06:45AM BLOOD ALT-95* AST-107* [**2148-2-19**] 02:55PM BLOOD ALT-184* AST-255* AlkPhos-92 TotBili-0.9 [**2148-2-20**] 03:07AM BLOOD Calcium-8.1* Phos-2.1* Mg-1.6 Iron-123 Cholest-229* [**2148-2-20**] 03:07AM BLOOD calTIBC-231* Ferritn-798* TRF-178* [**2148-2-20**] 03:07AM BLOOD Triglyc-66 HDL-41 CHOL/HD-5.6 LDLcalc-175* [**2148-2-19**] 02:55PM BLOOD Osmolal-430* [**2148-2-20**] 03:07AM BLOOD TSH-2.5 [**2148-2-20**] 03:07AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2148-2-19**] 02:55PM BLOOD ASA-NEG Ethanol-574* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2148-2-19**] 02:55PM BLOOD LtGrnHD-HOLD [**2148-2-20**] 03:07AM BLOOD HCV Ab-NEGATIVE [**2148-2-19**] 04:10PM BLOOD Type-ART pO2-90 pCO2-45 pH-7.44 calTCO2-32* Base XS-5 Intubat-NOT INTUBA Comment-ROOM AIR [**2148-2-19**] 03:04PM BLOOD Lactate-4.2* [**2148-2-20**] 01:30PM BLOOD Lactate-2.3* . LIVER ULTRASOUND: Echogenic liver consistent with fatty infiltration. Other forms of liver disease and more advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on this study. No liver lesions identified. No splenomegaly. . CHEST X-RAY: No acute cardiopulmonary process. Brief Hospital Course: 32 yo male with history of EtOH abuse and comorbid psychiatric problems presents with acute intoxication and withdrawal. . MICU COURSE: He was seen by psychiatry and social work. He was placed on a standing taper as CIWA scales had been unreliable given baseline tachycardia. His osmolality gap went from 145 to 60. Lipids WNL. No acidosis. No evidence of withdrawal. Heart rate improved from 130s to 70s. . EtOH WITHDRAWAL: Patient admitted with elevated blood alcohol level, so likely was not in withdrawal. CIWA scales consistantly < 10. He was started on a benzodiazepine taper per psychiatry recommendations. Osm gap resolved. He was given thiamine, folate, and MVI. His atenolol was held. . TACHYCARDIA: Currently normal rate. Patient had tachycardia to the 120s on admission. This trended down to 60-80s in the ICU with IVF. His tacycardia was atributed to agitaion vs. withdawel, but he has a history of tachycardia, unclear etiology. TSH wnl. As he was not tachycardic on discharge, he probably does not need this medication except prn anxiety. . LFT abnormalities: likely related to EtOH ingestion with AST > ALT (although not the classic 2:1). Liver ultrasound showed fatty liver. Hepatitis serologies negative. - Patient should have these rechecked as an outpatient. . LEUKOPENIA and THROMBOCYTOPENIA: There were thought to be most likely [**1-29**] direct EtOH toxicity. He has been trending up as an inpatient. No splenomegaly on ultrasound - further outpatient w/u if not resolved . DEPRESSION and ANXIETY: Per report, he had reported SI to EMS. Since admission, he denyied SI/HI. He has history of depression and anxiety. He was seen by psych and felt to be not suicidal, not a danger to self or others, and not in need of inpatient admission. He was continued on citalopram. . ELEVATED LIPASE: Asymptomatic, possibly subclinical pancreatitis from etoh. Improving. - continue to trend . CODE: FULL . CONTACT: [**Name (NI) 21206**] [**Name (NI) **] [**Name (NI) 7208**], [**Telephone/Fax (1) 80478**](c) [**Telephone/Fax (1) 80479**] (h) Medications on Admission: atenolol 25 klonipin 4 citalopram 20 Discharge Medications: 1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Seroquel 100 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. Disp:*30 Tablet(s)* Refills:*0* 4. Multivitamins Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: ALCOHOL WITHDRAWAL TACHYCARDIA LIVER FUNCTION TEST abnormalities LEUKOPENIA and THROMBOCYTOPENIA DEPRESSION ANXIETY ELEVATED LIPASE Discharge Condition: Stable. CIWA 4 Discharge Instructions: You were admitted with alcohol intoxication. You were monitored in the ICU for signs of withdrawal. Although you did not have signs of withdrawal, you blood tests did show signs of damage from chronic alcohol use. You should follow up with your PCP for follow up testing and to consider further evaluation. You should avoid alcohol use entirely as this is particularly dangerous for you. We encourage you in seeking assistance to help stay sober. If you have fevers, sweats, shaking, agitation, confusion, or feling of alcohol withdrawal, please seek medical attention. Followup Instructions: Mon [**2-26**], with Dr. [**Last Name (STitle) 62417**], 9:10 AM in [**Location (un) 2274**] ([**Telephone/Fax (1) 50515**]. Please bring this paperwork with you. [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**] Completed by:[**2148-2-27**]

[ "300.00", "311", "287.5", "288.50", "303.01", "291.81", "785.0" ]

icd9cm

[ [ [] ] ]

[ "94.62" ]

icd9pcs

[ [ [] ] ]

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335, 342

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275, 297

370, 2036

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14,302

174,023

24995

Discharge summary

report

Admission Date: [**2142-2-14**] Discharge Date: [**2142-3-1**] Date of Birth: [**2086-12-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3984**] Chief Complaint: CC:[**CC Contact Info 62774**] Major Surgical or Invasive Procedure: Bronchoalveolar Lavage History of Present Illness: 55 yo man with Hx of extensive tobacco use, metastatic esophageal cancer s/p stent placement x 2, course complicated by pain from acid reflux, unable to control at home with Tagamet, Protonix, and Carafate. He was admitted to the hospital for pain mgmnt, and poor po intake leading to acute renal failure. He complains of pain, burning and severe gas after placement of his esophageal stent on [**2142-2-15**].He denies any vomiting or hematemesis and complains of occassional nausea. He was evaluated by ICU team for progressive SOB x 3 days and increased work of breathing. His pulse oximetry dropped to as low as 85% on 6L NC and recovered to low 90's on 100% NRB. At that time he had a resp rate of 24, ABG was 7.43/ 36/82 on 100%NRB. in addition he was found to have tachycardia to 130's a lactate of 4.6 and WBC increase to 16.2. Received IV lasix 40 mg x 2, Nebs x 1. Past Medical History: 1)Hypertension 2)Metastatic Esophageal cancer s/p 6 cycles of cisplatin and Irinotecan. Mets to mediastinal and Abd lymph nodes, Liver, Adrenal 3)Severe GERD Social History: 2 packs of cigarette per day for the last few years, 1 ppd before that since age 20. He denies any alcohol use. He owns his loan business detail in [**Location (un) **]; however, he has been unable to work since the end of [**Month (only) 205**]. He is divorced. He has 1 child. The child does not live locally. . Family History: Father and aunt -pancreatic cancer Uncle - liver cancer Grandfather -liver cancer Physical Exam: vitals: 99.1 130 140/83 26 87-90% on 100%NRB GENERAL: awake, in mild resp distress on NRB mask, cooperative HEENT: atraumatic, anicteric sclerae, dry mucosa, clear OP NECK: Supple, no JVD, Ant Cerv LAD LUNGS: Diffuse end exp wheeze b/l, no accessory muscle use, no ronchi or crackles BACK: no spinal or CVAT HEART: Regular, tachy, no M/R/G ABDOMEN: soft, Mild midepigastric tenderness, normal BS, no guarding, no rebound, no masses appreciated EXTREMITIES: trace b/l le edema. Warm, full DP pulses B/L NEURO: CN II-XII intact, no focal deficits Pertinent Results: [**2142-2-14**] 02:15PM WBC-12.0* RBC-3.81* HGB-12.2* HCT-35.7* MCV-94 MCH-32.0 MCHC-34.2 RDW-14.7 [**2142-2-14**] 02:15PM PLT COUNT-407 [**2142-2-14**] 02:15PM GRAN CT-[**Numeric Identifier 60243**]* [**2142-2-14**] 02:15PM ALBUMIN-3.5 CALCIUM-8.7 PHOSPHATE-2.5* MAGNESIUM-2.1 CHOLEST-168 [**2142-2-14**] 02:15PM LIPASE-14 GGT-87* [**2142-2-14**] 02:15PM ALT(SGPT)-21 AST(SGOT)-28 ALK PHOS-117 AMYLASE-13 TOT BILI-0.3 DIR BILI-0.1 INDIR BIL-0.2 [**2142-2-14**] 02:15PM GLUCOSE-119* UREA N-30* CREAT-1.6* SODIUM-133 POTASSIUM-4.1 CHLORIDE-97 TOTAL CO2-23 ANION GAP-17 [**2142-2-14**] 07:50PM CK-MB-2 cTropnT-0.02* [**2142-2-14**] 07:50PM CK(CPK)-32* ABDOMEN (SUPINE & ERECT) [**2142-2-14**] 4:38 PM ABDOMEN (SUPINE & ERECT) Reason: perforation, obstruction, stent placement [**Hospital 93**] MEDICAL CONDITION: 55 year old man with esophageal carcinoma, s/p stent placement REASON FOR THIS EXAMINATION: perforation, obstruction, stent placement INDICATION: 55-year-old man with esophageal carcinoma, status post stent placement. TECHNIQUE: Supine and upright abdominal radiographs. No comparison. FINDINGS: The patient is status post esophageal stent placement at lower esophagus and GE junction. Note is made of unremarkable bowel gas pattern with few air-fluid levels, without evidence of significant dilatation or obstruction. No evidence of ascites is seen on this radiograph. The osseous structures are unremarkable. . CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Reason: please eval pulmonary embolism with CTA, but please also inc Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 55 year old man with esophageal cancer, pleural effusions, worsening hypoxia REASON FOR THIS EXAMINATION: please eval pulmonary embolism with CTA, but please also include cuts to eval for worsening lung injury from chronic aspirations vs pneumonia, also eval size of pleural effusions CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Hypoxia, history of esophageal cancer. COMPARISON: Non-contrast CT from a PET study of [**2142-1-25**], chest x-ray from [**2142-2-19**]. TECHNIQUE: Multidetector CT scanning was performed of the chest before and after the administration of 100 cc of Optiray intravenous contrast. Multiplanar reformations were obtained. CT OF THE CHEST: Bilateral hilar as well as mediastinal adenopathy is seen. The heart and pericardium appear unremarkable. There is a dilated esophagus with a stent extending to the gastroesophageal junction. A central venous catheter seen with its tip terminating in the superior vena cava. The great vessels appear unremarkable. The pulmonary arteries do not demonstrate any central or segmental filling defects to suggest pulmonary embolism. Bilateral moderate pleural effusions are identified of simple fluid attenuation, which were not present on the [**1-25**] study. There has been new development of extensive ground glass and consolidative opacities involving the majority of the upper lobes bilaterally, as well as the lingula, right middle lobe, and lower lobes to a lesser extent. The airways are patent to the level of the segmental bronchi bilaterally. In the visualized abdomen again seen are multiple low-attenuation masses within the liver, which appear to be increased in size and extent since the prior study of [**1-25**]. The osseous structures demonstrate no concerning lytic or sclerotic lesions. IMPRESSION: 1. Bilateral ground-glass and consolidative opacities involving multiple lobes, but most notably the upper lobes. This has developed since the prior CT of [**1-25**] and is worsened since the recent chest x-ray. These findings are most consistent with aspiration pneumonia, though there may be an element of superimposed pulmonary edema. Bilateral moderate-sized pleural effusions have also developed in the interim. 2. Dilated esophagus with a stent extending to the gastroesophageal junction. Extensive hilar and mediastinal lymphadenopathy. Multiple liver hypodensities consistent with metastatic disease. 3. No evidence of central or segmental pulmonary embolism. These findings were discussed with Dr. [**Last Name (STitle) **] at 4:30 p.m. on [**2142-2-21**]. IMPRESSION: Esophageal stent in lower esophagus and GE junction. Unremarkable bowel gas pattern. Please also refer to the official report of chest radiograph obtained on the same day. . BRONCHIAL WASHINGS Procedure Date of [**2142-2-21**] REPORT APPROVED DATE: [**2142-2-23**] SPECIMEN RECEIVED: [**2142-2-22**] 06-[**Numeric Identifier 62775**] BRONCHIAL WASHINGS SPECIMEN DESCRIPTION: Received 7.5 ml of bloody fluid and 1 hematology slide for referal. Total 2 slides. CLINICAL DATA: Known esophageal cancer, acute hypoxemic respiratory failure. PREVIOUS BIOPSIES: [**2141-8-25**] [**-4/3463**] MEDIASTINAL LYMPH NODE REPORT TO: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] DIAGNOSIS: Bronchial lavage: POSITIVE FOR MALIGNANT CELLS consistent with adenocarcinoma Brief Hospital Course: A/P: 55 yo male with metastatic esophagel cancer, recent ARF [**1-18**] dehydration who was transferred to ICU for increased oxygen demand, Lactic Acidosis, and Elevated WBC Count: . 1. Increased oxygen demand/ARDS: Unclear etiology, initially thought to be secondary to pneumonitis/PNA 2x2 aspiration. There was no evidence of PE. BAL did not show an infectious etiology. Bacteremia was revealed by blood cultures. Patient was initially treated with IV antibiotics and ARDS low volume ventilation strategy. Despite this measures, patient continue to be febrile, with elevated lactic acidosis and high WBC. Even an steroid trial was given but patient still required high FIO2. . Fevers and elevated WBC: Initially treated as a pulmonary source. Patient initially responded to antibiotics, but later on developed high grade fevers. Last blood cultured showed Gram positive cocci. . Elevated Lactate. Persistent elevated lactate despite adequated CVP and Mix venous saturations. It was thought to be secondary to sepsis, with contribution of tumor burden and liver metaastasis. . Acute renal failure: thought to be secondary to prerenal azotemia in setting of sepsis. Creatinine remained at 1.4-1.6. . On [**2142-3-1**] a family meeting was held. The clinical situation was explained to the family worsening ARDS, severe dead space ventilation, worsening leukocytosis and fevers, associated with metastatic esophageal cancer gave him very low possibilities of recovery. Family felt that the medical team should direct goals of care towards confort at thats time. Patient passed away quietly in the presence of his family. Medications on Admission: Levaquin 500 mg po qd Flagyl 500 po tid Maalox QID Anzemet PRN Colace 100 mg po bid Fentanyl patch 75 mcg q72 Heparin 5000 sq tid Reglan 5 mg qid Metoprolol 50 [**Hospital1 **] Morphine PCA Morphine SE 30 mg [**Hospital1 **] Nexium 40 [**Hospital1 **] Zantac 300 mg qhs Sucralfate 1 qid Simethicone 40 qid Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Acute Respiratory Distress Syndrome Metastatic esophageal cancer Multiorgan failure Discharge Condition: expired Discharge Instructions: n/a Followup Instructions: n/a [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**] Completed by:[**2142-9-24**]

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icd9cm

[ [ [] ] ]

[ "96.04", "96.72", "96.6", "45.13", "38.93", "33.24", "99.04" ]

icd9pcs

[ [ [] ] ]

