ChanBeDu/relevant_section_length · Datasets at Hugging Face

7,804

139,156

8628

Discharge summary

report

Admission Date: [**2125-2-4**] Discharge Date: [**2125-2-16**] Date of Birth: [**2054-1-15**] Sex: M Service: MEDICINE Allergies: Ticlid / Integrilin / Zocor / Zetia Attending:[**First Name3 (LF) 2078**] Chief Complaint: urinary rentetion Major Surgical or Invasive Procedure: AICD placement - [**2125-2-14**] History of Present Illness: This is a 71 yo male with significant cardiac hx with CABG x 2, who was recently discharged [**2125-2-2**] for a re-stent to his SVG-LAD. He presents this time with urinary frequency and pain on urination ever since his foley was discontinued from that prior admission. He does not have h/o prostate disease, urinary frequency or dysuria. He denies fever or chills and does not have hematuria. . His PSA was 1.0 on 8/[**2123**]. . In the ED, his vitals were 98.6, 87, 168/60, 20, 98%RA. His prostate on exam was enlarged but non-tender. UA was positive for UTI. Urology was consulted and a foley was placed with difficulty but only a small volume (not documented) came out. Per Urology, he had low post-void residual. He was given Cipro 500mg x 1 and sent to medicine for further care. Past Medical History: # CAD s/p CABG [**2096**] (SVG to OM, SVG to RCA, SVG to LAD), redo CABG [**2110**] (LIMA to diag, SVG to OM, SVG to RCA), PTCA to SVG-LAD [**7-/2117**], PTCA to SVG-LAD [**1-/2118**], DCA and PTCA to SVG-LAD for ISRS [**5-/2118**], thrombectomy/brachytherapy and PTCA to SVG-LAD [**12/2118**], Cypher stents to SVG-LAD and SVG-OM in [**5-4**], [**Hospital **] Hospital ? 2 stent in unknown location Cypher stent to mid-LAD just after SVG insertion [**8-3**], s/p stent to SVG-LAD [**2-4**] # CHF(EF <20%) # HTN # Hypercholesterolemia # Peripheral arterial disease s/p stent implantation to L ext iliac in [**6-3**] # CRI (baseline Cr 2) . Social History: Originally from [**Country 18084**], lives in [**Location 47**] with his wife. Smoked 1/2-1 ppd x 50 years, quit a 4/[**2124**]. Rare EtOH. Used to work designing signs. Family History: Father with HTN, MI in his 60s, mother with stomach CA, sister with some type of nasal cancer. Physical Exam: VITALS: 99.5 160/90 104 35 95%RA GEN: A+Ox3, tachypneic, cannot complete long sentences HEENT: OP clear, MMM NECK: no LAD CV: tachycardic, regular rate, no m/g/r, ?s3 PULM: distant heart sounds, scattered wheezes and mild bibasilar crackles ABD: soft, nt, nd, +bs EXT: trace pedal edema, no clubbing, cynosis. faint pedal pulses but cap refill <2 seconds Pertinent Results: Imaging: CHEST (PORTABLE AP) [**2125-2-4**] 11:09 AM IMPRESSION: Unchanged radiograph from previous. Mild vascular congestion.. . ECHO Study Date of [**2125-2-6**] Conclusions: The left atrium is mildly dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe regional left ventricular systolic dysfunction with extensive akinesis of the anterior, lateral, and apical left ventricle and hypokinesis of the inferior wall and septum. The basal inferior and inferolateral walls contract best. A left ventricular mass/thrombus cannot be excluded due to extensive apical trabeculations. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. An eccentric jet of moderate (2+) mitral regurgitation is seen. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. Compared with the prior study (images reviewed) of [**2125-1-11**], the severity of mitral regurgitation may have increased slightly. Otherwise, the findings are similar. . BILAT LOWER EXT VEINS PORT [**2125-2-8**] 2:20 PM IMPRESSION: No evidence of deep venous thrombosis in either lower extremity. . CHEST (PORTABLE AP) [**2125-2-8**] 8:11 AM IMPRESSION: 1. Increased pulmonary vascular engorgement, particularly prominent on the right, could be indicative of pulmonary embolism. 2. Airspace opacity in the right lower lobe could represent evolving pulmonary infarction or an area of aspiration. 3. Interval development of mild pulmonary edema. 4. Gaseous distention of the stomach. . CHEST (PORTABLE AP) [**2125-2-9**] 9:06 AM IMPRESSION: Worsening of pulmonary edema. No sizeable pleural effusion. . CHEST (PORTABLE AP) [**2125-2-10**] 4:46 AM IMPRESSION: Mild-to-moderate pulmonary edema unchanged. Unchanged retrocardiac density. New opacity projecting over the left mid lung zone. . CHEST (PORTABLE AP) [**2125-2-11**] 7:20 AM IMPRESSION: Worsening fluid overload and question focal infiltrate on the right. . Micro: Urine Culture [**2125-2-4**] - E.coli SENSITIVITIES: MIC expressed in MCG/ML ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- 16 I CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN----------<=0.25 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- 32 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . Labs on admission: [**2125-2-4**] 09:45AM URINE BLOOD-LG NITRITE-POS PROTEIN-100 GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2125-2-4**] 09:45AM URINE RBC-[**7-8**]* WBC->50 BACTERIA-MANY YEAST-NONE EPI-0-2 [**2125-2-4**] 10:30AM PLT COUNT-175 [**2125-2-4**] 10:30AM WBC-11.8*# RBC-3.36* HGB-9.8* HCT-29.1* MCV-87 MCH-29.1 MCHC-33.6 RDW-15.2 [**2125-2-4**] 10:30AM CK-MB-8 cTropnT-0.79* proBNP-6557* [**2125-2-4**] 10:30AM CK(CPK)-150 [**2125-2-4**] 10:30AM GLUCOSE-140* UREA N-43* CREAT-2.4* SODIUM-138 POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-27 ANION GAP-15 [**2125-2-4**] 06:05PM CALCIUM-8.9 PHOSPHATE-2.3* MAGNESIUM-1.9 Brief Hospital Course: 71 yo male with CAD recently discharged on [**2-2**] s/p stent to SVG-PDA p/w urinary retention. . 1. CAD: The patient has h/o CABG with multiple stents, recently to SVG-LAD on [**2125-2-2**]. His EKG on this admission does not show any ST-T changes consistent with ischemia compared to previous ones on [**2125-2-1**] and [**2125-2-2**]. His troponins were elevated to 0.79 but are trending down since last admission, probably from cath procedure. The CK portion is normal so that is reassuring. From ED signout, cardiology was called in ED and they were not concerned for ACS. Enzymes were cycled and were negative. Patient was continued on ASA, metoprolol, isosorbide & lisinopril (later switched to hydral to protect his kidneys). While on the floor the patient experienced a CODE BLUE at which time he was found to be in Vfib, was cardioverted once, reverted to nsr, and sent to the CCU for monitoring. He was briefly intubated and on pressors, both of which were weaned promptly. The patient did well on the floor, and was given an BIV pacer ICD placed by EP. He will follow up with EP for his pacer check and have a repeat Echo on [**2-21**]. . 2. CHF: The patient had an echo revealing an EF of 20%. He was on lasix 40mg PO bid and hydrocholorothizide 25 daily before the last admission but these were discontinued after recent cath. He seemed volume overloaded causing SOB. CXR consistent with unchanged pulmonary edema and lungs with mild crackles. He was diuresed with good result and given his low EF, recent code, he had an ICD placed on [**2125-2-14**] without event. He will have to follow-up in device clinic after discharge, and continue his lasix. . 3. Ventricular fibrillation: Patient was admitted to CCU after CODE BLUE for Ventricular fibrillation. He was cardioverted and reverted to nsr. Since this episode he was placed with an ICD, and will follow-up with the clinic as an outpatient. . 4. Inflammatory urinary obstruction: The patient had urinary retention secondary to an enlarged prostate in the setting of a UTI. He had no h/o GU disease or complications. Urology saw patient in ED and the scope did not show any strictures. Urology does not feel that he has prostatitis since his prostate is not tender. Per urology, would benefit from foley for [**3-3**] weeks with repeated voiding trials and also suggested treatment with cipro 500mg [**Hospital1 **] x 7 days. The patient was treated with CTX and flomax 0.4mg daily. He will continue prophylactic cipro while his foley is in place, given his ICD. He has a follow-up appointment with urology. . 5. ARF on CRI: The patient was admitted with a creatinine above his baseline, likely [**3-2**] to post renal obstruction and UTI. He improved to his baseline at discharge. Medications on Admission: 1. Clopidogrel 75 mg qdaily 2. Digoxin 125 mcg qdaily 3. Isosorbide Mononitrate 30 mg qdaily 4. Pantoprazole 40mg qdaily 5. Nitroglycerin SLNTG prn 6. Aspirin 325 mg qdaily 7. Warfarin 5 mg QOD, 2.5 QOD (not taking) 8. Lisinopril 10 mg qdaily 9. Metoprolol Tartrate 50 mg [**Hospital1 **] 10. Colace 100mg [**Hospital1 **] 11. Senna [**Hospital1 **] PRN Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 5. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2* 7. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual AS DIRECTED as needed for chest pain: use 1 every 5 minutes for chest pain; may repeat up to three times . 8. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN (as needed). Disp:*qs 1* Refills:*2* 9. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 11. Hydralazine 10 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). Disp:*240 Tablet(s)* Refills:*2* 12. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2* 13. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*qs 1* Refills:*2* 14. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl Topical PRN (as needed). Disp:*qs 1* Refills:*2* 15. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO QOD () for 14 days: take only while foley in place. Disp:*7 Tablet(s)* Refills:*0* 16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital6 1952**], [**Location (un) 86**] Discharge Diagnosis: PRIMARY: 1. Congestive heart failure 2. Benign prostatic hypertropy 3. UTI 4. Inflammatory Urinary obstruction 5. Ventricular fibrillation SECONDARY: 1. Coronary artery disease 2. Hypertension 3. Hypercholesterolemia 4. Chronic renal insufficiency Discharge Condition: Afebrile, stable vital signs, tolerating POs Discharge Instructions: You came in and were treated for a urinary tract infection, heart failure and ventricular fibrillation. You had an ICD placed due to your abnormal rhythm. Please take all medication as prescribed. Keep all appointments listed below. If you have chest pain or shortness of breath, seek medical attention immediately. If you have trouble urinating such as pain, difficulty or frequency, call your doctor or go to the emergency room. In general, if you have medical questions or concerns, you should talk to your PCP or go to the emergency room. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet every day. Followup Instructions: 1. Please follow up with your PCP next week: [**Last Name (LF) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 4775**] (call to schedule within the week) 2. Please make a follow-up appointment to see Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] call for appointment within 2-4 weeks ([**Telephone/Fax (1) 7236**] OTHER APPOINTMENTS: 1. Provider: [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], MD Phone:[**Telephone/Fax (1) 8645**] Date/Time:[**2125-3-6**] 8:30 2. Please have your echo before your EP appointment Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2125-2-21**] 10:00 3. Please attend your pacemaker follow-up Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2125-2-21**] 11:30 4. Please attend your urology appointment: Provider: [**Name10 (NameIs) **] [**Name8 (MD) 30235**], MD Phone:[**Telephone/Fax (1) 8645**] Date/Time:[**2125-3-1**] 9:00

[ "414.8", "599.0", "584.9", "285.21", "788.20", "427.1", "428.41", "440.21", "403.91", "V45.82", "410.72", "600.01", "427.5", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.62", "96.71", "57.94", "00.51", "96.04", "99.60" ]

icd9pcs

[ [ [] ] ]

11317, 11392

6239, 9012

313, 348

11685, 11732

2527, 5558

12441, 13425

2036, 2132

9416, 11294

11413, 11664

9038, 9393

11756, 12418

2147, 2508

256, 275

376, 1170

5573, 6216

1192, 1833

1849, 2020

1,140

171,540

11433

Discharge summary

report

Admission Date: [**2109-11-7**] Discharge Date: [**2109-11-13**] Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: An 81-year-old male with no history of hypertension or diabetes complaining of chest tightness and shortness of breath on exertion. He had an exercise tolerance test at an outside hospital and was positive and subsequently was catheterized on [**11-7**]. The catheterization, in summary, showed an ejection fraction of 55%, left main 85% stenosis, left anterior descending artery was normal, circumflex had 90% stenosis, right coronary artery had 40% stenosis. Please see catheterization report for full details. Catheterization was done the [**Hospital 1562**] Hospital. The patient was subsequently transferred to [**Hospital1 1444**] for coronary artery bypass grafting. PAST MEDICAL HISTORY: The patient had no significant past medical history. PAST SURGICAL HISTORY: Past surgical history only significant for hemorrhoidectomy. ALLERGIES: He has no know allergies. MEDICATIONS ON ADMISSION: Medications prior to admission included aspirin 325 mg p.o. q.d., atenolol 25 mg p.o. q.d., and Altace 5 mg p.o. q.d. PHYSICAL EXAMINATION ON ADMISSION: HEENT revealed pupils were equally round and reactive to light. Neurologically, alert and oriented times three. Chest was clear to auscultation bilaterally. Heart had a regular rate and rhythm, S1 and S2. No murmurs. No rubs. Abdomen was soft, nontender, and nondistended. His extremities revealed no edema. LABORATORY DATA ON ADMISSION: Sodium 140, potassium 4.4, chloride 104, bicarbonate 27, BUN 18, creatinine 0.8, glucose of 221. Cholesterol 42. [**Known lastname 1007**] blood cell count was 7.4, hematocrit 39, platelets 230. PTT 23, PT 12.6, INR 1.1. HOSPITAL COURSE: On hospital day two, the patient was brought to the operating room where he underwent coronary artery bypass grafting times three. Please see the Operative Report for full details. In summary, the patient had coronary artery bypass graft times three with a left internal mammary artery to the left anterior descending artery, and saphenous vein graft to right coronary artery, and saphenous vein graft to the obtuse marginal. He tolerated the operation well and was transferred from the operating room to the Cardiothoracic Intensive Care Unit. At the time of transfer, the patient had a mean arterial pressure of 79, a central venous pressure of 16. He was in a normal sinus rhythm at 82 beats per minute. He had an arterial line and a central venous pressure catheter, two atrial pacing wires, two mediastinal, and a left pleural chest tube. At the time of transfer, the patient's only intravenous medication was a Neo-Synephrine drip. In the immediate postoperative period the patient did well. He was weaned off of all vasoactive drugs. His anesthesia was reversed. He was weaned from the ventilator and extubated shortly after arrival to the Cardiothoracic Intensive Care Unit. He remained hemodynamically stable overnight, and on the morning of postoperative day he was transferred from the Intensive Care Unit to Far Six for continuing postoperative care and cardiac rehabilitation. On postoperative day two, the patient had an episode of atrial fibrillation with a ventricular response rate of 90 to 100 beats per minute. He maintained a blood pressure of about 100/70 during these episodes. He was treated initially with Lopressor and was subsequently started on oral amiodarone, after which he converted to a normal sinus rhythm. On postoperative day three, the patient experienced an episode of confusion following the administration of Percocet. As part of the workup for his confusion, he was seen by the Psychiatry Service who thought it was postoperative delirium, and he had a head CT which was read as negative, and he had a negative metabolic workup as well. He has had no further episodes of confusion since the narcotics were discontinued. Over the next two postoperative days the patient remained hemodynamically stable. He was deemed to be ready for discharge to home on postoperative day five. CONDITION AT DISCHARGE: At the time of discharge, the patient's was stable. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Status post coronary artery bypass grafting times three with a left internal mammary artery to the left anterior descending artery, saphenous vein graft to right coronary artery, and saphenous vein graft to obtuse marginal. 3. Hypertension. 4. Hypercholesterolemia. PHYSICAL EXAMINATION ON DISCHARGE: The patient's physical examination at the time of discharge revealed vital signs with heart rate 70 sinus rhythm, blood pressure 126/74, respiratory rate 14, oxygen saturation 94% on room air. Weight preoperatively was 68.8 kg, at discharge was 70.1 kg. Physical examination revealed he was ambulating in room without difficulty. Alert and oriented times three. Moved all extremities. Cardiovascular examination revealed a regular rate and rhythm, S1 and S2. Lungs were clear to auscultation bilaterally. The abdomen was soft and nontender with positive bowel sounds. Last bowel movement on [**11-13**]. The sternal incision was well approximated with Steri-Strips. No erythema along the wound margins. In the past there had been a small amount of serous drainage from the sternal wound; however, there was none present on the day of discharge. Right leg incision with Steri-Strips was intact, open to air, and well approximated. LABORATORY DATA ON DISCHARGE: Laboratory data on [**11-13**] revealed a [**Known lastname **] blood cell count of 11.7, hematocrit 24.3, platelets 355. Sodium 139, potassium 3.9, chloride 101, bicarbonate 29, BUN 27, creatinine 0.9, and glucose was 102. MEDICATIONS ON DISCHARGE: 1. Metoprolol 25 mg p.o. b.i.d. 2. Furosemide 20 mg p.o. q.d. times seven days. 3. Potassium chloride 20 mEq p.o. q.d. times seven days. 4. Ranitidine 150 mg p.o. b.i.d. times two weeks. 5. Aspirin 81 mg p.o. q.d. 6. Amiodarone 400 mg p.o. t.i.d. times two days; then 400 mg p.o. b.i.d. times seven days; then 400 mg p.o. q.d. 7. Ibuprofen 400 mg p.o. q.6h. p.r.n. for pain. DISCHARGE STATUS: The patient was to be discharged home with [**Hospital3 **] [**Hospital6 407**] to come into his home. DI[**Last Name (STitle) 408**]E FOLLOWUP: He was to have followup with Dr. [**Last Name (Prefixes) 411**] in three to four weeks and follow up with his primary care physician in three to four weeks. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 415**] MEDQUIST36 D: [**2109-11-13**] 14:00 T: [**2109-11-14**] 09:52 JOB#: [**Job Number 36545**]

[ "427.31", "411.1", "997.1", "293.9", "414.01", "401.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

4228, 4551

5790, 6747

1046, 1186

1793, 4139

918, 1019

4154, 4207

5538, 5764

136, 816

1549, 1774

840, 894

13,837

110,857

10732

Discharge summary

report

Admission Date: [**2159-2-23**] Discharge Date: [**2159-3-2**] Date of Birth: [**2086-7-12**] Sex: F Service: MEDICINE Allergies: Colchicine / Atorvastatin Attending:[**First Name3 (LF) 8684**] Chief Complaint: AV fistula thrombus, GNR bacteremia Major Surgical or Invasive Procedure: Right AV thrombectomy removal of hemodialysis line History of Present Illness: Ms. [**Known lastname **] is a 72 y.o. female with h/o HTN, CHF (diastolic, EF of 55% and LVH on echo [**11-17**]), hyperlipidemia, gout, sarcoid, ESRD on HD who was admitted for thrombectomy of left AV graft. Had low-grade temp at admission to 100.0F. Tunneled HD line placed one month ago for temporary HD. Thrombectomy successful, graft patent. One day s/p thrombectomy, spiked a temp post-procedure. She has had persistent fevers and Tmax of 103.4. Pt was empirically started on vancomycin and flagyl overnight on [**2-24**], and had bcx drawn. Dialyzed [**2-24**] through tunneled R IJ line without complication. On [**2-25**], bcx grew 3/4 bottles of GNRs. Zosyn added, and one dose gentamicin 80mg IV given. Pt appeared more somnolent and tachycardic, so was transferred to the MICU. Pt denies CP, SOB, diarrhea, abd pain, chills or confusion. Past Medical History: - ESRD on HD, right upper extremity AV fistula, hemodialysis on Tuesday, Thursday and Saturday, revision AV limb [**1-20**], thrombectomy [**1-21**], placement of tunneled right IJ - Hypertension, h/o left RAS - IDDM - Sarcoidosis with ocular involvement - gout - CHF Echo [**11-17**] LVEF >55%, LVH, mild AS, pulm art systolic hypertension, [**2-13**]+ MR - h/o knee surgery - CVA ~20 yrs ago w/out residual deficits Social History: The patient lives with daughter, has [**Name (NI) 269**]. She has 4 children, 3 local. No etoh, tobacco or drugs Family History: Hypertension and diabetes Physical Exam: Vitals: T - 101.1 HR 87 BP 134/57 RR 18 O2 sat 98% on 2L NC General : Awake, conversing but sleepy, oriented x 2 HEENT: sl dry MM, anicteric sclera Neck: Supple CV: S1, S2 nl, III/VI systolic murmur heard throughout (documented in previous exams) Lungs: CTA b/l Abd: Soft, NT, ND, hypoactive BS Ext: no peripheral edema, warm extremities, palpable thrill RUE AV graft. Graft site appears clean, no exudate on recently changed dressing, no erythema. Neuro exam: A & Ox 2 Pertinent Results: Admission Labs: [**2159-2-24**] 08:00AM BLOOD WBC-4.9 RBC-4.20# Hgb-12.2# Hct-38.5# MCV-92 MCH-29.0 MCHC-31.6 RDW-17.0* Plt Ct-254 [**2159-2-24**] 08:00AM BLOOD Plt Ct-254 [**2159-2-24**] 08:00AM BLOOD Glucose-180* UreaN-38* Creat-7.9*# Na-138 K-4.9 Cl-97 HCO3-26 AnGap-20 [**2159-2-24**] 08:00AM BLOOD Calcium-10.9* Phos-4.6* Mg-2.3 . [**2159-2-24**] CXR: No pulmonary edema or pneumonia or pneumothorax. . [**2159-2-27**] TTE: The left atrium is moderately dilated. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.2-1.9cm2) No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. No vegetation seen (cannot definitively exclude). Compared with the prior study (images reviewed) of [**2158-12-4**], findings are similar. Brief Hospital Course: 72 yo female with ESRD on hemodialysis, gout, hypertension, CHF, s/p thrombectomy of AVF whom postoperatively was found to have fever, tachycardia, somnolence, GNR bacteremia (proteus mirabilis), treated with Cipro with resolution of signs and symptoms. . #Fever: Fever was in the setting of Proteus mirabilis bacteremia. The patient's right tunnelled IJ catheter tip was also culture positive for Proteus, and this was thought to be the source. The bacteria was pan-sensitive, and she was treated with Cipro beginning [**2159-2-25**]. She had been on Zosyn for one day until the culture came back pan-sensitive. Urinalysis was negative. Surveillance cultures were negative after [**2159-2-25**]. Plan to continue on Cipro for a total course of 14 days ([**2159-3-12**]). TTE was negative for vegetations, although could not be definitively ruled out. It was decided to defer TEE as the patient was clinically much improved and suspicion for endocarditis was low. Some surveillance cultures were not yet finalized on the day of discharge, and the results will be followed up as an outpatient. . # Mental status change: the patient was somnolent on initial presentation. This was felt to be due to the acute infection, and mental status improved with treatment of her bacteremia. She was at baseline mental status, appropriately answering questions, and oriented to person, place, and year prior to transfer to the floor. During the remainder of her stay, there were no other mental status changes. . # ESRD : She was followed by Nephrology and underwent dialysis under usually weekly schedule (T/Th/Sat). Transplant surgery evaluated and cleared the right AV fistula for use through which she was dialyzed on [**2159-2-27**]. She also continues on sevelamer. . # Gout: Not active. Continued allopurinol. . # HTN/CAD: no acute issues. Intially when the patient presented to the MICU, febrile, her home medications were held. Prior to transfer to floor her home po antihypertensives were resumed. She continues on amlodipine and labetalol, titrate labetalol as needed (outpatient). . # CHF: ECHO performed during this admission (to rule out vegetations) showed no changes from previous, EF > 55% but with LVH. no acute decompensation. Continued Irbesartan and Amlodipine for afterload reduction. . # Dispo: Full code. Daughter [**Name (NI) 19267**] is her health care proxy should one be needed. Physical therapy evaluated the patient and determined that she would need rehad inpatient PT/OT. Medications on Admission: Home Medications: (from [**2159-2-4**] d/c summary): 1. Aspirin 81mg PO qD 2. Irbesartan 75mg PO BID (HD DAYS ONLY) 3. Irbesartan 150mg PO BID (NON-HD DAYS ONLY) 4. Labetalol 800mg PO TID 5. Allopurinol 100mg PO qD 6. Zantac 75mg PO qD 7. Metoclopramide 10mg PO QIDACHS 8. Docusate Sodium 100mg PO BID 9. Pravastatin 20mg PO qD 10. Norvasc 10mg PO bid on non-HD days; 5mg PO bid on HD days 11. Hexavitamin 1 Cap PO qD 12. Insulin NPH 12U SC qAM. 13. Humalog Insulin Sliding Scale . Medications on transfer: Labetalol HCl 200 mg PO TID Metoclopramide 10 mg PO QIDACHS Acetaminophen 325-650 mg PO Q4-6H:PRN MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Allopurinol 100 mg PO DAILY Oxycodone-Acetaminophen 1 TAB PO Q4-6H:PRN Amlodipine 5 mg PO BID Piperacillin-Tazobactam Na 2.25 gm IV Q12H Dolasetron Mesylate 12.5 mg IV Q8H:PRN Ranitidine 150 mg PO DAILY Docusate Sodium 100 mg PO BID Sevelamer 800 mg PO TID Heparin 5000 UNIT SC TID Vancomycin HCl 1000 mg IV ONCE Insulin SC Discharge Medications: 1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 2. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 3. Irbesartan 75 mg Tablet Sig: One (1) Tablet PO BID q [**Month/Day/Year **], Thurs, Saturday only: on dialysis days only. 4. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO BID q Mon, Wed, Fri, Sun only: non dialysis days only. 5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 10. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 12. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days. 14. Insulin Lispro (Human) 100 unit/mL Solution Sig: sliding scale Subcutaneous ASDIR (AS DIRECTED): please continue your home sliding scale. 15. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twelve (12) units Subcutaneous qam. Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: Primary Diagnoses: Right Arterio-venous thrombosis now s/p thrombectomy Proteus Bacteremia/Septicemia Infected hemodialysis line Secondary Diagnoses: Congestive heart failure hypertension Sarcoidosis diabetes mellitus type 2 end-stage renal disease on hemodialysis Discharge Condition: Good Discharge Instructions: You have been admitted with an infection related to your dialysis line. You are being treated with antibiotics for this infection, and your line was removed. If you have fever, chills, shortness of breath, or any other new or concerning symptoms, please call your doctor or return to the emergency room for evaluation. Please continue taking all of your medications as prescribed. -you dose of labetalol has been decreased to 400mg three times a day, but this can be increased if your doctor instructs -your dose of amlodipine has also been decreased to 5mg daily. -you will continue taking ciprofloxacin, an antibiotic, until [**2159-3-12**] to complete the course of treatment. Please follow up with your primary care physician as instructed. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 608**]. You will be seen by a physician at the rehab and they will arrange a followup appointment for you. You also have the following appointments already scheduled: Provider: [**First Name11 (Name Pattern1) **] [**Known lastname 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2159-3-19**] 1:40 Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2159-6-13**] 10:45 Completed by:[**2159-3-2**]

[ "403.91", "996.73", "250.00", "287.5", "428.30", "135", "041.6", "453.8", "996.62", "585.6", "V58.67", "038.49", "995.92", "274.9" ]

icd9cm

[ [ [] ] ]

[ "39.95", "88.49", "39.42" ]

icd9pcs

[ [ [] ] ]

8639, 8712

3720, 6241

321, 374

9022, 9028

2379, 2379

9825, 10375

1846, 1873

7258, 8616

8733, 8863

6267, 6267

9052, 9802

1888, 2360

8884, 9001

6285, 6749

246, 283

402, 1255

2395, 3697

6774, 7235

1277, 1698

1714, 1830

28,168

123,689

33683+57868

Discharge summary

report+addendum

Admission Date: [**2169-3-9**] Discharge Date: [**2169-3-16**] Date of Birth: [**2104-8-18**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1711**] Chief Complaint: transferred for evaluation of exertional dyspnea/acute CHF Major Surgical or Invasive Procedure: None History of Present Illness: This 64M with CAD s/p CABG in [**2162**] for a positive stress test and hyperlipidemia who stopped taking all his cardiac medications 8 months ago was traveling in [**State 350**] on business began experiencing dyspnea and chest pressure after walking 50-60 feet, which was new for him, four days prior to admission to this hospital. Two days prior to admission, he was dyspneic after just 20-25 feet, and presented to an OSH for evaluation. He was found to be in CHF with marked volume overload and also in rapid atrial fibrillation. . Diuresis was limited by acute renal failure (peak creatinine 1.8, up from 1.4 on admission). Control of atrial fibrillation was attempted with diltiazem and he was loaded with digoxin. Runs of NSVT were noted on telemetry. An echocardiogram showed LVEF 10% and a dilated, hypokinetic RV. CXR showed mild pulmonary edema. CTPA showed bilateral effusions but was negative for PE. . . On review of systems, he endorses cough productive of clear, whitish sputum over the last three weeks. He denies orthopnea, PND, or ankle edema. He reports a history of presyncope related to uptitration of antihypertensives in the past and this is why he self-discontinued beta blockers. He denies symptoms of stroke or TIA. No history of bleeding problems. Past Medical History: # CAD s/p CABG [**2162**] @ [**State 4595**]; LIMA to midLAD, SVG to midLCX, SVG to D2 # CHF (EF 10%) - post-CABG EF 20-30% # AF, noted at outpatient visit in [**2167**] in MN # hypercholesterolemia # ORIF of L tibial fracture, [**2160**]; hardware subsequently removed, [**2161**] Social History: Lives with wife in [**State 3706**], works in [**Name (NI) 22441**] but travels frequently to MA. Denies tobacco or illicit drug use. Drinks a glass of wine with dinner 2-3 times per week. Family History: Brother died of sudden cardiac death during a plane flight at age 62. Physical Exam: (on admission) VS: T:97.6, BP:98/66, HR:111, RR:18, O2: 98% on 2L NC Gen: obese middle aged male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of 16 cm H2O. CV: PMI located in 5th intercostal space, midclavicular line. RR, soft S1, paradoxically S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: Breathing with accessory muscles but able to speak in sentences. Decreased breath sounds at both bases with R > L crackles at the bases. Scattered wheezing. No rhonchi. Abd: Obese, NTND. Pulsatile liver. Groin: 2+ femoral pulses. No bruits Ext: WWP. 1+ bilateral ankle edema. 2+ DP pulses. Skin: Slight jaundice. No stasis dermatitis, ulcers, surgical scar on L ankle, surgical scar along R leg c/w vein harvesting Pertinent Results: LABORATORY DATA from OSH: Troponin I 0.18-->0.22 Cr 1.5-->1.87-->1.37 BNP 1164 . Admission Labs: [**2169-3-9**] 10:35PM GLUCOSE-106* UREA N-33* CREAT-1.4* SODIUM-134 POTASSIUM-3.7 CHLORIDE-92* TOTAL CO2-34* ANION GAP-12 [**2169-3-9**] 10:35PM ALT(SGPT)-748* AST(SGOT)-227* LD(LDH)-242 ALK PHOS-72 TOT BILI-1.2 [**2169-3-9**] 10:35PM proBNP-5719* [**2169-3-9**] 10:35PM WBC-12.3* RBC-4.58* HGB-14.3 HCT-41.2 MCV-90 MCH-31.2 MCHC-34.7 RDW-15.5 [**2169-3-9**] 10:35PM PT-15.0* PTT-41.0* INR(PT)-1.3* . Admission ECG: atrial fibrillation with PVCs vs aberrancy, LBBB; similar to tracings from [**Hospital3 2737**] dated [**3-7**] and [**3-8**], no older tracings available . Admission CXR (AP) ([**2169-3-10**]): The patient has had median sternotomy. The heart is mildly enlarged. Right lung is clear. Left lower lung is opacified, and there may be a small left pleural effusion. In the absence of prior imaging, I cannot ascribe the left lower lobe to benign post-surgical atelectasis and there is the suggestion of a left hilar mass. Chest CT imaging is recommended unless the explanation for the abnormal left lower lung is known. . Echo ([**2169-3-10**]): The left atrium is markedly dilated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis (LVEF = 20 %). A left ventricular apical mass/thrombus cannot be excluded. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with depressed free wall contractility. The ascending aorta is moderately dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**12-28**]+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. . CT ([**2169-3-10**]): 1. Mild pulmonary edema. Moderate right pleural effusion. No evidence of pneumonia. 2. The appearance on chest radiograph is likely secondary to a combination of the moderate-sized loculated left pleural effusion, left lower lobe and lingular atelectasis and cardiomegaly. 3. 6-mm right upper lobe nodule. In a high-risk patient (history of smoking or known malignancy), followup is recommended in six months. Otherwise, 12- month followup is recommended. . PVR at the time of d/c 193 . Discharge weight 110.7kg Brief Hospital Course: 64M with CAD s/p CABG in [**2162**], also hyperlipidemia, self-d/c'd all cardiac medications 8 months ago, now with acute on chronic systolic heart failure and rapid atrial rhythm. . # Acute on chronic systolic heart failure, LVEF 20% Pt was admitted with NYHA Class IV symptoms, acutely over the week prior to presentation but had been off all cardiac medications for the past 8 months (aside from lasix) as he wanted to be on herbal medications instead. Acute decompensation was most likely related to worsening of her cardiomyopathy [**1-28**] rapid heart rate over time, in the setting of no meds. On transfer, he was dyspneic at rest with 2L O2 requirement despite some diuresis at OSH, and on dobutamine for low blood pressure. He diuresed 1300cc overnight on lasix drip with dobutamine and SOB improved. Dobutamine was weaned off in the am the following day. The etiology of the acute HF was thought to be hypertension for stopping the meds (increased afterload and work on heart) +/- [**1-28**] paroxysmal afib with RVR. Pt was digoxin loaded at the OSH to control HR, and when seen in the CCU here was continued at 0.25 (given hr into 110-120s despite load. BB was also added for rate control once tolerated from BP standpoint. Lasix gtt was continued and 3-4L was taken off the following 2 days. Echo was done demonstrating severe global left ventricular hypokinesis with an LVEF = 20 % as previously known. Over the following days we continued lasix with boluses IV for diuresis, and the pt diuresed another 3-4 L prior to discharge and the dry weight at the time of discharge was 110.7kg. he was discharged on 40mg po lasix to maintain this dry weight. On day #4, afterload reduction was added in the form of [**First Name8 (NamePattern2) **] [**Last Name (un) **] (given hx of cough with ACEi) once bp tolerated. Also, aldactone was started for class IV heart failure. On the echo, a left ventricular apical mass/thrombus could not be excluded. The plan for this was to have pt anticoagulated for at least one month prior to possible DCCV in order to prevent possibly dislodging a thrombus from the LV. . # CAD: s/p CABG Pt was not currently taking any anti-ischemic therapy at the time of admission. ASA, plavix, simvastatin 40mg was started empirically and continued throught d/c. Lipid profile included a very low HDL and niacin and/or fibrates were considered. However, the thinking was that the cholesterol panel may be falsely low due peri-MI. Therefore, the recommendation was to recheck as an outpt and to consider niacin or fibrate if low. We also recommended exercise as this may raise HDL. Ischemic insult was felt very unlikely as a cause of HF and more likely related to medication noncompliance. BB and [**Last Name (un) **] were started as above. . # Rhythm: Atrial fibrillation Digoxin and BB for rate control as mentioned above as well as heparin gtt. DCCV was considered (although given the size of the atria will have have high risk of recurrence) but given that possible LV thrombus would not be better visualized with TEE than TTE the decisiton was made to have pt be anticoagulated for at least one month prior to possible DCCV in order to prevent possibly dislodging a thrombus from the LV. The pt was therefore started on coumadin with the heparin bridge although the heparin had to be held tha day prior to discharge. At this time the INR was 1.5. Since 3 days had passed after starting 5mg coumadin the dose was increased to 7.5 mg on [**3-15**]. At the time of discharge INR was still 1.5. He was instructed to have his INR checked on [**3-20**] in [**State **] and given a script for a lab draw. . # E.Coli UTI and bacteremia, pan-sensitive Pt was found to have positive UA on routine UA taken on admission and therefore ciprofloxacin was started on day#2. The urine culture grew out pan-sensitive E.Coli. Blood cultures taken at the same time (for hypotension) had 1/4 bottles positive for E.Coli as well. Pt continued to be HD stable and without s/s of sepsis and the abx regiment was therefore not changed and cipro was continued in hospital and at the time of discharge for a total of 14 days for complicated UTI. Pt did not have any lines in when blood culture was found to be positive, and foley was removed prior to this as well. Repeat cultures for clearing of blood were negative. . # Persistent Hematuria Started after placing foley on admission and thought likely [**1-28**] traumatic foley + anticoagulation + UTI. Pt slowly had clearing of his urine with treatment of UTI, but then on HOD#5 had recurrence of dark hematuria (no clots) likely [**1-28**] supratherapeutic PTT of 106.8. Urology were consulted and agreed. No imaging was recommended given no smoking hx and other liekly etiology. When heparin was held the hematuria resolved and was not present at the time of discharge. Pt probably had some underlying BPH but no meds were started since the prostate was probably a bit enlarged due to the foley trauma. If the pt continues to have sx's of retention when returning home he should be seen by a urologist. His PVR at the time of d/c was 193. . # Loculated L pleural effusion Pulm was initially conslted for a diagnostic tap but were they not able to given small effusions and it was almost completely resolved with diuresis. There was no reason to tap since remained afebrile without another reason for infection. teh most likely etiology we thought was scar tissue from CABG plus pulm edema. . # Multiple prominent mediastinal lymph nodes. Largest node in the prevascular space measures 22 x 12 mm. Pt had left lower lobe and lingular atelectasis that resolved but radiology recommended followup in six months. . # Abnml LFTs: Trended down after admission with diuresis and almost certainly [**1-28**] congestive hepatopathy from CHF. . # Contact: with patient, also wife [**Name (NI) **] [**Name (NI) 21628**] [**Telephone/Fax (1) 77971**] ***FAX this summary to [**Hospital3 14659**] at [**Telephone/Fax (1) 77972**] (ATTN: [**Doctor First Name 5638**]) at the time of discharge**** Phone [**Telephone/Fax (1) 77973**] Medications on Admission: asa 325 mg daily plavix 75 mg daily heparin gtt metoprolol 25 mg TID Protonix 40 mg daily Atorvastatin 40 mg daily hydralazine 20 mg QID spironolactone 25 mg daily bumex 2 mg [**Hospital1 **] digoxin 0.125 mg daily dobutamine gtt Discharge Medications: 1. Outpatient Lab Work please obtain PT q3d as pt. on coumadin 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 8 days. Disp:*16 Tablet(s)* Refills:*0* 6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once Daily at 16). Disp:*20 Tablet(s)* Refills:*0* 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*15 Tablet(s)* Refills:*2* 10. Losartan 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: # Acute on chronic systolic heart failure, LVEF 20% # CAD s/p CABG - [**2162**] @ [**State 4595**]; LIMA to midLAD, SVG to midLCX, SVG to D2 # Atrial fibrillation with RVR - digoxin and BB started for rate control - consider DCCV after antiacoag x1mo - first noted in [**2167**] but not on coumadin before # E.Coli UTI and bacteremia, pan-sensitive - cipro was continued for 14 days # Multiple prominent mediastinal lymph nodes - largest node in the prevascular space measures 22 x 12 mm - left lower lobe and lingular atelectasis; given hx history of smoking followup is recommended in six # Persistent Hematuria - likely [**1-28**] traumatic foley + anticoagulation + UTI --> resolved by time of d/c . Secondary Diagnosis: # Hypercholesterolemia # ORIF of L tibial fracture, [**2160**]; hardware subsequently removed, [**2161**] Discharge Condition: Stable Discharge Instructions: You were admitted and treated for acute on chronic congestive heart failure and atrial fibrillation which was making your heart contract too quickly. . If you develop fever greater than 101F, chest pain, shortness of breath, or if you at any time become concerned about your health please contact your PCP, [**Name10 (NameIs) 18**] at [**Telephone/Fax (3) **] or present to the nearest ED. . Please take your medications as prescribed. Not taking your prescribed heart failure medications likely played a large role in putting you in acute heart failure. . - The cardiology department at [**Hospital3 **] has been contact[**Name (NI) **] by us on your request and all you have to do is to call and give them your insurance info and shcedule a time to be seen within 2 weeks. There are times available but you have to call to make this appointment. - Please schedule an appointment to be seen by your primary care provider [**Name Initial (PRE) 176**] 1-2 weeks. - It is very important that you go to your doctors office and have a lab draw on Monday [**3-20**] to have your INR checked and your coumadin dose adjusted - If you have recurrence of hematuria or continue to have difficulty initiating urination, have a stream or frequesnt visits to the bathroom at night you should set up an appointment with a urologist. . Please weigh yourself daily and call your PCP if you gain >3lbs. Please adhere to a diet with <2g sodium day. Followup Instructions: - The cardiology department at [**Hospital3 **] has been contact[**Name (NI) **] by us on your request and all you have to do is to call and give them your insurance info and shcedule a time to be seen within 2 weeks. There are times available but you have to call to make this appointment. - Please schedule an appointment to be seen by your primary care provider [**Name Initial (PRE) 176**] 1-2 weeks. - It is very important that you go to your doctors office and have a lab draw on Monday [**3-20**] to have your INR checked and your coumadin dose adjusted - If you have recurrence of hematuria or continue to have difficulty initiating urination, have a stream or frequesnt visits to the bathroom at night you should set up an appointment with a urologist. Name: [**Known lastname 12594**],[**Known firstname 12595**] J Unit No: [**Numeric Identifier 12596**] Admission Date: [**2169-3-9**] Discharge Date: [**2169-3-16**] Date of Birth: [**2104-8-18**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 713**] Addendum: The following instructions were added to the discharge instructions: - It is very important that you go to your PCP's office (Dr. [**Last Name (STitle) 12597**]and have a lab draw on Monday [**3-20**] to have your INR checked and your coumadin dose adjusted. You have an appointment for this at 3pm. - You have an appointment to be seen by Dr. [**Last Name (STitle) 12597**] at 10am on tuesday [**3-21**]. Please make sure to go to this. Discharge Disposition: Home [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 714**] MD [**MD Number(1) 715**] Completed by:[**2169-3-16**]

[ "041.4", "428.23", "V15.81", "272.4", "599.7", "428.0", "790.7", "414.00", "584.9", "599.0", "427.31", "V45.81", "785.6", "425.4" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

17263, 17426

5854, 11969

373, 379

14153, 14162

3166, 3247

15644, 17240

2214, 2285

12249, 13230

13280, 13280

11995, 12226

14186, 15621

2300, 3147

275, 335

407, 1686

14024, 14132

3263, 5831

13299, 14003

1708, 1991

2007, 2198

28,530

136,938

34263

Discharge summary

report

Admission Date: [**2152-4-24**] Discharge Date: [**2152-5-12**] Date of Birth: [**2094-11-13**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 668**] Chief Complaint: OSH transfer- Lower extremity weakness/cauda equina Perforated bowel Major Surgical or Invasive Procedure: [**2152-4-27**] Exploratory laparotomy, Right colectomy, ileostomy placement [**2152-5-9**] Tracheostomy and percutaneous endoscopic gastrostomy. History of Present Illness: 57 y/o male w/ probable metastatic lung ca, met to L5 spine, who presents from OSH with leg weakness secondary to cauda equina syndrome. He was admitted to [**Hospital **] hospital on [**2152-4-17**] with a 20 lb weight loss and long standing history of progressive low back pain, followed by leg weakness. The low back pain has been an issue for the last 2-3 years, but over the last 2 months has become more severe and has radiated to his posterior thigh and calves. In addition he reports numbness of his feet, which began 2-3 years ago. Within the last 2 weeks he has not been able to walk and has been wheelchair bound. He reports that he cannot stand due to pain rather than to weakness. He denies loss of bowel or bladder function. Neuro evaluation there on [**2152-4-17**] showed normal pin sensation of LEs, although there was subjective numbness of the feet. No focal weakness of the extremity muscles was noted to manual testing and DTRs were noted to be 1+ and symmetric at knees, and absent at ankles. Work-up showed a destructive lesion in L5 with a soft tissue component, likely representing metastatic disease. There was also evidence of pathologic compression of the body of L5 and severe foraminal narrowing at L5-S1 with cauda equina compression. He was also found to have a cavitary lesion in the right upper lobe of the lung measuring almost 1cm, suspicious for nonsmall cell lung cancer, likely squamous cell. Biopsy of the L5 lesion was performed and results were pendning at time of transfer. The patient was started on reglan and external beam XRT. His pain improved after optimization of his pain regimen, however he became constipated. He also had a foley placed for ?urinary retention. He was seen daily by neurosurgery and there was a long debate on how to proceed. Clinically the patient was not improving and still had significant leg weakness, and therefore it was recommended by the neurosurgeons to transfer him for consideration of cyberknife treatment. Note dated [**2152-4-20**] comments that patient reported legs were weaker than the day prior. Note dated [**2152-4-24**] reports patient can lift lower extremities bilaterally but cannot wiggle toes with slight foot drop on L. On arrival today, patient reports pain in low back. Complains of weakness and numbness of his lower extremities, which he reports has become worse over the last 2 days. He reports constipation and abdominal distention, however he does admit to having a small BM yesterday. He also admits though that he does have numbness in his buttocks and does not feel that he has full control over his bowel movements. In regards to urinary retention, this is less clear, because he currently has a foley catheter. He reports this was placed after he was told his urine output was not as good as it should be. Denies upper extremity weakness or numbness. no cough, hoarseness, chest pain, sob. ROS: as per hpi. also denies cough, sob, sputum production or hemoptysis. no headache, n/v, vision changes. low back pain, + left hip pain, lower extremity weakness, and numbness in toes. Past Medical History: probable metastatic lung ca (9mm lesion RUL) h/o low back pain hepatitis C h/o ETOH Social History: smokes [**12-22**] pack cigarettes per day. drinks ETOH heavily, [**1-23**] beers per day and sometimes [**12-22**] pint of vodka per day Family History: Mother with lung ca Physical Exam: vitals- 98.6, 129/88, HR 82, RR 20, 95% RA, Wt 124 lb gen- cachectic appearing male, awake, alert, NAD heent- EOMI. MM moist. OP clear. neck- supple, no lad pulm- CTA b/l. no r/r/w cv- RRR. no m/r/g abd- soft, distended, tympanic to persussion, w/o tenderness to palpation, rebound or guarding. hypoactive bs. ext- + clubbing, no edema, rash. 2+ dp pulses neuro- CNII-XII intact. UE motor [**4-24**] b/l, w/ nl sensation. LE: no ability to plantar/dorsiflex b/l. not able to lift LLE against resistance, and only minimally against gravity. RLE able to lift leg strt against gravity, but easily breaks against resistance. passive ROM full. no pain ellicitid w/ knee flexion/extention. Pain ellicitid in right hip/low back w/ R hip flexion. no sciatica. Sensation largely intact to pinprick and light touch with exception of decreased sensation in large toes b/l (L>R) and reported decreased sensation in buttocks area, however felt examiner easily on rectal exam. unable to elicit anal wink on rectal exam, with decreased rectal tone. babinski reflexes equivocal b/l. unable to ellicit L patella reflex, with R patella reflex 1 + . Did not assess gait. On discharge: 102.8, 99.8, 101, 96/57, 27, 100 Trach mask Alert and Oriented He is able to fully move UE - has no LE motor function Tracheostomy in proper position without surrounding erythema or exudate Tachycardia but regular rhythm Coarse breath sounds bilateral lungs with R>L Abdomen is flat and nondistended. He has PEG in good position that is 2cm at skin. He has a midline wound that is granulating in nicely. Ostomy is pink and has good function. LE as mentioned no motor function. No edema Pertinent Results: Reports- MRI [**2152-4-18**]- Mild pathologic compression fx of L5. Tumor has destroyed posterior cortex of the vertebral body and causes critical spinal stenosis at this level with critical compression of the cauda equina. Extension of tumor into the posterior elements. Severe bilateral foraminal narrowing at L5-S1 and moderate bilateral foraminal narrowing at L4-L5. Ct guided bone bx [**2152-4-21**]- pending at time of transfer [**2152-4-22**] KUB no intestinal obstruction or other acute intr-abdominal abnormality. lytic metastatic dx involving left side body L5. [**2152-4-19**] Bone scan- probable mild to moderate generalized peripheral arthritic changes as described above. Otherwise negative for significant focal skeletal lesion in the rest of the whole body. Negative for significant focal skeletal lesion in the thoracolumbar vertebrae. [**2152-4-20**]- MRI brain- no evidence of intracranial metastasis. normal contrast enhanced brain MRI. Trace chronic paranasal sinus disease. [**2152-4-18**]- CT chest- Cavity lesion right upper lung, 9mm. Right hilar adenopathy. calcied lymph node left hilum. small non-calcified nodule left upper lung posteriorly. [**2152-4-18**]- CT abd- liver, spleen, panc, gb unremarkable. no extra or intrahepatic ductal dilatation. right and left kidneys unremarkable [**2152-4-27**] AXR - FINDINGS: There is a large amount of free intraperitoneal air. There is contrast in the large bowel. There is a right upper lobe lung mass, better characterized on recent chest radiograph, but appears to contain cavitation. CTA Chest [**2152-4-30**] FINDINGS: 1. No evidence of pulmonary embolism. 2. Multifocal ground-glass opacity and consolidation superimposed upon diffuse centrilobular emphysema. The most likely cause for these findings includes ARDS or multifocal pneumonia. 3. Small pneumoperitoneum. [**2152-5-4**] IMPRESSION: 1. Increase in size of the patient's right upper lobe cavitary lesion as noted. Decreased prominence of bilateral patchy airspace opacities previously noted. Persistent airspace opacities seen within the right lung with debris in the right mainstem bronchus as noted. Soft tissue attenuation surrounding the airways of the right lung as noted, likely reflecting the patient's known lung carcinoma. 2. Significant distention of numerous loops of small bowel. The diffuse nature of this distention suggests a functional ileus. No area of transition is seen to suggest a mechanical small-bowel obstruction. 3. Free fluid seen within the peritoneal cavity. If clinically dictated, this may be accessed for aspiration via ultrasound guidance to exclude infection. 4. Lytic L5 vertebral body lesion, previously seen on prior CT to better detail. [**2152-5-10**] CXR (most recent) REASON FOR THIS EXAMINATION: Assess cardiopulmonary process HISTORY: Ventilator-dependent failure with right cavitary lesion. FINDINGS: In comparison with the previous study, there is little overall change. Again there is a large left upper lung cavity. The atelectatic change at the left base has essentially cleared. The left lung also is clear. IMPRESSION Little change. Laboratory: CBC: [**2152-4-25**] HCT 34, WBC 34, Platelets 888 CBC: [**2152-5-12**] HCT 20, WBC 7.7, Platelets 435 Coags: [**2152-5-3**] INR 1.4, PTT 31.4 Chemistry: [**2152-5-12**] Na 128, K 4.0, Cl 108, HCO3 21, BUN 18, Cr. .6, Glc 100 LFTs: [**2152-5-5**] AST 13, ALT 20, Alk Phos 64, Amylase 109*, T. bili 4.6* CEA 2.1 PSA 1.1 Brief Hospital Course: A/P: 57 y/o male w/ probable metastatic lung ca, met to L5 spine, who presents from OSH with leg weakness secondary to cauda equina syndrome - will resulting colonic perforation. Neuro: He was admitted for workup and treatment of his symptomatic spine lesion. He was to be operated on but was found to have perforated bowel. He was never operated on and his symptoms of cauda equina persisted. After long discussion, it was decided to not pursue spine stabilization. CV: Patient was in sinus tachycardia throughout the hospitalization. He was transfused one unit of blood for a HCT of 20 on the day of discharge which brought his heart rate down to around 100. He was rate controlled on IV metoprolol. Pulm: He was maintained on a ventilator throughout most of his hospitalization. He had a tracheostomy placed on [**5-9**] (three days prior to d/c) and on the day of discharge was able to come off the vent and have good 02 sats on trach mask. He has a large right lung abscess that was assessed by the thoracics team. It was determined by them that in the current setting IV abx would be the best treatment. Any intervention would not likely improve survival GI: abdominal distention/constipation- KUB [**4-22**] w/o evidence of obstruction. suspect multifactorial from narcotics and cord compression. On the operating table for spine surgery he was found to have abdominal distension and a portable xray was done which showed air under the diaphragm. A STAT general surgery consult was called and patient was taken emergently to the OR for an exlap, R hemicolectomy, and placement of ileostomy. His fascia was closed but the skin was left open for wet to dry dressing changes. He was NPO and eventually had a PEG tube placed without problem. [**Name (NI) **] was tolerating tube feeds with good ostomy function at discharge. GU: He had has a foley in. His urine output has been adequate Endo: He was on a RISS ID: He was covered broadly for his lung abscess and post operative prophylaxis. He was discharged on Vanc, Cipro, Zosyn, and Flagyl. Fluconazole was started for yeast in Urine and Sputum. Should be d/c'ed on [**2152-5-15**]. FEN: has had hyponatremia - we have had him KVO and are trying to fluid restrict him. Prophylaxis: SQH Full Code Medications on Admission: Duragesic 25mcg q72 hours Senokot-S 2mg PO bid flexiril 10mg PO bid decadron 4mg PO qid reglan 10mg PO bid prn nausea lactulose 30mL PO bid prn zofran 8mg PO tid prn dilaudid 4-8mg PO q4prn Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 3. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed: given through G tube. 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): through J tube. 6. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 7. Piperacillin-Tazobactam Na 4.5 g IV Q8H 8. Ciprofloxacin 400 mg IV Q12H 9. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H 10. Vancomycin 1500 mg IV Q 12H 11. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 12. Metoprolol Tartrate 5 mg IV Q6H:PRN HR > 100 13. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours). 14. Potassium Phosphate Dibasic 3 mMole/mL Parenteral Solution Sig: One (1) Intravenous PRN (as needed). 15. Magnesium Sulfate 4 % Solution Sig: One (1) Injection PRN (as needed): Sliding Scale. 16. Potassium Chloride 20 mEq/50 mL Piggyback Sig: One (1) Intravenous PRN (as needed): sliding scale. 17. Calcium Gluconate 100 mg/mL (10%) Solution Sig: One (1) Intravenous ASDIR (AS DIRECTED): sliding scale. 18. Insulin Insulin sliding scale - please see printed sliding scale included in discharge material 19. Pantoprazole 40 po qday Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Hospital1 **] Discharge Diagnosis: Metastatic Lung CA Perforated Bowel R lung loculated abscess L5 metastatic lesion with cord compression Acute blood loss anemia Nutrional depletion Discharge Condition: Fair Discharge Instructions: Patient should call for additional questions regarding managment of ostomy, tracheostomy, PEG or any other surgical concerns. He should continue to receive dressing changes and suction of his tracheostomy. A passy muir valve may be used for patient to communicate. His tube feeds should be continued and q4 flushing should be done. Ostomy care should be undertaken. Abdominal wound should continue to have wet to dry dressing changes [**Hospital1 **]. Followup Instructions: He should follow up with his PCP as needed. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] is available on a as needed basis

[ "276.1", "486", "285.1", "344.60", "038.9", "E878.8", "998.0", "427.89", "V66.7", "518.81", "458.29", "198.5", "041.7", "569.83", "070.54", "564.00", "303.90", "707.8", "733.13", "V46.11", "E879.8", "162.3", "112.2", "041.4", "E935.8", "513.0", "788.30", "112.89" ]

icd9cm

[ [ [] ] ]

[ "45.73", "43.11", "38.93", "96.6", "96.07", "31.1", "93.90", "46.20", "99.15", "96.04", "96.72", "38.91" ]

icd9pcs

[ [ [] ] ]

13182, 13257

9142, 11422

383, 531

13449, 13456

5647, 8405

13960, 14112

3933, 3954

11662, 13159

13278, 13428

11448, 11639

13480, 13937

3969, 5123

5137, 5628

275, 345

8434, 9119

559, 3654

3676, 3762

3778, 3917

61,663

137,834

24815

Discharge summary

report

Admission Date: [**2169-4-26**] Discharge Date: [**2169-5-9**] Date of Birth: [**2103-1-4**] Sex: M Service: CARDIOTHORACIC Allergies: Plavix / Hydrochlorothiazide / Midazolam Attending:[**First Name3 (LF) 5790**] Chief Complaint: Right upper lobe nodule and mediastinal adenopathy. Major Surgical or Invasive Procedure: [**2169-4-26**]: Video-assisted thoracoscopic surgery, right upper lobe wedge resection and mediastinal lymph node dissection. History of Present Illness: Mr. [**Known lastname 62490**] is a 66-year-old gentleman who has a growing right upper lobe nodule suspicious for malignancy. He also has FDG-avid mediastinal adenopathy. Past Medical History: 1. occluded left internal carotid artery 2. right internal carotid artery with 40-59% stenosis 3. Smoker 4. MI [**2141**] 5. gout 6. hypercholesterolemia 7. HTN Social History: Smoker. Pertinent Results: [**2169-5-9**] WBC-12.8* RBC-3.25* Hgb-10.9* Hct-31.9* Plt Ct-456* [**2169-5-8**] WBC-15.6* RBC-3.05* Hgb-10.5* Hct-31.5* Plt Ct-365 [**2169-5-7**] WBC-19.3* RBC-3.50* Hgb-11.7* Hct-34.9* Plt Ct-391 [**2169-5-2**] WBC-10.6 RBC-3.70* Hgb-12.4* Hct-36. Plt Ct-218 [**2169-5-1**] WBC-10.6 RBC-3.61* Hgb-11.9* Hct-35.2* Plt Ct-191 [**2169-4-30**] WBC-10.4 RBC-3.67* Hgb-12.4* Hct-36.5* Plt Ct-169 [**2169-4-29**] WBC-12.7* RBC-3.89* Hgb-13.0* Hct-37.5* Plt Ct-160 [**2169-4-28**] WBC-14.3* RBC-3.86* Hgb-13.0* Hct-38.0* Plt Ct-150 [**2169-4-27**] WBC-12.9* RBC-3.27* Hgb-11.6* Hct-32.5* Plt Ct-168 [**2169-4-26**] WBC-17.1*# RBC-3.99* Hgb-13.3* Hct-39.3* Plt Ct-231 [**2169-5-8**] Creat-1.3* K-4.4 [**2169-5-7**] Glucose-129* UreaN-26* Creat-1.5* Na-138 K-4.3 Cl-100 HCO3-27 [**2169-5-6**] Glucose-112* UreaN-27* Creat-1.3* Na-132* K-4.0 Cl-99 HCO3-22 [**2169-5-2**] Glucose-109* UreaN-23* Creat-0.9 Na-146* K-3.9 Cl-107 HCO3-28 [**2169-5-1**] Glucose-142* UreaN-24* Creat-1.1 Na-142 K-3.7 Cl-106 HCO3-26 [**2169-4-30**] Glucose-98 UreaN-26* Creat-1.2 Na-139 K-4.2 Cl-102 HCO3-25 [**2169-4-27**] Glucose-130* UreaN-27* Creat-1.3* Na-141 K-5.1 Cl-109* HCO3-20* [**2169-4-26**] Glucose-111* UreaN-23* Creat-1.5* Na-141 K-5.1 Cl-110* HCO3-22 [**2169-4-30**] CK(CPK)-158 CK-MB-3 cTropnT-<0.01 [**2169-4-28**] CK-MB-4 cTropnT-<0.01 [**2169-5-2**] Calcium-9.1 Phos-3.6 Mg-1.9 [**2169-4-26**]: RIGHT UPPER LOBE NODULE. GRAM STAIN (Final [**2169-4-26**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [**2169-4-29**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2169-5-2**]): NO GROWTH. ACID FAST SMEAR (Final [**2169-4-27**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final [**2169-4-27**]): NO FUNGAL ELEMENTS SEEN. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2169-4-27**]): NEGATIVE for Pneumocystis jirovecii (carinii).. CXR: [**2169-5-9**]: Bilateral pleural effusion decreased, now tiny. Right pneumothorax is still small, loculated medially and anteriorly. Mild vascular redistribution increased. No other change. [**2169-5-2**]: As compared to the previous examination, the extent of the pre-existing right-sided pneumothorax is unchanged. Also unchanged is the position of the chest tube. The gas collection in the right-sided lateral soft tissues is not visualized on today's image. Unchanged aspect of the left hemithorax. [**2169-4-30**]: In comparison with the earlier study of this date, the right chest tube is apparently on waterseal. There is a small right pneumothorax, not appreciated on the prior study. Extensive subcutaneous emphysema persists. [**2169-4-27**]: subcutaneous gas collections are unchanged. Small right pneumothorax is more conspicuous today at the apex. The saber-sheath appearance of the trachea at the level of the thoracic inlet is stable. A right chest tube is still ending at the apex. Free intraperitoneal air is unchanged. Left lower lobe atelectasis is also stable. [**2169-4-26**]: ET tube tip is 8.6 cm above the carina. The cuff appears to distend the trachea. Please correlate clinically. There is improved aeration in the right upper lobe and left lower lobe. [**2169-5-7**] Chest CT 1) No pulmonary embolism. 2) Interval decrease in the moderate right pneumothorax. 3) No other short interval change since the CT of two days prior [**2169-5-5**]: 1. Extensive right-sided fluid or pneumothorax. Intrafissural position of the chest tube. 2. Moderate bilateral anterior and right lateral soft tissue air collections. 3. Right medial dorsal encapsulated pleural fluid collection, with multiple air-fluid levels Brief Hospital Course: Mr. [**Known lastname 62490**] was admitted on [**2169-4-26**] for Video-assisted thoracoscopic surgery, right upper lobe wedge resection and mediastinal lymph node dissection. He was a difficult respiratory management remained intubated, sedated on Propofol and on pressors for hypotension. He transferred to the SICU. Respiratory: Overnight he developed subcutaneous emphysema in chest and both arms. The chest tube was placed to suction with a large airleak. On POD1 he was extubated. His subcutaneous air migrated to his face. His oxygen saturations were in the high 80's low 90's on high flow mask at 100%. With aggressive pulmonary toilet and nebulizers his oxygenation improved. The subcutaneous emphysema slowly re-absorbed. A persistent airleak remained. His oxygenation slowly improved. His oxygen was titrated to nasal cannula 2-Liters with oxygen saturations in the low 90's. The chest tube was removed. He was followed by serial chest films which showed a persistent right pneumothorax which improved with conservative management. A chest CT showed confirmed the stable pneumothorax also a posterior collection of fluid with air space which improved. Cardiac: He had an episode of rapid atrial fibrillation with heart rate in the 170's. He was given diltiazem and IV Lopressor. He briefly converted to sinus rhythm. He became hypotensive, the diltiazem was stopped and his BP improved. He remained in sinus rhythm on his home dose of Lopressor. FEN: he was gently diuresis ed with IV Lasix. He tolerated a regular diet. His electrolytes were replete. ID: He spike a fever of 101.2 He was pan cultured with no growth. He had an elevated white count. He was started on a 14 day course of Levofloxacin for possible pneumonia. His intravenous line was removed for possible phelblitis. His white count slowly tended down. Pain: His pain was well controlled on a Dilaudid PCA converted to PO pain medication. Neuro: While in the SICU he had periods of confusion requiring Haldol with a good effect. Once out of the unit his mental status returned to his baseline. Disposition: He was seen by physical therapy who deemed him safe for home. He was discharged to home with his wife on nasal cannula oxygen. He will follow-up with Dr. [**Last Name (STitle) **] as an outpatient. Medications on Admission: Allopurinol 300mg daily, Amolopine 10mg daily, Atorvastatin 80mg daily, Clonidine 0.2mg [**Hospital1 **], Colchine 0.6mg daily, Ezetimibe 10mg daily, Hydroxychloroquine 200mg [**Hospital1 **], Lisinopril 40 mg daily, Lopressor 200mg [**Hospital1 **] Percocet prn Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day. 5. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day. 6. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 8. Lopressor 100 mg Tablet Sig: Two (2) Tablet PO twice a day. 9. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:*10 Tablet(s)* Refills:*0* 11. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. Disp:*15 Tablet(s)* Refills:*0* 12. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 14. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO once a day. 15. Combivent 18-103 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation four times a day as needed for shortness of breath or wheezing: use spacer. Disp:*1 inhaler* Refills:*0* 16. Home oxygen [**2-14**] LPM continuous via Nasal Cannula maintains Sats > 90% Conserving device for portability 17. Pulse Oximeter Monitor O2 Sats titrate oxygen to maintain Sats > 90% Discharge Disposition: Home Discharge Diagnosis: Right upper lobe nodule and mediastinal adenopathy. Discharge Condition: stable Discharge Instructions: Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if develops: -Fever > 101 or chills -Increased shortness of breath, cough or sputum production -Chest pain -Incision develops drainage -Chest tube site cover with a bandaid until healed -You may shower. No tub bathing or swimming for 4 weeks -No driving while taking narcotics. Take stool softners with narcotics -Home oxygen: 2-3 Liters titrate to maintain sats > 90% Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] [**5-16**] at 9:30am in the [**Hospital Ward Name 121**] Building Chest Disease Center, [**Hospital1 **] I Report to the [**Hospital Ward Name 517**] Clincal Center [**Location (un) 470**] Radiology Department for a Chest X-Ray 45 minutes before your appointment. Completed by:[**2169-5-9**]

[ "518.89", "451.84", "440.1", "272.0", "428.0", "518.5", "433.30", "E878.6", "427.31", "E879.8", "414.01", "433.10", "512.1", "785.6", "403.90", "412", "486", "274.9", "997.2", "305.1", "458.29", "998.81", "585.9", "511.0", "443.9" ]

icd9cm

[ [ [] ] ]

[ "32.20", "96.71", "34.20", "40.11", "96.04" ]

icd9pcs

[ [ [] ] ]

8893, 8899

4827, 7137

358, 487

8995, 9004

925, 2673

9487, 9826

7451, 8870

8920, 8974

7163, 7428

9028, 9464

2709, 2709

2742, 4804

266, 320

515, 689

711, 880

896, 906

28,998

151,342

32368

Discharge summary

report

Admission Date: [**2119-11-5**] Discharge Date: [**2119-11-10**] Date of Birth: [**2098-1-15**] Sex: M Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 3223**] Chief Complaint: stabbing Major Surgical or Invasive Procedure: 1. Left closed tube thoracostomy insertion. 2. Exploratory laparotomy. 3. Takedown of splenic flexure 4. Repair of left colonic serosal injury. 5. Washout and closure of multiple stab wounds. History of Present Illness: 21M with multiple (~9) stab wounds to the chest, back, abd with omentum exposed, extremities. Transferred from [**Hospital3 **] with a R CT, intubated and sedated s/p OR [**11-5**]. Past Medical History: none Social History: + tobacco, + EtOH, +marijuana, no IVDU, + percocet (per mother) Family History: noncontributory Physical Exam: AFebrile, VSS gen: NAD CV: RRR, nl S1S2, no m/r/g Pulm: mildly decreased bibasilar BS Abd: incisions c/d/i, soft, appropriately tender Ext: no c/c/e, extremity lesions c/d/i Pertinent Results: [**2119-11-5**] 07:40AM BLOOD WBC-28.1* RBC-4.61 Hgb-15.0 Hct-43.0 MCV-93 MCH-32.6* MCHC-35.0 RDW-13.6 Plt Ct-336 [**2119-11-5**] 10:35AM BLOOD WBC-19.0* RBC-4.45* Hgb-13.8* Hct-39.9* MCV-90 MCH-31.1 MCHC-34.7 RDW-14.2 Plt Ct-282 [**2119-11-6**] 01:49AM BLOOD WBC-12.8* RBC-3.37* Hgb-10.4*# Hct-29.8* MCV-88 MCH-30.9 MCHC-35.1* RDW-14.6 Plt Ct-230 [**2119-11-6**] 12:06PM BLOOD Hct-28.9* [**2119-11-8**] 04:19AM BLOOD WBC-9.7 RBC-2.80* Hgb-8.9* Hct-25.3* MCV-91 MCH-31.6 MCHC-34.9 RDW-13.8 Plt Ct-230 [**2119-11-9**] 02:25AM BLOOD Hct-29.2* CT torso [**11-5**]: 1. Left lower pole of the kidney laceration with perinephric hematoma and extravasation of contrast. 2. Small focal segment VIII liver laceration. 3. Bilateral chest tubes and small residual pneumothoraces and incidental small right middle lobe nodule. 4. Extensive subcutaneous emphysema in chest and abdomen. 5. Suboptimal positioning of urinary catheter CT C-spine [**11-5**]: 1. No evidence of acute bony traumatic injury of the cervical spine. 2. Extensive subcutaneous emphysema secondary to multiple stab wounds. CT head [**11-5**]: No intracranial hemorrhage or evidence of acute major vascular territorial infarction. CXR [**11-9**]: The right chest tube has been removed. There is no evidence of a pneumothorax on this side. Brief Hospital Course: Pt was transferred to [**Hospital1 18**] ED with a R CT (after needle thoracostomy), intubated and sedated from [**Hospital3 **] after having been stabbed multiple times. In the [**Hospital1 18**] ED, a second left sided chest tube was placed. The patient was examined and rescusitated in the ED briefly then taken to the OR emergently for operative treatment and evaluation of the multiple penetrating stab wounds. The patient was extubated and taken to the PACU for initial recovery, and tolerated the procedure well. For details, please see the operative report; the patient initially had a PCA for pain control. The patient was taken to the floor for recovery with bilateral chest tubes. When the output from the chest tubes was appropriately low, the chest tubes were removed with chest x-rays to follow; his pneumothoraces resolved by the end of his hospital stay. Plastic surgery was consulted for IV infiltration of R arm and stab wounds to forearm, R hand and R thigh. His wounds were closed with staples, and the IV infiltration resolved. The patient's diet was advanced when appropriate; his post op course was complicated by constipation (relieved by a strict bowel regimen/medicationg), and one bout of emesis. His diet was put back to sips, and the patient was advanced once he was able to tolerate food. On discharge, the patient was tolerating a diet, voiding without assistance, ambulating, pain controlled on po pain medications. The patient denied any chest pain or shortness of breath, and both he and the trauma team both agreed the patient was ready for discharge. 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:*2* 2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. Disp:*1000 ML(s)* Refills:*1* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q3-4H () as needed. Disp:*45 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: s/p stabbing Discharge Condition: good Discharge Instructions: Incision Care: Keep clean and dry. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. . Please call your doctor or return to the ER for any of the following: * NO heavy lifting * No changes in altitude (mountains, airplanes) for ~1 month. * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 519**] in [**12-13**] weeks; call [**Telephone/Fax (1) 6429**] to schedule an appointment [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]

[ "861.32", "518.81", "881.00", "882.0", "866.00", "863.52", "860.1", "958.7", "868.14", "864.15", "285.9", "E966", "890.0" ]

icd9cm

[ [ [] ] ]

[ "34.04", "86.59", "96.71", "54.11", "46.75" ]

icd9pcs

[ [ [] ] ]

4397, 4403

2362, 3960

281, 475

4460, 4467

1038, 2339

5888, 6157

812, 829

4015, 4374

4424, 4439

3986, 3992

4491, 4491

4507, 5865

844, 1019

233, 243

503, 686

708, 714

730, 796

27,039

154,986

24387

Discharge summary

report

Admission Date: [**2195-11-23**] Discharge Date: [**2195-11-29**] Date of Birth: [**2115-8-24**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1**] Chief Complaint: colon cancer Major Surgical or Invasive Procedure: 1. Laparoscopic-assisted lysis of adhesions, takedown splenic flexure and low anterior resection ([**11-23**]) 2. EGD ([**2195-11-26**]) History of Present Illness: Ms. [**Known lastname **] is an 80 y.o. F with a hx of HTN, who presents today for surgical removal of a large pedunculated sigmoid polyp which had been found on routine colonoscopy in [**Hospital1 1562**] MA several months ago- sent to Dr. [**Last Name (STitle) **] for repeat colonscopy in [**2195-10-21**]- sigmoid polyp which nearly completely obstructed the lumen, scope could not be passed beyond. Biopsy consistent with 'mucosal prolapse'. Past Medical History: PMHx: HTN, asthma, hypercholesterol PSHx: s/p TAH, CABG Social History: Retired.Married.Denies current use of tobacco products & illicit drug use. Prior smoker, minimal etoh. Family History: extensive family history of colon cancer in mutliple siblings Physical Exam: PAT Pre-Procedure Assessment Vitals: HR-68, BP-172/89, O2 sat-97%, Height:65in, Weight:125 lb Gen: Well groomed, NAD Psych: A/Ox3, speech clear, no tremors, PERL 3mm b/l Heart: NS1/S2, no S3/S4, + Grade [**2-24**] harsh, systolic murmur, 2nd ICS, RSB, LSB, 5th ICS LSB with radiation to carotids b/l Lungs: CTAB Other: no cervical LAD b/l, no thyroid masses, trachea midline . Gen [**Doctor First Name **] POC ABD:soft, appropriately tender, ND, incision C/D/I, dressing in place EXTREM: no C/C/E, pneumoboots Pertinent Results: [**2195-11-28**] 09:45AM BLOOD Hct-31.7* [**2195-11-27**] 04:57AM BLOOD WBC-6.0 RBC-3.04* Hgb-8.6* Hct-26.4* MCV-87 MCH-28.3 MCHC-32.6 RDW-15.8* Plt Ct-230 [**2195-11-26**] 04:22AM BLOOD WBC-8.2 RBC-3.15* Hgb-9.2* Hct-26.5* MCV-84 MCH-29.2 MCHC-34.8 RDW-15.7* Plt Ct-220 [**2195-11-25**] 06:22PM BLOOD WBC-11.0 RBC-2.89* Hgb-7.9* Hct-24.3* MCV-84 MCH-27.3 MCHC-32.5 RDW-15.6* Plt Ct-247 [**2195-11-24**] 05:05AM BLOOD WBC-9.3 RBC-3.68* Hgb-10.1* Hct-30.9* MCV-84 MCH-27.5 MCHC-32.7 RDW-15.4 Plt Ct-231 [**2195-11-23**] 11:30AM BLOOD Hct-31.4* [**2195-11-27**] 04:57AM BLOOD Plt Ct-230 [**2195-11-26**] 04:22AM BLOOD PT-12.4 PTT-26.6 INR(PT)-1.0 [**2195-11-25**] 06:22PM BLOOD PT-13.4 PTT-28.5 INR(PT)-1.1 [**2195-11-28**] 06:35AM BLOOD Glucose-96 UreaN-9 Creat-0.6 Na-141 K-3.7 Cl-101 HCO3-35* AnGap-9 [**2195-11-24**] 05:05AM BLOOD Glucose-86 UreaN-20 Creat-0.9 Na-141 K-3.8 Cl-104 HCO3-28 AnGap-13 [**2195-11-28**] 06:35AM BLOOD Calcium-8.8 Phos-2.7 Mg-1.6 [**2195-11-24**] 05:05AM BLOOD Calcium-8.1* Phos-3.9 Mg-2.8* . [**2195-11-25**] 11:01 am SPUTUM Source: Expectorated. GRAM STAIN (Final [**2195-11-25**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [**2195-11-29**]): MODERATE GROWTH OROPHARYNGEAL FLORA. PSEUDOMONAS SPECIES. MODERATE GROWTH. gram stain reviewed: 4+ GRAM NEGATIVE RODS were observed ([**2195-11-27**]). sensitivity testing performed by Microscan. MEROPENEM. <=1MCG/ML. GRAM NEGATIVE ROD(S). RARE GROWTH. ACID FAST SMEAR (Final [**2195-11-26**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Pending): . Pathology Examination Procedure date [**2195-11-23**] DIAGNOSIS: Rectosigmoid colon, resection: 1. Adenocarcinoma of the colon, see synoptic report. 2. Multiple diverticula of the colon. 3. Separate fragment of colon donut, within normal limit. Colon and Rectum: Resection Synopsis MACROSCOPIC Specimen Type: Rectal/rectosigmoid resection(low anterior resection). Specimen Size Greatest dimension: 30 cm. Additional dimensions: 6.5 cm x 3 cm. Tumor Site: Sigmoid colon. Tumor configuration: Ulcerating. Tumor Size Greatest dimension: 4 cm. Additional dimensions: 3 cm x 0.5 cm. MICROSCOPIC Histologic Type: Adenocarcinoma. Histologic Grade: Low-grade (well differentiated). EXTENT OF INVASION Primary Tumor: pT3: Tumor invades through the muscularis propria into the subserosa. Regional Lymph Nodes: pN0: No regional lymph node metastasis. Lymph Nodes Number examined: 13. Number involved: 0. Distant metastasis: pMX: Cannot be assessed. Margins Margin #1: Uninvolved by invasive carcinoma: Distance of tumor from closest margin: 100 mm. Margin #2: Uninvolved by invasive carcinoma: Distance of tumor from closest margin: 150 mm. Circumferential (radial) margin: Uninvolved by invasive carcinoma: Distance of tumor from closest margin: 105 mm. Lymphatic Small Vessel Invasion: Absent. Venous (large vessel) invasion: Absent. Perineural invasion: Absent. Tumor border configuration: Infiltrating. Clinical: Rectosigmoid carcinoma. . Thursday, [**2195-11-26**] G.I. BLEED Esophagitis in the lower third of the esophagus and gastroesophageal junction compatible with erosive esophagitis Small hiatal hernia Erosion in the antrum Brief Hospital Course: Mrs.[**Location (un) 61752**] operative course was uncomplicated. She was routinely observed in the PACU, and transferred to [**Hospital Ward Name **] for post-op care. . UGI Bleed:She had a few episodes of dark brown emesis with clots on POD [**1-24**]. Hematocrit was checked, and dropped from 30.9 to 27.3, and even further to 24.5 which was evident for a bleed. GI service was consulted. She was transferred to ICU for an EGD to evaluate for upper GI bleed (please refer to Pertinent Results section). She remained in the ICU for a few days for blood transfusion, and close monitoring of HCT's. She had no evidence of active bleeding per EGD, and her HCT's stabilized. She was eventually transferred back to [**Hospital Ward Name **], and discharged home a few days after. . ABD:Her abdomen is soft, NT/ND with active bowel sounds. Her abdominal incision is OTA with staples, healing and intact. She will have the staples removed at the follow-up appointment with Dr. [**Last Name (STitle) **]. . NUT:She was NPO post-op. Her diet was advanced as her bowel function resumed. Her diet was reverted to NPO during post-op evaluation for dark brown emesis with clots. Once her condition stabilized, she was advanced to regular food. She has been tolerating a regular diet without complaints of nausea and/or vomiting prior to discharge. . ELIM:She had a foley catheter inserted intra-op. The catheter was removed, and she was able to urinate without difficulty. She reports passing flatus, but has not had a bowel movement since surgery. . PAIN:Her pain was managed with an IV PCA post-op. She was advanced to oral Percocet once tolerating oral fluids. She reports her pain is well tolerated. She will be discharged with a 2 week supply of Percocet, and colace to prevent constipation. . Medications on Admission: HCTZ 25", simvastatin 20', levoxyl 75', advair INH, albuterol INH Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H-Q6H PRN as needed for pain for 14 days. Disp:*30 Tablet(s)* Refills:*0* 2. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for 1 months. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID PRN for 1 months. Disp:*60 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1.Rectosigmoid carcinoma 2.Esophagitis/small hiatal hernia w ulcerations Discharge Condition: good tolerating regular diet bowel movement x 1 pain controlled Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are 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 Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or becoming progressively worse, or inadequately controlled with the prescribed pain medication. * 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. . Medications: Please continue your home medications as prescribed. You have also been prescribed pain medication, stool softener, and a proton pump inhibitor. Please take all medications as prescribed. Incision Care: *You may shower. Pat incision dry. *Avoid swimming and baths until further instruction at your followup appointment. *You will have your staples removed at your postoperative clinic visit with Dr. [**Last Name (STitle) **] *Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Followup Instructions: 1. Please follow-up with Dr. [**Last Name (STitle) **] in [**1-24**] weeks; call [**Telephone/Fax (1) 9**] 2. Please follow-up with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 61753**],M.D. (Gastroenterology) in [**1-24**] weeks; call ([**Telephone/Fax (1) 8622**] 3. Please follow-up with Dr. [**Last Name (STitle) **] (your PCP). call ([**Telephone/Fax (1) 61754**] for an appointment. Completed by:[**2195-11-30**]

[ "530.19", "568.0", "272.0", "493.90", "V45.81", "V15.82", "553.3", "V45.77", "401.9", "578.0", "154.0" ]

icd9cm

[ [ [] ] ]

[ "48.63", "54.51", "45.13", "99.04" ]

icd9pcs

[ [ [] ] ]

8028, 8034

5304, 7094

326, 465

8151, 8217

1766, 3533

10653, 11093

1158, 1221

7210, 8005

8055, 8130

7120, 7187

8241, 10257

10272, 10607

1236, 1747

3562, 5281

274, 288

493, 942

964, 1022

1038, 1142

3,267

134,934

48319

Discharge summary

report

Admission Date: [**2191-11-4**] Discharge Date: [**2191-12-24**] Date of Birth: [**2138-3-6**] Sex: F Service: SURGERY Allergies: Lisinopril Attending:[**First Name3 (LF) 2777**] Chief Complaint: Infected/bleeding L LE wound Major Surgical or Invasive Procedure: L BKA, STSG [**2191-12-9**] Debridement of necrotic left leg wound and change of a wound VAC dressing [**2191-11-16**] Resection of pseudoaneurysm and ligation of fistula [**2191-11-17**] Exchange of vac under conscious sedation [**11-23**] Debridement of necrotic left leg wound [**2191-11-8**] History of Present Illness: This woman with previously ischemic left leg who has developed multiple infections around her incision lines and along fascial planes, presented with systemic infection from her open left leg wounds. She was treated with IV antibiotics and dressing changes but was noted to have extensive necrotic and purulent material particularly from her lateral calf wound and also extending posteriorly. These were not amenable to bedside debridement. Past Medical History: renal failure secondary to diabetes mellitus on HD status post R nephrectomy for renal cell cancer depression cholecystectomy gastric ulcer PVD s/p Left SFA to dorsalis pedis artery bypass for L gangrenous heel in [**2187**]; R proximal SFA to proximal AT bypass on [**2191-3-31**] OSA on CPAP Gastroparesis Ischemic colitis Right thigh wound LVH, EF 55% COPD on 3-4L NC at home Social History: Denies illicit drug use. Denies smoking. Denies drinking alcohol. Lives alone. Recent Stressor of her son fatally shot this week. Family History: Mother died of stomach cancer in her 40s. Father had an unknown cancer in his 70s. Stated that diabetes, high cholesterol, and high blood pressure run in her family. Physical Exam: AAOx3, VSS, Neuro intact. Lungs: CTA Cardiac: HR RRR Abd: Obese, positive bowel sounds Extremities: LLE-BKA Pulses: Fem [**Doctor Last Name **] graft Rt 2+ None palp Lt 2+ None palp Pertinent Results: RADIOLOGY Final Report PICC W/O PORT [**2191-11-7**] 8:03 AM IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 5 French double lumen PICC line placement via the right brachial venous approach. Final internal length is 36 cm, with the tip positioned in SVC. The line is ready to use. [**2191-11-7**] 1:57 PM ART DUP EXT LO UNI;F/U FINDINGS: Duplex evaluation was performed of left lower extremity bypass. Peak velocities in cm/sec are 52 in the native proximal vessel, 38 at the proximal anastomosis, 53 at the distal anastomosis and 144 in the native distal vessel. From proximal to distal, velocities are 230, 85, 70, 80, 77, 72 and 76 cm/sec within the vein graft. IMPRESSION: Patent left leg bypass with elevated velocities in the proximal graft suggestive of significant stenosis greater than 75% [**2191-11-7**] 10:44 AM CHEST (PORTABLE AP) Left infrahilar opacification has improved. Pulmonary vascular congestion and mild cardiomegaly have also decreased. No pleural effusion or pneumothorax. Upper lungs entirely clear. [**2191-11-5**] 3:08 PM FINDINGS: There is extensive reticular edema in the subcutaneous fat. Evaluation for the presence of a subtle abscess is limited in the absence of contrast; however, no large fluid collections are seen within the subcutaneous fat or muscle. A small subtle collection, however, cannot adequately be excluded. Additionally, extensive vascular calcific atherosclerosis is noted. There is extensive subcutaneous edema. Evaluation of the osseous structures demonstrates demineralization of the bones with periosteal thickening which can be seen in the setting of renal insufficiency and chronic venous stasis. No fractures are present. IMPRESSION: 1. Limited examination for the detection of an abscess without the use of contrast; however, no large abscess is identified. Extensive edema and subcutaneous edema is present. 2. Extensive calcific atherosclerosis and evidence of chronic venous stasis. 3. Extensive demineralization of the bones. [**2191-11-5**] 2:55 pm SWAB Site: LEG Source: Right leg ulcer. STAPH AUREUS COAG +. MODERATE GROWTH. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). MODERATE GROWTH. _________________________________________________________ STAPH AUREUS COAG + | ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S Brief Hospital Course: This is a 53 y.o woman with previously ischemic left leg who developed multiple infections around her incision lines and along fascial planes, presented with systemic infection from her open left leg wounds. She was treated with IV antibiotics and dressing changes but was noted to have extensive necrotic and purulent material particularly from her lateral calf wound and also extending posteriorly. These were not amenable to bedside debridement. Patient was admitted on [**2191-11-8**], was taken to the OR for debridement of necrotic left leg wound. Post-operatively, was recovered then transfered to the ICU. Successfully extubated the next day, recovered and transfered to [**Hospital Ward Name 121**] 5. For details, please see operative note. The patient remained on IV antiobiotics, and received daily wound care and dressing changes. On [**11-16**], the patient returned to the operating room for another wound debridement after which a VAC was placed to the wound; please see operative note for details. The patient recovered in the PACU initially, and then on [**Hospital Ward Name 121**] 5. On [**2104-11-16**], a large ulcerated lesion on an AV graft was noted to be bleeding despite compression, and the patient was taken to the operating room on [**11-17**] for a resection of a pseudoaneurysm and ligation of her AV fistula. On [**11-23**], the patient was brought to the operating room for a change of the VAC dressing. DEspite repeated debridements, continued wound care and intravenous antibiotics, it was felt that a left below the knee amputation would be the best intervention; this surgery along with a split thickness skin graft and a VAC dressing placement was performed on [**12-9**]. Neuro: A pain consult was called initially for help controlling the patient's chronic pain. Her medications were altered with good results. Prior to dressing changes, VAC changes, and other procedures, the patient received adequate pain control. Psychiatry was also consulted during this admission for depression, who recommmended Seroquel and Haldol which were used with good effect. CV: The patient received metoprolol during her hospitalization, and her vital signs were routintely monitored. Pulmonary: The patient was extubated from her multiple surgeries when appropriate, and recovered well. She required good pulmonary toilet, and was encouraged to get up and out of bed. She remained on supplemental oxygen throughout her stay, and was unable to be weaned. GI/GU: The patient's diet was advanced post operatively as tolerated; she was put on a diabetic diet during her stay. Her urine output was monitored closely, and her intravenous fluids were managed accordingly for post op hypovolemia. Heme: The patient's hematocrit was monitored frequently, and when appropriate, the patient was transfused for post operative blood loss/anemia. Endo: Managed with Glargine and regular insulin sliding scale. renal was consulted for further management and the patient was dialysed per routine. Her antibiotics and other medications were renally dosed. Wound/ID: [**12-5**] AVfistula site found to be infected-she received routine wound care, cultured grew 1+ GNRs-klebsiella, resistant to cipro, treated with Ceftazidime, which will end on [**12-21**]. [**2191-11-16**]- stool positive C-diff, ID recommended PO Metronidazole and vancomycin x 4wks (slated to end on [**1-4**]). The amputation/skin graft wound was dressed daily with Adaptic and the AV fistula site had wet to dry dressing changes QDay-[**Hospital1 **]. Granulation tissue did form under the skin graft. The superior edge of the skin graft was the slowest to take. Prophylaxis: The patient received aspirin and subcutaneous heparin throughout her stay for DVT prophylaxis. Medications on Admission: [**Last Name (un) 1724**]: tylenol 650"", cinacalcet 60', Colace 100", heparin 5000''', gabapentin 300', Lantus 5U Q12pm, HISS, mirtazapine 15', oxycodone 10''', protonix 40", niferex 150', Renagel 2400''', simvastatin 20', tramadol 25", mvi, albuterol neb PRN, lactulose 10''' PRN, milk of magnesia 30ml' PRN, ondansetrol 2''' PRN, senna 17.2" PRN, miconazole topical''' PRN, accuzyme" topical Discharge Medications: 1. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 6. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 7. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HD PROTOCOL (HD Protochol). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 12. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO QOD (). 13. Insulin Regular Human 100 unit/mL Solution Sig: per scale sc as directed Injection breakfast lunch dinner and bedtime: SC Sliding Scale Humalog Insulin Dose 0-70 mg/dL 4 oz. Juice and 15 gm crackers 4 oz. Juice and 15 gm crackers 4 oz. Juice and 15 gm crackers 4 oz. Juice and 15 gm crackers 71-120 mg/dL 0 Units 0 Units 0 Units 0 Units 121-160 mg/dL 2 Units 2 Units 2 Units 2 Units 161-200 mg/dL 4 Units 4 Units 4 Units 4 Units 201-240 mg/dL 6 Units 6 Units 6 Units 6 Units 241-280 mg/dL 8 Units 8 Units 8 Units 8 Units > 280 mg/dL Notify M.D. . 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 16. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital **] Nursing care Discharge Diagnosis: S/p LLE debridement of wound S/p LBKA, STSG ([**12-9**]) history of DM2 history of ESRD on HD history of depression history of PVD history of PUD history of OSA history of osteoporosis history of HTN history of RCC history of diabetic gastroparesis Discharge Condition: stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOLLOWING BELOW OR ABOVE KNEE AMPUTATION This information is designed as a guideline to assist you in a speedy recovery from your surgery. Please follow these guidelines unless your physician has specifically instructed you otherwise. Please call our office nurse if you have any questions. Dial 911 if you have any medical emergency. ACTIVITY: There are restrictions on activity. On the side of your amputation you are non weight bearing until cleared by your Surgeon. You should keep this amputation site elevated when ever possible. You may use the other leg to assist in transferring and pivots. But try not to exert to much pressure on the amputation site when transferring and or pivoting. Please keep knee immobilizer on at all times to help keep the amputation site straight. No driving until cleared by your Surgeon. PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: Redness in or drainage from your leg wound(s) . Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. Exercise: Limit strenuous activity for 6 weeks. Do not drive a car unless cleared by your Surgeon. Try to keep leg elevated when able. BATHING/SHOWERING: You may shower immediately upon coming home. No bathing. A dressing may cover you??????re amputation site and this should be left in place for three (3) days. Remove it after this time and wash your incision(s) gently with soap and water. You will have sutures, which are usually removed in 4 weeks. This will be done by the Surgeon on your follow-up appointment. WOUND CARE: Sutures / Staples may be removed before discharge. If they are not, an appointment will be made for you to return for staple removal. When the sutures are removed the doctor may or may not place pieces of tape called steri-strips over the incision. These will stay on about a week and you may shower with them on. If these do not fall off after 10 days, you may peel them off with warm water and soap in the shower. Avoid taking a tub bath, swimming, or soaking in a hot tub for four weeks after surgery. MEDICATIONS: Unless told otherwise you should resume taking all of the medications you were taking before surgery. You will be given a new prescription for pain medication, which can be taken every three (3) to four (4) hours only if necessary. Remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (Check with your physician if you have fluid restrictions.) If you feel that you are constipated, do not strain at the toilet. You may use over the counter Metamucil or Milk of Magnesia. Appetite suppression may occur; this will improve with time. Eat small balanced meals throughout the day. CAUTIONS: NO SMOKING! We know you've heard this before, but it really is an important step to your recovery. Smoking causes narrowing of your blood vessels which in turn decreases circulation. If you smoke you will need to stop as soon as possible. Ask your nurse or doctor for information on smoking cessation. Avoid pressure to your amputation site. No strenuous activity for 6 weeks after surgery. DIET : There are no special restrictions on your diet postoperatively. Poor appetite is expected for several weeks and small, frequent meals may be preferred. For people with vascular problems we would recommend a cholesterol lowering diet: Follow a diet low in total fat and low in saturated fat and in cholesterol to improve lipid profile in your blood. Additionally, some people see a reduction in serum cholesterol by reducing dietary cholesterol. Since a reduction in dietary cholesterol is not harmful, we suggest that most people reduce dietary fat, saturated fat and cholesterol to decrease total cholesterol and LDL (Low Density Lipoprotein-the bad cholesterol). Exercise will increase your HDL (High Density Lipoprotein-the good cholesterol) and with your doctor's permission, is typically recommended. You may be self-referred or get a referral from your doctor. If you are overweight, you need to think about starting a weight management program. Your health and its improvement depend on it. We know that making changes in your lifestyle will not be easy, and it will require a whole new set of habits and a new attitude. If interested you can may be self-referred or can get a referral from your doctor. If you have diabetes and would like additional guidance, you may request a referral from your doctor. FOLLOW-UP APPOINTMENT: Be sure to keep your medical appointments. The key to your improving health will be to keep a tight reign on any of the chronic medical conditions that you have. Things like high blood pressure, diabetes, and high cholesterol are major villains to the blood vessels. Don't let them go untreated! Please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. This should be scheduled on the calendar for seven to fourteen days after discharge. Normal office hours are 8:30-5:30 Monday through Friday. PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE Followup Instructions: Provider: [**Last Name (NamePattern4) **].[**Name (NI) 24947**] Phone: [**Telephone/Fax (1) 2625**] Date/Time ----- Completed by:[**2191-12-24**]

[ "250.60", "585.6", "403.91", "996.72", "V10.52", "440.24", "250.70", "998.59", "337.1", "536.3" ]

icd9cm

[ [ [] ] ]

[ "39.95", "83.45", "39.42", "84.15", "38.93", "86.69" ]

icd9pcs

[ [ [] ] ]

10656, 10711

4663, 8432

299, 597

11004, 11013

2022, 4640

16370, 16518

1635, 1802

8877, 10633

10732, 10983

8458, 8854

11037, 12765

1817, 2003

231, 261

12778, 15673

15697, 16347

625, 1068

1090, 1470

1486, 1619

42,794

153,581

53592

Discharge summary

report

Admission Date: [**2127-3-12**] Discharge Date: [**2127-3-17**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1171**] Chief Complaint: cough and fatigue Major Surgical or Invasive Procedure: Aortic valvuloplasty History of Present Illness: Mr. [**Known lastname 110111**] is an 88M with severe aortic stenosis, diastolic heart failure, moderate pulmonary hypertension, stage IV chronic kidney disease, and bronchiectasis with several months of cough w/ trace hemoptysis. He came to the ED today b/c his cough is occuring more frequently and continues to be blood tinged. He has midline chest pain associated with the cough without radiation. . He has chronic exertional CP and SOB with ambulating 10 meters which he states is unchanged: this has been attributed to his severe AS in the past. . In terms of his bronchiectasis (radiographically mild) and hemoptysis, he has been seen in pulmonary clinic. He had MAC on an AFB smear in the fall of [**0-0-**] which he refused treatment for and which did not appear on 3 serial AFB smears in [**November 2126**]. Differential for his hemoptysis includes bronchiectasis vs severe valvular dz w/ subsequently increased filling pressures. . In the ED vitals were 98.4, 173/96, 64, 18, 100% 3LNC. EKG unchanged. BNP elevated. CXR with stable effusion and no overt pulmoanry edema. He was given aspirin 325 x1 and lasix 20 IV as his JVP appeared elevated. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: - Hypertension 2. CARDIAC HISTORY: - Severe Aortic Stenosis (peak vel 5m/s, mean grad 72, [**Location (un) 109**] 0.9 cm2) - Diastolic heart failure (LVEF 70-80%) - Pulmonary Hypertension (moderate, PASP >55) - moderate LVH (1.6cm) 3. OTHER PAST MEDICAL HISTORY: - Stage IV CKD (Baseline Cr~3) - Gastritis - Trigeminal neuralgia - Bladder cancer - BPH s/p TURP - Iron deficiency anemia (HCT mid 30s) - Vitamin B12 deficiency - RCC s/p nephrectomy [**2119**] - chronic mycobacterium avium intracellular infection positive sputum in [**2126-2-17**] (pulm follows) had three negative sputums in [**2126-11-19**] Social History: Patient lives alone in [**Location (un) **]. He was lieutenant colonel in Russian Army during WWII, and his entire family killed in war. After end of war went to medical school and became a dermatologist and practiced for 43 yrs. He moved to the US 18 years ago to be near his sons, in [**Name (NI) 86**]/SF who are in computers. He no longer practices but enjoys going to dermatology grand rounds at [**Hospital1 2025**] and BIMDC. He smoked until age 25. Rare alcohol use. He denied illicits/herbals. Family History: Father died from lung CA at age 45, though he worked in a tobacco store. Mother, siblings were all killed at a young age in WWII. He says his sons have no medical issues. Physical Exam: ON ADMISSION: VS: 97.6, 162/82 (initially 188/92), 64, 20, 96% 2Lnc GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. PERRL, surgical pupil, eyelid lag slightly more on right eye, EOMI. NECK: Supple with JVD 5cm above clavicle at 90 degrees. CARDIAC: III/VI crescendo systolic murmur heard over ao area, III/VI HSM at LSB, NORMAL S1, DULL S2 no rubs or gallops LUNGS: + rhonci throughout, NO WHEEZE, L>R slightly decreased BS at bases ABDOMEN: + BS, soft, NTND. EXTREMITIES: mild trace LE edema at ankles B/L. DP pulses +1 B/L. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. . AT TIME OF DISCHARGE: VS: 98.6, 136/69, 61, 20, 90% RA. GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. PERRL, surgical pupil, eyelid lag slightly more on right eye, EOMI. NECK: Supple with JVD 5cm above clavicle at 90 degrees. CARDIAC: III/VI crescendo systolic murmur heard over ao area, III/VI HSM at LSB, NORMAL S1, DULL S2 no rubs or gallops LUNGS: + rhonci throughout, NO WHEEZE, L>R slightly decreased BS at bases ABDOMEN: + BS, soft, NTND. EXTREMITIES: mild trace LE edema at ankles B/L. DP pulses +1 B/L. There is a large superficial ecchymosis of the R groin with no e/o hematoma. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Pertinent Results: Admission labs: [**2127-3-12**] WBC-6.7 RBC-3.90* Hgb-11.6* Hct-33.5* MCV-86 RDW-14.1 Plt Ct-339 Neuts-69.3 Lymphs-20.3 Monos-6.0 Eos-3.2 Baso-1.2 PT-11.9 PTT-28.0 INR(PT)-1.0 Glucose-111* UreaN-49* Creat-2.8* Na-140 K-4.1 Cl-105 HCO3-24 AnGap-15 . Cardiac Enzymes: [**2127-3-12**] 04:30PM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier **]* [**2127-3-12**] 04:30PM BLOOD cTropnT-0.04* [**2127-3-12**] 04:30PM BLOOD CK(CPK)-54 [**2127-3-14**] 11:09PM BLOOD CK(CPK)-86 . [**2127-3-15**] CT head: No acute intracranial abnormality. In case of continued clinical concern for infarction, an MRI can be obtained. [**2127-3-15**] CT abd/pelvis: 1. 8.0 x 4.6 x 5.8 cm hematoma in the right groin just deep to the femoral vessels with surrounding fat stranding. Evaluation for active extravasation cannot be done due to lack of IV contrast. 2. Multiple stable pancreatic cysts. [**2127-3-14**] Echo: There is symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF>75%); outflow tract obstruction cannot be excluded and is probably present. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are severely thickened/deformed. Significant aortic stenosis is present (not quantified). Mild (1+) aortic regurgitation is seen. The severity of aortic regurgitation may be underestimated due to the technically limited nature of this study. The mitral valve leaflets are mildly thickened. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2126-11-26**], no definite change. [**2127-3-14**] Post Aortic Valvuloplasty Echo: There is symmetric left ventricular hypertrophy. The left ventricular cavity is small. Left ventricular systolic function is hyperdynamic (EF>75%). Mild to moderate ([**12-21**]+) aortic regurgitation is seen. The severity of aortic regurgitation may be underestimated. There is no pericardial effusion. . [**2127-3-12**] CXR: Relatively stable pleural effusion as previously documented. There is improved aeration of the lung bases with only mild residual opacities remaining, likely atelectasis. . [**2127-3-16**]: Right Femoral U/S IMPRESSION: No evidence of aneurysm in the right groin. No discrete organizing fluid collection also identified. The area of known hematoma is likely intramuscular and not well appreciated on this study Brief Hospital Course: Mr. [**Known lastname 110111**] is a 87 yo male with severe aortic stenosis, dCHF with preserved EF, PAH, CKD, HTN, chronic cough/hemoptysis who presents with worsening cough and chest pain associated with cough. Physical exam on admission was suggestive of mild fluid overload. . # COUGH/HEMOPTYSIS: Acute worsening of chronic cough is main presenting symptom. Pt previously grew out MAC (untreated) and has been diagnosed with bronchiectasis and chronic lung disease. His presenting complaint of worsened cough with assoc CP was most suggestive of a bronchiectasis flare. Patient was treated with Ciprofloxacin for 7 days (he completed 3 days of his course at time of discharge). Patient's cough was managed with tesalon pearls and robitussin with some symptomatic relief. . # Chest pain: Chest pain really only occurred in the setting of cough. He was noted to have a Trop of 0.04 in setting of CKD which is consistent with his prior troponin. Patient refused additional sets of enzymes, but his symptoms were felt to be very unlikely ACS. He was discharged on aspirin, statin & metoprolol. . # CHF: Patient was gently diuresed with lasix until euvolemic. He should continue on a low dose of furosemide 20mg daily. He will need teaching regarding daily volume assessment and weights. . # Aortic stenosis: Patient underwent a valvuloplasty with a decrease in mean gradient from 45mmHg to 20mmHg. He was transferred to CCU post procedure for low blood pressures that were thought most likely due to vasovagal response. Patient refusing aortic valve repair but may be eligible for core valve replacement clinical trial. # Chronic renal failure: Had renal cell carcinoma s/p nephrectomy in [**2119**]. creatinine at baseline prior to discharge 3.1 (on [**2127-3-15**]) with baseline of 2.8. The patient refused further blood draws as inpatient. . # HTN: Controlled with metoprolol and amlodopine added . # Iron deficiency anemia, B12 deficiency anemia: Patient had HCT drop after valvuloplasty from 35 to 30. Last HCT checked [**3-15**] found to be relatively stable at 28.7. The patient refused further lab draws. Patient stated that he understood that if we were unable to monitor hematocrit he could bleed, have a heart attack, and die. He was willing to take those risks because lab draws caused him pain. CT head, abd/pelvis were done to find source of bleed. CT abd/pelvis suggested hematoma but follow up ultrasound of right femoral area showed no evidence of hematoma or aneursym. Of note, the patient did have a stable large ecchymotic area near the R inguinal area without evidence of hematoma at the time of discharge. . # Bladder agents: continued finasteride & detrol. . # Seizure d/o: continued trileptal. . CODE STATUS: Confirmed as FULL CODE this admission. Medications on Admission: ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2 (Two) puffs inhaled twice a day as needed CALCITRIOL - 0.25 mcg Capsule - 1 (One) Capsule(s) by mouth Sunday,Monday, Wednesday, and Friday FINASTERIDE - 5 mg Tablet - 1 Tablet(s) by mouth once a day FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth once every monday, wednesday, and friday as needed for . LIDOCAINE [LIDODERM] - 5 % (700 mg/patch) Adhesive Patch, Medicated - apply each knee once a day METOPROLOL SUCCINATE - 100 mg Tablet Sustained Release 24 hr - 1 (One) Tablet(s) by mouth once a day OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 (One) Capsule, Delayed Release(E.C.)(s) by mouth once a day OXCARBAZEPINE [TRILEPTAL] - 300 mg Tablet - 2 Tablet(s) by mouth daily as directed TOLTERODINE [DETROL LA] - 4 mg Capsule, Sust. Release 24 hr - 1 Capsule(s) by mouth once a day ACETAMINOPHEN - 325 mg Tablet - 1 to 2 Tablet(s) by mouth every six (6) hours as needed for pain ASPIRIN - 81 mg Tablet - 1 Tablet(s) by mouth once a day BACK BRACE - Misc - apply daily for back fracture and back pain CYANOCOBALAMIN [VITAMIN B-12] - (Prescribed by Other Provider) - Dosage uncertain DOCUSATE SODIUM - 100 mg Capsule - 1 (One) Capsule(s) by mouth twice a day constipation FERROUS GLUCONATE - 325 mg Tablet - 1 Tablet(s) by mouth once a day Discharge Medications: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puff Inhalation twice a day as needed for shortness of breath or wheezing. 2. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY OTHER DAY (Every Other Day). 3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 5. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. Disp:*4 Tablet(s)* Refills:*0* 9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 10. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 11. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 12. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. Vitamin B-12 Oral 14. Detrol LA 4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 15. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 16. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] of [**Location (un) 55**] Discharge Diagnosis: Primary Diagnosis: Severe Aortic Stenosis Bronchiectasis . Secondary Diagnosis: Acute on Chronic Diastolic Heart Failure Discharge Condition: Stable, alert, ambulating with assistance. Discharge Instructions: You were admitted to the hospital with chest pain when you coughed and worsening fatigue. Your chest pain was not due to a heart attack and is likely only caused by your cough. We tried to control your cough with cough medications and an antibiotic. . We think that your fatigue is due to a narrow aortic valve, or aortic stenosis and heart failure. You had a procedure called an aortic valvuloplasty. This enlarged your aortic valve and improved blood flow. Your heart failure was treated with a medication called lasix. . We have made the following changes to your medication list: 1. Ciprofloxacin 250mg by mouth once a day for 4 days 2. Start Atorvastatin 80mg by mouth once a day 3. Start Amlodopine 5mg by mouth once a day Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: PLEASE CALL DR. [**First Name (STitle) 251**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 253**] to reschedule your eye appointment originally scheduled for [**2127-3-17**] at 10:30. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2127-3-19**] 12:40 Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1114**], M.D. Date/Time:[**2127-3-26**] 12:00

[ "428.0", "494.0", "403.90", "416.8", "V10.52", "786.3", "424.1", "428.33", "345.90", "280.9", "414.01", "585.9", "790.01" ]

icd9cm

[ [ [] ] ]

[ "37.23", "35.96", "88.56" ]

icd9pcs

[ [ [] ] ]

12353, 12425

6733, 9513

288, 311

12590, 12635

4208, 4208

13502, 13989

2728, 2903

10887, 12330

12446, 12446

9539, 10864

12659, 13479

2918, 2918

1607, 1810

4474, 4696

231, 250

339, 1499

4705, 6710

12526, 12569

4224, 4457

12465, 12505

2932, 4189

1841, 2188

1543, 1585

2204, 2712

74,285

181,859

48285

Discharge summary

report

Admission Date: [**2132-4-27**] Discharge Date: [**2132-4-29**] Date of Birth: [**2071-9-19**] Sex: F Service: [**Year (4 digits) 662**] Allergies: Aspirin / Sulfa (Sulfonamide Antibiotics) / Penicillins / Strawberry / Ace Inhibitors Attending:[**First Name3 (LF) 2641**] Chief Complaint: Lip Swelling Major Surgical or Invasive Procedure: None History of Present Illness: MICU ADMISSION NOTE 60y/o F with angioedema of upper lip which started this afternoon at 2 pm while she was driving in her car. She denies SOB or difficulty swallowing, but does say that her throat feels "scratchy." No obvious inciting factor recently (no new soaps/foods/detergents/makeup), has history of anaphylaxis to strawberries/some oranges in the past although this is not like those times. She denies any rash, no pruritis, no pain. Has no history of an episode exactly like this in the past. Has been on an ACE-I (enalapril) for the last 5+ years. For about 1 week she has had a somewhat sore throat and nasal congestion, denies productive cough, no CP/SOB. In the ED, initial vs were: T 96.8 P 87 BP 194/94 --> 166/80 R 15 O2 sat 100% RA. Patient was given IV solumedrol and benadryl and was sent to the MICU On the floor, the patient is without complaints, HPI as above. 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. FLOOR ADMISSION NOTE Please see MICU [**Location (un) **] H&P for full details, Briefly, 60y/o F with angioedema of upper lip which started at 2 pm on [**4-27**]. Patient had no SOB, dysphagia. Pt admits to having a prior history of anaphylaxis to strawberries/oranges. The patient was unable to identify any new inciting factors (new medications, new soaps/foods/detergents/makeup). Pt reports 1 week of sore throat and nasal congestion, denies productive cough, no CP/SOB. . Patient presented to the ER and initial VS were T 96.8 P 87 BP 194/94 --> 166/80 R 15 O2 sat 100% RA. Patient was given IV solumedrol and benadryl and was sent to the MICU for airway protection. . The patient was stable overnight in the MICU. Patient's Upper lip swelling slightly improved, however is still impressive. No difficulty swallowing, no SOB. Patient was transitioned to PO Prednisone 60mg and continued on Benadryl. . On the transfer, the patient is without complaints, HPI as above. . 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: HTN DM II HL arhtritis back surgery, s/p laminectomy several episodes of anaphylaxis requiring Epi pen, including oranges and strawberries [**4-/2132**] admission for upper lip angioedema, ACEi was discontinued Social History: Works as a VP at the [**Location (un) 86**] [**Hospital1 **] Museum. Denies any history or current use of alcohol, tobacco, or drugs. Family History: Mother and father with various types of cancer, nobody with angioedema Physical Exam: MICU ADMISSION PHYSICAL EXAM Vitals: T:97.6 BP: 154/86 P: 78 R: 16 O2: 98% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, upper lip with marked swelling, uvula midline without edema,OP otherwise without erythema/exudate Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema By discharge, pt's upper lip had improved significantly Pertinent Results: [**2132-4-29**] 07:05AM BLOOD WBC-6.5 RBC-4.77 Hgb-10.7* Hct-34.3* MCV-72* MCH-22.3* MCHC-31.1 RDW-14.8 Plt Ct-377 [**2132-4-28**] 01:11PM BLOOD WBC-9.3# RBC-4.98 Hgb-11.5* Hct-36.2 MCV-73* MCH-23.1* MCHC-31.7 RDW-15.2 Plt Ct-387 [**2132-4-27**] 06:30PM BLOOD WBC-5.4 RBC-4.78 Hgb-11.0* Hct-34.7* MCV-73* MCH-23.0* MCHC-31.8 RDW-15.0 Plt Ct-401 [**2132-4-27**] 06:30PM BLOOD Neuts-60 Bands-0 Lymphs-32 Monos-6 Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-0 [**2132-4-27**] 06:30PM BLOOD Hypochr-OCCASIONAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-1+ Polychr-NORMAL [**2132-4-27**] 06:30PM BLOOD PT-11.6 PTT-22.8 INR(PT)-1.0 [**2132-4-29**] 07:05AM BLOOD Glucose-100 UreaN-17 Creat-0.7 Na-143 K-4.1 Cl-105 HCO3-30 AnGap-12 [**2132-4-28**] 01:11PM BLOOD Glucose-244* UreaN-17 Creat-0.7 Na-139 K-4.6 Cl-102 HCO3-27 AnGap-15 [**2132-4-27**] 06:30PM BLOOD Glucose-196* UreaN-20 Creat-0.8 Na-140 K-4.4 Cl-102 HCO3-28 AnGap-14 [**2132-4-29**] 07:05AM BLOOD Calcium-9.2 Mg-1.8 [**2132-4-28**] 01:11PM BLOOD Calcium-9.2 Mg-1.7 [**2132-4-27**] 06:30PM BLOOD Calcium-9.3 Phos-3.4 Mg-1.6 [**2132-4-27**] 06:30PM BLOOD C4-64* Brief Hospital Course: 60yoF with HTN on ACEi with acute onset of upper lip swelling likely due to ACEi, who was treated with steroids, Benadryl, with improvement in the swelling. ACEi was discontinued. 1. Angioedema: Pt had been on ACEi for five years before but per Allergy consult, can see this up to 10 years. Pt was admitted to MICU for airway monitoring but had no respiratory symptoms through admission and was stable. Started on scheduled Benadryl and oral Prednisone after having gotted 1 dose of IV Solumedrol. Her lip swelling improved by discharge and vitals were stable. Allergy was consulted and thought this classic for ACEi given pt's age and race, that there was no associated itching and that the swelling was not significantly improved with steroids given that the ACEi reaction is bradykinin mediated. She was discharged to complete a 1 week course of Prednisone, tapered as below under discharge medications. She was instructed to follow up with her outpt [**Hospital1 **] allergist who knows her well. ACEi was discontinued and pt was started on Metoprolol for bp control instead. She was instructed that she should discuss with her PCP and allergist whether to start [**First Name8 (NamePattern2) **] [**Last Name (un) **]. She was also discharged with a Rx for Ranitidine which was started in house, and also a Rx for Epi pens. 2. Hypertension: Stopped ACEi as above and started on Metoprolol for bp control. Instructed to f/u with PCP/allergist about starting [**Last Name (un) **] in the future. 3. DM: Pt on Metformin and Glyburide which were held while admitted and blood sugars controlled with insulin however these were restarted on discharge. Medications on Admission: pt. does not know doses of her meds Enalapril Metformin Glyburide Simvastatin Albuterol Discharge Medications: 1. Metformin Oral 2. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day: [**4-30**]: 6 tabs [**5-1**]: 5 tabs [**5-2**]: 4 tabs [**5-3**]: 3 tabs [**5-4**]: 3 tabs [**5-5**]: 2 tabs [**5-6**]: 1 tab THEN STOP. Disp:*24 Tablet(s)* Refills:*0* 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Glyburide Oral 5. Simvastatin Oral 6. Albuterol Sulfate Inhalation 7. Epinephrine 0.3 mg/0.3 mL Pen Injector Sig: One (1) Pen Injector Intramuscular ONCE MR1 (Once and may repeat 1 time) as needed for anaphylaxis. Disp:*1 Pen Injector(s)* Refills:*3* 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Angioedema, likely due to ACE inhibitor Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You were admitted to [**Hospital1 18**] with upper lip swelling most likely due to your ACE inhibitor, which was held on admission. You were monitored closely in our ICU and on the general [**Hospital1 **] [**Hospital1 **] and did not have any respiratory compromise or symptoms. You were given Benadryl and started on Prednisone to decrease the swelling, which you will need to continue for one week after discharge. It is important to follow up with your primary care and allergist doctors. The following changes were made to your medication regimen: 1. STOP Enalapril. This likely caused the allergic reaction. You should discuss with your doctors starting a [**Name5 (PTitle) **] called [**First Name8 (NamePattern2) **] [**Last Name (un) **]. 2. START Prednisone and taper over the next week: 60 mg on the day after discharge, then 50 mg the day after, 40 mg the day after, 30 mg TWICE on the two days after, then 20 mg, then 10 mg, then stop. 3. START Metoprolol 25 mg twice daily. This [**Last Name (un) **] is to help control your blood pressure now that Enalapril has been held 4. START Ranitidine daily. This is an antihistamine 5. You are being given a prescription for Epi pens, to take as needed if you think you are having a severe allergic reaction. Please continue the rest of your medicines as you were before admission. The list below does not state the dosages because you did not know them, but you should continue taking your medicines as you were before admission as your doctor [**First Name (Titles) **] [**Last Name (Titles) 2875**] (EXCEPT for the changes made above). Followup Instructions: Please call your primary care doctor SRIDHAR,SHANTHY at [**Telephone/Fax (1) 3530**] to schedule a follow up appointment in the next [**2-9**] weeks. Also, importantly, please follow up with your allergist Dr. [**Last Name (STitle) 101724**] at [**Hospital1 **] as we discussed to discuss whether you could start an [**Hospital1 **] called [**First Name8 (NamePattern2) **] [**Last Name (un) **] (Angiotensin receptor blocker). Completed by:[**2132-4-29**]

[ "272.4", "250.02", "E941.2", "493.90", "995.1", "716.90", "401.9", "V45.89" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8086, 8092

5543, 7201

376, 382

8175, 8175

4403, 5520

9943, 10402

3613, 3685

7340, 8063

8113, 8154

7227, 7317

8322, 9920

3700, 4384

2764, 3212

324, 338

410, 1297

8190, 8298

3234, 3446

3462, 3597

77,484

190,904

719

Discharge summary

report

Admission Date: [**2164-6-24**] Discharge Date: [**2164-7-20**] Date of Birth: [**2086-4-12**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3223**] Chief Complaint: persistent anemia, bloody ostomy output, leukocytosis Major Surgical or Invasive Procedure: [**2164-6-28**]: PEG placement [**2164-7-1**]: Decompression of septic left pelvic hematoma, irrigation and debridement via arthrotomy down to the acetabular space, cultures and placement of vacuum sponge. [**2164-7-1**]: Re-exploration of left thigh bleeding. [**2164-7-5**]: Serial irrigation and debridements of left hip; removal of remaining acetabulum hardware (cemented cup, cage, four screws) with closure over deep packing. [**2164-7-7**]: Serial irrigation debridement of left hip. Removal Kerlix sponges. Closure left hip wound. History of Present Illness: HPI: 78yo F well-known to East Surgery service from prolonged hospitalization [**Date range (1) 5324**]/10. She had initially presented with a colonic perforation due to erosion from a L hip prosthesis, and underwent a Hartmann's procedure (sigmoid colectomy with end colostomy). She then required an emergent R-->L Fem-Fem bypass for acute LLE ischemia. The hip was treated with sequential washouts and hardware removal. Her post-operative course was extensive, but notable for GI bleeding presenting as falling anemia, for which an EGD showed mild esophagitis managed with [**Hospital1 **] protonix. A colonoscopy through the stoma was unsuccessful because the stoma had sloughed and retracted below the skin level. She also developed CHF and hypothyroidism managed with diuretics and synthroid, respectively. Wound issues included minor wound infection at the midline incision managed with wet-to-dry, a VAC at the L hip changed serially in the OR and later at the bedside, and mild breakdown at the Fem-Fem bypass site treated with betadine swabs. She was finally discharged on [**2164-6-12**] on a prolonged course of Zosyn, Daptomycin, and Fluconazole via a PICC. Since discharge she has required 4u PRBC transfusion for anemia and guaiac positive ostomy output: 2u on [**6-18**] and 2u on [**6-23**] (Hct was 23). She denies headache, dizziness, CP, or SOB. She denies abdominal pains, nausea, although did have one episode of non-bloody non-bilious emesis this morning and one earlier episode 4d ago. Per the rehab notes, the heparin SQ was discontinued in favor of coumadin, which the pt's daughters relate was done because she was "bleeding" at the injection site. Past Medical History: PMHx: HTN, anxiety, psoriasis, osteoporosis, anemia, goiter, cataracts PSHx: h/o lymphoma in spleen s/p splenectomy [**2160**] (no f/u oncology notes are seen in OMR), s/p TAH-BSO for cervical cancer in [**2147**], L THR x 3 Social History: born in [**Country 2559**], denies ETOH use, does not smoke, lives with husband Family History: non-contributory Physical Exam: 97.8 82 110/50 14 100% on RA A&Ox3, NAD CTAB except dim BS BL bases RRR soft, NT, ND. well-healed midline incision with open wound at inferior pole with clean granulation tissue. LLQ ostomy productive of dark-green liquid stool which is guaiac positive, but stoma sits below the skin level. LLE edema 3+, RLE 1+ edema. WWP, DP/PT 2+ BL. Pertinent Results: Labs on admission [**2164-6-24**] 06:45PM BLOOD WBC-19.7* RBC-3.70* Hgb-10.9* Hct-33.3* MCV-90 MCH-29.5 MCHC-32.7 RDW-23.5* Plt Ct-549* [**2164-6-24**] 06:45PM BLOOD Neuts-71* Bands-3 Lymphs-14* Monos-5 Eos-5* Baso-1 Atyps-0 Metas-0 Myelos-1* NRBC-13* [**2164-6-24**] 06:45PM BLOOD PT-42.8* PTT-39.5* INR(PT)-4.5* [**2164-6-24**] 06:45PM BLOOD ESR-38* [**2164-6-24**] 06:45PM BLOOD Glucose-102* UreaN-33* Creat-1.1 Na-140 K-3.3 Cl-104 HCO3-19* AnGap-20 [**2164-6-24**] 06:45PM BLOOD ALT-33 AST-58* AlkPhos-210* TotBili-0.9 [**2164-6-27**] 09:00PM BLOOD cTropnT-0.16* [**2164-6-24**] 06:45PM BLOOD Albumin-2.0* [**2164-6-24**] 06:45PM BLOOD CRP-181.9* [**2164-6-25**] 05:30AM BLOOD Calcium-7.2* Phos-4.0 Mg-1.8 CBC: WBC RBC HGB HCT PLT N% %L %M %E %B [**2164-7-5**] 03:57 12.6* 4.01* 11.7* 36.1 287 [**2164-7-12**] 05:03 15.4* 3.20* 9.8* 28.8* 447 [**2164-7-19**] 07:11 28.6*2 3.03* 9.0* 27.7* 775 54.1 35.0 7.5 2.9 0.5 [**2164-7-20**] 05:10 23.9*1 3.45* 10.3* 32.3* 576* Cardiac biomarkers [**2164-6-28**] 05:20AM BLOOD CK-MB-3.0 cTropnT-0.14* [**2164-6-30**] 01:59AM BLOOD cTropnT-0.13* [**2164-7-2**] 03:01AM BLOOD CK-MB-3 cTropnT-0.08* BLOOD CX: [**2164-7-6**]: ESBL-Klepsiella IMAGING: [**2164-6-24**] hip plain film on admission showed status post left hip arthroplasty and Girdlestone procedure. Methyl methacrylate remains in the defect produced by the removal of the left femoral stem. Multiple clips and left pelvic embolization coils are unchanged in appearance. [**2164-6-24**] CT pelvis on admission showed new high-density material envelops the femur and there are locules of gas in the left gluteal area where there is an open wound. Locules of gas are also seen within the femur. High-density material is also seen overlying the left iliac intraabdominally. Right lower lobe consolidation/atelectasis raises the possibility of infection. Interval fem-fem bypass. New pelvicaliceal prominence bilaterally. Persistent cholelithiasis. [**2164-6-27**] CT guided hip aspiration: heterogeneous collection in the lateral subcutaneous tissues over the left hip. The portion of the collection just anterior/superior to the skin staples at the lateral aspect of the hip was targeted for aspiration with only a few cc of dark blood could be aspirated. [**2164-6-30**] CT Chest and abdomen after patient developed hypoxia showed no acute pulmonary embolus. Small right pleural effusion with associated compressive atelectasis. Scattered ground-glass opacity in the bilateral lungs. No acute intra-abdominal abnormality.Large heterogeneous left thyroid lesion. There was also question of tracheobronchomalacia although formal diagnosis would require dedicated CT chest with tracheal protocol. [**2164-7-1**] Lower extremity ultrasound to evaluate for leg edema and to rule out DVT was markedly limited duplex examination of the left lower extremity secondary to patient body habitus difficulty with patient positioning. Apparent compressibility of the common femoral vein, proximal superficial femoral vein and popliteal vein without convincing color Doppler flow identified. While this may be secondary to slow flow, a deep venous thrombosis cannot be excluded. Repeat exam demonstrated flow in all of the deep veins. [**2164-7-2**] TT Echo showed moderate regional left ventricular systolic dysfunction, c/w LAD disease. Mild aortic regurgitation. Mild to moderate mitral regurgitation. Mild pulmonary hypertension. [**2164-7-2**] CTA pelvis after patient became acute anemic to evaluate for bleed: show Fem-fem bypass graft patent, with a pseudoaneurysm of the left external iliac, but similar to prior study. There was chronic thrombosis of the portions of the left external iliac artery which are stable. No evidence of new acute hemorrhage or active extravasation. Stable appearance of left hip with destruction of left proximal femur with gas seen within the medullary cavity of the proximal femur. The residual hip prosthesis is similar in appearance to prior study, with an approximately 8.7 cm x 4.8 cm x 20 cm focus of air and debris within the left gluteal soft tissues. Thickening of the left iliacus relative to the right. Severe stenosis of the SMA. Small bilateral pleural effusions associated with basal atelectasis. Cholelithiasis, with gallbladder mildly distended though without evidence of wall thickening or pericholecystic fluid. [**2164-7-17**]: CT of pelvic and L thigh after patient's WBC continued to trend upward for show left pelvic gluteal collection now contains predominantly air with air extending medial to the left iliac [**Doctor First Name 362**]. Persistent osseous destruction of the left femur with multiple pockets of fluid and inflammatory reaction involving the left pelvis and left femur are once again noted. An area of mixed density over the left femur and medial to iliac bone may represent soft tissue/ versus collection of thick viscus fluid such as pus. Thickening and inflammatory changes of the left iliacus muscle and left pelvic sidewall is slightly improved since [**2164-7-2**]. [**2164-7-20**]: CXR 1 day after patient decompensated due to possible aspiration pneumonia showed a diffuse area of increased opacification in the right lung, consistent with aspiration pneumonia. A developing area in the left lower lung zone could well be the same etiology. Brief Hospital Course: GI bleed: The patient's increased bleeding from her ostomy was in the setting of supratheraputic INR of 4.5. The patient underwent colonoscopy through her ostomy which did not show evidence of bleeding but only revealed diverticulosis. She did not require any blood transfusions for her GI bleed and her Hct remained stable in the 30s. She was continued on protonix [**Hospital1 **]. On [**2164-7-19**], after patient was noted to aspirated, maroon colored bloody ostomy output was noted. She was transfused 2 units of PRBC at that time. Hip infection: The patient had a long and complicated hospital course in [**Month (only) 116**] from a colonic perforation secondary to erosion of her L hip prosthesis. She developed VRE infection of the hip and underwent multiple surgical take backs for washout and the femoral portion of the hardware was removed, but the acetabular portion retained. A wound vac was eventually placed and she was discharged on Daptomycin, Fluconazole and Zosyn for a prolonged outpatient course. Upon admission, she was noted to have a rash and her zosyn was changed to meropenem. A CT scan showed fluid around the femur which was tapped on [**6-27**] and grew 2 strains of ESBL E coli and vanc sensitive enterococcus. Ortho planned to take the patient to the operating room on [**6-30**], however this was delayed by tachypnea from pneumonia and CHF (see below). On [**7-1**] the patient went to the OR for hip washout and wound vac placement. After the procedure she developed increased bleeding from the wound and went back to the OR for exploration of the hip. No active bleeding was noted. She was transfused 5 units of RBCs with inappropriate bump in Hct. She underwent CTA of her arteries to rule out arterial leak and there was none, but there was pseudoanuerysm of the external iliac that was stable from prior study. Vascular surgery thought no intervention was needed. All anticoagulation was held. Pt went to the OR for subsequent washouts and removal of all hardware on [**6-23**], [**7-7**]. The blood cultures on [**2164-7-6**] grew ESBL klebsiella. Pt was treated with meropenem, fluconazole, daptomycin for an 8 week course. Pt transfered to the surgical floor on [**2164-7-10**]. Although patient was stable on the floor and was seen regularly by PT for future rehap, her WBC continue to elevated. Her initial left shift resolved but WBC persisted. CT scan of her pelvis showed destruction of her L femur and air pockets in L hip/thigh. Per orthopedic surgery service, she was planned to undergo CT guided drain placement along her left femur on [**2164-7-20**]. However, patient's condition decompensate quickly on [**7-19**] after she noticed to have aspirated her feed. Pneumonia: On [**6-30**] the patient was transfered to the ICU for monitoring of tachypnea and diuresis for presumptive CHF exacerbation. She promptly developed a fever to 102. A CTA was performed to rule out PE and was negative for PE, but revealed ground glass opacities consistent with pneumonia. Ciprofloxacin was added to her antibiotics for double coverage of pseudomonas, but this was stopped the following day. She was intubated to go to the OR for hip I and D. She recoved well and was extubated with eventual transfer to regular surgical floor. CHF/ : On [**6-29**] the patient became tachypneic in the setting of having received IV fluids. She also had an elevated troponin to 0.13. A BNP was elevated and it was thought that the patient was in heart failure. Cardiology was consulted for pre-op risk assessment and recommended that her volume status be optimized prior to surgery. She was diuresed with lasix 10 mg IV with good urine output and improvement of symptoms. She underwent echocardiogram which showed a hypo- to akinetic apex (mid-LAD territory) with EF 35%. It was unclear if an ACS precipitated the new heart failure as there were no signs of ischemia on ECG, yet the troponin was trending down. Cardiology was consulted. The patient was started on coreg, simvastatin, but was not started on aspirin given her bleeding risk. She should be started on an ACEi if her BP tolerates it. Pt had a few episodes of hypotension which responded to fluid boluses. Carvedilol was resumed on [**2164-7-7**]. # Poor PO intake: The patient had G tube placed [**2164-6-28**] for poor PO intake and hypoalbuminemia. . # Drug rash: Eos were found in urine. Zosyn was thought to be the culprit. So this was stopped and the patient was changed to meropenem. Her rash resolved. . # Possible aspiration, shortness of breath/tachycardia: The patient became acutely short of breath and tachycardic immediately after an episode of tube-feed colored emesis on [**2164-7-19**]. Her shortness of breath and hypoxemia did not improve after a nebulizer treatment and supplemental O2. She was subsequently transferred to the ICU the evening of this episode for close monitoring. Her dyspnea progressed and she was intubated in the ICU for respiratory failure. Her CXR on the following day showed opacity consistent with aspiration pneumonia. She became hypotensive, placed on two pressors. Patient's condition deteriorated quickly and comfort measure only was initiated by her family. She passed away at 1:45pm on [**2164-7-20**]. Medications on Admission: Medications (from d/c sumamry [**2164-6-12**]): 1. Aspirin 325 mg Qday 2. Atenolol 25 mg [**Hospital1 **] 3. Hydromorphone 2 mg Q 4 PRN 4. Fluconazole 400 mg Q 24 5. Levothyroxine 50 mcg Tablet Q day 6. Sodium Chloride Nasal TID (3 times a day) 7. Folic Acid 1 mg Q day 8. Furosemide 20 mg Q day 9. Pantoprazole 40 mg Tablet Q 24 10. Camphor-Menthol 0.5-0.5 % Lotion Sig: [**Hospital1 **] 11. Dronabinol 2.5 mg [**Hospital1 **] 12. Piperacillin-Tazobactam-Dextrs 4.5 gram/ Q 8 13. Daptomycin 500 mg Q 24 Discharge Medications: deceased Discharge Disposition: Expired Discharge Diagnosis: Left hip infected hardware Left hip hematoma ESBL Klebsiella bacteremia Failure to thrive Pneumonia Aspiration pnemonia CHF GI bleed Discharge Condition: Expired Discharge Instructions: deceased Followup Instructions: deceased [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]

[ "518.5", "996.66", "998.12", "995.92", "038.49", "V10.79", "V10.41", "486", "785.52", "599.0", "401.9", "285.1", "693.0", "244.9", "507.0", "428.31", "428.0" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.71", "99.15", "86.22", "86.28", "38.93", "43.11", "86.01", "80.05", "00.14", "80.85", "45.13", "45.22", "86.09" ]

icd9pcs

[ [ [] ] ]

14651, 14660

8790, 14064

368, 909

14836, 14845

3384, 8767

14902, 15041

2989, 3007

14618, 14628

14681, 14815

14090, 14595

14869, 14879

3022, 3365

275, 330

937, 2625

2647, 2875

2891, 2973

79,450

129,042

15725

Discharge summary

report

Admission Date: [**2160-7-27**] Discharge Date: [**2160-7-28**] Date of Birth: [**2084-2-26**] Sex: M Service: MEDICINE Allergies: Morphine / Ace Inhibitors / Toprol XL / Bystolic / Zestril Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 76M history of invasive squamous cell carcinoma of the neck, radiation/chemo, complains of worsening shortness of breath and acutely worsened dysphagea today. Patient states that since this morning, he has felt a "choking" sensation around his throat and thinks that his tumor is moving inward toward his airway. He has felt short of breath, has coughed up some clear phlegm, but has denied fever, chills, excessive sputum production, or upper respiratory symptoms. He has had odynophagea for the past month since he's been receiving XRT, and this is slightly worse today as well. He was able to swallow a cup of food earlier today as well as a small amount of water, which is how much he's been able to take in orally recently. He denies fever, chills, chest pain, nausea/vomiting. . In the ED, initial vs were: 98.8 72 143/61 18 100%(RA). Patient was given Decadron 10 mg IV. A CT neck was obtained that showed mass around sternal notch is larger but not impinging on airway. Labs were significant for Hct 33 (at or higher than previous baseline), WBC 2.3, Lactate 1.4. Blood and urine cultures were sent. There was no evidence of airway compromise or hemodynamic instability during his ED stay. He is being admitted to the ICU for airway monitoring. VS on transfer were: 98.7, 82,129/73, 20, 100% 2L. . On arrival to the ICU, patient's vitals were: T98.3 HR69 BP152/60 RR19 O2sat 98% (2L). His dyspnea was improved after decadron and oxygen, although he still feels short of breath. His odynophagea remains as it was in the morning. Patient is comfortable and denies chest pain. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. 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: -Invasive squamous cell carcinoma (T3N0M0 Stage II) of upper sternum s/p 5 weeks low dose paclitaxel/carboplatin with concurrent XRT -He has a history of basal cell cancer of the right chest. - CAD- S/p 3 DES to RCA after unstable angina [**2158-1-16**]; Recath with diffuse and severe CAD and left main and LAD/LCX disease leading to CABG [**2158-1-12**] in [**State 38104**] (LIMA to LAD, RIMA to ramus, RSVG to D1, RSVG sequentially to OM3 and PDA). - systolic CHF: EF 45-50% on TTE [**3-8**] - Cardiac arrhythmias. - Hypercholesterolemia. - PVD: Bilateral carotid endarterectomies - HTN - Osteoarthritis. - DJD. - Urolithiasis. - Left total knee replacement. Social History: Retired two years ago, previously worked in real estate. Married. Lives with his wife in apartment in [**Location (un) 7073**], and on [**Hospital3 **] where he has a second home. Two children. He has a 10 pack-year tobacco smoking history, has quit, and he drinks alcohol socially; no other drug use. Family History: Sister had breast cancer Physical Exam: Physical Exam on Admission: Vitals: T:98.3 BP:152/60 P:69 R:19 O2: 98(2L) General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, no LAD, no carotid bruits. erythematous raised growth over manubrium roughly size of golfball Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: PEG site intact, dressed, +BS, soft, non-tender, non-distended, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, no edema Pertinent Results: Labs on admission: [**2160-7-26**] 09:45PM BLOOD WBC-2.3*# RBC-3.52* Hgb-11.5*# Hct-33.0* MCV-94 MCH-32.7* MCHC-35.0 RDW-15.6* Plt Ct-178 [**2160-7-26**] 09:45PM BLOOD Neuts-67.7 Lymphs-14.3* Monos-16.2* Eos-1.4 Baso-0.4 [**2160-7-26**] 09:45PM BLOOD Plt Ct-178 [**2160-7-26**] 09:45PM BLOOD Glucose-92 UreaN-26* Creat-1.1 Na-138 K-4.6 Cl-102 HCO3-26 AnGap-15 [**2160-7-26**] 09:45PM BLOOD Calcium-9.0 Phos-3.3 Mg-2.0 [**2160-7-26**] 09:56PM BLOOD Lactate-1.4 Imaging Studies: CT neck [**7-26**]: Known mass centered in the sternal notch is larger in size with increased central low density most compatbile with necrosis, though no impingement on the airway. . CXR [**7-26**]: Superior mediastinum somewhat obscured by a known partially cystic mass as better delineated on current CT examination of neck. Lungs are clear, no pleural effusions, or PTX. Cardiac mediastinal contours are unremarkable. No acute cardiopulmonary process. . Microbiology: blood cultures ([**7-26**], [**7-27**]): pending upon discharge . Discharge Labs: [**2160-7-28**] 06:00AM BLOOD WBC-2.5*# RBC-3.09* Hgb-9.9* Hct-28.2* MCV-91 MCH-31.9 MCHC-35.0 RDW-15.2 Plt Ct-130* [**2160-7-28**] 06:00AM BLOOD Glucose-143* UreaN-27* Creat-1.0 Na-137 K-4.7 Cl-103 HCO3-24 AnGap-15 [**2160-7-28**] 06:00AM BLOOD Calcium-8.4 Phos-3.6 Mg-2.3 Brief Hospital Course: Primary Reason for Hospitalization: 76M with invasive squamous cell carcinoma in area of manubrium, presents with shortness of breath, concerning for impingment of tumor on trachea, admitted to ICU for airway management. Active Diagnoses: # Respiratory Distress: On admission, the patient endorses a subjective sense of SOB, but O2 sat is 100% RA and respiratory rate is normal. He has hx of invasive SCC overlying manubrium, but by CT tumor is not impinging on trachea. He was given dexamethasone 10mg IV x3 over 24 hours to reduce swelling. ENT was consulted and performed laryngoscopy. This revealed minimal supraglottic edema and erythema that could likely represent early post-radiation changes versus reflux. There was also minimal paradoxical motion of his vocal cords that may contribute to dyspnea. His airway was otherwise open. Per their recommendation, he was given an increased dose of his home PPI to reduce any reflux that might exacerbate his breathing. He was given a total of 3 doses of Decadron 10mg to prevent airway swelling. During his stay he continued to have good oxygen saturation. On the third day of admission, given his improvement and stability, he was discharged home after receiving previously scheduled radiation therapy. # Dysphagia/Odynophagia: Likely esophagitis/mucositis related to radiation therapy effect, as the timing coincides and this is a known side effect. Patient endorses pain upon swallowing and frequently becomes dehydrated secondary to poor PO intake from odynophagia. He comes in frequently for IV hydration, but has been trying to transition to PEG tube and oral hydration. On admission, he BUN was slightly elevated which may be sign of hypovolemia. He was given IV fluid and encouraged to take in fluids PO as much as possible. He was given several liquid pain relief agents. # Esophagitis: Patient has no recollection of being on Protonix, but recent EGD for placement of PEG noted moderate to severe esophagitis and recommended [**Hospital1 **] PPI. This was continued during his stay per ENT recs as mentioned above. Chronic Diagnoses: # Anemia. Patient's Hct at presentation was 33, above his baseline (~30), which is low likely [**1-2**] chemo. He received 1 unit pRBCs on [**7-24**] for sxs of fatigue with bump from 26.8 to 33.0. His hct trended down to 28 by discharge, but this was not felt to be significant enough of a decrease to treat. # Leukopenia. WBC 2.3, ANC 1541 on presentation, so patient was not neutropenic. He likely has chemo-induced leukopenia. He was monitored for fever and signs of infection. # CAD. Status post DES to RCA after unstable angina [**2158-1-16**] (3 Xience DES placed to RCA). Recath with diffuse and severe CAD and left main and LAD/LCX disease leading to CABG [**2158-1-12**] in [**State 38104**] (LIMA to LAD, RIMA to ramus, RSVG to D1, RSVG sequentially to OM3 and PDA). His home statin, ASA, Plavix and [**Last Name (un) **] were continued. He reported no chest pain. # HTN. The patient was hypertensive on admission (152/60). He was continued on his home antihypertensive regimen with good effect. # Invasive Squamous Cell Carcinoma. s/p 5 doses of low dose paclitaxel/carboplatin with concurrent XRT, with one more round of XRT to end [**2160-7-29**]. He was initially planned to receive a final round of chemo on [**7-25**] but chose not to continue. He received his final found of radiation therapy while in house on [**7-28**]. He will follow up with Medical Oncology and Radiation Oncology. # BPH: The patient's home tamsulosin was continued with good effect. Transitional Issues: # Communication: Patient, [**Telephone/Fax (1) 45300**] Medications on Admission: CARVEDILOL - 3.125 mg Tablet - 1 Tablet(s) by mouth twice daily CLOPIDOGREL [PLAVIX] - 75 mg daily EPLERENONE - 25 mg daily ISOSORBIDE MONONITRATE ER - 30 mg daily LIDOCAINE-DIPHENHYD-[**Doctor Last Name **]-MAG-[**Doctor Last Name **] [FIRST-MOUTHWASH BLM] - 400 mg-400 mg-40 mg-25 mg-200 mg/30 mL Mouthwash - PRN LORAZEPAM - 0.5 mg Tablet - [**12-2**] Tablet(s) q6h nausea/insomnia METOCLOPRAMIDE - 10 mg qid prn NITROGLYCERIN - 0.4 mg prn ONDANSETRON - 8 mg prn nausea/vomiting OXYCODONE-ACETAMINOPHEN [ROXICET] - 5 mg-325 mg/5 mL Solution q6h prn pain PANTOPRAZOLE - (Patient does not recall being prescribed this medication) 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **] SIMVASTATIN - 80 mg daily TAMSULOSIN [FLOMAX] - 0.4 mg daily hs ASPIRIN - 325 mg daily Discharge Medications: 1. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. eplerenone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 5. oxycodone 5 mg/5 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed for throat pain. Disp:*250 ml* Refills:*0* 6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 8. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. lidocaine-diphenhyd-[**Doctor Last Name **]-mag-[**Doctor Last Name **] 200-25-400-40 mg/30 mL Mouthwash Sig: One (1) Mucous membrane four times a day as needed for pain. 10. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for nausea. 11. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO four times a day. Discharge Disposition: Home Discharge Diagnosis: post-radiation esophagitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname **], It was a pleasure taking care of you here at [**Hospital1 18**]. You were admitted because you had shortness of breath. CT scan of your neck showed that the cancer is ot impinging on your airway. ENT doctors examined [**Name5 (PTitle) **] as well and determined that your symptoms are likely due to some mild swelling from the radiation therapy. Your pain was well controlled with Maalox cocktail and liquid Oxycodone. You were then discharged home. No changes were made to your medications. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2160-7-29**] at 12:00 PM With: PADDY [**Name8 (MD) **], RN [**Telephone/Fax (1) 22**] Building: [**Hospital6 29**] [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2160-7-30**] at 1 PM With: PADDY [**Name8 (MD) **], RN [**Telephone/Fax (1) 22**] Building: [**Hospital6 29**] [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [**2160-8-1**] at 12:00 PM With: PADDY [**Name8 (MD) **], RN [**Telephone/Fax (1) 22**] Building: [**Hospital6 29**] [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "600.00", "530.19", "715.90", "272.0", "276.52", "V45.81", "195.0", "V45.82", "288.50", "428.0", "E879.2", "401.9", "285.22", "909.2", "428.22", "414.00", "787.20", "V43.65" ]

icd9cm

[ [ [] ] ]

[ "31.42", "92.29" ]

icd9pcs

[ [ [] ] ]

10967, 10973

5358, 5580

346, 352

11044, 11044

4028, 4033

11749, 12645

3413, 3440

9869, 10944

10994, 11023

9071, 9846

11195, 11726

5060, 5335

3455, 3469

8987, 9045

1991, 2391

287, 308

380, 1972

4047, 4489

11059, 11171

5598, 8966

2413, 3077

3093, 3397

4506, 5044

76,654

172,043

1621

Discharge summary

report

Admission Date: [**2163-1-2**] Discharge Date: [**2163-1-18**] Date of Birth: [**2111-11-5**] Sex: F Service: NEUROSURGERY Allergies: Sulfa (Sulfonamides) / Tape / Ativan / Aloe Attending:[**First Name3 (LF) 3227**] Chief Complaint: Severe Headache Major Surgical or Invasive Procedure: [**2163-1-2**]: Right Crani for Frontal Hemorrhagic mass [**2163-1-6**]: OR placement of EVD drain History of Present Illness: 51F with h/o melanoma and recent LEEP awoke this morning with severe headache and slurred speech. EMS to OSH with progressive neurologic decline requiring intubation. Ct showed large right frontoparietal hemorrhage with extension into right lateral ventricle with casting into 3rd and 4th. Also several lesions present. Past Medical History: melanoma with excision of lesion on back [**9-/2160**] followed by Dr [**Last Name (STitle) 1729**]; Grave's disease Social History: lives with parents, smoker Family History: non-contributory Physical Exam: Upon Admission: PHYSICAL EXAM: O: T: 98.8 BP: 123/60 HR:97 R 16 O2Sats100% Gen: WD/WN, comfortable, NAD. HEENT: proptosis Pupils:2.5mm R 3 mm L EOMs nystagmus Neck: Supple. Extrem: Warm and well-perfused. Neuro:intubated examined in ED, opens eyes to voice and follws commands on right. attempts to lift L LE to noxious, minimal movement to noxious L UE Toes upgoing right, mute left Upon Discharge: AOx3. Afebrile for 24+ hours. MAE [**6-15**]. Difficulty with upper gaze but improved. head incision is C/D/I Pertinent Results: CT Head [**2163-1-2**]: IMPRESSION: 1. Large right frontoparietal hemorrhage, with vasogenic edema, extending into the ventricles. Subfalcine herniation. 2. Multiple foci of hyperdensity with round shape in the brain, concerning for possible underlying secondary deposits. Please correlate with history of primary cancer if available. MRI is recommended for further evaluation of the underlying disease. CT Head [**2163-1-2**]: Status post right craniectomy for intraparenchymal right frontal hemorrhage. No new foci of intraparenchymal hemorrhage. Expected postoperative changes with pneumocephalus and high-attenuation material, likely blood at the operative site. Decreased leftward shift to 2 mm. MRI Brain [**2163-1-3**]: Post-op changes seen. CT Torso [**2163-1-3**]: CT OF THE CHEST WITH CONTRAST: [**Hospital1 **]-apical paraseptal emphysema and scarring is present. Multiple nodules are noted within the lung parenchyma, including 1-2 mm lesion within the right upper lobe (3:15), suspicious probable metastatic lesion within the right lower lobe measuring 6.5 x 7 mm (3:29) and 2.5-mm lesion within the left lower lobe (3:39). Dependent linear and nodular atelectasis is noted. There is no pleural or pericardial effusion. Heart and great vessels appear unremarkable. No pathologically enlarged central or axillary lymph nodes are present. Endotracheal tube and nasogastric tube are in situ and appropriately located. CT OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST AND WITH ORAL CONTRAST: The liver, gallbladder, spleen, stomach, small bowel, pancreas, kidneys, and right adrenal gland are unremarkable. A 12 x 13 mm left adrenal lesion is noted which displays Hounsfield attenuation values of [**8-20**] on the un-enhanced images, suggestive of an adenoma. No pathologically enlarged retroperitoneal or mesenteric lymph nodes are present. Atherosclerotic disease is present within the intra-abdominal aorta. CT OF THE PELVIS WITH INTRAVENOUS AND ORAL CONTRAST: There are findings of left-sided pelvic congestion with reflux of contrast and dilatation of the left gonadal vein extending into the periuterine plexus. The uterus and adnexa appear otherwise unremarkable. Air is present within a Foley containing urinary bladder. Intrapelvic bowel appears normal, no pathologically enlarged sidewall or inguinal lymph nodes are present. A suspicious enhancing soft tissue focus is noted within the left gluteal subcutaneous fat immediately abutting the adjacent gluteal musculature measuring 8 x 15 mm (3:80). No additional intramuscular or soft tissue foci are identified. BONE WINDOWS: No malignant-appearing osseous lesions are noted. Mild degenerative changes are present within the spine with probable rudimentary ribs noted to project off L1. IMPRESSION: 1. Probable metastatic disease within the right lower lobe and left gluteal subcutaneous tissues as detailed above. Additional smaller pulmonary nodules are noted, also suspicious for metastatic foci. 2. Enhancing left adrenal nodule meets criteria for a benign adenoma by Hounsfield values on the unenhanced examination. This can be followed on subsequent examinations. 3. Incompetent/refluxing dilated left gonodal vein. This is often seen in the setting of pelvic congestion syndrome but needs correlation with exam/patient symptoms. If treatment is desired, consultation with interventional radiology is recommended. CT Head [**2163-1-6**]: IMPRESSION: New worsening of shift of normally midline structures towards the left, now measuring approximately 4 mm. In addition, mild effacement of the suprasellar cistern and dilation of the temporal horns concerning for hydrocephalus. CT Head [**2163-1-6**]: IMPRESSION: 1. Significant interval improvement in degree of subfalcine herniation with normally midline structures now shifted only [**2-12**] mm to the left. 2. Ventriculostomy catheter from the left burr hole frontal approach terminates just right of midline, but it has decompressed the ventricular system, but no evidence of continued hydrocephalus. 3. Interval slight increase in degree of postoperative blood in right frontal lobe; otherwise, other sites of hemorrhage are stable. Brief Hospital Course: 51 yo female admitted to [**Hospital1 18**] after onset of a severe headache and slurred speech. EMS to OSH with progressive neurologic decline requiring intubation. Ct showed large right frontoparietal hemorrhage with extension into right lateral ventricle with casting into 3rd and 4th. Also several lesions present on CT head. She was taken to the OR by Dr. [**First Name (STitle) **] for right sided craniotomy for evacuation of the bleed. Pathology was able to review the blood clot for pathology and identified melanoma cells. She was transferred to the ICU unit post-surgery and remain intubated. On [**1-3**] post-operative MRI was done which revealed 4 other lesions in the brain. She was extubated on [**1-3**] and transferred to the floor that evening. On [**1-4**] rehab screening was started. Neuro-Oncology was consulted. On [**1-6**] in the early am, Ms. [**Known lastname 1806**] was found to be more lethargic. A CT of thead was obtained and there was observed to be devloplment of hydrocephalus. She was then transferred to the ICU and a EVD was placed. Subsequent to this, her mental status improved. She was maintained in the ICU on q4h** neurochecks, with an EVD level of 10cm until [**1-8**]. On [**1-8**], the EVD was raised to 15cm. On [**1-9**], the EVD was raised to 20cm. On [**1-10**] she was transferred to the Step Down and EVD remained open at 20cm. She was unable to tolerate weaning and was readied for OR for VP shunt placement which was performed on [**1-14**]. On [**1-15**] she was febrile to 103.0, fever work-up was begun. [**1-16**] temp spiked to 101.5 with a productive cough, placed on droplet precautions. PT cleared pt to go home with services and family support. [**1-17**] Flu swab was negative, afebrile, droplet precautions discontinued. On [**1-18**] she remained afebrile and neurologically stable and was discharged home with services. Pathology findings were finalized on [**1-10**] and confirmed metastic melanoma as the histology. Medications on Admission: MVI Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 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. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 days. Disp:*2 Tablet(s)* Refills:*0* 9. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day): Follow Taper as directed. Disp:*90 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Right frontoparietal hemorrhagic mass: metastatic melanoma Hydrocephalus Discharge Condition: Neurologically Stable Discharge Instructions: General Instructions/Information ??????Have a friend/family member check your incision daily for signs of infection. ??????Take your pain medicine as prescribed. ??????Exercise should be limited to walking; no lifting, straining, or excessive bending. ??????Your wound closure uses dissolvable sutures, you must keep that area dry for 7 days. There is one suture where your drain was located- that one will need to be removed (the suture is black) ??????You may shower before this time using a shower cap to cover your head. ??????Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ??????Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ??????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**]. ??????You are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ??????Clearance to drive and return to work will be addressed at your post-operative office visit. ??????Make sure to continue to use your incentive spirometer while at home. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ??????New onset of tremors or seizures. ??????Any confusion or change in mental status. ??????Any numbness, tingling, weakness in your extremities. ??????Pain or headache that is continually increasing, or not relieved by pain medication. ??????Any signs of infection at the wound site: increasing redness, increased swelling, increased tenderness, or drainage. ??????Fever greater than or equal to 101?????? F. ** Please begin to taper down your Dilantin: [**Date range (1) 9395**] Dilantin 200mg 2x/day [**Date range (1) 9396**] Dilantin 200mg every morning, 100mg at bedtime [**Date range (1) 9397**] Dilantin 200mg every morning [**Date range (1) 5300**] Dilantin 100mg every morning [**1-29**] Discontinue Followup Instructions: Follow-Up Appointment Instructions You will need to have the one suture removed on Friday [**1-21**]. This can be done with us or with your PCP. [**Name10 (NameIs) 357**] call [**Location (un) 3230**] for an appointment. [**Telephone/Fax (1) 3231**] Dr.[**Doctor Last Name 9398**] office will call you with a radiation appointment closer to your home. ??????You will need to follow-up in the Brain [**Hospital 341**] Clinic with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and Dr. [**Last Name (STitle) 724**]. Please call [**Telephone/Fax (1) 1844**] to make this appointment. You will not need an MRI at that time. You will need to follow-up with Dr. [**First Name (STitle) **] 3 months after surgery with an MRI with and without contrast. Please follow up with your Oncologist within one week of discharge. Please follow up with your Primary Care Physcian within two weeks of discharge. Please be sure to bring your Medication list with you. Have your PCP monitor your blood pressure and make any necessary changes to your medication. Please call Dr.[**Name (NI) 9399**] office with any questions or concerns: [**Telephone/Fax (1) 3231**] Completed by:[**2163-1-18**]

[ "E936.1", "198.89", "786.2", "242.00", "431", "780.62", "197.0", "348.5", "342.90", "198.3", "693.0", "348.4", "V10.82", "331.4" ]

icd9cm

[ [ [] ] ]

[ "01.59", "02.2", "02.34" ]

icd9pcs

[ [ [] ] ]

8798, 8869

5757, 7750

323, 424

8986, 9010

1549, 5734

11447, 12653

975, 993

7804, 8775

8890, 8965

7776, 7781

9034, 11424

1039, 1403

268, 285

1419, 1530

452, 775

1024, 1024

797, 915

931, 959

64,980

134,699

37365

Discharge summary

report

Admission Date: [**2107-12-22**] Discharge Date: [**2108-1-1**] Service: CARDIOTHORACIC Allergies: Codeine Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2107-12-26**] - Off-Pump CABGx3 (Left internal mammary artery->Left anterior desecending arerty, Saphenous vein graft (SVG)->Ramus, SVG->Posterior left ventricular artery). History of Present Illness: This 89 year old white male who had a week of productive sputum, weakness and malaise and presented to the [**Hospital3 10494**] ED and was found to have elevated troponins and ST depressions on the lateral leads of his EKG. He had CHF on CXR and was admitted to the telemetry floor and was given 300 mg of Plavix and was also given IV Lasix and Lopressor. He underwent cardiac catheterization today which revealed 99%LM and 99%RCA lesions and he was transferred to [**Hospital1 18**] for further management. Past Medical History: Past Medical History: HTN COPD dyslipidemia colon ca- s/p surgery and radiation prostate ca unsteady gait Past Surgical History: s/p colostomy and reversal Social History: Race: Caucasian Last Dental Exam: 2 years ago Lives with: wife Occupation: retired insurance appraiser Tobacco: 40 pk year, 2 pppd x 20 years, quit 30 years ago ETOH: rare Family History: unremarkable Physical Exam: Pulse:70 Resp.: 19 sat: 95% on RA B/P Right: 106/56 Left: Height: Weight: General: Skin: Dry [x]intact [x] HEENT: PERRLA [x]EOMI [x] Neck: Supple [x]Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x]non-distended [x]non-tender [x] bowel sounds + [x] Extremities: Warm [x] well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+Left: 2+ Radial Right: 2+Left: 2+ Carotid Bruit Right: no Left: no Pertinent Results: [**2107-12-22**] - Chest CT 1. Diffuse vascular calcifications of the thoracic aorta, most marked in the arch and descending region, but also involving the ascending aorta. These images are available for review for preoperative planning. 2. Small left and trace right pleural effusions. 3. Multifocal bronchial wall thickening, small airways disease and patchy dependent consolidation, likely due to multifocal infection. Distribution and appearance favors aspiration pneumonia, but a mycoplasma or other atypical infection is also within the differential diagnosis. If infectious symptoms are absent, followup CT may be considered in two to three months to exclude a more chronic cause for these findings. 4. Emphysema with both centrilobular and panlobular features. The panlobular basilar component suggest the possibility of alpha-1-antitrypsin deficiency. 5. Diffuse coronary artery calcifications. [**2107-12-26**] ECHO The left atrium is elongated. No mass/thrombus is seen in the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. Overall left ventricular systolic function is mildly depressed (LVEF= 50 %). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] with borderline normal free wall function. The aortic root is mildly dilated at the sinus level. There are complex (>4mm) atheroma in the ascending aorta. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. There is partial mitral leaflet flail of the anterior leaflet and posterior leaflet restriction. An eccentric, inferiorly directed jet of Moderate (2+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). There is no pericardial effusion. Post-CABG: All findings similar to pre-CABG findings. Biventricular systolic function is preserved. All findings communicated to the surgeon. Brief Hospital Course: Mr. [**Known lastname 75612**] was admitted to the [**Hospital1 18**] on [**2107-12-22**] via transfer from [**Hospital6 3872**] for surgical management of his severe coronary artery disease. His plavix was stopped and heparin was started. He was worked-up in the usual preoperative manner. As his cardiac catheterization showed a severely calcified aorta, a CT scan was performed. This confirmed a very heavily calcified aorta including the ascending aorta. Given the severity of his calcified aorta, it was elected to perform the surgery off-pump. On [**2107-12-26**], Mr. [**Known lastname 75612**] was taken to the operating room where he underwent off-pump coronary artery bypass grafting to three vessels. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. Over the next several hours, he awoke neurologically intact and was extubated. Beta blockade, aspiriin and a statin were resumed. His chest tubes and temporary pacing wires were removed per protocol. He was evaluated and treated by physical therapy and rehab was recommended. He was discharged to rehab on POD# 6. Medications on Admission: Simvistatin 20 mg PO daily Amlodipine 5 mg PO daily Spiriva 18 mcg 1 PO daily Levoxyl 137 mcg PO daily Doxazosin 2 mg PO daily ASA 81 mg PO daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/ fever. 5. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours). 7. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: [**1-7**] Caps Inhalation DAILY (Daily). 11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 12. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a day: hold HR<60, SBP<100. 14. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 7 days: while on lasix. 15. Furosemide 10 mg/mL Solution Sig: One (1) Injection once a day for 7 days: or until edema resloved. Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Rehab & Nursing Center - [**Location (un) 47**] Discharge Diagnosis: CAD s/p off-pump CABGx3 HTN COPD dyslipidemia colon ca- s/p surgery and radiation prostate ca unsteady gait Colsotomy and reversal Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with percocet prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Please call to schedule appointments Surgeon Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] Primary Care Dr. [**First Name (STitle) **]. in [**1-7**] weeks Cardiologist Dr. [**Last Name (STitle) 14334**] in [**1-7**] weeks Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse will schedule [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2108-1-4**]

[ "424.0", "440.0", "V10.46", "V10.05", "433.10", "401.9", "428.0", "414.01", "492.8", "486", "410.71", "428.20" ]

icd9cm

[ [ [] ] ]

[ "36.12", "38.93", "36.15" ]

icd9pcs

[ [ [] ] ]

7150, 7290

4293, 5433

231, 409

7465, 7561

2090, 4270

8102, 8584

1445, 1460

5630, 7127

7311, 7444

5459, 5607

7585, 8079

1210, 1239

1475, 2071

181, 193

437, 949

993, 1187

1255, 1429

8,364

134,294

15281

Discharge summary

report

Admission Date: [**2104-12-15**] Discharge Date: [**2104-12-22**] Date of Birth: [**2058-5-21**] Sex: M Service: SURGERY Allergies: Duricef / Gentamicin / Aminoglycosides Attending:[**First Name3 (LF) 3127**] Chief Complaint: SOB, abdominal pain Major Surgical or Invasive Procedure: Right colectomy History of Present Illness: Pt is a 46 y/o M with hx of ESRD on hemodialysis, DM, Htn, CAD and recent diagnosis of SVT who presents with SOB. Pt normally has HD on MWF. This am, he missed his HD because he was taking care of his sister's children. Over the course of the day he gradually became more short of breath and decided to come to the ED. Pt denies any dietary indiscretion. He also tries to watch his fluid intake but reports that he has more difficulty with this. He estimates that [**5-6**] kilos of fluid are removed at each dialysis session. Pt denies CP. . Of note, pt reports that he has had "a cold" since [**Holiday 1451**]. He was treated with a course of Biaxin with some improvement, but that he has had worsening cough and fatigue again since the end of that treatment. He reports temperatures around 99, without chills. He also reports coughing up greenish-brown sputum. He reports that the rest of the family is suffering with similar symptoms. . He reports feeling extremely tired, especially since his Toprolol XL dose was increased to 200mg. He denies CP. He does complain of abdominal discomfort in the epigastric area, but says this pain is not new for him. He had a EGD and colonoscopy in the past which was normal according to the pt. He also reports diarrhea but says that he has had diarrhea off and on for "a long time". The diarrhea recently worsened, so he took Immodium with some relief. He reports that the diarrhea is liquidy but not watery and that he has been going to the bathroom up to 7-8 times per day, at its maximum, but its now improving. He does still make urine, approximately 1 L per day. . In the [**Name (NI) **], pt had CXR consistent with fluid overload. He was given Lasix 80mg IV and started on a Nitro drip to titrate BP to 110-130. He was also given calcium gluconate for his hyperkalemia. He was sent for HD where he began to feel decreasing SOB. Past Medical History: 1. CAD s/p drug eluting stent to mid-LCx in [**9-2**] for single vessel disease; Echo showed EF of 55%, bicuspid aortic valve with moderately thickened leaflets but without discrete vegetation (cannot exclude). Mild-moderate aortic regurgitation. Mild mitral regurgitation. 2. DM - 25 years, requiring insulin, complicated by retinopathy, neuropathy and nephropathy 3. ESRD on HD MWF (for 2-3 years) 4. Htn 5. Hyperlipidemia 6. Charcot foot s/p L distal 2nd MTP and proximal phalanx resection 7. chronic anemia 8. OSA - does not use his bi-pap machine because he does not like the way it feels 9. Endocarditis in [**8-2**] 10. s/p cholecystectomy [**09**]. carpal tunnel bilat 12. rotator cuff injury bilat s/p rotator cuff surgery [**11**]. L4-L5 disc herniation 14. Bilateral hearing loss secondary to gentamicin 15. hx of MRS [**Last Name (STitle) **] neg Staph 16. GERD 17. Severe AS and elevated R and L sided pressures. 18. Splenic infarct Social History: Lives at home with his fiancee, his 2 children, his mother and his brother. EtOH - occasionally Tob - none Family History: DM in mother, father, brother; heart disease in mother who has hx of CABG in early 50s, a-fib and is s/p ablation Physical Exam: Vitals - T 98.2 HR 95 BP 128/93 RR 31 SaO2 99% RA General - Obese man, sleepy, sitting up, in bed, NAD HEENT - mmm, clear op Chest - increased work of breathing, using accessory muscles, speaking in complete sentences, good air movement bilat, crackles bilaterally [**12-2**] of the way up, few expiratory wheezes bilaterally, coarse upper airway sounds CV - JVP at ear lobe, RRR, III/VI crescendo-decrescendo murmur, over RUSB, radiating into axilla Abd - large, soft, non-tender, non-distended, -HSM Extrem - 2+ pitting edema bilat, pedal pulses present bilat, no ulcers or sores on feet, L. Charcot foot Neuro - somnolent, falling asleep mid-sentence, answers questions appropriately with arousal Pertinent Results: On admission 10.1#>38.4*<130* Diff 75*N 3B 16*L 3M 1E 1B PT 13.3 INR1.2 ESR 15 134/7.3*/93*/22/87/13.2/291 Ca 7.4* Mg 1.6 Phos 8.2* ALT 29 AST 23 CK 482* Amylase 151* TBili 0.4 . Studies: AP UPRIGHT PORTABLE CHEST X-RAY: The cardiac silhouette is enlarged. There is bilateral hilar fullness in pulmonary vascular distribution and interstitial edema. Consistent with Moderate/severe volume overload. . CT ABDOMEN/PELVIS [**2104-12-18**]: Subtle pericolonic stranding in the cecum, ascending colon, thought likely to reflect an infectious etiology. As the patient has some subtle colonic thickening here, a tumor with microperforation is considered, although thought less likely. . ECHO [**2104-12-22**]: EF 25-30%, new pan-wall motion abnormalities Brief Hospital Course: # SOB: The pt's shortness of breath is most likely related to fluid overload since he developed the SOB after missing his scheduled HD. On exam, the pt appeared to be working hard to breathe, crackles were heard in both lower lung fields and the pt had an elevated JVP and lower extremity edema. The CXR was consistent with fluid overload. There were a few expiratory wheezes bilaterally, indicating a component of reactive airway disease likely exacerbated by a respiratory tract indection. The pt reported that he has had a cough productive of greenish-brown sputum since [**Holiday 1451**]. He also reports that the rest of the family is suffering with similar symptoms. After dialysis the pt was only mildly short of breath. He was also treated with albuterol and then atrovent for presumed reactive airways disease. By the morning after admission, the pt reported that his SOB had resolved. . # Afib with RVR: The pt has had several recent ER visits for paroxysmal Afib with RVR. Prior episodes were well controlled with metoprolol. On the evening of admission, the pt was noted to have a low blood pressure of 70/40 with a heart rate of 119. The pt was mentating normally throughout the episode. He did not complain of any CP, SOB, light headedness or dizziness. An EKG showed Afib with RVR, in addition to anterior ischemia. The patient's Afib did not repond to 2 IV doses of 5mg metorpolol, but it did responded to Diltiazem 2x 10mg IV. The pt's heart rate came down to the mid 80s to mid 90s. The pt's low BP responded to IV fluids and was 100-110s/60-70s after the pt received 1.5L of fluid during the episode of RVR. The pt spontaneously converted to sinus rhythm the following morning. Pt had no further episodes of Afib. His Toprol dose was reduced to 100mg QD and Diltiazem 60mg PO QID was added. Three sets of cardiac enzymes were stable and did not suggest any myocardial infarction. The pt's EKG after converting back to sinus rhythm showed no persisting evidence of infarction. LFTs and TSH were sent in case pt would need to be started on amiodarone. LFTs and TSH were normal. PFTs should be done as an outpatient before pt starts amiodarone. Pt will follow up with his cardiologist, Dr. [**Last Name (STitle) **], on Monday and to get home monitoring to determine how frequently he has episodes of Afib. . # Abdominal pain - On [**12-17**], after dialysis pt began to complain of crampy abdominal pain. He had 3 normal bowel movements and then developed non-bloody diarrhea. Overnight he vomited once, non-bloody, non-bilious. On the morning of [**12-18**] the pt spiked a temperature to 102.2. Pt's labs showed a WBC of 17.8. The pt's pain became worse over the morning. Pt was extremely tender in the right upper and lower quadrants. His abdomen was soft, but he did have some voluntary guarding. Pt was made NPO and had an upright AXR which showed no free air but was limited due to pt's body habitus. Pt was evaluated by surgery who recommended a CT abdomen which showed mild stranding around the cecum and mild wall thickening???? Pt's history is concerning for ischemic bowel in the context of atrial fibrillation with possible clot vs hemoconcentration after hemodialysis with decreased flow. The pt has a known hx of Afib, but he was not on Tele when the abdominal pain developed.Other possible causes were infectious causes, including gastroenteritis and C. difficile colitis. Pt had no known sick contacts and had a very focal abdominal exam, and a high WBC, so gastroenteritis seemed unlikely. Stool cultures and C. diff toxin were sent. The first C. diff was negative. Other possible causes included appendicitis, a right sided diverticulitis or another bowel abscess. There was no evidence of any of these processes on CT. Surgical consultation was obtained. The patient was not felt to have an acute abdomen on the evening of [**2104-12-18**] but was placed on intravenous antibiotics with a plan for serial exams. The patient developed worsening abdominal pain a fever and was taken to the operating room [**Last Name (un) **] on [**2104-12-19**] for a right colectomy. A focal area of necrosis was found in the ascending colon without gross fecal contamination. Post-operatively the patient was taken intubated to the SICU where he weaned off neosynephrine within 18 hours. Hemodialysis was performed on [**12-20**] and the patient was extubated. He persisted with tachycardia and low-grade fever over the next 2 days. Cardiology consultation was obtained and they did not feel that the patient was having myocardial ischemia/infarction. His aspirin and beta-blockers were continued perioperatively. On POD#3, the patient was noted to become tachycardic shortly after a R IJ CVL change over wire and subsequently arrested. ACLS protocol was performed but the patient expired after 40 minutes of resuscitation efforts. The patient's family was notified and they agreed to a post-mortem examination. . # Lethargy - Pt was extremely lethargic on presentation. He was falling asleep mid-sentence, but did answer questions appropriately when he was arroused. Possible causes of pt's lethargy include a component of prolonged infection, the possible contribution of medications especially B Blocker and Gabapentin, and a contribution of pt's severe and untreated OSA. Pt reported that he has tried bipap in the past and that he does not like the way it feels. Pt was councelled that his OSA is putting added strain on his heart and that he should consider giving bipap another try. The pt noted that he has felt more tired since his metoprolol dose was increased dueing his last admission. The pt's Metoprolol dose was decreased from 200mg QD to 100mg QD and Diltiazem was added for further rate contol. After the B blocker dose was decreased, the patient was much more alert. . # DM: Pt continued his outpatient regimen of 42U of 70/30 at bedtime and in the morning. He was also covered with an ISSC while he was in house. No acute issues. . # Hyperkalemia: Pt was noted to have K of 7.7 on admission. Pt was asymptomatic with this K. Pt received calcium gluconate in the ED. After dialysis pt's K has been [**3-4**] Medications on Admission: On discharge [**2104-10-3**] 1. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO daily. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY 5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H. 8. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS. 9. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY 10. Pyridoxine 100 mg Tablet Sig: One (1) Tablet PO DAILY 11. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 12. Topiramate 100 mg Tablet Sig: 1.5 Tablets PO HS 13. Testosterone 1 % (50 mg) Gel in Packet Sig: One (1) gel Transdermal qday (). 14. Meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO BID 15. Hydromorphone 2 mg Tablet Sig: 2-3 Tablets PO Q4-6H as needed. 16. Insulin NPH-Regular Human Rec 70-30 unit/mL Suspension Sig: Forty Two (42) units Subcutaneous twice a day. current (as above, plus the following meds) 17. Metoprolol XL 200 mg PO DAILY 18. Heparin 5000 UNIT SC TID 19. Albuterol [**12-1**] PUFF IH Q6H:PRN 20. Insulin sliding scale Discharge Medications: None Discharge Disposition: Home Discharge Diagnosis: Fluid overload due to missing hemodialysis session Paroxysmal atrial fibrillation Coronary artery disease s/p stenting Right colectomy for likely embolic ischemia of right colon Cardiac arrest .................... Diabetes mellitus complicated by retinopathy, neuropathy and nephropathy End-stage renal disease on hemodialysis Severe aortic stenosis Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None