9520, 9529

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276, 307

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1473, 1790

63,447

121,712

38372

Discharge summary

report

Admission Date: [**2173-7-13**] Discharge Date: [**2173-7-26**] Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 78**] Chief Complaint: altered mental status. garbled speech Major Surgical or Invasive Procedure: [**2173-7-19**]: Left craniotomy and evacuation of SDH History of Present Illness: HPI: This is an 87 year old female with PMH only notable for Hypertension, who was found by her family this morning to have AMS and garbled speech. Per family report, she has been having frequent falls lately, and she fell last week from a chair and hit her head. She was reportedly fine all weekend, but was found to have changes in her mental status this morning. She was brought to [**Hospital3 68**] where a Head CT demonstrated a Large L-Sided SDH with midline shift. She was brought to [**Hospital1 18**] for further care. Past Medical History: HTN Social History: Lives alone at home. Widowed. Has many family members in the area that check on her daily. No etoh/tobacco history Family History: non-contributory Physical Exam: PHYSICAL EXAM: O: T: 98.7 BP: 120/74 HR:85 R:20 O2Sats: 98% Gen: WD/WN, comfortable, NAD. HEENT: NC, AT Pupils: PERRLA EOMs intact Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, but not to date which is baseline for patient. Recall: [**3-10**] objects at 5 minutes. Language: Mild dysarthria. Per family, much improved from this morning. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 2 to 1.5 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Subtle R-sided weakness in upper and lower extremities, 5-/5. L sided full strength. R sided pronator drift Sensation: Intact to light touch, proprioception, pinprick and vibration bilaterally. Toes downgoing bilaterally EXAM UPON DISCHARGE: Patient is OOB in chair, eyes open sponteously. attends and attempts to interact with examiner. mumbling in [**Country 85458**]-croatian. PERRL, EOMI. left eye edema/ecchymosis. MAE's spontaneously and purposefully. Staples intact. Exam on discharge: Patient awake and interactive, back at her baseline mental status per her family, ambulating without assitive devices in the halls with family. Wound C/D/I and closed with staples. Pertinent Results: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2173-7-13**] 17:50 9.9 4.71 13.8 40.0 85 29.3 34.5 14.0 281 BASIC COAGULATION ( PT, PTT, INR) [**2173-7-13**] 17:50 13.8* 25.1 1.2* Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2173-7-13**] 17:50 118* 1 40* 1.1 138 3.6 104 24 14 CT Head outside Hospital: Large Chronic Left subdural hematoma measuring up to 3cm, with acute membranes components. 8mm Midline Shift present. Downward herniation impressing on the suprasellar cistern. [**7-14**] ECG: Atrial fibrillation. Compared to the previous tracing no change. Rate PR QRS QT/QTc P QRS T 88 0 76 388/437 0 1 -18 [**7-15**] Head CT:1. Overall stable appearance of large left subdural collection, with interval evolution of blood products but overall chronic appearance. Slight improvement in rightward subfalcine herniation [**7-18**] Head CT: IMPRESSION: Left subdural hematoma, with increased 1-cm rightward subfalcine herniation [**7-19**] Head CT: Left subdural hematoma improved compared to prior study. New left postsurgical epidural hematoma, decreased subfalcine herniation. [**7-20**] Head CT: New, acute blood products in the left subdural and epidural collections. The epidural collection is stable in size, and the subdural collection is smaller in size, with decreased mass effect. [**7-21**]: CXR: There is no change in cardiomegaly, mild. Mediastinal contours are unremarkable. There is new opacity at the left lung base that might represent either atelectasis or developing infection and should be closely followed. The rest of the lungs are unremarkable. [**7-23**]: CXR:In comparison with study of [**7-21**], there is decrease in the retrocardiac opacification consistent with atelectasis. Cardiomediastinal silhouette is unchanged. No evidence of vascular congestion or acute pneumonia. Brief Hospital Course: The patient was admitted to the NSurg service, ICU for Q1 neuro checks. She was kept NPO in case of need for intervention. She was given a unit of platelets for ASA history and Keppra 500mg [**Hospital1 **] for seizure prophylaxsis. Pt remained stable overnight. Upon discussion of the situation with the patient's family, it was decided that she would attempt waiting evacuation until able to proceed via burr holes. She was cleared for transfer out of the ICU to the floor. [**7-15**] She was seen by physical therapy who recommended discharge to acute rehab. On [**7-16**] She was started on ciprofloxacin for a UTI. Pt remained neurologically stable and was awaiting bed availability at a facility. on [**7-18**] the patient's neurological exam declined and required transfer to the ICU. A stat Head CT was obtained and revealed increased herniation. On [**7-19**] She was brought to the operating room and underwent a left sided craniotomy and evacutation of SDH. She was transfered back to the ICU post op for close neurological monitoring. It was noted at this time that the patient was in afib, but upon review of earlier records it was confirmed that she had been pre op as well. Cardiac Enzymes x3 were drawn and all negative. on [**7-20**] a CT was performed and revealed improvement of MLS. Her neurological exam was improving. She cont to have agitation/confusion but was moving all extremities spontaneously with good strengths. A speech and swallow exam was performed and cleared her for a pureed diet, thin liquids and crushed medications. On [**7-21**] she was cleared for transfer back to the floor. On telemetry the patient was noted to be in Afib RVR with rates up to 200. Her metoprolol was increased and an ECG was done which was stable. a CXR was obtained which revealed a left base opacity. Pt afebrile and without respiratory distress therefore was just monitored at this time. On [**7-22**] She again remained stable and was seen by PT and OT who cont to recommend acute rehab upon discharge. Seroquel was initiated qHS for her overnight agitation. After receiving this the patient's overnight agitation was resolved. On [**7-23**] HR stable in the 80's. A repeat CXR was obtained to re-evaluate opacity which revealed improvement. On [**7-26**], patient continues to be stable, she was discharged to rehab. Medications on Admission: Metoprolol ER 25mg Daily Metoprolol 100mg Daily HCTZ 25mg Daily Lisinopril 20mg Daily Aspirin 325mg Daily Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 3. Senna 8.6 mg Capsule Sig: One (1) Capsule PO at bedtime. 4. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 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. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 10. Insulin Regular Human 100 unit/mL (3 mL) Insulin Pen Sig: One (1) Subcutaneous per sliding scale. 11. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 12. Ondansetron 4 mg IV Q8H:PRN N/V 13. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 14. HydrALAzine 10 mg IV MRX1:PRN SBP>160 15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital1 **] Senior Healthcare of [**Location (un) **] Discharge Diagnosis: Left Subdural Hematoma Discharge Condition: Neurologically Stable Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin prior to your injury, Do not restart until seen in follow up. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. If you have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. Completed by:[**2173-7-26**]

[ "781.8", "348.4", "401.9", "298.9", "427.31", "307.9", "852.20", "E884.2", "V15.88", "599.0", "781.94", "780.97" ]

icd9cm

[ [ [] ] ]

[ "01.31" ]

icd9pcs

[ [ [] ] ]

8526, 8611

4779, 7114

302, 359

8678, 8700

2855, 3564

10378, 10740

1098, 1116

7271, 8503

8632, 8657

7140, 7248

8875, 10355

1146, 1339

225, 264

387, 922

1626, 2380

2653, 2836

4047, 4756

8715, 8851

944, 949

965, 1082

2401, 2634

17,278

105,855

10596

Discharge summary

report

Admission Date: [**2153-2-8**] Discharge Date: [**2153-2-19**] Date of Birth: [**2109-1-1**] Sex: M Service: [**Location (un) 259**] HISTORY OF PRESENT ILLNESS: This is a 48-year-old male with pulmonary alveolar proteinosis secondary to occupation silica dust exposure, status post whole lung lavage on [**2150-1-31**] who is admitted for elective repeat lavage. Patient also found to have a positive acid fast bacilli alveolar lavage, but negative mycobacterium. Had state laboratory that was started on oral drug tuberculosis therapy. Patient's symptoms significantly improved post previous lavage. He resumed work at his previous job as a stone crusher and has since been having worsening dyspnea on exertion over the last months to years. Currently he is unable to walk less than one block prior to getting short of breath. No chest pain with exertion, no orthopnea or paroxysmal nocturnal dyspnea. He does have a cough with clear fluid and no sputum or hemoptysis, no wheezes. Patient recently finished a course of Bactrim and prednisone taper for pneumonia last month. He has self- discontinued all medications except for Serevent. No over-the-counter medications. Currently still smoking two packs per day, greater than ten alcoholic beverages per night. Longest sobriety three weeks, years ago. PAST MEDICAL HISTORY: 1. Pulmonary alveolar proteinosis, diagnosed in [**2150-1-16**]. Complicated by pneumothorax and intubations, status post whole lung lavage. 2. Anxiety disorder with a question of bipolar disorder. 3. History of alcohol abuse. 4. Negative PPD in [**2149**], but alveolar lavage with acid fast bacilli. He was treated with a four drug regimen for three to four months. 5. HIV negative in [**2150-1-16**]. SOCIAL HISTORY: Works as a stone cutter. Tobacco: Greater than 40 pack years. Currently two packs per day. Drug use: Ten years of crack cocaine, quit in [**2145**]. Alcohol greater then ten liquor drinks per night. Divorced with two kids. FAMILY HISTORY: Alcoholism in brother, asthma in niece, brother with coronary artery disease at 61. MEDICATIONS: He is currently only on Serevent. He discontinued Paxil, Prozac, Depakote. He also finished prednisone, Bactrim taper. He takes over-the-counter folate. PHYSICAL EXAMINATION: Temperature 95.8. Blood pressure 159/109. Heart rate 95. Respiratory rate 14. Oxygen saturation 96% on room air. General: Anxious, tremulous, alcohol on breath. Head, eyes, ears, nose and throat: Anicteric. Pupils equal, round and reactive to light. Extraocular movements intact. Chest: End inspiratory crackles, right greater than left. Heart: Tachycardic with no murmur. Abdomen: Soft, nontender, nondistended with no hepatosplenomegaly. Extremities: 2+ peripheral pulses, no edema. Neurological: Alert and oriented times three, tremulous. LABORATORIES: White blood cell count 14.6, hematocrit 52.5, platelet count 430,000. Electrolytes were unremarkable. HOSPITAL COURSE: 1. Pulmonary: The patient underwent a pulmonary alveolar lavage secondary to his increasing dyspnea on exertion similar to the bilateral lung lavage that appeared in [**2149**]. The patient was on the ventilator for a prolonged period of time and had a change in mental status. This was believed secondary to medication effect. Perhaps it was secondary to the fact that he has a high alcohol intake. The patient was then extubated and removed from the Medical Intensive Care Unit and was transferred to the floor and his breathing improved each day. 2. Alcohol history: The patient was placed on a CIWA scale and also received thiamine and folate and multivitamins throughout his period of course. Ativan was also used as needed. 3. Fever: The patient developed perhaps a clostridium difficile by [**Doctor First Name **] testing. HE also grew out 1/4 bottles with coagulation negative Staph which was felt to be secondary to a contaminant. He received vancomycin which was then discontinued. Patient was discharged on a 14 day course of Flagyl. 4. Change in mental status: The patient had a right deviation with his right eye, but this improved along with his alertness once the Ativan and propofol were discontinued. Therefore, an MRI and lumbar puncture were not performed. DISCHARGE STATUS: To home. DISCHARGE CONDITION: Patient able to ambulate and required no oxygen. DISCHARGE MEDICATIONS: 1. Folate 1 mg q.d. 2. Flagyl 500 mg t.i.d. times 12 days. 3. Multivitamin. FOLLOW-UP: The patient is to follow-up with his pulmonologist, Dr. ............, pulmonary specialist of [**Hospital3 15516**], [**Last Name (un) 34839**], [**Hospital1 1562**], [**Numeric Identifier 34840**]. Phone number: [**Telephone/Fax (1) 34841**]. He does not have any primary care physician and this is the physician caring for him. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**] Dictated By:[**Name8 (MD) 26705**] MEDQUIST36 D: [**2153-2-19**] 02:05 T: [**2153-2-19**] 14:40 JOB#: [**Job Number 34842**]

[ "516.0", "502", "305.01", "008.45", "305.1", "518.81", "300.00", "349.82" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.04", "33.99", "96.72" ]

icd9pcs

[ [ [] ] ]