[ "585.6", "428.0", "427.41", "403.91", "250.40", "557.0", "427.31", "424.1" ]

icd9cm

[ [ [] ] ]

[ "34.09", "37.0", "96.04", "45.73", "39.95" ]

icd9pcs

[ [ [] ] ]

12590, 12596

4989, 11150

320, 338

12991, 13001

4208, 4966

13054, 13062

3356, 3471

12561, 12567

12617, 12970

11176, 12538

13025, 13031

3486, 4189

261, 282

366, 2246

2268, 3216

3232, 3340

20,356

161,825

51287

Discharge summary

report

Admission Date: [**2154-12-20**] Discharge Date: [**2155-2-14**] Date of Birth: [**2096-2-29**] Sex: F Service: MEDICINE Allergies: Milk / Dilantin Attending:[**First Name3 (LF) 2160**] Chief Complaint: seizure Major Surgical or Invasive Procedure: EGD PEG placement Intubation History of Present Illness: 58 yo f w/ h/o DM1, htn, hyperlipidemia, who was found down at home by her son at approximately 3am. The patient was noted to be convulsing at that time. It is unclear how long the patient had been seizing for but was last seen 1d PTA at approximately 1pm. By report the patient had previously been well, but was feeling somewhat lethargic yesterday. Patients son reports that she has otherwise been well. Also states that he believes that she has been stretching her insulin doses since she lost her Mass Health. Reports that she developed DKA on multiple occasions in this setting. . In the ED, the patient was found to be in sustained convulsion w/ R eye deviation, broke w/ ativan 2mg x2. Noted to be febrile to 102.6 and hypertensive to 226/12. Given labetolol x1. Further assessment revealed bs to 700s and anion gap of 29. Started on an insulin drip with improvement in AG. . LP was performed, positive for leukocytosis and patient was given ceftriaxone, vancomycin, dexamethasone, and acyclovir to cover empirically for meningitis. Gram stain neg. . Upon arrival in the MICU, the patient is intubated and sedated with propofol, with EEG leads attached Past Medical History: Type 1 Diabetes Mellitus w/ h/o multiple episodes of DKA and poor compliance htn asthma hyperlipidemia fibroids cataracts adenomatous polyps Social History: She is not married. She lives in an apartment in [**Hospital1 1474**] with her son. She used to work taking care of children. Denies any tobacco or IVDA. She drinks approximately a 6 pack of beer week. Family History: aunt with type 2 diabetes. Her mom had a fatal MI at the age of 54. Her dad had ?COPD. Physical Exam: t 101.1, bp 148/91, p 106, r 20, 100% AC 400 x 20, 50% fiO2, peep 5 Intubated, sedated. Atraumatic, normocephalic, EEG leads in place. [**Last Name (un) **] but sluggish OP clear, around ETT. 6 cm JVP Regular s1,s2. No m/r/g LCA b/l +bs. soft. nt. nd. no le edema/c/c. no rashes/skin breakdown. Pertinent Results: ADMISSION LABS: [**2154-12-20**] 05:43AM BLOOD UreaN-34* Creat-2.1* Na-139 K-4.2 Cl-97 HCO3-13* AnGap-33* [**2154-12-20**] 05:43AM BLOOD PT-12.6 PTT-30.1 INR(PT)-1.1 [**2154-12-20**] 05:43AM BLOOD Plt Ct-131* [**2154-12-20**] 05:43AM BLOOD WBC-20.1*# RBC-4.54# Hgb-13.9# Hct-40.9# MCV-90 MCH-30.6 MCHC-33.9 RDW-13.8 Plt Ct-131* [**2154-12-20**] 05:43AM BLOOD Neuts-89.7* Bands-0 Lymphs-6.9* Monos-2.6 Eos-0.2 Baso-0.6 [**2154-12-20**] 05:43AM BLOOD Calcium-10.1 Phos-4.1 Mg-1.7 [**2154-12-20**] 05:43AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2154-12-20**] 03:37PM BLOOD Type-ART Temp-38.3 Rates-20/ Tidal V-400 PEEP-5 FiO2-100 O2 Flow-8.0 pO2-515* pCO2-29* pH-7.37 calTCO2-17* Base XS--6 AADO2-190 REQ O2-40 -ASSIST/CON Intubat-INTUBATED . [**12-20**] CXR: Endotracheal tube terminating in the right main bronchus 2 cm below the carina. No consolidation or effusion in the lung. . [**12-20**] head CT: HEAD CT WITHOUT CONTRAST: Comparison was made with a prior head CT dated [**2154-4-11**]. There is no acute intracranial hemorrhage. There is no mass effect. No shift of normally midline structure is noted. The appearance of the brain is unchanged since the prior study, and there are multiple hypodensities in the basal ganglia representing chronic lacunar infarct. There is mucosal thickening in ethmoid sinus and right maxillary sinus, with densely calcified cystic lesion as noted previously, now filled with secretions, not significantly changed from [**2148-2-28**]. This likely relates to chronic sinusitis. The osseous structures are otherwise unremarkable. Unchanged appearance of the brain without acute intracranial hemorrhage. Densely calcified cystic lesion in the right maxillary sinus, now opacified with mucus. . Carotid US: Bilateral less than 40% carotid stenosis . EEG [**12-22**]: ROUTINE TIME SAMPLING: Showed a very low voltage background with occasional bursts of generalized slowing and some faster frequencies, also generalized. Much of the background was very supressed and slow. There were no prominent focal features, and there were no epileptiform abnormalities. SLEEP: No normal waking or sleeping morphologies were seen. CARDIAC MONITOR: Showed a generally regular rhythm. SPIKE DETECTION PROGRAMS: Showed some artifact and occasional sharp features but no definite epileptiform abnormality. SEIZURE DETECTION PROGRAMS: There are 2 entries in these files. They showed some minimally rhythmic slowing but no epileptiform activity. PUSHBUTTON ACTIVATIONS: There were none. IMPRESSION: This telemetry captured no pushbutton activations. The background rhythm remained supressed throughout, often correlated with use of substantially sedating medications. There were still some cortical rhythms. There were no prominent focal features although encephalopathies and medication effect can obscure focal findings. There were no epileptiform features or electrographic features. . MRI Head [**12-21**]: IMPRESSION: 1. Several areas of slow diffusion could be due to small subacute infarcts in the left cerebral hemisphere. 2. Increased signal along the sulci predominantly in the parieto- occipital region indicates increased protein content of the CSF and could be related to meningitis. Clinical correlation recommended. . MRV OF THE HEAD: Head MRV demonstrates normal flow signal in the superior sagittal and transverse sinuses as well as in the deep venous system. IMPRESSION: Normal MRV of the head. . MRI/MRA Head [**12-24**]: FINDINGS: There is much more extensive restricted diffusion involving the cortex of the left cerebral hemisphere than on the study of three days previously. There is extensive involvement of the frontal and parietal cortex with some involvement of the insula as well. The abnormalities extend to involve the posterior surface of the occipital lobe, which can be occasionally supplied by the MCA. There is probably some medial occipital involvement as well suggesting PCA territory involvement. There is also involvement of the deep left frontal white matter near the caudate nucleus, as seen previously. . There are several small areas of relatively increased signal in the right cerebral hemisphere, on the diffusion-weighted images, which might be artifactual. Currently the FLAIR images show FLAIR hyperintensity in the involved cortex and white matter but no increased signal and subarachnoid hemorrhage to suggest increased protein. . As seen previously, there is an old left putaminal hemorrhage with associated hemosiderin. There is old infarct in the left corona radiata. There is no mass effect on the ventricular system or midline structures. . IMPRESSION: There is extensive primarily cortical infarct within the left MCA territory. As discussed above, there is involvement of least portions of the occipital lobe, perhaps also supplied by the MCA in this patient as opposed to representing a PCA territory infarct. There are questionable right cerebral abnormalities. . MRA OF THE HEAD. The distal left internal carotid artery is widely patent. The proximal left MCA remains normal and unchanged from [**2151-9-15**]. Currently there is more extensive visualization of distal left MCA branches than right, suggesting luxury perfusion. The left PCA originates from the basilar artery and is symmetric with the right and normal in appearance. The ACAs remain normal. There is some irregularity of the right MCA proximally and distally, which could be artifactual or perhaps related to mild atherosclerosis. This questionable finding was not present previously. The opacification of the paranasal sinuses has improved slightly compared to the prior study. . IMPRESSION: There is no evidence of intracranial left internal carotid artery or left MCA stenosis. The left MCA is unusually well seen distally, and quite asymmetric with the right MCA suggesting luxury perfusion. . TTE [**12-24**]: 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. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50%) secondary to extensive, severe apical hypokinesis with focal dyskinesis. An apical thrombus was NOT seen but CANNOT be excluded with certainty on the basis of this study. There is no ventricular septal defect. Right ventricular chamber size is normal. There is focal hypokinesis of the apical free wall of the right ventricle. The ascending aorta is mildly dilated. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are mildly thickened. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The left ventricular inflow pattern suggests impaired relaxation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . Compared with the findings of the prior study (images reviewed) of [**2151-9-8**], extensive apical akinesis is now present. . Focused study using Definity contrast [**Doctor Last Name 360**]. No masses or thrombi are seen in the left ventricle. There is no pericardial effusion. The left ventricular apex is severely hypokinetic with focal dyskinesis. No apical thrombus seen . TTE [**2155-1-3**]: 1. The left atrium is mildly dilated. The left atrium is markedly dilated. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is mild to moderately depressed. 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic valve leaflets are moderately thickened. Mild (1+) aortic regurgitation is seen. 5.The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. 6.There is moderate pulmonary artery systolic hypertension. 7. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. . Compared to the images of [**2154-12-24**], the anterior and anteroseptal wall motion abnormalities were present ( though not mentioned in the last report)). The EF was decreased previously but it is probably slightly worse now. . ct abdomen: IMPRESSION: 1. No evidence of intra-abdominal abscess or colitis. 2. Small amount of perihepatic ascites, without enhancing rim or other suspicious features. 3. Small bilateral pleural effusions with associated atelectasis, not significantly changed in appearance from prior study. No evidence of pneumonia. 4. Mild mediastinal, axillary and inguinal lymphadenopathy again noted. Clinical correlation recommended. 5. Pancreatic calcifications, consistent with chronic pancreatitis. Brief Hospital Course: ED and MICU course: In the ED LP was performed and showed CSF - Protein 84, Glucose 327, TUBE 4: 10 WBC 7 RBC, TUBE 1: 14 WBC 256 RBC poly 87 lymph 8. She was admitted to the MICU and started on Propofol gtt for seizures and Acyclovir 500 mg IV Q12H, Ceftriaxone 2 gm IV Q12H, Vancomycin HCl 1000 mg IV Q48H, and Ampicillin 2 gm IV Q6H to cover for meningitis. CSF gram stain and cultures returned negative and HSV PCR was negative, so antibiotics were d/ced. No source was found for fevers, blood and urine cultures were negative. Pt. was loaded on Dilantin IV initially, but had 15 seconds of asystole and hypotension with this, and so was loaded instead on Depakote. She was continued on this and was seizure free in the MICU. She was monitored on bedside EEG x 2 days (see results above) which showed a suppressed rhythm with no assymetries or epileptiform discharges. . MR [**Name13 (STitle) 430**] was performed on [**12-21**] and showed some question of subtle areas of slow diffusion in the left cerebral hemisphere. It was initially unclear if this was [**1-31**] changes from status or stroke, but when it was repeated on [**12-24**] the lesions had evolved (see results below) and were felt to be most c/w infarct. It was felt that this could have been her seizure focus and could have been the seminal event. Carotid US showed no stenosis and pt. has been in NSR on telemetry, but TTE showed new apical hypokinesis (no clot seen on TTE) . In terms of her DKA she was initially covered with an Insulin drip, which was transitioned to sliding scale insulin and NPH (8U [**Hospital1 **] -> titrated up to 12 U [**Hospital1 **]). Her FS were well controlled prior to transfer to the floor. She was extubated on [**12-23**] without incident and has had some upper airway secretions initially but has been stable from a respiratory standpoint recently. . Floor Course: 1. Neuro (seizure/cva): As above, the patient was noted to have a L-sided cerebral infarction on MRI. The patient was transitioned from Depakote to Trileptal given concern for possible Coumadin/Depakote reaction, and was therapeutic on 600 [**Hospital1 **]. Given that the mechanism of her stroke was felt to most likely be cardioembolic from new apical hypokinesis it was felt that she would benefit from Coumadin in the short term. She will likely need Coumadin for 2-3 months, while the risk for apical thrombus is highest, and then her Neurologist should consider stopping it given her co-morbidites with longterm Coumadin. This was initially held given concerns for anemia, for procedures (PEG placement), and later Guaiac + stools (see below), but as hct stabilized and procedures were performed she was started on Coumadin. However, during her course she developed an increased inr largely related to profound vitamin K deficiency, she was discharged on daily lovenox as described below. She remained on asa and a statin for the stroke, and trileptal for the seizures. She had no further seizures during her course. In collaboration with the hematology and neurology services, she will receive full-dose aspirin (325mg) for secondary stroke prophylaxis with regard to the LV apical akinesis. . 2. GI (gastritis): Pt. failed a speech and swallow eval x 2 and PEG was recommended. This was placed by IR on [**2154-12-31**]. After the procedure her hct dropped and she was noted to have Guiac + stools. GI was consulted and felt that this was [**1-31**] PEG placement. Hct stabilized after transfusion, and EGD showed gastritis around the PEG site but no other pathology. She should be continued on PPI [**Hospital1 **] while on anticoagulation. . 3. Endocrine (DKA/DM/Hypoglycemia): As above, the patient's DKA was treated and once resolved she was followed by [**Last Name (un) **] on the floor, and transitioned to Lantus and Humalog sliding scale. She initially did well, but during her course developed hypoglycemia. [**Last Name (un) **] consult decreased her insulin substantially, and an am cortisol level was sent to rule out adrenal insufficiency. This was normal, and the patient's hypoglycemia improved and her insulin was adjusted accordingly by [**Last Name (un) **]. She was discharged with stable blood sugars. An receiving glargine insulin and every 6 hour fingersticks and humulin insulin sliding scale. . 4. ID (fever of unknown origin): On the floor the patient spiked a low grade fever, which was felt to be [**1-31**] aspiration pneumonia given right LL infiltrate on CXR and high risk for aspiration. She was started on Levaquin on [**2154-12-31**] and changed to Ceftriaxone and Flagyl on [**1-3**] given concern for prolonged Qt on EKG on Levaquin. She continued to spike fevers and CTX was changed to Flagyl. All cultures were negative (blood, urine and stool), and her CXR was unchanged. CT Chest/Abd perfomed to r/o abcess or other source of infection and was negative. Chest CT did not show evidence of PNA. Repeat cultures were negative. ID consult was obtained. They felt that her continued fevers and increasing eosinophil count pointed to drug fever. All antibiotics were discontinued on [**1-16**]. She continued to be febrile (to 101) and cultures were repeated. All cultures remained negative, though her sputum grew MRSA. ID felt with a normal cxr and no hypoxia, treatment should be deferred. Eventally her fever resolved with the holding of abx and lasix, and her fever was attributed to drug fever as she had high peripheral eosinophilia. She spiked again during her course, and at that time cultures were resent, and a ct abdomen and pelvis was obtained (which was non-revealing). She developed diarrhea, and while her cdiff remained negative she was empirically treated with flagyl. She continued to spike and per ID Aztreonam and Vanco were added while all cultures continued to pend. As ultimately no source for an infection was found (including negative C. dif toxins A and B), all antibiotics were stopped and the patient remained afebrile until time of discharge. . 5. PULM (tachypnea): The patient has had periods of hyperventilation and apnea which are most likely central in origin, EEG obtained to r/o subclinical seizure activity and this showed encephalopathy, but no seizures. This resolved and then appeared again, an abg showed mild respiratory alkalosis. She was closely followed and her breathing gradually normalized. . 6. CV (elevated troponin/CHF): During the patient's course she developed elevated troponins on the floor. Cards was consulted and felt that the elevated troponins were likely due to demand ischemia from her illness and anemia. They recommended optimal medical management with aspirin, bb, ace, and statin. Her cardiovascular status remained stable, though later in her course she had periods of increased wob and respiratory distress which were attributed to mild chf. Her respiratory status improved with diuresis, and when she was euvolemic her diuresis was stopped. Ultimately her blood pressure was controlled with the medicines listed in the discharge medication list. . 7. Heme(anemia/coagulapathy). The patient has a baseline hct of ~ 27, and after her G-tube was placed her hct dropped. An egd showed gastritis, and with a PPI and 2 units of blood her hematocrit remained stable. Given her stroke, as above she had been receiving coumadin, and during her course developed elevated pt/ptt/inr. DIC was ruled out and coumadin and sc heparin was held. Her mixing study was negative and heme was consulted. They felt her coagulapathy was due to vitamin k deficiency. Her vitamin K was repleted, and her coags eventually normalized. However, she continued to have hematuria. After consulting neurology, it was decided to anticoagulate with 325mg aspirin daily for secondary stroke prevention. She will likely need continued tranfusion support while her hematuria persists. If it stops, the possibility of adding clopidogrel can be readdressed. . 8. Renal (ARF on CRI): The patient appears to have a baseline creatinine ~ 1.3-1.5. Post diuresis this rose slightly, but once diuresis stopped this remained at baseline for a while. Later in her course the patient developed severe diarrhea and her creatinine increased and her uop decreased. Her urine lytes revealed a pre-renal etiology and she was given fluids aggressively (while closely watching her exam and oxygen sats given her chf). Her course was further complicated by and episode of contrast induce nephropathy with resulting transient decrease in renal function. Upon discharge, her Cr had normalized and she was stabilized on her ACEi regimen to decrease progression of her proteinuria. . 9. Code Status: FULL CODE Medications on Admission: atorvastatin 20 mg QD Calcium Carbonate 500mg TID Asa 81mg QD MVI Vitamin D 400u QD Nifedipine SR 90 mg QD Famotidine 20 mg QD Metoprolol 100mg [**Hospital1 **] Fluticasone Albuterol Furosemide 20mg QD RISS Discharge Medications: 1. Oxcarbazepine 600 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 2. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 3. Albuterol Sulfate 0.083 % Solution [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as needed. 4. Atorvastatin 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 5. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as needed. 6. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID (3 times a day) as needed. 7. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Hospital1 **]: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed for pain: [**5-8**] ml po. 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 9. Hydrochlorothiazide 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 10. Epoetin Alfa 40,000 unit/mL Solution [**Last Name (STitle) **]: One (1) mL Injection once a week. 11. Loperamide 2 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO QID (4 times a day) as needed for diarrhea: maintain <2 BM per day. 12. Insulin Glargine 100 unit/mL Solution [**Last Name (STitle) **]: Eight (8) units Subcutaneous at bedtime. 13. Amlodipine 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). 14. Lisinopril 20 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). 15. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 16. Carvedilol 12.5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a day). 17. Valsartan 80 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary: 1. Diabetic Ketoacidosis. 2. Left MCA Stroke - presumed cardioembolic. 3. Status Epilipticus. 4. Aspiration Pneumonia. 5. Ischemic Cardiomyopathy. 6. Acute Renal Failure - Contrast Nephropathy. 7. Coagulopathy/Vitamin K Deficiency. 8. Nephrotic Range Proteinuria ~ 10g/day. 9. Diabetic Nephropathy. 10. Systolic heart failure. 11. Non-ST Elevation MI. 12. Fever NOS. 13. Diarrhea NOS. 14. Eosinophilia NOS. 15. Hypoproliferative Anemia - CKD/Inflammation. 16. MRSA Colonized. Secondary: 1. Diabetes Mellitus Type I. 2. Chronic Kidney Disease Stage II. 3. Hypertension. 4. Osteoporosis. 5. Asthma. 6. Coronary Artery Disease s/p Anteroapical MI. Discharge Condition: Improved with residual aphasia and R sided hemiparesis. tolerating G tube feeds at goal. Discharge Instructions: 1. You presented with seizures and DKA. You were noted to have a stroke. You had a complicated course including difficulty controlling your sugars, mild heart failure, acute on chronic renal failure, anemia, and fevers. . Make all follow-up appointments . Please return to the ER if you experience increasing weakness, fever to greater than 101F or new weakness. Followup Instructions: Primary Care: Please call Dr.[**Name (NI) 53539**] office at [**Telephone/Fax (1) 250**] to set up a follow up [**Telephone/Fax (1) 648**] for 2-4 weeks. . Neurology: Dr. [**First Name (STitle) **] [**Name (STitle) **], [**Telephone/Fax (1) 2574**], [**Hospital Ward Name 23**] 8, [**Hospital1 18**] [**Hospital Ward Name 516**], [**2155-3-25**] at 1:00. Please call prior to the [**Month/Day/Year 648**] to update your insurance information.

[ "345.3", "584.5", "493.90", "E947.9", "427.5", "438.82", "403.90", "250.11", "434.11", "285.21", "535.50", "780.6", "585.2", "428.20", "287.5", "733.00", "V58.61", "410.71", "250.41", "327.27", "438.20", "518.81", "507.0", "581.81", "599.7", "414.8", "286.7", "438.11" ]

icd9cm

[ [ [] ] ]

[ "45.13", "96.04", "99.04", "46.32", "96.6", "96.71", "03.31", "38.93" ]

icd9pcs

[ [ [] ] ]

21887, 21966

11142, 19842

285, 316

22680, 22771

2332, 2332

23184, 23632

1911, 2001

20100, 21864

21987, 22659

19868, 20077

22795, 23161

2016, 2313

238, 247

344, 1506

3272, 11119

2348, 3263

1528, 1671

1687, 1895

64,160

160,250

47147

Discharge summary

report

Admission Date: [**2172-11-11**] Discharge Date: [**2172-11-19**] Date of Birth: [**2096-3-12**] Sex: F Service: MEDICINE Allergies: Penicillins / Univasc Attending:[**First Name3 (LF) 7333**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: cardiac catheterization with drug eluting stents to left main artery and Left anterior descending artery History of Present Illness: 76 year old female with a history of CAD s/p MI [**12-29**] with stenting x 5 (likely RCA) c/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] on HD, DM, HTN, CVA [**2167**] presented this afternoon to [**Hospital1 18**] [**Location (un) 620**] with Chest Pain. The patient reports that at 5 pm, while she was at rest and lying down, she began to experience sharp, non-radiating, substernal pain. The patient also became diaphoretic. When she asked for some ginger ale, the patient noticed that she was nauseated. The patient had never experience this constellation of symptoms before. By 10pm, the pain had significantly worsened, and an ambulance was called. She was given ASA and NTG en route. On arrival at [**Location (un) 620**], her EKG demonstrated NSR with STD in V5, V6, STE in V1, aVR. She was initially placed on a NTG drip, but this was discontinued once it was noted that the patient has a history of AS. She was transferred to [**Hospital1 18**] [**Location (un) 86**] for urgent cardiac catheterization. . On cath, a 70% stenosis of the left main was treated with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2. An 80% lesion of the LAD was treated with one DES. A 90% stenosis was nboted in the RCA, but intervention was deferred. She was chest pain free after the procedure and transferred to the CCU for further management. . The patient recently had a fall that resulted in damage to her knee. During her previous catheterization at [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 108**] hospital, she experienced kindey failure witha creatinine that peaked at 8. On review of systems, the patient endorses regular diarrhea with occasional bouts of constipation. She also reports that she often feels diaphoretic and hot at night. The patient reports easy bruising, but has been told it is a sequela to her ASA therapy. The patient denies any changes to eyesight, sinus congestion, dysphagia, cough. The patient also denies dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, Hyperlipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: None -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: # H/o CVA [**2157**] # Visceral stenosis (70% stenosis of the celiac, SMA, and [**Female First Name (un) 899**] followed by [**Doctor Last Name **]) # PVD # DM II - not on insulin, most recent A1c 7.1 in [**6-25**] # Hypertension # Migraine headaches # Gastritis - no peptic ulcer disease history. # Depression x30 years, initially reactive. Social History: Widowed, daughter lives with her. Previously independent. The patient denies tobacco history. EtOH: Will have one drink when she goes out to dinner. Has long history of depression and bipolar disorder, on multiple meds in the past Family History: Mother had CAD and MI. Father died at a young age of MI. Physical Exam: Gen:alert, talkative, NAD lying in bed HEENT: supple, no JVD CV: RRR, 3/6 systolic murmur at RUSB RESP: [**Month (only) **] BS left side, no crackles, ABD: soft, NT EXTR: no peripheral edema, pulses palp NEURO: alert, oriented x2, denies hallucinations or Extremeties: Groin Pulses: Right: DP 1+ PT 1+ Left: DP 2+ PT 1+ Skin: stage 1 ulcer on coccyx, chronic per pt. Pertinent Results: Labs on Admission: [**2172-11-11**] 04:23AM BLOOD WBC-11.8*# RBC-3.11* Hgb-10.1* Hct-28.6* MCV-92 MCH-32.3* MCHC-35.1* RDW-13.2 Plt Ct-343 [**2172-11-11**] 04:23AM BLOOD Neuts-91.4* Lymphs-7.7* Monos-0.5* Eos-0.3 Baso-0.2 [**2172-11-11**] 04:23AM BLOOD PT-12.5 PTT-29.6 INR(PT)-1.1 [**2172-11-11**] 04:23AM BLOOD Glucose-277* UreaN-26* Creat-1.1 Na-136 K-5.4* Cl-107 HCO3-20* AnGap-14 [**2172-11-11**] 04:23AM BLOOD ALT-26 AST-33 CK(CPK)-127 AlkPhos-180* TotBili-0.2 [**2172-11-11**] 04:23AM BLOOD CK-MB-9 cTropnT-0.18* [**2172-11-11**] 01:01PM BLOOD CK-MB-11* MB Indx-8.9* cTropnT-0.39* [**2172-11-11**] 04:23AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.7* Cholest-174 [**2172-11-14**] 04:56AM BLOOD VitB12-424 [**2172-11-12**] 04:38AM BLOOD Hapto-121 [**2172-11-11**] 04:23AM BLOOD Triglyc-223* HDL-63 CHOL/HD-2.8 LDLcalc-66 . Labs on Discharge: [**2172-11-18**] 05:20AM BLOOD WBC-10.7 RBC-3.40* Hgb-10.3* Hct-30.8* MCV-91 MCH-30.4 MCHC-33.6 RDW-14.8 Plt Ct-352 [**2172-11-14**] 04:56AM BLOOD Neuts-74.6* Lymphs-15.4* Monos-8.4 Eos-1.4 Baso-0.1 [**2172-11-18**] 05:20AM BLOOD Glucose-113* UreaN-37* Creat-2.1* Na-140 K-3.7 Cl-106 HCO3-24 AnGap-14 URINE CULTURE PENDING . ECG [**11-17**]: Sinus rhythm. Inferolateral lead ST-T wave abnormalities are non-specific but cannot exclude myocardial ischemia. Clinical correlation is suggested. Since the previous tracing of [**2172-11-16**] there is probably no significant change. TRACING #2 . ECHO [**2172-11-11**]: The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild aortic valve stenosis. Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Compared with the prior study (images reviewed) of [**2171-5-14**], the aortic valve gradient has increased. Regional and global left ventricular systolic function are similar. . Cardiac catheterization [**2172-11-11**]: FINAL DIAGNOSIS: 1. Patent stents in LMCA and mid LAD 2. Successful PTCA/stenting of mid RCA with Endeavor drug eluting stent. 3. Patent bilateral renal arteries with 20% proximal left renal artery stenosis. Additional Cardiac cath [**11-13**]: IVUS guided ENDEAVOR stent mid RCA 3.5 X 15 mm. LMCA and LAD stent patent . Chest CT [**2172-11-18**]: Unsigned at discharge. But, "there are two featuers whcih are concerning for diagnosis other than a serous pleural effusion. The first is a roughly 15x33 mmm wide elliptical region in the anterior costal pleural space adjacent to the ligula, [**Doctor Last Name **] 46, which could be a mass or a resudila hematoma. The second is a 28mm wide elliptical op-acity probably in the left lower lobe up against the major fissure wich contains pleural effusion. [**Month (only) 116**] be consistent with mass or atelectasis. " Brief Hospital Course: A/P: 76 year old female with a history of CAD, hx [**Last Name (un) **] on HD, DM, HTN, CVA [**2167**] transferred from [**Location (un) 620**] for cardiac cath, found to have 70% stenosis of the left main treated with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2, 80% lesion of the LAD treated with one DES, and 90% stenosis of RCA, but intervention was deferred. Post-cath course c/b continued chest pain associated with SOB and hypertension, [**Last Name (un) **] req UF, delerium. . # NSTEMI: s/p DES to LM, LAD and RCA during the course of two catheterizations. Minimal CK leak but pos trop. No further chest pain. She was continued on aspirin and [**Last Name (LF) **], [**First Name3 (LF) **] likely need these medicines indefinitely. BP was quite high and responded to Hydralazine 50 mg TID. She may require additional Hydralazine IV for SBP > 190. Imdur was continued at 120 mg. Olmesartan was held because of kidney function and Metoprolol was increased to 300 mg daily. Additionally, Norvasc was increased to 10 mg daily. Goal SBP is 120. Atorvastatin was continued at 80 mg. . # HCT drop: Transfused [**11-14**] for total 2U pRBCs during LOS. S/P angioseal failure, no retroperitoneal bleed by CT scan. Right groin site stable. Given extensive cardiac history, hct should be maintained > 24. . # Acute on Chronic Renal Failure: Related to contrast load in cardiac cath, required ultrafiltration in CCU and has been followed by nephrology. No evidence of renal artery stenosis. She has required sevelamer to treat high phosphate levels. Creatinine down dramatically in the last few days. UOP has been stable. Please monitor creatinine every few days until at baseline of 1.0. . # Hypertension: See above. Now on Hydralazine and increased Metoprolol. Olmesartan has been held due to renal function but can restart once creatinine nl and taper down somewhat on Metoprolol. . # Acute Diastolic dysfunction: CXR [**11-17**] showed improving pulmonary [**Month/Year (2) 1106**] congestion, thought [**1-21**] ischemia. Received Lasix IV in CCU for pulmonary edema and hypoxia. Now on RA. ECHO with preserved global and regional biventricular systolic function (EF>55%). No sig edema. Weight stable. CXR with ? LLL collapse. Non contrast chest CT performed to further evaluation and final read was not available at time of discharge, but there were several areas concerning for possible masses that could look like atelectasis, thus it would be prudent to obtain a chest CT in 1 month as an outpatient. Would continue daily weights and low Na diet. . # RHYTHM: Patient in normal sinus rhythm. - Telemetry . # Aortic stenosis. Stable. Echocardiogram shows Mild AS, mild AR. . # Hyperlipidemia: Atorvastatin 80 mg daily continued . # Diabetes: Held home PO meds and started on Glargine 10 units for blood sugar control. Would continue this during rehabilitation stay and convert back to oral medicines once ready to discharge home. Humalog sliding scale attached. . # Right hip pain/cramping: Unknown cause, now resolved. Can continue Baclofen prn. . # Depression: Hx of depression and bipolar on mult meds in the past. Was delerious in the CCU, slowly clearing after transfer to the floor. Unable to access recent psych notes in OMR. Restarted on home dose of Trazadone and wellbutrin. Contact[**Name (NI) **] [**Name2 (NI) 3782**] geriatric psychiatrist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 77126**] who did not call back at time of discharge. She will need to follow up with this doctor as an outpatient. . FEN: Heart-healthy, carb-consistent diet . Prophylaxis: Heparin SC BID and bowel regimen. . CODE: Full . *****Incidental Finding on Abdominal CT: finding of left ovarian lesion, likely cyst, recommend f/u U/S as [**Last Name (NamePattern1) 3782**]. *****Incidental Finding on Chest CT: there are two featuers whcih are concerning for diagnosis other than a serous pleural effusion. The first is a roughly 15x33 mmm wide elliptical region in the anterior costal pleural space adjacent to the ligula, [**Doctor Last Name **] 46, which could be a mass or a resudila hematoma. The second is a 28mm wide elliptical op-acity probably in the left lower lobe up against the major fissure wich contains pleural effusion. [**Month (only) 116**] be consistent with mass or atelectasis. recommend f/u Chest CT in one month as an [**Month (only) 3782**]. Medications on Admission: confirmed with Daughter [**Name (NI) **] AMLODIPINE [NORVASC] 5 mg PO qhs ATORVASTATIN [LIPITOR] 80 mg PO daily METOPROLOL Succs 25 mg PO daily CLOPIDOGREL [[**Name (NI) **]] - 75 mg Tablet PO daily ISOSORBIDE MONONITRATE - 60 mg PO daily METFORMIN - 500 mg PO daily OLMESARTAN [BENICAR] - 20mg PO daily OMEPRAZOLE - 20 mg Capsule PO daily prn TRAZODONE - 75mg PO daily ASPIRIN - 325 mg PO daily Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. isosorbide mononitrate 60 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for pain. 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day) as needed for muscle cramping. 9. hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Hold SBP< 100. 10. trazodone 50 mg Tablet Sig: 1.5 Tablets PO at bedtime. 11. metoprolol succinate 100 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily): Hols SBP < 100, HR < 55. 12. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) syringe Injection twice a day. 13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 15. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for Chest pain. 16. bupropion HCl 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 1110**] Discharge Diagnosis: Hypertension ST elevation Myocardial Infarction Coronary Artery Disease Acute Diastolic dysfunction Acute blood loss Anemia Delerium Acute Kidney Injury Diabetes Mellitus type 2 Depression Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You had chest pain at home and [**Hospital1 **] [**Location (un) 620**] transferred you to [**Hospital1 18**] for a cardiac catheterization. You had a heart attack and needed 3 drug eluting stents to open up blockages in your coronary arteries. You were in the CCU with acute kidney failure, diastolic heart dysfunction, high blood pressure and anemia. All of these problems are resolving. An abdominal CT scan was done to check for bleeding and a mass was seen on the left ovary. This is probably a cyst but an ultrasound should be performed after you leave rehabilitation to further assess the mass. We made the following changes in your medicines: 1. STOP taking Olmesartan and Metformin because your kidney function is worse, as your kidneys improve, these medications can be restarted 2. Start taking nitrogycerin as needed to treat your chest pain 3. Start taking heparin injections to prevent a blood clot 4. Increase your Metoprolol to 300 mg daily 5. Increase your Norvasc (Amlodipine) to 10 mg daily 6. Increase the Imdur to 120 mg daily 7. Start Tylenol as needed for pain 8. Start Baclofen as needed for muscle cramps 9. Start Hydralazine three times a day to control your blood pressure 10. Start a long acting insulin to be taken every day and a short acting insulin before meals. 11. Start taking Buproprion (Wellbutrin) to help your depression. 12. Start taking Sevelamer_________ . Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. Followup Instructions: Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) 122**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Location (un) **]CARDIOLOGY Address: [**Location (un) **], 7TH FL, [**Location (un) **],[**Numeric Identifier 6422**] Phone: [**Telephone/Fax (1) 5068**] Appt: [**11-30**] at 8:40am . Please follow up with Dr. [**Last Name (STitle) 77126**] (outpatient Psychiatrist) regarding your psychiatric medications. [**Apartment Address(1) 99914**] [**Location (un) 745**], [**Numeric Identifier 99915**] Phone: ([**Telephone/Fax (1) 99916**] Please follow up with your primary care provider regarding the CT findings, as you may need a follow up CT scan of your chest. Pt should have ultrasound to assess left ovarian mass Completed by:[**2172-11-19**]

[ "285.1", "428.0", "428.33", "424.1", "620.2", "996.73", "346.90", "447.4", "786.6", "584.8", "535.50", "V45.82", "585.6", "E879.8", "412", "786.09", "272.4", "403.90", "E947.8", "410.71", "440.1", "296.50", "780.09", "414.01", "440.20" ]

icd9cm

[ [ [] ] ]

[ "00.47", "39.95", "38.95", "00.40", "00.66", "38.03", "88.45", "37.22", "00.45", "88.56", "36.07", "00.41" ]

icd9pcs

[ [ [] ] ]

13619, 13702

7229, 11631

295, 402

13935, 13935

3792, 3797

15667, 16464

3331, 3389

12078, 13596

13723, 13914

11657, 12055

6351, 7206

14113, 15644

3404, 3773

2619, 2692

245, 257

4631, 6334

430, 2512

3811, 4611

13950, 14089

2723, 3067

2534, 2599

3083, 3315

2,361

149,243

7879

Discharge summary

report

Admission Date: [**2107-6-29**] Discharge Date: [**2107-7-2**] Date of Birth: [**2036-10-8**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1854**] Chief Complaint: progressive mental status changes Major Surgical or Invasive Procedure: craniotomy History of Present Illness: 70M with 3 weeks of progressive problems with [**Name2 (NI) **] and [**Location (un) 1131**] numbers. Found to have right homonymous hemianopsia and work up found left parietal -occipital lesion. Past Medical History: PMH: NIDDM,HTN,Hypercholesterolemia,CAD,s/p CABG ('[**01**]), EF=47%h/o varicose veins Social History: SH:works as a tailor. No Tobacco/occasional EtOH/No Drugs Family History: FH: Mother-DM,Father died @age 39 from an ulcer Physical Exam: a and o x3 ht: rrr lungs: cta Neuro: PERRLA no nystagmus CN2-12 grossly intact with exception of R hemianopsia motor: full [**Last Name (un) 36**] intact to LT Pertinent Results: MRI [**6-29**]:Presurgical study demonstrating stable and unchanged heterogeneous enhancing lesion located in the left parietal and occipital lobes as described above. Persistent and unchanged effacement of the sulci and anterior deviation of the left occipital ventricular [**Doctor Last Name 534**]. Post- surgical changes on the left parietal convexity consistent with burr hole. No new areas with abnormal enhancement are demonstrated. Persistent opacity of the right maxillary sinus. Brief Hospital Course: pt was admitted and monitored closely. His neuro exam did not change. He was brought to the OR on [**6-30**] where under general anesthesia he underwent left craniotomy with tumor resection. He tolerated this well and post op was transferred to ICU. He was extubated. His neuro exam remained intact. He had post op MRI showing status post resection of the left parietal mass, there is evidence of persistent enhancement in the left side of the splenium of the corpus callosum, likely consistent with residual neoplastic process, no significant midline shifting is detected, the pattern of edema and mass effect on the left lateral ventricle remains unchanged. Areas of restricted diffusion in the surgical bed is likely consistent with blood products and residual neoplastic process. He was transferred to the floor. His diet and activity were advanced. His incision had some bloody drainage but ultimately was clean and dry. PT saw him and recommended a walker at home. Medications on Admission: metoprolol lisinopril Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): take while on pain med. Disp:*60 Capsule(s)* Refills:*0* 2. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. 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* 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Home Discharge Diagnosis: brain mass Discharge Condition: neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? You have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: PLEASE RETURN TO THE OFFICE IN 7 DAYS FOR REMOVAL OF YOUR STAPLES/SUTURES PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.[**Last Name (STitle) **] TO BE SEEN IN 1-2WEEKS. PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.[**Last Name (STitle) **] TO BE SEEN IN 1-2WEEKS. Completed by:[**2107-7-2**]

[ "454.9", "401.9", "272.0", "368.46", "250.80", "414.00", "V45.81", "191.3" ]

icd9cm

[ [ [] ] ]

[ "01.59" ]

icd9pcs

[ [ [] ] ]

3305, 3311

1552, 2532

352, 364

3365, 3388

1037, 1529

4743, 5091

792, 841

2604, 3282

3332, 3344

2558, 2581

3412, 4720

856, 1018

279, 314

392, 590

612, 700

716, 776

2,405

152,280

24808

Discharge summary

report

Admission Date: [**2174-9-13**] Discharge Date: [**2174-9-23**] Date of Birth: [**2095-6-20**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1055**] Chief Complaint: Afib with RVR Major Surgical or Invasive Procedure: Lumbar puncture [**2174-9-16**] ERCP [**2174-9-13**] PICC line placed [**2174-9-14**] Arthrocentesis left knee [**2174-9-21**] Knee injection with cortisone [**2174-9-23**] History of Present Illness: 79 y.o. female transfered from [**Hospital3 4107**] for an elective ERCP for elevated LFT's found to be in rapid Afib (rates 140-160) during the procedure with hypotension. ECG showed rapid afib with rate 150 and no ST segment changes. Pt had received 2mg Versed, 75mcg Fent and 6.25mg phenergan for sedation. Procedure was aborted and pt received 5mg Lopressor and carotid massage resulting in rate control to 80-90's and BP back up to 130s systolic. Unable to assess change in mental status durng the procedure as pt presented intially non-verbal and contracted. Pt transfered to ICU and found to be in NSR with BP 120's/40's, still non-verbal. . Per [**Hospital3 4107**] records the patient presented approx 2 months ago with altered MS. She had previously lived in an assited living facility and was able to perform all ADL's. Found to have a proteus UTI, treated with ABX and discharged to nursing home. Per Nephew, who is the health care proxy, she has been declining since this admission. She is now confined to bed and will only occassionally communicate. She was found to have recurrent fevers while in the nursing home and was readmitted to [**Hospital3 4107**] on [**2174-9-6**]. Pt found to have elevated LFT's (AST 41, ALT 75 max) and hep panel sent which was negative. Sed rate 112. U/s on [**9-8**] showed absent GB, CBD 7mm, no intrahepatic dilation, and a heterogenous liver with no discreet lesion. CT abd on [**8-17**] was negative. Chest CT from [**8-19**] showed small non-specific opacities, no LAD and no PE. CT head [**2174-7-4**] was negative. Urine cx showed E.coli and morganella morgani on [**9-8**]. Blod cx from OSH also positive on [**2174-9-6**] for Moraxella; 1/8 bottles. Repeat blood cx's from [**9-8**] NGTD. Past Medical History: Afib on coumadin ? CAD Recurrent UTIs Bipolar schizzoaffective d/o s/p appendectomy s/p cholecystectomy Social History: Origially from [**Location (un) 2312**], worked as a cashier. Estranged from 2 daughters. [**Name (NI) **] smoking and was never a heavy drinker. Now lives in NH. Family History: Father with MI Physical Exam: VS:98.7, 99, 126/44, 100% 2L, RR22 GEN: Elederly female, non-verbal but will respond to pain by screaming, contracted in bed but appears comfrotable when no one touching her. HEENT: pupils equal, sclera non-icteric, mm dry, neck with no LAD, rigid but this is consistent with rest of body. CV: Irreg, irreg, no murmurs appreciated. CHEST: Ant and lat fields clear. ABD: NDNT, normoactive BS and soft. No masses appreciated. EXT: warm and well perfused, 1+ pedal edema, 2+ pulses. Upper ext contracted. Pertinent Results: [**2174-9-13**] 08:37AM ALT(SGPT)-45* AST(SGOT)-25 ALK PHOS-140* AMYLASE-46 TOT BILI-1.9* [**2174-9-13**] 08:37AM LIPASE-40 [**2174-9-13**] 08:37AM WBC-9.5 RBC-3.62* HGB-9.7* HCT-29.9* MCV-83 MCH-26.8* MCHC-32.5 RDW-13.9 [**2174-9-13**] 08:37AM NEUTS-77.5* LYMPHS-16.6* MONOS-2.5 EOS-3.1 BASOS-0.3 [**2174-9-13**] 08:37AM HYPOCHROM-1+ POIKILOCY-1+ [**2174-9-13**] 08:37AM PLT COUNT-385 [**2174-9-13**] 08:37AM PT-16.3* PTT-26.3 INR(PT)-1.8 [**2174-9-13**] 03:45PM GLUCOSE-145* UREA N-11 CREAT-0.9 SODIUM-141 POTASSIUM-4.0 CHLORIDE-109* TOTAL CO2-22 ANION GAP-14 [**2174-9-13**] 04:37PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-6.5 LEUK-NEG [**2174-9-13**] 04:37PM URINE RBC-0 WBC-6* BACTERIA-NONE YEAST-NONE EPI-<1 ECG: Sinus arrhythmia Left axis deviation - anterior fascicular block Possible inferior infarct - age undetermined Anterior T wave changes are nonspecific Low QRS voltages in precordial leads [**2174-9-17**]: RIGHT UPPER EXTREMITY ULTRASOUND: This study is severely limited secondary to patient combativeness, and restricted motion. Due to the above factors, only the right internal jugular vein could be fully evaluated. The vein demonstrates normal compressibility and color flow. Phasicity is erratic, consistent with underlying heart failure or tricuspid regurgitation. No evidence of DVT within the right internal jugular vein. Underlying evidence of right heart failure. [**2174-9-16**] EEG: This is an abnormal portable EEG due to the presence of a slow and disorganized background rhythm with bursts of generalized slowing. This finding suggests a deep, midline subcortical dysfunction and is consistent with a mild encephalopathy. No lateralizing or epileptiform abnormalities were seen. [**2174-9-16**] [**Month/Day/Year 4338**] SPINE: From T1-2 to T12-L1, disc degenerative changes are identified. No evidence of acute compression fracture is noted. No evidence of discitis or osteomyelitis seen. At T7-8 there is disk bulging and a central and left paracentral disc herniation noted indenting the thecal sac. The spinal cord demonstrates normal intrinsic signal. Fusion of L1 and L2 vertebra with focal kyphotic deformity possibly related to previous infection. No evidence of osteomyelitis or discitis seen. No evidence of focal fluid collection. No abnormal enhancement. Laminectomies from L1-L5 with decompression. Patent spinal canal. Multilevel degenerative changes. Mild multilevel degenerative changes. Mild spinal stenosis at C3-4 and C4-5 levels without extrinsic spinal cord compression or intrinsic spinal cord signal abnormalities. [**Month/Day/Year 4338**] HEAD: No intracranial mass effect, hydrocephalus, shift of normally midline structures, acute minor or major vascular territorial infarct is apparent. There are periventricular hyperintensities seen on FLAIR imaging consistent with probable small vessel disease. The surrounding osseous and soft tissue structures are unremarkable. ECHO: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is at least moderate pulmonary artery systolic hypertension. There is no pericardial effusion. CTA ABDOMEN: 1. Mild peripancreatic stranding without evidence of pancreatic mass. Images are somewhat limited due to overlying streak artifact. No biliary dilatation. 2. Multiple bilateral pulmonary nodules measuring up to 5 mm in diameter. These could be further evaluated with dedicated chest CT. Alternatively, three-month followup may be obtained to assess stability. 3. Numerous mesenteric and retroperitoneal lymph nodes which do not meet criteria for pathologic enlargement. 4. Mild diffuse mesenteric stranding and stranding within the subcutaneous fat suggestive of anasarca. 5. Deformity of the L1 and 2 vertebrae with sclerotic margins, features which are suggestive of a chronic process. Correlation with patient's history is recommended. 6. Possible mesenteric cyst in left mid abdomen. 7. Tiny hypodense lesion in left kidney, too small to characterize. US: 1. Heterogeneous liver with no evidence of lesions. No evidence of obstruction. [**2174-9-14**]: CT HEAD: 1. No intracranial hemorrhage or mass effect. 2. Chronic small vessel ischemic change and lacunar infarcts. CT CHEST: 1. Multiple small noncalcified pulmonary nodules in random distribution and nonspecific in appearance. In the absence of known primary malignancy, these probably represent granulomas. However, by radiographic appearance metastatic lesions are included in the differential. Three-month followup CT chest is recommended for surveillance. 2. Bilateral small pleural effusions, slightly increased since previous exam. 3. Symmetric mild enlargement of the thyroid gland, homogeneous in appearance. Clinical correlation is advised. 4. Coronary artery calcifications. KNEE: Three views of the left knee demonstrate chondrocalcinosis within the medial and lateral compartments. There is no evidence of fracture or bone obstruction. The lateral radiograph is not a true lateral thus assessment for joint effusion is not possible. There is some suprapatellar soft tissue swelling. Dense vascular calcifications are present. IMPRESSION: No fracture. Chondrocalcinosis. [**Month/Day/Year 4338**] Left Knee: 1. Medial meniscal tear. 2. Abnormal appearance of the joint space and synovium, may represent nodular synovial thickening versus hemorrhagic products within the joint space. Other low signal interarticular mass lesions such as pigmented villonodular synovitis are not excluded, and a repeat the [**Month/Day/Year 4338**] before and after the administration of gadolinium, as well as with gradient echo sequences is recommended to complete the assessment. 3. No evidence of occult fracture. Nonspecific soft tissue edema about the knee. 4. [**Hospital Ward Name 4675**] cyst. 5. Tricompartmental osteoarthritis that is moderate in severity. Brief Hospital Course: 79 year old female presents with rapid atrial fibrillation, mental status changes and rigidity. 1) Afib: Pt has a history of Afib but has not been treated with any rate controlling medications. Causes of her rapid afib is most likely due to increased sympathetic tone due to procedure and/or infection. Patient was ruled out for myocardial infarction with three sets of enzymes. She was started on lopressor for rate control and this was titrated up with good effect. Chest x-ray showed no sign of acute infection. Patient was started on warfarin. An echocardiogram showed a mildly dilated left atrial size and normal ventricular function with 2+ TR and 1+MR. 2) ID: Patient had a positive urine culture for e.coli and Morganella done at the outside hospital. These organisms were sensative to Zosyn. Patient was continued on Zosyn for a fourteen day course. In addition, patient has one set of positive blood culture for Moraxella at OSH with no sensitivities. One of eight bottles were positive and this was thought to be a contaminant. There was no sign of infiltrate on chest xray. Patient was afebrile during her admission. Surveillence blood and urine cultures were negative. Hepatitis serologies were negative. 3) Rigidity: Patient was seen by the neurology service. It was thought that her rigidity was partly volitional and that her arm rigidity was distractable. She had hyper-reflexia in her legs with increased tone. Therefore, a lumbar puncture and [**Hospital Ward Name 4338**] of the brain and spine were performed. The opening pressure was 14 and the spinal fluid showed no abnormality. The [**Hospital Ward Name 4338**] showed T7-8 disk bulging and a central and left paracentral disc herniation noted indenting the thecal sac which may be accounting for her rigidity. Another possibility, is that the patient was recently admitted to a nursing home where her medications are administered. In the past she was prescribed mellaril but did not always take it. In the nursing home she was taking mellaril and this may have contributed to rigidity. We discontinued Seroquel and Lithium. Rigidity improved greatly during hospital stay. 4) Psych/Delirium: No toxic or metabolic cause for delirium. Patient appeared less delirious and more paranoid throughout her hospital stay. Patient was consistently alert and oriented but exhibited difficult behaviors such as screaming loudly if she was left alone but then quieting when she was with someone. If she did not have full attention she would act out. She was seen by the psychiatry service and they recommended starting zyprexa and discontinuing her other psychiatric medications. 5) Elevated LFT's: ERCP aborted due to atrial fibrillation. Ultrasound was normal. Abdominal CT showed mild peripancreatic stranding. LFTS improved. 6) Pulmonary nodules: Patient has hx of pulm nodules seen on CT scan on [**8-17**]. We repeated CT scan which showed multiple non calcified nodules. Recommend repeat in [**3-6**] months. Blastomycosis, histoplasma and coccidiomyodes antigens were pending at the time of discharge. Lyme antigen was negative. 7) Anemia: Patient was anemic with hematocrit as low as 24. She received two units of packed red blood cells. Spep and Upep were negative. She was seen by the hematology service for evaluation. They felt that since she had an appropriate reticulocytosis and spherocytes on smear the anemia was either due to blood loss or hemolysis. Haptoglobin was 81. LDH was 297 and bilirubin was 0.9. Reticulocyte count was 4.2% with hematocrit of 27.4. RPI was 1.27%. Patient may have had mild hemolysis. Recommend outpatient colonoscopy to evaluate for bleeding and direct coombs test to evaluate for hemolytic anemia. 8) Knee Effusion: Patient was noted to have a left knee effusion on exam. Due to concern that this was contributing to her inability to ambulate the effusion was tapped. It showed 525 wbc, 27% polys, 71,500 rbc, gram stain negative and no pmn, no crystals consistant with a traumatic effusion. Knee was injected with 60 mg solumedrol for pain relief. An [**Date Range 4338**] was performed which showed thickening of the synovium, [**Hospital Ward Name **] cyst, osteoarthritis and medial meniscal tear. This was thought to be consistent with either a synovitis or blood clot. Radiology recommended a repeat [**Hospital Ward Name 4338**] with and without gadolidium for further evaluation. Patient was scheduled for this test. Patient was seen by orthopedic service and they recommended follow up with Dr. [**Last Name (STitle) 2719**] after [**Last Name (STitle) 4338**] was performed. They also recommended range of motion exercises and strengthening exercises. 7) Access: PICC placed. 8) Communication: Nephew [**Name (NI) **] [**Name (NI) 62484**], home: [**Telephone/Fax (1) 62485**], cell: [**Telephone/Fax (1) 62486**]. Legal health care proxy. 9) Code: FULL Medications on Admission: Lithium 150mg [**Hospital1 **] Protonix 40 QD Colace Senna Zosyn 3.375 g IV Q6 Seroquel 25mg Qam, 50mg Qhs Trazadone PRN aggitation Discharge Medications: 1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 7. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO at bedtime. 8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): HOLD UNTIL INR IS < 3.0. 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 11. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 12. Zyprexa 10 mg Tablet Sig: One (1) Tablet PO qam. 13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 14. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed. 15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 16. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day. 17. Magnesium 300 mg Capsule Sig: One (1) Capsule PO once a day. 18. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. Discharge Disposition: Extended Care Facility: [**Location (un) 38**] Manor - [**Location (un) 38**] Discharge Diagnosis: Primary: Delerium Atrial fibrillation Transaminitis Morganella and E coli Urinary tract infection Dementia Anemia Left medial meniscal tear Left knee synovitis with effusion Secondary: Schizoaffective disorder Bipolar disorder Discharge Condition: Stable Discharge Instructions: Call your physician if you experience chest pain, shortness of breath, abdominal pain. We have changed many of your medications. Please take the medications we are discharging you on, and discard your prior medications. We stopped your lithium and seroquel and have started you on zyprexa. We have communicated with your psychiatrist at [**Location (un) 38**] Manor. Please continue on the zyprexa. Followup Instructions: Follow-up with your primary care physician and with your psychiatrist. Follow up with orthopedics to evaluate your medial meniscal tear in your knee. You have an appointment: Provider: [**Name10 (NameIs) 8741**] [**Name11 (NameIs) **], MD Where: [**Hospital6 29**] ORTHOPEDICS Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2174-11-2**] 1:20 You had an [**Month/Day/Year 4338**] of your knee to evaluate your effusion. This showed a thickening of the synovium that could be due to trauma or inflammation. You will need a repeat study for further evaluation. We have scheduled this: Provider: [**Name10 (NameIs) 4338**] Where: CC CLINICAL CENTER [**Name10 (NameIs) 4338**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2174-10-12**] 1:00 If your knee effusion reaccumulates you can schedule follow up with orthopedics by calling: [**Telephone/Fax (1) 2226**].

[ "790.5", "724.8", "790.4", "280.9", "041.85", "518.89", "712.36", "275.49", "719.06", "295.70", "796.1", "276.8", "296.80", "599.0", "283.19", "294.8", "V64.1", "836.2", "427.31", "041.6", "727.00", "458.9", "293.1" ]

icd9cm

[ [ [] ] ]

[ "99.04", "81.92", "99.23", "03.31", "81.91", "38.93", "45.13" ]

icd9pcs

[ [ [] ] ]

16236, 16316

9568, 14455

329, 504

16588, 16597

3155, 7773

17045, 17914

2601, 2617

14637, 16213

16337, 16567

14481, 14614

16621, 17022

2632, 3136

276, 291

532, 2278

7782, 9545

2300, 2405

2421, 2585

30,810

102,577

7350

Discharge summary

report

Admission Date: [**2185-10-3**] Discharge Date: [**2185-10-7**] Date of Birth: [**2111-7-21**] Sex: M Service: MEDICINE Allergies: Diltiazem Attending:[**First Name3 (LF) 19193**] Chief Complaint: fever/vomiting Major Surgical or Invasive Procedure: None History of Present Illness: Patient is a 74yo M with h/o CAD s/p MI and PCI to LAD [**2179**], hypertension, type II diabetes mellitus, aortic stenosis, paroxysmal atrial fibrillation on coumadin, ankylosing spondylitis, peripheral [**Year (4 digits) 1106**] disease s/p left popliteal-posterior tibial bypass [**2183-10-29**], non-healing left foot ulcer for multiple years who presents w/ c/o fever and vomiting beginning the morning of presentation. Patient was on way to PCP's office when began to feel maialase, fevers, and chills. Patient began to feel nauseus and began vomiting. Was sent from PCP's office to the ED. In the ED, patient had a fever of 102. Patient increased SOB over the last few weeks, and endorses a slight worsening of baseline cough, producing a white mucous. He has a 50+ years smoking history, but denies history of COPD. He denies diahrea, and had well formed BM this morning. Denies dysuria. He currently feels much improved when hitting the floor. Past Medical History: peripheral [**Month/Day/Year 1106**] disease with h/o nonhealing left foot ulcer hypertension coronary artery disease s/p MI, s/p LAD stent [**7-/2180**] -- stress [**5-/2181**] with mild reversible apical defect, EF 59% congestive heart failure aortic stenosis type II diabetes mellitus; on insulin tobacco use hyperlipidemia paroxysmal atrial fibrillation ankylosing spondylitis Social History: lives with his wife works as a tax lawyer [**Name (NI) **]: 1ppw x 50yrs EtOH: rare Illicits: none Family History: mother d. CAD in 60s father d. MI in 70s Physical Exam: T 98.8 HR 98 BP 134/52 RR 18 97% on 3L Gen: comfortable, well appearing, NAD HEENT: PERRL, anicteric, MMM, OP clear Neck: supple, no LAD, JVP nondistended CV: RRR with occasional PVC, no m/r/g Resp: slight crackles in LLL, otherwise CTA Abd: +BS, soft, NT, ND, no masses, no HSM, large rightsided scar. Ext: No LE edema, left ankles wrapped in bandange with ampuated big toe, 1+ right DP Skin: erythematous papules with excoriation on B arms Neuro: A&Ox3, CN II-XII intact, strength 5/5 throughout, sensation intact grossly Pertinent Results: [**2185-10-3**] 11:20AM [**Month/Day/Year 3143**] WBC-14.8*# RBC-4.49* Hgb-14.9 Hct-43.3 MCV-96 MCH-33.1* MCHC-34.4 RDW-14.9 Plt Ct-205 [**2185-10-3**] 11:20AM [**Month/Day/Year 3143**] Neuts-82* Bands-8* Lymphs-8* Monos-1* Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0 [**2185-10-3**] 11:20AM [**Month/Day/Year 3143**] PT-17.6* PTT-25.9 INR(PT)-1.6* [**2185-10-3**] 12:20PM [**Month/Day/Year 3143**] Glucose-118* UreaN-26* Creat-1.0 Na-141 K-4.2 Cl-104 HCO3-30 AnGap-11 [**2185-10-3**] 12:20PM [**Month/Day/Year 3143**] ALT-19 AST-22 CK(CPK)-143 AlkPhos-75 Amylase-355* TotBili-1.0 [**2185-10-3**] 12:20PM [**Month/Day/Year 3143**] CK-MB-5 cTropnT-<0.01 [**2185-10-3**] 12:20PM [**Month/Day/Year 3143**] Lipase-22 [**2185-10-3**] 12:20PM [**Month/Day/Year 3143**] Albumin-4.1 Calcium-9.1 Phos-2.1* Mg-1.9 [**2185-10-3**] 11:28AM [**Month/Day/Year 3143**] Lactate-2.6* . PA AND LATERAL CHEST RADIOGRAPHS: Allowing for marked kyphosis, the cardiomediastinal silhouette is stable and within normal limits. There is an elevated right hemidiaphragm with a small amount of adjacent atelectasis. No areas of consolidation are visualized. No effusions are appreciated. There is no evidence of CHF. Patient positioning limits evaluation of the lung apices. There are no suspicious lytic or sclerotic osseous lesions. IMPRESSION: No acute cardiopulmonary process. . COMPARISON: Abdominal angiogram [**2177-5-12**]. Multiple clips are within the right upper quadrant and a single clip is overlying the right lower quadrant. There are several loops of air-filled small bowel with no evidence of obstruction. The descending colon is filled with stool, however, not distended. IMPRESSION: No evidence of obstruction. . ECHO: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with basal and mid-inferior hypokinesis (c/w RCA disease). The remaining segments contract normally (LVEF = 50%). 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 number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with mild regional systolic dysfunction, c/w CAD. No significant aortic valve disease seen. Compared with the prior study (images reviewed) of [**2180-1-12**], the findings are similar. Brief Hospital Course: Pt is a 74yo M with h/o CAD s/p MI and PCI to LAD [**2179**], hypertension, type II diabetes mellitus, aortic stenosis, paroxysmal atrial fibrillation on coumadin, non-healing left foot ulcer for multiple years, who presents w/ c/o fever, malaise, DOE and 1 episode of vomiting at presentation. U/A indicating UTI as possible source of infection. Pt developed a-fib with [**Hospital 26875**] transferred to MICU for rate control. He converted to sinus within a few hours of arrival to the MICU with rapid improvement in BP to baseline. Digoxin was discontinued, and Metoprolol was increased to 25 TID. He was doing well at discharge. . HOSPITAL COURSE BY PROBLEM: # Fever/Leukocytosis: Source likely urinary. Pt had initial O2 requirement and SOB at presentation. CXR showed no consolidation. Pt is a chronic smoker w/ chronic cough, no h/o asthma or documented COPD and he does not use inhalers at home. Azithromycin was stopped given no pulmonary source. L foot ulcer is stable with no e/o infection. Pt denies any symptoms to suggest abdominal/GU source, vomiting on presentation resolved. Patient was started on ciprofloxacin 10 day course. Although patient is on coumadin and had increasing INR, pt was reluctant to change antibiotics. [**Hospital **] cx were negative and white count remained stable. . # CAD: s/p MI in '[**79**] and stenting. CK peak 700, MB peak of 12, trop peak 0.04 [**10-4**], but pt is chest pain free, no EKG changes. Rise may have been [**12-24**] cardiac demand in setting of infection. Pt had episode of chest pressure in setting of a-fib with RVR, CE remained flat and symptoms resolved w/ rate control. Continue daily ASA, lipitor, BB, but will hold [**Last Name (un) **] in setting of lowish BPs. Echo was obtained which showed mild symmetric left ventricular hypertrophy with mild regional systolic dysfunction, c/w CAD. No significant aortic valve disease seen, EF 50%. . # HTN: patient on metoprolol and [**Last Name (un) **] as outpt. [**Last Name (un) **] held in setting of lower [**Last Name (un) **] pressures while in-house, furosemide also held. Will defer to PMD to restart medications as indicated. . # anemia: Hct drop since admission, BL 40s, may be dilutional and pt has had lower Hct in setting of infection in past. No clear source for bleeding. Hct was stable throughout this admission. . # PAF: Patient in NSR on presentation. Supratherapeutic INR while on ciprofloxacin. Pt was transferred to MICU for rapid rate and had some chest pressure. Rate controlled with metoprolol increased to 25mg TID. Patient was stable on discharge. His coumadin dose was decreased while he is taking ciprofloxacin. Antibiotic was not changed given good response and patient's apprehension towards change. Patient's coumadin dose will be adjusted per his PCP. . # DM: Continued outpatient NPH + ISS regimen. . # BPH: continued outpatient flomax. . # contact: wife [**Name (NI) 1328**] [**Telephone/Fax (1) 27101**] Medications on Admission: Lipitor 10mg daily Lasix 40mg daily Insulin NPH Human Recomb 26U am / 40 U pm + HISS metaprolol 25mg [**Hospital1 **] Tamsulosin 0.4mg daily Valsartan 10 mg daily Warfarin 7.5mg daily Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Insulin Regular Human 100 unit/mL Cartridge Sig: sliding scale sliding scale Injection four times a day: dose as indicated. 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at [**Hospital1 21013**]). 6. Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 9 days: to finish [**10-15**]. Disp:*36 Tablet(s)* Refills:*0* 7. Warfarin 2 mg Tablet Sig: One (1) Tablet PO at [**Month/Year (2) 21013**]: please adjust dose with your primary care physician. 8. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: Seventy Five (75) mg PO once a day: please provide correct tablet size for 75mg dose daily. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 9. Outpatient Lab Work please draw pt/ptt/inr on monday and follow-up result with your primary care physician to adjust your warfarin dose. You may call his office. Discharge Disposition: Home With Service Facility: [**Location (un) 932**] Area VNA Discharge Diagnosis: Primary Diagnosis: Urinary tract infection Atrial tachycardia and paroxysmal atrial fibrillation Secondary Diagnosis: Coronary Artery Disease Peripheral [**Location (un) 1106**] disease Chronic foot ulcer Diabetes Tobacco Use Ankylosing Spondylitis ?congestive heart failure Discharge Condition: Good; T 97.4/98.0 BP 130/64 Discharge Instructions: You were admitted with a fever and were found to have a urinary tract infection. Your fever improved with Ciprofloxacin antibioitics. You will finish a 10-day course of oral antibiotics on [**10-15**]. Please finish all of your medications. . You also had a rapid heart rate which may have started because of your infection. You were transferred to the ICU and they were able to stabilize your rate with medications. Your metoprolol was changed from 25mg twice a day to three times a day and you can take Toprol XL 75mg daily for ease of dosing. Please discuss this with your cardiologist. . Your coumadin levels (INR) have been high because you are taking ciprofloxacin. We recommend taking 2mg at night until you have a lab draw. Please have your INR drawn on Monday and follow-up with your primary care physician. [**Name10 (NameIs) 2172**] medication will need to be adjusted and will likely change once you are off of the antibiotics. . Your Valsartan was held given some low [**Name10 (NameIs) **] pressures. You pressures were stable on discharge. Please discuss restarting the Valsartan with your primary care physician and do not take it for now. . Your breathing was stable at discharge and you did not require any oxygen. We advise you to quit smoking, as smoking cigarettes will cause problems for your lungs and will make breathing more difficult. Your cough appears to be chronic and there was no concern for a pneumonia. We again advise you to quit smoking. . If you develop any concerning symptoms such as persistent fevers, chest pain, shortness of breath, please call your physician or go to the emergency department. Followup Instructions: Please see your physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on Tuesday at 1:15pm. Please have your PT/PTT/INR drawn prior to your appointment, and if possible, on Monday. . Please arrange to see your cardiologist 1-2 weeks after your discharge . Provider [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2185-10-11**] 1:30

[ "V58.61", "428.20", "288.60", "599.0", "250.00", "428.0", "V58.67", "412", "285.9", "427.0", "737.10", "V45.81", "440.23", "427.31", "305.1", "440.0", "707.15", "272.4", "414.00", "600.00" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9533, 9596

5196, 5833

286, 292

9915, 9946

2437, 5173

11641, 12064

1822, 1865

8390, 9510

9617, 9617

8181, 8367

9970, 11618

1880, 2418

232, 248

5861, 8155

322, 1282

9735, 9894

9636, 9714

1304, 1687

1703, 1806

81,229

194,995

1273

Discharge summary

report

Admission Date: [**2195-2-17**] Discharge Date: [**2195-2-21**] Date of Birth: [**2132-3-19**] Sex: M Service: MEDICINE Allergies: Penicillins / Tetracyclines / Sulfa (Sulfonamides) / Erythromycin Base / Amiodarone Attending:[**First Name3 (LF) 458**] Chief Complaint: Intermittent palpitations Major Surgical or Invasive Procedure: n/s History of Present Illness: 62 yo male with history of nonischemic dilated cardiomyopathy (s/s chemotherapy/radiation for Hodgkins disease in [**2175**]), recurrent paroxysmal atrial flutter/fibrillation initially treated with dofetilide however after 2.5 years became ineffective and patient transitioned to amiodarone. Amiodarone discontinued in [**2194-7-2**] secondary to pulmonary toxicity. Patient developed recurrent episodes of atrial flutter/fibrillation in [**2194-12-2**]. Recently presented to OSH with 6 hour episode of atrial arrythmia and fast heart rate. In the past, atrial arrythmia has caused decompensated heart failure. Admitted for initiation of dofetilid in hopes of maintaining Normal Sinus Rythm. Past Medical History: 1. CARDIAC HISTORY: -Dilated Cardiomyopathy [**2-3**] chemo and xrt 20 years ago (EF 10-15%) -atrial flutter s/p ablation [**6-/2190**] -atrial fibrillation prev controlled on amio (stopped in [**8-10**] [**2-3**] amio lung toxicity) 2. OTHER PAST MEDICAL HISTORY: -Hx of Hodgkin's disease [**2175**], s/p Chemo and XRT -Severe GERD -Chronic constipation -Chronic lung disease with sleep apnea, emphysema and bronchiectasis with a history of severe hemoptysis in [**2193-6-2**], currently off of amiodarone; ? amiodarone induced pulmonary toxicity -History of diverticulitis x2; the last one was five years ago. -CRI -Dyslipidemia -Depression -Obstructive Sleep Apnea - uses nasal CPAP at home Family History: Father with CAD age 70's. No other family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: v/s: 94.7 - 78 - 20 - 97/55 Gen: Alert and oriented X 3 Lungs: CTA Neck: JVP 8 cm CV: S1, S2, no S3 or S4 Abd: Soft, NT, ND + bowel sounds Ext: 2+ femoral pulse, no bruit 2+ pedal pulse, no edema Neuro: intact Pertinent Results: Admission labs: [**2195-2-17**] 03:49PM PT-32.4* INR(PT)-3.3* [**2195-2-17**] 03:49PM MAGNESIUM-2.2 [**2195-2-17**] 03:49PM WBC-4.7 RBC-4.21* HGB-10.4* HCT-34.6* MCV-82 MCH-24.6* MCHC-29.9* RDW-18.1* [**2195-2-17**] 03:49PM GLUCOSE-97 UREA N-24* CREAT-1.2 SODIUM-136 POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-29 ANION GAP-12 . [**2195-2-19**] AP CXR: AP single view of the chest has been obtained with patient sitting upright position. Comparison is made with the next previous available chest examination of [**2194-10-23**]. The patient has recently undergone implantation of a left-sided permanent pacer seen in anterior axillary position. The pacer is connected to a dual electrode system. One of these is terminating in a position compatible with the right atrial appendage. The second with two electrode enforcements representing the ICD terminates in a position compatible with the apical portion of the right ventricle. Heart size is unchanged and remains within normal limits. No pulmonary congestion is seen and no pneumothorax can be identified. . [**2195-2-17**] ECG: Normal sinus rhythm. Intraventricular conduction delay with left bundle-branch block pattern and QRS duration of 140 milliseconds. Leftward axis at minus 50 degrees. Compared to the previous tracing of [**2195-1-25**] no diagnostic interim change. . [**2195-2-18**] ECG: Sinus bradycardia with sinus arrhythmia. P-R interval prolongation. Left axis deviation. Probable inferior myocardial infarction of indeterminate age. ST-T wave changes that are non-specific. Compared to the previous tracing of [**2195-2-18**] multiple described abnormalities persist. QTc 466 Brief Hospital Course: 62 y/o M with dilated cardiomyopathy admitted for initiation of dofetilide, complicated by torsades, no s/p pacer/ICD placement. . # RHYTHM: He was admitted for inpatient monitoring during the initiation of dofetilide. He was initiated on dofetilide 500mcg Q12hours with EKG 2 hours after each dose, and magnesium oxide 400mg twice daily. Patient had torsades the morning of [**2-19**] in the setting of a prolonged QT interval and worsening bradycardia. He was emergently cardioverted, but the rhythm recurred two more times. He was given IV magnesium sulfate, and taken for pacer/ICD placement. The insertion of the pacer was without incident and he was kept overnight in the CCU. No further dofetilide was given and it should simply wash out of his system. He is now paced at 80bpm and had no further arrhythmias on telemetry. Given his history of MRSA and penicillin allergy, he got one day of vancomycin and two days of clindamycin for prophylaxis after pacer placement. He was discharged back on all of his home medications, including warfarin with a goal INR of [**2-4**]. . # PUMP: He has a history of dilated cardiomyopathy (EF15%), but appeared euvolemic throughout his stay. He was continued on his home doses of lasix, aldactone, lisinopril. The atenolol was held in the setting of bradycardia, but restarted once he was being paced. Medications on Admission: ALLERGIES: Amiodarone: pulmonary toxicity Sulfa: Rash Tetracycline: Rash PCN: Rash Erythromycin: Rash --------------- --------------- --------------- --------------- Active Medication list as of [**2195-2-17**]: Medications - Prescription ATENOLOL - 50 mg Tablet - 1 Tablet(s) by mouth daily BUPROPION HCL - (Prescribed by Other Provider) - 150 mg Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth daily CAPTOPRIL - (Prescribed by Other Provider) - 12.5 mg Tablet - 1 Tablet(s) by mouth three times a day DIGOXIN - (Prescribed by Other Provider) - 125 mcg Tablet - 1 Tablet(s) by mouth once a day DOXAZOSIN - (Prescribed by Other Provider) - 1 mg Tablet - Take one Tablet(s) by mouth every day/bedtime FLUTICASONE [FLOVENT HFA] - (Prescribed by Other Provider) - 110 mcg/Actuation Aerosol - 1 puff inhaled twice a day FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1.5 Tablet(s) by mouth twice a day GABAPENTIN [NEURONTIN] - 600 mg Tablet - 2 Tablet(s) by mouth 3 times daily IPRATROPIUM BROMIDE [ATROVENT HFA] - 17 mcg/Actuation Aerosol - 1-2 puffs(s) inhaled four times daily as needed for shortness of breath LANSOPRAZOLE [PREVACID SOLUTAB] - 30 mg Tablet,Rapid Dissolve, DR - 1 Tablet(s) by mouth dissolve in mouth 30 min ac [**Hospital1 **] LORAZEPAM - (Prescribed by Other Provider) - 0.5 mg Tablet - 1 Tablet(s) by mouth at bedtime daily METOCLOPRAMIDE - (Prescribed by Other Provider) - 5 mg Tablet - [**1-3**] tab in am Tablet(s) by mouth 1 day Last dose was [**2-15**] prior to dofetilide initation RANITIDINE HCL - 150 mg Tablet - 1 Tablet(s) by mouth hs SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day SPIRONOLACTONE [ALDACTONE] - (Prescribed by Other Provider) - 25 mg Tablet - 1 Tablet(s) by mouth once a day WARFARIN - (Prescribed by Other Provider) - 4 mg Tablet - 1 Tablet(s) by mouth daily dosing is INR dependent/quest in [**Location (un) **]/followed by dr [**Last Name (STitle) **]. Also has 1mg, 2mg, 3mg, and 6mg tablets as needed for dose adjustments. Medications - OTC ACETAMINOPHEN - (Prescribed by Other Provider) - 500 mg Tablet - 2 Tablet(s) by mouth prn for headache OXYGEN-AIR DELIVERY SYSTEMS - Device - 2 L/min by nasal cannula nocturnally SENNOSIDES [SENOKOT] - (Prescribed by Other Provider) - 8.6 mg Tablet - 2 Tablet(s) by mouth once a day Discharge Medications: 1. Atenolol 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 2. Bupropion HCl 150 mg Tablet Sustained Release [**Last Name (STitle) **]: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 3. Captopril 12.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day). 4. Digoxin 125 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 5. Doxazosin 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime). 6. Fluticasone 110 mcg/Actuation Aerosol [**Last Name (STitle) **]: One (1) Puff Inhalation [**Hospital1 **] (2 times a day). 7. Furosemide 20 mg Tablet [**Hospital1 **]: Three (3) Tablet PO BID (2 times a day). 8. Gabapentin 400 mg Capsule [**Hospital1 **]: Three (3) Capsule PO TID (3 times a day). 9. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff Inhalation QID PRN () as needed for wheezing/dyspnea. 10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] twice a day. 11. Lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime. 12. Ranitidine HCl 150 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime). 13. Simvastatin 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 14. Spironolactone 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 15. Warfarin 2 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Once Daily at 4 PM. 16. Senna 8.6 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: atrial fibrillation Chronic systolic heart failure torsades de point ventricular fibrillation GERD chronic renal insufficiency depression Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Worked with PT, able to walk stairs without difficulty. Discharge Instructions: You were admitted because we wanted to start you on dofetilide for control of your atrial fibrillation. While you were here, your heart went into a dangerous rhythm, and you had to be shocked and go to the intensive care unit. You had a cardiac defibrillator implantated that also works as a pacemaker, and you are now safe to go home. . No changes were made to your medications. Please take all of your medications as you were prior to admission. . You have heart failure and will accumulate fluid if you are not careful. Please weigh yourself every morning and call your doctor if your weight goes up more than 3 lbs. Please drink less than 1.5 liters of fluid per day. . You have an appointment in the device clinic to make sure your pacemaker is functioning properly. That is Thursday, [**2-26**] at 9:30am. . Your most recent INR was 2.7, meaning that you are therapeutic. Please call Dr.[**Name (NI) 7916**] office Monday morning at [**Telephone/Fax (1) 2205**] to tell them your INR and ask when it should be tested next. Followup Instructions: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2195-2-26**] 9:30 Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2195-3-11**] 3:00 Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 1112**]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2195-3-5**] 1:30 Completed by:[**2195-2-22**]

[ "427.31", "530.81", "428.22", "427.1", "V87.41", "428.0", "V10.72", "327.23", "425.4", "496", "311", "V15.3", "585.9" ]

icd9cm

[ [ [] ] ]

[ "37.94" ]

icd9pcs

[ [ [] ] ]

9322, 9328

3914, 5271

369, 374

9510, 9510

2242, 2242

10769, 11216

1836, 1983

7684, 9299

9349, 9489

5297, 7661

9711, 10746

1998, 2223

304, 331

402, 1101

2258, 3891

9524, 9687

1388, 1820

6,983

173,511

5099

Discharge summary

report

Admission Date: [**2177-7-30**] Discharge Date: [**2177-8-5**] Date of Birth: [**2103-4-6**] Sex: M Service: HISTORY OF THE PRESENT ILLNESS: The patient is a 74-year-old gentleman with multiple medical problems who was transferred from an outside hospital for further management of acute on chronic subdural hematoma. The patient has a past medical history of type 1 diabetes, idiopathic cirrhosis of the liver, status post CABG, partial colectomy, atrial fibrillation, CHF, PVD, gout, and myelodysplastic syndrome. The patient was admitted to the ICU setting for close neurologic observation. He was awake, alert, and oriented times three with a mild right-sided drift. His smile was symmetric. His pupils were 1.5 down to 1 mm and reactive. He had a repeat head CT on admission which showed stable appearance of the left subdural hematoma which was subacute with new left frontal acute portion which was 3 cm thick at its thickest portion with 4-5 mm of midline shift. Apparently, the patient fell on [**7-11**] weekend and was seen in the [**Location (un) 3844**] ER and was hospitalized from [**2177-7-11**] to [**2177-7-14**] without surgical treatment. Over the past 1-2 weeks, he has become increasingly lethargic and confused with right-sided weakness. PHYSICAL EXAMINATION ON ADMISSION: General: The patient was pleasant, elderly, in no acute distress. There were no overt signs of trauma. HEENT: The sclerae were nonicteric. The pupils were equal, round, and reactive to light. EOMs full. Neck: No lymphadenopathy. Cardiovascular: There was a II/VI systolic murmur. Regular rate and rhythm. Lungs: Clear to auscultation. Abdomen: Soft, positive bowel sounds, nontender, nondistended. Extremities: No edema. Neurologic: There was some right-sided weakness. Otherwise, pretty much intact neurologically. HOSPITAL COURSE: He was followed closely by the Hematology/Oncology Service for his myelodysplastic syndrome and he had thrombocytopenia in attempts to get his coagulation studies and his platelet counts within the normal range to prevent further bleeding. His platelet count was 62 on admission, PT 12.9, PTT 35.2, INR 1.5 on admission. He was given multiple transfusions of FFP, vitamin K, cryoprecipitate and platelet transfusion to get his platelets above 75,000 and his INR less than 1.3. After long discussion with the patient and his extended family they wish not to have the subdural drained at this time and opted for close observation. He remained in the ICU for close neurologic observation until [**2177-8-3**]. He was transferred to the regular floor where he has remained neurologically stable with some mild right-sided weakness, [**4-12**] in the biceps, triceps, and grasp, but very minimal drift. His IPs were strong bilaterally. He did receive 2 units of FFP and 30 of IV Lasix on [**2177-8-4**] for an INR of 1.6. Level of today, [**2177-8-5**], is pending. He remains neurologically stable. He has been seen by Physical Therapy and Occupational Therapy and found to require rehabilitation. DISCHARGE MEDICATIONS: 1. Trazodone 50 mg p.o. q.h.s. p.r.n. 2. Percocet one to two tablets p.o. q. four hours p.r.n. 3. Insulin sliding scale. 4. Lactulose 30 cc p.o. t.i.d. 5. Metoprolol XL 25 p.o. q.d. 6. Propanolol 40 mg p.o. q. 24 hours. 7. Lasix 40 mg p.o. q.d. 8. Spironolactone 25 mg p.o. q.d. CONDITION ON DISCHARGE: Stable. FOLLOW-UP: The patient will follow-up with Dr. [**First Name (STitle) **] in two weeks time with repeat head CT. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2177-8-5**] 10:13 T: [**2177-8-5**] 10:30 JOB#: [**Job Number 20966**]

[ "284.8", "238.7", "286.7", "571.5", "430", "908.9", "V45.81" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

3101, 3389

1875, 3078

1324, 1858

3414, 3820

28,058

183,595

33085

Discharge summary

report

Admission Date: [**2173-1-17**] Discharge Date: [**2173-1-19**] Date of Birth: [**2139-5-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3984**] Chief Complaint: ETOH intoxication. Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a 33 yo man with no significant pmhx who presents with etoh intoxication. Per report from girlfriend, patient was out last night at a russian bar and was drinking vodka and beer with friends. [**Name (NI) **] had multiple shots of vodka and disappeared from restaurant around 11 pm. He wandered into a chinese restaurant and was reportedly breaking plates in the kitchen and police were called. He assaulted a police officer and a nurse in the ED and required 4 point leather restraints and police escort to the ICU. In the ED, initial vs were T 98, BP 139/90, HR 110, R 18, 96% on RA. Patient receive 5 liters of IVF, 10 mg IV haldol and 22 mg IV ativan. On admission to the unit, initial vs were T 99.3, HR 123, BP 143/98, R 18, 100% on 100% NRB. Patient was quicky weaned 98% on 4 liters nasal cannula. Initially, patient was very lethargic but cleared quickly and was oriented x 3. Patient denies using any other illicit drugs. Past Medical History: none Social History: Smoked x15 years and quit 2 months, occasional alcohol but no history of abuse or withdrawl, no drug use. Family History: non-contributory Physical Exam: (on admission to ICU) VS: Temp: 99.3 BP: 143/98 HR: 123 RR: 18 O2sat 100% on 100% NRB GEN: lethargic, arousable to sternal rub, 4 point restraints HEENT: NCAT, anicteric, no injections, PERRL, 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, tacchycardia, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, 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. Pertinent Results: [**2173-1-17**] 10:50PM CK(CPK)-4404* [**2173-1-17**] 10:50PM CK-MB-14* MB INDX-0.3 [**2173-1-17**] 12:59PM LACTATE-2.6* [**2173-1-17**] 12:46PM GLUCOSE-110* UREA N-10 CREAT-0.9 SODIUM-144 POTASSIUM-3.7 CHLORIDE-108 TOTAL CO2-24 ANION GAP-16 [**2173-1-17**] 12:46PM CK-MB-18* MB INDX-0.4 [**2173-1-17**] 12:46PM ASA-NEG ETHANOL-67* ACETMNPHN-NEG [**2173-1-17**] 12:46PM OSMOLAL-322* [**2173-1-17**] 03:30AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2173-1-17**] 03:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2173-1-17**] 01:35AM ASA-NEG ETHANOL-328* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG . EKG: sinus tacch at 130 bpm, nl intervals , no st-t wave changes . Imaging: cxr negative [**2173-1-17**] 10:50PM CK(CPK)-4404* [**2173-1-18**] 04:42AM BLOOD ALT-36 AST-94* LD(LDH)-272* CK(CPK)-3901* AlkPhos-55 Amylase-51 TotBili-1.4 [**2173-1-19**] 06:40AM BLOOD CK(CPK)-1587* Brief Hospital Course: A/P: Pt is a 33 yo man with etoh intoxication and tacchycardia. . # ETOH intoxication- patient presented with etoh level of 328 which has now trended down. Elevated AST: ALT ratio c/w etoh intoxication. Pt received fluids and MVI/folate/B12. Pt cliniclaly sober x 24 hours without any signs of withdrawal and is feeling great, asx and denies chronic etoh use. # Elevated ck- unclear if patient fell while intoxicated and he also was physically abusive with cops/nurses, therefore likely [**1-16**] struggle in restraints. Has cleared appropriately throughtout stay and has been asx. . # Leukocytosis- likely stress response as pt is afebrile and no localizing signs of infection. Resolved appropriately without issue or si infection. . # F/E/N: lytes repleated and stayed well hydrated with good uop and on reg diet. # PPx: pt remained on sqh and PPI throughout. # Access: PIV x 2 . # Dispo: pt is clinically clear to d/c Medications on Admission: none Discharge Medications: 1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Alcohol intoxication dehydration Discharge Condition: good Discharge Instructions: Please return to the ER if you have fevers, chills, nausea, vomiting, diarrhea, bleeding, headaches, confusion, or any other symptoms that worry you or your family. Followup Instructions: f/u with your PCP within two weeks [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**] Completed by:[**2173-1-19**]

[ "305.00", "728.88", "276.51" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

4289, 4295

3224, 4148

334, 341

4372, 4379

2182, 3201

4592, 4784

1476, 1494

4203, 4266

4316, 4351

4174, 4180

4403, 4569

1509, 2163

276, 296

369, 1308

1330, 1336

1352, 1460

76,141

100,755

4467

Discharge summary

report

Admission Date: [**2132-9-6**] Discharge Date: [**2132-9-11**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4891**] Chief Complaint: hypoxia, mental status changes Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 2866**] is a [**Age over 90 **]-year-old man with a history of Parkinson's disease, dementia, hypertension, and recent aspiration pneumonia who presents with altered mental status and is admitted to the [**Hospital Unit Name 153**] with hypoxic respiratory failure. She was recently admitted in [**2132-6-26**] for delirium and gradually worsening mental status and was found to have aspiration PNA and treated with antibiotics. This admission was notable for a speech and swallow evaluation concluding in the recommendation for aspiration precautions, and a discussion about goals of care with his daughter and subsequent change in his code status to DNI/DNR. He was discharged to rehab and then transferred to [**Hospital1 **] nursing home for long term care. He was doing well until the day prior to admission when his daughter noted that he was less oriented than usual (he is A/0 to person and sometimes place or time at baseline) and having a productive cough with difficulty managing his oral secreations. He was transferred to the ED for further evaluation. ROS is notably negative for fevers, nausea, vomiting, diarrhea, dysuria, and rash. EMS reports he was 92%ra. In the ED, initial VS: 99.2 74 126/107 24 98%NRB. He was tachypneic to the 40s with copious oral secretions. O2 sats fell to the high 80s and he was put on a NRB with improvement in his hypoxia. He was given 500cc NS initially because it was felt she was dry, and then lasix 10iv x 1 because of concern for volume overload. She also received morphine for dyspnea. CXR showed mew LLL infiltrate and resolution of prior RLL pneumonia and she was treated with vanc/levoflox. He also had a negative head CT. He was initially admitted to the ICU for stabilization. Past Medical History: 1. Parkinson's disease 2. Memory loss 3. Urinary incontinence 4. Hypertension 5. Hearing impairment 6. Depression 7. Anemia 8. Chronic kidney disease 9. Colon cancer s/p resection 10. Cholecystectomy [**32**]. Pacemaker 12. Leg injury in World War II 13. Amblyopia, left eye, due to childhood injury Social History: Pt born in NY, has one daughter who lives in [**Name (NI) 7349**]. Wife has AD and lives in [**Hospital1 **] of [**Location (un) 55**]. He is an artist who owned an industrial cleaning company. Until recently, he had been living at CCB with 45 hours/week of private assistance. No tobacco use. No current etoh use. Family History: Non-Contributory Physical Exam: ON ADMISSION: 99.2 74 126/107 24 98%NRB General: agitated HEENT: Sclera anicteric, mucous membranes dry Neck: supple, JVP elevated Lungs: rales on left > right CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, distended, bowel sounds present Ext: warm, trace lower extremity edema Psych: not able to answer questions; responded to verbal stimuli Pertinent Results: [**2132-9-6**] 08:20PM BLOOD WBC-16.0*# RBC-3.48* Hgb-10.6* Hct-32.2* MCV-93 MCH-30.5 MCHC-32.9 RDW-13.7 Plt Ct-284 [**2132-9-7**] 04:26AM BLOOD WBC-16.4* RBC-3.09* Hgb-9.2* Hct-28.8* MCV-93 MCH-29.8 MCHC-32.0 RDW-13.2 Plt Ct-235 [**2132-9-6**] 08:30PM BLOOD Glucose-113* UreaN-41* Creat-1.6* Na-147* K-5.2* Cl-111* HCO3-26 AnGap-15 IMAGING: [**9-6**] CXR: Left basilar opacity concerning for infection with small left pleural effusion. Prominent hila bilaterally. [**9-6**] CXR: There has been little change compared to the prior study. Again noted is a left basilar airspace opacity concerning for infection. Small left pleural effusion persists. There is a patchy opacity as well on the right lung base which could represent an atelectasis. Both hila remain prominent, and underlying lymphadenopathy may be present. The cardiac and mediastinal contours are unchanged. Pulmonary vascularity is not engorged. Hemithorax. Left-sided dual-chamber pacemaker leads terminating in right atrium and right ventricle are again noted. [**9-7**] CT Head w/o Contrast: Essentially unchanged study from [**2132-7-6**]. No acute intracranial process. Similar global atrophy, particularly bifrontal, and unchanged cystic encephalomalacia in the left cerebellar hemisphere. Brief Hospital Course: Mr. [**Known lastname 2866**] is a [**Age over 90 **]yo male w a history of Parkinson's disease, dementia, hypertension, and recent aspiration pneumonia who presents with altered mental status and is admitted to the [**Hospital Unit Name 153**] with hypoxia and tachypnea. # Pulmonary Process: Patient with recent admission for PNA in [**Month (only) 205**], admitted with elevated WCC, AMS, CXR with new L basilar opacity concerning for infection with small left pleural effusion. At this time it was believed this was secondary to a recurrent aspiration pneumonia, however heart failure, PE and atelectasis were also considered within the differential. A urine legionella antigen was negative. He was started on vancomycin, levofloxacin and cefepime to cover for hospital and community acquired PNA, but then switched to vancomycin, cipro and cefepime for better pseudomonal coverage. Given the concern for aspiration, he was ordered for a speech and swallow evaluation, who has evaluated him previously for a similar condition. Once he was stabilized, he was transitioned to the medicine HMED service, and he was gradually transitioned to PO antibiotics with cipro and flagyl to avoid the need for a PICC line. # Dysphagia: Attributed to his underlying parkinson's and dementia. Appears stable, per speech and swallow evaluation. A ground diet with thin liquids was recommended., with aspiration precautions, with special consideration made for the days that his mental status is poor, to consider reassessing before offering him food. Per discussions with his daughter/HCP [**Name (NI) **], the decision was made for him to eat for comfort and not pursue invasive measures related to the dysphagia. # Acute kidney injury: On admission the patient's creatinine was elevated to 1.6 from a baseline of 0.9. This was believed to be secondary to hypovolemic hypoperfusion. In the ED, the patient had received both a fluid bolus and a one-time dose of IV lasix 10mg. On arrival in the [**Hospital Unit Name 153**], the patient received an additional fluid bolus. His serum Cr stabilized at 1.5 and this may be a new baseline. He did not appear intravascularly contracted or overloaded at the time of discharge. # Goals of care: Extensive discussion with his HCP/daughter, including a geriatrics inpatient consult, was helpful in clarifying the patient's goals of care. The daughter expressed interest in discussing goals of care and potential transition to inpatient hospice in the near future. We discussed avoiding IV antibiotics, as they would require a PICC line that he might find uncomfortable, but did choose to have him remain on PO antibiotics at this time. His prognosis due to the recurrent aspirations is poor, and his daughter understands that the point may arise when she no longer wishes for him to be readmitted to the hospital. She will discuss the goals of care further with Dr [**Last Name (STitle) **], at [**Hospital1 **]. Dr [**Last Name (STitle) **] was updated by the writer on the day prior to discharge. Medications on Admission: Doxazosin 1mg PO qhs Omeprazole 20mg qd MVI PO qd ASA 81mg PO qd Amlodipine 5mg PO qd Carbidopa-Levodopa 25-100 PO qid Cholecalciferol Vitamin D3 400unit PO qd Calcium carbonate 500mg [**Hospital1 **] Cyanocobalamin 100mcg PO qd Sertraline 25mg PO qd Folic acid 1mg PO qd DuoNeb nebulizer INH tid prn Aricept 10mg PO qd Namdena 5mg PO qd Discharge Medications: 1. Doxazosin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 9. Cyanocobalamin (Vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: [**12-29**] Tablet, Delayed Release (E.C.)s PO DAILY (Daily) as needed for Constipation. 12. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) neb Inhalation three times a day as needed for shortness of breath or wheezing. 13. Sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days: Please continue this to complete aspiration pneumonia course, through [**2132-9-13**]. 15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 3 days: Please continue for aspiration pneumonia until [**2132-9-13**]. 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] Senior Healthcare of [**Location (un) 55**] Discharge Diagnosis: Aspiration pneumonia Dementia/Parkinson's disease Discharge Condition: Discharge condition: stable Mental status: alert and oriented at times, to person. Not oriented to place or date. Conversation is usually tangiential, delirious at times but not agitated. Ambulatory status: with assistance, patient able to ambulate. Discharge Instructions: Mr [**Known lastname 2866**], It was a pleasure to take care of you during your admission. You were treated for aspiration pneumonia, and your cough improved. We spoke to your daughter during your time here and updated her daily. We are talking to your daughter about controlling your symptoms and considering hospice, and we have spoken to Dr [**Last Name (STitle) **] about this, but we have not yet started this plan. We will be discharging you on PO antibiotics, with a foley catheter due to hematuria (or blood in your urine). Followup Instructions: Dr [**Last Name (STitle) **] was updated today [**9-10**] about the discussions and plans for your care. She will resume caring for you when you return to [**Hospital1 **]. We held sertraline, namenda and aricept while he was in the hospital. We restarted sertraline on [**9-10**]. The namenda and aricept can be restarted once his delirium improves to some degree.

[ "403.90", "787.29", "368.00", "584.9", "331.82", "276.0", "507.0", "518.81", "293.0", "332.0", "V45.01", "294.11", "V10.05", "294.10", "599.71", "585.9", "530.81" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9547, 9637

4506, 7550

292, 298

9752, 9759

3217, 4483

10566, 10936

2770, 2788

7939, 9524

9658, 9710

7576, 7916

10007, 10543

2803, 2803

222, 254

326, 2098

2817, 3198

9774, 9983

2120, 2421

2437, 2754

23,583

184,881

25048

Discharge summary

report

Admission Date: [**2191-9-29**] Discharge Date: [**2191-10-14**] Date of Birth: [**2136-11-3**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: chest pain with exertion for one week. Major Surgical or Invasive Procedure: [**2191-10-3**] AVR/ Ascending Aorta/CABG x 1 sternal rewiring/evac. mediastinal clot and effusion History of Present Illness: 54 yo male with one week history of chest pain. Admitted to [**Hospital6 **] on [**9-27**] and rulewd out for MI. Cath done on [**9-28**] revealed: CX 75%, severe AS. Echo [**9-28**] showed EF 25-30%, trace AI, moderate AS with [**Location (un) 109**] 0.9 cm2, mild MR, trace TR. He had no prior cardiac history. Past Medical History: new borderline DM (diet/exercise controlled) renal calculi laminectomy [**2179**] Social History: married no tobacco, no ETOH Family History: father died of DM complications, mother died, cause unknown Physical Exam: 98. 2T 112/60 HR85 RR 18 97% RA sat 83.3 kg NAD, PERRL, EOMI, no scleral icterus CTAB RRR S1 S2, 2/6 SEM at LSB soft , NT, ND + BS, no peripheral edema Pertinent Results: [**2191-9-29**] 09:36PM PT-13.1 PTT-27.6 INR(PT)-1.2 [**2191-9-29**] 09:36PM PLT COUNT-250 [**2191-9-29**] 09:36PM WBC-7.9 RBC-4.41* HGB-14.2 HCT-38.2* MCV-87 MCH-32.1* MCHC-37.1* RDW-13.0 [**2191-9-29**] 09:36PM %HbA1c-5.6 [Hgb]-DONE [A1c]-DONE [**2191-9-29**] 09:36PM ALBUMIN-4.1 CALCIUM-9.1 PHOSPHATE-4.0 MAGNESIUM-2.0 [**2191-9-29**] 09:36PM LIPASE-46 [**2191-9-29**] 09:36PM ALT(SGPT)-30 AST(SGOT)-22 LD(LDH)-206 ALK PHOS-70 AMYLASE-50 TOT BILI-0.5 [**2191-9-29**] 09:36PM GLUCOSE-158* UREA N-19 CREAT-1.2 SODIUM-139 POTASSIUM-4.6 CHLORIDE-103 TOTAL CO2-28 ANION GAP-13 [**2191-9-29**] 10:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2191-9-29**] 10:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018 [**10-12**] WBC 9.1 Hct 33.2 PLT ct 322 glucose 105 NA 138 K 4.2 CHlor 94 Bicarb 29 BUN 21 Creat 1.0 Brief Hospital Course: Admitted on [**9-29**] for pre-op work-up prior to AVR/CABG with Dr. [**Last Name (STitle) 1290**]. A difficult crossmatch delayed surgery briefly. He underwent AVR/ CABG x1/ Asc. Aortic replacement on [**2191-10-3**]. He was transferred to the CSRU in stable ondition on a milrinone, insulin, propofol, and amiodarone drips. ON POD #1, he remained on those drips plus a lidocaine drip for ectopy. He was weaned and extubated later that evening and was alert and oriented. Diuresis with lasix and natrecor was started , along with an ACE inhibitor. Chest tubes were also removed. Beta blockade was begun on POD #2 and the PA cath was removed. Pacing wires were removed without incident on POD #3. Natrecor was also stopped and he was transferred to the floor. He was transitioned to PO pain meds and began to increase his activity level. He also received nebulizers for wheezes and improved pulmonary toilet. Stool was sent for culture and diuresis continued. He was readmitted to CSRU on [**10-8**] for better pulmonary toliet given his continued wheezing/ SOB, and some stridor. Echo ruled out tamponade, and CXR appeared to be unchanged. A radial arterial line was replaced after intubation. Significant seepage began to soak his sternal dressing and Dr. [**Last Name (STitle) **] opened a small portion of the incision at bedside. It was apparent he had fluid underneath, and he was returned to the OR with Dr. [**Last Name (STitle) **] for evacuation of mediastinal clot/effusion and rewiring of a sternal dehiscence. He was transferred back to the CSRU in stable condition on a titrated propofol drip. He was weaned for extubation slowly over the next 2 days, and ORL service saw him again. Social work also spent time with patient's wife. [**Name (NI) **] was extubated on [**10-11**] and transferred back to the floor. Chest tubes and foley were removed on [**10-12**], and gentle diuresis continued. He was also seen by anesthesia and the dental team for evaluation of a loose tooth after his 2 intubations. Dental care will be required and the anesthesia attending assisted the patient with the patient relations representative. He also complained of some soreness in his right groin which was treated with some warm packs and motrin. He continued to work on increasing his pulmonary toilet and ambulating more. He made good progress and was cleared for discharge on [**10-14**]. Medications on Admission: none at home ASA lopressor (from OSH) Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 tabs* Refills:*0* 2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 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:*0* 4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 5. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*0* 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*0* 7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q2H (every 2 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 8. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6-8:PRN PAIN as needed for 1 weeks. Disp:*30 Tablet(s)* Refills:*0* 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO twice a day for 1 weeks. Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 weeks. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: S/p AVR/ asc. aortic replacement/ CABG x1 (SVG to OM) s/p sternal rewiring NIDDM s/p renal calculi laminectomy [**2179**] Discharge Condition: Good. Discharge Instructions: Shower, wash incision with soap and water and pat dry. No baths, lotions, creams or powders. Call with fever, redness or drainage from incision, weight gain more than 2 pounds in one day or five in one week, or pain that is unrelieved by pain medicine. No heavy lifting or driving. [**Last Name (NamePattern4) 2138**]p Instructions: Dr. [**First Name (STitle) 1075**] 2 weeks Dr. [**Last Name (Prefixes) **] 4 weeks PCP 2 weeks Completed by:[**2191-11-9**]

[ "998.11", "998.31", "746.4", "511.9", "E878.2", "427.5", "424.1", "414.01", "427.1", "441.2" ]

icd9cm

[ [ [] ] ]

[ "00.13", "36.11", "38.45", "96.71", "35.21", "34.03", "96.04" ]

icd9pcs

[ [ [] ] ]

5916, 5965

2176, 4570

361, 461

6131, 6139

1227, 2153

969, 1031

4659, 5893

5986, 6110

4596, 4636

6163, 6446

6497, 6623

1046, 1208

283, 323

489, 803

825, 908

924, 953

32,383

116,091

34259

Discharge summary

report

Admission Date: [**2111-6-16**] Discharge Date: [**2111-6-26**] Date of Birth: [**2065-6-19**] Sex: F Service: SURGERY Allergies: Codeine Attending:[**First Name3 (LF) 6346**] Chief Complaint: septic shock Major Surgical or Invasive Procedure: [**2111-6-17**]: ERCP History of Present Illness: 45 yo F with recent admission for gallstone pancreatitis s/p ERCP w/ pseudocyst now transferred from [**Hospital3 3583**] with hypotension, leukopenia and gram negative rod bacteremia. Past Medical History: PMH: h/o gallstone pancreatitis, thoracic outlet syndrome s/p rib resection, with chronic pain PSH: CCY [**2100**], umbilical hernia [**2095**], epigastric incisional hernia [**2103**] Family History: N/A Physical Exam: On discharge: AFVSS Gen: NAD RRR CTAB Abd: soft, mild distended, mild TTP in epigastrium, +BS Ext: WWP Pertinent Results: [**2111-6-16**] 08:12PM BLOOD WBC-7.7 RBC-2.82* Hgb-9.5* Hct-28.8* MCV-102* MCH-33.7* MCHC-33.0 RDW-13.8 Plt Ct-110*# [**2111-6-18**] 01:40AM BLOOD WBC-8.4 RBC-2.97* Hgb-9.9* Hct-29.4* MCV-99* MCH-33.2* MCHC-33.5 RDW-15.1 Plt Ct-97* [**2111-6-21**] 02:32AM BLOOD WBC-7.5 RBC-2.98* Hgb-9.7* Hct-28.7* MCV-96 MCH-32.5* MCHC-33.8 RDW-15.1 Plt Ct-146* [**2111-6-24**] 04:23AM BLOOD WBC-13.6* RBC-3.25* Hgb-10.3* Hct-32.5* MCV-100* MCH-31.6 MCHC-31.6 RDW-15.8* Plt Ct-475*# [**2111-6-25**] 04:48AM BLOOD WBC-11.4* RBC-3.22* Hgb-10.4* Hct-32.4* MCV-101* MCH-32.3* MCHC-32.1 RDW-15.5 Plt Ct-538* [**2111-6-16**] 08:12PM BLOOD Fibrino-185 D-Dimer-5454* [**2111-6-17**] 03:30PM BLOOD Fibrino-322# [**2111-6-21**] 02:32AM BLOOD Fibrino-322 [**2111-6-16**] 08:12PM BLOOD Gran Ct-7200 [**2111-6-16**] 08:12PM BLOOD Glucose-142* UreaN-14 Creat-0.9 Na-141 K-4.1 Cl-117* HCO3-16* AnGap-12 [**2111-6-17**] 03:30PM BLOOD Glucose-100 UreaN-12 Creat-0.6 Na-137 K-3.9 Cl-113* HCO3-16* AnGap-12 [**2111-6-20**] 02:06AM BLOOD Glucose-110* UreaN-3* Creat-0.4 Na-140 K-3.5 Cl-107 HCO3-27 AnGap-10 [**2111-6-24**] 04:23AM BLOOD Glucose-107* UreaN-16 Creat-0.5 Na-138 K-4.7 Cl-104 HCO3-27 AnGap-12 [**2111-6-25**] 04:48AM BLOOD Glucose-104 UreaN-15 Creat-0.5 Na-138 K-4.4 Cl-105 HCO3-25 AnGap-12 [**2111-6-16**] 08:12PM BLOOD ALT-126* AST-251* LD(LDH)-302* AlkPhos-199* Amylase-31 TotBili-1.2 [**2111-6-17**] 02:29AM BLOOD ALT-137* AST-210* CK(CPK)-91 AlkPhos-224* Amylase-39 TotBili-2.5* [**2111-6-17**] 03:30PM BLOOD ALT-120* AST-110* AlkPhos-231* Amylase-33 TotBili-3.5* [**2111-6-18**] 01:40AM BLOOD ALT-96* AST-79* AlkPhos-223* Amylase-28 TotBili-2.9* [**2111-6-19**] 01:48AM BLOOD ALT-65* AST-38 AlkPhos-251* TotBili-2.3* [**2111-6-20**] 02:06AM BLOOD ALT-53* AST-30 AlkPhos-310* TotBili-2.2* [**2111-6-21**] 02:32AM BLOOD ALT-42* AST-25 AlkPhos-336* Amylase-29 TotBili-1.3 [**2111-6-22**] 05:20AM BLOOD ALT-33 AST-18 AlkPhos-333* TotBili-0.8 [**2111-6-25**] 04:48AM BLOOD ALT-22 AST-22 LD(LDH)-240 AlkPhos-277* Amylase-42 TotBili-0.6 [**2111-6-16**] 08:12PM BLOOD Lipase-28 [**2111-6-17**] 02:29AM BLOOD Lipase-21 [**2111-6-17**] 03:30PM BLOOD Lipase-11 [**2111-6-18**] 01:40AM BLOOD Lipase-9 [**2111-6-21**] 02:32AM BLOOD Lipase-24 [**2111-6-25**] 04:48AM BLOOD Lipase-40 GGT-215* [**2111-6-25**] 04:48AM BLOOD Albumin-3.6 Calcium-9.2 Phos-4.9* Mg-2.0 [**2111-6-16**] 08:12PM BLOOD Albumin-2.7* Calcium-5.7* Phos-2.5*# Mg-1.2* UricAcd-3.9 [**2111-6-21**] 02:32AM BLOOD Albumin-2.5* Calcium-8.1* Phos-2.9 Mg-2.0 [**2111-6-23**] 04:09AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.2 . CT abd/pelvis: [**2111-6-22**] IMPRESSION: 1. Marked improvement of the pancreatitis and pseudocysts, with a residual pseudocyst near the body of the pancreas measuring 3.5 cm. 2. Small bilateral pleural effusions, the left is larger and the right is new from prior study. 3. Multiple low-attenuating foci within a large uterus, likely represents degenerating fibroids. 4. Stable hepatic cysts. Brief Hospital Course: 45 yo F with recent admission for gallstone pancreatitis s/p ERCP w/ pseudocyst now transferred from [**Hospital3 3583**] with hypotension, hypoxia, acidemia, leukopenia and gram negative rod bacteremia. Admitted intubated and sedated on pressors, first to MICU and then transferred to SICU. Broad spectrum abx were given. Review of her CT scan from [**Hospital3 3583**] showed resolving pancreatitis, no abscess. However, her LFTs were elevated, notably her Tbili=2.5. A RUQ u/s showed: No intrahepatic or extrahepatic biliary dilatation. Nonvisualization of the pancreas and peripancreatic region. Two small liver cysts. The GI team was consulted and felt that ERCP with stent placement was indicated. This was performed on [**2111-6-17**]. This showed sphincterotomy was widely patent, mormal bliliary tree, and a bilary stent was placed. Cultures from [**Hospital3 3583**] grew out Enterobacter sensitive to cefepime. Thus her abx were switched to cefepime. She was weaned off her pressors and then weaned off of the vent on HD5. She was then transferred to the floor. A follow-up CT on [**6-22**] showed Marked improvement of the pancreatitis and pseudocysts, with a residual pseudocyst near the body of the pancreas measuring 3.5 cm. Of note, she was on TPN during her hospitalization, but was weaned off and tolerating a regular low fat diet by the day of discharge. All cultures from this hospitalization were negative (bld, urine, cath tip). She had had 11 days of abx, and was discharged on po cipro for 3 more days for a total course of 14 days. On the day of discharge she was in stable condition, Afebrile, VSS, tolerating a regular low fat diet, had had a bowel movement the day prior and continued to pass flatus, was making adequate urine with no foley and pain was well=controlled on po pain medications. Medications on Admission: diazapam 5', amytriptyline 50', oxycodone 15''', vicodin 500''' Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed: Do not drive or drink alcohol while taking this. take a stool softener while taking this. Disp:*40 Tablet(s)* Refills:*0* 2. Diazepam 5 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed. 3. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Take this while taking taking your narcotic pain medications. Disp:*60 Capsule(s)* Refills:*2* 5. 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* 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 3 days: Please take all of your antibiotics. Disp:*6 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Sepsis gallstone Pancreatitis Discharge Condition: stable Discharge Instructions: Please contact us or seek medical attention immediately for any increased abdominal pain, abdominal distention, nausea, vomiting, chest pain, shortness of breath, or any other concerning signs or symptoms. Please continue to eat a low fat diet until instructed otherwise. Followup Instructions: Please follow-up with Dr. [**First Name (STitle) 2819**]. Please call his office for an appointment: ([**Telephone/Fax (1) 6347**] Please also follow-up with Dr. [**Last Name (STitle) **], please call [**Telephone/Fax (1) 65629**] for your appointment. It is currently scheduled for [**2111-7-16**] at 11am. Please call to verify.

[ "577.0", "574.51", "995.92", "518.81", "276.4", "996.62", "785.52", "599.0", "038.9" ]

icd9cm

[ [ [] ] ]

[ "99.15", "96.72", "38.93", "51.87" ]

icd9pcs

[ [ [] ] ]

6752, 6758

3858, 5689

280, 303

6832, 6841

885, 3835

7161, 7497

742, 747

5804, 6729

6779, 6811

5715, 5781

6865, 7138

762, 762

776, 866

228, 242

331, 518

540, 726

32,730

196,963

31108

Discharge summary

report

Admission Date: [**2189-5-15**] Discharge Date: [**2189-5-23**] Date of Birth: [**2134-2-11**] Sex: M Service: SURGERY Allergies: Mycelex Attending:[**First Name3 (LF) 668**] Chief Complaint: HCV/HCC Major Surgical or Invasive Procedure: [**2189-5-15**] liver transplant History of Present Illness: 55 y/o male with Hepatitis C and HCC s/p RFA who presents today for liver transplant. Last RFA was done [**2188-11-20**]. Current MELD listed as 22 for HCC. He reports feeling well recently except for some fatigue. He denies fever, chills or recent sick contacts. [**Name (NI) **] reports stable weight, good appetite, normal bowel function. He complains of some numbness, tingling in left foot (s/p CVA last year) for which he sometimes uses a cane for stability. He did not take medications and had only tea this morning for breakfast. Patient notes always having had bradycardia. Past Medical History: Hypertension Diabetes Mellitus Type 2 on oral meds Hepatitis C Question of Cirrhosis Hepatocellular Carcinoma s/p Prior Radiofrequency Ablation and Chemo Nephrolithiasis CVA with resolved left hemiparesis [**2189-5-15**] OLT Social History: No alcohol, tobacco, or drug use. Married with three children. Family History: From [**Male First Name (un) 1056**] originally. Living in the US for 27 years. Lives in [**Location **]. His mother died from complications from a cerebral vascular accident and myocardial infarction. His father has diabetes. Physical Exam: 97.6, 57, 153/82, 18, 99% RA 59.4 kg, height 5'8", Gen: Alert oriented, speaks some English, NAD. Slight build HEENT: oral mucosa pink, moist, no eveidence of infection, no LAD, PERRLA Lungs: CTA bilaterally Cards: Regular, slight brady, no M/R/G Abd: Non-distended, non-tender, no scars, no evidence of ascites, + BS Extr: Warm, well perfused, 2+ DPs, 2+ femorals . Pertinent Results: [**2189-5-15**] 08:40AM FIBRINOGE-169 [**2189-5-15**] 08:40AM PT-12.9 PTT-29.5 INR(PT)-1.1 [**2189-5-15**] 08:40AM PLT COUNT-145* [**2189-5-15**] 08:40AM WBC-5.0 RBC-3.79* HGB-13.2* HCT-37.8* MCV-100* MCH-34.9* MCHC-35.0 RDW-13.3 [**2189-5-15**] 08:40AM ALBUMIN-3.2* CALCIUM-9.4 PHOSPHATE-3.8 MAGNESIUM-1.6 [**2189-5-15**] 08:40AM ALT(SGPT)-189* AST(SGOT)-131* ALK PHOS-216* TOT BILI-0.7 [**2189-5-15**] 08:40AM GLUCOSE-154* UREA N-16 CREAT-1.0 SODIUM-138 POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-28 ANION GAP-11 [**2189-5-20**] 05:54AM BLOOD WBC-9.5 RBC-3.31* Hgb-10.9* Hct-29.7* MCV-90 MCH-32.9* MCHC-36.7* RDW-15.4 Plt Ct-87* [**2189-5-18**] 05:14AM BLOOD PT-11.4 PTT-20.3* INR(PT)-0.9 [**2189-5-20**] 05:54AM BLOOD Glucose-70 UreaN-43* Creat-0.9 Na-144 K-3.9 Cl-108 HCO3-29 AnGap-11 [**2189-5-20**] 05:54AM BLOOD ALT-245* AST-98* AlkPhos-99 TotBili-0.9 [**2189-5-20**] 05:54AM BLOOD Albumin-2.7* [**2189-5-19**] 04:58AM BLOOD Albumin-2.6* Calcium-8.2* Phos-3.2 Mg-2.2 [**2189-5-20**] 05:54AM BLOOD FK506-10.7 Brief Hospital Course: On [**2189-5-15**] he underwent dad[**Name (NI) 73432**] deceased donor liver transplant. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Two [**Doctor Last Name 406**] drains were placed in the abdomen, one behind the right lobe of liver, the second behind the hilum. Please see operative report for further details. He received induction immunosuppression consisting of cellcept and solumedrol. He was sent directly to the SICU postop intubated. PRBC were given for hct of 26. JP fluid was sero-sanguinous. He was extubated on pod 1. He was alert and oriented. Clear fluids were started and tolerated. An insulin drip was initiated for hyperglycemia. [**Last Name (un) **] was consulted. IV fluid was decreased. LFTs trended down and hct stabilized. Diet was advanced. Insulin drip was switched to NPH [**Hospital1 **] and sliding scale humalog. He was transferred to the med-[**Doctor First Name **] unit on [**5-17**] where he continued to do well. The medial JP was removed on poe 4. The incision remained clean/dry and intact. He was ambulatory. PT evaluated him and felt that he was safe when discharged home. Total bilirubin elevated to 1.0 on [**5-19**] but then steadily declined over the following days and was 0.6 on day of discharge. Prograf was started on pod 2. Trough levels increased quickly. The dose was adjusted to 2 mg [**Hospital1 **]. After discussions with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**], he agreed to participate in the Maribivir Study. Baseline EKG was without any acute changes. Of note, SBP ran high in 150-170 range and DBP in 90-104 range. Lopressor was started then norvasc 5mg qd was added. Lopressor was up titrated to 50mg [**Hospital1 **]. On discharge the norvasc was discontinued and the lopressor was increased to 75mgBID. Medications on Admission: Lisinopril 40 mg daily Glyburide 5 mg daily Discharge Medications: 1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 2. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty (20) units Subcutaneous once a day. Disp:*1 bottle* Refills:*1* 9. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Eight (8) units Subcutaneous at bedtime. 10. Insulin Lispro 100 unit/mL Solution Sig: follow sliding scale Subcutaneous four times a day. Disp:*1 bottle* Refills:*1* 11. syringes Sig: insulin syringes-low dose (25 gauge) four times a day. Disp:*1 * Refills:*2* 12. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 13. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). Disp:*180 Capsule(s)* Refills:*2* 14. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: VNA of [**Doctor Last Name **] Discharge Diagnosis: HCV cirrhosis HCC HTN DM II Discharge Condition: good Discharge Instructions: Please call the Transplant office [**Telephone/Fax (1) 673**] if fever, chills, nausea, vomiting, inability to take any of your medications, jaundice, increased abdominal pain, or incision redness/bleeding or drainage. Labs every Monday and Thursday Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2189-5-25**] 10:50 Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2189-5-26**] 8:15 Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2189-5-27**] 2:00

[ "438.6", "427.89", "070.54", "401.9", "155.0", "571.5", "782.0", "250.00" ]

icd9cm

[ [ [] ] ]

[ "00.93", "50.59", "38.93" ]

icd9pcs

[ [ [] ] ]

6310, 6371

2948, 4791

274, 309

6443, 6450

1900, 2925

6749, 7126

1269, 1497

4886, 6287

6392, 6422

4817, 4863

6474, 6726

1512, 1881

227, 236

337, 923

945, 1172

1188, 1253

21,301

157,121

49742

Discharge summary

report

Admission Date: [**2135-1-16**] Discharge Date: [**2135-1-22**] Date of Birth: [**2060-9-21**] Sex: F Service: MEDICINE Allergies: Augmentin / Levaquin Attending:[**First Name3 (LF) 613**] Chief Complaint: Pericardial effusion and tamponade Major Surgical or Invasive Procedure: Pericardiocentesis History of Present Illness: Ms [**Known lastname **] is a 74 year old female with history notable for breast ([**2111**]; s/p lumpectomy + XRT; ductal CA [**2132**]) and stage IIIa T2N2 NCLC s/p RLL resection in [**2132-10-17**] and chemo (cisplatin + taxol)/XRT in [**2132**]. . Since [**2134-6-17**] she has had progressive dyspnea and has seen Dr. [**Last Name (STitle) 2168**] to w/u this process. And has had a bronch [**8-/2134**] negative for malignancy; + atypical cells suggestive of post-XRT change however; Cx + for MAC (grew out after 1 month). She has not undergone any therapy for this. This dyspnea was very slowly progressive and did not require supplumental Oxygen. . 2 weeks ago Ms [**Known lastname **] began having pleuritic chest pain and resting chest pain worse with lying supine and leaning forward. She also experienced worsening dyspnea and fatigue, night sweats, cough productive of clear sputum, she denied fevers or chills. She presented to an OSH where she was found to have a pericardial effusion (no tamponade) and she was treated with NSAIDS. Since this eccho her dyspnea has progressed despite 3 days of levoflox, to the point of being unable to walk so she presented to the ED yesterday. . In the ED she was given flagyl to cover anaerobic infection and bedside eccho did not appear changed. CTA chest showed potential RUL infection vs lymphangitic dz and large pericardial effusion. She was transferred to the floor where she was noted to be dyspneic with RR 32 +accessory muscle use, but was satting well on 4L n/c with ABG 7.41/43/306/22. VS at that time RR 32, 100% 3L, BP 127/74, P 105. A trigger was called and bedside eccho showed large 3cm effusion with RV collapse and emergent bedside pericardiocentesis was performed with 390 cc serosanguinous fluid drained. Her dyspnea improved dramatically. . She currently feels much better; she endorses constipation, + orthopnea, pain at site of drain. Also c/o thirst Past Medical History: #. Right lower lobe lung CA - found incidentally in [**2132**] on a preoperative chest x-ray in anticipation of surgery for a ductal carcinoma - Resected [**2132-10-17**], path: stage IIIa T2, N2 nonsmall cell lung cancer - s/p 3 cycles of adjuvant carboplatin and Taxol, complicated by thrombocytopenia and anemia. The patient received concurrent radiotherapy. - serial CTs concerning for malignancy recurrence - [**Month (only) 404**]: CT with RML consolidation/effusion with PET correlation - [**Month (only) 205**]: CT with progressive cavitation in R lower lung field along with atelectasis and bronchiectasis - [**Month (only) 216**]: Bronch: Negative cytology, no micro - [**Month (only) 216**]: induced sputum MAC+, s/p 2 weeks levo #. Right breast cancer, s/p lumpectomy and radiation therapy in [**2111**] - Ductal cancer diagnosed [**2132**], s/p lumpectomy alone #. Tuberculosis at age 18 with 10-month stay in sanatorium at that time - treated #. ? MDS #. GERD #. Urinary urgency #. Anxiety #. Hypertension #. Leg cramps #. Status post left knee surgery Social History: The patient is married, with 3 kids and lives in [**Hospital3 **]. She worked previously as a receptionist 2 days a week for the family's boarding kennel. Her husband is a veterinarian. They live in [**Hospital3 **]. Tobacco: None ETOH: Rare Illicits: None Family History: Mother-breast cancer [**Name (NI) 104002**] cancer Grandmother-cancer Physical Exam: Vitals: T- 98.0 BP: 111/52 HR: 98 RR: 22 O2: 98% 2L (difficulty with pulse ox [**2-18**] acrylic nails) . General: Patient is a pleasant female, looks younger than stated age, NAD HEENT: NCAT, EOMI. OP: MMM, no lesions Neck: Supple, no LAD. JVP at level of clavicles, disappear with inspiration. Lymph nodes: no axillary, supraclavicular or cervical LAd Breast: + R breast post-surgical scar; no discrete nodules felt. Chest: + inspiratory dry crackles bilaterally anteriorly. Posterior: rhonchi and crackles + bronchial BS over right mid and lower lung fields. Few intermittent high pitched wheezes Cor: RRR, no rubs appreciated Abdomen: Soft, NT, ND +BS Extremity: No C/C/E DP2+ Pertinent Results: [**2135-1-16**] CHest CT: IMPRESSION: 1. Large pericardial effusion. Bilateral small pleural effusions. 2. Right upper lobe parenchymal opacities and interstitial thickening concerning for aspiration or infection. No recurrent tumor evident. 3. No evidence for pulmonary embolus. 4. Right breast soft tissue nodule which should be correlated with mammogram. . [**2135-1-17**] ECHO: Conclusions: prepericardiocentesis: Left ventricular wall thicknesses are normal. The left ventricular cavity is small. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. There is a large pericardial effusion. The effusion appears circumferential. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There is brief right atrial diastolic collapse, consistent with early cardiac tamponade. . postpericardiocentesis: A small, echodense residual pericardial effusion is present. There is no evidence of cardiac tamponade. . [**2135-1-20**] CXR: Small-to-moderate bilateral pleural effusion, stable. Right perihilar mass longstanding. No change in caliber of the cardiomediastinal silhouette. Left lung hyperinflated. Stable left apical calcification. . [**2135-1-20**] ECHO: hyperdynamic EF 80%. Effusion smaller . . Labs: [**2135-1-17**] Pericardial fluid: 1100 WBC; [**Numeric Identifier **] RBC; 80poly, 10 monos, 10 lymphs NEGATIVE FOR MALIGNANT CELLS. . [**2135-1-19**] C diff x1 negative [**2135-1-19**] sputum: [**2135-1-17**] EBV IgG/IgM/EBNA Antibody Panel all negative. [**2135-1-17**] pericardial fluid: [**2135-1-15**]: BCX x2 NG . [**2135-1-22**] head CT: No acute intracranial pathology, no intracranial hemorrhage, no evidence of metastatic disease. Brief Hospital Course: Ms. [**Known lastname **] is a 74 year old female with extensive Onc history as above who is admitted for progressive dyspnea and found to have pericardial tamponade. 1. Pericardial effusion - The differential diagnosis for her pericardial effusion included viral infection (EBV, coxackie, adenovirus) but given patient's history there is also possibility malignant effusion (breast or lung) or radiation induced pericarditis. Given h/o TB and + MAC on culture it is also possible that the patient could have mycobacterial pericarditis. Cytology did not show malignant cells in the pericardial fluid. Stains are still pending for AFB and viral serologies show no EBV. Her effusion was noted to be decreasing on subsequent ECHOs, pulsus not elevated. . 2. Dyspnea - Her dyspnea on admission was most likely secondary to pericardial tamponade and pulmonary parenchmal etiology. She also had MAC in a sputum culture from [**2134**] which is being followed as an outpatient. Her dyspnea improved greatly once the pericardial effusion was drained. She was treated with azithro and cefpodoxime for the MAC (per Dr. [**Last Name (STitle) **]- outpatient pulm) and new infiltrate on CXR for 7 days and is to follow-up with Dr. [**Last Name (STitle) **] as an outpatient. She was also sent home with home oxygen and nebulizer machine to help with her dyspnea. . 3. Diarrhea: C diff high on differential, although post abx diarrhea also possible. C diff x3 was negative, other cultures also negative. She was given pepto bis for symptom relief with good effect. She had low grade fevers, but her WBC has been trending down during the admission. Possibly [**2-18**] drug effect or viral gastroenterology. . 4. A fib/flutter with RVR: to 140's and ventricular trigeminy-always hemodynamically stable. This was likely secondary to irritation of pericardial catheter initially. She was rate controlled with metoprolol 75mg TID in CCU but again had a.fib with RVR again [**2135-1-21**]. Rate control discussed and decided to be kept strictly on BB so was switched to ToprolXL for discharge 225mg. Anticoagulation was considered but initally held off given question of need for pericardial window. When effusion resolved, anticoagulation was still held given h/o cancer with no head scan recently to rule out mets to brain. Head CT was done and negative so she was discharged on coumadin and will have levels checked by her PCP. . 4. Onc - not an acute issue; to f/u with [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] as outpatient. . 5. Anemia - patient with admission Hct 25.8 on admission, from 30.6 on [**2134-10-14**] although of note patient with variable Hct previously 25 to 35 with dx of MDS on recent Onc note. Iron studies c/w AoCDz, hct stable. . 6. Anxiety - she was noted to be very anxious this admission, and has been responding to prn ativan. Of note her venlafaxine was held on admission (not clear why, not documented) so this was restarted [**2135-1-22**], she was also discharged with ativan for home. . 7. PPx: SQ Heparin and PPI per outpatient regimen . 8. Code: Full, confirmed this admission ATTENDING ADDENDUM: The majority of this patient's hospitalization occurred in the ICU. She was transferred out to the floor on [**1-20**], and I met her on [**1-21**]. She was discharged the following day after confirmation of the appropriate home services. Medications on Admission: Patient stopped taking all meds 3 days ago given nausea and low BP at OSH, is taking Levoflox Levofloxacin 500mg daily, Day 3 of 14 Paxil 20 mg daily Prilosec 20 mg daily Ambien qhs Ditropan 5 mg daily Triamterene 1 a day Discharge Medications: 1. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for anxiety. 2. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. Disp:*400 ML(s)* Refills:*0* 3. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Oxygen-Air Delivery Systems Device Sig: 1.2-2L/min Miscellaneous continous: Home O2. Disp:*qs qs* Refills:*12* 5. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 7. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime). Disp:*60 Tablet(s)* Refills:*2* 8. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-18**] Sprays Nasal QID (4 times a day) as needed for dry stuffy nose. 9. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO DAILY (Daily). 11. Metoprolol Tartrate 100 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*2* 12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 13. Ativan 1 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for anxiety. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Cardiac tamponade pneumonia atrial fibrillation mycobacteria avium complexum infection radiation pneumonitis Discharge Condition: good Discharge Instructions: You were admitted because of pneumonia and because of fluid around your heart that caused a condition called "tamponade." Because of your pericardial fluid you developed an abnormal heart rhythm called atrial fibrillation; this may go away in several months. You will need to take 2 new medicines for this: metoprolol to control your heart rate, and coumadin to thin your blood and prevent stroke. You will need to follow up with a cardiologist for a repeat ecchocardiogram to evaluate the fluid around your heart. You should also see Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 2168**] in follow up for your cancer history and lung disease. . You have one more dose left of cefpodoxime to treat your pneumonia. If you begin having fevers, chills, worsenining cough, or difficulty breathing this may be a sign that you need to be treated further and you should see a doctor. If you have worsening dyspnea, fatigue, lower extremity swelling this could be a sign of reaccumulation of fluid around your heart and you should see a doctor. You also have an abnormal heart rate called atrial fibrillation; if you begin having heart palpitations and feel light headed, this could be a sign that your heart is going too fast and you should seek immediate medical attention. Followup Instructions: Please call to [**Last Name (STitle) **] follow-up with Cardiology to follow-up with regarding your cardiac tamponade and atrial fibrilation within 1-2 weeks ([**Telephone/Fax (1) 2037**]. . Please also call to [**Last Name (un) 21610**] follow-up with Dr. [**Last Name (STitle) **] of pulmonology around that time. . Please follow-up with Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] as scheduled [**2135-2-10**] at 10:00am. . Please call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] follow-up in [**1-18**] weeks from discharge. He will need to monitor your anticoagulation and adjust your coumadin dose. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "V10.3", "031.9", "285.9", "486", "427.31", "V10.11", "508.0", "423.9" ]

icd9cm

[ [ [] ] ]

[ "37.0" ]

icd9pcs

[ [ [] ] ]

11380, 11431

6303, 9696

315, 335

11584, 11591

4463, 6172

12927, 13719

3674, 3745

9970, 11357

11452, 11563

9723, 9947

11615, 12904

3760, 4444

241, 277

363, 2291

6182, 6280

2313, 3383

3399, 3658

25,935

137,825

51948

Discharge summary

report

Admission Date: [**2121-4-14**] Discharge Date: [**2121-4-18**] Date of Birth: [**2062-2-8**] Sex: M Service: [**Year (4 digits) 662**] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: Cellulitis Major Surgical or Invasive Procedure: none History of Present Illness: 59 year old male with h/o Type I DM c/b b/l BKA (left [**2113**] and right [**2118**]), neuropathy, retinopathy and nephropathy, HTN, COPD who was admitted to medical floor with cellulitis of b/l stumps. . The patient was recently admitted on [**2036-3-20**] for dyspnea secondary to PNA vs COP treated with levoflox x 10days. He was also found to have a Enterococcal UTI, for which he was started on Ampicillin x7 days. The patient left AMA with PCP [**Last Name (NamePattern4) 702**]. The prior admission between [**Date range (1) **] started with a MICU stay for hypoxia, hypercarbia and resultant lethargy. BiPap was used intermittently with improvement in mental status and ventilation . After leaving AMA during most recent hospitalization, Patient reports completing course of levofloxacin and ampicillin for CAP/UTI. Pt notes increasing redness and pain over past week in both stumps. He denied associated fevers/chills, dyspnea, or chest pain. . Upon presentation to the ED, he was given Vanco and Unasyn, was intermittently hypoxic with O2 sats 85% while sleeping and was placed on 2L NC and admitted to floor. He was being treated on broad spectrum abx for cellulitis in the setting of poorly controlled Type I DM: vanc/zosyn/clinda, vascular surgery was following. CXR showed improvement of left basilar atelectasis without focal consolidation. . He triggered yesterday for no UOP -> 700ml after foley catheter insertion. Also with relative hypotension SBP 90s (b/l 130s) with improvement of SBP 110s after 1L bolus NS yesterday. Was noted to be intermittently lethargic during day, ABG obtained was 7.32/57/68. He underwent a CT scan pelvis/extremities eval for possible fasciitis, and was noted to be more somnolent (arousable only to sternal rub). Repeat gas unchanged at yesterday at 9pm: 7.32/58/69. Patient was on unchanged methadone maintenance without any additional prn pain medications, and patient has not been able to be setup with BIPAP at home, has documented OSA and received sleep eval during recent hospitalization. Currently on 2-3L in low 90s. Unable to initiate emergent BIPAP on floor so he was transferred to the unit overnight to receive BiPAP. He also received Narcan in the unit, which improved his lethargy. . ABG following BiPAP this morning was 7.31/56/73. . Currently, the patient notes improved pain control in his stumps. (-)n/v/d/f/c. has not had BM since admission, denies constipation. On ROS, does endorse orthonpea, no PND. (-) abd pain. Past Medical History: Past Medical History: 1. Diabetes, insulin dependent, with neuropathy, retinopathy, nephropathy, and diabetic foot ulcers. s/p bilateral BKAs due to nonhealing ulcers. LBKA [**2113**], RBKA [**2118**] 2. h/o IVDU/morphine addiction: On methadone. 3. COPD: 1 ppd / 40 years. No PFTs on file 4. Chronic renal insufficiency: Recent baseline 1.2. Multiple hospitalizations with bumps into the 2s. 5. HTN 6. PVD: h/o recurrent leg ulcers, cellulitis 7. ? Hepatitis C 8. GERD 9. h/o MRSA and VRE infection 10. h/o decubitus ulcer, now healed Social History: Lives with his girlfriend, [**Name (NI) **], in [**Name (NI) 3146**], who helps him with ADLs. Has VNA care who he says helps wash him, give him medications and prepare his meals. He has spoked 1ppd x 40 years. Denies Etoh use. Denies recreational drug use currently. Family History: NC Physical Exam: PE: T:96.2 BP:120/78 HR:62 RR:18 O2 93% 2L Gen: NAD/ obese/ unkept/ appears stated age/ pleasant HEENT: AT/NC, PERRLA, EOMI, anicteric, no conjuctival pallor, MMM NECK: supple, trachea midline, no LAD LUNG: pt with poor respiratory effort, slight exp wheeze, coarse breath sounds in the left base. no accessory muslce use and speaks in full sentences CV: S1&S2, RRR, no R/G/M ABD: Soft/+BS/ NT/ ND/no rebound/ no guarding/ obese [**Name (NI) **]: No C/C/ 1.5cm ulceration over the left stump, granulation tissue and slight purulence. Foul smelling, B/l erythema, warmth and crust over the b/l stumps. Erythema extending over up the thigh. TTP fingertips are brown. SKIN: No lesions, rashes, bruises NEURO: AAOx3. Cranial nerves II-XII intact. Normal bulk, strength and tone throughout. No abnormal movements noted. No deficits to light touch throughout. PSYCH: Listens and responds to questions appropriately, pleasant Exam at discharge: T 97 HR 58 95% RA 156/82 NECK: supple, trachea midline, no LAD LUNG: improved lung exam, rare bibasilar rales, otherwise CTA CV: S1&S2, RRR, no R/G/M ABD: Soft/+BS/ NT/ ND/no rebound/ no guarding/ obese. Inguinal folds with erythema, small excoriations, healing well [**Name (NI) **]: 1 cm ulceration over the left stump, granulation tissue, healing well. B/l erythema, warmth and crust over the b/l stumps, also improving. SKIN: No lesions, rashes, bruises NEURO: AAOx3. Cranial nerves II-XII intact. Normal bulk, strength and tone throughout. No abnormal movements noted. No deficits to light touch throughout. PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**2121-4-14**] 03:50AM PLT COUNT-230 [**2121-4-14**] 03:50AM NEUTS-79* BANDS-0 LYMPHS-15* MONOS-4 EOS-1 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [**2121-4-14**] 03:50AM WBC-8.0 RBC-4.77 HGB-13.9* HCT-43.3 MCV-91 MCH-29.1 MCHC-32.1 RDW-17.3* [**2121-4-14**] 04:00AM CALCIUM-8.7 PHOSPHATE-3.9# MAGNESIUM-1.7 [**2121-4-14**] 04:00AM estGFR-Using this [**2121-4-14**] 04:00AM GLUCOSE-110* UREA N-26* CREAT-1.9* SODIUM-141 POTASSIUM-4.7 CHLORIDE-104 TOTAL CO2-28 ANION GAP-14 [**2121-4-14**] 04:01AM LACTATE-2.1* [**2121-4-14**] 04:01AM COMMENTS-GREEN TOP [**2121-4-14**] 02:17PM LACTATE-1.2 [**2121-4-14**] 02:17PM TYPE-ART PO2-68* PCO2-57* PH-7.32* TOTAL CO2-31* BASE XS-0 [**2121-4-14**] 06:17PM URINE HYALINE-[**3-7**]* [**2121-4-14**] 06:17PM URINE RBC-0-2 WBC-0-2 BACTERIA-MOD YEAST-NONE EPI-[**6-12**] [**2121-4-14**] 06:17PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2121-4-14**] 06:17PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015 [**2121-4-14**] 09:13PM LACTATE-1.0 [**2121-4-14**] 09:13PM TYPE-ART PO2-69* PCO2-58* PH-7.32* TOTAL CO2-31* BASE XS-1 [**2121-4-14**] 11:47PM PT-12.7 PTT-35.8* INR(PT)-1.1 [**2121-4-14**] 11:47PM PLT COUNT-210 [**2121-4-14**] 11:47PM WBC-6.2 RBC-4.08* HGB-11.7* HCT-36.9* MCV-91 MCH-28.7 MCHC-31.7 RDW-17.2* [**2121-4-14**] 11:47PM HCV Ab-POSITIVE* [**2121-4-14**] 11:47PM HBsAg-NEGATIVE HBc Ab-POSITIVE [**2121-4-14**] 11:47PM ALBUMIN-2.5* CALCIUM-8.0* PHOSPHATE-3.9 MAGNESIUM-1.6 [**2121-4-14**] 11:47PM ALT(SGPT)-3 AST(SGOT)-14 ALK PHOS-59 TOT BILI-0.2 [**2121-4-14**] 11:47PM GLUCOSE-158* UREA N-27* CREAT-1.9* SODIUM-142 POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-26 ANION GAP-14 Labs at discharge: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 5.8 3.73* 11.1* 34.4* 92 29.7 32.1 16.5* 262 Glucose UreaN Creat Na K Cl HCO3 AnGap 69 22 1.7 140 4.6 105 29 11 Hb A1c 8.6 HBsAg HBcAb HepC core Ab NEGATIVE POSITIVE POSITIVE Reports: ECG: Artifact is present. Sinus rhythm. Atrial ectopy. Left axis deviation. Left anterior fascicular block. Non-specific ST-T wave changes. Compared to the previous tracing the Q-T interval is shorter and ST-T wave changes are more prominent LENIs: No evidence of deep vein thrombosis in either leg Chest PA and lateral: In comparison with the study of [**3-24**], there is some decrease in the atelectatic change at the left base. The cardiac silhouette remains at the upper limits of normal without vascular congestion or pleural effusion. Mediastinal and hilar contours are normal. CT pelvis/LEs: IMPRESSION: Findings consistent with right greater than left lower extremity cellulitis. No focal fluid collection or subcutaneous gas to suggest Fournier's gangrene. Brief Hospital Course: ASSESSMENT & PLAN: 59 yo M with PMHx IDDM complicated by b/l BKA (left [**2113**] and right [**2118**]), neuropathy, retinopathy and nephropathy, HTN, COPD admitted with cellulitis over both BKA stumps. . # Hypoxia: Patient with known COPD, baseline pCO2 likely around high 40s, found to have pCO2 in high 50s associated with lethargy - has recently spent night in ICU for BIPAP. He also had improved ventilation followning Narcan administration. Hypoxia is likely from chronic hypoventilation from morbid obesity and COPD. Methadone likely is exacerbating hypoventilation. He has had a recent sleep study suggesting BiPAP auto SV EPAPmin=EPAPmax= 6, Pressure support min 3 and Pressure support max 6 with back up rate 8. Following transfer from the ICU to the floor, the patient was continued on BIPAP overnight, which he tolerated well. He did not require supplemental oxygen to maintain his oxygen saturation. Methadone dose was slowly increased for pain control. The patient was discharged with BiPAP at the above settings. He was ordered an outpatient sleep study in order to qualify for long term BiPAP, which his PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 3535**], [**First Name3 (LF) **] follow up with. . #. Cellulitis: Pt with b/l BKA secondary to diabetes and PVD. Has been treated with vanc/zosyn/clinda since presentation. Did thorough cleaning on arrival to the MICU. Following transfer to the floor, the patient's antibiotic regimen was simplified from vancomycin and zosyn to bactrim DS [**Hospital1 **] alone. Local wound care was continued, the cellulitis improved clinically, and the patient was discharged with a full course of bactrim. Topical antifungals were also continued. . #. COPD: Pt with extensive smoking history. No evidence of exacerbation. Tiotropium and Advair were continued, with albuterol and ipratropium nebs as needed. . #. IDDM: Pt last documented A1C was 9.2, but was in [**2118**]. Will continue home regimen. Repeat A1c showed improved control with A1c of 8.6. Home insulin regimen was decreased to 20 units of 70/30 in the morning and 10 units of 70/30 at night given pre-breakfast hypoglycemia. The patient had been on 40 units and 20 units, respectively. He was discharged with the lower doses, and will uptitrate as needed. Aspirin and statin therapy were continued. . #. CKD: Pt with Cr 1.9 and at his baseline 1.8-2.0. . #. Chronic Pain: Methadone dose was uptitrated to 60 mg [**Hospital1 **] at time of discharge. The patient was informed of the risks of hypoventilation. . # FEN: replete lytes prn / diabetic diet . # PPX: heparin SQ, bowel regimen . # ACCESS: PIV, PICC . # CODE: Full code . # COMM: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 44865**] [**Telephone/Fax (1) 107541**] and [**Telephone/Fax (1) 107542**] Medications on Admission: 1. Nicotine 14 mg/24 hr Patch 24 hr 2. Aspirin 81 mg daily 3. Methadone 10 mg/mL Concentrate Sig: 90mg [**Hospital1 **] 5. Ranitidine HCl 150 mg daily 6. Simvastatin 80mg daily 7. Senna 8.6 mg [**Hospital1 **] 8. Docusate Sodium 100 mg [**Hospital1 **] 9. Fluticasone-Salmeterol 250-50 mcg/Dose [**Hospital1 **] 10. Amlodipine 5 mg daily 11. Gabapentin 300 mg q12 12. Tiotropium Bromide 18 mcg Capsule daily 13. Insulin NPH & Regular Human 100 unit/mL (70-30): 40U qAM 14. Insulin NPH & Regular Human 100 unit/mL (70-30): 20U qPM 15. Ferrous Sulfate 300 mg daily Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 7. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. 8. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): apply to affected areas. [**Hospital1 **]:*1 unit* Refills:*2* 9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 10. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Transdermal once a day. 12. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 1 weeks. [**Hospital1 **]:*28 Tablet(s)* Refills:*0* 13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): apply to affected areas. [**Hospital1 **]:*1 unit* Refills:*2* 14. Insulin NPH & Regular Human 100 unit/mL (70-30) Insulin Pen Sig: as directed, see attached Subcutaneous twice a day: see attached for dosing. 15. Methadone 10 mg Tablet Sig: Nine (9) Tablet PO twice a day. 16. Other BiPAP Auto Inspiratory maximum 25 mmHg, Expiratory minimum 6 mmHg, IPS 10 Full face medium ([**Doctor Last Name **] [**Last Name (un) 107543**]) Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary Diagnosis: Cellulitis COPD/chronic hypoventilation Secondary Diagnoses: -Diabetes, insulin dependent, with neuropathy, retinopathy, nephropathy, and diabetic foot ulcers. s/p bilateral BKAs due to nonhealing ulcers. LBKA [**2113**], RBKA [**2118**] -h/o IVDU/morphine addiction: On methadone. -Chronic renal insufficiency -HTN Discharge Condition: alert and oriented x 3 wheelchair bound stable and improved Discharge Instructions: You were admitted to the hospital with worsening stump pain. Initially, there was a concern for a deep tissue infection, which a CT scan showed you did not have. You were initially treated with IV antibiotics, which were changed to oral antibiotics, which improved your soft tissue skin infection. You were also noted to sleepy at the beginning of your hospital course, which was thought to be due to sleep apnea, COPD, and excessive methadone dosing. You were monitored overnight in the ICU and received BiPAP overnight to help you breathe. The BiPAP was continued after you left the ICU, and it improved both your breathing and sleepiness. Your pain was controlled with methadone. You were discharged on [**2121-4-18**] in improved condition. Please see below for your follow up appointments. The following changes have been made to your medications: Please continue taking Bactrim DS twice a day for 7 more days Please decrease your insulin dosing. Take 20 units of 70/30 in the morning, and 10 units of 70/30 in the evening. No other changes were made to your medications. Followup Instructions: Department: [**Hospital3 249**] When: THURSDAY [**2121-4-24**] at 1:40 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**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

[ "357.2", "278.01", "518.81", "362.01", "458.9", "070.70", "327.23", "304.01", "585.3", "997.62", "403.90", "250.51", "583.81", "250.41", "707.03", "443.9", "E878.5", "112.3", "250.61", "707.23", "530.81", "305.1", "682.6", "707.19", "V58.67", "496", "338.29", "070.30" ]

icd9cm

[ [ [] ] ]

[ "93.90", "38.93" ]

icd9pcs

[ [ [] ] ]

13364, 13421

8244, 11074

341, 347

13802, 13864

5399, 7143

14998, 15331

3734, 3738

11687, 13341

13442, 13442

11100, 11664

13888, 14975

3753, 4678

13523, 13781

4692, 5380

291, 303

7163, 8221

375, 2871

13461, 13502

2915, 3432

3448, 3718

58,530

128,810

53379

Discharge summary

report

Admission Date: [**2138-4-3**] Discharge Date: [**2138-4-12**] Date of Birth: [**2069-5-27**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: Angina Major Surgical or Invasive Procedure: [**2138-4-8**] - Coronary artery bypass grafting to four vessels. (Left internal mammary->Left anterior descedning artery, Saphenous vein graft(SVG)->Diagonal artery. SVG->Obtuse marginal artery, SVG->Posterior descending artery.) [**2138-4-4**] - Cardiac Catheterization History of Present Illness: 68 y.o with history of Wegners disease resulting in acute renal failure and a 3 month hospitalization, who continues with chronic renal failure. He has had several years of angina symptoms. He had a stress test in [**2134**] showing a mid apical and inferior wall perfusion defect. Due to his renal function it was decided to treat him medically. He now is reporting a significant increase of sublingual nitroglycerin use up to 3 a day. His symptoms are not predictable and occur both with exertion and rest. He underwent a stress test earlier this month, during which he exercised for 3.9 minutes and developed chest pressure and dyspnea. He had 1-2mm of inferolateral ST depression and a moderate to large sized severe intensity inferolateral and posterolateral defect which was primarly fixed. This is not much different from a stress test in [**2134**]. Dr [**Last Name (STitle) **] increased his Imdur from 30mg to 60mg during his last visit. Pt now reports less sublingual use, down to one a day. His creatinine is presently at 3.6 and pt is being admitted for prehydration prior to cardiac catheteriztion. Past Medical History: HTN Hyperdipidemia Coronary artery disease Gastroesophageal reflux disease Chronic kidney diseas - Wegener's granulomatosis Depression, currently working with counselor bimonthly Appendectomy Hernia repair in his 20??????s. Leg cramps Anemia Social History: Pt smoked for over 25 years up to 4 packs a day. He quit about 10 years ago. Lives in [**Location (un) 538**] by himself. He is retired, but states he still works part time. Daughter [**First Name8 (NamePattern2) 11556**] [**Last Name (NamePattern1) **] is his health care proxy, she is available to pick him up at time of discharge. Her home number is [**Telephone/Fax (1) 109793**], cell 1-[**Telephone/Fax (1) 109794**], or her husband cell 1-[**Telephone/Fax (1) 109795**]. Pt has been sober for over 10 years. Denies illicit drug use. Family History: None Physical Exam: 98.6 126/62 72 20 97% RA 103.2KG General: pleasant, answers questions appropriately Chest: lungs clear to auscultation bilaterally. COR: RRR. NL S1S2. No Murmurs, rubs, gallops appreciated. Sternum: stable. Incision clean and dry Abdomen: decreased bowel sounds, soft and nontender without rebound or guarding extremities: warm with 2+ pitting edema to mid shins Pertinent Results: [**2138-4-8**] - ECHO PRE-BYPASS: 1. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). There is mild regional left ventricular systolic dysfunction with mild apical hypokinesis. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the aortic root. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. There is no aortic valve stenosis. No aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. MR [**First Name (Titles) **] [**Last Name (Titles) **] and increased to moderate to severe when BP increased to 150/90. During OPCAB, MR was severe. Dr. [**Last Name (STitle) **] was notified in person of the results. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including phenylephrine and is in Sinus Rhythm. 1. Biventricular function is normal. 2. MR is mild 3. Aorta is intact post decannulation [**2138-4-4**] Cardiac Catheterization 1. Selective coronary angiography of this co-dominant system demonstrated severe three vessel coronary artery disease. The LMCA had mild diffuse disease. The LAD had diffuse proximal 50% and mid 60% disease. The LCX had proximal 80% stenosis with a large OM2 vessel with a 60% mid and 90% distal stenosis. The RCA had diffuse proximal 90% and mid 60-70% stenosis. 2. Limited resting hemodynamic measurement demonstrated normal left sided filling pressure with an LVEDP of 10mmHg. Pullback of the catheter from the left ventricle across the aortic valve did not demonstrate a pressure gradient. Brief Hospital Course: Mr. [**Known lastname 61387**] was admitted to the [**Hospital1 18**] on [**2138-4-2**] for a cardiac catheterization.This revealed severe three vessel disease. Given the severity of his disease, the cardiac surgical service was consulted for surgical revascularization. Mr. [**Known lastname 61387**] was worked-up in the usual preoperative manner. On [**2138-4-8**], Mr. [**Known lastname 61387**] was taken to the operating room where he underwent coronary artery bypass grafting to four vessels. Please see operative note for details. Part of the operation was performed off pump in effort to protect his kidneys. Postoperatively he was taken to the intensive care unit for monitoring. On postoperative day one, Mr. [**Known lastname 61387**] [**Last Name (Titles) 5058**] neurologically intact and was extubated. Beta blokcade, aspirin and a statin were resumed. He was transferred to the step down floor where he was gently diuresed given his renal issues. Physical therapy was consulted to work on strength and balance. By post-operative day 4 he ws ready to be discharged to rehab. Medications on Admission: Atenolol 10', Calcitriol 0.25', Imdur 60', Lisinopril 2.5', Lovastatin 40', NTG SL-prn, Quinine Sulfate 324 hs Sucralfate 1"", Asa 81', Omeprazole 20" Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Disp:*qs Tablet(s)* Refills:*0* 4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. Disp:*5 Suppository(s)* Refills:*0* 5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. Disp:*qs ML(s)* Refills:*0* 6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Quinine Sulfate 324 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:*30 Capsule(s)* Refills:*0* 8. 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* 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 10. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*0* 11. Epoetin Alfa 4,000 unit/mL Solution Sig: as directed Injection QMOWEFR (Monday -Wednesday-Friday). Disp:*qs qs* Refills:*0* 12. 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* 13. Furosemide 20 mg IV Q12H Discharge Disposition: Extended Care Facility: [**Location (un) 86**] Center - [**Location (un) 2312**] Discharge Diagnosis: CAD Hypertension Hyperlipidemia Chronic Kidney Disease due to Wegener's Granulomatosis Depression Anemia Obesity 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 from date of surgery. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: Please follow-up with Dr. [**First Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**] Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. [**Telephone/Fax (1) 5068**] Please follow-up with Dr. [**Last Name (STitle) **] in [**3-12**] weeks. [**Telephone/Fax (1) 798**] Scheduled appointemnts: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2138-5-21**] 10:00 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2138-4-12**]

[ "311", "285.21", "413.9", "530.81", "403.90", "414.01", "585.4", "446.4", "E937.8", "368.16", "276.2", "272.4" ]

icd9cm

[ [ [] ] ]

[ "36.15", "39.61", "36.13", "37.22", "88.55", "88.52" ]

icd9pcs

[ [ [] ] ]

7833, 7916

4880, 5971

326, 600

8073, 8080

2996, 4857

8878, 9459

2587, 2593

6173, 7810

7937, 8052

5997, 6150

8104, 8855

2608, 2977

280, 288

628, 1745

1767, 2012

2028, 2571

26,036

197,892

52973+59483

Discharge summary

report+addendum

Admission Date: [**2136-8-18**] Discharge Date: [**2136-8-22**] Date of Birth: [**2087-5-18**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: sepsis Major Surgical or Invasive Procedure: None History of Present Illness: 49yoF c extensive psychiatric history including PTSD, anxiety, ? sz d/o who presented to the ED intoxicated with alcohol c/o recent theft of bzds (which she says is an anti-seizure medication for her) and rape 3 days ago. Pt says she was sodomized, but had no vaginal intercourse. Stated during this incident she was also "hit in the head". History in ED limited [**3-14**] EtOH intoxication. Further history on arrival to ICU revealed that the event was 3 days ago and the assault was by a friend of a friend. She says that her attacker initially was hitting her friend, but she stepped in and he began attacking her. She says she meant to report this to the police, but she was feeling too poorly and finally they came to her home yesterday. She states that he stole her medications and "all kinds of things." The details remain vague. In [**Name (NI) **] pt was tachycardic with lactate of 6.3. CBC showed WBC 28.6 with 28% bands and MUST protocol was started. R IJ was placed and she received 6L NS, although she was never hypotensive, and lactate decreased to 2.7. O2sats were 80%RA, increased to low 90%'s on 5L, and high 90%'s on NRB. Abd CT revealed RLL pna. She was given doses of ceftriaxone, Vancomycin, Flagyl, and Levofloxacin. She was noted to be hysterical and would become hyperarousable when staff would approach her. . On arrival to the [**Hospital Unit Name 153**], the patient was oriented with odd affect and anxious appearing. She c/o HA, neck pain, ear pain, photophobia, diffuse body aches, fever at home for ? days, cough x past month diagnosed previously as bronchitis, + productive of sputum, + several episodes of post-tussive emesis. Denies dysuria, abdominal pain. Past Medical History: PTSD Anxiety Seizure d/o (pt denies having seizure related to alcohol withdrawal) depression (?with psychotic features) anorexia self- injurious behavior benzo dependence alcohol dependence s/p suicide attempts. multiple involuntary admissions to psychiatric facilities. "subclinical leukemia" as a child h/o atypical chest pain headaches per OMR, Hep C (pt denies) Social History: drinking 10 beers per day last several days "because clonazepam stolen". Denies IVDU not obtained on admit; will follow up once patient awake Family History: Sister, mother with depression. Physical Exam: Gen: thin anxious appearing F in no repsiratory distress. + coarse cough HEENT: PERL. EOMI. mmm. no icterus. CV: tachycardic, regular. Nl S1, S2. No m/r/g. Lungs: decreased BS in RLL. + bronchial breath sounds. Abd: active BS. soft. NT. ND. no masses. Rectal: performed in ED, guiac negative with no apparent lesions or other signs of trauma. Extr: warm, no edema Neuro: CN II-XII intact. MAE. no tremulousness. no focal deficits. Pertinent Results: [**2136-8-18**] 09:20PM PHOSPHATE-1.4* MAGNESIUM-1.7 IRON-6* [**2136-8-18**] 09:20PM calTIBC-163* FERRITIN-176* TRF-125* [**2136-8-18**] 03:11PM LACTATE-0.7 [**2136-8-18**] 11:47AM CEREBROSPINAL FLUID (CSF) PROTEIN-32 GLUCOSE-90 [**2136-8-18**] 11:47AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-3* POLYS-0 LYMPHS-29 MONOS-71 [**2136-8-18**] 09:06AM GLUCOSE-133* UREA N-7 CREAT-0.5 SODIUM-134 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-22 ANION GAP-12 [**2136-8-18**] 09:06AM ALT(SGPT)-23 AST(SGOT)-27 LD(LDH)-163 ALK PHOS-47 AMYLASE-34 TOT BILI-0.5 [**2136-8-18**] 09:06AM LIPASE-36 [**2136-8-18**] 09:06AM ALBUMIN-2.7* CALCIUM-7.0* PHOSPHATE-1.0*# MAGNESIUM-1.6 [**2136-8-18**] 09:06AM WBC-20.6* RBC-3.10* HGB-9.9* HCT-29.0* MCV-94 MCH-31.9 MCHC-34.1 RDW-16.2* [**2136-8-18**] 09:06AM PLT COUNT-147* [**2136-8-18**] 09:06AM RET AUT-2.6 [**2136-8-18**] 07:30AM PT-13.4* PTT-34.8 INR(PT)-1.2 [**2136-8-18**] 07:28AM LACTATE-2.2* [**2136-8-18**] 06:31AM LACTATE-2.7* [**2136-8-18**] 03:49AM LACTATE-6.3* [**2136-8-18**] 03:49AM LACTATE-6.3* [**2136-8-17**] 11:44PM URINE HOURS-RANDOM [**2136-8-17**] 11:44PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2136-8-17**] 11:44PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005 [**2136-8-17**] 11:44PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2136-8-17**] 11:44PM URINE RBC-0-2 WBC-[**4-14**] BACTERIA-FEW YEAST-NONE EPI-[**7-20**] [**2136-8-17**] 08:30PM GLUCOSE-122* UREA N-6 CREAT-0.6 SODIUM-132* POTASSIUM-3.3 CHLORIDE-95* TOTAL CO2-22 ANION GAP-18 [**2136-8-17**] 08:30PM ASA-NEG ETHANOL-387* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2136-8-17**] 08:30PM WBC-28.6*# RBC-3.77* HGB-11.9* HCT-35.6* MCV-94 MCH-31.5 MCHC-33.3 RDW-16.2* [**2136-8-17**] 08:30PM NEUTS-55 BANDS-28* LYMPHS-5* MONOS-8 EOS-0 BASOS-0 ATYPS-0 METAS-4* MYELOS-0 [**2136-8-17**] 08:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL [**2136-8-17**] 08:30PM PLT SMR-NORMAL PLT COUNT-202 . [**8-17**] Head CT No evidence for intracranial hemorrhage. . [**8-17**] CXR Partial collapse of the right middle lobe; no definite underlying pneumonia, but considering the clinical presentation and severe leukocytosis, a chest CT could be performed to exclude both pneumonia and an endobronchial lesion. . [**8-20**] CXR - improved pneumonia, No evidence of layering effusions on either side. The previously noted right pleural effusion on the study of [**2136-8-19**] has resolved. Brief Hospital Course: A/P: 49yo female with extensive psych history, who is s/p a sexual assault three days ago, who is admitted on sepsis protocol with RLL/RML pneumonia. . 1. Pneumonia/Sepsis: Likely that sepsis was secondary to patient's severe pneumonia. Patient presented with temp 101.9, HR 130s, lactate 6.3, WBC of 28.6, and 96% on RA (100% on NRB). CXR showed partial collapse of the right middle lobe and recommended CT scan for better evaluation of what caused the collapse (likely a pneumonia). CT scan of the abdomen and pelvis identified a RLL pneumonia but no abscess or other foci of fever in pelvis. Had right pleural effusion, most likely a para-pneumonic effusion. Abdominal CT and urinalysis were negative for other fever sources and urine cx is negative at time of discharge. Blood cultures x2 were obtained and are negative at time of discharge. Pt complained of achiness all over, stiff neck, photophobia and a fever, so an LP was performed to r/o meningitis. Gram stain of her CSF showed no microorganisms and only 1 WBC, 3 RBC on cell count. Glu and protein were normal. Once her CSF was normal, abx were narrowed down to IV levaquin. CSF cx was negative at time of discharge. . She was treated initially with IV levofloxacin. Her fever broke and she felt much better over the next two days. She was changed to po levofloxacin and remained afebrile with good oxygenation on room air for the rest of the admission. CXray on [**8-20**] demonstrated improvement of her pneumonia and complete resolution of the pleural effusion. She will need to have 10 more days of oral levofloxacin to complete her treatment. No further imaging is required. . 2. Psych/Benzo/EtOH withdrawal: Pt was placed on a CIWA scale with diazepam 5-10mg IV q2-4h prn for CIWA >10. She was continued on the CIWA scale for the first 4 days of her admission requiring valium. SHe remained hemodynamically stable. Currently the patient is hallucination free. She has severe anxiety and has been medicating herself with benzos, and further self medicating with EtOH. She was also evaluated by psych who felt she was appropriate for an inpatient psych facility. . 3) Pain - Patient reports "total body pain". The pain is not localized to any anotomical cause. This is likely a functional pain and does not have a specific medical cause as evidenced by her normal labs, abd/pevis CT, and lumbar puncture. Opoids are not the treatment of choice. She benefitted with treatment of her anxiety with valium. Furthermore the patient also felt better with tylenol and ibuprophen. . FEN: Taking regular diet well . Code status: FULL CODE Medications on Admission: Clonazepam 2 mg po QID Discharge Medications: 1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days. 2. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 4. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 5. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 6. Diazepam 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for anxiety/pain. Discharge Disposition: Extended Care Facility: [**Hospital1 1680**] - [**Hospital **] Hospital - [**Location (un) **] Discharge Diagnosis: Primary: 1. Multilobar Pneumonia. 2. Sepsis. 3. Lactic Acidosis. 4. ETOH and Benzodiazepine Intoxication. 5. Hyponatremia. 5. Possible Sexual Assault. Secondary: 1. Atypical chest pain. 2. Hepatitis C. 3. PTSD. 4. Depression with Psychotic Features. 5. Self-injurious behavior. 6. Alcohol and Benzodiazepin dependence. 7. Multiple suicide attempts. Discharge Condition: stable vital signs eating well stable oxygenation on room air walking independently Discharge Instructions: PLease take all medications and make all appointments as indicated in the discharge paperwork. If she has fevers, chills, chest pain, shortness of breath, abd pain please [**Name6 (MD) 138**] her MD or take her to the hospital. Followup Instructions: PLease follow up with Dr. [**First Name4 (NamePattern1) 2048**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 29679**] at the [**Hospital3 **] Women's Health Center in [**2-12**] weeks. Name: [**Known lastname 17890**],[**Known firstname 17891**] Unit No: [**Numeric Identifier 17892**] Admission Date: [**2136-8-18**] Discharge Date: [**2136-8-22**] Date of Birth: [**2087-5-18**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 175**] Addendum: The afternoon of discharge the patient self administered an enema. She then noticed a small about of red blood on her toilet tissue. 30 minutes later she noticed a small amount of red blood again while having a bowel movement "a few drips and some on the toilet paper. Rectal exam demonstrated no signs of trauma or infection. Rectal tone was normal with brown stool and no blood on my glove. Her Blood pressure and pulse are stable and she does not complain of lightheadedness. This bleeding was likely secondary to trauma from the enema. The bleeding has since stopped. Discharge Disposition: Extended Care Facility: [**Hospital1 3288**] - [**Hospital **] Hospital - [**Location (un) 382**] [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 181**] MD [**MD Number(1) 182**] Completed by:[**2136-8-22**]

[ "276.5", "296.23", "304.11", "303.01", "780.39", "276.1", "309.81", "276.2", "518.0", "E968.8", "070.70", "511.9", "995.91", "486", "038.9" ]

icd9cm

[ [ [] ] ]