4355, 4405

2031, 2287

4428, 5083

3008, 4084

2310, 2990

179, 1333

4100, 4333

1355, 1767

1784, 2014

13,033

189,079

43036

Discharge summary

report

Admission Date: [**2186-10-21**] Discharge Date: [**2186-10-25**] Date of Birth: [**2148-4-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5893**] Chief Complaint: nausea/vomiting, abdominal pain, inability to tolerate PO Major Surgical or Invasive Procedure: HD line change Hemodialysis History of Present Illness: The patient is a 38-yo male with DM1 complicated by severe gastroparesis, poorly-controlled hypertension with severe autonomic dysfunction, ESRD on HD (Tu/Th/Sat), CAD, well-known to medicine service for multiple admissions [**3-17**] gastroparesis and hypertensive emergency, who presented to the ED with severe nausea/vomiting and abdominal pain. Symptoms were of sudden onset at home, lasted about [**2-14**]-hour, so patient came to ED. He was unable to hold any food down, so did not take his blood pressure meds today. . Most recently, pt was admitted to medicine service on [**2186-8-12**] for management of severe nausea/vomiting [**3-17**] gastroparesis. BP was monitored closely given his tendency to go into hypertensive urgency while in severe pain from gastroparesis, but was stable overnight. He was treated with Ativan, Dilaudid, and Reglan overnight, and discharged to home with those prescriptions. . In the ED: VS - Temp , HR , BR , Sat % RA. Labs notable for anion gap 18, BUN 61, Cr 10.8, glucose 315. Given Ativan 4mg and Dilaudid 4mg with good effect, started on HD (regularly scheduled for Saturdays), and admitted to Medicine. At HD: BP 160/100, but on floor: BP 210/130, was transferred to MICU for increasing nursing care needs for HTN control. Past Medical History: 1. Diabetes mellitus type I 2. End-stage renal disease on hemodialysis started [**2-/2184**] TuThSa 3. Severe autonomic dysfunction with multiple hospitalizations for hypertensive emergency, gastroparesis, and orthostatic hypotension 5. History of esophageal erosion, [**Doctor First Name **]-[**Doctor Last Name **] tear 6. Coronary artery disease with 1-vessel disease (50% stenosis D1) - Fixed, small, moderate severity perfusion defect involving the LAD (diagonal) territory by MIBI on [**2186-6-7**] 7. History of foot ulcer - 2 months, healing slowly 8. History of clot in AV fistula clot on coumadin - [**Month (only) 958**]/[**Month (only) 205**] of [**2185**] s/p multiple attempts to remove clot 9. History of coagulase negative Staphylococcus bacteremia Social History: Denies alcohol or tobacco use. Endorses occassional marijuana use. Family History: His father died of ESRD and diabetes. His mother is in her 50s and has hypertension. He has two sisters, one with diabetes, and six brothers, one with diabetes. Physical Exam: General - Lying in bed, on dialysis machine, drowsy but arousable, NAD HEENT - NC/AT, PERRL, EOMI, sclera anicteric, MMM, OP clear Neck - supple, no thyromegaly or LAD, JVP, carotid bruits Lungs - CTA bilat, no r/rh/wh Heart - RRR, no MRG, nl S1-S2 Abdomen - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding Extremities - WWP, no c/c/e, no calf pain, DPs 2+ bilat Neuro - A&Ox3, CNs II-XII grossly intact, muscle strength 5/5 and symmetric in BUE/BLE, sensation grossly intact to light touch, DTRs 2+ throughout, toes downgoing Skin - warm, no rashes/lesions/ecchymoses Pertinent Results: Labs on Admission: [**2186-10-21**] 10:20AM WBC-7.8# RBC-4.59* HGB-12.5* HCT-39.1* MCV-85 MCH-27.3 MCHC-32.1 RDW-18.6* [**2186-10-21**] 10:20AM NEUTS-63.3 LYMPHS-27.6 MONOS-5.2 EOS-3.2 BASOS-0.6 [**2186-10-21**] 10:20AM GLUCOSE-315* UREA N-61* CREAT-10.8*# SODIUM-138 POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-25 ANION GAP-22* [**2186-10-21**] 10:20AM ALBUMIN-4.6 [**2186-10-21**] 10:20AM ALT(SGPT)-9 AST(SGOT)-10 ALK PHOS-124* AMYLASE-68 TOT BILI-0.2 [**2186-10-21**] 10:20AM LIPASE-71* Labs on Discharge: [**2186-10-25**] 06:26AM BLOOD WBC-5.3 RBC-3.99* Hgb-11.3* Hct-35.1* MCV-88 MCH-28.3 MCHC-32.1 RDW-19.0* Plt Ct-177 [**2186-10-22**] 03:52AM BLOOD Neuts-88.6* Lymphs-8.3* Monos-2.6 Eos-0.1 Baso-0.4 [**2186-10-25**] 06:26AM BLOOD Plt Ct-177 [**2186-10-24**] 03:52AM BLOOD PT-17.2* PTT-31.4 INR(PT)-1.6* [**2186-10-25**] 06:26AM BLOOD Glucose-233* UreaN-25* Creat-7.9*# Na-138 K-4.6 Cl-99 HCO3-26 AnGap-18 [**2186-10-21**] 10:20AM BLOOD ALT-9 AST-10 AlkPhos-124* Amylase-68 TotBili-0.2 [**2186-10-21**] 10:20AM BLOOD ALT-9 AST-10 AlkPhos-124* Amylase-68 TotBili-0.2 [**2186-10-25**] 06:26AM BLOOD Calcium-9.2 Phos-5.3*# Mg-1.8 [**2186-10-23**] HD line exchange: IMPRESSION: Successful exchange of tunneled hemodialysis catheter with new 15.5F x 28 cm (23 cm tip to cuff) catheter, with tip positioned in the right atrium. The line is ready for use. Brief Hospital Course: Mr. [**Known lastname **] is a 38-yo male with DM1, severe gastroparesis, poorly-controlled hypertension with severe autonomic dysfunction, ESRD on HD (Tu/Th/Sat), CAD, p/w acute-onset nausea, vomiting, abdominal pain, and now hypertensive urgency. Hypertensive urgency: Mr. [**Known lastname **] was initially admitted to the floor for hypertensive urgency, however his blood pressure was not well controlled and he was quickly transferred to the ICU for initiation of a labetolol drip. He remained on the labetolol gtt overnight and was subsequently transitioned to oral medications. He was restarted on his home medications including metoprolol, nifedipine, and lisinopril. One medication was changed and this was his Clonidine patch, which was increased to a 0.3mg patch from a 0.1mg patch. He did require 1 dose of IV hydralazine and 2 doses of IV metoprolol for elevated BP while being transitioned to home medications. However, prior to discharge he had >24hrs of good blood pressure control. Gastroparesis/abdominal discomfort/N/V: On admission he was made NPO and was given IVF. He was given reglan, ativan, dilaudid, and PPI. His diet was slowly advanced to regular and he was tolerating POs prior to discharge. ESRD on HD: He receives HD T/Th/Sat. While in the hospital he underwent his planned HD line exchange without complication. Dialysis was planned for the day following discharge. DM1: Blood sugars were checked q4H and he was treated with a SS insulin and NPH 5 units [**Hospital1 **]. Glucose was in good control at time of discharge. Medications on Admission: 1. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTUES (every Tuesday). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 7. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 9. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Three (3) units Subcutaneous twice a day. 11. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Capsule PO once a day. 12. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 13. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. 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* 15. Dilaudid-5 1 mg/mL Liquid Sig: [**3-19**] ML PO every four (4) hours as needed for pain. 16. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed. . Discharge Medications: 1. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 2. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO HS (at bedtime). Disp:*30 Tablet Sustained Release(s)* Refills:*2* 3. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 6. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTUES (every Tuesday). Disp:*4 Patch Weekly(s)* Refills:*2* 7. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Tablet, Chewable(s)* Refills:*2* 8. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO Q6HR (). 9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 10. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 11. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Three (3) units Subcutaneous twice a day. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 13. B Complex-Vitamin C-Folic Acid Tablet Sig: One (1) Tablet PO once a day. 14. Ativan 1 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. 15. Dilaudid-5 1 mg/mL Liquid Sig: [**3-19**] mL PO every four (4) hours as needed for pain. 16. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Home Discharge Diagnosis: Hypertensive urgency ESRD on HD (MWF) Diabetes Mellitus, type 1 Gastroparesis Coronary artery disease, 1 vessel disease Discharge Condition: Stable. Blood pressure stable, stable blood glucose. Discharge Instructions: You were admitted with elevated blood pressure related to your gastroparesis and being unable to take your medications. Please take all medications as prescribed. - One medication has been changed and that is your Clonidine patch. The patch is now a 0.3mg/24hr patch to be changed each Tuesday. It is very important that you follow up with your regular doctor. If you have any further abdominal pain, difficulty taking medications by mouth, headaches, lightheadedness, dizziness, blurry vision or any other concerning symptoms please call your doctor. Followup Instructions: You have the following appointments: 1. [**First Name8 (NamePattern2) **] [**Name8 (MD) 815**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2186-11-27**] 3:30 You also have outpatient dialysis tomorrow, [**10-26**]. Please have INR checked at dialysis.

[ "250.61", "536.3", "414.01", "585.6", "403.01" ]

icd9cm

[ [ [] ] ]

[ "38.95", "39.95" ]

icd9pcs

[ [ [] ] ]

9804, 9810

4760, 6334

375, 405

9974, 10030

3373, 3378

10634, 10899

2597, 2760

7934, 9781

9831, 9953

6360, 7911

10054, 10611

2775, 3354

278, 337

3888, 4737

433, 1706

3392, 3869

1728, 2496

2512, 2581

32,315

101,791

29988

Discharge summary

report

Admission Date: [**2137-8-29**] Discharge Date: [**2137-9-7**] Date of Birth: [**2056-10-13**] Sex: M Service: MEDICINE Allergies: Shellfish Attending:[**First Name3 (LF) 3561**] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: Hip fracture repair, intubation History of Present Illness: Mr. [**Known lastname 724**] is an 80 y/o man with T2DM, CRI with a baseline Cr 1.9, and dementia who presented after a witnessed fall in his nursing home with right hip pain. Reportedly this was a mechanical fall per witnesses. Pt is poor historian and does not recall event, but reportedly at time of fall denied CP, SOB, N/V, no LOC, no head trauma. He was unable to bear weight after the fall. He was sent to the [**Hospital1 18**] ER where a right hip XR showed an impacted femoral neck fracture. CXR showed subacute L rib fractures but no acute process. Knee XR pending final read. . ROS: currently denies CP, SOB, abd pain, n/v, no hip pain at rest but states mild hip pain if moves hip. Past Medical History: T2DM Diabetic nephropathy Parkinsons Dementia Anemia with unknown baseline hct 30, believed due to CKD CRI with reported baseline Cr 1.9, but none on file here Hyponatremia with reported baseline ~130 CHF HTN Depression BPH s/p TURP Irritable bowel syndrome h/o pancreatitis DJD Hiatal hernia Reflux esophagitis Social History: Lives in [**Location 35689**] House. Single. Family History: N/C Physical Exam: Vitals: 98.6, 168/88, 18, 100% RA, FS 129, wt 59kg General: NAD, resting flat on back, pleasant, conversant, oriented x 2 (believes he is at his NH) HEENT: no OP injection, MMM, no sinus tenderness Neck: supple, no LAD Pulmonary: CTAB anteriorly Cardiac: RRR, I/VI systolic murmur heard throughout precordium, s1s2 Abdomen: soft, NT, ND, +BS Extremities: no c/c/e, R leg shortened and externally rotated, mild R hip tenderness to palpation, R hip tenderness on rotation of hip. sensation grossly intact in BLE, DP 2+bilat Pertinent Results: [**2137-8-29**]: CXR: Subacute fractures involving the anterolateral left sixth and seventh ribs as detailed above. No radiographically evident pneumothorax seen. . [**2137-8-29**]: Right hip XR: Impacted femoral neck fracture. Marked degenerative changes in lumbar spine. . [**2137-8-29**] Right Knee XR: There are no signs for acute fractures or dislocations. There is joint space narrowing medially. Extensive vascular calcifications are present. There is no joint effusion. Limited cross-table lateral views of the right hip are markedly limited and provides limited diagnostic detail. Please refer to the AP view of the pelvis where there is a known right femoral neck fracture. . EKG: NSR at 70. nl axis, nl intervals (borderline PR about 200ms), no peaked T waves. no Q waves. TWF in III. No prior for comparison. . [**2137-9-1**] CT Abdomen and Pelvis W/O Contrast No evidence of retroperitoneal hematoma. Post-surgical changes are noted about the right hip as detailed above. Small pleural effusions and small pericardial effusions as noted. Signs of chronic pancreatitis. Sigmoid colonic wall thickening as noted above, nonspecific finding. . [**2137-9-4**] U/S RLE No DVT. . [**2137-9-5**] V/Q Scan No evidence of pulmonary embolism. . [**2137-9-5**] TTE The left atrium is mildly dilated. The estimated right atrial pressure is 0-5mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. . Micro Data: Blood cultures: No growth . Urine cultures: No growth . C diff: Negative . [**2137-8-29**] 06:15PM BLOOD WBC-4.9 RBC-2.63* Hgb-8.9* Hct-27.7* MCV-105* MCH-34.0* MCHC-32.3 RDW-15.3 Plt Ct-195 [**2137-9-7**] 04:18AM BLOOD WBC-7.5 RBC-3.07* Hgb-9.7* Hct-28.9* MCV-94 MCH-31.7 MCHC-33.8 RDW-17.9* Plt Ct-190 [**2137-8-29**] 06:15PM BLOOD Glucose-131* UreaN-16 Creat-1.9* Na-127* K-5.0 Cl-93* HCO3-24 AnGap-15 [**2137-9-7**] 04:18AM BLOOD Glucose-64* UreaN-20 Creat-1.6* Na-136 K-4.6 Cl-108 HCO3-21* AnGap-12 [**2137-9-1**] 03:29AM BLOOD ALT-10 AST-29 AlkPhos-55 Amylase-30 TotBili-1.8* [**2137-9-7**] 04:18AM BLOOD Calcium-7.6* Phos-1.7* Mg-1.9 [**2137-9-5**] 05:08AM BLOOD TSH-3.3 [**2137-9-1**] 11:20AM BLOOD HEPARIN DEPENDENT ANTIBODIES- Negative Brief Hospital Course: 80 y/o man with T2DM, anemia, dementia, and CRI who presented s/p mechanical fall with subsequent right hip fracture. His hospital course was complicated by bleeding and hypotension along with atrial fibrillation. The following issues were addressed during this admission. . 1. Reason for MICU admission: The patient was initially transferred to the MICU for hypotension that was thought to be secondary to hypovolemia. The patient had pulled his foley catheter and had profuse bleeding from the catheter site. For this he was transfused and seen by urology. Initially the patient had a 3-way catheter with aggressive irrigation. Cystoscopy showed improved hemostatsis and bladder irrigation was stopped. Bleeding was stable. CT of abdomen/pelvis did not show retroperitoneal bleeding. No hemolysis. Hematocrit stable since [**2137-9-1**]. . 2. Hypotension: The patient had persistent hypotension despite cessation of bleeding from foley site as well as no signs of hematoma in the OR. The patient was actively resusitated with fluids and blood with improvement in his blood pressures. Patient received 4 units of PRBC on [**9-1**]. Blood pressures remained stable after that. Most likely he was hypotensive in setting of blood loss. . 3. Respiratory distress The patient had period of a apnea after returning from the OR and required reintubation. Given that the patient was clinically unstable from a blood pressure standpoint, he remained intubated. He did not have signs of respiratory compromise and maintained his saturations. Patient was quickly extubated on [**2137-9-2**] and remained stable. . 4. Thrombocytopenia The patient was noted to have a dramatic platelet drop, concern for possible HIT, heparin was initially held and appropriate studies were ordered. HIT returned negative. Platelet count increased slowly and remained stable after Hct stabilized. This was most likely in setting of blood loss. . 5. Right Hip fracture The patient was evaluated by orthopedics upon admission and taken to the OR on [**8-31**]. The operation was without complications but post-op had to be reintubated. Per ortho, there was no hematoma at the surgical site while in the OR. Pre-op betablocker was started for risk reduction but was limited by hypotension as above. After patient's hematocrit was stabilized, he was started on Lovenox for AC in the setting of recent ORIF of right hip. He will continue on Lovenox for 4 weeks. He will follow up with orthopedics in 2 weeks after discharge with Dr. [**Last Name (STitle) 7376**]. . 6. HTN Initially pt's outpt lisinopril and catapres were held and a perioperative BB was given, but discontinued with hypotension. Given his new onset atrial fibrillation, he was started on verapamil which was uptitrated to HR. . 7. Atrial fibrillation On [**2137-9-5**], the patient developed atrial fibrillation with a HR to the 130s. EKG revealed evidence of atrial fibrillation without any acute ST changes. Cardiac enzymes were drawn which did not indicate an ischemic etiology for his atrial fibrillation. A TSH was checked which was normal. The patient had a TTE which revealed mild left atrial enlargement and an EF greater than 60%. The patient also had a V/Q scan to r/o PE given his recent hip fx and surgery which was negative. He was started on verapamil as a nodal [**Doctor Last Name 360**] after IV diltiazem was successful in controlling his heart rate. . 8. Rib fractures These appeared subaccute on XR. Likely these are not from his admission fall, as appear subacute and also on L as opposed to R side. . Communication: case manager [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 15582**] (w) [**Telephone/Fax (1) 71590**]; (c) [**Telephone/Fax (1) 71591**]. Per note call CM first. Secondary contact brother [**Name (NI) **] [**Telephone/Fax (1) 71592**]. . Full code Medications on Admission: catapres 3 patch qweek lisinopril 10mgpo qday aricept 10mgpo qhs asa 81mg po qday sinemet 25/100: 0.5 tab [**Hospital1 **] calcitriol 0.25mcg po qday celexa 20mg po qday cyanocobalamin 1000 mcg po qday epo 4000 units qweek lasix 20mg po qday ferrous gluconate 25mgpo qday glipizide 2.5mg po qday omeprazole 20mg po qday kayexelate 60mL (15g) po bid Discharge Medications: 1. Donepezil 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at bedtime). 2. Carbidopa-Levodopa 25-100 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 3. Calcitriol 0.25 mcg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY (Daily). 4. Citalopram 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day) as needed. 6. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: per sliding scale Injection ASDIR (AS DIRECTED). 7. Cyanocobalamin 500 mcg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 8. Epoetin Alfa 2,000 unit/mL Solution [**Hospital1 **]: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 9. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H (every 6 hours). 10. Magnesium Hydroxide 400 mg/5 mL Suspension [**Hospital1 **]: Thirty (30) ML PO Q6H (every 6 hours) as needed. 11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 12. Ferrous Sulfate 300 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO DAILY (Daily). 13. Olanzapine 5 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet, Rapid Dissolve PO DAILY (Daily). 14. Morphine Sulfate 2-4 mg IV Q4H:PRN pain Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Right Hip fracture Hemorrhage Thrombocytopenia Hypotension Acute renal failure Dementia Discharge Condition: stable Discharge Instructions: Please take your medication as prescribed and follow up with Dr [**Last Name (STitle) 5351**]. Please call your doctor with any concerning symptoms. Followup Instructions: Dr [**Last Name (STitle) 5351**] Completed by:[**2137-9-7**]