[ "03.31" ]

icd9pcs

[ [ [] ] ]

11016, 11273

5761, 8383

320, 327

9465, 9550

3118, 5738

9827, 10993

2618, 2651

8456, 8951

9092, 9444

8409, 8433

9574, 9804

2666, 3099

274, 282

355, 2052

2074, 2442

2458, 2602

10,969

168,795

1920

Discharge summary

report

Admission Date: [**2123-12-9**] Discharge Date: [**2123-12-15**] Date of Birth: [**2067-11-8**] Sex: M Service: CT SURGERY HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 10678**] is a 56-year-old male with a past medical history significant for hypertension, hypercholesterolemia, and a positive family history for coronary artery disease, who presented with complaints of left chest wall numbness and tingling and pressure with radiation into the left arm for 24 hours. This was intermittent in nature, was non-exertional, had no associated symptoms of shortness of breath, palpitation, nausea or vomiting. This was different from what the patient usually experienced with his anginal equivalent, which was typically chest pain extending to the throat with shortness of breath and often with exertion and relieved by rest. Of note, recently on [**2123-11-26**], the patient had undergone a stress echocardiogram that was positive, showing inferolateral ST depressions with hypokinesis on echocardiogram with an ejection fraction estimated at 55%. Due to the patient's positive stress test and now his new onset symptoms, he was evaluated in the [**Hospital1 190**] Emergency Room on the [**9-9**] by the Cardiac Critical Care team. Ironically, the patient had previously agreed for an elective coronary artery catheterization to be done prior to the [**Holiday **] holiday, but now presents with new symptoms of chest pain. PAST MEDICAL HISTORY: Gout, gastroesophageal reflux disease, symptomatic premature atrial contractions, hypertension, hypercholesterolemia. The hypertension is borderline. ALLERGIES: No known drug allergies. PAST SURGICAL HISTORY: Unremarkable. MEDICATIONS ON ADMISSION: Atenolol 37.5 mg by mouth once daily, Lipitor 10 mg by mouth once daily, Norvasc 5 mg by mouth once daily, a baby aspirin per day, and [**Name (NI) 6196**] 40 mg by mouth once daily, which the patient had recently stopped taking. SOCIAL HISTORY: Remarkable for occasional ethanol, no tobacco history. Lives with his wife. FAMILY HISTORY: Positive for coronary artery disease. PHYSICAL EXAMINATION: Temperature 98.7, blood pressure 155/84, pulse 60, 99% on room air. He is alert and oriented x 3, comfortable. Jugular venous pressure was less than 7 cm. There was no bruit. The trachea was midline. The lungs were clear to auscultation bilaterally. There was a questionable hyperesthetic left chest wall. He had a normal S1, S2 on auscultation, with no murmurs, gallops or rubs. His peripheral pulses were 2+, dorsalis pedis and posterior tibial bilaterally. The abdomen was soft, nontender, nondistended, with positive bowel sounds. The extremities were not edematous. LABORATORY DATA: White blood cell count 7,000, hematocrit 44, platelets 193. Potassium 4.1, BUN and creatinine 12 and 1.0. His admission CK was 72, with a troponin-I of less than .3. Chest x-ray on [**2123-12-6**] was within normal limits, no evidence of failure or cardiomegaly, no pneumothorax. His coagulation profile was normal. His electrocardiogram on admission was sinus bradycardia to sinus rhythm, rates in the 58 to 60 range. He had a normal axis and intervals. There is evidence of left atrial enlargement. He had J-point elevation. There were no ST/T changes as compared to an electrocardiogram from [**2118**]. HOSPITAL COURSE: Given the patient's significant risk factors for coronary artery disease and positive stress testing with new onset anginal equivalent, he was therefore admitted to the C-MED service for same day cardiac catheterization as well as for management of presumptive acute coronary syndrome. He was placed on beta blockade, nitrates, ACE inhibitors, aspirin and a statin. His enzymes were cycled accordingly. He underwent a cardiac catheterization that showed a right dominant circulation, ejection fraction of approximately 60%. He had a mid-left anterior descending lesion of 50%, a D1 lesion of 80%, a left circumflex of 90% stenosis, the middle right coronary artery was 100% occluded. The ramus was also noted to be 80% occluded. Given the significant three vessel coronary artery disease, a Cardiothoracic Surgical consultation was obtained with Dr. [**Last Name (STitle) **]. The patient ultimately consented to go to the operating room on [**2123-12-10**], where he underwent an elective coronary artery bypass graft x 5, including a left internal mammary artery graft to the diagonal, saphenous vein graft to the distal left anterior descending, saphenous vein graft to obtuse marginal I, sequential to the obtuse marginal II, as well as saphenous vein graft to the posterior descending artery. The patient tolerated the procedure well. He left the operating room with an arterial line, a CVP right atrial catheter. He had two ventricular pacing wires and two atrial pacing wires, two mediastinal chest tubes, one left pleural tube. He was A-paced, with a rate of 90. His mean arterial pressure was 76, with a CVP right atrial pressure of 12. His blood pressure was being supported with Neo-Synephrine at 3 mcg/kg/minute, and he was on propofol for sedation at 20 mcg/kg/minute. Once transferred to the Cardiac Surgical recovery unit, the patient was rapidly extubated. He remained on Neo-Synephrine at 1.25 on postoperative day number one. He had low-grade temperatures of 100.9 for T-max, and postoperatively by the morning of postoperative day one, he was 98.8. Blood pressure was still low at 90/47. Therefore, he was maintained on Neo-Synephrine. His hematocrit was noted to be 22 postoperatively. As a consequence, he was transfused a unit of blood. His lasix and beta blockers were withheld. BUN and creatinine on postoperative day number one were 10 and .8. His diet was advanced. He was given perioperative dosing of vancomycin. His chest tubes were also removed. His Neo-Synephrine was weaned once his blood was transfused, and he was ultimately transferred to the floor on postoperative day number one. On postoperative day number two, the patient was stable and doing well. He was ambulating at a Level III. His diet was being tolerated for a cardiac diet. His post-transfusion hematocrit was only 22. His Lopressor was titrated for heart rate of 102 and blood pressure of 110. He did spike a low-grade temperature to 101.8, and also 102.1 orally on the evening of postoperative day one into two. He ultimately had sputum cultures, blood cultures and urine cultures sent. He was maintained on his perioperative vancomycin dosing. The wound was noted to be clean, dry and intact, with no evidence of erythema or exudate. By postoperative day number three, the patient continued to have low-grade temperatures to 100.1. He was in sinus rhythm in the 80s, with blood pressures of 110 systolic. His finger sticks remained under 200. His hematocrit was 28 status post transfusion, and his BUN and creatinine were noted to be 12 and 1.0. His wires were removed. His antecubital intravenous was removed, with a peripheral replaced. He continued his aggressive physical therapy and pulmonary toilet. He was ambulating at a Level IV at this time in his postoperative course. On postoperative day number four, the patient was doing well, had no complaints. His hematocrit was 28, with a BUN and creatinine of 14 and 1.1. He continued to have sinus rhythm in the 90s, with blood pressures 128/60. As a consequence, his Lopressor was titrated again to a dose of 75 mg by mouth twice a day. He had persistent low-grade temperatures to 101.1 on postoperative day number four. He was re-cultured at this point. To date, he had blood cultures x 3, urine cultures, as well as sputum cultures with no growth to date. His white blood cell count was 10,000. He had a hematocrit of 28 and a BUN and creatinine of 12 and 1.0. He was continued on aggressive pulmonary toilet with chest physiotherapy, incentive spirometry, and ambulation three times a day with assist. His chest x-ray postoperatively on day number four just showed right basilar atelectasis but no other evidence of infiltrate or effusion. By postoperative day number five, the patient was afebrile, following a cardiac diet. Heart rate was in the 80s, blood pressures 110s to 120s. The chest was stable, with Steri-Strips dried, open to air, no evidence of drainage was noted. His heart was regular, with no murmur, rub or gallop. The lungs showed crackles at the bases, otherwise clear. The abdomen was soft, nontender, nondistended, normal active bowel sounds. His lower extremities were warm and well perfused. He had 2+ palpable pulses of the dorsalis pedis and posterior tibial bilaterally. The patient had no Foley, chest tube or pacing wires present at this time. DISCHARGE MEDICATIONS: Lopressor 75 mg by mouth twice a day, [**Date Range 6196**] 40 mg by mouth once daily, K-Dur 20 mEq by mouth every morning for seven days, lasix 20 mg by mouth every morning for seven days, aspirin 325 mg by mouth once daily, percocet 5/325 one to two tablets by mouth every four to six hours as needed, Colace 100 mg by mouth twice a day, as well as a multivitamin by mouth once daily. DISCHARGE PLAN: Follow up in the Wound Care Clinic in one week to have wound check. He will additionally be seen by Dr. [**Last Name (STitle) **] in 30 days from the time of discharge, and will follow up with his primary care provider in approximately three to four weeks from the date of discharge. DISCHARGE STATUS: Stable, afebrile, to go home with VNA. DISCHARGE DIAGNOSIS: 1. Significant three vessel coronary artery disease status post coronary artery bypass graft x 5, including left internal mammary artery to the diagonal artery, saphenous vein graft to the distal left anterior descending as well as saphenous vein graft to the obtuse marginal I to obtuse marginal II sequentially, and saphenous vein graft to the right coronary artery and posterior descending artery. 2. Hypertension 3. Hypercholesterolemia 4. Gastroesophageal reflux disease 5. Gout 6. Postoperative fever [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern4) 3204**] MEDQUIST36 D: [**2123-12-14**] 23:11 T: [**2123-12-15**] 00:17 JOB#: [**Job Number 10679**]

[ "518.0", "272.0", "414.01", "411.1", "780.6", "998.89", "401.9" ]

icd9cm

[ [ [] ] ]

[ "37.22", "88.55", "88.53", "36.14", "39.61", "36.15" ]

icd9pcs

[ [ [] ] ]

2084, 2123

8797, 9185

9568, 10363

1739, 1970

3381, 8772

1696, 1711

2147, 3363

174, 1456

9202, 9547

1480, 1671

1988, 2066

56,128

155,909

33853

Discharge summary

report

Admission Date: [**2138-12-15**] Discharge Date: [**2138-12-23**] Date of Birth: [**2094-6-5**] Sex: F Service: MEDICINE Allergies: Penicillins / Zantac / Morphine / Tylenol / Naprosyn / ketorolac Attending:[**First Name3 (LF) 4891**] Chief Complaint: right-sided abdominal pain, nausea, vomiting, low blood pressure Major Surgical or Invasive Procedure: Femoral central venous line ([**2138-12-15**]) History of Present Illness: 44 yo F with ESRD on HD, IDDM, and CAD s/p MI who presents from dialysis with abdominal pain and hypotension. Patient was at dialysis today for one hour, and ate some lunch. Approximately half an hour later, she suddenly started complaining of RLQ abdominal pain and became hypotensive to 60s (per EMT report). She was also reported to have some nausea and vomiting right after eating. She was in her USOH at her rehab prior to dialysis today, other than an episode of diarrhea on Sunday (brown, non-bloody). Denied any fevers. Has had a cough productive of sputum for a few days now. Denies any chest pain, shortness of breath, joint pains, new rashes, blood in her stools, LH, or syncope. No recent changes in her medications per patient, although her rehab list of medications is not completely congruent with her last discharge medications, as they do not contain any anti-hypertensives. She was brought by the EMTs to the ED for further evaluation for her hypotension. In the emergency department, VS were 97.7 61 87/41 20 99% RA. Pt received 1 L IVFs, Vancomycin IV, Cefepime IV, dilaudid 1 mg IV x1. R femoral line was placed and pt was started on levophed gtt due to blood pressure dropping to 70s in the ED. It is unclear if this occurred in the setting of receiving her dilaudid. Labs sig for WBC of 5.0, Hct of 40.7, Cre of 9.0. Per ED resident, pain was thought to be out of proportion to physical exam, concerning for mesenteric ischemia. Lactate was 1.4. Of note, also having difficulty getting good pulse oximetry on the patient. CT abdomen pre-lim read showed no acute intra-abdominal process. No CXR was performed. Pt transferred to the MICU for further work-up. In the MICU, pt admitted to not feeling 'good' about her symptoms, and asked the team 'not to leave her alone'. Complaining of some mild RLQ pain that improved with IV medication. Of note, patient states she was hospitalized for several months recently at [**Hospital1 882**] and [**Hospital1 112**] recently. REVIEW OF SYSTEMS: (+)ve: (-)ve: fever, chills, night sweats, loss of appetite, fatigue, chest pain, palpitations, rhinorrhea, nasal congestion, cough, sputum production, hemoptysis, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, nausea, vomiting, diarrhea, constipation, hematochezia, melena, dysuria, urinary frequency, urinary urgency, focal numbness, focal weakness, myalgias, arthralgias Past Medical History: ESRD on HD Tues/Thurs/Sat with LLE AV fistula CAD s/p inferior MI (cath [**2129**] with non-obstructive CAD, EF 65%, inf hypokinesis) IDDM II h/o LLE DVT (on coumadin), most recently had popliteal DVT [**2136-8-25**] on U/S s/p IVC filter placement HTN Hyperlipidema GERD reported history of MRSA Social History: Born in [**Country 2045**]. Moved from [**State 108**] to Mass. recently. Lives at [**Location **] Manor. Divorced; has 21 and 16 y/o daughters who live with their father. Denies [**Name2 (NI) **]/etoh/illicits. Family History: Non-contributory, daughters (x2) without insulin-dependent diabetes Physical Exam: GEN: anxious, NAD HEENT: PERRLA. MMM. NECK: neck supple PULM: CTAB no crackles + expiratory wheezes CARD: RRR soft SM heard best at LLSB, no g/r ABD: NTTP, +BS, no g/rt, no HSM. EXT: cold distal extremities, DPs, PTs 1+ SKIN: multiple excoriations NEURO: AOx3e, very anxious Pertinent Results: Admission Labs [**2138-12-15**] 04:10PM BLOOD WBC-5.0 RBC-4.59 Hgb-13.3 Hct-40.7 MCV-89 MCH-29.0 MCHC-32.8 RDW-16.3* Plt Ct-154# [**2138-12-15**] 04:10PM BLOOD Neuts-70.3* Lymphs-16.8* Monos-7.1 Eos-4.5* Baso-1.3 [**2138-12-15**] 04:10PM BLOOD Glucose-132* UreaN-47* Creat-9.0*# Na-136 K-4.0 Cl-93* HCO3-27 AnGap-20 [**2138-12-15**] 04:10PM BLOOD ALT-14 AST-16 CK(CPK)-76 AlkPhos-223* TotBili-0.2 [**2138-12-15**] 04:10PM BLOOD Lipase-28 [**2138-12-15**] 10:50PM BLOOD Cortsol-5.6 [**2138-12-15**] 04:21PM BLOOD Lactate-1.4 Pertinent Labs [**2138-12-15**] 04:10PM BLOOD cTropnT-0.08* [**2138-12-15**] 10:50PM BLOOD CK-MB-5 cTropnT-0.27* [**2138-12-16**] 05:12AM BLOOD CK-MB-6 cTropnT-0.35* [**2138-12-16**] 09:14AM BLOOD CK-MB-5 cTropnT-0.29* [**2138-12-16**] 02:12PM BLOOD CK-MB-5 cTropnT-0.26* [**2138-12-15**] 10:50PM BLOOD Cortsol-5.6 [**2138-12-16**] 05:12AM BLOOD Cortsol-6.8 [**2138-12-15**] 10:51PM BLOOD Lactate-1.2 [**2138-12-16**] 05:33AM BLOOD Lactate-1.1 Labs on Discharge: [**2138-12-23**] 09:50AM BLOOD WBC-4.2 RBC-4.08* Hgb-12.0 Hct-37.6 MCV-92 MCH-29.5 MCHC-32.0 RDW-16.6* Plt Ct-177 [**2138-12-23**] 09:50AM BLOOD Glucose-220* UreaN-28* Creat-7.1*# Na-135 K-5.5* Cl-94* HCO3-30 AnGap-17 [**2138-12-23**] 09:50AM BLOOD Calcium-9.3 Phos-4.1 Mg-2.4 Pertinent Reports CT abdomen/pelvis with contrast ([**2138-12-15**]) 1. No acute pathology identified to account for the patient's symptoms. The appendix is normal. 2. Heterogeneous-appearing endometrium with possible polyp. Clinical correlation is recommended and a pelvic ultrasound can be obtained for further evaluation on a nonemergent basis. 3. Atrophic native kidneys. 4. Sebaceous cyst within the right inferior anterior chest wall. TTE ([**2138-12-16**]): Normal global and regional biventricular systolic function. No pulmonary hypertension or clinically-significant valvular disease seen. CXR ([**2138-12-16**]): Unchanged moderate cardiomegaly with minimal retrocardiac atelectasis. Small overall lung volumes. No pulmonary edema. No pleural effusion. No pneumonia. The hilar and mediastinal contours are unremarkable. Transvaginal Ultrasound: 1. Endometrial lesion measuring up to 17 mm with internal vascularity. Most likely represents endometrial polyp but differential diagnosis consideration includes submucosal fibroid and hyperplasia. Neoplastic process deemed less likely given patient's age, but cannot be completely excluded. Recommend short-term followup with son[**Name (NI) 16012**] and/or biopsy for further assessment. 2. 1.9 cm left ovarian cyst. The study and the report were reviewed by the staff radiologist. Pending data at discharge: Aldosterone, renin levels Brief Hospital Course: 44 year old female with ESRD on HD, IDDM, CAD who presented with hypotension and abdominal pain at HD session. #. Hypotension: Initial differential included septic [**Name (NI) **], hypovolemic [**Name (NI) **], cardiogenic [**Name (NI) **], neurogenic [**Name (NI) **] and adrenal insufficiency. She was initially started on norepineprhine to keep her MAP > 65 but able to wean off norepinephrine after her blood pressure responded to intravenous fluid boluses. She did not have a source of infection on imaging (CT abdomen/pelvis and CXR), fever or inappropriate mixed venous oxygen. Unlikely to be septic [**Last Name (LF) **], [**First Name3 (LF) **] antibiotics were discontinued on [**2138-12-16**]. Unlikely to be neurogenic [**Date Range **] with no history of stroke, trauma and appropriate mental status. Unlikely to be cardiogenic [**Date Range **] with no change in TTE, normal stress test within past year seen on records obtained from [**Hospital 882**] Hospital. Once transferred to the floor, she was administered a trial of dexamethasone. She was evaluated by endocrine service for question of adrenal insufficiency. She had cosyntropin stim test performed which showed adequate adrenal response. Her random and AM cortisol is low, however, this was drawn after she was given empiric dexamethasone. Random levels are appropriate. Endocrine believed may be component of autonomic neuropathy socondary to long standing DM. She was started on Fluorinef and continued at discharge. Her blood pressures remained stable in 85-110 range systolic. Renin and aldosterose are pending at the time of discharge. # Abdominal pain: Unclear etiology. CT abdomen/pelvis with contast showed no underlying etiology. Her pain responded with bowel rest and dilaudid. She was able to tolerate advanced diet on [**2138-12-16**]. # Troponin leak: 0.08 on admision. Peaked at 0.35. Trended downward. CKs flat. Likely due to demand ischemia with hypotension in underlying ESRD. Checked lipid panel for risk stratification and started on atorvastatin 80 mg po qdaily. TTE showed no focal wall motion abnormality with normal structure and function. #. ESRD on HD Tues/Thurs/Sat with LLE AV fistula: Underwent dialysis as an inpatient. Continued renal meds. Converted to aranesp to epo while in house #. CAD: s/p inferior MI (cath [**2129**] with non-obstructive CAD, EF 65%, inf hypokinesis). Continued ASA and started on atorvastatin 80 mg po qdaily due to elevated troponins. Not on BB on admission and not started due to low blood pressures. #. IDDM II: Continue RISS with Levemir 6 U QHS (Glargine while in- house). Sugars fluctuated dramatically in setting of dexamethasone trial, and resolved as the dexamethasone wore off gradually. # Endometrial polyp: Patient experienced vaginal bleeding as inpatient, but HCT remained stable. Underwent trans-vaginal pelvic ultrasound which showed endometrial lesion measuring up to 17 mm with internal vascularity. Most likely represents endometrial polyp but differential diagnosis consideration includes submucosal fibroid and hyperplasia. Neoplastic process deemed less likely given patient's age, but cannot be completely excluded. Recommend short-term followup with son[**Name (NI) 16012**] and/or biopsy for further assessment. Medications on Admission: Aranesp 04 mcg/0.4 mL 4 PM SQ weekly Artificial tears Bisacoldyl 10 mg PO Qdaily Fluticasone Nasal Spray 2 sprays INH daily HISS + Levemir 6 U QHS Lidoderm 5% PATCH TP q12H on q12H off Miralax Nephrocaps 1 cap PO daily Neurontin 200 mg PO daily Prilosec 20 mg PO daiy Renal getl 800 mg PO TID with meals Senna Xalatan eye drops Diazepam 5 mg PO daily:PRN anxiety Dilaudid 1 mg PO q6H:PRN pain Haldol 5 mg PO q6H:PRN behavior/anxiety Immodium prn: diarrhea Tyelenol 325 mg PO q4H:PRN Discharge Medications: 1. Aranesp (polysorbate) 40 mcg/0.4 mL Syringe Sig: One (1) injection Injection once a week. 2. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One (1) Appl Ophthalmic [**Hospital1 **] (2 times a day). 3. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day. 4. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). 5. Levemir 100 unit/mL Solution Sig: Six (6) units Subcutaneous at bedtime. 6. Insulin sliding scale As previous 7. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) patch Topical 12 hours on, 12 hours off. 8. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 9. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 10. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. diazepam 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for anxiety. 14. Dilaudid 2 mg Tablet Sig: 0.5 Tablet PO every six (6) hours as needed for pain. 15. Xalatan 0.005 % Drops Sig: One (1) drop Ophthalmic QHS. 16. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 17. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Renagel 800 mg Tablet Sig: Three (3) Tablet PO three times a day. 19. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital 16662**] Nursing and Rehab Center - [**Street Address(1) **] Discharge Diagnosis: - End Stage Renal Disease on Hemodialysis - Autonomic Dysfunction - Type I Diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [**Known lastname 78242**], You were admitted to the hospital with abdominal pain and low blood pressure. In the intensive care unit, you were given fluids and medication to help maintain your blood pressure. We also ruled out the possibility of infection. After leaving the intensive care unit, you continued to have lower blood pressures. We started you on a new medication called Fludrocortisone in order to prevent this from happening again. You were also found to have vaginal bleeding during your hospital stay. This is likely related to a polyp which was discovered on ultrasound. You will need to follow-up with OB-GYN as an outpatient in order to further evaluate this issue. Please START the following medication after discharge: FLUORINEF (Fludrocortisone Acetate) 0.1 mg by mouth twice daily (for your blood pressure) ATORVASTATIN 40 mg daily ASPIRIN 81 mg daily Please INCREASE the following medication: From Sevelamer 800 mg TID to 2400 mg TID Should you experience dizziness, lightheadedness, fevers, chills, or additional heavy bleeding after discharge, please call your doctor or return to the emergency room as soon as possible. Followup Instructions: Please follow-up with your physician at the [**Name9 (PRE) 4820**] care facility. You are also scheduled for an appointment with the gynecologist: Department: OBSTETRICS AND GYNECOLOGY When: TUESDAY [**2138-12-30**] at 10:15 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 8246**] Building: [**Hospital6 29**] [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "337.1", "V45.11", "536.3", "250.51", "250.61", "530.81", "V58.67", "414.01", "585.6", "621.0", "V12.51", "255.41", "403.91", "V58.61", "362.01", "272.4", "357.2", "789.03", "412", "285.21" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

11858, 11957

6495, 9782

391, 439

12085, 12085

3805, 4775

13454, 13913

3426, 3495

10316, 11835

11978, 12064

9808, 10293

12270, 13431

3510, 3786

6444, 6472

2479, 2858

287, 353

4794, 6430

467, 2460

12100, 12246

2880, 3180

3196, 3410

20,385

177,271

26939

Discharge summary

report

Admission Date: [**2167-3-28**] Discharge Date: [**2167-4-10**] Service: MEDICINE Allergies: Heparin Agents / Lipitor Attending:[**First Name3 (LF) 30**] Chief Complaint: sepsis Major Surgical or Invasive Procedure: R IJ central line placement History of Present Illness: 81 F presents from [**Hospital1 **] with fever, hypotension, and altered mental status. Pt s/p CABG [**5-29**] c/b bowel ischemia s/p resection with ileostomy with high level of output resulting in intermittent dehydration. Pt had PICC placed recently for TPN to improve nutritional status before closure of ileostomy shceduled for [**4-13**]. On admission, pt c/o nonproductive cough. Denied dysuria, abdominal pain, nausea/vomiting, diarrhea, chest pain, back pain, or SOB. In the [**Name (NI) **], pt was given vancomycin 1g x1, levofloxacin 500mg IV x1; a Foley was placed, Ucx and BlCx sent. Pt was given 2L NS. BP was 93/28 on arrival, decreased to 82/39. Code sepsis was called, and pt was transferred to [**Hospital Unit Name 153**]. Past Medical History: - 3V CABG [**5-29**] - Mesenteric ischemia s/p resection and temportary ileostomy - Short gut syndrome - HIT - Depression Social History: Denied ETOH, tobacco, IVDA. Currently lives at [**Hospital **] rehab in preparation for ileostomy reversal. Family actively involved in care Family History: NC Physical Exam: Gen: awake, alert, mild respiratory distress HEENT: PERRL, EOMI, MM dry Neck: JVP flat, no cervical LAD CV: irregular, nl S1/S2, no m/r/g Pulm: diffusely wheezy, no crackles Abd: soft, NT/ND, ostomy patent, draining brown liquid stool Ext: warm, no edema Skin: no rashes Pertinent Results: Admission labs: electrolytes: GLUCOSE-102 UREA N-28* CREAT-1.3* SODIUM-140 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-26 ANION GAP-14 CALCIUM-8.0* PHOSPHATE-3.1 MAGNESIUM-2.1 LFTs: ALT(SGPT)-16 AST(SGOT)-30 AMYLASE-44 LIPASE-14 CBC: WBC-7.6 RBC-3.40* HGB-10.0* HCT-28.8* MCV-85 MCH-29.6 MCHC-34.8 RDW-14.7 PLT COUNT-185 NEUTS-83.5* BANDS-0 LYMPHS-10.7* MONOS-4.0 EOS-1.7 BASOS-0.1 LACTATE-1.6 Imaging: [**3-27**] CXR: No acute cardiopulmonary abnormality identified. [**3-30**] CXR: There is new bilateral lower lobe infiltrates and effusions with volume loss in the left lower lobe as well. There is hazy bilateral vasculature with vascular redistribution. It is unclear how much of this process due to CHF or if there is an underlying infectious infiltrate. Dual-lead pacemaker is unchanged. Right subclavian line tip is in the superior vena cava. IMPRESSION: New bilateral lower lobe infiltrates and effusion. Micro: [**3-27**] Blood Cx: 4/4 bottles with coag neg Staph: STAPHYLOCOCCUS, COAGULASE NEGATIVE | ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 4 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 2 S [**3-28**] PICC tip with coag negative Staph, same sensitivities as above [**3-28**] UCx: Enterococcus: ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S LEVOFLOXACIN---------- =>8 R NITROFURANTOIN-------- <=16 S VANCOMYCIN------------ <=1 S [**3-28**], [**3-31**] blood cultures NGTD . CXR [**4-5**]: Interval resolution of previously seen congestive heart failure. Small, persistent, bilateral effusions. . Tunneled Cath placement [**4-6**]: Successful placement of a 10-French double-lumen tunneled central venous catheter by way of the right internal jugular vein with tip in the superior vena cava. The catheter can be used immediately. Brief Hospital Course: 1. Sepsis - Pt was admitted to the [**Hospital Unit Name 153**] and was administered approximately 5L IV fluid for hypotension. Pt required levophed support for 24 hours and was subsequently weaned off pressors. Cortisol stimulation test was normal. CXR was without infiltrate; UCx grew Enterococcus and [**4-28**] blood cultures grew coag negative Staph with same sensitivity profile as coag neg Staph from PICC tip. Pt was initially treated broadly with Zosyn and Vanco; once sensitivities returned from blood cultures and PICC tip, antibiotics were reduced to Vancomycin alone, to continue for 14 days total (last dose [**2167-4-11**]). Patient remained hemodynamically stable and afebrile on the floor. . 2. Congestive heart failure - Patient was fluid overloaded on exam after aggressive resuscitation in the setting of sepsis. Pt autodiuresed well and lung exam improved through hospital course. Patient was weaned off supplemental oxygen on the floor, and continued to oxgenate well on room air. . 3. s/p bowel resection with ostomy, short-gut syndrome - PICC line had initially been placed for nutritional optimization prior to reversal of ostomy planned for later this month at [**Hospital1 2025**]. Ileostomy had high-ouput drainage; in discussion with patient's PCP at [**Name9 (PRE) 2025**], numerous medical interventions had been tried without success. Patient was continued on Ranitidine [**Hospital1 **], and Lansoprazole added to regimen for GERD-type symptoms with good effect. Once access was obtained (R IJ tunneled cath), TPN was cycled, first over 24 hours, now 12 hours overnight. . 4. Coronary artery disease s/p CABG - Given high output from ileostomy, patient was not on ACE or BB as she was prone to dehydration and BPs ran asymptomatically low at baseline. Pt was continued on aspirin. Patient with statin allergy - rhabdomyloysis on prior administration. Patient without coronary issues on this admission. . 5. Depression - continued on outpatient Amitriptyline 15 . 6. Access - A right subclavian was placed while in ICU which was subsequently dc'd after hemodynamically stable. PICC was removed shortly after admission as it was the etiology of sepsis. After surveillance cultures were negative x72 hours, PICC replacement was attempted but unsuccessful due to subclavian stenosis on right, and left was not engaged due to presence of pacemaker. Cardiology was curbsided and they recommended against PICC placement on left. Patient then received double-lumen tunneled R IJ via Interventional Radiology on [**2167-4-6**]. . 7. PPX Patient with history of Heparin-induced thrombocytopenia, NO heparin products were administered. Patient was given Fondaparinux for DVT prophylaxis. . 8. CODE: FULL Medications on Admission: ASA 81 mg po qd, elavil 12.5 mg po qhs, Alphagan gtt, Citracel+D 1 tab po tid, folate 1 mg po qd, arixtra 2.5 mg SC qhs, MVI 1 tab po qd, zantac 150 mg po qd, loperamide 2mg po q8h prn Discharge Medications: 1. Amitriptyline 25 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 2. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 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. Albuterol Sulfate 0.083 % Solution Sig: One (1) inhalation Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 10. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 5 days. 11. Fondaparinux 2.5 mg/0.5 mL Syringe Sig: One (1) injection Subcutaneous DAILY (Daily). 12. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Five (5) mL PO DAILY (Daily). 13. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 14. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q 24H (Every 24 Hours) for 1 days. Recon Soln(s) Discharge Disposition: Extended Care Discharge Diagnosis: Principal: 1. Methicillin Sensitive Coagulase Negative Staph Line Sepsis. 2. Enteroccocus Urinary Tract Infection. 3. Diastolic Heart Failure. 4. Malnutrition - Moderate Degree. 5. High Ouput Ileostomy. 6. Stage III Chronic Kidney Disease. Secondary: 1. Coronary Artery Disease s/p CABG. 2. Perioperative bowel ischemia s/p resection. 3. Short-Gut Syndrome with Ileostomy. 4. Immune Mediated Heparin Induced Thrombocytopenia. 5. Dual Chamber Pacemaker. 6. Gastroesophageal Reflux Disease. 7. Depression. 8. S/P Cholecystectomy. 9. Statin associated Rhabdomyolysis. Discharge Condition: feeling well, no oxygen requirement, without pain Discharge Instructions: 1. Please take all medications as prescribed 2. Please make all follow-up appointments 3. Patient will need nutrition follow-up at [**Hospital1 2025**] for TPN 4. Patient on Vancomycin for line sepsis - last dose [**2167-4-11**] Followup Instructions: Please follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 66248**] as needed [**Telephone/Fax (1) 66249**] Completed by:[**2167-4-10**]

[ "995.92", "V45.81", "263.0", "038.19", "V44.2", "428.0", "785.52", "428.31", "287.4", "599.0", "579.3", "585.3", "996.62", "E934.2", "V45.01" ]

icd9cm

[ [ [] ] ]

[ "99.15", "38.93" ]

icd9pcs

[ [ [] ] ]

8062, 8077

3726, 6458

237, 266

8687, 8739

1673, 1673

9016, 9182

1363, 1367

6693, 8039

8098, 8666

6484, 6670

8763, 8993

1382, 1654

191, 199

294, 1044

1690, 3703

1066, 1189

1205, 1347

21,995

160,896

13302

Discharge summary

report

Admission Date: [**2154-5-22**] Discharge Date: [**2154-6-13**] Date of Birth: [**2128-9-22**] Sex: M Service: MICU HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 40503**] is a 25 year-old white male who was transferred from outside hospital with the diagnosis of aspiration pneumonia and adult respiratory distress syndrome. The patient was initially admitted to [**Hospital6 1597**] on [**2154-5-10**] after ingestion of OxyContin with alcohol and found down by his girlfriend with blue color and abnormal breathing pattern. His time down was unknown. EMS arrived and gave him Narcan with some arousal. The patient had traumatic intubation in the Emergency Department at [**Hospital3 **] with desaturation and vomiting and aspiration of charcoal. On admission to [**Hospital3 **] Intensive Care Unit the patient was found to be unresponsive and had evidence of bilateral pneumonitis and was found to be hypotensive. On [**2154-5-11**] the patient was started on Ceftriaxone and Flagyl for a fever and bilateral pneumonitis. He was started also on Decadron. He was presser dependent at this time. The patient remained difficult to oxygenate and ventilate and his FIO2 requirement increased to 80% on [**2154-5-12**]. He remained on Ceftriaxone and Flagyl and remains paralyzed. The patient then had a waxing and [**Doctor Last Name 688**] course between [**5-14**] and [**5-17**]. The patient spiked temperatures and found to have leukocytosis in his blood. The patient had showed transient clinical recovery up to the point of potential extubation on [**2154-5-15**]. However he had further temperature spikes and had increased FIO2 requirement back up to 80% by [**2154-5-16**]. By [**2154-5-17**] the patient's oxygen requirement had increased to 90% inspired FIO2. On this day Vancomycin was started in addition to Ceftazidine. He was diagnosed with adult respiratory distress syndrome and started on Solu-Medrol. On [**2154-5-18**] the patient was found to have a large pneumothorax requiring a chest tube placement on his right side. The patient remained difficult to ventilate and oxygenate and remained persistently hypoxemic requiring high saturation oxygen on ventilator. The patient was finally transferred to [**Hospital1 69**] on [**2154-5-22**] for further management of his adult respiratory distress syndrome. MEDICATIONS ON TRANSFER: 1. Protonix 40 mg po bid. 2. Albuterol Atrovent nebulizers. 3. Ativan 20 mg per hour drip. 4. Heparin. 5. Ceftazidine. 6. Flagyl. 7. Vancomycin. 8. Ceftriaxone. 9. Solu-Medrol. 10. Morphine drip. 11. Nystatin swish and swallow. SOCIAL HISTORY: The patient lives at home. He works as a technician. The patient has a positive history of alcohol abuse and marijuana use. ALLERGIES: The patient has no known allergies. MEDICATIONS: The patient takes no medications at home. LABORATORY DATA ON ADMISSION: Hematocrit 29.2, white count 23.6, platelet count 593,000. Serum chemistry sodium 144, potassium 4.6, chloride 99, bicarbonate 39, BUN 31, creatinine 0.7, sugar 89. The differential on the patient's white count revealed 86% neutrophils, 3% bands and 4% monocytes. The patient's amylase was 120, lipase 123, alkaline phosphatase 88, INR 1.2, albumin 2.9, calcium 8.4, phosphate 0.3, magnesium 23, ALT 96, AST 28, LDH 714. PHYSICAL EXAMINATION: On admission to [**Hospital1 190**] was not recorded. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit for further management of his acute adult respiratory distress syndrome. He was placed on pressure controlled ventilation with a driving pressure of 25 and a positive end expiratory pressure of 15. He was maintained on antibiotics. He had draining chest tube for his pneumothorax. The patient was maintained on steroids for potential benefit in diagnosis of adult respiratory distress syndrome. Due to the patient's fever and leukocytosis, all of his central lines were re-sited. A right upper quadrant ultrasound was obtained to rule out a cholecystitis. The patient was also started on total parental nutrition for nutritional support on [**2154-5-24**]. Initially on transfer to [**Hospital1 69**] the patient's paralytics were removed. The patient had become increasingly agitated and required higher doses of sedation and analgesia. The paralytics were restarted on [**2154-5-25**]. The patient's intravenous steroids were stopped on [**2154-5-27**]. During his entire time in the Medical ICU the patient became more and more difficult to ventilate. The patient required additional boluses of Doxacurium, Fentanyl and Ativan and despite which the patient continued to have spontaneous breathing episodes with subsequent desaturations. Due to increasingly difficult ventilation the patient was started on high frequency jet ventilator at 3 hertz per minute. Also on [**2154-5-11**] due to the patient's continuous febrile illness and leukocytosis and clinical deterioration, Infectious Disease was consulted and recommended continued Vancomycin, CT scan of the sinuses and starting Ciprofloxacin 400 twice a day. On this day the patient began to manifest septic physiology and all of his lines including arterial lines and central lines were re-sited again. The patient developed a spontaneous pneumothorax on his right side on [**2154-5-28**] and required another chest tube placement. This was detected following a desaturation at 3:30 in the afternoon of [**2154-5-28**] where chest x-ray showed a large right sided pneumothorax. On this date the patient was placed back to pressure controlled ventilation. The patient also on this day was found to have decreased urine output and increased serum creatinine to 1.4. A renal consult was obtained at this time. Renal consultants at this time found no evidence of interstitial nephritis and recommended keeping mean arterial blood pressure to be greater than 60 and avoid further diuresis. On [**2154-5-30**] the patient now has positive blood cultures as well as line cultures for staph aureus. He was diagnosed with staph aureus sepsis. The patient remained hypoxic with high oxygen requirements, requiring FIO2 of 0.9. The patient continues to have worsening renal function. His serum creatinine increased to 2.9 by [**2154-5-30**]. On [**5-30**] to [**5-31**] the patient continued to deteriorate quickly clinically. The patient had gone into episodes of hyperkalemia with no EKG changes but had a potassium of 5.9. The patient was treated with Kayexalate. On this date the patient had also culture evidence of both staph epidermidis and staph aureus infecting his blood stream. On this day Oxicillin was started in addition to intravenous Vancomycin for the patient's septic syndrome. The patient was started on continuous renal [**Last Name (un) **] hemodialysis on this day due to his persistent total renal failure, decreased urine output and hyperkalemia. His central lines were re-sited and a Swan Ganz catheter was flown to measure the patient's hemodynamic guidance of medical therapy. At this time the patient remained on pressure control ventilation with high driving pressuring of 32 and PEEP of 12.5 for a rate of 36 and oxygen FIO2 of 0.9. During this interim the patient also received multiple bags of packed red blood cells as he had dropped hematocrit of unclear source. The patient was treated therapeutic, support keeping his hematocrit greater than 25. A Hematology consult was requested on [**2154-6-1**] due to the patient's persistent drop in hematocrit for potential treatment of hemolysis. No therapy was recommended. The patient's condition remained tenuous. After proper treatment of his staph aureus and staph epidermidis bacteremia his hypotension resolved and the patient was weaned off from pressors. However his respiratory status remained tenuous with high driving pressures and high oxygen requirement. On [**2154-6-5**] the patient again had desaturation episode requiring increasing positive end expiratory pressure to improve his oxygenation. Careful surveillance at this time showed no other evidence of infections. At this time the patient had high intrapulmonary volume and persistent leakage through bilateral pneumothoraces despite bilateral chest tubes. A CT surgery was re-consulted at this time and did not recommend insertion of new chest tube. The patient remains anuric and is on intermittent hemodialysis at this time. The patient was switched to continuous renal [**Last Name (un) **] hemodialysis on [**2154-6-3**] with bicarbonate drip to correct his ongoing acidosis. Throughout the patient's entire tenuous course in the Medical Intensive Care Unit multiple discussions had been held with his family daily. The patient's family insist everything be done to save this patient's life. They however do recognize that they have been informed the patient is in very critical condition and has very poor prognosis given the respiratory distress syndrome and his septic syndromes. The patient clinically worsened yet again on [**2154-6-6**] with increased leukocytosis, decreased serum glucose and decreased blood pressure requiring fluid boluses. Cultures through blood, urine and sputum and each line were obtained again. On [**2154-6-7**] a leak through the ET tube cuff was observed. The patient underwent elective bedside ET tube change over supported by anesthesia. Prior to this procedure the pros and cons had been discussed with the family and the very possible complication of death was discussed. The patient had mild hypotensive episodes after his ET tube change over and responded to fluid boluses. The patient's overall clinical status at this time remained tenuous and unstable. He had persistent leukocytosis and slowly increasing white blood cell on daily CBC. Multiple discussions had been held with the family who recognize that the patient is in a very critical state with a very poor prognosis but felt that they were not ready to let go. At this time the patient has frequent desaturations along with high oxygen requirement on 100% oxygen FIO2 supply. A bronchoscopy was performed on [**2154-6-9**] in attempt to remove any mucous plugging from the patient's bronchial tree and improve oxygenation as well as to obtain samples for further culture in case the patient has an occult pulmonary infection. On the evening of [**2154-6-9**] the patient had two severe desaturations down to a oxygen saturation of 60%. Two ................... maneuvers were tried and the patient after that required very high positive end expiratory pressure and driving pressure and send backs to maintain oxygen saturation in the mid 80s. At this time the patient was on a driving pressure of 34 and a positive end expiratory pressure of 28.5. Soon after the patient became pressor dependent and had hypotension. On [**2154-6-11**] the patient became hypothermic and required bear hugger treatment. Discussions with the family regarding ECMO support had been held. The patient was finally turned down by the ECMO team as he was high risk and septic. At this time the patient is persistent at very high oxygen requirement at 100% pure oxygen through his ventilator. He remains poorly saturating in mid 80s in his oxygen saturation and in his serum. The patient continues to mound high leukocytosis responds and his white blood cell count on this day was 45 was 15% bandemia. The patient remains on broad spectrum antibiotic coverage including fungal coverage at this time. The family was informed of the patient's extremely critical condition and highly likely bad prognosis. Again they requested that we do everything to save the patient's life and felt that they were not ready to consider withdraw of support. On [**2154-6-12**] the patient was beginning to be weaned off pressor support. On this day Meropenem was added for his persistent sepsis. His leukocytosis continued and on this day his white blood cell count was 50. On [**2154-6-13**] the patient continued to decline with decreasing blood pressure, renew hypotension and severe hypoxia, non-responsive to high pressure ventilation and 100% oxygen. The patient finally had a VT Vfib arrest which was non-responsive to resuscitation efforts. The family remained adamant of their wish for the patient to remain full code. The patient expired on this date despite resuscitative efforts. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**] Dictated By:[**Name8 (MD) 9921**] MEDQUIST36 D: [**2154-7-18**] 20:19 T: [**2154-7-22**] 10:24 JOB#: [**Job Number **]

[ "038.10", "E850.2", "482.41", "507.0", "518.1", "518.5", "518.81", "965.09", "512.1" ]

icd9cm

[ [ [] ] ]

[ "99.15", "34.04", "33.24", "96.72", "38.93", "38.91", "39.95", "96.04" ]

icd9pcs

[ [ [] ] ]

3406, 12611

3334, 3389

161, 2352

2890, 3312

2377, 2615

2631, 2876

7,287

108,868

50643

Discharge summary

report

Admission Date: [**2152-6-3**] Discharge Date: [**2152-6-6**] Date of Birth: [**2080-4-11**] Sex: F Service: MEDICINE Allergies: Penicillins / Sudafed / Tequin Attending:[**First Name3 (LF) 30**] Chief Complaint: found down Major Surgical or Invasive Procedure: intubation/extubation History of Present Illness: 72 yo female with pmhx sig for breast cancer, aortic aneurysm, gastritis, and hypertension who was brought to [**Hospital1 18**] ED by ambulance after being found down by neighbors for an undetermined amount of time. The patient had large hematoma to left forehead, but head CT did not show any evidence of bleed. CT c-spine negative. Patient limited historian, responsive to pain, not able to answer questions. . In the [**Name (NI) **], pt was intubated for airway protection. Infectious workup started w/ blood, urine cultures and CXR. Lactate wnl. Given dose of Levo/Flagyl for possible aspiration pneumonia. Transferred to MICU for further care. . Patient unable to give further history or ROS. Daughter [**Name (NI) 653**], states that pt called her aunt early today and complained of feeling "disoriented", said that she hit her head and needed to go to the hospital. She then pressed her lifeline and the ambulance and neighbor came, at which time they found her conscious but disoriented; with a large hematoma on her right forehead. The daughter states that she has otherwise been in her usual state of health, but has been on pain medications for chronic pancreatitis and most recently for shoulder pain. In addition, she has a history of falls and LOC in the past from "dehydration", most recent episode about one month earlier, did not require medical attention Past Medical History: autoimmune pancreatitis: during recent hospitalization for abdominal pain, cystic mass in the head of the pancreas was noted and also "fullness" in the area of the SMA, which could represent mesenteric vasculitis -L lumpectomy for stage I breast ca s/p lumpectomy and XRT in [**2151-2-10**]. BRCA (-). - Spiculated LUL mass, stable from [**11-14**] to [**1-16**] - outpt pulmonary f/u with Dr. [**Last Name (STitle) **] at [**Hospital1 18**] - 3cm descending thoracic, and 3cm AAA and RCI aneurysmal ectasia seen on CTA and abdominal [**Hospital1 4338**]/A, supposed to f/u with vascular surgery (Pompaselli) [**5-15**]. -Gastritis -Chronic esophagitis with Barrett's esophagous -Hypertension -Anemia (baseline Hct 35, has EPO injections every two weeks)--recent bone marrow biopsy suggestive, but not diagnostic, of myelodysplastic syndrome -Spinal stenosis -Depression Social History: Lives alone, with help from son and daughter who live in the area. Retired nurse. [**First Name (Titles) **] [**Last Name (Titles) **]. Long smoking history (100+ pack year), quit 15 years ago. Family History: Mother with [**Name2 (NI) 499**] cancer. Two sisters with breast cancer. Physical Exam: GEN: intubated, lethargic but [**Last Name (LF) 18248**], [**First Name3 (LF) **] follow commands HEENT: R hematoma on R superior forehead. Pupils constricted but equal and reactive, EOMI CV: 2/6 systolic murmur, LUSB, non-radiating. RRR. Large ecchymoses on R breast LUNGS: bronchial BS B/L, no focal crackles or wheeze ABD: soft, nt, nd, nabs EXT: warm, dry. Ecchymoses and edema around L wrist. NEURO: responds to voice, follows commands, moves all extremities spontaneously, reflexes intact B/L Pertinent Results: [**2152-6-2**] 10:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-POS [**2152-6-2**] 10:10PM GLUCOSE-132* UREA N-39* CREAT-1.8* SODIUM-130* POTASSIUM-4.0 CHLORIDE-96 TOTAL CO2-25 ANION GAP-13 [**2152-6-2**] 10:10PM ALT(SGPT)-26 AST(SGOT)-42* LD(LDH)-277* CK(CPK)-653* ALK PHOS-96 AMYLASE-35 TOT BILI-0.4 [**2152-6-2**] 10:10PM CK-MB-22* MB INDX-3.4 cTropnT-<0.01 [**2152-6-3**] 02:57AM WBC-3.4* RBC-2.90* HGB-9.2* HCT-27.1* MCV-94 MCH-31.6 MCHC-33.7 RDW-15.4 Brief Hospital Course: 72 yo female with ho breast cancer, aortic aneurysm (conservative managment, gastritis, and hypertension, autoimmune pancreatitis who was brought to [**Hospital1 18**] ED by ambulance after being found down after unintentional opiod overdose. 1 Loss of consciousness- diff includes opiate OD, syncope from hypovolemia, arrythmia, stroke, infectious process, seizure; improved with time and pt able to give a more detailed history of what happened and most likely secondary to narcotics and benzos 2 pain control for autoimmune pancreatitis - given her intentional Opiod overdose, will continue morphine SR 30mg [**Hospital1 **], and stop dilaudid 4mg [**Hospital1 **] to avoid confusion. - morphine 15mg IR q4-6 h prn for break through pain - continue creon - f/u w/ GI Dr. [**Last Name (STitle) 174**] regarding further managment of autoimmune pancreatitis 3 Hypertension- continue atenolol (titrated up to 37.5 mg from 25 mg daily) and dilt (120mg daily home dose) 4 pancytopenia - stable. Normal EGD in [**2152**], no c-scope on record. Iron studies in [**Month (only) **] w/ low iron, elevated ferritin. Bone marrow in past suggestive of MDS. Also w/ chronic gastritis; continue H2B. 5 Respiratory Failure- patient intubated for airway protection secondary to altered mental status (narcs). Extubated morning after admission. On cxr has R lower lobe infiltrate, likely aspriation. Briefly on azithromycin, and CXR improved, and abx stopped. 6 ARF- baseline creatinine .8. Likely pre-renal given elevated BUN. ATN also possibility if patient hypotensive in field for unknown time; improved with fluid 7 Elevated CK- likely secondary to fall. Could consider rhabdo given renal failure. No blood on UA. improved w/ IVFs 8 Breast cancer- s/p lumpectomy and radiation in left breast one year ago, apparently no injections or blood draws from left arm per daughter; held femara 9 Aortic aneurysm- followed by Vascular [**Doctor First Name **], plan for repeat US in 6 months HCP is [**Name (NI) **] [**Telephone/Fax (3) 105383**] Medications on Admission: 1. Creon 30 mg daily 2. Lipitor 40 mg qhs 3. Morphine ER 30 mg [**Hospital1 **] 4. Lidocaine patch 5. Miralex 6. Diltiazem 120 mg qd 7. Ambien CR 6.25 mg qd 8. NTG SL prn 9. Trevatan eye gtt 10. Trazadone 225 mg qhs 11. Doxepin 150 mg qhs 12. PPI 40 mg [**Hospital1 **] 13. Folic acid 1 mg qd 14. Atenolol 25 mg qd 15. Klonopin 0.5 mg [**Hospital1 **] 16. Dilaudid 4 mg prn 17. ?Prednisone (was on taper, unclear if still on prednisone; if so, would be on 5mg daily at this point) Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 4. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). Disp:*60 Tablet Sustained Release(s)* Refills:*2* 5. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO QIDWMHS (4 times a day (with meals and at bedtime)). 6. Atenolol 25 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:*45 Tablet(s)* Refills:*2* 7. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day. 8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Topical once a day as needed for pain. 9. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 10. Miralax 17 g (100%) Powder in Packet Sig: One (1) PO once a day as needed for constipation. 11. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain: do not take within 4 hours of your long acting morphine. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Accidental opiate overdose chronic autoimmune pancreatitis pancytopenia, likely myledysplastic syndrome Discharge Condition: good Discharge Instructions: Do not take your short acting pain medication within 4 fours of the long acting medication. Please test your lifeline when you get home since it's not clear that it worked for you. Call your doctor if you get fevers, chills, cough, or any other concerning symptom. You always need to walk with a walker to stay safe. Please note, we increased your atenolol. Please also note, we did not restart the dilaudid but instead, you are on morphine extended release and instant release for breakthrough pain. Followup Instructions: Provider: [**Name10 (NameIs) 13368**] [**Last Name (NamePattern4) 13369**], MD Phone:[**Telephone/Fax (1) 1091**] Date/Time:[**2152-6-9**] 11:00 Provider: [**Name10 (NameIs) 4338**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2152-7-5**] 10:45 Provider: [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2152-7-18**] 9:20

[ "E850.2", "250.00", "V10.3", "577.0", "584.9", "965.00", "530.85", "285.9", "238.75", "535.40", "780.97" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

7789, 7847

3979, 6019

298, 321

7995, 8001

3459, 3956

8550, 8949

2848, 2922

6551, 7766

7868, 7974

6045, 6528

8025, 8527

2937, 3440

248, 260

349, 1726

1748, 2621

2637, 2832

18,301

145,048

10002

Discharge summary

report

Admission Date: [**2171-10-3**] Discharge Date: [**2171-10-8**] Date of Birth: [**2102-1-27**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: SOB, decreased exercise tolerance Major Surgical or Invasive Procedure: AVR History of Present Illness: 69 y/o male w/known AS, now w/progressive SOB, decreased exercise tolerance. Cardiac cath:normal coronaries, [**Location (un) 109**] 0.7, 3+AI. Past Medical History: AS AI Prostate cancer arthritis Social History: works as an artist married, lives w/wife ETOH ~ 4/week quit smoking 30 years ago Family History: non-contrib Physical Exam: unremarkable pre-op Pertinent Results: [**2171-10-7**] 05:50AM BLOOD WBC-8.0 RBC-2.47* Hgb-7.8* Hct-22.0* MCV-89 MCH-31.7 MCHC-35.7* RDW-14.7 Plt Ct-119* [**2171-10-7**] 05:50AM BLOOD Glucose-87 UreaN-17 Creat-1.1 Na-140 K-4.1 Cl-101 HCO3-31 AnGap-12 Brief Hospital Course: Admitted directly to the OR on [**2171-10-3**]. He underwent an AVR ([**Street Address(2) 33461**]. [**Male First Name (un) 923**] porcine/tissue). POst-op he was taken to the Cardiac Surgery Recovery Unit on stable condition, on phenylephrine gtt. He was extubated the day of surgery, and weaned off phenylephrine and transferred to the telemetry unit on POD # 1. During the night of POD # [**3-1**], he had an episode of disorientation, and fell while walking independently. By the morning, he was alert & oriented, and had no further episodes of confusion. His hematocrit on [**10-7**] was 23, he has remained on iron and vitamin C, hct today, [**10-8**] is 23, and he is ready to be discharged home. Medications on Admission: Lupron Q 3 mos Wellbutrin [**Hospital1 **] Casodex Keflex prn dental Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. Disp:*14 Tablet(s)* Refills:*0* 2. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day for 2 weeks. Disp:*28 Capsule, Sustained Release(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. 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* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 6. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. Disp:*30 Tablet(s)* Refills:*0* 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:*60 Tablet(s)* Refills:*0* 8. Famciclovir 500 mg Tablet Sig: One (1) Tablet PO three times a day for 1 weeks. Disp:*21 Tablet(s)* Refills:*0* 9. Bicalutamide 50 mg Tablet Sig: One (1) Tablet PO once a day. 10. Bupropion 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. Lopressor 50 mg Tablet Sig: [**1-28**] Tablet PO three times a day: 25 mg TID. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: s/p AVR(#25 StJude Biocor Porcine) PMH: AS/AI, Prostate CA s/p prostatectomy/hormone tx, Arthritis, s/p hernia repair Discharge Condition: good Discharge Instructions: Keep wounds clean and dry. OK to shower, no bathing or swimming. Take all medication as prescribed. Call for any fever, redness or drainage from incision No lotions, creams or powders on incision Followup Instructions: [**Hospital 409**] clinic in 2 weeks Dr [**Last Name (STitle) 33462**] in [**3-1**] weeks Dr [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **] in [**3-1**] weeks Dr [**Last Name (STitle) **] in 4 weeks Completed by:[**2171-10-8**]

[ "424.1", "427.41", "V10.46", "E888.9", "746.1", "293.9", "428.0" ]

icd9cm

[ [ [] ] ]

[ "35.21", "39.61", "99.62", "88.72" ]

icd9pcs

[ [ [] ] ]

3155, 3204

1008, 1719

355, 361

3366, 3373

772, 985

3617, 3870

704, 717

1838, 3132

3225, 3345

1745, 1815

3397, 3594

732, 753

282, 317

389, 535

557, 590

606, 688

72,163

180,686

34832

Discharge summary

report

Admission Date: [**2188-6-19**] Discharge Date: [**2188-6-23**] Date of Birth: [**2105-3-31**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 552**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: [**2188-6-19**] RIJ placement in ED [**2188-6-21**] midline placement History of Present Illness: 83 yo M after recent prolonged hospital course for MSSA septic prosthetic joint infection and respiratory failure presents from rehab with fever and hypotension after episode of emesis x4 around 12:30 am. An hour later his temp rose to 99.9, his sat dropped to 88-89 on 4L, and he became tachycardic. On exam it was noted he had emesis at his trach stoma site and suction was attempted. Of note, his stoma was recently decanulated 3 days ago. In the ED, initial vs were: T 100.7 HR 112 BP 78/45 RR 24 POx71 on RA. Patient was given vancomycin 1gm, levofloxacin 750mg, and flagyl 500mg IV. Tylenol 650mh x2 was given for fever and levophed was begun for hypotension. Lactate of 5.2. A right IJ triple lumen was place and confirmed by CXR. He received 3L NS to support his BP and repeat CXR showed prgression in RML infiltrate. On arrival to the MICU, patient reporting feeling comfortable on oxygen face mask with occassional cough, chills, and crushing back/sacral pain. He denied further nausea, abd pain, chest pain, diarrhea, or fevers. Review of systems: (+) Per HPI (-) No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: Recent prolong hospitalization for septic prosthetic joint (MSSA)requiring skin grafting, prolonged intubation w/ trach and post-pylori g-tube placement, discharged to rehab on [**2188-5-10**] HTN Peripheral neuropathy elevated cholesterol osteoarthritis R TKA [**2188-3-4**] complicated by above h/o ESBL UTI Social History: He is a retired executive from the Emhart Corporation. He is a widower. He is a former smoker, smoked up to two packs per day for about 45 years, now quit. After prolonged hospital course, he has been at rehab since [**2188-5-10**]. Family History: Positive for cancer in his brother and in-laws. Mother had cardiomyopathy and cardiac hypertrophy, father had a CVA, lung disease in a brother, COPD. [**Name2 (NI) **] disease in a brother. Daughter has skin cancer. Physical Exam: Admission Vitals: T:99.9 BP:98/46 P:101 R: 24 O2:93% on face mask General: Alert, oriented to place and month, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD, airleak at trach stoma, covered w/ dressing Lungs: decreased BS at right base, coarse crackles throughout lower lung fields, no wheezing, good air movement, no accessory muscle use CV: Tachy, Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: clean/dry/non-tender g-tube site, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Back: Large 10 x8 cm stage III/VI sacral decub w/ scant tan discharge Ext: Warm, 1+ pulses, no clubbing, cyanosis or edema . Discharge: PE:VS: T 98.2 HR 72 BP 122/70 R 20 94%2L GENERAL: Pleasant, chronically ill appearing man in NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. dryMM. OP with white lesions in back of throat. Neck Supple, No LAD, No thyromegaly, scar from old trachestomy CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. JVP=6cm LUNGS: faint crackles at b/l bases but poor inspiratory effort ABDOMEN: PEG tube in place, NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 1+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes, ecchymoses. Scar from surgery on Right knee. Sacral stage 4 decubitus ulcer. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [**1-11**]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: Admission labs [**2188-6-19**] 04:00AM BLOOD WBC-22.6*# RBC-3.70*# Hgb-10.8*# Hct-33.5*# MCV-91 MCH-29.2 MCHC-32.3 RDW-15.6* Plt Ct-460*# [**2188-6-19**] 04:00AM BLOOD Neuts-93* Bands-0 Lymphs-2* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* [**2188-6-19**] 04:00AM BLOOD PT-15.7* PTT-27.0 INR(PT)-1.4* [**2188-6-19**] 04:00AM BLOOD Glucose-107* UreaN-26* Creat-1.2 Na-135 K-4.7 Cl-100 HCO3-19* AnGap-21* [**2188-6-19**] 08:32AM BLOOD Calcium-7.9* Phos-3.6 Mg-1.7 . [**2188-6-19**] 04:13AM BLOOD Lactate-5.2* [**2188-6-20**] 06:09AM BLOOD Lactate-1.0 . [**2188-6-19**] 04:00AM BLOOD CK(CPK)-41 CK-MB-NotDone cTropnT-0.10* [**2188-6-20**] 03:35AM BLOOD CK(CPK)-44 CK-MB-NotDone cTropnT-0.11* . [**2188-6-19**] Bcx NGTD x 2 [**2188-6-19**] UCx >100,000 Yeast [**2188-6-19**] C. diff negative . [**2188-6-19**] CXR: Rounded retrocardiac opacity is concerning for abscess. Recommend PA and lateral radiographs, or chest CT, for further evaluation. . [**2188-6-19**] CT chest: 1. Bilateral dependent parenchymal consolidations are improved compared to CT chest of [**2188-4-21**]. Since more recent CT abdomen/pelvis of [**2188-5-8**], consolidation in the right lung base is slightly increased. Together with findings on recent chest radiograph, this is likely due to aspiration. These changes may be followed radiographically. No abscess is seen. 2. Interval resolution of bilateral pleural effusions since [**2188-4-21**] as well as small pericardial effusion. 3. Several prominent mediastinal lymph nodes are slightly larger than that seen on [**2188-4-21**] and could represent reactive change. Attention to these is recommended on followup studies. 4. Upper lobe predominant emphysema. 5. Aortic valvular calcifications. 6. Narrowed right subclavian vein with opacification of multiple chest wall collaterals. . [**2188-6-23**] 06:10AM BLOOD WBC-10.1 RBC-3.32* Hgb-9.7* Hct-29.7* MCV-90 MCH-29.1 MCHC-32.5 RDW-15.9* Plt Ct-257 [**2188-6-22**] 05:42AM BLOOD WBC-8.4 RBC-3.07* Hgb-8.9* Hct-27.8* MCV-90 MCH-28.8 MCHC-31.9 RDW-15.6* Plt Ct-230 [**2188-6-21**] 02:20AM BLOOD WBC-9.4 RBC-2.96* Hgb-8.7* Hct-25.9* MCV-88 MCH-29.4 MCHC-33.5 RDW-16.1* Plt Ct-243 [**2188-6-20**] 03:35AM BLOOD WBC-12.5* RBC-2.52*# Hgb-7.4*# Hct-22.4* MCV-89 MCH-29.5 MCHC-33.2 RDW-16.1* Plt Ct-270 [**2188-6-21**] 02:20AM BLOOD PT-15.9* INR(PT)-1.4* [**2188-6-19**] 04:00AM BLOOD PT-15.7* PTT-27.0 INR(PT)-1.4* [**2188-6-23**] 06:10AM BLOOD ESR-82* [**2188-6-23**] 06:10AM BLOOD Glucose-107* UreaN-15 Creat-0.6 Na-143 K-3.4 Cl-112* HCO3-23 AnGap-11 [**2188-6-22**] 05:42AM BLOOD Glucose-118* UreaN-17 Creat-0.6 Na-143 K-3.0* Cl-111* HCO3-24 AnGap-11 [**2188-6-21**] 02:20AM BLOOD Glucose-102 UreaN-21* Creat-0.7 Na-137 K-3.2* Cl-107 HCO3-21* AnGap-12 [**2188-6-20**] 03:35AM BLOOD Glucose-86 UreaN-23* Creat-0.7 Na-137 K-4.0 Cl-107 HCO3-21* AnGap-13 [**2188-6-19**] 05:00PM BLOOD Glucose-118* UreaN-28* Creat-0.9 Na-135 K-4.4 Cl-104 HCO3-21* AnGap-14 [**2188-6-19**] 08:32AM BLOOD Glucose-113* Na-137 K-4.7 Cl-108 HCO3-20* AnGap-14 [**2188-6-19**] 04:00AM BLOOD Glucose-107* UreaN-26* Creat-1.2 Na-135 K-4.7 Cl-100 HCO3-19* AnGap-21* [**2188-6-22**] 05:42AM BLOOD ALT-12 AST-20 AlkPhos-99 TotBili-0.5 [**2188-6-19**] 08:32AM BLOOD LD(LDH)-199 [**2188-6-23**] 06:10AM BLOOD Calcium-8.6 Phos-2.3* Mg-1.9 [**2188-6-22**] 05:42AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.9 [**2188-6-19**] 08:32AM BLOOD Calcium-7.9* Phos-3.6 Mg-1.7 [**2188-6-20**] 03:35AM BLOOD Hapto-266* [**2188-6-23**] 06:10AM BLOOD CRP-87.0* . [**2188-6-19**] 4:49 pm URINE Source: Catheter. **FINAL REPORT [**2188-6-20**]** URINE CULTURE (Final [**2188-6-20**]): YEAST. >100,000 ORGANISMS/ML.. Brief Hospital Course: # Shock: Likely [**2-11**] aspiration pneumonia v. pneumonitis; may have also had infectious component from osteomyelitis at sacral decub. Pt on Vanc/Zosyn to cover HAP as from Rehab. PICC line pulled and cultured. He remained afebrile with resolution of leukocytosis. Pressors were able to be weaned off after first night in MICU. Cx neg to date other than yeast in urine which was treated. Foley changed. C. diff negative. Cont vanc/zosyn x 7 days for tx of PNA. . # Fungal UTI: Foley changed to condom cath but had urinary retention so repleaced. Started on fluconazole for 7d course per ID. . # Hypoxia: Developed in setting of recent aspiration event. Treated for pneumonia as above and weaned off face mask to nasal cannula. Discharged on 2LNC. Cont Vanc/Zosyn to complete 7 days course. . # Sacral Decubitus c/b osteomyelitis: Developed on last hospitalization and worsened at rehab. Had been started on Vanc/Zosyn on [**6-18**] (day prior to admission) at rehab for worsening appearance. CT L-spine with evidence of osteomyelitis; able to probe to bone. Seen by Wound nurse [**First Name (Titles) **] [**Last Name (Titles) 3595**], who recommended wound care and nutritional support. Cont Vanc/Zosyn for at least 6 week course. . # H/O MSSA right knee prothestic joint arthritis: Followed by ID as outpatient. Outpatient rifampin 300mg po daily being held initially but resumed prior to discharge. F/u with ID and ortho as outpatient. . # Anemia: Unclear source. No evidence of hemolysis. Transfused 2 units pRBC with Hct bump of only 2 pts but stable Hct overnight. Noted to have trace guaiac positive stool. Trend Hct daily which was improving upon discharge. . # ROMI: Pt with rate-related EKG changes which resolved on subsequent EKG when rate controlled. Cardiac enzymes cycled and negative. . # Mediastinal lymph nodes: Noted to have several prominent mediastinal lymph nodes on CT chest that are slightly larger than those seen on [**2188-4-21**] and could represent reactive change. Attention to these is recommended on followup studies. . # General Care: FEN: Restarted on tube feeds. (NPO), Access: midline on right, Ppx: Pneumoboots, SQ heparin, H2 blocker, Communication: Patient, [**Telephone/Fax (1) 79762**] daughter/HCP([**Name (NI) **] [**Last Name (NamePattern1) 17025**]), son is [**Name2 (NI) **] physician, [**Name10 (NameIs) 7092**] status: DNR/DNI, confirmed w/ daughter/HCP & family. Disposition: rehab Medications on Admission: acetaminophen 975mg Q8H Acetylcysteine 200mg Q8H Ascorbic Acid 500mg po daily Calcium carbonate 650mg po BID cholecalciferol 1000units daily citalopram 20mg daily cyanocobalamin 50mcg daily ferrous sulfate 325mg daily insulin humalog SS ipratropium neb Q4H Lactobcacillus 2 tabs daily lisinopril 5mg po daily metoclopramide 10mg Q8H MVI daily nystatin 5cc TID swish and spit omperazole 440mg po daily Zosyn 4.5mg IV Q6H (started [**6-18**]) Potassium Chloride 40 MEQ daily Rifampin 300mg po daily saliva substitue 2.4ml TID swish and swallow Vancomycin 1gm IV Q12H (started [**6-18**]) Oxycodone 5mg po Q4H prn Oxycodone 10mg po Q4H prn Discharge Medications: 1. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 2. Heparin Flush (10 units/ml) 2 mL IV PRN line flush Mid-line, heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above, daily and PRN per lumen. 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection Q8H (every 8 hours). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 6. 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. 7. Metoclopramide 5 mg/5 mL Solution Sig: Ten (10) mg PO Q 8H (Every 8 Hours). 8. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: One (1) PO DAILY (Daily). 9. Vancomycin 1,000 mg Recon Soln Sig: One (1) g Intravenous twice a day: Please continue through [**2188-7-31**]. 10. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours): Continue through [**2188-7-31**]. 11. Morphine 2 mg/mL Syringe Sig: 0.5 mg Injection Q6H (every 6 hours) as needed for pain. 12. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 13. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. 14. Rifampin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 15. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 17. Vitamin A 10,000 unit Capsule Sig: Two (2) Capsule PO DAILY (Daily) for 6 days. 18. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily) for 6 days. 19. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for fever or pain. 20. Calcium 600 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO twice a day. 21. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 22. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day. 23. Cyanocobalamin 50 mcg Tablet Sig: One (1) Tablet PO once a day. 24. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 25. Multivitamins Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 26. Artificial Tears Drops Sig: One (1) Ophthalmic four times a day. 27. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 28. Ascorbic Acid 90 mg/mL Drops Sig: Five Hundred Four (504) mg PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary - Aspiration pneumonia - Sacral decubitus complicated by osteomyelitis - Fungal Urinary tract infection Secondary - Right TKA complicated by MSSA septic prosthetic joint - Hypertension - Peripheral neuropathy - Hypercholesterolemia - Osteoarthritis - H/o ESBL UTI Discharge Condition: vital signs stable, moves all 4 extremities but bedridden Discharge Instructions: You were admitted with septic shock in the setting of an aspiration event. You required some medications to help your blood pressures initially but improved with treatment of your infection. You were also started on antibiotics to treat your aspiration pneumonia and infection of the bone in your sacrum. . There is evidence that your sacral decubitus ulcer has progressed to osteomyelitis, an infection of underlying bone. You will required at least 6 weeks of antibiotics to treat this. . The following changes were made to your medication regimen: Discontinued omeprazole. Started famotidine. Started Vancomycin and Zosyn for your infection for the next 6 weeks. . Please take all medications as prescribed. Call your doctor or 911 if you develop chest pain, difficulty breathing, fever > 101, dizziness, worsening confusion, bleeding, inability to tolerate food/liquids, inability to pass gas/stools, or any other concerning problems. Followup Instructions: Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], within 1 week of discharge from rehab. His office number is [**Telephone/Fax (1) 79763**]. . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2188-7-4**] 1:30 Provider: [**Name10 (NameIs) **] SURGERY CLINIC Phone:[**Telephone/Fax (1) 4652**] Date/Time:[**2188-7-4**] 2:00 Provider: [**First Name4 (NamePattern1) 8495**] [**Last Name (NamePattern1) 8496**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2188-8-6**] 11:00 Completed by:[**2188-6-24**]

[ "707.24", "707.03", "401.9", "682.6", "117.9", "599.0", "263.9", "730.28", "V43.65", "996.66", "V44.1", "909.3", "272.0", "792.1", "786.09", "998.59", "507.0", "E878.1", "285.9", "785.50" ]

icd9cm

[ [ [] ] ]

[ "38.93", "38.91", "96.6" ]

icd9pcs

[ [ [] ] ]

13702, 13774

7874, 10311

334, 406

14090, 14150

4170, 7851

15138, 15812

2205, 2424

10998, 13679

13795, 14069

10337, 10975

14174, 15115

2439, 4151

1496, 1602

275, 296

434, 1477

1624, 1936

1952, 2189

29,664

181,862

4205

Discharge summary

report

Admission Date: [**2141-10-8**] Discharge Date: [**2141-11-22**] Date of Birth: [**2088-3-25**] Sex: M Service: MEDICINE Allergies: Capoten Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Intubation, central line, PICC line, PEG tube placement History of Present Illness: This is a morbidly obese [**Location 7979**] 53-year-old man with DMII, hypertension, AF, and cocaine-induced MI in the past who p/w 3 days of worsening SOB. He was recently admitted [**Date range (1) 18291**]/08 for CHF exacerbation [**1-14**] cocaine use. Now presents with 3 days of increasing dyspnea at rest and on exertion, PND, and orthopnea. The patient does not know if his LE edema has increased. The patient denies any chest discomfort, cough, fevers or chills but feels like "fluid on the lungs". He does note some abdominal distension after meals but no abdominal pain, N/V/diarrhea. He states that he has been taking all his medications and has actually been taking 120mg PO lasix [**Hospital1 **] for 2 days prior and then 160mg PO BID for 2 days before admission but states that he did not increase his urination. Patient notes that he has been eating primarily vegetables and fruits but occasionally eating sardines. Adamantly denies using cocaine but positive on tox screen. . EMS was called and by report EtCO2 was 80 but improved to 50s after a neb. In the ED, initial vitals 98.9 128 (AF) 164/106 37 88%RA, --->96%CPAP. A CXR showed no definite evidence of pulmonary edema but severe cardiomegaly. He was started on BiPAP, nitro gtt, heparin gtt, given lasix 100mg IV and then another 60mg IV, Solumedrol 125mg, Levofloxacin, and Ceftriaxone to treat multiple causes of dyspnea. LLE LENIS showed no DVT. CTA was not done because of inability to lay flat even with BiPAP. BNP was elevated at 663. Past Medical History: History of cocaine-induced myocardial infarction in [**2129**]. [**7-22**], [**2132**], echocardiogram showed bilateral atrial dilation, severe concentric left ventricular hypertrophy, ejection fraction of greater than 55%, trace mitral regurgitation, diastolic dysfunction. On [**1-5**], a Persantine MIBI showing a moderate reversible perfusion defect in the anterior and inferolateral walls with an ejection fraction of 23%. On [**2134-1-20**], there was a catheterization that showed normal coronaries and global hypokinesis. [**6-/2138**] PMIBI showed mild reversible inferior wall perfusion defect in the presence of considerable soft tissue attenuation, although the calculated left ventricular ejection fraction is 46%, visual observation suggests that the ejection fraction is normal. # Congestive heart failure, systolic (most recent EF from [**2137**] PMIBI of 46%), diastolic w/ severe LVH # Severe pulmonary HTN noted on [**2133**] c. cath # Gout. # Morbid obesity, OSA, uses BiPAP at night # Atrial fibrillation, chronically anticoagulated w/ coumadin. # Hypertension. # Hypercholesterolemia. # Sleep apnea on CPAP, baseline oxygen requirements of 2-3L # Degenerative joint disease. # S/P right ankle fracture in [**2121**], s/p ORIF Social History: Lives in [**Location 686**] w/ his wife and 2 [**Name2 (NI) 18287**]. On disability, used to be a grocer. Denies tobacco use, occasional EtOH use, denies illicit drug use. Is fairly active and goes out into the community. Family History: Father and Mother alive and in good health. Physical Exam: VS: 98.4, 120 (AF), 148/85, 90% on BiPAP 12/10 Wt: 390lbs up from 340 [**2141-8-1**] Gen: Morbidly obese male, in moderate respiratory distress, AOx3 HEENT: PERRL, EOMI, MMM, OP clear, unable to evaluate JVD [**1-14**] to habitus Pulm: Difficult exam [**1-14**] to habitus but no obvious rales/rhonchi/wheezes heard CV: Tachy, [**Last Name (un) **], no MRGS appreciated Abdominal: Obese, soft, NT/ND, +BS Extremities: 3+ LE edema, L>R with bilateral erythema, 1+ DP pulses bilaterally Neuro/Psych: AOx3, strength 5/5 in all extremities. Pertinent Results: Admission Labs: WBC-6.7 RBC-4.23* Hgb-11.4* Hct-38.6* MCV-91 MCH-26.9* MCHC-29.5* RDW-18.0* Plt Ct-145* Neuts-73.7* Bands-0 Lymphs-15.5* Monos-7.7 Eos-2.7 Baso-0.4 PT-18.1* PTT-24.0 INR(PT)-1.7* Glucose-169* UreaN-31* Creat-1.2 Na-139 K-4.7 Cl-95* HCO3-34* ALT-42* AST-77* CK(CPK)-355* AlkPhos-339* Lipase-56 CK-MB-8 cTropnT-0.03* proBNP-663* Calcium-9.0 Phos-5.3* Mg-2.1 calTIBC-319 VitB12-1015* Folate-12.3 Hapto-177 Ferritn-79 TRF-245 Lactate-1.2 URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011 URINE Blood-NEG Nitrite-NEG Protein-500 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG URINE RBC-0 WBC-0-2 Bacteri-OCC Yeast-NONE Epi-<1 URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-POS amphetm-NEG mthdone-NEG [**2141-10-8**] EKG - Atrial fibrillation with rapid ventricular response. Low QRS voltage in the limb leads. Poor R wave progression which is probably a normal variant. Lateral ST-T wave changes which are non-specific. Compared to the previous tracing of [**2141-7-12**] rapid ventricular response is new. Otherwise, no other significant diagnostic change. [**2141-10-8**] EKG - IMPRESSION: Limited study due to poor penetration. Severe cardiomegaly with no definite evidence of pulmonary edema. Left retrocardiac region was not completely evaluated. Underlying pneumonia can not be excluded. [**2141-10-8**] Bilat LE ultrasound - IMPRESSION: No evidence of DVT in either lower extremity. [**2141-10-8**] CXR - FINDINGS: As compared to the previous examination, the patient is now intubated. The tip of the endotracheal tube projects 2 cm above the carina and should be pulled back by 1 to 2 cm. The newly placed nasogastric tube shows a normal course, but the tip of the tube is not visible. Extensive cardiomegaly that is unchanged as compared to the previous examination, subsequent retrocardiac atelectasis at both the left and the right lung base. Nobvious evidence of overhydration. [**2141-10-10**] CXR - IMPRESSION: Right subclavian central venous catheter ends in the right atrium. [**2141-10-18**] CT abdomen/pelvis - IMPRESSION: 1. Diverticulosis without diverticulitis. 2. No evidence of colitis. 3. Small amount of free fluid throughout the abdomen and mild edema within the subcutaneous tissues of the back. 4. Small bilateral pleural effusions, with consolidation at the visualized lung bases, likely reflects atelectasis. However, superimposed developing pneumonia cannot be excluded. 5. Right adrenal nodule is larger. Adrenal CT washout study suggested. Result posted in Critical Readings dashboard. incompletely characterized. [**2141-10-23**] Bilateral lower extremity veins - IMPRESSION: No evidence of deep vein thrombosis in either leg. [**2141-10-23**] CT sinus/mandible - IMPRESSION: 1. Pansinus opacification as detailed above. 2. Opacification of the mastoid ear cells and fluid in the bilateral middle ear cavities. 3. Exophthalmos with prominent retrobulbar fat suggesting possible thyroid ophthalmopathy. Clinical correlation is recommended. [**2141-10-27**] TTE - The atria are markedly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The number of aortic valve leaflets cannot be determined. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis or regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: No vegetations seen (poor-quality study). Normal global biventricular systolic function. In presence of high clinical suspicion, absence of vegetations on transthoracic echocardiogram does not exclude endocarditis. [**2141-10-28**] CXR - FINDINGS: In comparison with the study of [**10-24**], the central catheter has been removed. Endotracheal tube remains in place, with the tip above the level of the clavicles and approximately 5 cm above the carina. Unchanged cardiomegaly with widening of the mediastinum that could reflect vascular engorgement. Relatively mild prominence of interstitial markings, raising the possibility of cardiomyopathy. Probable bilateral pleural effusions without definite pneumonia. The left subclavian catheter extends to the upper portion of the SVC. [**2141-11-1**] CXR - IMPRESSION: 1. Dobbhoff tube with tip in the stomach. 2. Patient is status post tracheostomy. 3. Increased width of the mediastinal vascular pedicle, which is may be due to supine patient positioning, however mediastinal hematoma cannot be excluded and would recommend short-term radiographic followup and measurement of the patient's hematocrit. 4. Mild pulmonary vascular congestion and bibasilar atelectasis. [**2141-11-3**] CXR - IMPRESSION: 1. Tip of right-sided PICC catheter cannot be determined and repeat radiograph will need to be performed. 2. Marked improvement in bilateral pleural effusions and bilateral pulmonary edema. 3. Stable marked cardiomegaly. [**2141-11-5**] EKG - Atrial fibrillation with a slow ventricular response.. Compared to the previous tracing of [**2141-10-9**] no change. [**2141-11-9**] CXR - IMPRESSION: Right base collapse and/or consolidation, probably with a moderate-sized effusion. Increased retrocardiac density, consistent with left lower lobe collapse and/or consolidation. No significant change is detected compared with [**2141-11-8**]. However, the opacity at the right base is entirely new compared with [**2141-11-7**] and the opacity at the left base may be slightly worse. [**2141-11-9**] left upper extremity ultrasound - IMPRESSION: No left upper extremity DVT. Brief Hospital Course: Mr. [**Known lastname 10010**] is a morbidly obese 53 year old male with DMII, HTN, afib, and a history of a cocaine-induced MI who presented with acute dyspnea and subsequent respiratory failure whose hospital course has been complicated by fevers, C. difficile infection, and difficulty weaning from the ventilator. # Respiratory failure: The patient's initial respiratory failure was likely multifactorial due to CHF, OSA, and morbid obesity in the setting of decompensated heart failure from dietary noncompliance (sardines) and beta adrenergic stimuli secondary to cocaine use. In addition he was volume overloaded on presentation with marked pulmonary edema. All of these factors combined with body positioning (leaning forward) contributed to his acute decompensation that required intubation. As he was diuresed, ventillator settings were gradually able to be weaned. His oxygenation worsened and ventillator settings had to be increased when the patient became ill with a C. diff. infection. On [**10-28**] he was empirically started on zosyn for presumed VAP due to continued fevers, though sputum cultures never grew any organisms. The patient required high levels of PEEP to maintain oxygenation, likely due to body habitus. He had a transeosophageal balloon placed to calculate pleural pressures and had an initial PEEP of 26, which was weaned down over several weeks to 12. The patient had frequent problems with [**Name2 (NI) **]-recruitment and atelectasis following decreases in PEEP, slowing his wean significantly. Following tracheostomy placement on [**11-1**], the patient became hypoxic and PEEP had to be increased to 20 again. Weaning from the vent was once again begun, but the patient acutely decompensated on the morning of [**11-5**] and CXR showed opacification of the left lung field. This worsening of his clinical status was thought to be related to aspiration from extensive nose bleeds that he had the night prior. The patient underwent bronchoscopy on [**11-9**] and was noted to have mucous plugging in his airways. A sample of washings showed gram positive cocci on gram stain, cultures ended being negative with subsequent cx's negative as well. With increased urine output starting [**11-17**] pt improved on vent and able to reduce PEEP to 5 before discharge. # CHF: The patient had a history of a cocaine-induced MI and severe diastolic dysfunction by ECHO. He was diuresed over 11 liters over 3 weeks using at first a lasix drip and later combined with metolazone. Diuresis had to be slowed given worsening renal function and frequent infections also required slowing or suspension of diuresis. Pt eventually began to autodiurese [**11-17**] with no pharmacologic intervention and improvement in Cr and decreased PEEP requirements. # Fevers: The patient developed low-grade fevers and had a positive C.diff toxin on [**2141-10-16**], for which he was first started on IV flagyl, and later placed on PO vancomycin as well. The patient had decreased stool output, but abdominal CT scan showed no colitis or ileus. He defervesced, but then began spiking low-grade fevers again. He had purulent nasal discharge, CT of the sinuses showed opacification, and he was placed on Unasyn, which was stopped briefly over concern for worsening C.diff colitis. The patient continued to spike fevers, and had 1 bottle on [**10-22**] grow coagulase negative staph, which was oxacillin resistant, vancomycin sensitive. On [**10-24**], he had 2/2 bottles growing the same and was started on IV vancomycin and had his central line and arterial line pulled and replaced. Neither tip had any bacterial growth on culture. The patient subsequently began having increased thick, tan secretions, and zosyn was started empirically on [**10-28**] for VAP. Sputum gram stain from [**10-29**] showed gram positive cocci but grew nothing on culture. The patient's fevers defervesced, but he began spiking fevers again after his tracheostomy was placed. No localizing source could be found. On [**11-9**] he underwent bronchoscopy and washings contained 2+ gram positive bacteria, but culture revealed oropharyngeal flora. Blood, urine, and subsequnt bronchial/sputum cx's never grew anything. No infectious source was identified. White count remained low in midst of fevers suggesting another source. The etiology of the fevers is unclear, but infectious source was deemed unlikely after multipls attempts during the course of the last two weeks to identify a source. # Bleeding: The patient had several episodes of epistaxis, which did not respond completely to oxymetazoline and nasal saline. ENT was consulted and cauterized the bleeding site in the right nares. Bleeding subsequently resolved until the patient was placed on a trial of anticoagulation with a heparin gtt. Prior to admission the patient was on coumadin for afib and this medication was held during his admission. He was started on a heparin gtt to determine if he could tolerate anticoagulation on discharge. He began bleeding from both nares again, and in addition, bled at the insertion sites of his PICC and central lines, despite being within the therapeutic range for heparin. The heparin gtt was stopped and the patient was continued on heparin sc 5000 units TID for DVT prophylaxis. He will likely not tolerate anticoagulation for his atrial fibrillation in the near future. # Proptosis: Per the family, this is a long-standing issue. He had a normal-high TSH, not consistent with [**Doctor Last Name 933**]. CT imaging showed excess retro-orbital fat. # Ischemic Cardiomyopathy: The patient has a prior history of an MI and had a positive cocaine tox screen on admission. ECHO showed diastolic dysfunction, mild pulmonary hypertension and tricuspid regurgitation. The patient is ACE allergic, so he did not receive an ACE. The patient had diastolic dysfunction with EF 60-70%, so would not benefit from afterload reduction. Beta blockade was instituted with labetalol, but was not up-titrated given the patient's fevers, diuresis, and critical illnesses. Carvediolol and diovan were added during this admission with good BP control. If blood pressure increases consider adding on diovan. # Atrial fibrillation: On Metoprolol and coumadin as an outpatient. Was briefly on a heparin gtt, but that was stopped secondary to bleeding complications. His CHADS score is 2 (CHF, DM). Carvediolol for rate control. HR in 70-90s on average, with intermittent asymptomatic dips to 50s during sleep. # Normocytic Anemia: Chronic issue, with slight downward trend since admission. Iron study labs are not conclusive with a low reticulocyte count suggesting a mild production problem. [**Name (NI) **] may be mildly iron deficienct with a superimposed elevated ferritin as an acute phase reactant. He did not have any evidence of hemolysis. We did not start iron replacement therapy given his resolving ileus several days prior to discharge. # Gout: Outpatient allopurinol regimen was continued. Pt had knee swelling [**11-16**], had knee tapped and was positive for gout. Started on colchicine for 2 week total course - last day is [**11-30**]. Continue on allupurionol. Please ensure both allopurinol and colchicine are renally dosed. # LE erythema/edema: Consistent with chronic stasis dermatitis secondary to edema and venous insufficiency. Improved with aggressive diuresis. No evidence of cellulitis. # Agitation: Brief periods of agitation causing increased respiratory work as sedation was weaned. Considered secondary to pain since he is also tachycardic and goes up in BP during these episodes. Methadone used for pain and with weaning of versed and fentanyl with start of seroquel. Pt more clear and interactive today. Plan is to wean fentanyl and continue seroquel until pt improves. Now that pt is improving seroquel was changed to 150 mg TID. As mental status improves seroquel should be weaned further (150 tid on discharge), as well as methadone as tolerated. Please check EKGs for length of seroquel course as QTc was found to be prolonged during treatment. # Acute Renal failure: Pt developed ARF during hospitalization which responded to fluid boluses during hospitalization. Creatinine slowly improved with hydration and renally dosed medications with diuresis and return to baseline at discharge. Will need to follow electrolytes with further diuresis. Prior to discharge, creatinine was 1.3. # Elevated Transaminases ?????? slight bump in LFTs noted on [**11-20**] - no abdominal pain or complaints from pt. Likened to the change in seroquel, which in long term will be weaned as pt's mental status continues to improve. # DM: ISS with standing glargine - well controlled during hospitalization requiring 92 units of glargine at night with sliding scale starting at 6 units of Humalog at FSBG of 151 with increases in 2 units for each increase of 50 points in FSBG. Max dose is 14 units ISS for 351-400 FSBG. Medications on Admission: ALBUTEROL - QID PRN ALDACTONE - 50MG PO daily ALLOPURINOL - 300 MG PO daily BETAMETHASONE DIPROPIONATE - 0.05 % Ointment - apply qd twice a day as needed for qd FUROSEMIDE - 80 mg PO BID Lantus 25 units before breakfast Humalog 15 units with meals IPRATROPIUM BROMIDE - 17 mcg INH [**Hospital1 **] LIPITOR - 20MG PO daily METOPROLOL TARTRATE - 25 mg PO BID PANTOPRAZOLE 40mg PO daily WARFARIN 10mg PO daily ASPIRIN - 325 mg Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 3. Fentanyl Citrate (PF) 50 mcg/mL Solution Sig: 25-100 mcg Injection Q6H (every 6 hours) as needed for pain. 4. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO Q6H PRN (). 6. 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. 7. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). 8. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 9. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 12. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 13. Humalog 100 unit/mL Cartridge Sig: One (1) dose Subcutaneous ACQHS: Per sliding scale, 6 units for 151-200 8 units for 201-250 10 units for 251-300 12 units for 301-350 14 units for 351-400. 14. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 10 days. 15. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q6H (every 6 hours). 16. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Methadone 10 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 18. Acetaminophen 160 mg/5 mL Solution Sig: 1000 (1000) mg PO Q6H (every 6 hours) as needed for pain/fever. 19. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4-Q6 (). 20. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) dose Injection TID (3 times a day). 21. Sodium Chloride 0.65 % Aerosol, Spray Sig: Three (3) Spray Nasal TID (3 times a day). 22. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID (3 times a day). 23. Insulin Glargine 100 unit/mL Solution Sig: Ninety Two (92) units Subcutaneous at bedtime. 24. Seroquel 150mg po tid *please taper slowly and check EKG for length of seroquel course Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Primary diagnoses Respiratory Failure - Not ARDS/[**Doctor Last Name **] Fever, Unknown source AMS ARF Diarrhea Electrolyte/Fluid Disorder Secondary diagnoses Morbid Obesity CHF Pulm HTN Afib Anxiety Discharge Condition: Stable, remains on vent Discharge Instructions: Seek emergent medical care: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, worsening fevers, increased redness, swelling or discharge from tube or line sites, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. Followup Instructions: You are scheduled to see Dr. [**Last Name (STitle) **] on [**2142-1-4**] at 1115AM. If you cannot make your appointment or need to change your appointment you can reach his office at [**Telephone/Fax (1) 7976**]. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "008.45", "780.60", "518.81", "274.0", "416.0", "584.9", "327.23", "427.31", "428.0", "428.33", "278.01", "285.9", "401.9", "784.7", "459.81", "997.31", "250.00", "272.0" ]

icd9cm

[ [ [] ] ]