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icd9cm

[ [ [] ] ]

[ "81.52" ]

icd9pcs

[ [ [] ] ]

10378, 10448

4750, 8596

279, 312

10580, 10589

2020, 4727

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1450, 1455

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10469, 10559

8622, 8972

10613, 10763

1470, 2001

231, 241

340, 1037

1059, 1372

1388, 1434

45,304

148,183

36701

Discharge summary

report

Admission Date: [**2190-7-17**] Discharge Date: [**2190-7-20**] Date of Birth: [**2135-5-19**] Sex: M Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 974**] Chief Complaint: s/p fall from horse Major Surgical or Invasive Procedure: [**2190-7-19**]: embolization of the right inferior gluteal artery History of Present Illness: Patient is a 51 year old male who was riding a horse this afternoon. While in a gallop, the horse became agitated and the patient jumped off the horse, landing on his sacrum/right flank. Afterwards, the patient was ambulating without difficulty but began to complain of groin pain afterwards. He presented to a referring hospital, where he was briefly hypotensive to SBP 70s but responsive to fluid. The patient was also hypotensive once more in the setting of receiving IV morphine. On transfer, the patient was reported to be hemodynamically stable. Past Medical History: PMH: None PSH: R knee surgery x30 years Social History: Pt is 55 yr-old man adm on trauma service s/p fall off horse. Pt w/fx??????d pelvis. Met w/pt at bedside: he is A&Ox3, states he was out riding horse with one of his 20 yr-old twin dtrs when he realized that horse was acting edgy and metal fence was ahead, so pt decided to fall backwards off horse rather than be thrown. He states he drove home with his dtr and then began to feel worse. He states dtr was instrumental in getting him to OSH ([**Hospital3 417**] in [**Location (un) 24356**]) ED. Pt says his dtr is somewhat traumatized, but doing well overall. He says family support is good, he owns own co and has partner who will continue to work & pt states he has no concerns about taking time off or around finances. Pt appears to be coping appropriately with traumatic event and injuries. Reviewed reactions to trauma & provide written material. Provided emotional support to pt. Family History: NC Physical Exam: General: awake and alert CV: RRR Lungs: CTA bilaterally Abodmen: soft, (+) tenderness RLQ/LLQ, hypoactive BS Rectal: heme grossly neg, nl tone Pulses: Fem [**Doctor Last Name **] DP PT R 2+ 2+ 2+ 2+ L 2+ 2+ 2+ 2+ Pertinent Results: [**2190-7-20**] 04:42AM BLOOD WBC-7.0# RBC-2.93*# Hgb-8.7*# Hct-25.1* MCV-86 MCH-29.6 MCHC-34.5 RDW-14.6 Plt Ct-172 [**2190-7-18**] 12:26AM BLOOD WBC-15.7* RBC-3.95* Hgb-11.7* Hct-33.7* MCV-85 MCH-29.6 MCHC-34.7 RDW-15.0 Plt Ct-212 [**2190-7-17**] 11:02PM BLOOD WBC-19.0* RBC-3.99* Hgb-11.9* Hct-34.6* MCV-87 MCH-29.9 MCHC-34.5 RDW-14.0 Plt Ct-250 [**2190-7-20**] 04:42AM BLOOD Plt Ct-172 [**2190-7-19**] 01:01AM BLOOD Plt Ct-186 [**2190-7-19**] 01:01AM BLOOD PT-13.5* PTT-29.2 INR(PT)-1.2* [**2190-7-18**] 12:26AM BLOOD PT-14.2* PTT-26.6 INR(PT)-1.2* [**2190-7-20**] 04:42AM BLOOD Glucose-149* UreaN-10 Creat-0.7 Na-139 K-3.8 Cl-105 HCO3-28 AnGap-10 [**2190-7-19**] 01:01AM BLOOD Glucose-153* UreaN-16 Creat-0.8 Na-140 K-3.5 Cl-108 HCO3-26 AnGap-10 [**2190-7-18**] 12:26AM BLOOD Glucose-214* UreaN-16 Creat-0.8 Na-142 K-3.8 Cl-109* HCO3-21* AnGap-16 [**2190-7-20**] 04:42AM BLOOD Calcium-7.8* Phos-2.5* Mg-2.2 [**2190-7-19**] 01:01AM BLOOD Calcium-7.9* Phos-2.4* Mg-2.2 [**2190-7-17**] 11:02PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2190-7-17**] 11:17PM BLOOD Glucose-211* Lactate-2.2* Na-140 K-3.5 Cl-106 calHCO3-24 INDICATION: Fall from horse. Evaluate for bleeding in the pelvis. No prior examinations. TECHNIQUE: Multidetector helical scanning of the chest, abdomen, and pelvis was performed following the administration of 90 cc of Isovue contrast. This exam was performed at [**Hospital3 10377**] Hospital at 20:25 on [**2190-7-17**]. Coronal reformatted images were displayed. CT OF THE CHEST: There is a small amount of vague soft tissue anterior to the aorta, with a clean fat plane between this tissue and aorta. While this appearance could represent residual thymic tissue, this would be unusual for a patient of this age, and small amount of mediastinal blood is not excluded. The heart, pericardium, and great vessels are normal. A left-sided SVC terminates within the coronary sinus. Right precarinal lymph node measures up to 10 mm. The lungs are mostly clear. There are dependent atelectatic changes bilaterally. In addition, there is a 9-mm focus of ground-glass in the right middle lobe (3:32) which likely represents a tiny focus of inflammation or contusion. CT OF THE ABDOMEN: 10-mm hepatic cyst is seen within segment VII (3:81). There is also a well-defined rounded hypodense structure within the spleen which is likely a splenic cyst and measures 9 mm (3:110). There is a tiny amount of perihepatic fluid along the inferior border of segment VI (3:118). No definite hepatic laceration. Equivocal hypodensity within the right lobe, segment VIII (3:89) is indeterminate, though a tiny contusion is not excluded. The gallbladder, adrenal glands, pancreas, and small and large bowel loops are normal. The abdominal aorta is of normal caliber. Retroperitoneal lymph nodes do not meet CT criteria for pathologic enlargement. The kidneys enhance and excrete contrast symmetrically. CT OF THE PELVIS: Centered within the right pelvis in an extraperitoneal location, there is a large hematoma measuring 10.6 cm AP x 8.4 cm TRV x 10 cm SI. There are at least three discrete foci of active extravasation within this hematoma, these may be due to pubic branches arising from the obturator artery (from the internal iliac artery) or the inferior epigastric artery. The obturator artery is favored and that the inferior epigastric artery is seen superiorly to be coursing posterior to the hematoma. The hematoma extends superiorly in an extraperitoneal location along the right rectus sheath, and also extends intraperitoneally between loops of the transverse colon and small bowel, possibly through a small peritoneal rent. There is no free fluid intraperitoneally. The bladder is displaced to the left; however, there is no real evidence of bladder injury. The sigmoid colon and rectum are normal. There is no pelvic lymphadenopathy. The internal and external iliac arteries are intact. There is 14-mm diastasis of the pubic symphysis as well as diastasis of the right sacroiliac joint, likely due to AP compression forces which contributed to the pelvic hematoma. Tiny osseous fragment off the right pubic symphysis may represent a tiny avulsion fracture (3:215). Expansion within the left adductor muscle group is consistent with intramuscular hematoma. IMPRESSION: 1. Large extraperitoneal pelvic hematoma with active extravasation, possibly due to pubic branches of the obturator artery or less likely inferior epigastric artery. 2. Diastasis of the pubic symphysis and right sacroiliac joint in an open- book configuration, with no pelvic fracture (left SI joint does not appear widened). 3. Nonspecific soft tissue in the anterior mediastinum which may represent a small amount of hematoma; residual thymic tissue felt unlikely in a patient of this age group. No adjacent vascular injury is evident. 4. Tiny segment VIII hepatic hypodensity, which is nonspecific and a tiny contusion is not excluded. 5. Hepatic and splenic cysts. 6. Incidentally noted left-sided SVC. PFI: PELVIC AORTOGRAM: Small area of active extravasation was seen arising from the femoral branch of the right inferior gluteal artery. This was subsequently embolized with four 3 x 3 coils as well as two 4 x 3 coils. There is near-complete blockage of the origin of the inferior gluteal artery on the right with preserved flow of the right inferior pudendal artery. There is no evidence of continued active extravasation on final angiogram. Final Report STUDY: AP pelvis, [**2190-7-19**]. HISTORY: Patient with pelvic fractures. FINDINGS: Standing view of the pelvis demonstrates again widening of the pubic symphysis measuring 11.3 mm. There are degenerative changes of both hips, right side worse than left, with joint space narrowing and spurring. Brief Hospital Course: The patient was admitted to the ICU for further monitoring. His hematocrit was monitored intensively and he was given 3 units of pRBC for acute blood loss anemia. It was discovered that he had an enlarging extraperitoneal hematoma which was not able to be controlled conservatively. He was ultimately brought to the interventional radiodlogy suite on HD 3 and a selective pelvic angiogram was performed which showed active extravasation from a branch of the right inferior gluteal artery. Selective embolization with 6 microcoils was performed. He tolerated this procedure well and was monitored with q4h HCT which were stable. On HD 4 he worked with PT after being cleared for weight bearing as tolerated by the orthopaedic service and he was able to leave with no symptoms and was stable from a pain and diet perspective. 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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas. Discharge Disposition: Home Discharge Diagnosis: Fall from horse with right inferior gluteal artery bleed Discharge Condition: Stable Discharge Instructions: Please call your Primary care physician or trauma surgeon if you develop chest pain, shortness of breath, fever greater than 101.5, severe abdominal pain or distention, persistent nausea or vomiting, inability to eat or drink, or any other symptoms which are concerning to you. Activity: Activity as tolerated. No heavy lifting greater than 15 lbs for 2 weeks. Medications: Resume your home medications. You should take a stool softener, Colace 100 mg twice daily as needed for constipation. You will be given pain medication which may make you drowsy. No driving while taking pain medicine. Followup Instructions: 1. Please follow up with Dr [**Last Name (STitle) **] in 2 weeks. Call ([**Telephone/Fax (1) 15940**] to make an appointment. 2. Please follow up with Dr [**Last Name (STitle) **] in Trauma Clinic in 2 weeks. Call [**Telephone/Fax (1) 2359**]. Completed by:[**2190-7-20**]

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icd9cm

[ [ [] ] ]

[ "88.49", "39.79", "99.04", "88.47" ]

icd9pcs

[ [ [] ] ]

9503, 9509

8056, 8881

290, 359

9610, 9619

2233, 8033

10261, 10536

1929, 1933

8904, 9480

9530, 9589

9643, 10238

1948, 2214

231, 252

387, 941

963, 1006

1022, 1913

70,445

104,027

45254

Discharge summary

report

Admission Date: [**2143-4-8**] Discharge Date: [**2143-4-11**] Service: MEDICINE Allergies: Augmentin / Tetanus / Biaxin / Clindamycin / Zometa / Enoxaparin / hydrochlorothiazide Attending:[**Last Name (NamePattern1) 13129**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 86 F with PMH of metastatic breast ca, HTN, and dCHF who presented to the ED with respirtory distress and HTN to the 190's. . She recently presented with similar symptoms of hypertensive urgency c/b pulmonary edema requiring a brief intubation from [**Date range (3) 96701**], then again from [**Date range (1) 96702**] for similar presentation. During her admission on [**2143-3-6**], her home nifedipine was discontinued and she was started on a BP regimen of carvedilol/ lasix/ lisinopril. She was readmitted about a week after with similar symptoms and findings consistent with CHF exacerbation in setting for fluid overload, hypertension, and flash pulmonary edema. She responded to BIPAP, lasix, nitro gtt. She was discharged on Carvedilol 25mg by mouth twice a day. The lisinopril was stopped at the time. Her discharge wt was 58.9 kg. She recently saw her PCP, [**Name10 (NameIs) 1023**] [**Name11 (NameIs) 15618**] her lasix to 40mg on [**2143-3-29**], and planned to restart her lisinopril later. . On the day of this admission, pt was shopping when she felt sudden onset of SOB. She was BIBEMS placed on BIPAP in the field. Found to be hypertensive to 190s sbp. . In the ED: VS: HR115 BP170/90 RR35 100% on BIPAP. EKG with no acute changes with an old LBB and CXR with pulm edema. Pt was given Aspirin, Nitro gtt, vancomycin, and 40 mg iv furosemide. She also got vanc and zosyn as CXR could not exclude PNA. She put out 950cc. She was initially going to be admitted to the CCU for Bipap, but she was able to be weaned off the bipap and was conversing comfortably on 4L NC. She was felt to be appropriate for the floor. VS prior to transfer: 150/75 75 18 97% on 4L. On nitro gtt with bp in the 130's . On arrival to the floor patient reports she is feeling much better and no longer feel short of breath. She reports that she has had no weight gain at home (weight was 60kg at home, dry weight here 59kg). She denies increased [**Location (un) **] but states that her legs are always swollen and slightly red on both sides.. At baseline she sleeps in a recliner. . On review of systems, she denies any prior history of stroke, TIA, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS:(-)Diabetes,(-)Dyslipidemia,(+)Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: None -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: - Breast Cancer with mets to lung and bone, including skull bone, stable on anti-estrogen therapy, primary oncologist (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 96699**]) at [**Company 2860**]. Has lumpectomy and left-sided LN dissection. - H/o DVT on Fragmin (has h/o allergy to Lovenox), currently dosed via [**Company 2860**] as part of a study protocol - Hypertension - [**Company **] cancer leading to a sigmoid resection in [**2109**]/[**2110**] - OA - severe glenohumeral osteoarthritis plus other joints - LUMBAR SPONDYLOSIS/SPINAL STENOSIS - GERD - Mild [**Doctor First Name **] Pos (1:40 titer) - clinically insignificant - Past Cdiff Pos ([**2139**]) . PAST SURGICAL HISTORY - per OMR - s/p bilateral TKA - L hip replacement, pins in right hip, most recent surgery [**1-17**] yr ago - S/p TAH in [**2098**] Social History: She lives alone in [**Location (un) 96700**] and is very active at baseline, independant in all ADL's, dives. Ambulates without assisance. Spends Mon/Fri at the cultural center, Tues playing trumpet in a band, and Weds/Thurs running erands. Has 3 cars at home and drives. Retired teacher. Never married and without children. Smoked 2ppd x 10-15 years until [**2094**], glass of wine <1x/week. No other drug use. No services at home currently. -Tobacco history: Past use, stopped [**2094**] -ETOH: <1 glass/wk -Illicit drugs: None Family History: Mother had [**Name2 (NI) 499**] cancer, died at age [**Age over 90 **]. Father died at 49 from coronary thrombosis. Sister with [**Name2 (NI) 499**] cancer. Another sister with pancreatic cancer. Niece and nephew (in same family) both with [**Name (NI) 4278**]. She is last surviving relative. HCP is his lawyer. Physical Exam: On Admission: VS: T=98 BP=159/66 on 215mcg nitro gtt HR=72 RR=24 O2 sat=97% on 4L GENERAL: Well apeparing elderly F in NAD, breathing comfortably and talking in complete sentences without difficulty HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Slightly dry MM NECK: Supple with JVP of 8 cm. CARDIAC: S1 S2 heard but difficult to discern over 4/6 systolic murmurs heard best at LUSB LUNGS: MOderate kyphosis, XRT mapping on skin, hard breast tissue. Crackles at bases but otherwise good air movement. ABDOMEN: Soft, NTND EXTREMITIES: Warm, well perfused, 2+ pitting edema to knees bilaterally with chronic venous stasis changes. SKIN: no rashes, + venous stasis changes PULSES: Right: Carotid 2+ DP 2+ Left: Carotid 2+ DP 2+ On Discharge: VS: T=98.3 BP= 149/62 (120s - 140s/50s -70s) HR= 55 (65s-70s) RR=18 O2 sat=97% on RA Is&Os: Yesterday - 1620/2450 First 8 hour shift - 0/600 Weight: 61.8 <- 61.5 GENERAL: Well apeparing elderly F in NAD, breathing comfortably and talking in complete sentences without difficulty HEENT: NCAT. Sclera anicteric. NECK: Supple, JVP not elevated. CARDIAC: S1 S2, 3/6 systolic murmur LUNGS: Moderate kyphosis. No accessory muscle use. Few basilar crackles. ABDOMEN: Soft, NTND EXTREMITIES: Warm, well perfused, 1+ pitting edema SKIN: no rashes, + venous stasis changes on LE b/l GU: Foley catheter in place, urine appears grossly bloody PULSES: Right: Carotid 2+ DP 2+ Left: Carotid 2+ DP 2+ Pertinent Results: Admission labs: [**2143-4-8**] 08:10PM BLOOD WBC-8.2# RBC-4.61 Hgb-12.3 Hct-39.4 MCV-85 MCH-26.8* MCHC-31.4 RDW-15.7* Plt Ct-332 [**2143-4-8**] 08:10PM BLOOD Glucose-202* UreaN-29* Creat-1.2* Na-136 K-6.0* Cl-96 HCO3-26 AnGap-20 [**2143-4-8**] 08:10PM BLOOD Calcium-9.0 Phos-6.7*# Mg-2.7* Discharge labs: [**2143-4-11**] 04:35AM BLOOD WBC-6.3 RBC-3.58* Hgb-9.7* Hct-29.6* MCV-83 MCH-27.0 MCHC-32.6 RDW-16.4* Plt Ct-261 [**2143-4-11**] 04:35AM BLOOD Glucose-107* UreaN-36* Creat-0.9 Na-138 K-4.1 Cl-100 HCO3-26 AnGap-16 [**2143-4-11**] 04:35AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.2 Other pertinent labs: [**2143-4-9**] 03:30PM BLOOD CK(CPK)-92 [**2143-4-9**] 05:35AM BLOOD CK(CPK)-106 [**2143-4-9**] 03:30PM BLOOD CK-MB-4 cTropnT-0.02* [**2143-4-9**] 05:35AM BLOOD CK-MB-6 cTropnT-0.04* [**2143-4-8**] 08:10PM BLOOD cTropnT-0.01 proBNP-[**2104**]* [**2143-4-9**] 05:35AM BLOOD TSH-2.9 [**2143-4-8**] EKG: Very marked baseline artifact. Sinus tachycardia, rate 103. Intraventricular conduction delay with left bundle-branch block pattern and secondary ST-T wave changes. Compared to the previous tracing of [**2143-3-18**] probably no diagnostic interval change. [**2143-4-8**] Portable CXR: CHEST, AP: There has been increase in diffuse interstitial and airspace pulmonary opacities, with confluent opacification in the left upper lobe and lingula, as well as the right perihilar region. Moderate cardiomegaly is unchanged, with a tortuous and calcified aorta. There are probable small bilateral pleural effusions. The bones are diffusely demineralized, with multilevel degenerative changes. IMPRESSION: Increased pulmonary opacities, likely representing worsening congestive heart failure, although underlying consolidation from infection/aspiration, mass is not excluded. Renal ultrasound with doppler: IMPRESSION: 1. Normal kidney size bilaterally. Incidental 8-mm right angiomyolipoma. Incomplete assessment of right renal vasculature but normal brisk upstroke arterial waveforms noted. 2. Normal left kidney with normal arterial and venous waveforms. 3. No evidence of renal arterial stenosis in either kidney. Brief Hospital Course: 86 F with PMH of metastatic breast ca, HTN, and dCHF who presented to the ED with respirtory distress and hypertensive urgency initially requiring bipap. Patient now breathing comfortably, blood pressure improved. ACTIVE ISSUES 1. Acute Pulmonary Edema: Likely related to hypertensive emergency as patient presented with SBPs in 190's. Patient had crackles to mid lung field, peripheral edema, and evidence of volume overload on CXR. Initially patient was placed on bipap in ED, butro gtt and iv lasix. Weaned quickly off bipap in ED and was admitted to the cardiology service. Patient initially diuresed with IV lasix and blood pressure was controlled with nitro gtt. Weaned off nitro gtt. Blood pressure control improved (see below). Patient diuresed well with IV lasix boluses and was transitioned to PO lasix. At discharge she was breathing comfortably on room air and her peripheral edema had improved. She was instructed to reduce sodium intake and weigh herself every day. 2. Hypertensive emergency: Patient has had three recent hospitalizations for CHF likely related to hypertensive emergency/urgency. Patient was initially treated with nitro gtt. Her home dose of carvedilol was continued. Lisinopril dose was increased from 10 mg daily to 30 mg daily. Patient was started on spironolactone 25 mg daily. Prior to discharge patient's blood pressure control improved. Work-up for secondary causes of hypertension was initiated in hospital. Patient had normal TSH. She also had renal artery ultrasound without evidence of renal artery stenosis. 3. Anemia: Patient had HCT drop on admission, but remained stable in the 29 - 30 range after admission. She had some hematuria with from foley trauma at admission, but not enough hematuria to explain drop. Patient's HCT remained stable. Stools were guaiac negative. Please continue outpatient anemia work-up. 4. Acute Renal Failure: On admission, creatinine was slightly elevated likely from poor forward flow in setting of acute diastolic CHF. Improved to baseline on day 2 of admission. 5. CAD: No documented cath in report, low suspicion for CAD. Troponin elevated likely in setting of demand ischemia. Peaked at 0.04 and came down to 0.02. Patient had no chest pain. CHRONIC/INACTIVE ISSUES 1. Breast CA: patient had been on oupatient regimen of Fluoxymesterone but unable to obtain from manufactuer. Patient's oncologist is aware and she will follow-up with her oncologist. 2. CODE: Patient wished to be DNI but not DNR. This was discussed with patient as it is difficult to resuscitate someone without intubating. This should be further addressed with patient. TRANSITIONAL ISSUES: 1. Hypertensive emergency: Initiated work-up for secondary causes of hypertension with TSH (normal) and Renal ultrasound with dopplers that did not show renal artery stenosis. Patient to continue endocrine work-up for secondary causes of hypertension as outpatient. Medications on Admission: Aspirin 81 mg qd Omeprazole 20 mg qd Fluoxymesterone 10 mg [**Hospital1 **] - unable to get from manufactuer for last several months, so not taking Carvedilol 25 mg [**Hospital1 **] Furosemide 40 mg qd Scopolamine base 1.5 mg Patch q72 hr Roxicet 5-325 mg q6 prn pain - patient states she is not taking Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day. 4. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 5. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7. Outpatient Lab Work Monday [**2143-4-15**]. Please check chem 10. Fax results to: Name: [**Last Name (LF) 2204**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone: [**Telephone/Fax (1) 2205**] Fax: [**Telephone/Fax (1) 7922**] Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: PRIMARY: Acute on chronic diastolic congestive heart failure exacebation, hypertensive emergency SECONDARY: Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure to participate in your care Ms. [**Known lastname 96703**]. You were admitted to the hospital because your blood pressure was very high, you had too much fluid in your lungs, making it difficult for you to breathe. You were given medications to help remove the fluid from your body as well as lower your blood pressure. You felt much better and did not need any supplemental oxygen to breath. You blood pressure is also much better. Please have your blood drawn on Monday [**4-15**] prior to your doctor's appointment on Tuesday [**4-16**] so that your doctor has the information prior to your appointment. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Please make the following changes to your medications: 1. Increase your dose of lisinopirl to 30 mg daily from 10 mg daily 2. Increase your dose of lasix to 40 mg twice a day from 40 mg daily 3. ADD aldactone 25 mg daily Please see below for your follow-up appointments. Followup Instructions: Department: [**State **]When: TUESDAY [**2143-4-16**] at 4:40 PM With: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 6564**], MD [**Telephone/Fax (1) 2205**] Building: [**State **] ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: On Street Parking Department: CARDIAC SERVICES When: WEDNESDAY [**2143-4-24**] at 3:00 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

[ "428.33", "285.9", "401.9", "530.81", "V10.05", "174.8", "584.9", "428.0", "198.5", "197.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12692, 12750

8513, 11163

322, 329

12915, 12915

6370, 6370

14081, 14715

4516, 4830

11806, 12669

12771, 12894

11478, 11783

13066, 13811

6676, 6949

4845, 4845

3006, 3079

5664, 6351

11184, 11452

13840, 14058

263, 284

357, 2896

6386, 6660

6971, 8490

4859, 5650

12930, 13042

3110, 3953

2918, 2986

3969, 4500

73,572

168,789

47078

Discharge summary

report

Admission Date: [**2141-7-2**] Discharge Date: [**2141-7-7**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2901**] Chief Complaint: Unresponsiveness Major Surgical or Invasive Procedure: pt expired History of Present Illness: [**Known firstname 2155**] [**Known lastname 41171**] is a [**Age over 90 **]F with CHF, CAD, Afib on a/c, COPD, Parkinson's who was recently admitted to [**Hospital Unit Name 153**] for respiratory distress COPD vs CHF, found unresponsive today in [**Hospital 4382**] facility for unknown duration. Patient was discharged [**6-30**] feeling well other than an intermittent cough. At 6PM evening of admission, she was seen by grandson in normal state of health. At 7PM, she began to watch a movie alone and at 9PM she was found unresponsive in bed. . EMS was called. In the field, ECG detected ST elevations in II, III, and aVF. . In the ED, initial vitals were 97.8 120s/80s 80s ST elevations in II, III with some reciprocal changes fent/versed, intubated . REVIEW OF SYSTEMS Unable to obtain as patient was intubated and sedated on arrival Past Medical History: CHF: admitted [**Date range (1) 96195**] with dyspnea, found to have BNP [**Numeric Identifier **]. TTE revealed moderate to severe MR [**First Name (Titles) **] [**Last Name (Titles) **], severe pulmonary HTN, and EF 55-60%. Symptoms improved with Lasix and she was discharged to her [**Hospital3 **] facility. Torsemide and spironolactone as outpatient. - Coronary artery disease/NSTEMI: s/p 3V CABG in [**2123**]. In her CHF hospitalization last month, troponin peak to 0.39 and EKG with evidence of prior inferolateral MI. Given h/o severe bradycardia and family's reluctance to place a pacemaker, a beta-blocker was not started. She was started on high dose atorvastatin and continued on ASA. - Atrial Fibrillation w/ [**1-27**] second pauses and periods of bradycardia to high 30s. On coumadin. - Bacterial pneumonia (s/p hospitalization in [**6-/2139**]); daughter reports that pt has had many PNAs, including Legionella, beginning with one debilitating episode of several months before the antibiotic era. - Parkinsonism (essential tremor but no cogwheel phenomenon) - Diabetes mellitus (currently not requiring treatment) - Hypertension (well-controlled with baseline 120s/80s) - Hyperlipidemia - Acid reflux - s/p TAH-BSO - s/p cholecystectomy - s/p bilateral cataract surgery - hypothyroidism Social History: TOBACCO: 5 cigarettes per day, quit 40 years ago (~10PY) ALCOHOL: denies due to medications. OTHER DRUGS: denies. No intravenous drugs ever. The patient currently lives alone in Springhouse ([**Hospital 4382**]) in [**Location (un) 538**] where she gets OT, PT, and medication assistance. Also gets assistance in shower and while eating. Her husband passed away in [**2129**]. She was a nurse at the [**Hospital3 **] Hospital as a young woman. Her daughter is on the board of the hospital and her son-in-law is a pediatrician; they visit her very frequently and keep close track of her health issues. Family History: Diabetes: patient's mother and father, both late in life. Sister living with diabetes. Physical Exam: VS: T=97.5 BP= 118/60 HR= 73 RR= 14 O2 sat=100% on 70%FiO2 GENERAL: intubated, sedated HEENT: NCAT. Sclera anicteric. anisocoria, L pupil 4mm, R pupil 2mm, both reactive to light Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of [**7-2**] cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g appreciated. No thrills, lifts. No S3 or S4. LUNGS: Intubated, ronchi and crackles throughout all lung fields. some blood being aspirated from ET tube ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: trace pitting edema in LE b/l. 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+ NEURO- sedated, anisocoric, b/l babinski sign, withdraws to deep painful stimuli b/l Pertinent Results: [**2141-7-2**] 09:25PM WBC-14.2* RBC-3.18* HGB-9.1* HCT-28.9* MCV-91 MCH-28.7 MCHC-31.6 RDW-15.8* [**2141-7-2**] 09:25PM NEUTS-75.6* LYMPHS-19.3 MONOS-3.6 EOS-1.3 BASOS-0.2 [**2141-7-2**] 09:25PM GLUCOSE-258* UREA N-70* CREAT-2.5* SODIUM-131* POTASSIUM-5.7* CHLORIDE-103 TOTAL CO2-11* ANION GAP-23* [**2141-7-2**] 09:25PM estGFR-Using this [**2141-7-2**] 09:40PM LACTATE-10.4* [**2141-7-2**] 09:25PM ALT(SGPT)-11 AST(SGOT)-68* ALK PHOS-100 TOT BILI-0.9 [**2141-7-2**] 09:25PM LIPASE-55 [**2141-7-2**] 09:25PM proBNP-[**Numeric Identifier 66667**]* [**2141-7-2**] 09:25PM cTropnT-0.11* [**2141-7-2**] 09:25PM ALBUMIN-3.8 Brief Hospital Course: ASSESSMENT AND PLAN #Unresponsiveness/Respiratory failure Patient was unresponsive with agonal breathing for unknown period of time. Causes of this episode include cardiac, infectious, and neurologic. Given previous hx of CAD and CABG with ST elevations in EMS concerning for large MI. However, the family was refusing cardiac catheterization so no intervention done. As patient was anisocoric upon presentation, along with elevated WBC and lactate that resolved within 24, and given hx of seizures, another hypothesis was that she had a seizure and stroke (one precipated the other). CT head was negative but this could not full rule it out as it could be a small bleed or ischemic event. Fatal arrhythmia cannot be ruled out, though patient has no history other than A Fib. Elevated WBC from baseline with L shift, elevated lactate and possible infiltrate on CXR indicate infectious etiology. Likely would be hospital acquired infection as she is s/p hospitalization 3 days ago. The patient was intubated upon arrival to the CCU and empiric antibiotics, IV steroids were initated for broad coverage and blood pressure support (family declined central lines and pressors). Mechanical ventilation parameters were good in the morning and the patient was successfully extubated, although had some difficulty with secretions and required face mask ventilation. After discussion with the family the patient was transitioned to comfort measures only. Morphine and lasix prn were given for air hunger and shortness of breath. Her other medications were withdrawn except for Keppra for seizure prophylaxis. The patient expired on [**2141-7-7**]. # CORONARIES: ST elevations with recoprocal depressions in EMS concerning for STEMI. Patient has history of CAD, s/p 3V CABG in [**2123**]. As mentioned above, no invasive intervention was performed as family did not opt for intervention. She was medically managed with aspirin and statin. #Pulmonary Infiltrate The initial CXR was read as pulmonary edema. We had initiated broad spectrum antibiotics (Vancomycin and Zosyn) initially as patient was recently hospitalized and there was concern for hospital acquired pneumonia. The antibiotics were kept on for some time as they were considered symptomatic relief. When patient transitioned to comfort care these medications were withdrawn. # PUMP- Chronic Diastolic CHF Patient has history of heart failure with preserved ejection fraction. While in house previous admission, heart failure was consulted. Team felt she was not decmpensated and recommended maintenace of torsemide dose and d/c spironolactone given creatinine and mild hyperkalemia. Increase in ProBNP on this admission to 16,000 from 8000 is concerning for acute fluid overload. Because her initial presentation was more concerning for sepsis patient did not receive diuresis (except fo palliative measures only) while in the ICU. # RHYTHM: Atrial [**Name (NI) **] Pt was on coumadin at home. This was held while in house due to supratherapeutic INR. #Parkinson's Diease We continued home levodopa-carvidopa until CMO. #Hypertension We held BP meds as concern for sepsis #?h/o Sz: no dx of seizure disorder per record; EEG [**2140-12-20**] negative for sz but possibly with epileptogenic focus -We continued keppra while in house. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from webOMR. 1. Albuterol-Ipratropium 2 PUFF IH Q6H:PRN SOB 2. Mucinex *NF* (guaiFENesin) 600 mg Oral [**Hospital1 **] 3. Symbicort *NF* (budesonide-formoterol) 80-4.5 mcg/actuation Inhalation Daily 4. Torsemide 20 mg PO DAILY 5. Amlodipine 10 mg PO DAILY 6. Atorvastatin 80 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Warfarin 1 mg PO DAILY16 3 Tabs MWF and 2 Tabs Sat, Sun, Tues, Thurs 9. Carbidopa-Levodopa (25-100) 1 TAB PO TID 10. Docusate Sodium 100 mg PO BID Hold for loose stool 11. LeVETiracetam 125 mg PO BID 12. Levothyroxine Sodium 25 mcg PO DAILY 13. Ranitidine 150 mg PO ONCE Duration: 1 Doses 14. Calcium Carbonate 500 mg PO TID nutrition 15. Vitamin D 400 UNIT PO DAILY Discharge Medications: Pt expired Discharge Disposition: Expired Discharge Diagnosis: pt expired Discharge Condition: pt expired Discharge Instructions: pt expired Followup Instructions: pt expired [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