[ "33.23", "45.13", "96.6", "96.72", "38.91", "31.1", "33.24", "38.93" ]

icd9pcs

[ [ [] ] ]

21792, 21863

10044, 19029

296, 353

22108, 22134

4047, 4047

22543, 22895

3428, 3473

19504, 21769

21884, 22087

19055, 19481

22158, 22520

3488, 4028

237, 258

381, 1901

4063, 10021

1923, 3173

3189, 3412

16,805

112,792

25793

Discharge summary

report

Admission Date: [**2179-9-17**] Discharge Date: [**2179-10-16**] Date of Birth: [**2102-1-20**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1561**] Chief Complaint: Tracheobronchomalacia Major Surgical or Invasive Procedure: 1. Right thoracotomy with posterior membranous wall tracheoplasty with mesh. 2. Bilateral bronchoplasties with mesh. 3. Flexible bronchoscopy-multiple 4. Open tracheostomy tube placement 5. Left thoracotomy with open lung biopsy 6. Percutaneous endoscopic gastrostomy tube placement 7. Foley catheter placement 8. Central line placement 9. Chest tube placement History of Present Illness: Patient was a 77 year-old gentleman who developed dyspnea in high 40s and was diagnosed with asthma years ago becaming progressively worse over the years and much worse in the last several months. He had multiple admissions for COPD exacerbations, bronchitis and pneumonia requiring steroids and antibiotic therapy. He had never been intubated for any of these episodes. He had a terrible intractable cough and inability to clear secretions having to sleep with his head elevated. He has required 2.5 to 3 liters of oxygen continuously over the past 5 months at home. He has required prednisone over the last 8 months and he is dyspneic to the point where he could not walk more than 50 to 100 feet nor could he walk up a flight of stairs. He was eventually diagnosed with tracheobronchomalacia and underwent stringent preoperative evaluation including respiratory questionnaires, 6-minute walk test, functional bronchoscopies, dynamic airway CT scan and a stenting trial. He did well with all these such that it was felt that he would benefit from definitive surgical management; namely, a tracheo- and bilateral bronchoplasties with mesh. Past Medical History: COPD Tracheobronchmalacia Osteoarthritis Diverticulosis Nephrolithiasis MRSA Asbestosis GERD Social History: Former insulation (asbestos) worker minimal smoking history Family History: none Brief Hospital Course: Mr. [**Known lastname 4580**] was admitted to Dr.[**Name (NI) 1816**] service on [**2179-9-17**] at [**Hospital1 18**]. On that day, he underwent a tracheobronchoplasty. The operation went smoothly, and his initial postoperative course was uneventful. Unfortunately, he developed an ARDS pattern requiring reintubation with progressive ventilatory support. The patient was then taken back to the operating room on [**2179-10-7**], where a left lung biopsy was performed. The initial pathological examination demonstrated end-stage lung disease with honeycomb change and moderate chronic interstitial inflammation with focal fibroplastic foci favoring end-stage UIP. It was known that the patient had some degree of UIP in his preoperative CT scan, but it was felt that his main respiratory issue limiting his functional status was his tracheobronchomalacia. Unfortunately, it appears that he developed an acute exacerbation of his UIP in the perioperative period. On [**2179-10-16**], he went into a peculiar arrhythmia of supraventricular tachycardia superimposed on atrial fibrillation with periods of hemodynamic instability. The patient's daughters were immediately contact[**Name (NI) **] and informed. The immediate family was then present at the bedside within the hour as was the Attending Surgeon. After discussion with the Nursing staff, House Staff and Attending Surgeon, the family decided to withdraw hemodynamic and ventilatory support and make the patient as comfortable as possible. He succumbed to his underlying condition in the presence of his family on the evening of [**2179-10-16**]. An autopsy was declined by the family. Medications on Admission: Fexofen Fluticasone Albuterol Ipratropium Guaifenesin Protonix Lopressor 25mg PO BID Diltiazem 60mg PO TID Psyllium Discharge Medications: Not applicable Discharge Disposition: Expired Discharge Diagnosis: Cardiopulmonary Collapse Usual interstitial pneumonia Discharge Condition: Expired

[ "519.1", "997.3", "518.0", "530.81", "518.5", "496", "486", "428.0", "515" ]

icd9cm

[ [ [] ] ]

[ "33.48", "31.1", "96.05", "31.79", "33.28", "43.19", "00.14", "97.23", "33.24" ]

icd9pcs

[ [ [] ] ]

3980, 3989

2123, 3775

352, 714

4086, 4096

2094, 2100

3941, 3957

4010, 4065

3801, 3918

291, 314

742, 1884

1906, 2000

2016, 2078

18,353

192,908

52580

Discharge summary

report

Admission Date: [**2166-5-4**] Discharge Date: [**2166-5-9**] Date of Birth: [**2101-6-19**] Sex: M Service: MEDICINE Allergies: Benadryl / Morphine / Ativan / Compazine / Dilaudid Attending:[**First Name3 (LF) 1974**] Chief Complaint: somnolence Major Surgical or Invasive Procedure: None. History of Present Illness: 64 y/o male with PMHx of IDDM, COPD, ESRD, PVD, CHF, OSA who was brought in by EMS to ED after family stated that for the past few days patient has been intermittent confusion and slurred speech. The patient denied significant use of narcotics. When patient came to the ED patient had head CT which was negative. He was put on NRB for low O2Sat and patient remained somnolent. Felt that patient may be somnolent from narcotics so gave him Narcan 0.4mg IV and felt that he intermittently woke up but then again became somnolent so was started on Narcan gtt. An initial VBG in the ED showed CO2 of 30 but when this was repeated it was 97 and felt patient had hypercapnic respiratory failure. He was given a dose of levofloxacin and given 40IV lasix and put on nitro paste. Narcan drip was stopped and patient sent to the ICU. On arrival to the ICU patient somnolent and was quickly put on 2L NC with O2Sat of 100%. He was arousable to painful stimuli and would open his eyes but then quickly fall asleep. A repeat ABG was obtained on 2L NC which revealed 7.31/72/95. A K+ was also drawn with the ABG which came back as 6.6. Given his dependence on HD and anuria, he was dialyzed both on [**5-4**] and [**5-5**], removing 3 kg on each session as he appeared volume overloaded. By [**5-5**], he was breathing comfortably on his own, and continued to do so on [**5-6**]. He has recent amputations of both toes during hospitalization [**Date range (1) 108564**]/07 which were noted to be draining purulent material, for which vancomycin and ceftriaxone were given. Azithromycin was added for coverage of possible atypical pneumonia. Past Medical History: 1. Coronary artery disease: Myocardial infarction in [**2155**], MQWMI in [**2160**]. Most recent cath, [**2163-10-18**]: LCx stenting; previous RCA stent patent at that time. 2. Nonischemic dilated cardiomyopathy; EF [**12-6**] 33%. EF [**2164-1-11**] to 25% 3. Diabetes greater than 20 years; with triopathy. 4. Hypertension. 5. End stage renal disease on hemodialysis, q. Monday, Wednesday and Friday via right arteriovenous fistula. 6. Hypothyroidism. 7. Chronic obstructive pulmonary disease. 8. Hepatitis C. 9. Chronic pancreatitis. 10. Peptic ulcer disease. 11. Right perinephric hematoma; status post embolization. 12. Obstructive sleep apnea on CPAP. 13. Ruptured right groin abscess; recurrent right groin abscess in [**2162-12-4**]. 14. Peripheral [**Year (4 digits) 1106**] disease. 15. Status post R PFA to BK [**Doctor Last Name **] bypasss graft with vein 16. Status post 2nd and 3rd toe amps 17. Status post left CFA to AK [**Doctor Last Name **] with PTFE 18. Status post L inguinal hernia repair 19. Status post umbilical hernia repair 20. Ischemic left foot 21. A - Fib- not well documented. Followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of cardiology who notes he was previously on coumadin. Social History: Lives in [**Location 686**] with wife, has older children tobacco: 1 ppd x 60 yrs. quit 3 months ago, no EtOH. +Hx of narcotic abuse. Family History: Non contributory Physical Exam: T 97 HR 60 BP 116/74 RR 11 O2Sat 100% 2L Awake and alert, appropriate. Breathing without difficulty. No bruits Lungs crackles B bases with faint exp wheezes RRR S1S2 no m/r/g Abd soft ND NT BS+ Extr healed LLE surgical scar, 1+ BLE pitting edema, s/p B toe amputations with dressings c/d/i over both feet Pertinent Results: [**2166-5-4**] CT HEAD: 1. No evidence of intracranial hemorrhage. 2. Scattered low-attenuation foci in bihemispheric periventricular white matter, overall unchanged from study dated [**2166-1-23**], likely reflect chronic microvascular infarction. . [**2166-5-4**] CXR: 1. Markedly low lung volumes limit examination for small areas of consolidation or mild pulmonary edema. Given limitations, no definite evidence of an acute cardiopulmonary process is identified. 2. Persistent left mid zone atelectasis/scarring and cardiomegaly. . [**2166-5-4**] ECG: Sinus rhythm. No significant change since the previous tracing of [**2166-4-20**]. . . . . [**2166-5-4**] 10:00AM WBC-8.8 RBC-3.71* HGB-11.4* HCT-38.2* MCV-103* MCH-30.8 MCHC-29.9* RDW-20.5* [**2166-5-4**] 10:00AM NEUTS-74* BANDS-0 LYMPHS-13* MONOS-10 EOS-3 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2166-5-4**] 10:00AM PT-13.9* PTT-35.0 INR(PT)-1.2* [**2166-5-4**] 10:00AM PLT SMR-NORMAL PLT COUNT-318 [**2166-5-4**] 08:55AM GLUCOSE-134* UREA N-44* CREAT-6.0* SODIUM-142 POTASSIUM-5.4* CHLORIDE-96 TOTAL CO2-33* ANION GAP-18 Brief Hospital Course: 1) Hypercapnic respitory failure: The etiology was mostly likely multifactorial with sleep apnea, fluid overload, medication effect, COPD exacerbation being most prominent. There was no evidence of a pneumonia. In ICU, pt was put on NIMV. He was also dialyzed serially for fluid removal. He was started on antibiotics (Ctx and azithro) for possible pneumonia though CXR showed no clear infiltrate. He was also given a regimen of bronchodilators. With these therapies, his breathing improved and returned to baseline. He was taken off O2. He continued nocturnal Bipap for OSA. Once transferred to the floor, his resp status remained stable. His neurontin dose was adjusted. He continued to require low dose oxycodone for b/l LE pain but was warned against the dangerous effects of overuse. . 2) Peripheral [**Year/Month/Day **] Disease: Initial exam in ICU was concerning for infection at right foot amputation site. Pt was started on ctx and vanco. A superficial culture was obtained which was consistent with MRSA and pseudomonas similar to previous strains. Ctx was changed to zosyn. [**Year/Month/Day **] surgery was consulted and did not feel there was active infection of the area. The recommended wound care but no necessity for antibiotics. Given culture was superficial, it likely represented colonizing bacteria. Antibiotics were then stopped. PT will f/u with Dr. [**Last Name (STitle) **] regarding planned BKAs. . 3) ESRD: Pt was dialyzed aggressively on admission and then resumed his normal tiw schedule. . 4) CARDIOVASCULAR: There was evidence of fluid overload on initial exam and this was managed with HD. Pt appeared euvolemic by discharge. There was no evidence of ACS. PT had moderate elevation in cardiac enzymes c/w CHF in ESRD. His outpt regimen of [**Last Name (STitle) **], [**Last Name (STitle) 4532**], statin, lopressor, and ACE-I were continued. . 4) DM2: placed on sliding scale. . 5) OSA: Pt received BiPAP while in house however because he has not had it at home recently, it could not be set up at this time. He was setup for a sleep evaluation after which the machine can be arranged for him. . Medications on Admission: 1. Atorvastatin 10 mg PO DAILY 2. Lisinopril 2.5 mg PO DAILY 3. Amiodarone 200 mg PO DAILY 4. Sevelamer 800 mg PO TID 5. Cinacalcet 30 mg PO DAILY 6. MVI 7. Metoclopramide 5 mg PO QIDACHS 8. Levothyroxine 50 mcg PO DAILY 9. Citalopram 20 mg PO DAILY 10. Pantoprazole 40 mg PO Q24H 11. Zinc Sulfate 220 (50) mg PO DAILY 12. Albuterol q6 prn 13. Clopidogrel 75 mg PO DAILY 14. Aspirin 81 mg PO DAILY 15. Tramadol 100 mg PO QID prn 16. Zolpidem 5 mg PO HS 17. Metoprolol Tartrate 25 mg PO BID 18. Neurontin 300 mg tid 19. Oxycodone 5 mg qid prn 20. Colace 100 mg PO prn Discharge Medications: 1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every 48 hours). [**Last Name (STitle) **]:*0 Capsule(s)* Refills:*0* 2. Becaplermin 0.01 % Gel Sig: One (1) Appl Topical DAILY (Daily): apply to feet with dressing. [**Last Name (STitle) **]:*30 g* Refills:*2* 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Last Name (STitle) **]:*30 Tablet(s)* Refills:*0* 5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). [**Last Name (STitle) **]:*15 Tablet(s)* Refills:*0* 6. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Last Name (STitle) **]:*30 Tablet(s)* Refills:*0* 7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Last Name (STitle) **]:*30 Tablet(s)* Refills:*0* 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). [**Last Name (STitle) **]:*30 Tablet, Chewable(s)* Refills:*0* 9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Last Name (STitle) **]:*30 Tablet(s)* Refills:*0* 10. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). [**Last Name (STitle) **]:*90 Tablet(s)* Refills:*0* 11. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Last Name (STitle) **]:*30 Tablet(s)* Refills:*0* 12. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO DAILY (Daily). [**Last Name (STitle) **]:*30 Capsule(s)* Refills:*0* 13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). [**Last Name (STitle) **]:*1 aerosol* Refills:*2* 15. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). [**Last Name (STitle) **]:*[**2159**] ML(s)* Refills:*2* 16. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). [**Year (4 digits) **]:*30 Cap(s)* Refills:*0* 17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Year (4 digits) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 18. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. [**Year (4 digits) **]:*1 aerosol* Refills:*0* 19. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). [**Year (4 digits) **]:*0 Tablet(s)* Refills:*0* 20. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. [**Year (4 digits) **]:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: COPD exacerbation ESRD Peripheral [**Location (un) 1106**] disease Discharge Condition: Good--afebrile, hemodynamically stable. Discharge Instructions: 1. Take medications as prescribed. Continue to check fingersticks and use insulin. Use oxycodone sparingly given risk to your breathing and do not exceed prescribed dose. 2. Follow with Dr. [**First Name (STitle) **] as below. 3. Continue dialysis as previous schedule. 4. Please call Dr. [**First Name (STitle) **] for increasing shortness of breath, chest pain, fevers. Followup Instructions: 1. Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5004**] [**Last Name (NamePattern1) **], M.D. (PCP) Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2166-5-15**] 10:40 2. Provider: [**Name10 (NameIs) 1037**] [**Name8 (MD) 5647**], MD (dermatology) Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2166-5-22**] 11:00 3. Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5004**] [**Last Name (NamePattern1) **], M.D. (PCP) Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2166-6-17**] 9:00. 4. You have an appointment scheduled in the Sleep Clinic at [**Hospital1 18**], [**Hospital Ward Name **], [**Hospital Ward Name 23**] Building [**Location (un) **]. Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **]/DR. [**First Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2166-6-6**] 4:00. . 5. Please call the office of Dr. [**Last Name (STitle) **] to schedule a follow-up appointment in 1 week. ([**Telephone/Fax (1) 1798**]

[ "585.6", "583.81", "997.62", "362.01", "414.01", "250.40", "428.0", "440.23", "427.31", "357.2", "250.60", "E878.5", "041.11", "250.50", "707.15", "E849.8", "327.23", "518.81", "425.4", "403.91", "577.1", "070.70", "491.21" ]

icd9cm

[ [ [] ] ]

[ "93.90", "39.95" ]

icd9pcs

[ [ [] ] ]

10242, 10299

4893, 7046

321, 329

10410, 10452

3782, 3797

10878, 11884

3423, 3441

7664, 10219

10320, 10389

7072, 7641

10476, 10855

3456, 3763

271, 283

357, 1988

3806, 4870

2010, 3255

3271, 3407

80,339

124,871

54798+59632

Discharge summary

report+addendum

Admission Date: [**2168-6-29**] Discharge Date: [**2168-7-9**] Date of Birth: [**2094-12-1**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 165**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: [**2168-6-29**] CABG x3(LIMA->LAD,SVG->OM,SVG->diag) History of Present Illness: 73 year old male with newly discovered cardiomyopathy admitted in [**Month (only) 116**] to [**Hospital1 18**] [**Location (un) 620**] with cellulitis. TTE at the time showed moderate focal and global left ventricular systolic dysfunction consistent with multivessel coronary artery disease and moderate pulmonary artery systolic hypertension. He reports fatigue and shortness of breath on exertion such as climbing 2 flights of stairs. He also reports left leg swelling which does not change throughout the day. He was referred for left heart catheterization. Cardiac catheterization found to have coronary artery disease and referred to cardiac surgery for revascularization. Past Medical History: Past Medical History: Cardiomyopathy Congestive heart failure Anemia Cellulitis of his legs, [**3-/2168**] Prostate cancer s/p radiation therapy followed at [**Hospital1 2025**] [**2161**] Past Surgical History: Partial colectomy for sigmoid diverticulitis bilateral eye surgery for cataracts hernia repair right eye surgery Social History: Race:Caucasian Last Dental Exam:edentulous Lives with:alone (has a lifeline) Contact:[**Name (NI) **] [**Name (NI) **] (sister) Phone #[**Telephone/Fax (1) 111998**] Occupation:retired Cigarettes: Smoked no [] yes [x] Hx:quit 20 years ago and restarted about 2 years ago and recently quit 6 months ago, smoked 2 pdd for 30 years Other Tobacco use:denies ETOH:[**11-24**] glasses of wine daily, stopped 7 days prior to catheterization Illicit drug use: denies Family History: Premature coronary artery disease- Father died of heart attack at age 79 Physical Exam: Admission Pulse:54 Resp:18 O2 sat:100/RA B/P Right:154/72 Left:147/75 Height:5'[**65**]" Weight:175 lbs General: NAD, appears stated age Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] pterygium on right Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [x] _none_ Varicosities: None [] small Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left:2+ DP Right: Left: PT [**Name (NI) 167**]: 2+ Left:2+ Radial Right: 2+ Left:2+ Carotid Bruit Right: Left: no bruits Pertinent Results: Admission labs: [**2168-6-29**] 02:42PM BLOOD WBC-21.1*# RBC-3.23* Hgb-10.0* Hct-30.3* MCV-94 MCH-31.2 MCHC-33.2 RDW-14.1 Plt Ct-198 [**2168-6-29**] 02:42PM BLOOD PT-12.1 PTT-29.1 INR(PT)-1.1 [**2168-6-29**] 02:42PM BLOOD UreaN-22* Creat-1.3* Na-141 K-4.4 Cl-108 HCO3-27 AnGap-10 Discharge labs ECHO: PRE-BYPASS: Essentially perserved LV systolic function with no segmental wall motion abnormalities and no significant valvular abnormalities or other significant unexpected findings. The left atrium and right atrium are normal in cavity size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. 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%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Diastolic dysfunction present with pseudonormal transmitral diastolic spectral Doppler profile with lateral mitral annular tissue Doppler e' = 6.7 cm/sec. Intact interatrial septum. No clot in LAA. Normal appearing coronary sinus. POST-BYPASS: LVEF > 55% no segmental wall motion abnormalities. Otherwise unchanged. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16164**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2168-6-29**] 13:30 Radiology Report CHEST (PORTABLE AP) Study Date of [**2168-7-6**] 7:28 AM Final Report: In comparison with the study of [**6-30**], the right IJ sheath has been removed. Enlargement of the cardiac silhouette persists in this patient with intact midline sternal wires. There is continued hazy opacification bilaterally, more prominent on the left, with preservation of pulmonary markings consistent with bilateral layering pleural effusions and underlying compressive atelectasis. This appears to be increasingly prominent on the left, though this could merely reflect differences in patient position. In view of the prominent bilateral effusions, the possibility of supervening pneumonia would be extremely difficult to exclude. DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**] Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [**2168-6-29**] where the patient underwent Coronary artery bypass graft x3, left internal mammary artery to left anterior descending artery and saphenous vein graft to diagonal and obtuse marginal arteries. Endoscopic harvesting of long saphenous vein. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Cefazolin was used for surgical antibiotic prophylaxis. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable on no inotropic or vasopressor support. Beta blocker was not initiated in the immediate post-operative period due to sinus bradycardia in the 40's requiring temporary pacing until he recovered his native rhythm. He subsequently developed rapid afib with conversion pauses requiring a permanent pacemaker which was placed on [**2168-7-8**]. He will complete a 5 day course of keflex s/p pacer. He 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 # 10 from his CABG and POD#1 from his pacer the patient was ambulating with assistance, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to [**Hospital3 4103**] on the [**Doctor Last Name **] in good condition with appropriate follow up instructions. Medications on Admission: Medications at home: FUROSEMIDE 20 mg Daily METOPROLOL SUCCINATE 100 mg Daily THIAMINE/VITAMIN B1 100 mg Daily VALSARTAN 320 mg Daily ASCORBIC ACID 500 mg Daily ASPIRIN Not Taking as Prescribed: stopped 5 wks ago for severe nose bleeds VITAMIN D3 1,000 unit Daily Saline nasal spray Discharge Medications: 1. Aspirin EC 81 mg PO DAILY if extubated 2. Acetaminophen 650 mg PO/PR Q4H:PRN temperature >38.0 3. Amiodarone 200 mg PO TID 4. Atorvastatin 20 mg PO DAILY 5. Colchicine 0.6 mg PO BID 6. Hydrocerin 1 Appl TP TID to bilateral heels 7. Metoprolol Tartrate 50 mg PO BID Hold for HR<60 SBP<90 8. Oxycodone-Acetaminophen (5mg-325mg) [**11-23**] TAB PO Q4H:PRN pain RX *oxycodone-acetaminophen 5 mg-325 mg [**11-23**] tablet(s) by mouth every four (4) hours Disp #*65 Tablet Refills:*0 9. Ranitidine 150 mg PO DAILY 10. Furosemide 40 mg PO DAILY 11. Docusate Sodium 100 mg PO BID 12. Potassium Chloride 20 mEq PO BID Hold for K > 4.5 13. Warfarin MD to order daily dose PO DAILY afib dose to be determined based on INR 14. Thiamine 100 mg PO DAILY 15. Vitamin D 1000 UNIT PO DAILY 16. Ascorbic Acid 500 mg PO DAILY 17. Valsartan 320 mg PO DAILY 18. Cephalexin 500 mg PO Q8H Duration: 5 Days Discharge Disposition: Extended Care Facility: Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**] Discharge Diagnosis: coronary artery disease-s/p CABG x3 post-operative atrial fibrillation with conversion pauses requiring pacer PMH: cardiomyopathy, CHF, anemia, cellulitis of legs ([**3-/2168**]), prostate ca s/p XRT ([**2161**]), partial colectomy (sigmoid diverticulitis), b/l eye surgery (cataracts), hernia repair 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: none Discharge Instructions: Sponge bathing only until [**2168-7-11**] then Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2168-7-12**] 10:15. [**Hospital **] Medical Office Building, [**Last Name (NamePattern1) **] [**Hospital Unit Name **] Surgeon: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2168-8-9**] 1:00/[**Hospital **] medical office building, [**Doctor First Name **] [**Hospital Unit Name **] DEVICE CLINIC for pacer check Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2168-7-14**] 9:30 Cardiologist:Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4135**] MD Please call to schedule appointments with your Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 111999**] in [**2-25**] weeks Labs: PT/INR for Coumadin ?????? indication atrial fibrillation Goal INR 2-2.5 First draw day after discharge then every M-W-F- ***sensitive to coumadin dosing Results to rehab medical provider for [**Name9 (PRE) 16070**] dosing - will need coumadin follow up arranged upon discharge from rehab **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:[**2168-7-9**] Name: [**Known lastname 7410**],[**Known firstname **] Unit No: [**Numeric Identifier 18397**] Admission Date: [**2168-6-29**] Discharge Date: [**2168-7-9**] Date of Birth: [**2094-12-1**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 265**] Addendum: Temporary epicardial pacing wires were cut at the skin per Dr. [**Name (NI) 18398**] request due to elevated INR 3.1 on day of discharge. Discharge Disposition: Extended Care Facility: Newbridge on the [**Doctor Last Name **] - [**Location (un) 1502**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**] Completed by:[**2168-7-9**]

[ "427.31", "584.9", "997.1", "428.0", "425.4", "E878.2", "427.81", "V10.46", "414.01", "E934.2", "790.93", "428.32", "416.8", "274.01" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

11945, 12158

5472, 7194

328, 383

8879, 9106

2763, 2763

9994, 11922

1935, 2010

7528, 8417

8555, 8858

7220, 7220

9130, 9971

7241, 7505

1325, 1442

2025, 2744

269, 290

411, 1091

2779, 5449

1135, 1302

1458, 1919

2,021

103,637

27181

Discharge summary

report

Admission Date: [**2163-10-7**] Discharge Date: [**2163-10-21**] Date of Birth: [**2097-1-6**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4111**] Chief Complaint: Vomiting Diarrhea Colon Cancer Major Surgical or Invasive Procedure: Exploratory lap, lysis of adhesions (3 hours), resection of fistula, and closure of the enterotomy, low anterior resection and colorectostomy, coloproctostomy, takedown of colostomy, transverse colostomy and frozen section biopsy History of Present Illness: 66F with locally advanced rectosigmoid adenocarcinoma s/p diverty colostomy and feeding jejunostomy [**5-21**]; s/p CT guided abscess drainage [**2163-8-22**]. She just finished a course of cemoradiation on [**2163-8-2**] (Capecitabine). Of note from her previous hspitalization, the abscess drain was prematurely removed and she was discharged home on Augmentin x 7 days. She was schedule dto be admitted for resection of her rectal cancer, but presents two days early with mild abdominal pain around ostomy and peri-ostomy hernia with vomiting and increased ostomy output x 1 day. Past Medical History: Obstructing Rectosigmoid Mass Emphysema PSH: Colostomy/[**Doctor Last Name **]/Jejunostomy Tube [**2163-5-19**] Open Cholecystectomy Social History: +ETOH (~2/day) +tobacco (50+ pk/yr history) No recreational drugs Family History: Mother died in late 70s of CVA Father died in mid 60s of "hiatal hernia" (?strangulated hernia) Physical Exam: Admission Physical Exam: [**2163-10-7**] 98.2 114 88/60 20 99%RA Neuro: AxOx3, NAD HEENT: PERRL, EOMI CVS: RRR, no m/c/r Resp: CTAB, no w/r/r Abd: soft/distended/tenderness to percussion around ostomy site and peri-ostomy hernia/NABS Ext: no c/c/e Pertinent Results: Admission Labs: [**2163-10-7**] 02:00PM BLOOD WBC-21.7*# RBC-4.47 Hgb-12.9# Hct-40.7 MCV-91 MCH-28.8 MCHC-31.6 RDW-17.6* Plt Ct-851* [**2163-10-7**] 02:00PM BLOOD Neuts-85* Bands-8* Lymphs-3* Monos-2 Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2163-10-7**] 02:00PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+ Macrocy-1+ Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+ Target-OCCASIONAL Schisto-1+ Burr-2+ [**2163-10-7**] 02:00PM BLOOD Plt Ct-851* [**2163-10-7**] 10:00PM BLOOD PT-11.8 PTT-24.3 INR(PT)-1.0 [**2163-10-7**] 02:00PM BLOOD Glucose-131* UreaN-30* Creat-0.8 Na-136 K-4.7 Cl-98 HCO3-21* AnGap-22* [**2163-10-7**] 02:00PM BLOOD ALT-10 AST-27 AlkPhos-79 Amylase-29 TotBili-0.4 [**2163-10-8**] 06:40AM BLOOD Calcium-8.1* Phos-3.0 Mg-1.3* [**2163-10-7**] 02:00PM BLOOD Albumin-4.2 Calcium-10.2 Mg-1.9 [**2163-10-7**] 05:40PM BLOOD Lactate-1.8 Discharge Labs: [**2163-10-20**] 05:07AM BLOOD WBC-15.0* RBC-3.36* Hgb-10.1* Hct-29.8* MCV-89 MCH-30.1 MCHC-33.9 RDW-16.8* Plt Ct-707* [**2163-10-20**] 05:07AM BLOOD Glucose-109* UreaN-13 Creat-0.4 Na-137 K-4.7 Cl-103 HCO3-27 AnGap-12 [**2163-10-20**] 05:07AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.0 ----------NUTRITION LABS---------- Date-----Alb-----Fe-----TIBC-----[**Last Name (un) **]-----TRF *[**10-7**]-----4.4 *[**10-10**]-----2.8-----26-----[**Telephone/Fax (3) 66698**] *[**10-17**]-----2.9-----38-----172-----280-----132 CT OF THE ABDOMEN WITH IV CONTRAST: There are new diffuse, but patchy, tree- in-[**Male First Name (un) 239**] and ground-glass opacities in the right middle, right lower, and left lower lobes with sparing of the lingula, most consistent with pneumonia. The liver appears normal. The patient is status post cholecystectomy. There are splenic arterial calcifications. The pancreas, adrenal glands and kidneys are within normal limits. The stomach appears normal. There is a jejunostomy tube overlying the left upper quadrant in suitable position. Enteric contrast has been administered via that tube for this study. There is marked dilatation of the proximal small bowel, to a greater extent than on the prior study. A segment of jejunum in the left upper quadrant measures 4 cm in diameter. More distally there are several segments of irregular narrowing, accompanied by wall thickening of the small bowel. These abnormal segments are mostly within or immediately above the pelvis, particularly near the residual rectum. More distally the terminal ileum is normal in caliber. Contrast passes freely into the cecum. The proximal residual colon is only mildly distended, and more distally, is almost collapsed near the colostomy site. Although contrast passes freely throughout, the appearance of proximal small bowel dilatation, worse than before, suggests either a low- grade obstruction, perhaps related to segments of abnormally thickened distal small bowel, or an ileus. There are multiple enlarged retroperitoneal and mesenteric lymph nodes, which are unchanged. As none of these is over 12 cm in shortest dimension, however, these may be reactive, but metastatic disease is also possible. There are vascular calcifications in the aorta with mild distal fusiform dilatation up to 2.9 cm at the aortic bifurcation. There is no free air. CT OF THE PELVIS WITH IV CONTRAST: There is a persistent collection of fluid in the presacral space of intermediate density with a smooth enhancing wall. It is only somewhat smaller than before and measures 1.9 x 2.5 cm in axial dimensions. The collection contains air, which suggests a fistulous connection to adjacent bowel or may be due to abscess formation. The rectal stump also contains air and fluid. More proximally the residual rectum is markedly thickened throughout, suggesting persistent tumor. There is also enteric contrast which has passed into the residual rectum, which outlines the convex contour of an apparent endoluminal mass more distally. There is no pelvic or inguinal lymphadenopathy or free fluid. BONE WINDOWS: There are no suspicious lytic or blastic lesions. IMPRESSION: 1. Increased dilatation of the proximal small bowel, with areas of narrowing and wall thickening in the more distal small bowel. This appearance may relate to radiation change or involvement with tumor. Proximal dilatation may be due to an ileus or low-grade obstruction, although contrast passes freely throughout. 2. Residual rectum with an overall similar appearance, including marked thickening and apparently an endoluminal mass. The residual rectum contains contrast proximally, implying a fistulous connection to the small bowel. There is also air and fluid more distally. 3. Persistent presacral fluid collection with enhancing rim. The presence of air within the collection also suggests fistulous connection to adjacent bowel, or may be due to abscess formation. 4. Mild lymphadenopathy, which could be either metastatic or reactive. Operative Note: PREOPERATIVE DIAGNOSIS: Carcinoma of the rectosigmoid with a question of an enterorectal fistula. POSTOPERATIVE DIAGNOSIS: Enterorectal fistula, question carcinoma of the rectosigmoid. INDICATIONS: The patient presented with massive weight loss and total obstruction of her rectum which may have been due to a pelvic abscess which was not seen early on. We could not get a histologic diagnosis and at the first operation I did not think that I could extirpate the rectum very well, and so we did an end sigmoid colostomy and treated her with radiation and chemotherapy. We then brought her back. She had 2 recurrent pelvic abscess which we believed probably was the result of an enterorectal fistula. At the time of surgery, we were able to take down the enterorectal fistula and close the enterotomy and then do a low anterior resection, takedown the colostomy and resect it and then do an anastomosis and then because of the situation with the previous radiation then do a protected colostomy. The following procedure was carried out. OPERATIONS: Exploratory lap, lysis of adhesions (3 hours), resection of fistula, and closure of the enterotomy, low anterior resection and colorectostomy, coloproctostomy, takedown of colostomy, transverse colostomy and frozen section biopsy. ASSISTANT: Dr. [**Last Name (STitle) 66699**] [**Name (STitle) **] [**Name8 (MD) **], MD (RES) Dr [**Last Name (STitle) **]. PROCEDURE: Under satisfactory general anesthesia, the patient was placed supine and prepped and draped in the usual manner. We excised the old incision and actually carried this higher on the abdominal wall, entering the abdomen cleanly. The liver had no disease. There were a number of adhesions. The principal adhesion, however, was to a loop of bowel which went down on the right side to the rectum and clearly was an enterorectal fistula. This was taken down and the opening in the small bowel was closed in 2 layers with 4-0 silk transversely and interrupted 4-0 Prolene. Attention was then turned to lysing all of the adhesions in the small bowel until we actually had a totally free small bowel and this was carried out without difficulty. We then started dissecting the rectum which we did by grasping the rectum with 3-0 silk sutures, getting behind it, freeing it up from the left ureter which was clearly seen and was intact and there was no hematuria and then gradually working our way down and doing a total mesenteric excision, getting below the entrance of the fistula into the rectum and then finally well below the sacral curve. Irrigation of the rectum revealed that it was entirely open at this point up into the point of the obstruction which the area of radiation at the bottom of which was the enterorectal fistula, the most distal. After we saw that we could get a reasonable length of rectum up to do the anastomosis, we took down the colostomy which had a pericolostomy hernia and then transected it with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3224**] stapler and then anastomosed it with 2 layers of 4-0 silk, initially by using the rectum as a handle, but then dealing with the front and taking it off and then getting a very nice 2-layer 4-0 silk interrupted anastomosis. We then irrigated the pelvis copiously. We were happy with the anastomosis. The rectal tube had been removed and we then changed gowns and gloves and closed the site of the colostomy which had a pericolostomy hernia and then prepared the transverse colostomy by getting a quarter inch Penrose drain under the transverse colon. We then changed gowns and gloves to closure kit and closed the peritoneum, put the Penrose drain which had a tie around it in the peritoneum, irrigated the peritoneum, checked for the nasogastric tube, checked for bleeding which there was very little and then closed the peritoneum with #1 chromic catgut. The paramedian incision was then closed as a lateral paramedian incision taking the freed up muscle and placing it in the midline and then #1 Vicryl on the fascia. After the fascia was closed, we then made a transverse incision over the right rectus, split the rectus and then brought up a loop of colon through the previous identified colon through and put a bridge underneath. This was subsequently matured at the end of the procedure by dividing the anterior wall. The closure was completed. We had previously closed the area of the colostomy with #1 Vicryl. The subcutaneous tissue of the incision was closed with 3-0 Vicryl and with 4-0 Monocryl and the same with the area of the previous transverse colostomy. Estimated blood loss was 600 cc. The patient tolerated the procedure well. She was slightly acidotic so she was left on the ventilator. Two sponge counts, needle counts and instrument counts were reported as correct by the nursing in charge. The patient tolerated the procedure well and was returned to the PACU and will likely go to the ICU. Brief Hospital Course: [**Known firstname 1743**] [**Known lastname 54371**] presented to the emergency department at [**Hospital1 18**] on [**2163-10-7**]. Her WBC was found to be elevated at 21.7. An abdominal/pelvic CT scan showed increased dilatation of the proximal small bowel, with areas of narrowing and wall thickening in the more distal small bowel; residual rectum with intraluminal mass; implied fistulous connection from residual rectum to the small bowel; persistent presacral fluid collection with enhancing rim; and mild lymphadenopathy (see pertinent results). A chest xray was obtained which was negative for acute process or effusion(see pertinent results). She was admitted to the surgery service under the care of Dr. [**Last Name (STitle) 957**] for questionable obstructive process and presacral fluid collection. She was placed NPO; tube feeds were held; and a foley catheter was inserted. Vancomycin/Levofloxacin/Flagyl were started for empiric coverage. At HD 2 a PICC line was placed; TPN was started. Her j-tube was placed to gravity. She was taken to interventional radiology for CT-guided aspiration of the presacral fluid collection which revealed 30-40ml of purulent, then serosanguinous drainage. A pigtail catheter was placed. A sample of the drainage was sent for culture. At HD 5 her abdomen remained distended with question of continued obstructive process. She denied pain or vomiting. She remained NPO and continued nutrition via TPN. At HD 6 Hibiclens washes and Neomycin/Erythromycin were provided. On HD 7 she was taken to the operating room where she underwent an exploratory lap, lysis of adhesions, resection of fistula, and closure of the enterotomy, low anterior resection and colorectostomy, coloproctostomy,takedown of colostomy, transverse colostomy and frozen section biopsy. She tolerated the procedure well. Estimated blood loss was 600ml and she received 2 units of PRBCs and 500ml albumin. She remained intubated after surgery and was taken to the ICU for further care. By POD 1 the presacral fluid culture grew staph aureus susceptible to Vancomycin and her Levo/Flagyl were discontinued. Blood cultures from the emergency department were negative. She was doing well. Urine output and vital signs were stable. She was extubated without complication. At POD 3 narcotic pain control was weaned and she was receiving tylenol with good control. Her colostomy was functioning well with good output. 1/2 strength tube feeds were started and TPN was continued. Her WBC count was elevated at 20.2 and a repeat abscess culture was sent from the pigtail. Vancomycin was continued. Levofloxacin/Flagyl were restarted. Her diet was advanced to sips, and she was deemed stable for transfer to the floor. On POD 4, she was transferred to a regular floor. She continued to be afebrile. Her tube feeds were advanced to 30cc/hr and her TPN was continued. She ctoninued to has gas and stool from her ostomy an her pigtail continued to drain 25 cc of serosanguinous fluid. She was continued on her vancomycin. On POD 5, she continued to be afebrile and stable. Her tube feeds were advanced to 40 cc/hr, which she tolerated well. She was advanced to sips and her TPN was continued. Her antibiotics were continued and her pigtail continued to have minimal output. On POD 6, she continued to do well and be afebrile. She was advanced to a soft diet and her TF were advanced to 50 cc/hr cycled overnight. Her pigtail continued to have minimal output of 10cc and her TPN was discontinued. Her metoprolol was increased for an elevated heart rate. On POD 7, she was deemed stable for discharge home. She remained afebrile and her tube feeds advanced to 70 cc/hr cycled overnight with non-generic imodium. On POD 8, she continued to do well, tolerating a soft diet. Her pigtail was discontinued. She was discharged home with nursing services for her tube feeds and IV antibiotics. Medications on Admission: Megace 40mg QID Metoprolol 25mg 1.5 [**Hospital1 **] ASA 81mg daily Discharge Medications: 1. Ampicillin Sodium 1 g Piggyback Sig: One (1) Intravenous every six (6) hours for 7 days. Disp:*4 4* Refills:*24* 2. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: One (1) Intravenous every eight (8) hours for 7 days. Disp:*3 3* Refills:*18* 3. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 5. Acetaminophen 160 mg/5 mL Solution Sig: Twenty (20) ml PO Q 8H (Every 8 Hours) for 10 days: Please flush down J-tube. Disp:*QS QS* Refills:*0* 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. Disp:*30 Tablet, Chewable(s)* Refills:*2* 7. Imodium A-D 1 mg/5 mL Liquid Sig: Two (2) mg PO twice a day: Give 10ml liquid down J-tube twice daily. Disp:*qs qs* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) **] home therapies Discharge Diagnosis: Enterorectal fistula, question carcinoma of the rectosigmoid. Discharge Condition: Stable Discharge Instructions: Please call your doctor [**First Name (Titles) **] [**Last Name (Titles) **] greater than 101.5, nausea/vomiting, inability to eat, wound redness/warmth/swelling/foul smelling drainage, abdominal pain not controlled by pain medications or any other concerns. Please take medications as prescribed. Please follow-up as directed. No heavy lifting (anything that makes you strain) for 4-6 weeks or until directed otherwise. Please leave water proof dressing on until follow-up with Dr. [**Last Name (STitle) 957**]. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 957**] in [**1-17**] weeks. Please call his office at ([**Telephone/Fax (1) 376**] to schedule an appointment. Completed by:[**2163-10-24**]

[ "560.89", "E879.2", "783.21", "569.69", "567.38", "909.2", "305.1", "041.11", "276.51", "568.0", "569.81", "V10.05", "562.11", "492.8", "569.49" ]

icd9cm

[ [ [] ] ]

[ "99.15", "46.52", "38.93", "96.6", "48.62", "46.74", "45.94", "54.91", "99.04", "54.59" ]

icd9pcs

[ [ [] ] ]

16623, 16689

11666, 15590

345, 576

16795, 16804

1835, 1835

17369, 17561

1448, 1545

15708, 16600

16710, 16774

15616, 15685

16828, 17346

2687, 11643

1585, 1816

275, 307

604, 1191

1852, 2670

1213, 1348

1364, 1432

25,780

199,988

277+278

Discharge summary

report+report

Admission Date: [**2169-1-24**] Discharge Date: [**2169-3-1**] Date of Birth: [**2095-1-13**] Sex: M Service: COLORECTAL SURGERY SERVICE HISTORY OF PRESENT ILLNESS: This is a 74 year old gentleman with a history of prostate cancer who presented in [**Month (only) 1096**] of last year with rectal bleeding. Evaluation included a colonoscopy which showed an ulcerative lesion in the rectum. These were biopsied and showed moderately differentiated adenocarcinoma. The patient presents for curative resection. PAST MEDICAL HISTORY: Prostate cancer with radiation implants and external beam radiation; hypercholesterolemia; history of peptic ulcer disease. SOCIAL HISTORY: No tobacco; occasional alcohol. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Cardura 2 mg once a day. 2. Lipitor 10 mg once a day. INITIAL PHYSICAL EXAMINATION: The patient was afebrile. Vital signs, within normal limits. Well developed male, no apparent distress. Chest was clear. Heart was regular. Abdomen, soft, nondistended, without masses. Extremities are warm. PREOPERATIVE LABORATORY: Preoperative labs were significant for a hematocrit of 40.4. BRIEF HOSPITAL COURSE: The patient was taken to the Operating Room on [**2169-1-24**], where he underwent a proctocolectomy with a coloanal anastomosis and a loop ileostomy under general endotracheal anesthesia. Estimated blood loss was 500 cc. The patient had a #14 French q day catheter placed due to his history of prostate cancer and ureteral stenosis. He tolerated the procedure well. There were no intraoperative complications and he was transported to the Recovery Room in stable condition. Immediately postoperatively, the patient was relatively comfortable with an epidural catheter in place for pain control. He remained hemodynamically stable, however, was without flatus. He was started on clear liquids on postoperative day #2 as well as restarted on his whole medications. Of note, he began to have a large amount of light brown loose output from his ostomy. Due to the large volume, he was started on intravenous fluid replacement to prevent dehydration. His diet was advanced to a regular diet and his fluid repletion was kept for the next few days. His Foley catheter was removed on postoperative day #7, however, he failed to void. Urology was consulted and a 18 French Foley was placed with a PVR of 190 cc. Towards postoperative day #8, the patient's ostomy output decreased. His abdomen became distended and his appetite worsened. He also had an episode of emesis as well. KUB revealed a PSBO. A small red rubber catheter was placed in the stoma with some relief, however, the patient remained distended. His partial small bowel obstruction was slow to resolve where on postoperative day #18 he was started on clears with continued decompression through his ostomy via the red rubber catheter. Postoperative day #13, the patient became hypotensive with a severe abdominal pain in the right upper quadrant above his ostomy. Abdominal CT with p.o. and intravenous contrast was done which showed dilated loops of small bowel and mild edema proximal to the ostomy without free air or contrast extravasation. He was made NPO and resuscitated with intravenous fluids, however, later that evening, his O2 sats were noted to decrease to the 80s on room air. Electrocardiogram was obtained which showed no change from prior, however, in light of the patient's obstruction, marginal urine output and pending instability, he was transferred to the Intensive Care Unit for further management. There he underwent a VQ scan which was low probability for pulmonary embolus. On rectal examination, he was found to have an area of anterior separation of his anastomosis and about 30 cc of serosanguinous fluid was drained. He was kept on broad spectrum antibiotics and close observation. CT scan of the abdomen was repeated which showed, again, thickened bowel but no contrast extravasation. Of note, as well, the patient's white blood cell count had increased to 24, however, over the next few days, he stabilized with a decreasing white blood cell count, pain abating and better urine output. During this time, while he was NPO, he was also started on TPN for nutritional support. Due to the patient's apparent stability, he was started on p.o. diet again which was advanced. He did continue over the next few days to require a few fluid boluses due to his high ileostomy output. He continued to make slow gains and required two additional CT scans that showed some free fluid in the abdomen which did not show evidence of having extravasated. These were percutaneously drained. The first around the 17th and the 18th with the initial culture growing E-coli and Morganella Morgani and subsequent cultures with no growth. As note, throughout his period of sepsis, several blood cultures were drawn which have showed no growth to date. Due to the patient's poor p.o. intake, a nasal gastric feeding tube was placed and he was started on tube feeds which he tolerated well. His antibiotics were also continued through this interval as well. Around postoperative day #30, he was started on a regular diet. His tube feeds had been at goal, however, his ileostomy output again started to increase for which he was placed on intravenous fluid replacement. He had a CT scan of his abdomen which did not show evidence of a leak or any new intra-abdominal fluid collections. He was slowly able to advance his diet. His TPN was d/c'd and at the time of this dictation, the patient is meeting 100% of his caloric and protein needs orally. His tube feeds have been decreased to 35 cc per hour to compensate for what he himself may not take in. His antibiotics were stopped on postoperative day #32. He remained afebrile, hemodynamically stable and otherwise feeling well. CONDITION OF DISCHARGE: Good. DISCHARGE STATUS: The patient will be discharged to a rehabilitation facility for conditioning and regain of strength. DISCHARGE DIAGNOSIS: 1. Rectal cancer. 2. Status post proctocolectomy with coloanal anastomosis and a loop ileostomy. 3. Partial small bowel obstruction, resolved. 4. Postoperative leak, resolved. 5. Hyperlipidemia. 6. History of prostate cancer. DISCHARGE MEDICATIONS: 1. Lipitor 10 mg p.o. q d. 2. .................... 2 mg p.o. q hs. 3. Heparin subcutaneous 5,000 units b.i.d. 4. Vitamin D 500 mg p.o. b.i.d. 5. Zinc Sulfate 220 mg p.o. q d for a total of two weeks. 6. Protonix 40 mg p.o. q d. 7. Lopressor 50 mg p.o. b.i.d. 8. Calcium Carbonate 1 gram p.o. b.i.d. 9. Imodium 4 mg p.o. b.i.d. DISCHARGE INSTRUCTIONS: This patient is to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1888**] at telephone # ([**Telephone/Fax (1) 2679**] in 10 to 14 days. He is also to follow up with his Urologist, Dr [**Last Name (STitle) 2680**] at telephone # ([**Telephone/Fax (1) 2681**] for planning of Foley catheter removal and further care. [**Last Name (LF) **], [**First Name3 (LF) 1112**] Dictated By:[**Last Name (NamePattern1) 2682**] MEDQUIST36 D: [**2169-2-27**] 14:08 T: [**2169-2-27**] 14:04 JOB#: [**Job Number 2683**] Admission Date: [**2169-1-24**] Discharge Date: [**2169-3-1**] Date of Birth: [**2095-1-13**] Sex: M Service: ADDENDUM: This is a continuation of the previously dictated discharge summary dated [**2169-2-27**], an update of the patient's condition. Mr. [**Known lastname 2684**] was initially started on Imodium for high ileostomy outputs totaling 2-3 liters per day. This had been coming down at the time of beginning the Imodium to about 2?????? liters per day upon starting the patient at a dose of 4 mg p.o. b.i.d. He received two doses and his output drastically decreased to less than 100 cc for the day with formed stool present. His dose was decreased in half for one dose and then discontinued altogether. The patient throughout this experienced no bloating, no abdominal pain or obstructive symptoms, and upon discontinuation of the Imodium, his ileostomy function picked up again with more liquid stool but still some formed solid stools. Again the patient was without obstructive symptomatology. DISCHARGE MEDICATIONS: The following doses/medications have been changed from the prior dictation: 1. Lopressor increased to 75 mg p.o. b.i.d. 2. No scheduled Imodium. DISCHARGE INSTRUCTIONS: If the patient's ileostomy outputs increase again to the tune of [**1-30**] liters per day, he would require very low dose, i.e. 1 mg, Imodium to which he seems rather sensitive. [**Last Name (NamePattern4) 1889**], M.D. [**MD Number(1) 1890**] Dictated By:[**Last Name (NamePattern1) 2682**] MEDQUIST36 D: [**2169-3-1**] 11:44 T: [**2169-3-1**] 11:54 JOB#: [**Job Number 2685**]

[ "998.59", "567.2", "997.4", "038.9", "272.0", "154.1", "560.9", "707.0", "E879.2" ]

icd9cm

[ [ [] ] ]

[ "38.91", "38.93", "96.6", "45.95", "48.49", "99.15", "54.91", "46.01", "99.77" ]

icd9pcs

[ [ [] ] ]

1197, 6035

8311, 8457

6056, 6289

8482, 8903

873, 1173

187, 533

556, 681

698, 850

9,584

105,048

50542+50543

Discharge summary

report+report

Admission Date: [**2178-5-8**] Discharge Date: [**2178-5-9**] Date of Birth: [**2121-7-17**] Sex: F Service: C-MED HISTORY OF PRESENT ILLNESS: The patient awoke at 4 a.m. with sharp chest pain radiating to her back associated with mild dyspnea. She states that the pain in similar to her prior angina; not pleuritic, but worse with recumbency. The pain not relieved by morphine, intravenous nitroglycerin, sublingual nitroglycerin, and the patient was referred to [**Hospital1 69**] for further evaluation. PAST MEDICAL HISTORY: (The patient is a 56-year-old female with a past medical history significant for) 1. Coronary artery disease, status post distant percutaneous transluminal coronary angioplasty; a [**2170-2-13**] catheterization with an ejection fraction of 50%; an [**2168-8-13**] catheterization with an ejection fraction of 60%, 50% first diagonal, right coronary artery proximal 50%; a [**2167-8-13**] catheterization with an ejection fraction of 70%, 70% first diagonal, first obtuse marginal 80%, right coronary artery middle 60%. 2. Type 2 diabetes mellitus. 3. Peripheral vascular disease, status post left below-knee amputation. 4. History of congestive heart failure; [**2178-2-13**] echocardiogram showing an ejection fraction of greater than 55%, no focal wall motion abnormalities. 5. Status post cholecystectomy. 6. History of gastrointestinal bleed. 7. Ovarian cancer, status post total abdominal hysterectomy/bilateral salpingo-oophorectomy. 8. Hip fracture. ALLERGIES: Her allergies are to PENICILLIN, CEPHALOSPORIN, ERYTHROMYCIN and IBUPROFEN. MEDICATIONS ON ADMISSION: Her medications include insulin, Levoxyl 200 mg p.o. q.d., Plavix 75 mg p.o. q.d., [**Doctor First Name **] 60 mg p.o. q.d., isordil 80 mg p.o. t.i.d., Aldactone 100 mg p.o. b.i.d., Lasix 40 mg p.o. q.d., Norvasc 5 mg p.o. q.d., Lopressor 50 mg p.o. q.d., K-Dur 20 p.o. q.d., Lopid 600 mg p.o. b.i.d., Ativan 1 mg p.o. b.i.d., Epogen. SOCIAL HISTORY: Prior tobacco, no ethanol. FAMILY HISTORY: Family history was noncontributory. REVIEW OF SYSTEMS: On review of systems, she mentions a history of cerebrovascular accident following prior catheterization. PHYSICAL EXAMINATION ON PRESENTATION: On examination, blood pressure was 112/60, heart rate of 70, saturation of 92% to 93% on room air. Temperature was 99.5. She was a pleasant, blind female in no apparent distress. Jugular venous distention of 7 cm to 8 cm. Carotids were without bruits. The lungs were clear to auscultation bilaterally. Heart was beating with a regular rate and rhythm. Normal first heart sound and second heart sound with a 3-component friction rub. The abdomen was soft and nontender. There were no bruits. Symmetric radial pulses bilaterally. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories from the outside hospital revealed creatine kinase of 74, troponin was negative. Hematocrit of 32. Creatinine of 1.4. RADIOLOGY/IMAGING: Electrocardiogram showed normal sinus rhythm at a rate of 67, Q wave in III and F, V1 and V3; similar to prior. Peaked T waves with J point elevation in V1 through V3; more prominent than [**2177-1-13**]. HOSPITAL COURSE: In general, this is a 56-year-old female with longstanding type 2 diabetes presenting with chest pain with pericardial friction rub consistent with pericarditis. An echocardiogram was obtained which left ventricular function and pericardial effusion essentially unchanged from two months prior. The patient was ruled out for myocardial infarction by enzymes. Her pericarditis was treated with aspirin 650 mg p.o. q.i.d. because of her allergy to ibuprofen. The patient was still experiencing pain which she described as more pleuritic and constant on the morning of discharge and was reassured that this pain would resolve within a few days. She was to follow up with her primary care physician in one to two weeks or sooner if her pain does not begin improving. MEDICATIONS ON DISCHARGE: 1. Levoxyl 200 mg p.o. q.d. 2. Plavix 75 mg p.o. q.d. 3. [**Doctor First Name **] 60 mg p.o. q.d. 4. Isordil 80 mg p.o. t.i.d. 5. Aldactone 100 mg p.o. b.i.d. 6. Lasix 40 mg p.o. q.d. 7. Norvasc 5 mg p.o. q.d. 8. Lopressor 50 mg p.o. q.d. 9. K-Dur 20 p.o. q.d. 10. Lopid 600 mg p.o. b.i.d. 11. Ativan 1 mg p.o. b.i.d. 12. Epogen. 13. Aspirin 650 mg p.o. q.i.d. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Type 2 diabetes mellitus. 3. Peripheral vascular disease. 4. Pericarditis. DISCHARGE FOLLOWUP: She was to follow up with her cardiologist, Dr. [**Last Name (STitle) 24717**], in one month. CODE STATUS: Full code. [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 5219**] Dictated By:[**Name8 (MD) 4430**] MEDQUIST36 D: [**2178-5-9**] 12:22 T: [**2178-5-10**] 10:40 JOB#: [**Job Number 43533**] cc:[**Telephone/Fax (1) 105247**] Admission Date: [**2178-5-8**] Discharge Date: [**2178-5-16**] Date of Birth: [**2121-7-17**] Sex: F Service: C-MEDICINE HISTORY OF PRESENT ILLNESS: This is a 56 year old woman with coronary artery disease, status post myocardial infarction times two, with a distant percutaneous transluminal coronary angioplasty, insulin dependent diabetes mellitus, peripheral vascular disease, congestive heart failure with a normal ejection fraction, history of ovarian cancer, admitted to C-Medicine [**2178-5-8**], with chest pain for several hours and an electrocardiogram with diffuse ST elevations and echocardiogram with mild effusion consistent with pericarditis. On [**2178-5-9**], the patient became bradycardic, heart rate 40 to 50 with a decrease in mental status, systolic blood pressure 80s. The patient was transferred to the CCU. In the CCU, Dopamine and Atropine were given and with the Dopamine, the blood pressure increased to 100 to 110 over 80, no change in heart rate. Swan Ganz done at that time revealed right atrial pressure 15, right ventricle 37/15, pulmonary artery 42/17, pulmonary capillary wedge 22, cardiac output 4.7, SVR 681. Of note, the patient was found to have white blood cell [**10-30**] with 91% polys, temperature maximum 100.2. Chest x-ray with a question of left lower lobe infiltrate. She was started on intravenous Levofloxacin for question of pneumonia. With relative equalization of right ventricular pulmonary artery pressures, she was sent to the catheterization laboratory to rule out tamponade versus ischemia. Her coronaries were without significant disease. Right atrial pressure was 18, right ventricle 57/14, pulmonary artery 51/14, PCW 25, cardiac output 4.0, cardiac index 2.1. An echocardiogram was done which showed a small effusion, no right atrial, right ventricular collapse. CT surgery was consulted and they took her to the operating room for pericardial window with 150 ccs of turbid fluid removed. After the procedure, her heart rate went to the 60s, blood pressure 110/40 and without Dopamine. Mediastinal drain was placed with small output of about 20 ccs of bloody fluid. Of note, on [**2178-5-10**], two units of packed red blood cells were given for low hematocrit at 27.0 which bumped to 32.0. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post myocardial infarction times two. Catheterization in 02/94, [**8-/2168**], [**5-/2167**]. 2. Insulin dependent diabetes mellitus for thirty years. 3. [**Doctor Last Name 105248**] syndrome. 4. Lipodystrophy with complications of retinopathy, gastroparesis. 5. Chronic renal insufficiency. 6. Peripheral vascular disease, status post left below the knee amputation, [**7-13**]. 7. Congestive heart failure with a normal ejection fraction. 8. Ovarian cancer, status post total abdominal hysterectomy, bilateral salpingo-oophorectomy. 9. Hip fracture on the right. 10. Lower gastrointestinal bleed in [**3-13**], due to ileal arteriovenous malformation. 11. Septic cholecystitis. 12. Sciatica. 13. Chronic urinary tract infection. 14. Gout. 15. Hypothyroidism. ALLERGIES: Penicillin, Cephalosporin, Erythromycin, Ibuprofen. MEDICATIONS ON ADMISSION: 1. Insulin U-500. 2. Insulin sliding scale. 3. Levoxyl 200 q.d. 4. Plavix 75 mg q.d. 5. [**Doctor First Name **] 60 mg q.d. 6. Isordil 80 mg t.i.d. 7. Aldactone 100 mg b.i.d. 8. Lasix 40 mg once a day. 9. Norvasc 5 mg q.d. 10. Lopressor 50 mg q.d. 11. K-Dur 20 meq q.d. 12. Tylenol #3. 13. Percocet. 14. Allopurinol 100 mg q.d. 15. Lopid 600 mg b.i.d. 16. Ativan 1 mg b.i.d. 17. Epogen 10,000 every Sunday. SOCIAL HISTORY: The patient is married. She has some prior history of smoking, no history of alcohol. PHYSICAL EXAMINATION: On physical examination, the patient was sitting comfortably, denied chest pain, complained of some incisional pain at the mediastinal drain site. Temperature currently is 98.2, heart rate 64, blood pressure 118/60, respiratory rate 20, oxygen saturation 96% in room air. The patient is blind, resting comfortably in no acute distress. Cardiovascular is regular rate and rhythm, no murmurs, rubs or gallops. Respiratory - lungs clear to auscultation anteriorly. The abdomen revealed positive bowel sounds, subxiphoid drain, dressing clean, dry and intact. Extremities - trace lower extremity edema in the right leg. LABORATORY DATA: White blood cell count 8.4, hematocrit 27.2, platelets 291,000. Sodium 142, potassium 4.1, chloride 109, bicarbonate 21, blood urea nitrogen 46, creatinine 1.2, glucose 83. Calcium 9.1, phosphate 3.7, magnesium 2.2. ALT 117, AST 131. HOSPITAL COURSE: During the course of the patient's hospitalization, heart rate and blood pressure were controlled by taking her off most of her medications and we tried to elucidate the etiology of her pericarditis, investigated for infectious versus rheumatologic versus neoplastic. From the pericardial effusion, cultures were sent which were negative for fungal, bacterial and otherwise gram stain was negative. PPD was placed which was negative. Rheumatologic - [**Doctor First Name **] was done which was negative. Rheumatoid factor was negative. ESR was done which came back at 131 which was consistent with ESR done two years ago which was 140. Her neoplastic workup considering her history of ovarian cancer and she had some complaint of chronic abdominal pain, we had a CT of the abdomen which was negative. Also, CT of the chest was negative. Endocrine workup for the pericarditis, TSH was not elevated so hypothyroid cause of pericarditis was excluded. Throughout her hospital course, she also had an issue of anemia. In the CCU, her hematocrit was down to 23.0 to 24.0. They transfused her two units of packed red blood cells and it went up to 33.0 to 34.0. After one day, her hematocrit drifted back down to 27.0. Another two units of packed red blood cells were given and it went up to 40.0. Hematology was consulted and it was their opinion that the anemia was most likely a picture of chronic hypoproliferative anemia with some component of low iron. It was their feeling that this might likely be due to autoimmune disease. With stabilization of blood pressure and heart rate and no proven cause of etiology of pericarditis, the patient is discharged in stable condition to home with VNA and her husband. DISCHARGE DIAGNOSIS: Constrictive pericarditis versus restrictive cardiomyopathy with pericardial effusion requiring a pericardial window. MEDICATIONS ON DISCHARGE: 1. Insulin U-500 sliding scale as per the patient's schedule. 2. Levoxyl 200 mcg q.d. 3. [**Doctor First Name **] 60 mcg b.i.d. 4. Epogen 10,000 units every Sunday. 5. Lopid 600 mg b.i.d. 6. Plavix 75 mg p.o. q.d. 7. Allopurinol 100 mg q.d. 8. Zestril 5 mg p.o. q.d. 9. Lopressor 25 mg p.o. b.i.d. 10. Ativan 1 mg b.i.d. 11. Tylenol #3 one to two tablets q4hours p.r.n. pain. 12. Percocet one to two tablets q6hours p.r.n. [**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**MD Number(1) 2144**] Dictated By:[**Last Name (NamePattern1) 105249**] MEDQUIST36 D: [**2178-5-15**] 17:06 T: [**2178-5-17**] 19:09 JOB#: [**Job Number **]

[ "425.4", "V45.82", "428.0", "423.2", "443.9", "250.00", "486", "785.59", "V10.43" ]

icd9cm

[ [ [] ] ]

[ "88.56", "37.12", "89.64", "37.23" ]

icd9pcs

[ [ [] ] ]

2032, 2069

4396, 4507

11336, 11455

11481, 12166

8153, 8570

9593, 11314

8698, 9575

2090, 3178

4529, 5083

5112, 7233

7255, 8127

8587, 8675

8,238

166,038

4782

Discharge summary

report

Admission Date: [**2153-2-11**] Discharge Date: [**2153-2-15**] Date of Birth: [**2086-5-31**] Sex: F Service: MICU [**Location (un) **] CHIEF COMPLAINT: Left groin pain, increasing hematoma, hypertension, acute blood loss anemia. HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is a 66-year-old female with a history of atrial fibrillation status post retroperitoneal and rectus sheath bleed, myocardial infarction, with acute blood loss anemia, DVT status post IVC filter, pulmonary embolism status post filter placement, who was currently doing well until [**2153-2-9**] when she noticed an increase in the left groin hematoma. The hematoma extended into the left lower quadrant of the abdomen into the left midabdomen. Her pain intensified in the area of the Department. A hematocrit was drawn and was 37, with an INR of 2.8. The patient was sent home from the Emergency Department. The patient's pain intensified on the morning of [**2153-2-11**], and she presented to the [**Hospital6 2018**] Emergency Department. Of note, the patient stated that she had an INR in the 5-6 range in the week prior to her admission, and she recently started intensive exercise with leg-lifts several days prior to the increased hematoma size and pain. The patient's vitals in the Emergency Department were blood pressure of 98/50, heart rate 60, and INR 2.0. In the Emergency Department, the patient was given 4 units of FFP, Vitamin K 1 mg IV. Her hematocrit was 32 on admission. She received IV fluids. A CT scan of the abdomen was performed and demonstrated no retroperitoneal blood, a large rectus sheath bleed with liquefied hematoma in the space of Retzius--finding consistent with an acute bleed. Her hematocrit decreased to 26.8 on the morning of [**2153-2-12**], and she was transfused 2 units of packed red blood cells. The patient's hematocrit increased to 31.3. The Medical ICU team was called to evaluate the patient secondary to decreasing systolic blood pressures to the 90s with a "inappropriate" increase in her hematocrit status post transfusion. On evaluation, the patient denied fevers, chills, or night sweats. She admitted to episodes of lightheadedness in the past week. She denied chest pain, shortness of breath, or pleuritic pain. The abdominal pain was as noted above. She noted currently being comfortable. She denied bowel or bladder dysfunction. She denied any numbness or tingling in the extremities. PAST MEDICAL HISTORY: 1) Paroxysmal atrial fibrillation status post ablation, DC cardioversion, ablation as above, 2) Right leg DVT in [**2151-11-16**] status post IVC filter placement; she has had multiple pulmonary embolisms after the IVC filter placement during her MICU stay in [**11-17**]) Increasing retroperitoneal bleed and rectus sheath bleed on anticoagulation for pulmonary embolisms, 4) MI status post acute blood loss anemia, 5) Hypertension, 6) Dyslipidemia, 7) Mitral valve prolapse, 8) Status post hysterectomy, 9) Status post appendectomy. ALLERGIES: Morphine--pruritus. HOME MEDICATIONS: 1) accupril 20 mg po bid, 2) Lopressor 100 mg po bid, 3) flecainide 100 mg po bid, 4) Coumadin 2.5 mg po hs, 5) hydrochlorothiazide 25 po qd. MEDICATIONS ON TRANSFER: 1) flecainide 100 mg po bid, 2) hydrochlorothiazide 25 mg po qd, 3) tramadol 50 mg po q 4-6 h prn, 4) Tylenol, 5) Ambien 5 mg po hs prn, 6) colace, 7) senna, 8) metoprolol 150 mg po bid, 9) quinapril 10 mg po bid. SOCIAL HISTORY: No tobacco, no significant alcohol usage, no history of IV drug abuse. PHYSICAL EXAMINATION: Vital signs - temperature 99.1, pulse 61, blood pressure 119/68, oxygen saturation 96% on room air. General - pleasant, alert, cooperative, no acute distress. HEENT - pupils equally round and reactive to light and accommodation, extraocular movements intact, sclerae anicteric, mucous membranes moist, oropharynx clear. Neck - no JVD. Chest - clear to auscultation bilaterally anterior and posterior. Cardiovascular - regular rate and rhythm, normal S1 and S2, no S3 or S4, no murmurs or rubs. Abdomen - positive tenderness to palpation left lower quadrant, left adnexal tenderness and firmness, nondistended, normoactive bowel sounds. Extremities - no clubbing, cyanosis or edema. Neuro - cranial nerves II through XII grossly intact, distal strength 5/5, in ankle, biceps, reflexes 2+, distal sensation to light touch intact. LABORATORY ON ADMISSION: WBC 11.4, hematocrit 32, platelets 213. [**Name (NI) 2591**] - PT 17.2, INR 2.0, PTT 33.6. LABORATORY ON TRANSFER: Hematocrit 29.0, PTT 27.7, PT 17.8, INR 1.1. IMPORTANT LABORATORY ON DISCHARGE: Hematocrit 39.3. IMPRESSION: Ms. [**Known lastname **] is a 66-year-old female with paroxysmal atrial fibrillation status post ablation, DC cardioversion, and repeat ablation complicated by rectus sheath and retroperitoneal bleed in the past. She had an acute blood loss anemia secondary to supertherapeutic INR and likely relation to significant exertion prior to her presentation. PLAN - 1) HEME - ACUTE BLOOD LOSS ANEMIA: The patient had a significant hematocrit drop to 26.8. She was transfused 2 units of packed red blood cells with an increase in her hematocrit ultimately to 39.3 on the day of discharge. Her supertherapeutic INR was not demonstrated in the Emergency Department; her INR was 2.0. However, she thought she had an INR of [**3-20**] in the past week. She received some Vitamin K, and her INR on discharge was 1.0. She had been followed by the vascular service and electrophysiology service during this admission. The vascular service recommended an ultrasound to rule out a pseudoaneurysm of the hypogastric artery, and she was found to have no pseudoaneurysm. 2) CARDIOVASCULAR: Ms. [**Known lastname **] had a history of acute blood loss anemia in the past complicated by a myocardial infarction. Her cardiac enzymes were cycled during this admission and were negative. ECGs were cycled and demonstrated no ischemic changes. Ms. [**Known lastname **] remained in sinus rhythm with the rate in the 50s-60s during her ICU admission. She had remained on flecainide and Lopressor. Blood pressures were transiently in the 90s systolic; however, upon admission to the ICU, her blood pressures remained in the 130s/60s-70s. She remained off her hydrochlorothiazide and Accupril secondary to concern for hypotension. Upon discharge, the patient's hydrochlorothiazide and Accupril will remain discontinued. She will have her Accupril restarted as an outpatient and titrated upward from there. DISCHARGE DIAGNOSES: 1) Acute blood loss anemia. 2) Rectus sheath hemorrhage / retroperitoneal bleed. 3) Ruled out for myocardial infarction. DISCHARGE MEDICATION: 1) flecainide 100 mg po bid, 2) Lopressor 150 mg po bid, 3) Tylenol 325 mg q 4-6 h prn pain. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: Discharged to home in good condition. PHYSICIAN [**Last Name (NamePattern4) **]: The patient should follow-up with her primary care physician in one to two weeks. Ms. [**Known lastname **] is to call to schedule an appointment with Dr. [**Last Name (STitle) **] in six weeks. She will follow-up in the [**Hospital **] Clinic with Dr. [**Last Name (STitle) **] in two to three weeks. DISCHARGE INSTRUCTIONS: Ms. [**Known lastname **] is to follow-up with physician for increasing pain, or expanding hematoma. She should avoid heavy lifting and heavy exertion for the next two months. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**] Dictated By:[**Last Name (NamePattern1) 20056**] MEDQUIST36 D: [**2153-2-15**] 12:14 T: [**2153-2-15**] 11:09 JOB#: [**Job Number 20057**]

[ "424.0", "412", "401.9", "427.31", "V58.61", "E878.8", "998.12", "285.1" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6847, 7263

6584, 6825

7288, 7726

3084, 3227

3580, 4420

4635, 6562

175, 253

282, 2473

4435, 4620

3253, 3468

2496, 3065

3485, 3557

29,311

101,160

32874

Discharge summary

report

Admission Date: [**2108-12-5**] Discharge Date: [**2108-12-17**] Date of Birth: [**2043-6-16**] Sex: M Service: MEDICINE Allergies: Cozaar / Nitroglycerin / Primidone / Zestril Attending:[**First Name3 (LF) 4765**] Chief Complaint: gangrenous left heel and right heel/great toe ischemia Major Surgical or Invasive Procedure: 1.Ultrasound-guided imaging for vascular access;contralateral second-order catheter placement with bilateralextremity runoff & abdominal aortogram. ([**2108-12-6**]) 2.Right lower extremity bypass graft with nonreversed saphenous vein graft. ([**2108-12-10**]) 3.Left femoral to posterior tibial artery bypass with in situ saphenous vein graft. ([**2108-12-12**]) History of Present Illness: HPI: 65 M h/o CAD s/p MI in [**2085**], CHF (EF ~20%), DM2, ESRD on HD (? h/o [**Year (4 digits) 2091**] with urosepsis, on since [**10-18**]), admitted [**12-6**] for bilateral foot gangrene s/p b/l femoral bypass on [**12-11**] (right leg) and [**2107-12-13**] (left leg) transferred from vascular service for syncope in setting of V fib. . Patient admitted on [**12-6**] after noted to have gangrenous changes of both heels while at rehab. Underwent bypass sx w/o complication. On [**2108-12-13**] pt was finishing ultrafiltration ~1pm (renal note dated early), when he was noted to have a syncopal event for ~10seconds, with telemetry suggestive of VT/VF. He regained consciousness. Per pt, he had no further syncopal episodes. CODE BLUE called ~13:15 for a syncopal event. Pt was hemodynamically stable upon arrival, alert, oriented, breathing without difficulty. EP was called, and per EP interogation of ICD initially felt to have AF with intermittent conversion to NSR, then VT with attempt to ATP unsucessfull resulting in VF which was shocked x 1. . Of note, the prior evening, patient developed hypotension with sys bp in 60's of unknown etiology and was started on phenylephrine gtt with improvement in BP. Per surgical service, this was in the setting of slow VT, though it is unclear whether slow VT was the sole cause of hypotension (ddx includes sepsis, bleeding, adrenal insufficiency POD#1). He was being treated with cipro/flagyl/vanco empirically. . Patient had been in and out of the hospital since end of [**Month (only) 359**] with recent admissions at OSH for CHF exacerbation, UTI and syncopal episode [**10-18**] [**1-12**] afib with RVR. Discharged to rehab. Noted to be in V-tach at rehab during syncopal episode in 3rd week of [**Month (only) **]. per pt, CPR was administered and he was defibrillated. However, upon reevaluation of rhythm by his cardiologist, thought to be in afib with aberrancy. No history of syncope prior to [**10-18**]. At that time, amiodarone was increased and patient was again discharged to rehab. He was also started on hemodialysis for unclear reasons (?allergic reaction to [**Last Name (un) **]). . On review of symptoms, positive hx of L LE DVT (~[**2104**]). Denies any prior history of stroke, TIA pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, 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. Currently w pain in b/l legs with movement. No dysuria. Does report vomiting, approx [**3-16**] episodes post op. Approx 3 episodes today. Denies nausea. Passing flatus, no abdominal pain. Last BM 2 days prior. . *** Cardiac review of systems is notable for absence of chest pain, shortness of breath, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations. Sleeps on 2 pillows. Chronic nonproductive cough for 3 years. Past Medical History: PMH: ESRD/HD, HTN, CHF (preop EF 20%, 2+ MR),s/p AICD placement, CAD s/p MI [**2085**], hypercholestereolemia, gout,IDDM, diabetic neuropathy Social History: Social history is significant for the absence of current tobacco use. Patient is married, lives with wife. Lives in [**Location 11269**]. Able to complete ADLS without difficulty. Retired, in charge of construction and engineering in [**Location (un) 511**] division of [**Company **]. Quit ETOH in [**2100**]. Prior that would drink 6pack of 16oz beer/day + [**12-12**] hard alcohol/day for 15 years. No hospitalization for ETOH, NO hx of DTs. Family History: There is no family history of premature coronary artery disease or sudden death. . Pertinent Results: [**2108-12-5**] 06:26PM GLUCOSE-109* UREA N-26* CREAT-3.5* SODIUM-142 POTASSIUM-3.1* CHLORIDE-102 TOTAL CO2-30 ANION GAP-13 [**2108-12-5**] 06:26PM estGFR-Using this [**2108-12-5**] 06:26PM ALT(SGPT)-17 AST(SGOT)-19 ALK PHOS-174* TOT BILI-0.5 [**2108-12-5**] 06:26PM calTIBC-107* FERRITIN-303 TRF-82* [**2108-12-5**] 06:26PM CALCIUM-8.1* PHOSPHATE-2.2* MAGNESIUM-1.7 IRON-36* CHOLEST-75 [**2108-12-5**] 06:26PM %HbA1c-5.4 [**2108-12-5**] 06:26PM TRIGLYCER-97 HDL CHOL-38 CHOL/HDL-2.0 LDL(CALC)-18 [**2108-12-5**] 06:26PM WBC-6.9 RBC-3.96* HGB-13.0* HCT-40.0 MCV-101* MCH-32.9* MCHC-32.6 RDW-18.6* [**2108-12-5**] 06:26PM PLT COUNT-260 [**2108-12-5**] 06:26PM PT-20.2* PTT-29.0 INR(PT)-1.9* Brief Hospital Course: . ASSESSMENT AND PLAN . 65 M with MMP including CAD s/p MI, CHF(EF 20% s/p BiV/AICD), atrial fibrillation on coumadin, Type II DM, ESRD on HD, admitted for gangrenous heels [**1-12**] PVD s/p femoral bypass with course complicated by syncopal episode and V-fibrillation s/p AICD cardioversion. . # Bilateral femoral bypass: Underwent surgery on [**12-11**] and [**12-12**] for right and left femoral bypass. Procedure was uncomplicated with good distal pulses post procedure. . # Hypotension: Patient became hypotensive requiring pressors. Initially started on neosynephrine drip. Following day patient had syncopal episode secondary to Ventricular tachycardia and Code Blue was called. Given low SVR, normal PA diastolic, borderline leukocytosis and two possible infectious sources including BL gangrene and a mass on the RA lead of his AICD, hypotension was felt to be due to sepsis. Although he initially had a low cardiac index, this was thought to be consistent with CHF with EF of 20%, and unlikley to be due to cardiogenic shock. Attempted to wean neosynephrine, but MAPS dropped down to the 55 range. He did not respond to a 1L fluid bolus so a levophed drip was started to provide pressor support with some inotropy. Patient continued to require pressure support for the remainder of his course in the intesnive care unit. Pancultures were sent and antibiotic coverage was advanced to vancomycin and zosyn. However patient minimally improved. . . # CAD/Ischemia: Hx of MI. No evidence of ischemic changes on ECG. mild trop leak likely [**1-12**] renal failure, as CK and MB flat. Continued ASA. ACE and beta blocker held in setting of hypotension. Cardiac enzymes were cycled to rule out ischemic source of troponic leak. However cardiac enzymes remained flat. . # Rhythm: Hx of atrial fibrillation on coumadin since [**2105**]. Recent admission to OSH for syncopal episodes thought to be [**1-12**] atrial fibrillation with RVR. Being followed by EP during this admission for episodes of asymptomatic slow V-tach and afib, plan had been to cardiovert AFIB, and then ablate slow monomorphic VT, however patient later developed polymorphic VT. The patient had multiple episodes of wide complex tachycardiat. Trend has been that he converts from a paced rhythm, to atrial fibrillation, and then degenerates into either polymorphic or monomorphic ventricular tachycardia. Shocked once by ICD and three times externally overnight on [**12-15**], and given 2g of magnesium. EP was consulted, recommending to d/c amiodarone given polymorphic VT in the setting of a prolonged QT interval 450-500, start lidocaine gtt and aggressive repletion of electrolytes. Patient was started on mexilitine. However later due to altered mental status was unable to take oral medications. Patient became increasingly unstable with persistent ventricular tachycardia/fibrillation unresponsive to defibrillation by his AICD or externally. As team was unable to convert rhythm, prognosis was poor, he was unstable and requiring increasing pressure support and patient was in distress from persistent shocks, team had discussion with health care proxy and decision was made to change goals of care to comfort measures only. Pressors were discontinued and patient expired soon afterward. . # Pump: EF 20%, s/p ?biV AICD in [**2105**]. No evidence of frank pulmonary edema, hypotensive requiring pressors with CI 1.8->2.1, likely secondary to class III heart failure with EF of 20%. Therefore CHF regimen held. . # Valves: no evidence of valvular disease on ECHO. . # Thrombus on ICD wire: Reviewed echocardiogram with Dr. [**First Name (STitle) **], and the mass is consistent in nature to infection v. inflammatory. Recommending a TEE for further evaluation. However patient was increasingly unstable and unable to tolerate TEE. . # PVD: s/p bilateral bypass surgery. Extremities were cool, but well perfused, with scant blood oozing from L LE thigh wound, though otherwise groin sites were clean/dry/intact. Continued to be followed by vascular surgery throughout course. . # ESRD: etiology of [**Name (NI) 2091**] unclear(started HD [**10-18**]), s/p ultrafiltration [**2108-12-13**], ?stopped prematurely secondary to syncope and hypotension. Started on CVVH as respiratory status began to decline day prior to expiration. . # DM: insulin dependent, x 12 years. FS QID, continued on ISS. . # hyperlipidemia: - continue statin . . # gout - no sx currently, will follow. - cont allopurinol qod. Medications on Admission: coumadin 1mgm q48hrs ca++ 1000mg"' renagel 1600"' isordil10mg' lactulose 30cc' protonix 40mg' allopurinol 100mg' amidarone 200mg' mvt,hydralazine 50"" omeprazol 20mg' zocor 20mg' lopressor xl 100mg' NPH5u qpm 10u qam HISS ac/hs Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Primary: Ventricular tachycardia; Peripheral vascular disease s/p bypass; septic shock; End stage renal disease Secondary: Congestive heart failure Discharge Condition: Expired