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icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

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9039, 9048

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147,659

4889

Discharge summary

report

Admission Date: [**2117-9-13**] Discharge Date: [**2117-9-14**] Date of Birth: [**2058-5-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Fevers, Hypotension Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 59 yom with PMH ESRD, CAD s/p MI, CMP, seizure disorder and CVA, s/p recent ICU hospitalization for MSSA sepsis w/ lung abscesses possible [**1-25**] HD line infection p/w continued fevers and transient hypotension. After being discharged [**9-11**] for MSSA sepsis thought to be [**1-25**] HD line infection pt was sent to rehab. At [**Hospital 100**] rehab he was noted to have a temp of 103, transiently hypotensive to 80s. EMS found him to be hypoxic. On admission to the ED he was noted to be saturating 100% on NRB. When his NRB was removed he desaturated to 89-91% on RA. He was also noted to have a 1 time temp of 103 on rectal temp. His initial set of vitals were noted to be T100.3, HR 103, BP 86/46. CXR was obtained which showed progression of pleural effusion. Pt was not given IV fluids but started on Vancoymcin and Zosyn. Labs were significant for Lactate of 2.2, no leukocytosis but left shift. Past Medical History: - h/o Hepatitis B, successfully treated - Non-ischemic cardiomyopathy, EF 35-40% per echo in [**10/2115**] - MI [**2086**] per pt - CVA [**2086**] per pt (?residual LE weakness) - ESRD on hemodialysis [**1-25**] HTN. [**2-1**] right thigh HD graft placed. Removed from transplant list [**2-1**]. - History of MSSA TDC line infections. - Multiple thrombectomies in LUE and R thigh AV fistula - Graft excision for infected thight graft [**2117-5-26**] - Seizure disorder, onset of seizures in mid [**2097**] after starting dialysis. He seems to have seizures quite frequently at dialysis, per neurology this seems to be attributed to both non-compliance with the medications, as well as taking his medications later on those days. - Hungry bone syndrome status post parathyroidectomy - Pituitary mass - Anemia Social History: The patient has a Ph.D. in history and had a successful academic career until [**2103**], when he went on disability for unclear reasons. The patient currently is homeless. Although patient reports he is an organist and choir director at a local church, the church does not corroborate this. He denies tobacco and illicit drugs. ETOH twice weekly per his report. Family History: F - DM. M - Deceased age 41 of renal failure. One son - healthy. Physical Exam: At Admission: General: African American Male sitting up in NARD HEENT: Sclera anicteric, MMM, EOMI Neck: supple, JVP not elevated Lungs: Diffuse crackles noted. CV: Distant S1 + S2, difficult to auscultate [**1-25**] crackles, no gross murmurs, rubs, gallops, borderline tachy Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: RUE edema noted 2+, no lower extremity noted. Pertinent Results: [**2117-9-13**] 11:15AM NEUTS-82.7* LYMPHS-10.3* MONOS-3.4 EOS-2.7 BASOS-0.8 WBC-8.2 RBC-2.54* HGB-6.5* HCT-22.3* MCV-88 MCH-25.5* MCHC-29.1* RDW-16.3* PLT COUNT-715* [**2117-9-13**] 11:15AM TOT PROT-5.9* [**2117-9-13**] 11:15AM LD(LDH)-234 [**2117-9-13**] 11:31AM LACTATE-2.2* [**2117-9-13**] 03:15PM PLEURAL WBC-240* RBC-9250* POLYS-20* LYMPHS-56* MONOS-0 EOS-1* PLASMA-4* MESOTHELI-4* MACROPHAG-14* OTHER-1* TOT PROT-2.8 GLUCOSE-119 LD(LDH)-175 PH-7.40 Brief Hospital Course: Patient was admitted to the ICU on [**9-13**] for concern of fevers, transient hypotension, and respiratory distress. ##. Fevers: Patient was noted to be febrile at rehab and in the ED. Patient met SIRS criteria based on temperature, pulse and suspected source including prior diagnosis of pneumonia. Patient also reported diarhea and in the setting of antibiotics and hospitalization, a C. Diff toxin was sent and was negative. Patient never had a WBC count but did have a left shift at admission. Infectious Diseases was consulted which recommended continuing Vancomycin, Zosyn and Ciprofloxacin (noting that this may lower seizure threshold). They also requirested a diagnostic thoracentesis which showed 240 WBC, 9250 RBC, 20 % PMN, 56 % L. total protein 2.8, glucose 119, LDH 175, pH 7.43. Broad spectrum antibiotics with Zosyn + Vancomycin for MRSA and pseudomonal coverage. Sputum cultures grew out pseudomonas and MRSA swab was pos. Patient had some mild low grade fevers during his stay, typical of his fever curve during his prior admission. ##. Hypoxia: Patient was noted to be hypoxic in the ED and was initially noted to be on a non-rebreather saturating at 99 %. Upon arrival to the ICU, patient was aggresively suctioned with thick secretions returned and his saturations quickly improved. Patient was also given albulterol and ipratropium nebs as needed and underwent thoracentesis as documented above. Sputum cultures grew out pseudomonas and Vancomycin, Zosyn and Ciprofloxacin were continued pending sensitivities. ##. Diarrhea: Patient was noted to have diarrhea at outside rehab. There was initial concern for C.Diff colitis considering diarrhea in the setting of a recently hospitalized patient on antibiotics. C.Diff toxin was sent which was negative. ##. ESRD: Patient is hemodilaysis dependend and initial electrolyte panel showed now abnormalities. Patient received HD on [**9-14**] and was transfused 1 unit of PRBC's. ##. Tachycardia: Patient was initially noted to be tachycardic in the ED which was attributed to a physiologic response to his hypoxia and possible infection. Patient was persistently mildly tachycardic throughout prior admission. Patient was continued on telemtry throughout the admission. ##. Non-Ichemic CMY: Pt's prior Echo in [**2116**] shows an EF of 40% as well as mild-moderate regional systolic dysfunction with hypokinesis of the inferior, inferolateral, and septal walls. Digoxin was continued. ##. Seizure d.o.: Home regimen of Levetiracetam, Oxcarbazepine was continued. ##. FEN: Patient continued on hemodialysis. ##. Prophylaxis: subcutaneous heparin ##. Code: FULL CODE ##. Communication: [**Name (NI) 1094**] sister [**Name (NI) **] ([**Telephone/Fax (1) 20406**] ##. Disposition: pending above Medications on Admission: Acetaminophen 650mg q8hr PRN Allopurinol 150mg QOD ASA 81 mg daily Cefazolin 3gm qFriday Cefazolin 2gm qMon, qWed Digoxin 0.125mg PO EVERY SUN, TUE, [**Doctor First Name **], SAT Levetiracetam 500 mg po TID ON HD DAYS M, W, F Levetiracetam 500 mg PO BID ON NONHD DAYS Tu, Th, Sat, Sun. Folic Acid 1 mg po daily Fentanyl 50 mcg/hr Patch 72 hr Oxcarbazepine 300 mg po tid on non-HD days (Tu, Th, Sat, Sun). Oxcarbazepine 300 mg po QID on HD days (M-W-F) Gabapentin 300 mg PO BID Sevelamer HCl 1600 mg po tid w/ meals Omeprazole 40 mg po daily Heparin 5,000u SC TID Albuterol nebs PRN Ipratropium nebs PRN Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) syringe Injection TID (3 times a day). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain: Not to exceed 3g of Tylenol per day. 3. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO EVERY OTHER DAY (Every Other Day). 4. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHD (each hemodialysis). 7. Oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO four times a day: Please give on HD with 4th dose post HD. . 8. Oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO three times a day: On non-HD days. 9. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Please administer on HD days with last dose post-HD. 10. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): on non-HD days. 11. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed for wheezing. 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 14. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day): please administer on Sun, Tues, Thurs, Sat each week. 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 16. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 17. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours). 18. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous HD PROTOCOL (HD Protochol). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: methacillin sensitive staph aureus bacteremia, methacillin sensitive staph aureus lung abscesses, pseudomonas + sputum secondary diagnoses: dialysis dependent ESRD, seizure disorder, anemia Discharge Condition: Cccasional low grade fevers, alert, oriented to place and person, irritable and occasionally withdrawing from light touch, severe weakness of extremities, no gag reflex requiring deep suction for oral secretions to help facilitate adequate sats. Discharge Instructions: You were readmitted to the hospital for fevers and problems breathing. Your fevers were monitored and your breathing problems resolved with deep suction of your respiratory tract. You were discharged on [**9-11**] with a bacteria called methacillin sensitive staph aureus in your blood. The source was felt to be your hemodialysis line and that line was removed. You recieved another temporary line instead. You were also found to have pockets of bacteria (abscesses) in your lungs, which are also likely the same bacteria. When you had the infection you had some trouble breathing and a breathing tube was placed for you which we were later able to remove. You were treated with antibiotics and you slowly improved. You were initially continued on your regular hemodialysis but for a little while your blood pressures were too low and you were switched to a different kind of dialysis called CVVH which causes less of an effect on blood pressure. Eventually, we were able to switch you back from CVVH to regular dialysis. Please call your doctor or return to the hospital for any of the following: - documented high fevers with shaking chills - chest pain, difficulty breathing - nausea with continued vomiting and an inability tolerate PO - any other new or worsening symptoms which concern you Followup Instructions: -Pt must be seen in [**Hospital **] clinic within 2 weeks. please call [**Telephone/Fax (1) 457**]. Please tell receptioninst that he will need urgent care ID slot c any avail fellow or attg per their request while he was an inpatient. - Furthermore, pt should see [**First Name8 (NamePattern2) 4648**] [**Last Name (NamePattern1) **] MD, also of infectious diseases, on [**4-8**] at 10am (appointment already made). -Pt should also be scheduled for a repeat chest CT noncontrast early in [**Month (only) **] prior to the appointment on 16th. Please call [**Hospital1 18**] radiology at [**Telephone/Fax (1) 2756**] to set up that appointment. -Please also make an appointment with first available neurologist for his seizure disorder and muscular weakness. The number for neurology clinic is ([**Telephone/Fax (1) 2528**]. -Pt will also need urology evaluation for renal mass seen on abdominal CT. Urology phone number is ([**Telephone/Fax (1) 772**]. -Lastly, when pt is discharged please make pt appointment with his regular PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD at [**Telephone/Fax (1) 250**].

[ "482.1", "041.12", "585.6", "790.7", "275.5", "412", "345.90", "785.0", "996.62", "E879.8", "V45.11", "V12.54", "458.9", "285.21", "428.0", "787.91", "403.91", "511.9" ]

icd9cm

[ [ [] ] ]

[ "34.91", "38.93", "39.95" ]

icd9pcs

[ [ [] ] ]