[ "428.20", "250.40", "996.72", "403.91", "440.24", "785.52", "427.1", "428.0", "997.1", "038.9", "995.92", "998.59", "250.70", "427.31", "707.15", "276.2", "427.41", "585.6" ]

icd9cm

[ [ [] ] ]

[ "88.42", "39.95", "88.48", "39.29", "38.93" ]

icd9pcs

[ [ [] ] ]

9975, 9984

5186, 9667

362, 728

10175, 10185

4452, 5163

4348, 4433

9946, 9952

10005, 10154

9693, 9923

267, 324

756, 3703

3725, 3869

3885, 4331

74,463

106,269

14004

Discharge summary

report

Admission Date: [**2103-8-13**] Discharge Date: [**2103-8-27**] Date of Birth: [**2024-7-13**] Sex: M Service: CARDIOTHORACIC Allergies: Amiodarone Analogues Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: redo sternotomy, aortic valve replacement (25mm St. [**Male First Name (un) 923**] porcine) [**2103-8-14**] History of Present Illness: This 78 year old patient with complex past medical history s/p Coronary Artery Bypass Graft x 4 in [**2090**]. Pt had a cardiac cath at NEBH in [**12-8**]. The aortic area was 1.0 with a mean gradient of 33 and an EF of 58%. Then [**12-9**] he developed chest pain and ruled in for MI with a troponin of 6.5.He had a cardiac cath at [**Hospital1 18**] at that time which showed a valve area of 0.8 with a mean gradient of 34 and an EF of 40%. The study showed significant native CAD but all grafts were patent.He declined intervention at that time because he was going to [**State 108**] for the winter. When he returned this spring he was complaining of increased dyspnea on exertion. He had a cardiac cath [**2103-6-6**] at NEBH which showed severe aortic stenosis and a calculated [**Location (un) 109**] of 0.6 cm2 and a mean gradient of 34-35 mmHg. This catheterization also showed severe 3 vessel native CAD. The LIMA graft to the LAD was patent. The vein graft to the PDA was patent with a significant lesion in the native vessel downstream from the graft. The vein graft to diagonal branch is patent with distal native vessel severe disease and patent saphenous vein graft to the obtuse marginal with diffuse attenuation of native vessels. On [**2103-6-19**] he then underwent stenting of the PDA via the SVG. He now presents for surgical evaluation for Aortic valve replacement. Past Medical History: aortic stenosis s/p redo sternotomy, aortic valve replacement this admission PMH: coronary artery disease, s/p CABG [**2090**] chronic atrial fibrillation non-insulin dependent diabetes mellitus hypertension hyperlipidemia Social History: The patient is a retired salesman and lives with his wife. [**Name (NI) **] has a distant smoking history. He drinks an occassional glass of wine, no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: Physical Exam Pulse: 78 Resp: 18 B/P Left: 110/70 Height: 5'[**05**]" Weight: 195lbs General: WD/WN male, NAD Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X], except left eye Neck: Supple [X] Full ROM [X], -JVD Chest: Lungs clear bilaterally [X], Healed midline scar from CABG Heart: RRR [X] Irregular [] Murmur[X] 2/6 SEM Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema Varicosities: None [X] Healed RLE from groin to anke Neuro: Grossly intact, A&O x 3 Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit: Right: none Left: none Pertinent Results: [**2103-8-17**] 01:45AM BLOOD WBC-8.9 RBC-2.83* Hgb-9.6* Hct-27.2* MCV-96 MCH-34.0* MCHC-35.4* RDW-13.3 Plt Ct-129* [**2103-8-17**] 01:45AM BLOOD PT-16.2* INR(PT)-1.4* [**2103-8-17**] 01:45AM BLOOD Glucose-132* UreaN-26* Creat-0.7 Na-136 K-4.2 Cl-104 HCO3-23 AnGap-13 [**2103-8-17**] 01:45AM BLOOD Mg-2.2 PRE-CPB:1. The left atrium is moderately dilated. The left atrial appendage emptying velocity is depressed (<0.2m/s). A left atrial appendage thrombus cannot be excluded. 2. A patent foramen ovale is present. 3. 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 inferior hypokinesis. There is mild global left ventricular hypokinesis (LVEF = 40 %). Overall left ventricular systolic function is moderately depressed (LVEF= 40 %). 4. The right ventricular free wall is hypertrophied. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. 5. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. 6. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Mild (1+) aortic regurgitation is seen. 7. The mitral valve leaflets are mildly thickened. There is a minimally increased gradient consistent with trivial mitral stenosis. Mild to moderate ([**2-2**]+) mitral regurgitation is seen. 8. There is a moderate right pleural effusion. 9. There is a trivial/physiologic pericardial effusion. Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **] were notified in person of the results. POST-CPB: On infusions of epinephrine and phenylephrine. AV pacing. Well-seated bioprosthetic valve in the aortic position. Trivial AI. No paravalvular leak. Mitral regurgitation is 1+. TR is 1+. There is preserved biventricular systolic function on inotropic support. The aortic contour is normal post decannulation. The size of the left pleural effusion is significantly reduced. [**2103-8-27**] 05:00AM BLOOD WBC-11.0 RBC-3.07* Hgb-10.2* Hct-29.6* MCV-96 MCH-33.1* MCHC-34.4 RDW-13.5 Plt Ct-594* [**2103-8-27**] 05:00AM BLOOD PT-25.4* INR(PT)-2.4* [**2103-8-27**] 05:00AM BLOOD Glucose-52* UreaN-22* Creat-0.8 Na-136 K-4.7 Cl-100 HCO3-23 AnGap-18 Brief Hospital Course: Mr [**Known lastname 41819**] was admitted preoperatively for heparinization while off Coumadin. On [**8-14**] he was brought to the operating room for redo sternotomy and Aortic valve replacement with #25 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Porcine valve. Cross clamp time=75 minutes.Cardiopulmonary Bypass time=107 minutes. Please see Dr[**Last Name (STitle) **] operative report for further details. He tolerated the operation well and was transferred to the cardiac surgery ICU in stable condition on Epinephrine and Neosynephrine for optimal hemodynamic support. He was weaned from the ventilator and extubated on POD#1. Upon extubation he was found to be restless and somewhat agitated. This was initially felt to be from the narcotics he had received however these symptoms persisted. The neurology team was consulted and a head CT was done(A preliminary report read "No hemorrhage or large territorial infarct. Ill-defined low attenuation foci in the right frontal centrum semiovale/corona radiata white matter (2:25-28), may represent infarcts, age indeterminate). He was seen by Dr [**Last Name (STitle) 656**] who felt the patient did not have a new infarct. Over the next 48 hours his neurological exam improved dramatically, all lines and drains were discontinued in a timely fashion. Beta-blocker and diuresis was initiated. On POD3 he was transferrred to the stepdown floor for continued post-op care and recovery. Once on the floor he was noted to have a small amount of serous drainage from the inferior aspect of his sternal wound and was prophylactically started on Keflex. The remainder of his hospital course was essentially uneventful. Over the next several days he made slow but continuous progress in his physical activity and on POD #12 he was cleared for discharge by the cardiac surgery covering attendings, to home with VNA. All follow up appointments were advised. Medications on Admission: Digoxin 250 MCG 1 tablet daily Simvastatin 20 mg 1 tablet daily Warfarin 2.5 mg 1 tablet daily, 2 tablets on Sunday Lisinopril 10 mg daily Metoprolol 25 mg twice a day Plavix 75 mg daily Glyburide 5 mg twice a day Aspirin 325 mg daily Nitro Patch PRN Discharge Medications: 1. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO once a day for 1 weeks. Disp:*14 Tablet Sustained Release(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO Q AM. Disp:*60 Tablet(s)* Refills:*2* 5. Warfarin 1 mg Tablet Sig: adjust dose to target INR 2-2.5 Tablets PO DAILY (Daily): Pt to receive 2.5 mg on [**8-21**]. home regime preop was 2.5mg qd with 5mg on Sunday. 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six (6) hours as needed for pain/fever. 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 11. Lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 12. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO three times a day. Disp:*45 Tablet(s)* Refills:*2* 14. Keflex 500 mg Capsule Sig: One (1) Capsule PO twice a day for 10 days. 15. Glyburide 5 mg Tablet Sig: One (1) Tablet PO Q PM. Disp:*60 Tablet(s)* Refills:*2* 16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. Disp:*7 Tablet(s)* Refills:*0* Discharge Disposition: Home with Service Facility: tbd Discharge Diagnosis: aortic stenosis s/p redo sternotomy, aortic valve replacement(25 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] porcine) PMH: coronary artery disease, s/p CABG [**2090**] chronic atrial fibrillation non-insulin dependent diabetes mellitus hypertension hyperlipidemia Discharge Condition: good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month, and while taking narcotics No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **keep a log of your blood sugars and present to your PCP [**Last Name (NamePattern4) **] 1 week visit** Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) Dr. [**Last Name (STitle) **],[**First Name3 (LF) 198**] [**Telephone/Fax (1) 14525**] in 1 week, Please resume Coumadin/INR follow up with DR.[**Last Name (STitle) 7389**] Neurology -Dr. [**First Name8 (NamePattern2) 1692**] [**Last Name (NamePattern1) 1693**] -see in [**2-2**] weeks [**Telephone/Fax (1) 1694**] Please call for appointments Have INR drawn by VNA [**8-28**] with results to Dr. [**Last Name (STitle) 7389**] [**Telephone/Fax (1) 14525**] Completed by:[**2103-8-27**]

[ "401.9", "799.02", "414.01", "V45.81", "E878.1", "250.00", "V58.61", "272.4", "998.13", "412", "427.31", "V45.82", "745.5", "424.1" ]

icd9cm

[ [ [] ] ]

[ "88.72", "35.21", "39.61" ]

icd9pcs

[ [ [] ] ]

9393, 9427

5527, 7454

307, 417

9756, 9763

3144, 5504

10408, 10968

2295, 2377

7757, 9370

9448, 9735

7480, 7734

9787, 10385

2392, 3125

248, 269

445, 1836

1858, 2083

2099, 2279

64,944

152,631

36783

Discharge summary

report

Admission Date: [**2103-4-19**] Discharge Date: [**2103-4-24**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2901**] Chief Complaint: Transfer from OSH for dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 86 year-old female with CAD s/p MI [**7-31**] with unknown type stent to 80% proximal D1, also with LCx 70% in OM2, ICM (EF 25-30%), PAF not on coumadin, HTN, presented to [**Hospital2 **] [**Hospital3 6783**] [**Last Name (NamePattern1) **] [**2103-4-18**] with new dyspnea/PND. . Patient reported acute dyspnea which woke her from sleep. She reported PND, orthopnea. She denied fever, cough, chills. She denied chest pain, palpitations. She reported black stools x4-5 months. Has been on ASA/plavix since stent placement in 9/[**2101**]. Had recent cardiology visit where she declined coumadin for new afib with understanding of increased risk of stroke, MI, heart failure. . At OSH, was found to be guaiac positive with hematocrit 27.4 (per PCP, [**Name10 (NameIs) **] for pt with baseline Hct 36), WBC 12.8, troponin I 0.2 (normal <0.1), WBC 12.8, CK 142, BNP 2883. She complained of fatigue and was given 2 units packed red blood cells. She then went into flash pulmonary edema. She was started on NTG, Lasix 40mg IV and put on BiPAP. No EKG changes were noted. CXR with cardiomegaly, decompensated heart failure, and basilar infiltrates. Patient was unable to be weaned off of BiPAP. She was given azithromycin, ceftriaxone for ?pneumonia. Also placed on [**Hospital1 **] PPI for guaiac positive stool. She was subsequently transferred to [**Hospital1 18**] ED on BiPAP. . In the [**Hospital1 18**] ED, 184/99, 90, 22, 98%RA. On arrival, patient was started on nitroglycerin ggt, propofol ggt. Patient did have BP 200s/120s, RR 40s on BiPAP, temperature 101.4 during ED course. Given tachypnea, patient was intubated; AC, TV 450, RR 16, FiO2 100%. On exam, she was noted to have crackles with decreased breath sounds at bases, hematuria, guaiac positive brown stool. On EKG, she was noted to be in atrial fibrillation with Q waves in inferior leads without ST elevations. Patient ruled in for NSTEMI with CK: 1300 MB: 152 MBI: 11.7, troponin T 6.23. Also had leukocytosis to 16.5, hematocrit 33.2 (up from 27.4 after 2 units pRBCs), creatinine 1.7, lactate 2.4. Seen by cards fellow, no indication for emergent cath, and heparin not started given high risk of GIB and hematuria. Blood and urine cultures were sent. CXR with interstitial edema without infiltrate. Given hypotension, nitroglycerin was downtitrated and propofol stopped; fentanyl, midazolam were started. . On transfer from ED, 98.1, 64, 139/65, 19, 100%. Patient denies pain, was comfortable. She is intubated and therefore unable to participate in full review of systems. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes(-), Dyslipidemia(+), Hypertension(+) 2. CARDIAC HISTORY: - PERCUTANEOUS CORONARY INTERVENTIONS: 80% proximal D1 s/p unknown stent in [**7-31**] - CAD s/p MI [**7-31**] with stent placement (80% proximal D1 s/p stent, LCx 70% in OM2). Presented with weakness, fatigue, dyspnea, BP 140/80, had new afib - Ischemic cardiomyopathy, EF 25-30% - admitted in [**5-/2099**] for heart failure 3. OTHER PAST MEDICAL HISTORY: - Atrial fibrillation; by report, patient previously refused coumadin - Dyslipidemia - History of asymptomatic bradycardia; pacemaker was offered, patient had declined. Holter in 10/[**2101**]. - Baseline Hct 36.3 in [**7-/2102**]; has not had a colonoscopy (declined) since [**2089**] *****Per PCP review of records, had outpatient cards visit [**4-12**], [**2102**]: had conversation with cardiologist where she understood the risk of not treating the BP (190/84), ECG in afib - talked about coumadin, understood was increased risk of stroke, MI, heart failure. Patient was hesitant to take too many pills but willing increase lisinopril from 10 to 20.***** Social History: SOCIAL HISTORY: Can get more details in AM when extubated -Tobacco history: Prior smoker -ETOH, IVDU: Unknown Family History: Family history of colon cancer per PCP Physical Exam: 98.9 129/58 75 18 98%RA General - no acute distress HEENT - Sclera anicteric, MMM Neck - JVP 8cm Pulm - bibasilar crackles, diminished BS on R base CV - Regular with occasional ectopic beats, normal S1/S2; no murmurs Abdomen - Normoactive bowel sounds; soft, non-tender, non-distended Ext - Warm, well perfused, radial and DP pulses 2+; trace lower extremity edema to shins Neuro - Moving all extremities; able to sit without problem Pertinent Results: [**2103-4-19**] CXR: Cardiac enlargement including prominence of left atrium and pulmonary congestion consistent with CHF. No pneumothorax or acute parenchymal infiltrates. [**4-20**] ECHO The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with infero-lateral hypokinesis. There is no ventricular septal defect. with borderline normal free wall function. The aortic valve leaflets (3) 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. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade LABS: [**2103-4-19**] 09:00PM GLUCOSE-119* UREA N-39* CREAT-1.8* SODIUM-141 POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-25 ANION GAP-15 [**2103-4-19**] 09:00PM CK(CPK)-1024* [**2103-4-19**] 09:00PM CK-MB-96* MB INDX-9.4* cTropnT-5.27* [**2103-4-19**] 09:00PM WBC-14.1* RBC-3.78* HGB-10.0* HCT-31.2* MCV-83 MCH-26.4* MCHC-31.9 RDW-15.3 [**2103-4-19**] 09:00PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL [**2103-4-19**] 03:46PM LACTATE-2.4* [**2103-4-19**] 02:30PM CK-MB-152* MB INDX-11.7* [**2103-4-19**] 02:30PM WBC-16.5* RBC-4.00* HGB-10.9* HCT-33.2* MCV-83 MCH-27.2 MCHC-32.7 RDW-14.9 [**2103-4-19**] 02:30PM BLOOD ALT-39 AST-189* CK(CPK)-1300* AlkPhos-86 [**2103-4-19**] 09:00PM BLOOD CK(CPK)-1024* [**2103-4-20**] 04:07AM BLOOD CK(CPK)-658* [**2103-4-19**] 02:30PM BLOOD CK-MB-152* MB Indx-11.7* [**2103-4-19**] 02:30PM BLOOD cTropnT-6.23* [**2103-4-19**] 09:00PM BLOOD CK-MB-96* MB Indx-9.4* cTropnT-5.27* [**2103-4-20**] 04:07AM BLOOD CK-MB-49* MB Indx-7.4* cTropnT-4.88* [**2103-4-24**] 05:45AM BLOOD WBC-11.2* RBC-3.63* Hgb-9.7* Hct-30.2* MCV-83 MCH-26.7* MCHC-32.1 RDW-14.6 Plt Ct-275 [**2103-4-21**] 05:10AM BLOOD Neuts-69.1 Lymphs-21.7 Monos-5.8 Eos-2.9 Baso-0.4 [**2103-4-24**] 05:45AM BLOOD PT-14.4* PTT-30.6 INR(PT)-1.3* [**2103-4-24**] 05:45AM BLOOD Glucose-99 UreaN-44* Creat-1.9* Na-142 K-4.5 Cl-101 HCO3-31 AnGap-15 [**2103-4-24**] 05:45AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.9 URINE CULTURE (Final [**2103-4-20**]): NO GROWTH. Blood Cx: PENDGIN Brief Hospital Course: 86 year-old female with CAD s/p MI [**7-31**] with BMS to 80% proximal D1, also with 70% in OM2, ischemic cardiomyopathy (EF 25-30%), PAF not on coumadin, hypertension, with NSTEMI not on heparin gtt due to high risk of GIB. Hospital course was as follows. 1. CORONARIES: Patient ruled in for large NSTEMI with positive enzymes. CK peaked at 1300. Patient with known CAD with 80% proximal D1, OM2 70% with stent placement in former in [**2101**]. No ST elevations on EKG. ST depression V4, <1mm V5-V6 with TWI. Inciting event for NSTEMI was likely brought on by anemia [**12-25**] GI bleeding, although given rapid rise and fall of CK, acute occlusion may be also be possible. Hematocrit was maintained above 25. Patient was continued on aspirin. Plavix was discontinued given sufficient course of therapy after placement of BMS, and given risk of worsened GI bleed. Statin was continued. Patient was not placed on a beta-blocker given history of asymptomatic bradycardia. Heparin gtt was not started given GI bleed. 2. PUMP: Known ICM (EF 25-30%). Not on Lasix at home, had been on the past but self discontinued. Per PCP, [**Name10 (NameIs) **] has been euvolemic off diuretics. Per OSH records, may have had flash pulmonary edema in setting of getting blood transfusion. CXR with pulmonary congestion. On admission, patient did not appear overtly fluid overloaded. She was initially diuresed with Lasix 80mg IV, then transitioned to Lasix 10mg PO daily to maintain euvolemia. She was quickly extubated. ACE inhibitor was initially held given renal failure, and restarted prior to discharge. Goal in first three days of rehab should be approx even to -500cc fluid balance. Notify PCP if greater than 2 pound weight gain. Discharge weight = 73 lbs. 3. RHYTHM: Patient with known atrial fibrillation with CHADS2 3. Patient had declined anticoagulation therapy in the past, per discussion with her, discussion with her PCP, [**Name10 (NameIs) **] review of her medical record. She was continued on aspirin. Given bradycardia, further rate control was not needed. 4. UGIB: Patient with reported melena x several months with 10pt decrease in Hct since [**7-31**] which was new per PCP [**Name Initial (PRE) **] [**Name10 (NameIs) **] with chronic UGIB but unclear if any acute bleeding. Patient guaiac positive with black/brown stool. Given 2U PRBCs at OSH with appropriate bump in Hct from 27 to 33. Slowly trended downwards during hospital course. She did not have any episodes of melanotic stool while inhouse. No recent colonoscopy or EGD. Patient had colonoscopy in [**2089**] and has refused repeat study since that time. She has a significant family history of colon cancer. She was continued on a PPI [**Hospital1 **]. 5. Acute kidney injury: Creatinine elevated [**11-29**] - 1.9 in setting of diuresis. Unclear Cr baseline. Patient go to facility on low-dose lasix and will need to have Creatinine and CHM 7 checked 2 days after discharge and again at one week. Results should be sent to 6. FEN: Low salt diet / Heart Healthy 7. Code: Remained full during this hospital stay. Medications on Admission: Plavix 75mg PO daily Aspirin 325mg PO daily Lisinopril 20mg PO daily Oxazepam 15mg PO daily PRN insomnia Simvastatin 40mg PO daily Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 5. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day: Hold SBO under 100 or HR under 60. 8. Outpatient Lab Work HCT, CHM 7 (on Lasix), Creatinine 2 days and 7 days after discharge. Fax results to Dr. [**Last Name (STitle) 66694**]: Phone: [**Telephone/Fax (1) 66697**] Fax: [**Telephone/Fax (1) 83142**] 9. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 10. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY (Daily) as needed for Constipation. Discharge Disposition: Extended Care Facility: [**Hospital **] Health Care Center - [**Hospital1 1559**] Discharge Diagnosis: PRIMARY: s/p NSTEMI HTN Anemia [**12-25**] Bleeding Acute on Chronic Heart Failure Atrial Fibrillation SECONDARY: Bradychardia Dyslipidemia Discharge Condition: Good Discharge Instructions: You were admitted for dyspnea and bleeding. You had cardiac enzymes that suggested an NSTEMI. After discussion with you, we opted not to perform cardiac catheterization. You did have an ECHO that showed 2+ MR, moderate pulmonary hypertension and mild systolic dysfunction. . Please take all of your medications as prescribed. We have stopped: Plavix We have started: Lasix 20mg QD, Pantoprazole 40mg QD, Lisinopril 10mg QD. We have changed: ASA 325 to ASA 162mg QD . Return to the ED for CP, SOB, dizziness, decreased urine output or any other sysmptom that concerns you. Followup Instructions: Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) 66694**] ([**Telephone/Fax (1) 66697**]), [**5-1**] at 10:45. We have spoken on the telephone with Dr. [**Last Name (STitle) 66694**] just before your discharge to give him an update. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**] Completed by:[**2103-4-27**]

[ "427.31", "V15.82", "424.0", "428.23", "518.81", "401.9", "428.0", "280.0", "416.8", "578.9", "272.4", "584.9", "V45.82", "410.71", "414.01" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

11578, 11662

7230, 10325

292, 299

11847, 11854

4663, 7207

12474, 12934

4153, 4193

10506, 11555

11683, 11826

10351, 10483

11878, 12451

4208, 4644

2988, 3315

223, 254

327, 2875

3346, 4008

2897, 2968

4040, 4137

13,420

192,348

27339+57539

Discharge summary

report+addendum

Admission Date: [**2193-5-14**] Discharge Date: [**2193-5-18**] Date of Birth: [**2126-10-24**] Sex: F Service: MEDICINE Allergies: Augmentin / Bactrim / Keflex / Zithromax Attending:[**First Name3 (LF) 2880**] Chief Complaint: Probable RV dysfunction during cardiac cath Major Surgical or Invasive Procedure: PCI w/o stent, IABP, Swan placement History of Present Illness: 66 y/o female with PMH significant for RCA stent in [**2187**], cardiomyopathy, HTN, and hyperlipidemia admitted to the CCU following cath complicated by hypotension and probable RV infarct. Pt was initially admitted to [**Hospital3 3583**] on [**5-8**] with shortness of breath. Over the preceeding several weeks, she had had multiple admissions at the OSH for SOB. On the evening prior to admission, the pt developed wheezing and increased SOB. She took lasix and her inhalers without relief so called 911. On their evaluation, her VS were significant for an oxygen sat of 88% on RA, HR of 132, BP of 157/99. She was given SL NTG and combivent nebs and felt mildly beter on arrival to [**First Name4 (NamePattern1) 46**] [**Last Name (NamePattern1) **]. There, her oxygen sat was 91% on a 100% nonrebreather, HR 119, and BP 147/104. Pt was treated with IV solumedrol, Mg sulfate, 80 mg IV lasix, and zopenex neb. During this time, the pt denied CP or palpitations. Admission ECG was significant for sinus tach at 106 with first degree AV block and LBBB (per report-no tracing available at this time). . There was a concern at [**Hospital3 3583**] if the pt's SOB was due to a COPD exacerbation versus heart failure. A cardiology consult was obtained. The pt was ruled out for an MI with cardiac enzymes. She was treated for a COPD flair (nebs, steroids, oxygen, aldactone) with some improvement in symptoms. The pt was agressively diuresed initially but backed off on the lasix several days into admission secondary to an increase in creatinine. Pt had two episodes of asymptomatic NSVT on tele (one of four beats and one of seven beats). Per the cardiology consult recs, the pt was transferred to [**Hospital1 18**] for a cath and consideration of AICD placement. . Pt underwent cath at [**Hospital1 18**] on [**5-14**]. This was significant for a right dominant circulation with single vessel and branch vessel disease. The LMCA was angiographically normal. LAD system had a 70% stenosis of a moderate sized first diagonal and was otherwise angiographically normal. The LCX was a small vessel supplying a single OM that was free of disease. RCA was subtotally occluded in both the proximal and mid segment within the prior stents with TIMI II flow distally via antegrade and also filled via collaterals from the distal LAD. During attempted stenting of the RV branch of the RCA, the pt became hypotensive into the 70s systolic. There was a concern that the pt was suffering from RV dysfunction in the setting of her severe LV dysfunction. She was started on dopamine and an intraaortic balloon pump was placed. Pt was on the dopamine for six minutes. The pt's BP quickly recovered and she was weaned off of the dopamine. Pt was then started on a nitro drip for hypertension approximately ten minutes later. Pt also received 20 mg of IV lasix in the cath lab. At this time, she is hemodynamically stable and has been transferred to the CCU for further care. Plan is to leave the balloon pump in place over the next 24 hours. Then, pt will need to be reevaluated with a viability scan of the inferior wall. If her RCA territory has completely infarcted, she will need possible cath and stenting of her diag. If some RCA territory is still viable, she may be a candidate for CABG. . Hemodynamics during the cath were as follows: at the start of the case, the pt had moderately elevated right and left sided filling pressures with a RVEDP of 12, mean PCWP of 19, and LVEDP of 20. At the conclusion of the case, the PCWP was 20. Left ventriculography showed gloval severely depressed systolic function with a LVEF of 18%. No significant mitral regurg. . In discussion with the pt, she reports that she is feeling quite well on admission to the CCU. No recent fevers or chills. She reports that she never has CP, chest pressures, chest burning, or palpitations. She has been suffering from increased SOB over the past several weeks but reports that her breathing now feels comfortable. She is not on oxygen at home and does not use steroids. She is able to walk in her home and sometimes around the house, but is unable to walk even half a block outside. No PND or orthopnea. Pt has a chronic cough but no sputum production. Denies abdominal pain but feels hungrey. No LE tingling or numbness. . Past Medical History: 1. S/P MI and RCA stent in [**2187**]- Done at [**Hospital1 2177**]. Now about 99% occluded. LVEF at that time was 60% but has decreased since then. Last month, P-MIBI was significant for septal ischemia and a LVEF of 18%. There is a large predominantly fixed inferior defect and a septal anterior apical defect with some partial reversibility. 2. Cardiomyopathy- Most recent LVEF was 18% by P-MIBI in 03/[**2193**]. The LV was grossly dilated. Felt to be ischemic and non-ischemic in nature. 3. Hyperlipidemia 4. Type 2 diabetes mellitus 5. Hypertension 6. S/P [**Name (NI) 10060**] Pt had right arm paralysis for two days when she was 44 years old. No residual deficits from this. 7. COPD 8. PVD 9. Renal artery stenosis s/p vein bypass grafting revascularization 10. Anxiety 11. Mitral regurgitation 12. C section x3 Social History: Pt is single and lives alone. She is retired. She has three adult children. She quit smoking approximately six years ago after smoking three packs per day since age 12. Rare ETOH use. No drug use. Pt's cardiologist is Dr. [**Last Name (STitle) 5310**] and her PCP is [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Family History: [**Name (NI) 1094**] mother had a MI in her 50s. Her father died of PNA in his 30s. She reports that most of her siblings died of cancers-- leukemia, lung CA, and colon CA. Physical Exam: 96.9 130/79 81 17 93% 2L NC Nitro drip 0.18 Gen- Pleasant, obese lady resting in bed. Alert and oriented. NAD. HEENT- NC AT. PERRL. Anicteric sclera. MMM. No lesions in the oropharynx. Cardiac- Distant heart sounds. RRR. No appreciable m,r,g. No carotid bruits. Pulm- CTAB. No wheezes, rales, or rhonchi. Abdomen- Obese. Soft. NT. ND. Positive bowel sounds. Extremities- Warm. Trace pedal edema. 2+ DP pulses bilaterally. Neuro- Alert and oriented x2. Pertinent Results: ECG- Prior to cath: NSR at 77 beats per minute. Left axis deviation. QRS 160 ms. [**First Name (Titles) **] ST-T wave abnormalities. Following cath: NSR at 81 beats per minute. Left axis deviation. T wave inversions in V6. . [**5-14**] CATH: COMMENTS: 1. Selective coronary angiography of this right dominant system demonstrated single vessel and branch vessel disease. The LMCA was angiographically normal. The LAD system had a 70% stenosis of a moderate sized first diagonal and was otherwise angiographically normal. The LCX was a small vessel supplying a single OM that was free of disease. The RCA was subtotally occluded in both the proximal and mid segment within the prior stents with TIMI II flow distally via antegrade and also filled via collaterals from the distal LAD. 2. Resting hemodynamics at the start of the case [**Last Name (un) **] moderately elevated right and left sided filling pressures with RVEDP=12 mmHg, mean PCWP=19 mmHg and LVEDP=20 mmHg. At the end of the case mean PCWP was 20 mmHg. 3. Left ventriculography demonstrated global severely depressed systolic function with LVEF calculated at 18% with no significant mitral regurgitation. 4. Unsuccessful PTCA of the RCA. FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Severe systolic ventricular dysfunction. 3. Moderate diastolic ventricular dysfunction. 4. Unsuccessful PTCA of the RCA. . [**5-16**] ECHO: EF 15% Conclusions: 1. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis to akinesis with slight preservation of basal lateral wall motion. Overall left ventricular systolic function is severely depressed. 2. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. . [**5-16**] ECG: Sinus rhythm. First degree A-V heart block. Left axis deviation. Left bundle-branch block with ST-T wave changes. Compared to the previous tracing no significant change . [**5-17**] ABD/PELVIS CT: IMPRESSION: 1) No evidence of retroperitoneal or groin hematoma. 2) Atrophic native right kidney, with multiple likely simple cysts which are not fully characterized on this study. 3) Diffuse vascular calcification. 4) Sigmoid diverticulosis without evidence of diverticulitis. 5) Mild stranding in the anterior abdominal subcutaneous tissues as well as the subcutaneous tissues posterior to the paraspinal muscles of unclear etiology. . LABS: AT DISCHARGE: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2193-5-18**] 07:25AM 13.9* 3.85* 11.6* 34.2* 89 30.1 33.8 14.6 166 Glucose UreaN Creat Na K Cl HCO3 AnGap [**2193-5-18**] 07:25AM 178* 21* 1.2* 139 4.5 102 28 14 ADMISSION: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2193-5-14**] 03:04PM 15.2* 4.88 14.8 43.1 88 30.3 34.3 14.2 277 Glucose UreaN Creat Na K Cl HCO3 AnGap [**2193-5-14**] 03:04PM 240* 29* 1.3* 136 4.4 93* 32 15 CK-MB cTropnT [**2193-5-15**] 05:20AM 2 <0.01 X2 . TSH [**2193-5-16**] 03:40PM 1.0 OTHER ENDOCRINE Cortsol [**2193-5-17**] 04:18AM 15.7 . Cholest Triglyc HDL CHOL/HD LDLcalc [**2193-5-15**] 05:20AM [**Telephone/Fax (1) 67005**] 45 3.4 79 . MICRO-Urine Clxr w/No growth Brief Hospital Course: A/P: 66 y/o female with PMH significant for RCA stent in [**2187**], cardiomyopathy EF 15%, HTN, and hyperlipidemia admitted to the CCU following cath complicated by hypotension and probable RV dysfunction in the setting of severely depressed LVEF. . 1. [**Name (NI) **] Pt found to have subtotal occlusion of the RCA on cardiac cath. During attempted stenting of the RV branch, the pt became hypotensive and there was concern that she had sufferred a RV infarct. She was started on a dopamine drip and an intraaortic balloon pump was placed. Pt was able to be weaned off of the dopamine drip. IABP left in for 24%, she was also on a nitro gtt for hypertension immediately after dopa gtt off. She was weaned off the nitro gtt. Post 24 hours is was noted that pt did not require the IABP. There was an initial plan to do a viability study followed by possible cath and stenting of her diag if her RCA territory has completely infarcted. If some RCA territory is still viable, she may be a candidate for CABG. Per the pt, family and d/w Dr. [**Name (NI) **] pt deferred any surgical intervention (i.e. CABG) and cath would not be further beneficial given tortuosity and unsuccessful attempt at revascularization of occluded RCA. In setting of no further surgical intervention, she was started on her home meds, including plavix. She was started on statin low dose. Her BB and [**Last Name (un) **] were started as her BP improved after transient period of hypotension. Pt's CK did not increase and no evidence of ischemia on EKGs so RV infarct unlikely. Since pt had been on steroids could not [**Last Name (un) 104**] stim, pt assumed to possibly be adrenally insufficient or steroid dependent which contributed to transient hypotension. No evidence of embolism as no cardiac symptoms of CP, palpitations/N/V/Diaphoresis. Pt's BB and [**Last Name (un) **] doses were readjusted in setting of brief hypotensive period. . 2. [**Name (NI) 9520**] Pt is in sinus rhythm at this time. She had two episodes of NSVT at the OSH. She did not develop any dysrhythmmias post PCI. EP was consulted and did not feel pt should have an AICD at this time. Plan to reevaluate in three months, also address anticoagulation with coumadin at that follow up appointment given her severely depressed EF. . 3. [**Name (NI) 26573**] Pt with very depressed LVEF estimated to be 15% on ECHO. EP consulted regarding placement of an AICD and will reevaluate pt in three months to consider if she is a candidate for AICD placement. Started pt on digoxin per EP recs. Continued on lasix 40 mg daily, started on Aldactone and restarted her [**Last Name (un) **]. . 4. [**Name (NI) 15197**] Pt with increased SOB over the past several weeks. Most probably a combination of her COPD and CHF. Symptoms did improve at the OSH with treatment of her COPD exacerbation. She did not feel SOB at this time. She was continued on 5mg Prednisone for COPD exacerbation. She remained off of supplemental O2 with sats 93-95%. She was also continued on lasix. . 5. Type 2 DM- Will cover with a RISS. Hold oral hypoglycemics for now until plan for pt is clear. QID FS. [**Doctor First Name **] diet. resumed oral hypoglycemics when d/c to home. . 6. Depression/Anxiety- Continued fluoxetine and ativan. . . #. Code status- Full code. . Medications on Admission: Medications at home: 1. Albuterol MDI 2. Atrovent MDI 3. Prevacid 30 mg QOD 4. Prozac 40 mg daily 5. Ativan 1 mg QAM and 0.5 mg QPM 6. Glipizide 5 mg [**Hospital1 **] 7. Lasix 20 mg daily 8. Diovan 160 mg daily 9. Plavix 75 mg daily 10. Coreg 12.5 mg [**Hospital1 **] . Medications on transfer: 1. Carvedilol 25 mg [**Hospital1 **] 2. Plavix 75 mg daily 3. Fluoxetine 40 mg daily 4. Lasix 40 mg daily 5. Glipizide 5 mg [**Hospital1 **] 6. Lorazepam 1 mg QAM and 0.5 mg QHS 7. Metoclopramide 5 mg IV Q6H PRN 8. Metoclopramide 10 mg IV q6h PRN 9. Pantoprazole 40 mg daily 10. Prednisone 10 mg daily 11. Senna 2 tabs daily 12. Spironolactone 50 mg daily 13. Valsartan 160 mg daily 14. Albuterol nebs QID 15. Albuterol nebs Q2H PRN 16. Ipratropium nebs QID 17. Ipratropium nebs Q2H PRN 18. Tylenol 650 mg Q6H PRN 19. Nystatin powder PRN . Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Carvedilol 12.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. Ativan 1 mg Tablet Sig: asdir Tablet PO twice a day: Take 1 mg in the morning and 0.5 mg at night. 10. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. Disp:*qs 1month qs 1 month* Refills:*0* 12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. Disp:*qs 1 month qs 1month* Refills:*0* 13. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Nystatin 100,000 unit/g Powder Sig: moderate amount Topical three times a day as needed. Disp:*qs 1 month qs 1 month* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: CHF, Cardiomyopathy (EF 15%), CAD w/subtotal occlusion of RCA Discharge Condition: Stable. She was no longer short of breath and her blood pressure was stable. Discharge Instructions: Please take all your medications as directed and keep all your follow up appointments. . If you have chest pain, shortness of breath, have nausea, break out in sweats, feel lightheaded or dizzy call your physician and go to the emergengy room. . Please note the following changes in your medications: -Your Carvedilol was changed to 6.25mg twice daily -Your Valsartan was decreased to 80mg daily -Your Lasix was increased to 40mg daily -You were started on Digoxin 0.125mg and started on Aldactone 25mg daily and started on Simvastatin 20mg daily. -You were also continued on Prednisone 5mg daily Followup Instructions: Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 36012**] for a follow up appointment in [**1-7**] weeks. . Please call your cardiologist Dr. [**Last Name (STitle) 5310**] at [**Telephone/Fax (1) 5315**] for a follow up appointment in 2 weeks. . You need to follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in [**Hospital **] clinic in 3 months. Please call ([**Telephone/Fax (1) 9530**] his clinic for an appointment. [**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**] Completed by:[**2193-5-21**] Name: [**Known lastname 11636**],[**Known firstname 2243**] Unit No: [**Numeric Identifier 11637**] Admission Date: [**2193-5-14**] Discharge Date: [**2193-5-18**] Date of Birth: [**2126-10-24**] Sex: F Service: MEDICINE Allergies: Augmentin / Bactrim / Keflex / Zithromax Attending:[**First Name3 (LF) 3188**] Addendum: Post sheath pull had small bleed with small hematoma formation. Applied pressure with resolution of bleed. Pt dropped her HCT from admission 43.1 to 30. She received 1UPRBC and ABD/Pelvis CT to r/o RP bleed which she did not have. Her hypotension resolved and was not attributed to bleed. Her HCT responded appropriately to 34 s/p 1UPRBC. She remained stable without any evidence of bleeding. Her LE remained with good pulses, full ROM and good 2+DP pulses b/l. She had no further complications post cath. Discharge Disposition: Home [**First Name11 (Name Pattern1) 1332**] [**Last Name (NamePattern1) 3189**] MD, [**MD Number(3) 3190**] Completed by:[**2193-5-21**]

[ "414.01", "412", "998.12", "428.0", "443.9", "E879.0", "780.57", "425.4", "250.00", "402.91", "272.4", "496", "V64.1" ]

icd9cm

[ [ [] ] ]

[ "99.20", "88.56", "99.04", "88.53", "37.61", "00.17", "37.23" ]

icd9pcs

[ [ [] ] ]

17927, 18095

9778, 13067

346, 383

15592, 15672

6616, 7817

16317, 17904

5951, 6125

13952, 15457

15507, 15571

13093, 13093

7834, 9026

15696, 16294

13114, 13363

6140, 6597

9040, 9755

263, 308

411, 4707

13388, 13929

4729, 5551

5567, 5935

23,487

184,619

9592

Discharge summary

report

Admission Date: [**2111-5-14**] Discharge Date: [**2111-5-22**] Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Ace Inhibitors Attending:[**First Name3 (LF) 317**] Chief Complaint: chest pain, admission for cath Major Surgical or Invasive Procedure: cardiac catheterization x2; [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 32522**] stents to RCA and proximal LAD/Left main History of Present Illness: [**Age over 90 **]yo woman with history of document coronary artery disease, hypertension, ischemic cardiomyopathy, atrial fibrillation admitted for cardiac cath. . Patient was diagnosed with 3vessel disease [**9-/2110**] treated medically. She continues to have recurrent episodes of sharp substernal chest pain responsive to SL nitro and is admitted today for pre-cath hydration. Medical management has been optimized, and plan is in place for palliative stenting. Per the patient, chest pain episodes are occasionally associated with shortness of breath, not associated with nausea or diaphoresis, and do not radiate. . Previous work-up has included echo [**9-8**] showing moderate regional LV systolic dysfunction, EF 30-35%, 2+MR, 1+TR, mild AS. Cardiac cath [**9-8**] showed 3vessel disease, nml systolic function, diastolic dysfunction, moderate MR. . Patient is DNR/DNI and was DNH. She has agreed to this hospitalization for palliative treatment of her CAD. DNR/DNI is to be lifted during the catheterization according to Dr. [**Last Name (STitle) **]. Past Medical History: Gastritis Gerd Hypertension Angina Anemia Atrial fibrillation Social History: [**Hospital 100**] Rehab resident, walks with a walker no tobaccor, EtOH Daughter [**Name (NI) **] is HCP Family History: FH/x hypertension, diabetes mellitus Physical Exam: T 97.2 HR 72 BP 102/56 RR 16 95%RA Gen: comfortable, NAD HEENT: PERRL, anicteric, MMM, OP clear Neck: supple, no LAD, no carotid bruits, JVP not elevated CV: RRR, II/VI harsh SEM, nml s1s2, no s3s4 Resp: CTAB Abd: +BS, soft, NT, ND, no masses Ext: 1+ DP pulses, symmetric, no femoral bruits, no LE edema Neuro: A&Ox3, CN II-XII intact, MAEW Pertinent Results: ECG: rate 70bpm, sinus rhythm, nml axis, nml intervals, 1.5mm ST depressions I, aVL, V4-V6; 1.5mm ST elevation III with Q-waves III, aVF; TWI V1-V3 . [**2111-5-14**] 11:54PM GLUCOSE-110* UREA N-58* CREAT-1.2* SODIUM-143 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-28 ANION GAP-15 [**2111-5-14**] 11:54PM CK-MB-3 cTropnT-0.02* [**2111-5-14**] 11:54PM CALCIUM-8.9 PHOSPHATE-4.3 MAGNESIUM-1.9 [**2111-5-14**] 11:54PM WBC-5.6 RBC-4.28# HGB-11.1* HCT-35.2* MCV-82# MCH-25.9*# MCHC-31.5 RDW-17.6* [**2111-5-14**] 11:54PM PLT COUNT-222 [**2111-5-14**] 11:54PM PT-12.6 PTT-27.8 INR(PT)-1.1 . Cath [**2111-5-15**]: 1. Resting hemodynamics revealed significantly elevated left sided filling pressures with low C.I. 2. Selective coroanry angiography revealed severe three vessel disease (unchanged from prior). The LM had severe distal disease extening into the LAD which had diffuse severe disease. The LCX was occluded mid. The RCA was heavily calcified and had serial 90% stenoses. 3. Successful Rotational athetherectomy and stenting of the RCA (distal RCA to rPL 2.5x28mm Cypher, mid RCA 2.5x32mm Cypher and more proximally overlapping 3.0x33mm Cypher and more proximally (ostial) 3.5x23mm Cypher) with good result (See PTCA comments). FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Elevated left sided filling pressures with low C.I. 3. Successful Rotationsl Atherectomy and stenting of the RCA with multiple Drug Eluting Stents. . Cath [**2111-5-18**]: COMMENTS: 1. Selective coronary angiography revealed a right dominant system. The LMCA had severe diffuse disease up to 70%. The proximal LAD had adiffuse disease up to 90% (heavily calcified). The mid LAD had a 95% heavily calcified stenosis. The LCX was occluded and was filling via right to left collaterals. The previously placed RCA stents were widely patent. 2. Successful Rotational Atherectomy and stenting of the mid and proximal LAD all the way back to the ostium of the LM with a 3.0x28mm Cypher DES and an overlapping 3.5x23mm Cypher DES (See PTCA comments). FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Widely patent previously placed RCA stents. 3. Successful stenting of the mid LAd and the proximal LAD all the wsa back to the ostium of an unprotected LM with two overlapping Drug Eluting Stents. . Renal U/S [**2111-5-16**]: IMPRESSION: No evidence for hydronephrosis or stones within either kidney. 1.1 x 1.3 cm complex cyst within the midpole of the left kidney, which could be followed with ultrasound in 6 - 12 months to document stability if clinically indicated. . Right femoral U/S [**2111-5-16**]: FEMORAL VASCULAR ULTRASOUND: A small fluid collection measuring 1.3 x 0.3 x 1.2 cm is identified in the superficial subcutaneous tissues of the right groin. Deep to this structure are the right common femoral vein and artery. There is no evidence for an arteriovenous fistula. No definite pseudoaneurysm is identified; however, this is a limited study, as a radiologist was not present during the scanning of this patient. If there is a clinical concern for expanding hematoma in the right groin, a repeat examination at no charge to the patient can be performed with a radiologist present. . Echo [**2111-5-18**]: Conclusions: 1. The left atrium is mildly dilated. The left atrium is elongated. 2.There is severe global left ventricular hypokinesis with apical, distal anterior, mid or distal septal akinesis. Overall left ventricular systolic function is severely depressed. 3.Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The ascending aorta is mildly dilated. 5.The aortic valve leaflets are mildly thickened. There is moderate aortic valve stenosis. Mild (1+) aortic regurgitation is seen. 6.The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. 7.There is mild pulmonary artery systolic hypertension. 8. There is no pericardial effusion. Compared with the findings of the prior study (tape reviewed) of [**2110-9-24**], there is a further decrease in LV function with apical, mid and distal septal and distal anterior akinesis. Aortic stenosis is now moderate. Brief Hospital Course: [**Age over 90 **]yo woman with history of coronary artery disease, hypertension, previous cath [**9-8**] showing 3 vessel disease, medically managed, presenting with persistent substernal chest pain. During her hospitalization the following issues were addressed: 1. Coronary artery disease: The patient has a history of documented 3vessel CAD with ECG findings suggestive of panischemia, and persistant chest pain responsive to SL nitroglycerin. She was pretreated with hydration, bicarbonate, and mucomyst prior to cath for renal protection. She was brought to the cath lab and a stent was placed in the RCA without complication. She subsequently developed a small hematoma on the right side. Femoral ultrasound showed no pseudoaneurysm or Av fistula. The hematoma stabilized in size as did her hematocrit, and no further work-up was done. She continued to have chest pain during the following days, and so was brought back to the cath lab [**2111-5-18**] for repeat catheterization. She had two overlapping stents placed in the proximal LAD into the left main. She was monitored for another 48hours, and developed no further episodes of chest pain. An echocardiogram was done to evaluate for cardiac function. Ejection fraction is now decreased at 25%, and there is global hypokinesis and multiple areas of wall motion abnormalities. She was continued on aspirin, atorvastatin, metoprolol, losartan, and Plavix for secondary prevention. 2. Congestive heart failure: Ms. [**Known lastname 32523**] Lasix was held prior to cath, and she was treated with iv fluids for renal protection. She subsequently developed some shortness of breath with exertion. CXR showed an enlarged heart and mild pulmonary congestion. She required supplemental oxygen at 2L nasal canula. She was diuresed with iv lasix, and then her po lasix regimen was restarted. She was weaned to room air, and denies shortness of breath at rest, orthopnea, and PND on the day of discharge. She notes some ongoing shortness of breath with walking for long periods in the halls, but finds this consistent with her baseline. Echocardiogram showed reduced cardiac function as described above. 2. Hypertension: Blood pressure was initially contolled on the patient's outpatient doses of metoprolol, imdur, and losartan. On [**2111-5-20**] the metoprolol was changed to carvedilol. The patient did not tolerate this change and became acutely hypotensive with BP 60s/30s. She continued to mentate well throughout. She was treated with small iv fluid boluses, and SBP rebounded to the 80s. At the same time an emergent Hct was drawn and was shown to be 17, concerning for RP bleed. This value was later found to be in error as the lab was drawn from the line in which saline was infusing. Given the emergent concern, however, she was transferred to the CCU. There she received a total of 750cc NS and one unit PRBC. Blood pressure normalized, and antihypertensive meds were restarted at reduced doses. She tolerated these medications without any further episodes of hypotension. She was discharged to [**Hospital 100**] Rehab on metoprolol 25mg [**Hospital1 **] and losartan 25mg daily. 3. Cough: The patient had a chronic cough during her hospitalization, which she said repeatedly was her baseline. CXR showed a small left pleural effusion and a questionable retrocardiac opacity, could not rule out pneumonia. However, she was afebrile throughout, and with normal WBC and no left-shift. Thus, no antibiotics were started. Her cough is likely chronic and may be related to Gerd symptoms as she has a history of Gerd and had a small hiatal hernia on CXR. 4. Dispo: The patient was discharged back to [**Hospital 100**] Rehab. She was evaluated by physical therapy who found her independently mobile with a walker. Her code status is DNR/DNI. This was reversed during the cath, and then resumed on the floor and upon discharge. She will follow-up with Dr. [**Last Name (STitle) **] for further care. Medications on Admission: Aspirin 325mg daiy Atovastatin 60mg daily Calcium/Vit D Plavix 75mg daily Darbepoeitin 10mcg SC Furosemide 40mg daily Imdur 90mg daily Prevacid 30mg daily Levothyroxine 100mcg daily Losartan 50mg daily SL nitroglycerin prn Metoprolol 75mg [**Hospital1 **] Olopatadine 1drop [**Hospital1 **] left eye KCl 10mEq daily Prednisolone gtt 1% once daily left eye Senna 2tabs qHS Trazadone 50mg qHS Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin Calcium 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Olopatadine HCl 0.1 % Drops Sig: One (1) gtt Ophthalmic [**Hospital1 **] (): to left eye. 9. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic DAILY (Daily): OS- to left eye. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 12. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Losartan Potassium 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Discharge Diagnosis: Primary: coronary artery disease . Secondary: hypertension anemia gerd Discharge Condition: stable Discharge Instructions: If you develop worsening chest pain, shortness of breath, or any other concerning symptom, please contact your primary care physician [**Name Initial (PRE) **]/or return to the emergency department. . Your blood pressure medicines have been changed. You will no longer take the Imdur. Your other antihypertensive medication doses have been reduced. The [**Hospital 100**] Rehab staff may increase the doses if your blood pressure requires it. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] within the next month. You can call [**Telephone/Fax (1) 10012**] to schedule this appointment.

[ "396.2", "398.91", "426.0", "401.9", "412", "E879.0", "458.29", "411.1", "285.1", "584.9", "414.01", "427.31", "593.9", "998.12", "530.81", "414.8", "997.1" ]

icd9cm

[ [ [] ] ]

[ "37.22", "36.05", "37.23", "88.56", "39.64", "36.07", "99.04" ]

icd9pcs

[ [ [] ] ]

12133, 12148

6357, 10358

275, 409

12263, 12271

2160, 3397

12765, 12917

1731, 1769

10799, 12110

12169, 12242

10384, 10776

4226, 6334

12295, 12742

1784, 2141

205, 237

437, 1507

1529, 1592

1608, 1715

61,195

127,875

28997

Discharge summary

report

Admission Date: [**2111-5-18**] Discharge Date: [**2111-5-27**] Date of Birth: [**2058-4-15**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2297**] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: Subclavian line placement and removal PICC Placement History of Present Illness: 53 yo F with tracheomalacia s/p tracheostomy, mental retardation, DM, HTN, peripheral vascular disease, recently discharged from [**Hospital1 18**] after an episode of hypotension thought to be [**1-14**] viral gastroenteritis now presents from living facility after being found cyanotic with O2Sat in the low 80s%, somnolent, febrile to 101 and hyperglycemic to 283 per EMS. She was suctioned by EMS (thick secretion) and received Tylenol and Ativan. . In the ED, initial vs were: T 102.4, P 128, BP 111/66, RR 32, O2Sat 100% on 15L face mask. Per ED sign-out, patient was noted to have right sied and left sided infiltrate, ARF, lactate up to 4.5, + UA. Cultures were sent from the blood and urine. She was given cefepime, vancomycin, and ciprofloaxin in addition to 650 mg Tylenol and 600 mg ibuprofen. She was also noted to have transient hypotension 76/50 although unclear if it is an accurate read given that her SBP improved to the 110s with minimal IVF. She received 2L of IVF. Upon transfer, her VS T103.8F, BP 132/57, HR 115 O2Sat 97% on 50%. She has an 18 g IV, and is a difficult stick. Per report, patient is usually on trach mask and HCP is [**Name (NI) 4580**] [**Telephone/Fax (1) 69888**] . Per the facility, patient was at her usual state of health this morning with borderline temperature of about 100. When they saw her again in the afternoon, she was noted to be in respiratory distress, fever, and agitation. Therefore, she received Tylenol and Ativan. Of note, her warfarin was stopped about 3 days prior to admission because of some bleeding around the trach site and elevated INR up to At that time, it was decided that she should not be on anticoagulation anymore. . Upon reviewing record from [**Hospital3 **]. Patient was seen on [**5-5**] for SOB and blood with her cough in the setting of supratherapeutic INR for which it was held. According to that discharge instruction, patient was recommended to restart warfarin once INR improves. . On the floor, patient appears lethargic. Opens eyes to voice. Denies pain. On 3rd L of fluid. Past Medical History: Mental retardation tracheomalacia s/p tracheostomy h/o aspiration pneumonia diabetes mellitus h/o C. difficile infection, glaucoma hypertension HLD osteoarthritis depression/anxiety, constipation psychosis . PAST SURGICAL HISTORY: Tracheostomy and PEG [**2107**], R total knee replacement R hip replacement Right common iliac artery stent placement and right external iliac recanalization with stent placement x2. [**1-/2111**] Social History: lives at [**Hospital **] Nursing Home in [**Hospital1 **], MA. Father and Brother are [**Name2 (NI) **]-guardians Family History: unable to obtain Physical Exam: Admission Exam General: lethargic, opens eyes to voice, followed simple command ("open your mouth") HEENT: Sclera anicteric, mucous membrane dry Neck: supple, JVP difficult to appreciate Lungs: anterior lung field, diffused expiratory wheeze, diminished air movement, no rhonchi or crackles. CV: tachycardic, difficult to appreciate any murmur, rub, or gallops Abdomen: large well healed scar in the RUQ. soft, non-tender, non-distended, obese, bowel sounds present, no guarding, no organomegaly. G-tube in place GU: foley, clear yellow urine Ext: warm. Distal pulses (DP and PT) non-palpable but dopplarable. + dry gangrenous change in all digits of the right foot. Exam on Discharge T: 98.8 (axillary), HR 77, BP 107/50, O2Sat 96% on FIO2 of 40% General: alert, awake, answers questions with yes/no answers by nodding and shaking head HEENT: Sclera anicteric, mucous membrane moist, minimal crusting in the eye Neck: supple, JVP difficult to appreciate Lungs: anterior lung field, diffused poly-phonic expiratory wheeze, no crackles. CV: regular rate and rhythm, difficult to appreciate any murmur, rub, or gallops Abdomen: large well healed scar in the RUQ. soft, non-tender, non-distended, obese, bowel sounds present, no guarding, no organomegaly. G-tube in place GU: foley, clear yellow urine Ext: warm. Distal pulses (DP and PT) non-palpable but dopplarable. + dry gangrenous change in all digits of the right foot, worse on the little toe. Pertinent Results: 1. Labs on admission: [**2111-5-18**] 06:00PM BLOOD WBC-25.8*# RBC-3.56* Hgb-10.9* Hct-32.5* MCV-91 MCH-30.7 MCHC-33.7 RDW-17.1* Plt Ct-426 [**2111-5-18**] 06:00PM BLOOD PT-12.1 PTT-19.5* INR(PT)-1.0 [**2111-5-18**] 06:00PM BLOOD Glucose-312* UreaN-36* Creat-1.5* Na-133 K-4.7 Cl-83* HCO3-36* AnGap-19 [**2111-5-18**] 06:00PM BLOOD ALT-6 AST-21 AlkPhos-80 TotBili-0.5 [**2111-5-18**] 06:00PM BLOOD Albumin-3.5 Calcium-9.6 Phos-3.3 Mg-2.3 . 2. Labs on discarge: - Ammonia 80 - Lactate 1.5 - Na 143, K 4.3, Cl 98, Bicarb 38, BUN 32, Creatinine 0.9, Glucose 162, Calcium 9.6, Magnesium 2.6, Phosphate 2.4 - WBC 9.3, Hemoglobin 8.9, Hematocrit 27, Plt 307 - TSH 9.5, total T4 3.9, Free T4 0.60 . 3. Imaging/diagnostics: [**2111-5-18**] CXR IMPRESSION: 1. Low lung volumes. 2. Prominence and indistinctness of the hila may be due to pulmonary vascular engorgement. Bibasilar opacities may relate to fluid overload, although infection is not excluded. . [**2111-5-20**] ECHO Conclusions The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity is unusually small. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The pulmonary artery systolic pressure is unable to be determined. There is no pericardial effusion. IMPRESSION: Preserved global biventricular systolic function. No pathologic valvular regurgitation or stenosis. Compared with the prior report (images unable to be reviewed) of [**2111-1-15**], the findings are similar. . [**2111-5-20**] CTA IMPRESSION: 1. Technically limited study with no evidence of a central (main, lobar or segmental) pulmonary embolism. 2. Diffuse, severe tracheomalacia below the level of the tracheostomy tube with associated moderately severe air trapping in both lungs. 3. Small bilateral pleural effusions, bilateral lower lobe atelectasis and consolidation in the right lower lobe. . [**2111-5-22**] CXR IMPRESSION: 1. Left PIC catheter tip projects over mid to low SVC. No pneumothorax. 2. Unchanged right pleural effusion. 3. Bibasilar opacities, likely atelectasis, however, superimposed infection cannot be excluded. 4. Persistent pulmonary vascular congestion. MICROBIOLOGY: [**2111-5-18**] - Blood Culture, Routine (Final [**2111-5-21**]): ESCHERICHIA COLI. FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Anaerobic Bottle Gram Stain (Final [**2111-5-19**]): GRAM NEGATIVE ROD(S). Reported to and read back by [**First Name8 (NamePattern2) 26976**] [**Last Name (NamePattern1) **] (4I) @ 9:14 AM [**2111-5-19**]. Aerobic Bottle Gram Stain (Final [**2111-5-19**]): GRAM NEGATIVE ROD(S) - URINE CULTURE (Final [**2111-5-20**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [**2111-5-20**] [**2111-5-20**] 11:59 am SPUTUM GRAM STAIN (Final [**2111-5-20**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2111-5-23**]): Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. Piperacillin/Tazobactam sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. Piperacillin/Tazobactam sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. STAPH AUREUS COAG +. SPARSE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | PSEUDOMONAS AERUGINOSA | | STAPH AUREUS COAG + | | | CEFEPIME-------------- 4 S 2 S CEFTAZIDIME----------- 4 S 4 S CIPROFLOXACIN--------- 2 I 2 I CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=1 S <=1 S <=0.5 S LEVOFLOXACIN---------- =>8 R MEROPENEM------------- 2 S 4 S OXACILLIN------------- =>4 R PIPERACILLIN/TAZO----- 16 S 16 S RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S Last cultures: pending [**5-26**] blood cultures- no growth to date [**5-25**] C. diff negative [**5-25**] Urine culture negative Brief Hospital Course: Ms. [**Name14 (STitle) **] is a 53 year old woman with tracheomalacia s/p tracheostomy, mental retardation, DM, HTN, peripheral vascular disease, and other medical issues who presented from her living facility with hypoxia and tachycardia. . #. Hypoxic respiratory distress. When patient initially presented, there was concern of a pneumonia vs. pulmonary edema. She was initially treated for possible hospital acquired pneumonia and an aspiration pneumonia. Initial treatment was with vancomycin and zosyn. This was transitioned to cefepime, vancomycin, cipro, and flagyl. Her sputum grew out Pseudomonas and MRSA, though it was unclear whether this data reflected chronic colonization versus pathogenic infection. Treatment for PNA was continued based on CT evidence of RLL consolidation. She completed 8 days of vancomycin but then had a borderline fever, so it was restarted. He will continue a 14 day course of vancomycin and cefepime to co-treat pseuodmonas pneumonia and E coli urosepsis, to be completed on [**2111-6-1**]. With antibiotics and nebulizer treatments, her oxygen was weaned to baseline 35-40% via trach mask. Trach exchange and PMV can be done in the outpatient setting. . #. Urinary tract infection/Urosepsis. She was found to have pan-sensitive E.coli in her urine as well as in her blood. She was started on antibiotics and will complete a 14 day course of cefepime on [**2111-6-1**]. . #. Sepsis. On initial presentation patient had fever, leukocytosis, and tachycardia. Her lactate was 4.5. The infection was thought to be a combination of a urinary and pulmonary source. Her lactates trended down. As above, she will finish 14 days cefepime for E coli urosepsis/pseudomonal pneumonia and total of 14 days of vancomycin for possible MRSA pneumonia. She was aggressively fluid resuscitated initially . # Altered Mental Status: she had a waxing and [**Doctor Last Name 688**] level of interaction, at times following commands and answering questions, and at times indifferent to them. This pattern was felt to be due to hypoactive delirium in the setting of acute infection which improved by the time of discharge to her baseline. Per her PCP, [**Name10 (NameIs) **] is able to answer questions, read and write normally. By the time of discharge, patient was alert and was able to answer yes-no questions by nodding and shaking her head appropriately. She was also able to follow commands. She does exhibit waxing-wanning mental status, particularly after morning doses of Seroquel. It will be importnt for the rehab facility to reassess her mental status as she continue to improve from her recent infection to determine if dosage of her Seroquel should be lowered. #. Peripheral vascular disease. Ms. [**Known lastname 69887**] has a history of PVD. She is s/p stents in the right iliac. Previously she had been on warfarin. Her last discharge summary instructs her to continue this medication. However, her recent lists did not include this. We contact[**Name (NI) **] her living facility who stated it had been stopped for unclear reasons. In addition, on warfarin she had a subtherapeutic INR. Vascular was contact[**Name (NI) **]. They initially recommended starting heparin. However her primary vascular surgeon stated that aspirin was sufficient. Per her vascular surgeon, her dry gangrenous changes in the right toes have been stable for month. . #. Acute renal failure. On presentation her creatinine was up to 1.5 from baseline 0.7. This was thought likely to sepsis. She rapidly improved with fluids suggesting pre-renal azotemia. . #. Contraction alkalosis. Elevated bicarb toward the end of her stay in the ICU. This is the result of aggressive diuresis for her respiratory status. The plan is to restart home dose lasix 20 mg po daily once her bicarb return to less than 34. . #. DM. On 54 units of Lantus qHS according to med list from the d/c summary. Given that she will be NPO, will decrease her insulin dosage for now . #. Psychosis. Did not have symptoms while on home Seroquel 250 mg TID and valproic acid 500 mg qAM and 750 mg qPM. Valproic acid level was not hight but has a mildly elevated ammonia level. Would recommend repeating the level again once her infection is resolved. If still elevated, consider lactulose. . #. Subclinical hypothyroidism. TSH was found to be mildly elevated at 9.5 with free T4 at 0.6. Given in acute setting, she should get repeat TSH and free T4 checked again once she becomes clinically more stable to determine if replacement therapy will be needed. . #. Medications. Lopressor 75 mg TID was held initially given sepsis. It was restarted gradually, however, because of transient hypotension with SBP in the 80s-90s, metoprolol was stopped. Amlodipine was held given initial sepsis, and it was not restarted for the same reason. Transitional Care: Called Dr. [**Last Name (STitle) 69891**] at [**Telephone/Fax (1) 69892**] prior to transfer on [**2111-5-27**]. [] Outpatient follow up with her primary care provider [] Outpatient follow up with her interventional pulmonologist [] Outpatient follow up with her vascular surgeon [] Follow up of her electroltyes. Once bicarb is < 34, can restart lasix 20 mg po [] Monitor blood pressure and heart rate. Once returning to baseline, can restart home dose metoprolol and amlodipine [] Check vancomycin level on [**2111-5-28**] [] Check CHEM 10 on [**2111-5-29**] [] Repeat TSH and free T4 once infection is cleared to determine if she needs to be on replacement therapy [] Repeat ammonia level once her infection is resolved. Medications on Admission: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. quetiapine 250 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. valproic acid (as sodium salt) 250 mg/5 mL Syrup Sig: Seven [**Age over 90 1230**]y (750) mg PO QPM (once a day (in the evening)). 6. valproic acid (as sodium salt) 250 mg/5 mL Syrup Sig: Five Hundred (500) mg PO QAM (once a day (in the morning)). 7. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1) application Ophthalmic QID (4 times a day) for 1 weeks. 8. amlodipine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 9. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 10. fenofibrate 54 mg Tablet Sig: One (1) Tablet PO once a day. 11. Medication Administration ALL MEDICATIONS SHOULD BE GIVEN THROUGH G-TUBE 12. calcium carbonate 500 mg/5 mL (1,250 mg/5 mL) Suspension Sig: Five (5) ml PO DAILY (Daily). 13. Lantus 100 unit/mL Solution Sig: Fifty Four (54) U Subcutaneous at bedtime. 14. insulin regular human 100 unit/mL Solution Sig: One (1) injection Injection four times a day: Per humalog insulin sliding scale. 15. lactobacillus acidophilus 100 million cell Capsule Sig: One (1) Capsule PO once a day. 16. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM.--> per facility, this was discontinued 3 days prior to admission. Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. therapeutic multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO once a day. 4. valproic acid (as sodium salt) 250 mg/5 mL Syrup Sig: Fifteen (15) ml PO QPM (once a day (in the evening)): Total of 750 mg. 5. valproic acid (as sodium salt) 250 mg/5 mL Syrup Sig: Five (5) ml PO QAM (once a day (in the morning)): Total of 250 mg. 6. quetiapine 50 mg Tablet Sig: Five (5) Tablet PO three times a day: Please crush and give through PEG tube. . 7. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1) application Ophthalmic four times a day. 8. fenofibrate 54 mg Tablet Sig: One (1) Tablet PO once a day. 9. calcium carbonate 500 mg/5 mL (1,250 mg/5 mL) Suspension Sig: Five (5) ml PO once a day. 10. Lantus 100 unit/mL Solution Sig: Fifty Four (54) units Subcutaneous at bedtime. 11. insulin regular human 100 unit/mL Solution Sig: One (1) injection Injection four times a day: per sliding scale. 12. lactobacillus acidophilus 100 million cell Capsule Sig: One (1) Capsule PO once a day. 13. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 6 days: To be completed on [**6-1**]. Disp:*12 gram* Refills:*0* 14. cefepime 2 gram Recon Soln Sig: Two (2) grams Injection Q12H (every 12 hours) for 6 days: To be completed on [**2111-6-1**]. 15. Outpatient Lab Work Please check Chemistry 10 (sodium, potassium, chloride, bicarbonate, BUN, creatinine, calcium, phosphate, and magensium) on [**2111-4-28**]. Please fax the result the covering physician at [**Name9 (PRE) **]. 16. Outpatient Lab Work Please check vancomycin trough 1 hour prior to the schedule dose on [**2111-5-28**]. Please fax the result the covering physician at [**Name9 (PRE) **]. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Hospital1 **] Discharge Diagnosis: Primary diagnoses: - E. coli urosepsis - Respiratory distress from Pseudomonal and MRSA pneumonia - Delirium, resolved. Secondary diagnoses: - Tracheomalacia - Peripheral vascular disease - Diabetes mellitus - Subclinical hypothyroidism 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 Mrs. [**Known lastname 69887**], You were admitted to [**Hospital1 18**] for treatment of shortness of breath and a fast heart rate, which were likely due to a combination of a pneumonia and urinary tract infection that spread to your blood. You were treated with very strong antibiotics and your breathing and blood pressure eventually improved. You had some confusion as a result of this infection, although this symptom also improved with treatment. You will need few more days of antibiotics to help fight these infections to be completed on [**2111-6-1**]. Your vascular surgeon was contact[**Name (NI) **] about the need for warfarin given your peripheral vascular disease. It is decided that aspirin alone will be sufficient for now. Your pulmonologist (lung doctor) was contact to inform your admission to the hospital. You will need to follow up with him about further management of your trach. You will need to have your antibiotics level checked tomorrow on [**2111-4-27**]. You will also need to have your electrolytes checked on [**2111-4-28**]. Your doctor at the facility will help you to make adjustments in your medications as needed. The following changes were made to your medications: 1. START CEFEPIME 2 grams every 12 hours for 6 days, ending on [**2111-6-1**] 2. START VANCOMYCIN 1 g every 12 hours for 6 days, ending on [**2111-6-1**] 3. DISCONTINUE metoprolol. Your doctor will help you to decide when to restart this medication. 4. DISCONTINUE amlodipine. Your doctor will help you to decide when to restart this medication. 5. Discontinue furosemide. Your doctor will help you to decide when you can restart this medication. Followup Instructions: Please call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], when you return from rehab to follow up on your hospitalization Please call your interventional pulmonologist, Dr. [**Last Name (STitle) **], to set up a follow up appointment. Department: VASCULAR SURGERY When: WEDNESDAY [**2111-6-3**] at 10:45 AM With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1490**], MD [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2111-5-27**]

[ "518.84", "319", "038.42", "780.09", "298.9", "401.9", "482.1", "V44.1", "285.1", "599.0", "276.3", "250.00", "995.91", "443.9", "584.9", "272.4", "482.42", "244.9", "V43.65", "785.0", "V43.64", "300.4", "V44.0", "519.19" ]

icd9cm

[ [ [] ] ]

[ "96.6", "38.93" ]

icd9pcs

[ [ [] ] ]

20328, 20403

11284, 13132

325, 379

20685, 20685

4604, 4612

22559, 23182

3090, 3108

18463, 20305

20424, 20545

16902, 18440

20863, 22536

2743, 2942

3123, 4585

20566, 20664

265, 287

407, 2490

4626, 11261

20700, 20839

2512, 2720

2958, 3074

27,577

127,863

1322

Discharge summary

report

Admission Date: [**2164-8-2**] Discharge Date: [**2164-8-11**] Date of Birth: [**2089-7-2**] Sex: M Service: MEDICINE Allergies: Gluten Attending:[**First Name3 (LF) 425**] Chief Complaint: Pericardial tamponade Major Surgical or Invasive Procedure: Pericardiocentesis History of Present Illness: EVENTS / HISTORY OF PRESENTING ILLNESS: 75 year old male with a history of IDDM, HTN and CKD with recent admission for LLE cellulitis treated with Augmentin (he has 4 days left on this course) who was seen in clinic for malaise and admitted based on his laboratory results (Na of 129, anemia with HCT of 29.4 and acute renal failure with Cr of 3.2 from baseline of 2.0). . In the ED, vitals were: T:97.8, HR:102, BP:129/109, RR:20, O2Sat:95% on RA. He was found to have a UTI and was given Unasyn. He was given 2L normal saline for his sodium of 126 and admitted to night float. . The patient reports he was in his usual state of health which includes walking daily until Friday when he awoke from his nap and experienced shaking chills and whole chest, back and shoulder pain "in the muscles". He states that this improved after he was wrapped in several blankets. Then Saturday at 2 am, he awoke to check his blood glucose and noted whole chest, arm and back pain. He was unable to clarify this pain further other than to say it was unbearable. He states it was worse with movement, lying flat, and deep inspiration. He took tylenol and it resolved. He reports generalized fatigue, and decreased appetite. He developed nausea on monday prior to admission, and the day before admission felt unwell and saw his PCP. [**Name10 (NameIs) **] clinic he was felt to have a viral syndrome and was sent home with precautions. He recalled and admitted for lab abnormalities as above. . On morning assessment the patient was found to be in atrial fibrillation with rapid ventricular rate up to 150, hypotensive down to systolic 70s, temp 99.9, and respiratory distress 93% on 4LNC. The patient also endorsed pleuritic chest pain, similar to the pain he had no the saturday prior to admission. Due to his clinical deterioration, the patient was transferred to the MICU for further care. While in the MICU the patient had a TTE that showed a large pericardial effusion with evidence of tamponade (LVEF 55%). He was taken for an urgent pericardiocentesis. He continued on a course of antibiotics for a UTI. . In the cardiac cath lab he had 600 cc of clear pericardial fluid drained. On arrival to the CCU his chest pain was resolving and his breathing was improved. . ROS: The patient denies any dyspnea, fevers, diarrhea, constipation ( BM [**8-2**] ), vomiting, dysuria. He does report decreased amount of urine recently. He also endorses fatigue, malaise, poor appetite. No increased leg swelling, at baseline his left leg is swollen since a prior broken leg. He endorses dyspnea on exertion and exertional angina with walking up stairs quickly or walking carrying heavy bundles. The shortness of breath has been most notable over the past 3 days. Past Medical History: PAST MEDICAL HISTORY: IDDM * 45 years Hypercholesterolemia Hypertension CKD, from acute phosphate nephropathy, baseline (2-2.4) Anemia, attributed to CKD, on procrit, baseline HCT 33-36 Coronary artery disease s/p MI in ; negative ETT- echo for ischemia in [**8-23**] Celiac sprue BPH, [**2158**] bx negative, PSA [**1-18**] 4.5, [**3-22**] 3.6, [**4-24**] 4.5 Thyroid nodule . Cardiac Risk Factors: +Diabetes, +Dyslipidemia, +Hypertension . Cardiac History: none . Percutaneous coronary intervention: [**2150**] with PTCA of the mid RCA and OM2 . Pacemaker/ICD placed: none Social History: Born in [**Country 532**], moved to US in [**2150**]. Lives with his wife. Former organic chemistry professor. He has never smoked. He does not consume alcohol on a regular basis (1 drink every 2-3 months). Family History: None Physical Exam: VS: 98.5 128 95/66 29 91%10L PA 47/24 Gen: WDWN elderly Russian male in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP elevated CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: pericardial drain in place. No chest wall deformities, scoliosis or kyphosis. Resp were unlabored. crackles at lateral bases Abd: Obese, soft, NTND, No HSM or tenderness. No abdominal bruits. Ext: No c/c/e. No femoral bruits. arterial and venous access in right groin. 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 Neuro: alert and oriented x3 moving all 4 extremities symmetrically Pertinent Results: [**2164-8-1**] 09:45PM WBC-8.8 RBC-3.15* HGB-9.9* HCT-30.0* MCV-95 MCH-31.5 MCHC-33.1 RDW-13.4 [**2164-8-1**] 09:45PM GLUCOSE-307* UREA N-54* CREAT-3.9* SODIUM-126* POTASSIUM-4.8 CHLORIDE-90* TOTAL CO2-22 ANION GAP-19 [**2164-8-2**] 05:27AM CALCIUM-8.7 PHOSPHATE-3.8 MAGNESIUM-2.2 [**2164-8-1**] 09:45PM PT-13.3 PTT-24.8 INR(PT)-1.1 [**2164-8-1**] 09:45PM CK(CPK)-28* [**2164-8-1**] 09:45PM CK-MB-3 cTropnT-<0.01 [**2164-8-2**] 08:44AM BLOOD CK(CPK)-21* [**2164-8-2**] 08:44AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2164-8-2**] 03:45PM PERICARDIAL FLUID TOT PROT-5.0 GLUCOSE-349 LD(LDH)-369 AMYLASE-25 ALBUMIN-2.9 [**2164-8-2**] 03:45PM PERICARDIAL FLUID WBC-2335* RBC-[**Numeric Identifier 8130**]* POLYS-61* LYMPHS-14* MONOS-7* EOS-2* MESOTHELI-6* MACROPHAG-6* OTHER-4* [**2164-8-2**] 3:45 pm FLUID,OTHER PERICARDIAL FLUID. GRAM STAIN (Final [**2164-8-2**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2164-8-5**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2164-8-8**]): NO GROWTH. ACID FAST SMEAR (Final [**2164-8-3**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. [**2164-8-2**] PERICARDIAL FLUID CYTOLOGY: NEGATIVE FOR MALIGNANT CELLS. [**2164-8-7**] 05:40AM BLOOD TSH-2.4 [**2164-8-7**] 05:40AM BLOOD T4-8.3 Free T4-1.7 [**2164-8-3**] 04:37AM BLOOD [**Doctor First Name **]-POSITIVE Titer-1:80 [**Last Name (un) **] [**2164-8-3**] 04:37AM BLOOD RheuFac-23* L LENI [**2164-8-1**]: No evidence of left lower extremity DVT. L TIB/FIB XR: No radiographic evidence of osteomyelitis. CXR [**2164-8-1**]: Dense left basilar opacity, with at least some component of pleural fluid, possibly also representing some pneumonic consolidation or atelectasis. EKG [**2164-8-2**]: Atrial fibrillation with rapid ventricular response. Low voltage in limb leads. Non-specific inferolateral ST-T wave changes. Compared to the previous tracing of [**2160-2-7**] the rhythm is now atrial fibrillation. Limb lead voltage is lower. Clinical correlation is suggested. The precordial lead voltage is also lower. URINE CULTURE [**2164-8-2**]: No growth. Brief Hospital Course: 75 yo M w/ IDDM, CKD, HTN, presented with malaise, respiratory failure and renal failure, found to have pericardial effusion, s/p pericardiocentesis, developed Afib with RVR, pleural effusion. . # Pericardial effusion: TTE showed a large pericardial effusion with evidence of tamponade. He was taken to the cardiac cath lab for an urgent pericardiocentesis. Approximately 600 cc of clear pericardial fluid was drained, resulting in improvement in his symptoms. The tap was traumatic, but the pericardial fluid was clear and non-bloody per report. Cytology revealed no malignant cells. Echo following pericardiocentesis showed decreased pericardial effusion and no signs of tamponade. The patient was monitored clinically and with repeat echocardiograms which demonstrated further decreases in the size of the pericardial effusion. The effusion was likely of viral etiology given his history of recent prodromal symptoms. Less likely etiologies include malignancy (dysplastic nevi noted - r/o melanoma; has not been seen by a dermatologist in >10 years), vs. thyroid (TFTs normal) vs. autoimmune (RF and [**Doctor First Name **] neg) vs. Dresslers (CE negative on admission with no known recent cardiac events) vs. uremic (Cr bump likely not significant enough per Renal). Pt has scheduled outpatient follow up with cardiologist as well as dermatology. . # Pleural effusion/Respiratory failure/Diastolic CHF: On initial presentation, he was noted to be in respiratory distress and had a significant oxygen requirement. Significant bilateral pleural effusions were noted on CXR and the patient was clinically noted to have bilateral crackles and LE edema. He was diuresed, responding well to Lasix 20 mg IV and then 40 mg PO. His oxygen requirement gradually decreased. A pleural tap was considered but as pt subsequently with improvement on clinical exam and CXR, diuresis continued with continued improvement. On the final day of admission it was noted that the pt's oxygen sats were stable, but after diuresis the prior day the patient was mildly hypovolemic, with BP dropping to 80's systolic on standing. This was thought to be in part due to restarting his Flomax the night before and also in part due to vigorous diuresis. The patient was not discharged on a standing dose of lasix, and instead was instructed to follow up with outpatient doctor in a week to determine whether standing lasix would be necessary. On discharge, patient with no home oxygen requirement; satting in high 90s at rest, desats to low 90s on ambulation. . # Atrial fibrillation Pt developed paroxysmal atrial fibrillation which converted to sinus rhythm either spontaneously or after administration of Metoprolol 5-10 mg IV. However, as patient continued to have frequent episodes of a fib, amiodarone initiated. He was started on amiodarone on [**8-7**], with plans to give 400mg [**Hospital1 **] for 7 days, then 400mg QD for 7 days, and then 200mg QD. Baseline TFTs and LFTs wnl. Pt will need to have PFTs checked as an outpatient. As he has a CHADS score of 4, patient was started on anticoagulation with Coumadin with a goal INR of 1.8-2.5 as patient with recent pericardial tap and on amiodarone. [**Hospital 197**] clinic notified of goal INR. . # R Tibial DVT: LENIs showed thrombus in R tibial vein. Lower leg DVT is not likely to result in significant thromboembolism, and given his acute on chronic renal failure, he probably would not tolerate a PE CT well, so no workup for possible PE was pursued. However, pt adequately treated as already on systemic anticoagulation for Afib and ASA for CAD. . # Acute on chronic renal failure: FeNa 0.1%, suggestive of prerenal etiology. Likely [**2-18**] poor forward flow in setting of volume overload/pericardial tamponade. Urine output and Cr improved with diuresis. . # Cellulitis: Keflex initially started for cellulitic area on left leg. However, this was discontinued as outside records showed that pt had already completed a 14 day course of Augmentin. I&D was not indicated by physical exam. . # CAD No evidence of acute ischemic event on EKG or cardiac enzymes (negative over 12 hours). Patient continued on ASA, statin, beta blocker. . # UTI: Pt originally admitted with a question of possible UTI and treated with cipro, but as Ucx was negative, this was discontinued. . # Anemia: Hct was stable. Anemia is attributed to renal failure. Fe stores appear replete. Pt continued on Procrit. . # DM - Type I per records Pt was treated with glargine and lispro sliding scale. Due to high blood sugars, his glargine dosage was increased. Pt should discuss with PCP whether [**Name9 (PRE) **] clinic could help him improve his glycemic control. Medications on Admission: Aspirin 325 mg daily Isosorbide dinitrate 20 mg po tid (pt reports as 40mg am, and 20mg pm) Metoprolol 12.5 mg po bid Simvastatin 40 mg daily fluticasone nasal spray Fluticasone-Salmeterol 250/50 inh [**Hospital1 **] Albuterol Glargine 6 u subq daily Lispro sliding scale Montelukast 10 mg daily Calcitriol 0.25 mg po daily Sevelamer 400 mg po tid -- patient has not been taking this Tamsulosin 0.4 mg daily MVI Polysaccharide Iron Complex 150 mg Capsule [**Hospital1 **] Loratadine 10 mg daily Augmentin 500/125 [**Hospital1 **] Discharge Medications: 1. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection every 2 weeks. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). 5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) vial Inhalation Q6H (every 6 hours) as needed. 7. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 9. Sevelamer HCl 400 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 2 days: Last dose on [**2164-8-13**]. Disp:*10 Tablet(s)* Refills:*0* 13. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily). Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*0* 14. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: Start on [**8-14**] and continue for 7 days. . Disp:*14 Tablet(s)* Refills:*0* 15. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: Start on [**2164-8-21**]. Disp:*30 Tablet(s)* Refills:*2* 16. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 17. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. 18. Lispro insulin Please continue home sliding scale. 19. Lantus 100 unit/mL Cartridge Sig: Twelve (12) units Subcutaneous once a day. 20. Warfarin 3 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 **] Family & [**Hospital1 1926**] Services Discharge Diagnosis: Primary: Pericardial effusion Acute on chronic diastolic dysfunction Acute on chronic renal failure Paroxysmal atrial fibrillation . Secondary: Anemia of chronic disease Diabetes type I on insulin Hypercholesterolemia Hypertension Coronary artery disease s/p MI in [**2150**] Celiac sprue BPH Thyroid nodule Discharge Condition: Stable Discharge Instructions: You had fluid around your heart called a pericardial effusion that was tapped and has not reaccumulated. You have fluid near the base of your lungs called pleural effusions. You were started on a diuretic which improved the effusions, it also helped to decrease the fluid in the rest of your body. You have atrial fibrillation, a new irregular heart beat, and you were started on amiodarone to control the rhythm and coumadin to prevent blood clots. The dose of amiodarone for the first 2 days that you are at home is 400mg twice daily, the dose of amiodarone after that will be 200mg twice daily for 1 week, the dose of amiodarone after that will be 200mg once daily continuously. You were noted to have a blood clot in your left calf and the coumadin should help to dissolve this. You were noted to have many moles on your skin and should follow up with Dermatology. . You were started on the following new medications: - Amiodarone - Coumadin (dose adjusted by coumadin clinic) - Lovenox (take until coumadin level therapeutic) The following medications were changed: - Metoprolol 12.5 daily twice daily -> Toprol XL 75 mg daily - Glargine increased to 12 U daily The following medications were discontinued: - Isosorbide dinitrate - Augmentin Please take all medications as prescribed. . Please check your blood sugars before meals. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet so that you don't retain fluid. Please use your TEDS stockings every day and keep your legs elevated when you are sitting down. . If you experience chest pain, worsening shortness of breath, weakness on one side of your body, difficulty speaking or swallowing, fever/chills, please call 911 or go to the ER. Followup Instructions: You have the following appointments: Primary Care: Provider: [**First Name8 (NamePattern2) 1409**] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**] Date/Time:[**2164-8-21**] 8:10 Provider: [**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. Date/Time:[**2164-8-31**] 10:30 Provider: [**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. Date/Time:[**2164-9-10**] 2:10 Please speak with your PCP about whether you may benefit from an appointment at the [**Hospital **] clinic ([**Telephone/Fax (1) 8131**]) for better control of your blood sugars. . Cardiology: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 62**] Office will call you at home with appt. Please follow up lasix dose which was used inpatient for diuresis. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2164-11-29**] 9:20 . [**Hospital 197**] Clinic at [**Hospital6 733**]: [**Telephone/Fax (1) 2173**]. They will call you to arrange follow-up of your coumadin levels. . Dermatology: Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] Phone: ([**Telephone/Fax (1) 8132**] Date/Time: [**10-30**] at 1:45pm.