8883, 8949

3560, 6339

335, 349

9184, 9433

3068, 3537

10781, 11957

2521, 2587

6993, 8860

8970, 9090

6365, 6970

9457, 10758

2602, 3048

9111, 9163

276, 297

377, 1291

1313, 2124

2140, 2505

8,675

150,425

26285

Discharge summary

report

Admission Date: [**2163-1-21**] Discharge Date: [**2163-2-4**] Date of Birth: [**2098-4-13**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1561**] Chief Complaint: 64 M w/ recurrent pneumonia and hemoptysis from a right lower lobe lesion. Major Surgical or Invasive Procedure: right video assisted thorocoscopy, right thorocotomy Right middle, right lower lobectomy [**1-24**] for hilar lesion Tissue flap. Mediastinal lymphnode disection. History of Present Illness: Pt is a 64 yo man w/ long smoking history, recent recurrent PNA's, who was transferred from [**Hospital1 1562**] Hospitalto thoracics service on [**2162-12-31**] for work up of lung mass,throacics/IP consultation, with concern for lung ca. He has had recurrent, right sided pneumonias in recent months and was initially admitted to [**Hospital1 1562**] w/ shortness of breath. Initial brochnoscopy at [**Hospital1 1562**] on [**12-31**] showed endobronchial, friable, "pearly white" lesion @ "take off" of right lower lobe. CT scan here of airway showed large tumor burden on right with almost total collapse of RLL (see below for report). Patient then had rigid bronch on [**1-4**] which showed tumor origin extending into RLL orifice, obstructing entire RLL. Tumor excision and destruction was performed. Prelim biopsy report c/w lung ca, but final report pending. Patient was dischared home [**1-6**] to complete staging w/u (PET, etc), and now returns to [**Hospital1 18**] for O.R. VATS / RLLobectomy. Past Medical History: PMH: h/o tularemia [**2138**] (hospitalized) h/o babesiosis- 5 yrs ago (hospitalzed) chornic/recurrent right sided pnas 2-4 episodes in last year- last admit few weeks before current admission GERD eye surgery OTHER DATA: CT scan at [**Hospital1 1562**] by report [**12-18**]: R lower lobe infiltrate spirometry at [**Hospital1 1562**] [**2162-12-30**]: FEV1 2.63 (79% predicted). FEV1/FVC 63, DLCO 89% predicted. TLC 102% predicted. Flow volume loop with mild obstruction. Impression "Stage I COPD" thinks he may have had TIA many years ago w/ right arm tingling- not worked up Social History: Lives in [**Hospital3 4298**]. Has 1.5 ppd smoker x 50 years, quit on [**2162-12-31**]; heavy Etoh >10 yrs ago but now one beer per day but "100% whiskey is my weakness." Used to live/work on a farm, now works for [**Location (un) 65076**] road crew part time. Lives with friend. [**Name (NI) **] sister close by. Not married. No children. Family History: sister w/ CAD, CABG, DM. Brother passed away suddently at age 43, thinks he had MI. Father w/ "[**Name2 (NI) **]-induced cancer." Denies family h/o anesthesia complications Physical Exam: He is a thin elderly male in no acute distress. His vital signs are within normal limits. His pupils are equal, round, and reactive. His sclerae are anicteric. Cervical exam reveals no supraclavicular or cervical adenopathy. Lungs are clear to auscultation and bilaterally equal. Heart is regular without murmur. Thorax is symmetrical without lesions or masses. Abdomen is benign without masses or tenderness. Extremities show no clubbing or edema. Neurologic is grossly nonfocal with intact and appropriate mental status. Pertinent Results: CT trachea [**2163-1-1**]: Near-complete collapse of the right lower lobe secondary to a mass which obstructs the right lower lobe segmental bronchi and extends up to the level of the right middle lobe origin. Bronchoscopy report [**2163-1-4**]: There was normal anatomy down to the level of the right lower lobe. The right lower lobe had a white necrotic obstructing lesion emanating from the superior segment of the lower lobe (S6) and completely obstructing the right lower lobe. The right middle lobe was spared. The right middle lobe carina was spared. P-MIBI on [**2163-1-21**]: 1. Normal myocardial perfusion. 2. Normal left ventricular cavity size and systolic function. CXR [**2163-1-24**]: Moderate right pneumothorax with chest tubes in place. PORTABLE CHEST, [**2163-1-29**] AT 16:31. INDICATION: Recent lobectomy surgery - check PTX. COMPARISON: [**2163-1-29**] AT 13:06. FINDINGS: Compared with the prior study, the right chest catheter remains in place, and there is a persistent lower component pneumothorax, unchanged from prior. Pneumomediastinum also persists, unchanged. A bit more patchiness in opacity is seen in the right lower lung field, a finding which should be reassessed on subsequent followup studies. Left lung remains clear. IMPRESSION:Stable right basilar PTX. Possible developing airspace disease in the right base. [**1-31**]- CHEST, ONE VIEW, PORTABLE INDICATION: 64-year-old man with status post right middle and right lower lobectomy. COMMENTS: Portable erect AP radiograph of the chest is reviewed, and compared with the previous study of [**2163-1-30**]. The right chest tube remains in place. There is continued moderate-sized right basilar pneumothorax, which is unchanged in size. There is continued extensive subcutaneous emphysema in the right chest wall. The left costophrenic angle is not included in the radiograph. The left lung appears clear. The heart is normal in size. [**2-2**] [**Hospital 93**] MEDICAL CONDITION: 64 year old man with s/p RML/RLLobectomy , continued air leak REASON FOR THIS EXAMINATION: 64 year old man with s/p RML/RLLobectomy , continued air leak on.Please do at 10am HISTORY: Right middle and right lower lobectomy. PA and lateral chest (three images). The right hemithorax is diminished in size with previous thoracotomy and rib fractures plus skin staples. There is a small caliber chest tube in the lower right hemithorax. Moderate-sized right pneumothorax, most of which is seen adjacent to the diaphragm. Extensive right subcutaneous emphysema. Heart normal size without vascular congestion & left lung is clear. The overall appearances and size of postoperative right pneumothorax are little changed from one day previous ([**2163-2-1**]). IMPRESSION: No short interval change in postoperative right pneumothorax. [**2163-2-3**] 7:24 AM CHEST (PORTABLE AP) [**Hospital 93**] MEDICAL CONDITION: 64 year old man with s/p RML/RLLobectomy , continued air leak REASON FOR THIS EXAMINATION: 64 year old man with s/p RML/RLLobectomy , continued air leak REASON FOR EXAMINATION: Interval evaluation after right middle lobe and right lower lobe lobectomy. Portable AP chest x-ray was reviewed and compared to the previous study from [**2163-2-2**]. Right chest tube remains in place. Moderate sized right pneumothorax, which is most prominent in the lung base but also may be barely seen in the apex, remains unchanged. Extensive right subcutaneous emphysema is present and prevents the exact estimation of the apical part of the right pneumothorax. The heart size is normal without vascular congestion. The left lung is clear. IMPRESSION: The overall appearance of the x-ray is grossly unchanged in comparison to the previous film. CHEST (PA & LAT) [**2163-2-4**] 6:51 AM Reason: please eval for change--compared to [**2-3**]--9:30pm [**Hospital 93**] MEDICAL CONDITION: 64 year old man with s/p RML/RLLobectomy, s/p CT removal, worsenign crepitus and voice change REASON FOR THIS EXAMINATION: please eval for change--compared to [**2-3**]--9:30pm HISTORY: Status post right middle and right lower lobectomies and chest tube removal, with worsening crepitus and voice change. COMPARISON: [**2163-2-3**]. CHEST: PA and lateral views. Evaluation of the right-sided intrathoracic detail is once again limited by the extensive subcutaneous emphysema in the right chest wall. The moderate right hydropneumothorax appears unchanged. There is no change in the position of the heart and mediastinum, including the trachea. The left lung is clear. There is no left pleural effusion or pneumothorax. IMPRESSION: Unchanged moderate right hydropneumothorax. Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2163-1-31**] 06:10AM 8.1 3.88* 11.9* 34.9* 90 30.7 34.2 14.3 379 BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT) [**2163-1-31**] 06:10AM 379 BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino [**2163-1-21**] 07:02AM 328 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2163-1-31**] 06:10AM 108* 11 0.8 139 4.2 101 281 14 1 NOTE UPDATED REFERENCE RANGE AS OF [**2162-6-18**] ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2163-1-22**] 02:05AM 28* CPK ISOENZYMES CK-MB cTropnT [**2163-1-22**] 02:05AM NotDone1 <0.012 1 NotDone CK-MB NOT PERFORMED, TOTAL CK < 100 2 <0.01 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2163-1-31**] 06:10AM 9.4 4.0 HIV SEROLOGY HIV Ab [**2163-1-25**] 03:12PM NEGATIVE CONSENT RECEIVED HEPATITIS C SEROLOGY HCV Ab [**2163-1-24**] 08:48PM NEGATIVE Brief Hospital Course: Patient was planned to go to the OR on [**2163-1-21**] for VATS / RLLobectomy. OR was delayed for acute chest pain with bradycardia, no EKG changes or increase in cardiac markers were seen. Cardiology was consulted in the pre-operative area and OR was delayed. Due to a suboptimal pre-op exercise stress test a Persanthine MIBI was obtained which was normal. Per cardiology note, this presentation was consistent with an increase in vagal output likely [**1-20**] pain, a cold room etc. On [**2163-1-24**], the patient was taken for R VATS and R lower lobectomy (see operative log for details). The procedure was uncomplicated and the patient was transfered postoperatively to the ICU. On [**2163-1-25**], the patient was transfered to the floor. [**1-25**]: apneic periods, epidural/PCA, am cxr ->Persistent right PTX [**1-26**] slight increase in R PTX; HIV/HepC antibodies came back negative [**1-27**] CT's out, air leak on [**Doctor Last Name **], eating drinking, hep locked, epidural PCA combo [**1-28**] + air leak-> leave [**Doctor Last Name **] to suction, epidural/PCA d/c'd, PO pain meds, lopressor changed to PO, CXR-> no change [**1-30**] still w/ subQ-emphysema, incr PTX on a.m. CXR, put to 10cc sxn [**2-1**] water seal -> back to sxn [**2-2**] back to water seal, CXR Moderate-sized R PTX, extensive R subq emphysema [**2-3**] CT dc'd, repeat CXR looks okay. Patient developed some voice changes concerning for increase in subqutaneous emphysema. CXRY done in evening- stable, no changes. PLAN: [**2-4**] a.m CXR stable and without changes. Patient discharged to home in stable condition. Supported by sister who lives nearby and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19700**] VNA services, [**Telephone/Fax (1) 24288**], as appropriate to qualification criteria. Follow-up appt schedule: Call Dr. [**Last Name (STitle) **] [**Name (STitle) 65080**] office for appointment in 3 weeks for follow-up per DR. [**Last Name (STitle) 952**].-[**Telephone/Fax (1) 34841**]. CAll for Oncologist appointment in 4 weeks or per Dr.[**Name (NI) 65081**] recommendation- [**Telephone/Fax (1) 65082**]-Dr. [**Last Name (STitle) 65083**] and Dr. [**Last Name (STitle) 65084**] [**Name (STitle) 6814**] office. They are based in [**Hospital1 1562**] but come to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19700**] 2 days/week. Medications on Admission: None. Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-20**] Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*1 1* Refills:*0* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] Community Services Discharge Diagnosis: PMHx: 50 pk yr smoker, multiple pneumonias, ? Chronic obstructive pulmonary disease, Tularemia, Babesioses. Cardiac workup pre-op negative. Bradycardia episode pre-op. Discharge Condition: good Discharge Instructions: Call Dr.[**Name (NI) 1816**]/Thoracic Surgery office ([**Telephone/Fax (1) 170**]for: fever, shortness of breath, chest pain, redness and excessive foul smelling drainage from incision sites. Take old medications as directed. Take new medications as directed. Take pain medication as needed. No driving until not taking percocet narcotic pain medication. You may shower when you get home. Remove dressing after showering and replace with bandaid, and change daily as needed. Follow appointment instructions as below No tub baths or swimming for 3-4 weeks. Maintain/increase activity slowly to return to regular routine. Call Dr. [**Last Name (STitle) **] [**Name (STitle) 65080**] office for appointment in 3 weeks for follow-up per DR. [**Last Name (STitle) 952**].-[**Telephone/Fax (1) 34841**]. CAll for Oncologist appointment in 4 weeks or per Dr.[**Name (NI) 65081**] recommendation- [**Telephone/Fax (1) 65082**]-Dr. [**Last Name (STitle) 65083**] and Dr. [**Last Name (STitle) 65084**] [**Name (STitle) 6814**] office. They are based in [**Hospital1 1562**] but come to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19700**] 2 days/week. Followup Instructions: Call Dr. [**Last Name (STitle) **] [**Name (STitle) 65080**] office for appointment in 3 weeks for follow-up per DR. [**Last Name (STitle) 952**].-[**Telephone/Fax (1) 34841**]. CAll for Oncologist appointment in 4 weeks or per Dr.[**Name (NI) 65081**] recommendation- [**Telephone/Fax (1) 65082**]-Dr. [**Last Name (STitle) 65083**] and Dr. [**Last Name (STitle) 65084**] [**Name (STitle) 6814**] office. They are based in [**Hospital1 1562**] but come to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19700**] 2 days/week. Completed by:[**2163-2-7**]

[ "196.1", "162.5", "530.81", "E878.6", "427.89", "998.81", "496" ]

icd9cm

[ [ [] ] ]

[ "34.22", "32.4", "40.11", "40.3", "33.22", "34.51" ]

icd9pcs

[ [ [] ] ]

12088, 12154

9010, 11381

403, 569

12366, 12372

3315, 5250

13578, 14145

2582, 2756

11438, 12065

7167, 7261

12175, 12345

11408, 11415

12396, 13555

2771, 3296

289, 365

7290, 8987

597, 1606

1628, 2209

2225, 2566

16,186

162,998

43167

Discharge summary

report

Admission Date: [**2187-3-22**] Discharge Date: [**2187-3-29**] Date of Birth: [**2123-3-25**] Sex: M Service: CHIEF COMPLAINT: Direct admission for deep venous thrombosis from radiology. HISTORY OF PRESENT ILLNESS: This is a 63 year-old male with extensive recent medical history began with coronary artery bypass graft for coronary artery disease in [**2187-1-18**], discharged and then readmitted on [**2187-2-27**] for shortness of breath. He was subsequently found to have a hemothorax, gastrointestinal bleed and acute renal failure. A chest tube was placed and esophagogastroduodenoscopy performed, which showed a duodenal nonbleeding ulcer. His Plavix was held and his aspirin was held as well and was started on a high dose PPI and transfused for a low hematocrit. During his hospitalization a right subclavian line was readmitted on [**3-5**] for right arm swelling with a subclavian deep venous thrombosis. He was started on heparin and again had an upper gastrointestinal bleed described as severe requiring multiple transfusions and a MICU stay. He was discharged on the [**2-11**] and followed up with Dr. [**Last Name (STitle) **] after this who felt that his right leg was a bit swollen suggested an ultrasound evaluation for deep venous thrombosis. On the day of admission the patient was at ultrasound and was diagnosed with a right lower extremity deep venous thrombosis and was told to go to the [**Hospital1 69**] for a direct admit. The patient reports that since his last discharge he has not been able to ambulate as well, because limited by shortness of breath, but not leg pain. He has not experienced any angina nor orthopnea or paroxysmal nocturnal dyspnea, but sits up and sleeps due to swelling in his upper and lower extremities. He has no history of coagulopathies or hypercoagulable studies. No recent travel. No extended sitting at home other then when he is resting for his leg swelling. PAST MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery bypass graft in [**2187-1-18**]. 2. Cadaveric renal transplant. 3. Hypertension. 4. Diabetes. 5. Gastrointestinal bleed. 6. Deep venous thrombosis. 7. Anemia. 8. Depression. 9. Gout. 10. Appendectomy. MEDICATIONS: 1. Prednisone 5 mg q day. 2. Cyclosporin 100 q.a.m. and 75 q.p.m. 3. Hydralazine 75 q day. 4. Amlodipine 10 mg q day. 5. Toprol 125 mg t.i.d. 6. Pantoprazole 40 mg b.i.d. 7. Allopurinol 100 mg every day. 8. Lorazepam as needed. 9. Bactrim double strength q.o.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: He lives at home with his wife. PHYSICAL EXAMINATION: Vital signs 97.6. 150/82. 56, 20, 94% on room air. General, he is sitting upright in no acute distress. Appeared comfortable and slightly anxious. HEENT examination pupils are equal, round and reactive to light. Extraocular movements intact. Mucous membranes are moist. Cardiovascular examination regular rate and rhythm. No rubs or gallops. 2 out of 6 systolic ejection murmur most likely mitral regurgitation without any JVD. Pulmonary examination decreased breath sounds at the bases bilaterally. Crackles in the left mid lung field. No wheezes or rhonchi. Gastrointestinal examination good bowel sounds, nontender, nondistended. No hepatosplenomegaly. He was guaiac positive. Extremities he had 1+ pitting edema in the right upper extremity and 2+ radial pulses bilaterally. He had 2+ pitting edema on the left lower extremity bilaterally and 2+ dorsalis pedis pulses. No cords or [**Last Name (un) 4709**] signs were elicited. STUDIES: Ultrasound examination LENI showed a right lower extremity deep venous thrombosis at the superficial femoral vein. A repeat ultrasound of the cadaveric renal transplant showed increased __________ ________, but no acute change from previous studies. Chest x-ray showed cardiomegaly with a +1 mild effusions, some cephalization. Electrocardiogram within normal limits. LABORATORY: White blood cell count 8.1, hematocrit 29.5, platelets 299, sodium 139, potassium 3.4, chloride 104, bicarb 22, BUN 82, creatinine 3.9, glucose 153, PT 12.2, PTT 28.8, INR 1.0. Urinalysis within normal limits. ASSESSMENT/PLAN: This is a 63 year-old gentleman with a history of deep venous thrombosis in the right upper extremity who presented with a right lower extremity deep venous thrombosis. 1. Recurrent deep venous thrombosis: Given his recurrent deep venous thrombosis and absent _______________ coagulation given gastrointestinal bleed, we held off on anticoagulation with Warfarin, suggested starting heparin without bolus, but also considered placing IVC filter, however, given the cadaveric transplant and the increase in creatinine considered a different approach with IVC and given the fear of retrograde thrombosis and alternative to intravenous contrast. 2. Gastrointestinal bleed, we consulted gastrointestinal with regards to whether or not this person needed an esophagogastroduodenoscopy. A central line was placed and he was typed and screened for possible future transfusions. His Lasix was held given his renal transplant and increased creatinine. He was continued on his Prednisone and Cyclosporin. 3. Shortness of breath: The patient did not report any recurrence of his angina, however, recent hemothorax, we checked x-ray, which was normal. Most likely due to mild congestion. We diuresed gently after assessing renal function. He was well controlled on his current hypertensive medications. Will continue those throughout. HOSPITAL COURSE: On the following day after admission heparin was initially held given history of GI bleed and a question of whether or not there was a true deep venous thrombosis. Reassessment by radiology confirmed original read that the ultrasound was of good quality and there in fact was a right lower extremity deep venous thrombosis. We rediscussed with GI who said that they would like to scope him before we started heparin. Rescoping showed gastritis in the fundus of the stomach and also in the proximal folds of the duodenum. He was started on heparin without any bolus with a goal PT of 50 to 70. We discussed an IVC filter with Interventional radiology and increased creatinine with respect to his renal transplant was also discussed with them and in light of this we started a _______________ cystine protocol over the weekend given his rise in creatinine. Throughout the weekend the patient did well. His hematocrit slowly increased from 31.5 to 29.5 and then he went down to 26.6. He received a unit of packed red blood cells and bumped his hematocrit up to 30.5. On Monday as said before hematocrit remained stable over the weekend in the low 30s until [**Last Name (un) 1017**] night when it was measured to be 24.3 and then down to 29.9. Heparin was stopped and he was given 2 units of packed red blood cells and was scoped by GI Monday morning. This showed an ulcer in the bulb with a visible vessel. This was injected and treated thermally. On Monday morning he again had large maroon stools and so an IVC filter was felt to be the best option for this gentleman in light of his risk for continued anticoagulation. Cyclosporin measurement at that time showed a therapeutic 133, however, he was decreased to 75 b.i.d. in light of his creatinine of 3.9. In the afternoon he was transferred to the MICU for closer management of hematocrit and gastrointestinal bleed. A Foley was placed over the weekend. On Tuesday [**2187-3-27**] he was called out from the MICU and hematocrit was 28.2. It rose to 30.3 and then to 32.2 with a total of 9 units of packed red blood cells. He continued to have melena though decreased from previous days. His creatinine decreased from 3.5 to 3.2 with placement of a Foley. On Wednesday [**2187-3-28**] he had decreased melena. Hematocrit remained stable, but decreased slightly to 29.5 overnight. He received 1 unit of packed red blood cells, which bumped his hematocrit to 31.9. His creatinine again continued to trend down from 3.2 to 2.9 and urology felt that this was most likely benign prostatic hyperplasia with some component of retention and/or obstructive uropathy, which led to increase creatinine. On Thursday [**2187-3-29**] the patient's hematocrit continued to trend up from a 31.7 to a 32.3 and his creatinine continued to trend down to 2.9 to 2.5 and at this time a PSA was measured, which was in the low normal limits of 0.5, so the patient remained stable and was discharged with appropriate follow up with hematology for a workup of a hypercoagulable state versus heparin induced thrombocytopenia. He is also scheduled to follow up with renal given his history of increasing creatinine and possible cadaveric renal transplant rejection or failure. He should follow up with his primary care physician and the patient was given instructions on how to follow up with his Foley that he was discharged home with. [**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**] Dictated By:[**Last Name (Prefixes) 55130**] MEDQUIST36 D: [**2187-3-30**] 08:08 T: [**2187-3-30**] 08:12 JOB#: [**Job Number **]

[ "414.00", "532.40", "591", "584.9", "996.81", "V45.81", "428.0", "274.9", "453.8" ]

icd9cm

[ [ [] ] ]

[ "44.43", "38.93", "99.04", "45.13", "38.7" ]

icd9pcs

[ [ [] ] ]

5574, 9200

2644, 5556

149, 210

239, 1959

1981, 2571

2588, 2621

53,176

143,464

1142

Discharge summary

report

Admission Date: [**2110-12-30**] Discharge Date: [**2111-1-3**] Date of Birth: [**2045-3-5**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Known firstname 1711**] Chief Complaint: Sustained stable VT Major Surgical or Invasive Procedure: VT ablation History of Present Illness: 65M with a history of inferior posterior MI s/p three vessel CABG in [**2094**] with a large residual scar and recurrent VT s/p VT ablation on [**2110-12-18**] and discharged from the CCU service on [**2110-12-21**] who presents with recurrent symptomatic VT. He reports that he started having a feeling of palpitations and increased DOE and SOB even at rest starting at some point on Saturday. He denies CP, nausea, chest pressure, radiation, LE edema, orthopnea, or PND - but he wears a CPAP mask. He did have some night sweats. Today when he reported these symptoms to his cardiologist, he was referred to the [**Hospital1 **] ED. In the ED there he was in and out of VT. His pacer was interrogated with showed recurrent VT ongoing with some ATP and 18 continuous hours of VT on Saturday. He has a report of a BP of 59/34 there, but all other BPs were 100s/80s. Given this, he was transfered to here for further management. . In our ED, initial VS were T 97.8, P 60, BP 110/71, RR 20, O2sat 99%. He went into a perfusing VT at around 130/min with a BP of 101/72. He was symptomatic, but not syncopal or presyncopal. He was bolused with lidocaine 100 mg IV x1 and started on a drip at 1 mg/min with no improvement in his VT. He was admitted to the CCU for further management. . On the floor, he feels well. He complains of mild cough and a sensation that he cannot take a deep breath. Otherwise, he has no complaints. Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: -CABG: CAD, inferior lateral posterior MI treated with thrombolytics in [**2094-3-9**] complicated by ventricular tachycardia, subsequent three-vessel CABG in [**2094-3-9**] at [**Hospital1 18**]. Anatomy unclear. -PERCUTANEOUS CORONARY INTERVENTIONS: None -PACING/ICD: AICD implantation for ventricular tachycardia in [**2094-6-9**] at [**Hospital1 18**], generator placement in [**2098**] upgraded device due to battery depletion in [**2106-6-10**] with [**Company 1543**] AICD and new RV lead placement. 3. OTHER PAST MEDICAL HISTORY: - Paroxysmal atrial fibrillation with evidence of inappropriate firing of defibrillator. - VT s/p unsuccessful ablation on [**2110-12-18**] - Hypertension. - Hypercholesterolemia. - Cardiomyopathy, EF 30% seen on echocardiogram in [**2107-5-10**]. - Moderate mitral regurgitation. - Mild obesity. - Obstructive sleep apnea treated with CPAP. Social History: - Married. He has two children from his first marriage. He is self employed as a computer analyst - Tobacco: Denies - ETOH: One glass of wine twice a week Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: On admission VS: 120 106/81 19 96% on RA GENERAL: NAD, pleasant, lying in bed HEENT: non injected sclera. no lymphadenopathy. NECK: JVP at 11cm CARDIAC: RR, tachy, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4 but difficult to assess given rate CHEST: Well healed midline sternotomy and left pacer scars LUNGS: Bilateral crackles 1/4 up the lung fields ABDOMEN: BS+, overweight, soft, nondistended, no HSM. EXTREMITIES: 1+ pretibial edema to mid calf BL, no venous stasis changes. SKIN: no rash PULSES: Right: DP 2+ PT 2+ Radial 2+ Left: DP 2+ PT 2+ Radial 2+ Pertinent Results: On Admission: [**2110-12-30**] 03:45PM PT-23.8* PTT-25.7 INR(PT)-2.3* [**2110-12-30**] 03:45PM PLT COUNT-227 [**2110-12-30**] 03:45PM NEUTS-68.4 LYMPHS-23.3 MONOS-4.9 EOS-2.6 BASOS-0.8 [**2110-12-30**] 03:45PM WBC-7.6 RBC-4.53* HGB-14.3 HCT-41.2 MCV-91 MCH-31.5 MCHC-34.6 RDW-14.0 [**2110-12-30**] 03:45PM CALCIUM-8.7 PHOSPHATE-3.3 MAGNESIUM-1.9 [**2110-12-30**] 03:45PM CK-MB-4 [**2110-12-30**] 03:45PM cTropnT-0.22* [**2110-12-30**] 03:45PM GLUCOSE-92 UREA N-21* CREAT-0.7 SODIUM-144 POTASSIUM-4.2 CHLORIDE-109* TOTAL CO2-27 ANION GAP-12 . On Discharge: [**2111-1-3**] 05:47AM BLOOD WBC-9.4 RBC-4.28* Hgb-13.6* Hct-39.8* MCV-93 MCH-31.8 MCHC-34.2 RDW-14.2 Plt Ct-212 [**2111-1-3**] 08:17AM BLOOD PT-18.0* PTT-123.6* INR(PT)-1.6* [**2111-1-3**] 08:17AM BLOOD Glucose-93 UreaN-20 Creat-0.9 Na-140 K-3.7 Cl-105 HCO3-27 AnGap-12 [**2111-1-3**] 08:17AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.1 [**2111-1-1**] 08:41PM BLOOD QUINIDINE- pending IMAGING: CXR [**2110-12-30**] FINDINGS: Frontal and lateral chest radiographs were obtained. There is moderate cardiomegaly. Hilar and mediastinal contours are stable with a tortuous thoracic aorta. A left chest wall pacemaker with two leads in the expected position of the right ventricle are present. An additional lead terminates in the SVC, and is unchanged since the prior study. Multiple sternotomy wires and mediastinal surgical clips, suggestive of prior CABG. The lungs are moderately well expanded. There is mild increase in the interstitial markings, suggestive of mild pulmonary edema. The pleural surfaces are smooth without pleural effusion or pneumothorax. The retrocardiac left lung base atelectasis has improved. . IMPRESSION: 1. Stable moderate cardiomegaly, with mild pulmonary congestion. 2. No evidence of pneumonia. 3. Pacer leads position, as described above. . CXR [**2110-12-31**] FINDINGS: A left ICD is seen with two leads in the right ventricle and one lead in the upper SVC. The upper SVC lead was previously within the right atrium on prior CT. Left basilar atelectasis is minimal. Minimal pulmonary venous engorgement is seen without overt pulmonary edema. There is no pleural effusion or pneumothorax. Mild cardiomegaly and a slightly tortuous aorta are unchanged. . IMPRESSION: 1. Minimal pulmonary venous engorgement without overt pulmonary edema. 2. Pacer lead positions as described above. . EKG [**2110-12-30**]: Ventricular tachycardia with a fusion beat. Compared to the previous tracing, ventricular tachycardia is new. Brief Hospital Course: 65M with CAD s/p MI and CABG, CHF, HTN, HLD, VT s/p prior ablation and recent placement of an [**Company 1543**] AICD initially admitted to the floor, but transferred to the CCU with stable, perfusing VT, refractory to lidocaine for VT ablation procedure. . # RHYTHM: On arrival to the [**Hospital1 18**] ED, patient was in a perfusing ventricular tachycardia rhythm with BP 101/72 and rate in 130's. He complained of palpatations but was mentating well and not presyncopal. He was bolused with Lidocaine 100mg and started on a lidocaine drip without improvment in VT. On arrival to the CCU, he remained in VT in the 110-130 range and was normotensive. Home dose of Mexilitine and sotalol were discontinued and he was started on quinidine 324 mg PO Q8H and metoprolol 25mg TID. On HD2 his rhythm alternated between slow, perfusing VT and sinus rhythm. He was seen by electrophysiology who idenitifed the rhythm as re-entrant sinus tachycardia and performed an ablation when INR <2. Warfarin was intitially held prior to the procedure, then restarted with LMWH bridge, to be continued as an outpatient at his home dose with routine INR checks. He will be continued on quinidine 486mg daily, which may interfere with metabolism of coumadin, requiring a lower dose to keep his INR within proper range. He was also given higher doses of 10mg and 7.5mg prior to discharge to bring his INR to therapeutic range slightly faster. These dose adjustments will need to be followed by his PCP or coumadin clinic. He will follow-up with EP as an outpatient in about 1 month and should continue to hold the sotalol and mexilitine until his follow-up appointment. . # Blood pressure control: While in the CCU, his BPs were borderline hypotensive, so it was not aggressively controled and he was given B-blockers as tolerated. His home lisinopril will be held for 1 week after discharge and restarted at his home dose after that. He will continue on metoprolol at half-dose of his home regimen. . # PUMP: Chronic congestive heart failure with systolic dysfunction, EF 30%. On admission, patient showed signs of failure related to poor forward flow while in sustained ventricular tachycardia. With improved rhythm control, volume status improved. . # CORONARIES: CAD s/p MI and CABG x3 in [**2094**]. No concern for ischemia on this admission. ASA and simvastatin were continued on discharge. Medications on Admission: - Lisinopril 5 mg PO daily - Sotalol 120 mg PO BID - Mexilitine 150 mg PO TID - Warfarin 5 mg PO daily - Metoprolol succinate 50 mg PO daily - ASA 325 mg PO daily (did not take for the past week) - Simvastatin 80 mg PO daily Discharge Medications: 1. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please hold for one week and restart unless otherwise directed. 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. quinidine gluconate 324 mg Tablet Sustained Release Sig: 1.5 Tablet Sustained Releases PO Q8H (every 8 hours) for 30 days. Disp:*135 Tablet Sustained Release(s)* Refills:*0* 4. metoprolol succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 5. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day. 6. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 7. Outpatient Lab Work Please have INR checked on Monday [**1-5**] or Tuesday [**1-6**]. Please communicate the results to the patient and fax the results to [**Telephone/Fax (1) 7329**] attention: Dr. [**First Name (STitle) **] [**Name Initial (MD) **] [**Name8 (MD) 7327**], MD. 8. Lovenox 100 mg/mL Syringe Sig: One (1) Subcutaneous once a day. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Ventricular tachycardia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You presented for management of recurrent ventricular tachycardia and were admitted to the CCU for close monitoring. A VT ablation was performed with improvement of your rhythm. Several important medication changes were made to control your heart rate. You were started on Quinidine. Your dose of Metoprolol was decreased to 25 daily. The medications, Sotolol and Mexilitine were discontinued and your lisinopril was temporarily held. You were continued on warfarin and started on a lovenox bridge at home. In the following days please: 1. Please take 7.5mg (1.5 pills) of warfarin tonight, and then continue tomorrow with 5mg daily. Please have your INR checked on Tuesday and follow up these results with your primary care physician. [**Name10 (NameIs) 357**] continue to take lovenox as directed until you have your INR checked. 2. Please hold your Lisinopril for one week and restart it as directed by your cardiologist or primary care physician. 3. Please take your new medication list as directed, making the above adjustments. 4. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: The following appointments have already been scheduled for you here at [**Hospital1 18**]: Please call [**Telephone/Fax (1) 62**] to make an appointment with Dr. [**Last Name (STitle) **], your cardiologist in the following month. Please call [**Telephone/Fax (1) 7328**] to make and appointment with Dr. [**Last Name (STitle) **], your primary care physician in the following weeks. Please follow up your INR and coumadin dosing and lovenox overlap with Dr. [**Last Name (STitle) **] this week.

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