[ "785.51", "682.6", "423.3", "453.42", "584.9", "250.02", "579.0", "428.33", "285.21", "420.91", "272.0", "428.0", "V58.67", "518.81", "585.9", "276.7", "403.90", "427.31" ]

icd9cm

[ [ [] ] ]

[ "37.0", "37.21", "88.55" ]

icd9pcs

[ [ [] ] ]

14421, 14507

7151, 11843

286, 306

14859, 14868

4878, 6066

16664, 17999

3915, 3921

12423, 14398

14528, 14838

11869, 12400

14892, 16641

3936, 4859

6102, 6102

6135, 7128

225, 248

334, 3076

3120, 3674

3690, 3899

5,071

100,889

6616

Discharge summary

report

Admission Date: [**2175-2-7**] Discharge Date: [**2175-2-10**] Date of Birth: [**2094-6-28**] Sex: M Service: MEDICINE Allergies: Penicillins / Codeine Attending:[**First Name3 (LF) 983**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: colonoscopy esophagogastroduodenoscopy History of Present Illness: This is an 80 year old male with history of coronary disease s/p CABG with a patent LIMA-LAD per cath [**2171**] on plavix, peripheral [**Year (4 digits) 1106**] disease s/p popliteal to posterior tibial graft on right lower extremity, atrial fibrillation on coumadin, presenting with new onset of bright red blood per rectum. Mr [**Known lastname 25280**] developed acute onset of bright red blood this AM prior to making it to the bathroom - he had no abdominal pain or cramping, but daughter reported that he felt weak and looked pale. He passed about 200 ccs of blood in the toilet. EMS arrived on the scene and apparently had a difficult pressure to appreciate; however consequently BP was noted in the 160s. He's never had hematochezia before. Does take plavix and coumadin; INR was 3.9. Usually INRs are within range of [**2-10**]. No recent history of motrin, aspirin, ibuprofen. Had colonoscopy in [**2174**] which showed just external hemorrhoids with no other lesions. Transferred to MICU for further workup. GI evaluated and plan on scoping in AM (endoscopy and colonoscopy). Past Medical History: Diabetes Dyslipidemia Hypertension PVD w chronic LE ulcers CHF NYHA Class II, EF 20-30% (echo [**2-18**]) CAD s/p CABG x4 (LIMA->LAD, SVG->Diag->left-PL, SVG->ramus) in [**2-/2166**] Cath with SVGx2 occluded, patent LIMA-LAD in [**6-/2171**] VT s/p [**Year (4 digits) 3941**] placement ([**Company 2267**] Confient model E030 dual-chamber [**Company 3941**]) s/p rsxn R 1st MT joint [**2-10**] s/p R BK [**Doctor Last Name **] -DP w/nrsvg [**4-11**] s/p plasty of bpg [**4-13**] s/p agram [**3-14**] arteriogram 12/10 [**2174-2-10**] R 3rd toe debrid by podiatry [**2174-2-8**] right BK [**Doctor Last Name **] to PT bypass w/ NRSVG Social History: married. has 6 children. previously worked with polaroid. [**Doctor Last Name 4273**] tobacco. Quit ETOH 25 years ago. [**Doctor Last Name 4273**] illicits. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION EXAM VS: HR 80, BP 120/80, RR 12, 98% RA, temp 99 Gen: Black male, pleasant, alert, in no apparent distress Cardiac: Nl s1/s2, RRR Pulm: clear bilaterally Abd: soft, NT, ND, normoactive Ext: no edema noted . discharge exam VS: 97.9 118/65 (118/65-141/68) 59 (59-75) 16 97% RA GENERAL - well-appearing man in NAD, comfortable, appropriate HEENT - sclerae anicteric, MMM NECK - supple, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - irregular, 2/6 systolic murmur heard throughout, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no rebound/guarding EXTREMITIES - WWP, trace to 1+ pitting edema L>R, 2+ peripheral pulses (radials, DPs) NEURO - awake, A&Ox3 Pertinent Results: ADMISSION LABS [**2175-2-7**] 12:56PM BLOOD WBC-10.8 RBC-2.78* Hgb-8.0*# Hct-25.3*# MCV-91 MCH-28.8# MCHC-31.7 RDW-15.8* Plt Ct-238 [**2175-2-7**] 12:56PM BLOOD Neuts-55.4 Lymphs-38.1 Monos-3.9 Eos-1.7 Baso-0.8 [**2175-2-7**] 12:56PM BLOOD PT-36.8* PTT-29.2 INR(PT)-3.6* [**2175-2-7**] 12:56PM BLOOD Glucose-195* UreaN-37* Creat-1.5* Na-143 K-3.8 Cl-105 HCO3-21* AnGap-21* [**2175-2-8**] 03:38AM BLOOD ALT-21 AST-26 LD(LDH)-177 AlkPhos-43 TotBili-0.9 [**2175-2-8**] 03:38AM BLOOD Calcium-9.0 Phos-2.6* Mg-2.1 [**2175-2-7**] 01:01PM BLOOD Hgb-8.3* calcHCT-25 . OTHER LABS: [**2175-2-7**] 12:56PM BLOOD WBC-10.8 RBC-2.78* Hgb-8.0*# Hct-25.3*# MCV-91 MCH-28.8# MCHC-31.7 RDW-15.8* Plt Ct-238 [**2175-2-7**] 10:04PM BLOOD Hct-24.3* [**2175-2-8**] 03:38AM BLOOD WBC-9.8 RBC-2.59* Hgb-7.3* Hct-23.4* MCV-90 MCH-28.0 MCHC-31.0 RDW-16.0* Plt Ct-266 [**2175-2-8**] 05:45PM BLOOD Hct-23.9* [**2175-2-9**] 07:00AM BLOOD WBC-9.9 RBC-2.78* Hgb-8.0* Hct-25.0* MCV-90 MCH-28.7 MCHC-31.9 RDW-16.8* Plt Ct-246 [**2175-2-9**] 04:10PM BLOOD Hct-29.4* [**2175-2-10**] 06:55AM BLOOD WBC-7.0 RBC-2.94* Hgb-8.8* Hct-26.6* MCV-91 MCH-30.0 MCHC-33.1 RDW-16.3* Plt Ct-271 [**2175-2-8**] 03:38AM BLOOD PT-23.6* INR(PT)-2.3* [**2175-2-9**] 07:00AM BLOOD PT-16.1* PTT-30.0 INR(PT)-1.5* [**2175-2-8**] 10:44PM BLOOD CK(CPK)-59 [**2175-2-9**] 07:00AM BLOOD CK(CPK)-80 [**2175-2-9**] 04:10PM BLOOD CK(CPK)-87 [**2175-2-8**] 10:44PM BLOOD CK-MB-4 cTropnT-0.04* [**2175-2-9**] 07:00AM BLOOD CK-MB-6 cTropnT-0.11* [**2175-2-9**] 04:10PM BLOOD CK-MB-5 cTropnT-0.12* . discharge labs [**2175-2-10**] 11:20AM BLOOD Hct-28.2* [**2175-2-10**] 06:55AM BLOOD PT-13.4* PTT-29.1 INR(PT)-1.2* [**2175-2-10**] 06:55AM BLOOD Glucose-111* UreaN-15 Creat-1.4* Na-142 K-4.1 Cl-108 HCO3-26 AnGap-12 [**2175-2-10**] 06:55AM BLOOD CK(CPK)-66 [**2175-2-10**] 06:55AM BLOOD CK-MB-3 cTropnT-0.10* [**2175-2-10**] 06:55AM BLOOD Calcium-8.7 Phos-2.6* Mg-2.0 . micro HELICOBACTER PYLORI ANTIBODY TEST (Final [**2175-2-10**]): POSITIVE BY EIA. . studies ECG [**2175-2-7**]. HR 82, axis -30, old inferior q wave, non-specific t wave I, avel and t wave inversions laterally ? LVH. . ECG [**2175-2-8**]: HR 88, NS, + APC, old q waves inferiorly, <1mm st elevation III, t wave flatening I -avl and v4-v6 . ECG [**2175-2-9**]: HR 65, NSR, biphasic t wave waves v2-v3-v4 compared to prior. . EGD: Excavated Lesions Five cratered non-bleeding ulcers, with clean white base, ranging in size from 5 mm to 10 mm were found in the duodenal bulb. No fresh or old blood was noted. Impression: Ulcers in the duodenal bulb Otherwise normal EGD to third part of the duodenum Recommendations: Check H. pylori serology and eradicate if positive. F/U with inpatient GI team. . COLONOSCOPY: Protruding Lesions: Small internal & external hemorrhoids were noted. Excavated Lesions: A few diverticula were seen in the whole colon. Diverticulosis appeared to be of mild severity. Other Semi-solid and liquid stool was noted scattered in the whole colon. This was copiously irrigated and the patient was re-positioned to improve mucosal visualization. Despite these measures, small size pathology may have been missed. Normal terminal ileum No fresh or old blood was noted. Impression: Diverticulosis of the whole colon Bowel prep was fair. Normal terminal ileum No fresh or old blood was noted. Otherwise normal colonoscopy to cecum Recommendations: F/U with inpatient GI team. . Brief Hospital Course: Initial Presentation: 80 yo M with hx of CAD, PVD, HTN, HLD on plavix and coumadin who presented with GI bleed found to have drop in HCT and elevated INR. . # GI Bleed: Patient presented to the ED after found to have 1 episode of blood mixed with stool. In the ED he had stable vital signs but was found to have a Hgb/HCT of [**9-2**] (down from 12/35 in [**9-19**], however was previously anemic with HCTs between 25-30), and an elevated INR of 3.6. Patient was given 2 units of FFP and subsequently developed hives. He was then given benadryl and hives resolved. He was evaluated by GI with plans to do EGD/colonoscopy the following morning. His ASA, plavix, and coumadin were held. Patient was monitored overnight in the MICU. He was given IVF but no additional blood products. HCT remained stable around 24-25. He subsequently underwent an EGD/colonoscopy and was transferred to the medicine floor. Endoscopy was significant for duodenal ulcers, diverticulosis, and small internal and external hemorrhoids. He was transfused with 2 units of PRBC given demand ischemia (see below) and responded appropriately. ASA, plavix, and warfarin were restarted. H. pylori serology was ordered and patient was started on omeprazole 40 mg po BID. Patient had no further episodes of hematochezia or melana and HCT remained stable through remainder of admission. He was discharged with plans to follow up with his PCP and with gastroenterology. After discharge h.pylori serology were +, patient will need to be treated by PCP as an outpatient. . # Chest pain: On evening after endoscopy, patient had an episode of substernal chest pain with associated ECG changes. Troponins were elevated but CKMB was WNL. His chest pain resolved with sublingual nitro x2. The patient was evaluated by cardiology and it was felt this chest pain was most likely due to demand ischemia in the setting of GI bleed and anemia. He was subsequently transfused 2 units of PRBC. He remained chest pain free through the remainder of the admission and his troponins started to trend down by time of discharge. He was continued on his ASA, statin and plavix. He was also started on metoprolol. He has plans to follow up with cardiology as an outpatient. . # Chronic systolic CHF - Patient remained euvolemic throughout admission. His torsemide was initially held in the setting of GI bleed. However, it was subsequently restarted prior to discharge. He was also started on metoprolol and lisinopril during admission. . # Diabetes - Metformin was held during admission. His blood sugars were controlled with insulin sliding scale. . # Afib on coumadin - INR initially supratherapeutic (3.6) on presentation. He was treated with FFP initially and coumadin was held in the setting of GI bleed. Coumadin was restarted prior to discharge. He has plans to have his INR rechecked on [**2175-2-13**] at PCP follow up . # HTN - cont medications as above . # HLD - continued pravastatin . # PVD - Plavix and ASA initially held with GI bleed but restarted prior to discharge . Transitional Issues: - Just after discharge patients H. pylori antibody returned as positive. PCP and gastroenterologist were notified. Patient should be treated with Prevpac. - Patient was started on omeprazole 40 mg [**Hospital1 **] for PUD until GI follow up. - Patients INR was subtherapeutic upon discharge. His INR will need close follow up after discharge and coumadin dosing will likely need additional adjustment. - Patient was started on metoprolol and lisinopril during admission given his hx of CAD and CHF. Patient will need his electrolytes checked within 2 weeks of discharge. He will also need his blood pressure and heart rate rechecked. - patient was full code during admission Medications on Admission: 1. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Please start on 9/31. 6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Coumadin 2 mg Tablet Sig: 1-2 Tablets PO once a day: as directed by your PCP [**Name Initial (PRE) **] [**Name10 (NameIs) **] your home dose. Discharge Medications: 1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day. 5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Coumadin 2 mg Tablet Sig: Two (2) Tablet PO once a day: please take as directed by your PCP. 7. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 8. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain : take 1 tablet at onset of chest pain. if chest pain continues for 5 minutes take a second tablet. if chest pain contines after 10 minutes take a 3rd tablet and call 911. 9. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 10. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: primary diagnoses: GI bleed, Peptic Ulcer disease, chest pain secondary diagnoses: Coronary artery disease, congestive heart failure, diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 25280**], It was a pleasure caring for you while you were admitted to [**Hospital1 18**]. You were admitted because you were bleeding from your gastrointestinal tract. You were evaluated by the gastroenterologists and underwent an EGD and colonoscopy which showed some ulcers in the beginning of your small intestines and mild outpouchings of your colon. There was no evidence of an active bleeding site. You were started on a medication called omeprazole for your ulcers. . During your admission, your also had an episode of chest pain. Your electrocardiogram showed some changes and your heart enzymes were elevated. You were evaluated by the cardiologists who felt there was no need for intervention or additional testing and that the chest pain was most likely due to your low blood counts. You were subsequently transfused with 2 units of blood. You were also started on two medications to help your heart health. . The following changes have been made to your medication regimen Please START taking - omeprazole 40 mg twice daily for your ulcers (you can discuss decreasing this dose at your follow up appointment with your gastroenterologist) - lisinopril 2.5 mg daily - metoprolol succinate 25 mg daily Please take the rest of your medications as prescribed and follow up with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 1988**]. . You will need to have your INR checked on Monday at your appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 25287**]. You will need to have your electrolytes rechecked in 2 weeks to monitor your potassium and creatinine with your new medications. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 25287**], PA (works with Dr [**Last Name (STitle) 25288**] Location: [**Hospital 4323**] MEDICAL Address: [**Location (un) 4324**], [**Street Address(1) 4323**],[**Numeric Identifier 4325**] Phone: [**Telephone/Fax (1) 4326**] Appt: [**2-13**] at 11am Department: CARDIAC SERVICES When: THURSDAY [**2175-2-23**] at 2:40 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2175-3-1**] at 1:30 PM With: [**Name6 (MD) 2606**] [**Name8 (MD) 2607**], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Completed by:[**2175-2-13**]

[ "250.00", "V45.02", "440.23", "416.8", "V58.61", "397.0", "708.0", "272.4", "455.0", "V45.81", "707.19", "E879.8", "458.9", "455.3", "396.3", "041.86", "790.92", "428.22", "428.0", "999.89", "410.71", "427.31", "V15.82", "532.40" ]

icd9cm

[ [ [] ] ]

[ "45.13", "45.23" ]

icd9pcs

[ [ [] ] ]

12233, 12239

6614, 9643

286, 326

12426, 12426

3181, 3741

14356, 15338

2299, 2414

11061, 12210

12260, 12322

10367, 11038

12577, 14333

2429, 3162

12343, 12405

9664, 10341

241, 248

354, 1451

12441, 12553

1473, 2108

2124, 2283

3753, 6591

4,679

190,809

45089

Discharge summary

report

Admission Date: [**2195-9-5**] Discharge Date: [**2195-9-21**] Date of Birth: [**2128-12-29**] Sex: F Service: SURGERY Allergies: Vancomycin And Derivatives / Tetracyclines / Penicillins / Sulfonamides Attending:[**First Name3 (LF) 3223**] Chief Complaint: Gallstone pancreatitis Major Surgical or Invasive Procedure: Laparoscopic cholecystectomy History of Present Illness: None Past Medical History: HTN, DM, Breast Ca, Thyroid Ca - Thyroidectomy, TAH/SBO, Appendectomy Family History: Nonpertinent Physical Exam: Right upper quadrant pain. The patient was admited to the floor and respiratory failure addressed with an emergent intubation. Pertinent Results: [**2195-9-5**] 09:48PM ALT(SGPT)-381* AST(SGOT)-480* ALK PHOS-110 AMYLASE-717* TOT BILI-4.0* [**2195-9-5**] 09:48PM LIPASE-1066* [**2195-9-5**] 09:48PM WBC-24.0* RBC-3.14* HGB-9.4* HCT-26.0* MCV-83 MCH-29.8 MCHC-36.0* RDW-14.2 [**2195-9-5**] 09:48PM CALCIUM-8.6 PHOSPHATE-3.9 MAGNESIUM-2.1 [**2195-9-5**] 02:53PM ALT(SGPT)-279* AST(SGOT)-367* ALK PHOS-114 AMYLASE-1021* TOT BILI-3.5* CT PELVIS W/CONTRAST [**2195-9-8**] 12:51 PM CONCLUSION: 1. No intra or extrahepatic biliary dilatation. 2. Cholelithiasis, nondistended gallbladder. 3. Bibasilar effusion and associated partial atelectasis of the lower lobes. ERCP 8/13/5 Gallstone pancreatitis Impacted stone at the CBD Pre-cut sphincterotomy followed by completion sphincterotomy Stone extraction 10f x 8cm stent placement Brief Hospital Course: Patient was admited to the floor with a Gallstone Pancreatis requiring an emergent Endotracheal Intubation. Transfer to the ICU and ERCP was done with CBD Stent placed and stone removals. Her respiratory distress improved, persistend pleural effusion bilaterally and was extubate. Her LFT normalized and transfer to the Floor. She was schedule for a Laparoscopic Cholecystectomy and had no other complications. She had an uneventfull recovery from her operation and the plan to discharge her home with Physical therapy was established with the patient consent. Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*60 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* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Gallstone Pancreatitis Discharge Condition: Good Discharge Instructions: Go to an Emergency Room if you experience new and continuing nausea, vomiting, fevers (>101.5 F), chills, or shortness of breath. Also go to the ER if your wound becomes red, swollen, warm, or produces pus. If you experience clear drainage from your wounds, cover them with a clean dressing and stop showering until the drainage subsides for at least 2 days. No heavy lifting or exertion for at least 6 weeks. No driving while taking pain medications. Narcotics can cause constipation. Please take an over the counter stool softener such as Colace or a gentle laxative such as Milk of Magnesia if you experience constipation. You may resume your regular diet as tolerated. You may take showers (no baths) after your dressings have been removed from your wounds. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 519**] in [**1-25**] weeks. Please call his office at (([**Telephone/Fax (1) 5323**] to make an appointment. - Please follow up with DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Where: [**First Name8 (NamePattern2) **] [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) ENDOSCOPY SUITE Phone:[**Telephone/Fax (1) 463**] Date/Time: [**2195-10-8**] 9:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**] Completed by:[**2195-9-21**]

[ "276.2", "401.9", "995.92", "278.00", "038.9", "577.0", "576.1", "250.00", "574.41", "V10.3", "599.0", "V10.87", "272.4", "518.82", "V10.42", "584.5" ]

icd9cm

[ [ [] ] ]

[ "99.15", "96.6", "96.72", "51.88", "00.14", "51.87", "38.91", "51.85", "51.23", "38.93", "96.04", "00.17" ]

icd9pcs

[ [ [] ] ]

2372, 2430

1517, 2079

354, 384

2496, 2503

703, 1494

3320, 3984

527, 541

2102, 2349

2451, 2475

2527, 3297

556, 684

292, 316

412, 418

440, 511

11,341

137,194

2452+2453+3004+55381

Discharge summary

report+report+report+addendum

Admission Date: [**2144-4-19**] Discharge Date: Date of Birth: [**2082-1-26**] Sex: F Service: MEDICINE HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname **] is a 62-year-old female with a complicated medical history including sarcoidosis, hepatic cirrhosis, Grade II esophageal varices, hypertension, multiple orthopaedic procedures to her left hip, right hip and right knee, who presented with left thigh recently admitted to Surgery for ventral hernia repair, which had caused an ileus and ascites, which required two [**Location (un) 1661**]-[**Location (un) 1662**] drains. These drains were recently removed. The patient developed abdominal pain and diarrhea soon after. The patient also developed left thigh pain. The patient reported that the pain worsened to the point where she was unable to weight bear. She denied any nausea, vomiting, chills, feeling cold, and lightheadedness. This prompted her to present to the Emergency Department. In the Emergency Department, the patient was found to be hypotensive, with blood pressure 80/palpation, the heart rate in the 160s. Her white blood cell count was noted to be 30, with 26% bandemia, and the patient was found to also be in acute renal failure with a creatinine up to 3.0. She was also hyperkalemic, acidotic, with an anion gap of 14. Per the Emergency Department record, the patient appeared to have received 1 gram of vancomycin, 100 mg of hydrocortisone, 10 units of regular insulin, 1 amp of dextrose, and 2 mg of intravenous dilaudid. She was transferred to the Medical Intensive Care Unit on the [**Hospital Ward Name 516**]. On arrival to the [**Hospital 516**] Medical Intensive Care Unit, the patient was found to be lethargic, with pinpoint pupils secondary to dilaudid. An amp of Narcan was given, with improvement of mental status. On review of systems, the patient complains of exquisite pain in her left thigh, with decreased range of motion of her knee. PAST MEDICAL HISTORY: 1. Sarcoidosis diagnosed in [**2137**], with pulmonary and hepatic involvement, on chronic steroids 2. Status post ventral hernia repair on [**2144-2-29**] 3. History of cirrhosis diagnosed by CT in [**2143-10-31**] with Grade II varices 4. Status post right total hip replacement and right total knee replacement 5. Status post open reduction and internal fixation of her left hip 6. Osteoporosis 7. Hypertension 8. Choledocholithiasis 9. Hypercholesterolemia 10. Aortic stenosis with ejection fraction of 55% 11. Status post total abdominal hysterectomy and bilateral salpingo-oophorectomy MEDICATIONS ON ADMISSION: Lasix 20 mg by mouth once daily, Aldactone 15 mg twice a day, Actigall 300 mg three times a day, Protonix 40 mg by mouth once daily, prednisone 10 mg by mouth twice a day, Aleve 220 mg by mouth twice a day. SOCIAL HISTORY: The patient is divorced. She lives with her daughter. PHYSICAL EXAMINATION: On arrival to the Medical Intensive Care Unit, the patient's temperature was 99.2, blood pressure 120/84, heart rate 117, respiratory rate 12, oxygen saturation 96% on room air, and her weight was 70 kg. General examination revealed a lethargic patient, who became alert and oriented x 3 after Narcan administration. She was not in any acute distress. Head, eyes, ears, nose and throat examination revealed cataracts, normal mucous membranes. Pupils went from 1 mm to 3 mm after Narcan administration. Neck examination revealed no jugular venous distention. Cardiovascular examination revealed that the patient was tachycardic, with normal S1 and S2, and III/VI systolic ejection murmur at right upper sternal border. This murmur radiates to the carotids and apex. She had no S3 and no S4. Lung examination revealed lungs clear to auscultation bilaterally, with no wheezes or crackles. Abdominal examination revealed a soft abdomen with decreased bowel sounds. The patient had a well-healed surgical scar with a scab in the subumbilical abdominal area. The patient was mildly tender on palpation of the middle of her abdomen. Extremity examination revealed trace bilateral lower extremity edema, tenderness and warmth along her left lateral thigh. There was no induration or erythema. Neurologic examination: The patient was able to move all of her toes and her ankles. She was unable to bend her left knee to full flexion secondary to pain. She was otherwise alert and oriented x 3. LABORATORY DATA: On admission, hematocrit 41.2, white count 29, and platelet count of 367. Her serum chemistry revealed a sodium of 137, potassium 4.9, chloride 107, bicarbonate 16, BUN 83, creatinine 2.9, glucose 78. Anion gap was 14. On her initial blood work, her white count differential revealed 69% neutrophils and 26% bands. Coagulation studies revealed an INR of 1.4. Her ESR was 87. Liver studies revealed an ALT of 9, AST of 30, total bilirubin of 2.9, CK of 20, calcium of 8.2, magnesium of 2.1, and phosphate of 5.6. Her electrocardiogram revealed sinus tachycardia. Her chest x-ray revealed no effusion, no pneumonia, and no pneumothorax. There was minimal increased interstitial opacity, questionable atelectasis, in the lower lung bases. Her ultrasound of her left thigh revealed a small fluid collection in the left lateral thigh. HOSPITAL COURSE: After being found hypotensive with hyperkalemia, the patient was treated with intravenous fluids and insulin and D-50, as well as hydrocortisone for stress dose steroids. The patient's left thigh was evaluated by ultrasound, which showed a fluid collection suspicious for an abscess. This fluid collection was aspirated by Orthopaedic consultation team. The patient received a total of 12 liters of normal saline within 24 hours' time prior to producing any urine output. The patient was also started empirically on clindamycin for antibiotic coverage. Surgery was consulted to evaluate the possibility of fasciitis in her left thigh. They recommended ultrasound-guided tap aspirate of the left thigh fluid collection, which on Gram stain showed 4+ polymorhoneucleocytes. The patient's hypotension resolved with aggressive intravenous fluid hydration and a brief course of pressors. Her acute renal failure also appeared to improve after she was aggressively hydrated. The nephrolog was consulted. Her hyperkalemia began to resolved after insulin and D-50 treatments. The patient's initial tachycardia on admission resolved after intravenous fluid hydration. In terms of the patient's leukocytosis, the suspicion was that this is a reaction to the abscess in her left thigh. An MRI of her left thigh was obtained on [**2144-4-20**]. On this MRI, the patient was found to have a discrete fluid collection in the subcutaneous tissue of the anterior abdominal wall measuring 16 x 20 x 3 cm. It extends from above the umbilicus to the pubic symphysis, and is predominantly on the left side of the abdomen. The source of this fluid was not entirely clear on this MRI. Orthopedics thought this unlikely to involve her hip prosthesis. The patient was also found to have extensive subcutaneous edema and small fluid collections in her left thigh. She was found to not have any significant fluid within her left hip joint. At this time, the patient was on clindamycin and vancomycin as her antibiotic coverage. The patient also received a right internal jugular centrally-placed catheter on [**2144-4-20**], for access. On this date, the patient had continual hypotension requiring aggressive fluid hydration, and also low-dose dopamine to be added via her central catheter. Her blood culture on this date was found to have staphylococcus bacteremia. She underwent a transthoracic echocardiogram, which did not show any vegetations. On this date, the initial fluid aspirate from her left thigh also grew out coagulase positive staphylococcus aureus. The patient's hypotension was improved and was able to be weaned off dopamine on [**2144-4-21**]. On this date, she was also started on Fluconazole for yeast in her urine. Infectious Diseases was consulted on [**4-21**]. They recommended tapping of the patient's abdominal fluid collection, which was found on the MRI study of her left thigh and abdomen. However, at the same time, the Surgical consultants felt strongly that this fluid should not be tapped due to potential for infecting it, and a potential connection with the patient's abdominal cavity, especially in the setting of known ascites. This fluid collection therefore was not tapped on this date. The patient continued to improve. On [**2144-4-22**], the patient was no longer requiring pressor support, and her creatinine had decreased to 2.0. She was no longer febrile. The patient's final cultures came back as methicillin-sensitive staphylococcus aureus in her blood obtained on [**2144-4-19**]. She also grew methicillin-sensitive staphylococcus aureus at the aspirate of one fluid collection in her left thigh. In the same culture, she also grew some bacillus species. On [**2144-4-23**], the patient was found to have a positive urine culture growing Klebsiella pneumoniae. She was started on levofloxacin by mouth for this infection. Her Foley catheter was removed on this date. She was also started on prednisone for her sarcoidosis. By this time, the patient's white blood cell count had decreased to 19.4. Her serum creatinine had decreased to 1.9. As the patient has had stable blood pressure up until now, and has had peripheral edema due to saline resuscitation, the patient received a low-dose diuretic, and her urine output increased. On the early morning of [**2144-4-24**], the patient was called out of the Intensive Care Unit and transferred to the floor. By this time, her serum creatinine was down at 1.4. Her blood pressure has been stable. She is no longer tachycardic. Her methicillin-sensitive staphylococcus aureus bacteremia and left thigh abscess have been treated by continuing dosages of vancomycin, and the left thigh aspiration. Her left thigh pain was much improved at this time, with no requirement of narcotics for pain control. After arrival to the floor, the patient received a PICC line placement in the morning of [**2144-4-24**]. Her right internal jugular vein central catheter was therefore removed. The patient was continued on her levofloxacin and vancomycin. The plan at this time was to further treat the patient's infections, stabilize her, diurese her, and have physiotherapist screen her, with eventual plans to discharge her to a [**Hospital 3058**] rehabilitation center. With regards to the patient's methicillin-sensitive staphylococcus aureus bacteremia, the patient was determined to be too high risk to receive a transesophageal echocardiogram for further evaluation of her valves. This is because she has known Grade II varices in her esophagus. After much discussion with the Infectious Disease team and the patient's primary doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], it was determined that the patient should be treated for a total course of eight weeks with vancomycin. This is because she is thought to be high risk for seeding her known stenosed aortic valve. The patient did very well on the floor between [**4-24**] and 29. She was diuresed with initially 20 mg of lasix by mouth, with minimal effects. She received intravenous lasix after that, with better responses. The patient was still generally edematous, especially in her legs. She had not been able to ambulate because of her gross lower extremity edema. Her renal failure was completely resolved by this time. Her baseline creatinine of 0.7 was reached on [**2144-4-26**]. Her white blood cell count was also noted to be decreasing. Into the morning of [**4-27**], the patient was noted to be tachycardic up to 118 to 120s. This was thought to be from intravascular volume depletion due to aggressive diuresis. The patient received a trial of 250 cc of saline bolus, and her heart rate decreased from 120 to 108. This was thought to be a positive test result for her intravascular volume status. Her lasix was therefore discontinued. By the next morning, the patient's tachycardia had resolved, and her heart rate ranged between 80s to 100s. However, on the same day, the patient noted new onset left thigh tenderness. This was concerning for reaccumulation of fluids or reappearance of her left thigh abscess. The patient was afebrile on this date. Given the concerning symptoms, another ultrasound of her left lower extremity was obtained. On this ultrasound, the patient was again found to have hypoechoic fluid collection tracking along her left lateral thigh. This collection measures 3.2 cm in the largest AP diameter, and was thought to be more than 10 cm in length. After discussion with Surgery and Orthopaedics, it was determined that this fluid collection needed to be drained, with the placement of a pigtail catheter. This was done on the morning of [**2144-4-28**], without complications. The patient had purulent fluids drained from her left thigh fluid collection. This fluid was sent for cell count and culture. The patient also received a chest x-ray on this date for crackles noted on physical examination. On the chest x-ray, the patient had no evidence of pneumonia. The patient was thought to have low-grade atelectasis, and was encouraged to take deeper breaths in. The patient has been using an incentive spirometer ever since admission to the Intensive Care Unit. On the morning of [**2144-4-28**], the patient experienced an episode of spontaneous drainage of most likely the subcutaneous fluid collection seen on MRI in her abdomen. Per patient's report, she stood up to go to the commode, and all of a sudden she felt gushing fluid coming from her abdomen. The scab in her subumbilical region apparently lifted and clear fluid drained out in copious amounts. The scab was later on covered with dry dressing. The patient did require frequent dressing change, and had persistent leakage of clear-looking fluid from this site. The Surgery service was notified of this event. They recommended dry dressings frequently. They were not concerned that this fluid could be infected fluid. Due to the physical characteristics of the fluid drained from the patient's left thigh fluid collection, she was started on levofloxacin by mouth for broadening antibiotic coverage until this fluid culture returns. The concern here is multiorganism infection which was not covered by vancomycin. [**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. [**MD Number(1) 7551**] Dictated By:[**Name8 (MD) 9921**] MEDQUIST36 D: [**2144-5-1**] 17:39 T: [**2144-5-2**] 00:00 JOB#: [**Job Number 12570**] Admission Date: [**2144-4-19**] Discharge Date: Date of Birth: Sex: F Service: MEDICINE ADDENDUM HOSPITAL COURSE: 1. INFECTIOUS DISEASE: The patient continued on vancomycin for treatment of Staphylococcus bacteremia, abscess and possible endocarditis. The patient was also suffering from diarrhea which appeared to resolve with loperamide after three Clostridium difficile toxin ELISAs were obtained which were negative. In terms of the patient's left lateral thigh, which appeared to be the source seen in the patient's bloodstream with Staphylococcus aureus. A pigtail catheter placed on [**2144-4-28**] was discontinued after repeat ultrasound interventional radiology. Though the patient continues to have some mild tenderness over the left lateral thigh and continues to have demonstration of subcutaneous fluid, this is felt to be non infectious and representative of edema. 2. NUTRITION: The patient received four days of TPN. She appeared to get mildly hypervolemic on TPN as she was also taking her own. She was also taking good po's. This was discontinued on [**2144-5-13**]. 3. PHYSICAL THERAPY: The patient was seen again by PT and OT on [**2144-5-12**]. She required maximal assists just to get out of bed. The determination was made that she was severely deconditioned and would benefit from a stay in rehabilitation. Screening is ongoing. 4. RHEUMATOLOGIC: The patient continues on low dose of maintenance prednisone for sarcoidosis. DISCHARGE CONDITION: Rehabilitation DISCHARGE STATUS: Stable DISCHARGE DIAGNOSES: 1. MSSA bacteremia secondary to left lateral thigh fluid abscess, status post drainage. 2. Cirrhosis complicated by esophageal varices. 3. Sarcoidosis 4. Multiple valvular disease, including moderate aortic stenosis and 2+ mitral regurgitation. DISCHARGE MEDICATIONS: 1. Vancomycin 1 gm q 12 hours [**5-13**] represents day 24 of a 4 to 6 week course of vancomycin 2. Colace 100 mg po bid 3. Lopressor 12.5 mg po bid 4. Prednisone 10 mg po qd 5. Spironolactone 50 mg po bid 6. Furosemide 10 mg po qd 7. Betamethasone 0.1% topical [**Hospital1 **] prn 8. Evista 60mg po qd 9. Actigall 300 mg po tid DISCHARGE FOLLOW UP: The patient will follow up with her primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], in two weeks time and with Dr. [**Last Name (STitle) 519**], her surgeon, on [**5-21**] for abdominal suture removal. DR.[**Last Name (STitle) **],[**First Name3 (LF) 4283**] 12-740 Dictated By:[**Name8 (MD) 2653**] MEDQUIST36 D: [**2144-5-13**] 08:18 T: [**2144-5-13**] 08:45 JOB#: [**Job Number 12571**] 1 1 1 R Admission Date: [**2144-5-14**] Discharge Date: [**2144-5-18**] Date of Birth: Sex: F Service: GENERAL SURGERY ADDENDUM: The patient was medically stable over this period of time with no further medical events. The patient was waiting for a rehabilitation bed while insurance issues were worked out. The plan for discharge is [**2144-5-18**] to rehabilitation. [**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. [**MD Number(1) 7551**] Dictated By:[**Name8 (MD) 4575**] MEDQUIST36 D: [**2144-5-18**] 07:54 T: [**2144-5-18**] 08:01 JOB#: [**Job Number 14353**] Name: [**Known lastname **], [**Known firstname 1873**] Unit No: [**Numeric Identifier 1874**] Admission Date: [**2144-4-19**] Discharge Date: Date of Birth: [**2082-1-26**] Sex: F ADDENDUM: HOSPITAL COURSE: 1. Left thigh abscess: The patient's left thigh abscess grew Methicillin sensitive staph aureus with similar receive Vancomycin. Her pigtail drain that was placed in her left thigh continued to drain serosanguineous drainage but with decreased amounts every day. It was flushed three times per day and she was placed in a left knee immobilizer. The plan was to re-image her left thigh probably with MRI to look at the fluid collection seen previously and if still present, to reinvolve orthopedics so that it can be decided whether point tenderness along her old scar area of her thigh. However, the patient continued to refuse MRI or any other imaging given her severe diarrhea which developed in the last few days. 2. Abdominal wound: Patient had spontaneous abdominal drainage from her lower abdomen, thought to be not infected but also upon culture grew staph aureus. On [**5-2**] the patient was taken to the OR by Dr. [**Last Name (STitle) 1180**] and closure was done of her abdominal layers with two JP drains placed draining serosanguineous fluid. This also decreased over the next two days and are ready for removal. The patient had no abdominal pain after surgery. The patient was placed on Levofloxacin on Thursday, [**4-30**], for coverage of her abdominal wound until growth of the fluid culture, however, this was discontinued on [**Last Name (LF) 228**], [**5-4**] because it was not necessary anymore and her cultures grew Vancomycin sensitive organisms. 3. GI: The patient developed severe diarrhea on [**First Name3 (LF) 228**], [**5-4**]. She was also complaining of chills. White blood cell count increased at that point to 15 and she had a low grade temperature. It was thought that her diarrhea may be secondary to Clostridium difficile infection despite three negative toxin assays, so she was started empirically on Flagyl 500 mg po tid and given Kaopectate. Her diarrhea continued for the next three days until she received a dose of immodium following a KUB study at the bedside that showed no evidence of toxic megacolon. Her Levofloxacin was discontinued on [**5-4**], and thought possibly to be related to the diarrhea. Nutrition consult was requested and TPN may be initiated. The patient made npo. 3. Anemia: Patient with guaiac positive stools. Hematocrit was followed closely, at times [**Hospital1 **] and she did receive two units of packed red blood cells on [**5-1**] as well as on [**5-6**]. 4. Decreased urine output: Was reported to have decreased output on the night between [**5-5**] and [**5-6**], likely prerenal secondary to her severe diarrhea. Urinalysis and urine culture were checked and she was continued on IV fluids with potassium repletion. [**First Name11 (Name Pattern1) 970**] [**Last Name (NamePattern4) 971**], M.D. [**MD Number(1) 972**] Dictated By:[**Last Name (NamePattern1) 1875**] MEDQUIST36 D: [**2144-5-6**] 20:12 T: [**2144-5-6**] 20:29 JOB#: [**Job Number 1876**]

[ "998.59", "038.11", "518.0", "998.13", "682.6", "396.3", "276.2", "584.9", "599.0" ]

icd9cm

[ [ [] ] ]

[ "99.15", "86.04", "54.0", "86.22", "38.93" ]

icd9pcs

[ [ [] ] ]

16349, 16392

16413, 16663

16686, 17036

2618, 2826

18468, 21469

15978, 16327

17048, 18451

2924, 5279

153, 1967

1989, 2591

2844, 2900

56,502

180,332

42521

Discharge summary

report

Admission Date: [**2119-6-12**] Discharge Date: [**2119-6-13**] Date of Birth: [**2080-2-24**] Sex: F Service: MEDICINE Allergies: Wellbutrin / High Dose Steroids Attending:[**First Name3 (LF) 3326**] Chief Complaint: post EGD bronchospasm Major Surgical or Invasive Procedure: EGD intubation History of Present Illness: Ms. [**Known lastname 92011**] is a 39 year old woman with a significant PMH of TBM, asthma and presumed hypersensitivity pneumonitis requiring multiple past intubations, who presents intubated from the GI suite following bronchospasm following outpatient EGD procedure. Ms. [**Known lastname 92011**] was recently admitted from [**6-5**] to [**6-8**] for shortness of breath, when CT neck revealed new diagnosis of severe TBM. She is followed extensively for her pulmonary disease with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **]. She underwent elective EGD today to evaluate possible role of GERD in her newly diagnosied TBM with plan for potential airway stent to be placed in the near future. Following EGD, where she received only propofol for sedation, she developed severe intractable coughing and tachypnea. She initially received 1 treatment of albuterol and ipratroprium nebulizer without relief. Further treatments with nebulized lidocaine, continous lidocaine, and heliox were not successful. She received 4mg IV midazolam for severe anxiety. She did not tolerate BiPAP and she was subsequently intubated and sedated with propofol and midazolam and fentanyl boluses. She was transferred to the [**Hospital Unit Name 153**] for further management of presumed bronchospasm. On arrival to the MICU, patient's VS were 125 132/76, RR 21, O2 95% on PSV 8/5 with 50%FiO2. Reveiw of systems was unable to be obtained as patient was intubated and sedated. Past Medical History: 1. Asthma, multiple prior intubations 2. Tracheobronchomalacia, diagnosed on CT trachea [**2119-6-7**] 3. Possible inflammatory lung process such as hypersensitivity pneumonitis. (Had open lung biopsy in [**10/2118**] which was reviewed by [**Hospital1 18**] pathologists and showed undefined inflammatory process superimposed on normal lung,and poorly formed granulomas that seemed to be consistent with a hypersensitivity pneumonitis). Most recent CT trachea showed no evidence of hypersensitity pneumonitis. 4. History of positive PPD (the patient reports that it was borderline degree of induration for many years and has not received INH. She states the reason for no INH was a clear CXR 5. PCOS 6. Postpartum depression requiring psychiatric hospitalization 7. Multiple miscarriages requiring D and C 8. Status post multiple colposcopies and cervical LEEP procedure 9. Meningitis in [**2118-12-11**] 10. Status post tonsillectomy Social History: The patient is divorced and lives in a home with her 3 children. Works as a business analyst. Occasional etoh. Prior 1-1/2 pack per day smoking for 15 years, quit in [**2106**]. High likelihood of asbestos exposure according to the patient as she was a volunteer firefighter in the past. History of positive PPD. Has a dog, cat, a lizard and a hamster at home. Family History: Father alcoholic. [**Name2 (NI) **] family history of lung disease or DVTs Physical Exam: Physical Exam: Vitals: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi, no stridor Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Pertinent Results: [**6-12**] CXR Normal Brief Hospital Course: Ms. [**Known lastname 92011**] is a 39 year old woman with a significant PMH of TBM, asthma and presumed hypersensitivity pneumonitis requiring multiple past intubations, who presents intubated from the GI suite following bronchospasm following outpatient EGD procedure. # Respiratory failure: Patient intubated in the setting of intractable coughing and tachypnea following EGD. Etiology likely vocal cord dysfunction vs. possible post procedure bronchospasm complicated by severe TBM. Wheezing post-intubation has improved which goes against bronchospasm. Pt extubated the same day as being intubated given immediate improvement after intubation; consistent with a diagnosis of vocal cord dysfunction rather than severe bronhospasm. S/p extubation, patient was continually coughing, which was believed to be [**1-12**] to intermittent vocal cord dysfunction. Her coughing improved with ativan. # Asthma: Home regimen includes symbicort, ciclenoside, terbuliline, albuterol and ipratroprium. Patient also may have some element of undlerlying inflammatory pulmonary disease such as hypersensitivity pneumonitis, although this diagnosis is unclear. Based on how quickly she improved once intubated, asthma exacerbation seemed to be an unlikely cause. Therefore, she steroids were held. Of note, before intubation pt reported she has h/o steroid induced psychosis. She was continued on her home meds. # TBM: Likely exacerbating respiratory symptoms. Patient is planned for tracheal stent placement in the future. Will consult IP to assess whether this should be done sooner. . # Depression: continue home citalopram Medications on Admission: - Albuterol Inhaler [**12-12**] PUFF IH Q4-6HRS PRN shortness of breath or wheeze - Citalopram 10 mg PO DAILY - Terbutaline Sulfate 5 mg PO BID - traZODONE 75 mg PO QHS - Methotrexate 15 mg PO QFRI - ciclesonide, unknown dose - ipratropium-albuterol PRN, Unknown dosages. - Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation INHALATION [**Hospital1 **] Discharge Medications: 1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: [**12-12**] puff Inhalation every 4-6 hours as needed for SOB/wheeze. 2. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig: One (1) puff Inhalation every six (6) hours as needed for SOB/Wheeze. 3. citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. terbutaline 5 mg Tablet Sig: One (1) Tablet PO twice a day. 5. trazodone 50 mg Tablet Sig: 1.5 Tablets PO at bedtime. 6. methotrexate sodium 15 mg Tablet Sig: One (1) Tablet PO once a week: Fridays. 7. ciclesonide 80 mcg/actuation HFA Aerosol Inhaler Sig: One (1) Inhalation twice a day. 8. Symbicort 160-4.5 mcg/actuation HFA Aerosol Inhaler Sig: One (1) Inhalation twice a day. Discharge Disposition: Home Discharge Diagnosis: Bronchospasm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [**Known lastname 92011**], You were admitted to the ICU and required intubation after having breathing difficulties. We think that this is likely due to problems with your vocal cords rather than your asthma since it improved so quickly. You should discuss your medications with your physicians at the next visit. In particular, it is likely that methotrexate and terbutaline can be tapered or stopped. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] Address: [**Location (un) 92012**], EAST [**Hospital1 **],[**Numeric Identifier 82263**] Phone: [**Telephone/Fax (1) 92013**] *We have placed a call to your primary care provider but was unable to reach someone directly. Please give the office a call to book a follow up appointment for your hospitalization. It is recommended you be seen within 1 week of discharge. Department: RADIOLOGY When: TUESDAY [**2119-6-20**] at 9:00 AM With: CAT SCAN [**Telephone/Fax (1) 590**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PFT When: TUESDAY [**2119-6-20**] at 10:00 AM Department: PULMONARY FUNCTION LAB When: TUESDAY [**2119-6-20**] at 10:00 AM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) [**Location (un) 3971**] Campus: EAST Best Parking: Main Garage

[ "517.8", "478.5", "519.19", "300.00", "493.90", "135", "518.81", "V15.82" ]

icd9cm

[ [ [] ] ]

[ "45.16", "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

6783, 6789

4003, 5629

314, 330

6845, 6845

3957, 3980

7429, 8456

3199, 3275

6043, 6760

6810, 6824

5655, 6020

6995, 7406

3305, 3938

253, 276

358, 1842

6860, 6971

1864, 2804

2820, 3183

20,318

153,983

13119

Discharge summary

report

Admission Date: [**2158-1-16**] Discharge Date: [**2158-2-21**] Date of Birth: [**2086-2-25**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Coronary artery disease and chronicatrial fibrillation, unstable angina. Bladder neck contracture, status post radical prostatectomy. Pericardial effusion with suspected pericardial tamponade. Major Surgical or Invasive Procedure: [**1-18**] Coronary artery bypass grafting times five with the left internal mammary coronary artery grafted to the left anterior descending coronary artery and reversed saphenous vein graft to the left ventricular branch, posterior descending branch of the right coronary, diagonal branch, and first marginal branch. [**1-18**] Flexible cystoscopy and urethral dilatation with complex Foley catheter placement. [**1-23**] Emergent pericardial exploration with evacuation of pericardial fluid and hematoma. History of Present Illness: 71 y/o gentleman with coronary artery disease s/p MI presented to OSH with intermittent L arm pain for 2-3 weeks. He did not have EKG changes or cardiac enzyme elevation. He was transferred to [**Hospital1 18**] where a cardiac cath showed 3 vessel disease. He agreed to undergo coronary artery bypass surgery with Dr. [**Last Name (STitle) **]. Past Medical History: CAD, s/p MI [**2143**], angioplasties in '[**43**], '[**45**], '[**46**], '[**47**] CHF, chronic afib mild CRI HTN DM 2 peripheral neuropathy prostate cancer s/p XRT '[**42**] skin cancer, s/p multiple excisions anxiety, depression restless leg syndrome gout ingiunal hernia repair s/p cardiac arrest [**2152**] (hyperkalemia) Social History: Lives in [**Hospital1 392**] with wife, retired, drives himself, quit smoking more than 40 years ago (<20PPY hx), no ETOH Family History: Mother died of "CAD" in [**2137**] Physical Exam: VS 98.2 95.2 114/65 87 AF RR 28 95% 2L NC NAD, follows commands, moves all extremities, alert [**First Name9 (NamePattern2) 40056**] [**Last Name (un) **], B CTA Abd soft, NT/ND, BS + B LE WWP, no edema Pertinent Results: [**2158-2-21**] 03:46AM BLOOD WBC-10.9 RBC-3.17* Hgb-10.2* Hct-31.6* MCV-100* MCH-32.2* MCHC-32.3 RDW-18.3* Plt Ct-120* [**2158-2-21**] 03:46AM BLOOD Plt Ct-120* [**2158-2-21**] 03:46AM BLOOD PT-15.4* PTT-32.4 INR(PT)-1.5 [**2158-2-20**] Title: BEDSIDE SWALLOW FOLLOW UP Pt seen for follow up re: swallowing. Pt was seen for video swallow eval on [**2158-2-17**], and was cleared for p.o.'s of nectar thick liquids, pureed solids, meds whole in puree, alternate b/t liquids and solids, and no straws (impulsive). By chart review and RN report, pt has been tolerating this recommended diet well without overt s/s aspiration. He still has an NG tube in place. I gave him [**4-14**] cup of custard and about 2 ounces of nectar thick water by cup with one episode of cough/throat clear, but overall felt to tolerate this modified consistency well. Continue diet of nectar thick liquids and pureed solids as outlined above. Brief Hospital Course: After admission to [**Hospital1 18**], Mr. [**Known lastname 2523**] [**Last Name (Titles) 1834**] a cardiac catheterization study by the cardiology service on [**2158-1-17**]. This showed 1. Three vessel coronary artery disease 2. Normal ventricular function. COMMENTS: 1. Selective coronary angiography revealed a right dominant circulation with three vessel coronary artery disease. The LMCA did not have any angiographically apparent CAD. The LAD had a 90% ostial stenosis and serial 70% stenoses in the proximal and mid segments. The LCx had a 60% stenosis in a large OM1 branch. The RCA had a 90% proximal stenosis and a 60% mid-vessel stenosis. 2. Left ventriculography revealed an ejection fraction of 45%, there was no evidence of mitral regurgitation. 3. Limited hemodynamics revealed significant systemic hypertension. The LVEDP was normal. On the next day, he [**Date Range 1834**] following procedure in the operating room: Coronary artery bypass grafting times five with the left internal mammary coronary artery grafted to the left anterior descending coronary artery and reversed saphenous vein graft to the left ventricular branch, posterior descending branch of the right coronary, diagonal branch, and first marginal branch. A urology consult was obtained preop since it was impossible to place a Foley catheter. They found bladder neck contracture s/p radical prostatectomy and performed a flexible cystoscopy with urethral dilatation complex placement of a 6 French [**Last Name (un) 40057**] tip Foley catheter over a wire. Postoperatively, he was admitted to the CSRU intubated and on pressors. His cardiac index ranged just above 2 and was supported on milrinone. His immediate postoperative course was challenging because of a history of chronic atrial fibrillation in the presence of severe diastolic dysfunction and ventricular hypertrophy. The patient had a transient elevation in his creatinine and was maintained on Inotropes and was doing well. He was started on a heparin drip for his chrinic a fib. In the morning of [**2158-1-23**], he had good cardiac output and indices, was making good urine and his Swan Ganz catheter was discontinued. A little bit later that day, he had a decrease in his blood pressure and urine output. A Swan Ganz catheter was promptly reintroduced and showed marginal hemodynamics. A stat transesophageal echocardiogram was obtained that showed a large pericardial effusion that was not there a couple of days earlier. It was decided to take him back to the operating room for exploration and evacuation of what appeared to be a good size effusion with fibrinous strands and clots. On [**2159-1-24**] it was noted that he did not follow commands. A head CT and neurology consult was obtained. The CT was negative for hemorrhagic stroke and showed just chronic changes. His mental status improved over the next days and he soon could be extubated. His nutrition was optimized using tube feedings via a [**Date Range 40056**] catheter. However, he remained in the intensive care unit for aggressive pulmonary toilet and mild confusion with intermittent agitation. His home antidepresant medication was restarted and his mental status improved. Bilateral pulmonary effusions were tapped with consecutive improvement of his respiratory status. He received physical therapy with special intensity on his R arm where he developped a large hematoma after an arterial blood gas draw from his brachial artery. A Duplex U/S excluded a pseudoaneurysm. The hematoma was resolving and the mechanical function of his left arm improving. He failed several (video) swallow evaluation but finally passed his exam on [**2158-2-17**]. He was allowed to take po with consistency of pureed solids, nectar thick liquids, po meds may be given whole with thick liquids. He did well with this po diet in addition to his tube feedings. At discharge, he is in a good condition with stable and improving respiratory as well as nutritional parameters. His incisions were well healed without sign of infection. Medications on Admission: Coumadin 2.5mg qd Digoxin 0.125 qd Allopurinol 100 qd Lasix 20mg qd KCL 60 meq qd Amitriptyline 25mg qd Procardia 30mg qd Indural 40mg [**Hospital1 **] Neurontin 100mg [**Hospital1 **] Lovenox 60mg [**Hospital1 **] Darvocet 4 pils qhs Klonopin 0.5mg q6h Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 4. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 5. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 6. Albuterol Sulfate 0.083 % Solution Sig: [**2-12**] Inhalation Q6H (every 6 hours) as needed. 7. Labetalol HCl 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. Amitriptyline HCl 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. Potassium Chloride 20 mEq Packet Sig: Two (2) Packet PO PRN (as needed) as needed for K < 4.0. 12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Four (4) Capsule, Sustained Release PO DAILY (Daily). 13. Warfarin Sodium 1 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 14. Digoxin 250 mcg/mL Solution Sig: One (1) Injection EVERY OTHER DAY (Every Other Day). Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Coronary artery disease and chronic atrial fibrillation, unstable angina. Discharge Condition: Good. Discharge Instructions: Continue current medications. Physical and pulmonary rehab. Advance po as tolerated. Followup Instructions: F/u with Dr. [**Last Name (STitle) **], please call his office for appointment. Completed by:[**2158-2-21**]

[ "596.0", "423.9", "250.00", "511.9", "998.12", "997.3", "997.1", "427.31", "401.9", "411.1", "414.01" ]

icd9cm

[ [ [] ] ]

[ "36.15", "00.13", "36.14", "57.32", "58.6", "96.72", "34.91", "88.56", "88.53", "37.22", "39.61", "37.12" ]

icd9pcs

[ [ [] ] ]

8759, 8831

3132, 7175

515, 1023

8949, 8956

2182, 3109

9089, 9200

1903, 1939

7479, 8736

8852, 8928

7201, 7456

8980, 9066

1954, 2163

282, 477

1051, 1398

1420, 1748

1764, 1887

23,782

193,167

19353+19384

Discharge summary

report+report

Admission Date: [**2169-12-29**] Discharge Date: [**2170-1-11**] Service: CARDIOTHORACIC HISTORY OF PRESENT ILLNESS: This is an 86 year-old woman with known coronary artery disease status post myocardial infarction times two in [**2156**] and [**2158**] who reports having occasional chest pain and pressure on exertion and at rest over the past several years, always relieved by sublingual nitroglycerin and associated with diaphoresis. Her pain began to worsen over the holidays causing her to visit her primary care physician on [**12-28**] following an episode of substernal chest pain, which lasted ten minutes and was also relieved by two sublingual nitroglycerins at that time. It was also associated with blurry vision and diaphoresis. Her primary care physician referred her to [**Hospital3 **] where she ruled out for an myocardial infarction and had a stress test that was positive. Following positive stress test the patient was referred to [**Hospital1 69**] for cardiac catheterization. Catheterization was performed on [**12-29**] and revealed left main and three vessel disease. Following catheterization the patient was referred to be evaluated for coronary artery bypass grafting. PAST MEDICAL HISTORY: 1. Coronary artery disease status post myocardial infarction times two in [**2156**] and [**2158**]. 2. Hypertension. 3. Hypercholesterolemia. 4. Anemia. 5. Hiatal hernia. 6. Lower back pain causing left lower leg numbness. 7. Gastroesophageal reflux disease. 8. Bilateral breast fibroids. PAST SURGICAL HISTORY: 1. Hysterectomy. 2. Lumpectomies bilaterally of the breasts. 3. Appendectomy. 4. Tonsillectomy. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Metoprolol 50 mg b.i.d. 2. Norvasc 10 mg q.d. 3. Lipitor 10 mg q.d. 4. Aspirin 81 mg q.d. 5. Vitamin E. 6. Multivitamin. 7. Diovan prn for lower extremity pain. SOCIAL HISTORY: She lives with her husband in [**Name (NI) 5110**]. She is a retired secretary. Remote tobacco history. Quit 40 years ago after having smoked one pack per day times ten years. Alcohol is social use. FAMILY HISTORY: Noncontributory. LABORATORY DATA: White blood cell count 9.3, hematocrit 32.1, platelets 194, sodium 139, potassium 3.4, chloride 105, CO2 25, BUN 25, creatinine 1.2, glucose 119, ALT 26, AST 34, alkaline phosphatase 73, amylase 73, total bilirubin 0.3 and albumin is 3.3. At catheterization the patient was found to be left dominant with 70% left main occlusion, left anterior descending coronary artery had complex calcified 90% stenosis mid vessel and 90% at the origin of her major diagonal branch. Her circumflex had a 60% stenosis at obtuse marginal one and 80% stenosis at obtuse marginal two and an 80% stenosis at obtuse marginal three. Right coronary artery was small with a 70% proximal to mid stenosis. She had no left ventriculogram done during the catheterization. REVIEW OF SYSTEMS: The patient denies palpitations, shortness of breath, upper respiratory infections, cough or hemoptysis. The patient with known gastroesophageal reflux disease with occasional constipation. No ulcer disease. No melena. No hematochezia. No hematuria or urinary tract infections. No kidney disease. No diabetes. No strokes. No thyroid dysfunctions. No vascular problems. [**Name (NI) **] cerebrovascular accidents or psychiatric disorders. PHYSICAL EXAMINATION: General, alert and oriented woman in no acute distress. HEENT pupils are equal, round and reactive to light. Extraocular movements intact. Normal buccal mucosa. Partial dentures upper and lower. Neck si supple with no JVD and no lymphadenopathy or thyromegaly. No bruits. Chest is clear to auscultation bilaterally. Cardiovascular regular rate and rhythm. S1 and S2. No murmurs. Abdomen is soft, nontender, nondistended. Normoactive bowel sounds. Well healed mid abdominal incision scar. Extremities are warm with no edema or cyanosis and no varicosities. Pulses carotid 2+ bilaterally, radial 2+ bilaterally, femoral 2+ on the left, right has an indwelling catheter, dorsalis pedis pulse and posterior tibial pulse both 2+ bilaterally. Neurologically alert and oriented times three. Cranial nerves II through XII are grossly intact. Left leg with mild numbness. HOSPITAL COURSE: Over the next several days the patient was followed by the medical service. During that time she had a neurology consult and echocardiogram to assess her left ventricular function and carotid duplex showed a 40 to 59% stenoses bilaterally. Cardiac echocardiogram showed an ejection fraction of greater then 55%, mild to moderate aortic regurgitation and mild to moderate mitral regurgitation. The MRI showed no evidence of acute infarct with mild to moderate changes of brain atrophy and medial temporal atrophy. Normal flow signals within the arteries of the anterior and posterior circulation. Following this preoperative workup the patient was brought to the Operating Room where she underwent coronary artery bypass graft times three. Please see the operative report for full details. In summary, the patient had a coronary artery bypass graft times three with a left internal mammary coronary artery to the left anterior descending coronary artery, saphenous vein graft to the PLD and saphenous vein graft to obtuse marginal one. Her bypass time was 95 minutes and her cross clamp time was 69 minutes. She tolerated the procedure well and was transferred from the Operating Room to the Cardiothoracic Intensive Care Unit. The patient did well in the immediate postoperative period. Hemodynamically she remained stable. She was on and off of neo-synephrine and nitroglycerin intravenous infusions to maintain hemodynamic control following reversal from her anesthesia. She was weaned from the ventilator, however, showed a mild respiratory acidosis and was therefore kept intubated. On postoperative day one her acidosis had resolved and she was successfully extubated. She did, however, remain in the Cardiothoracic Intensive Care Unit, because following extubation the patient experienced some rapid atrial fibrillation at which point she was loaded with Amiodarone. On postoperative day two the patient remained in atrial fibrillation. She remained hemodynamically stable. Her Swans-Ganz catheter was removed. Her chest tubes were also removed, but she was kept in the Intensive Care Unit, because of her atrial fibrillation and poor urine output requiring a renal consultation. On postoperative day three the patient's overall condition continued to slowly improve. Her Amiodarone was changed to oral dosing. On postoperative day four she was transferred to the floor for continuing postoperative care and cardiac rehabilitation. Once on the floor the patient continued to show slow progress. Her atrial fibrillation had converted to normal sinus rhythm. Hemodynamically she remained stable. Her activity level was slowly increased with the assistance of the nursing staff and the physical therapy staff. On postoperative day nine it was decided that the patient would be stable and ready to be transferred to rehabilitation on the following day. At the time of this dictation the patient's physical examination is vital signs temperature 97.3, heart rate 60 sinus rhythm, blood pressure 137/40, respiratory rate 20, O2 sat 96% on room air. Weight preoperatively 65 kilos. At discharge 76 kilos. Laboratory data white blood cell count 9.5, hematocrit 26.9, platelets 270, sodium 137, potassium 4.5, chloride 100, CO2 30, BUN 27, creatinine 1.5, glucose 108, PT 17.2, PTT 60.2, INR 2.0. General no acute distress. Neurological alert and oriented times three, moves all extremities. Follows commands. Respirations clear to auscultation bilaterally. Cardiac regular rate and rhythm. S1 and S2. Sternum is stable. Incision with Steri-Strips. Open to air clean and dry. Abdomen soft, nontender, nondistended. Positive bowel sounds. Extremities are warm and well perfuse with 2+ edema bilaterally. Left lower extremity incision with Steri-Strips open to air, clean and dry. DISCHARGE MEDICATIONS: 1. Colace 100 mg b.i.d. 2. Prilosec 40 mg q.d. 3. Lasix 40 mg q.d. times two weeks. 4. Amlodipine 10 mg q.d. 5. Enteric coated aspirin 81 mg q.d. 6. Potassium chloride 20 milliequivalents q.d. times two weeks. 7. Amiodarone 400 mg q.d. times two weeks and then 200 mg q.d. 8. Metoprolol 25 mg b.i.d. 9. Coumadin 3 mg q.h.s. titrate Coumadin dose to keep INR 1.5 to 2.0. 10. Percocet 5/325 one to two tabs q 4 hours prn. CONDITION ON DISCHARGE: Good. DISCHARGE DIAGNOSES: 1. Coronary artery disease status post coronary artery bypass grafting times three with left internal mammary coronary artery to the left anterior descending coronary artery, saphenous vein graft to the PDL and saphenous vein graft to the obtuse marginal. 2. Hypertension. 3. Hypercholesterolemia. 4. Back problems. 5. [**Name2 (NI) 52659**]l reflux disease. 6. Bilateral breast fibroids. DI[**Last Name (STitle) 408**]E STATUS: The patient is to be discharged to rehabilitation. She is to have follow up with Dr. [**First Name (STitle) **] in two to three weeks and with Dr. [**Last Name (Prefixes) **] in one month. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 415**] MEDQUIST36 D: [**2170-1-11**] 11:10 T: [**2170-1-11**] 11:19 JOB#: [**Job Number 52660**] Admission Date: [**2169-12-29**] Discharge Date: [**2170-1-11**] Service: CARDIOTHORACIC CHIEF COMPLAINT: A woman with known CAD, status post MI in [**2156**] and [**2158**], with new onset substernal chest pain that occurs while walking down stairs, relieved with sublingual Nitroglycerin x 2. HISTORY OF PRESENT ILLNESS: As stated earlier, an 86-year-old woman, with a history of MI in [**2156**] and [**2158**], as well as hypertension, presented to [**Hospital3 **] on [**12-28**] after 10 minutes of substernal chest pain. The pain occurred while she was walking. It was relieved with Nitroglycerin. It was accompanied by blurry vision which resolved shortly after the chest pain resolved, also associated with diaphoresis, no radiation. At [**Hospital3 9683**], the patient ruled out for an MI. She had an ETT that showed lateral ischemia and was transferred to [**Hospital Ward Name 26168**] [**First Name (Titles) **] [**Last Name (Titles) **] for cardiac catheterization. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 415**] MEDQUIST36 D: [**2170-1-11**] 10:50 T: [**2170-1-11**] 10:59 JOB#: [**Job Number 52715**]

[ "518.0", "584.9", "414.01", "997.5", "997.1", "433.10", "997.3", "276.2", "276.5" ]

icd9cm

[ [ [] ] ]

[ "39.61", "88.57", "89.68", "88.41", "37.22", "36.12", "89.64", "99.04", "38.93", "36.15" ]

icd9pcs

[ [ [] ] ]

2124, 2910

8621, 9603

8137, 8568

4299, 8114

1562, 1886

3402, 4281

2930, 3379

9621, 9811

9840, 10753

1240, 1539

1903, 2107

8593, 8600

6,451

183,196

11316

Discharge summary

report

Admission Date: [**2164-12-6**] Discharge Date: [**2164-12-10**] Date of Birth: [**2099-3-6**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 65 year-old male who comes in with a history of abdominal aortic aneurysm repair and four vessel coronary artery bypass graft on [**8-27**] who presents to the [**Hospital1 69**] Emergency Department with abdominal pain and fevers. Mr. [**Known lastname 36303**] was in his usual state of health until he presented to [**Hospital3 3583**] four days prior for abdominal pain and fevers. He was given the diagnosis of possible acute cholecystitis. He was treated medical as operative intervention was deferred since the patient had abdominal aortic aneurysm repair as well as coronary artery bypass graft four months prior and a myocardial infarction. The patient was treated medically with Ticarcillin while at [**Hospital3 3583**] and improved then was discharged home with morning of [**12-5**] on Ciprofloxacin 500 b.i.d. On the night of [**2164-12-6**] the patient spiked a temperature of 101.2 and called his primary care physician. [**Name10 (NameIs) **] was urged to come to the Emergency Room. On arrival to the Emergency Department the patient had a temperature of 96.9, heart rate of 85 and a blood pressure of 54/35. Respiratory rate 24. He was 93% on 2 liters of oxygen. Blood pressure normally ranges 100 to 120 systolic for this patient. The patient remained alert and oriented and had palpable radial pulses on arrival in the Emergency Department. He received a total of 5 liters of normal saline. He had blood cultures done. He was started on Ampicillin, Gentamycin and Clindamycin antibiotics. A noncontrast CT of his abdomen and pelvis showed a 5 by 3.3 cm encapsulated air fluid collection in his posterior right costophrenic angle. The patient also had peripheral infiltrate in both lower lobes, question of acute cholecystitis. The patient had no leak from his abdominal aortic aneurysm repair. His right upper quadrant ultrasound showed gallbladder wall thickening and minimal cholestatic fluid with gallstones present. The patient had a right IJ line placed and was transferred to the MICU. On arrival to the floor his temperature was 97.6, heart rate 113. Blood pressure 135/56. Respiratory rate 18. 96% on 5 liters oxygen nasal cannula. The patient's blood pressure remained stable on pressors. He was maintained on Dopamine intravenous. PAST MEDICAL HISTORY: Abdominal aortic aneurysm repair on [**2164-8-28**]. The patient was discharged on [**2164-9-1**] and underwent resection with a graft. The patient had a myocardial infarction times two. He had an myocardial infarction on [**2164-9-10**]. Angioplasty showed three vessel disease. He had a coronary artery bypass graft on [**9-13**]. The patient has also peripheral vascular disease, diabetes type 2, peptic ulcer disease, gastroesophageal reflux disease, increased cholesterol, status post appendectomy, status post right knee surgery and tonsillectomy. MEDICATIONS: Zestril 5 mg twice a day, Plavix 75 mg once a day, aspirin 81 mg once a day, Combivent three puffs four times a day, Lasix 40 mg once a day, Digoxin .125 once a day, Lipitor 20 mg once a day, Glucophage 1 mg twice a day, Clonazepam .5 mg q.h.s., Glyburide 2.5 mg once a day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives with his second wife and kids in [**Name (NI) 3320**]. The patient has a one to two pack per day history forty years total. No alcohol or other drug use. He has three children. FAMILY HISTORY: Mother and father died of aneurysms. Father also had a stroke. PHYSICAL EXAMINATION: Temperature on admission 96.5. Heart rate 92. Blood pressure 68/41. Respiratory rate 24. 93% O2 sat on 2 liters. General, awake, alert and in no acute distress. The patient is a middle aged male in no acute distress. HEENT showed pupils are equal, round, and reactive to light and accommodation. Extraocular movements intact. Neck supple. Mucous membranes are dry. No lymphadenopathy. Chest clear to auscultation bilaterally. Cor regular rate and rhythm. Abdomen soft. Positive bowel sounds. Right upper quadrant tenderness. No [**Doctor Last Name 515**] sign. Positive scar healing on thorax and abdomen. Extremity no edema. Neurological alert and oriented times three. Cranial nerves II through X intact. LABORATORY: White blood cell count 12.3, hematocrit 28.9, platelets 231, 79 neutrophils, 8 bands, 12 lymphocytes, 4 monocytes. PT 14.1, PTT 34.3, INR 1.4. Urinalysis negative. Few bacteria. Chem 7 sodium 136, potassium 4, chloride 99, bicarb 22, BUN 42, creatinine 2.1, glucose 68, ALT 18, AST 19, CK 30, alkaline phosphatase 90, amylase 54, total bilirubin .7, lipase 19, calcium 8.7, magnesium 1.4, potassium 2.7, digoxin level 0.7, lactate 1.1, free calcium 0.93. Urine electrolytes, urine BUN 43, urine creatinine 67, urine sodium 73 with a FENA level of 1.3%. Blood cultures pending. Urine cultures pending. A right upper quadrant ultrasound on admission showed large gallstones and gallbladder and mild gallbladder wall thickening, mild pericolic fluid. No air in gallbladder. CAT scan of the abdomen showed 5 by 3.3 cm encapsulated fluid collection with air located in the posterior right costophrenic angle concerning for empyema. Electrocardiogram showed normal sinus rhythm, mild tachycardia to 103, question right bundle branch block, Q waves in 2, 3 and AVF. T wave inversions V1 through V4. No change compared to with [**2164-10-27**]. IMPRESSION/PLAN: The patient is a 65 year-old male with a history of abdominal aortic aneurysm repair and coronary artery bypass graft recently now presents with right upper quadrant pain and cholecystitis with a right pleural based empyema now septic. 1. Infectious disease: Patient with mildly elevated white blood cell count. Temperature spikes more likely source of gallbladder versus right pleural fluid collection. Question cholecystitis cause of fluid collection in right lower lobe, however, the patient is hypotensive and requires fluid, intravenous hydration. Will continue intravenous antibiotics Ampicillin, change to Levofloxacin and Flagyl for gut phlora, gram negatives and anaerobes including enterococci. Check blood cultures. 2. Cardiac: Patient with a history of coronary artery disease. No electrocardiogram changes. Will follow. Patient with no history of congestive heart failure. The patient is placed on Digoxin and will be closely monitored. Will consider an echocardiogram. Reflexes no issues. 3. Pulmonary: Question pneumonia with empyema. The patient with right lower lobe fluid collection. Will have CT guided drainage of fluid pocket after surgical issues resolved. 4. Gastrointestinal: Cholecystitis. Will evaluate and gastrointestinal consult. General surgery consult. Gallbladder reimaged likely has inflammation times five days. Appreciate general surgery input. 5. Renal: Increased creatinine probably prerenal from hypovolemia and hypotension. Prerenal, will check urine, electrolytes and FENA. FENA 1.3 suggests not prerenal, question ATN from hypovolemia and hypotension. Will continue to check urine. 6. Metabolic acidosis: Lactate acid level 1.1, however, probably from uremia. Will check acetone with a history of diabetes. 7. Endocrine: Diabetes, hold oral hypoglycemics and do finger stick checks. 8. Hematology: Continue intravenous fluids. 9. FEN, replete electrolytes intravenous. Prophylaxis with Zantac. 10. Full code. Communicating with his wife. HOSPITAL COURSE: The patient had central line, right IJ line placed for fluid. Surgery evaluated the patient. The patient is not a surgical candidate. Only four months out status post his surgery and myocardial infarction. The patient continued on antibiotics. The patient's Dopamine drip was discontinued. Blood pressure has remained stable. The patient with fluid collection in right lung base, which was drained per IR with a pigtail in place. The patient had placement of an 8 French pigtail catheter into small loculated right hydropneumothorax. While in the MICU the patient received 2 units of packed red blood cells and his hematocrit went up to 28.9. The patient also had electrolyte repletion of calcium and magnesium. The patient further states that some time ago he had bronchitis, which may be the reason for his empyema/versus his surgery. The patient's pleural effusion, pH of 7.0, LDH 3126, glucose 66, total protein 52. Pleural effusion also showed 50,000 white blood cells, 29,000 red blood cells, 84% polys, gram stain showed 4+ polys. No microorganisms. Culture was negative. Blood culture time two is still pending. Urine culture was negative. The patient had 40 cc of seropurulent material drained from the small collection in his right lower lobe. The patient's CT before discharge on [**2164-12-8**] showed no significant change in the basilar air space disease and with some continued mediastinal lymphadenopathy. No significant change in the size of his pleural fluid collection. Drain/pigtail was removed per the patient spontaneously pulling it out by accident. The patient did have an echocardiogram, which showed an EF of 55% with moderate global right ventricle free wall hypokinesis. No AI. Mild tricuspid regurgitation and mild mitral regurgitation. The was transferred to the medical floor. The patient is feeling well. "Best I felt in years." The patient is status post coronary artery bypass graft. Will continue aspirin, Lipitor. Will restart his Zestril as he was on at home. The patient's blood pressure is stable as well as the patient's BUN and creatinine is stable on discharge at 13 BUN and creatinine 0.9. The patient will continue on his Digoxin. Surgery has seen the patient prior to discharge and recommends outpatient elective cholecystectomy in the future. The patient did receive one unit of packed red blood cells on the floor for a hematocrit under 30 and on discharge the patient's hematocrit was stable at 30.6. Pulmonary consult, appreciated, recommends no indication for large bore chest tube, monitor the patient on antibiotics. The patient will be discharged on Levaquin 500 mg po and Flagyl 500 mg t.i.d. orally as Ampicillin has been discontinued. The patient's C-difficile stool culture was negative. The patient's blood cultures on [**2164-12-7**] no growth to date times three days. The patient has been afebrile times three days. The patient's urinalysis and culture was negative and showed no growth. The patient will be followed up by his primary care physician. [**Name10 (NameIs) **] patient will be kept on antibiotics for one month, Levofloxacin 500 mg po q day and Flagyl 500 mg po t.i.d. The patient knows to come back if any fever or new symptoms, which would indicate an infection reoccurring. The patient will follow up with surgery in regard to his elective cholecystectomy in the future. CONDITION ON DISCHARGE: Stable and improved. DISCHARGE DIAGNOSES: 1. Sepsis. 2. Hypotension. 3. Gallstones. 4. Coronary artery disease. 5. Diabetes. 6. Peripheral vascular disease. MEDICATIONS ON DISCHARGE: Plavix 75 mg once a day, Glucophage, Lipitor 20 mg once a day, Lasix 40 mg once a day, Diabeta twice a day, Zestril 5 mg twice a day, Levofloxacin 500 mg po q day for one month, Flagyl 500 mg t.i.d. for one month, Clonazapam .5 mg as needed. Combivent three puffs four times a day. Protonix 40 mg once a day. Digoxin .125 mg once a day, aspirin 81 mg once a day. The patient will follow up with his cardiologist and his primary care physician. [**Name10 (NameIs) **] patient needs monitoring for his blood pressure medications as well as his progress of his empyema to ensure resolution. [**First Name11 (Name Pattern1) 20**] [**Last Name (NamePattern1) 36304**], M.D. [**MD Number(1) 36305**] Dictated By:[**Last Name (NamePattern1) 4724**] MEDQUIST36 D: [**2164-12-10**] 16:40 T: [**2164-12-12**] 14:53 JOB#: [**Job Number 36306**]

[ "412", "510.9", "250.00", "038.9", "575.0", "414.01", "V45.81", "511.9" ]

icd9cm

[ [ [] ] ]

[ "54.91", "38.91", "38.93" ]

icd9pcs

[ [ [] ] ]

3604, 3669

11099, 11221

11248, 12128

7643, 11031

3692, 7625

156, 2459

2482, 3371

3388, 3587

11056, 11078

19,978

147,537

17991

Discharge summary

report

Admission Date: [**2104-1-7**] Discharge Date: [**2104-2-5**] Date of Birth: [**2038-10-3**] Sex: M Service: MEDICINE Allergies: Dilantin / Sulfa (Sulfonamides) / Unasyn Attending:[**First Name3 (LF) 18369**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: 65 y/o male with a h/o RCC (dx'd '[**85**]) s/p right nephrectomy, evidence of L renal mass since [**2100**], multiple bony mets, initially p/w path fx of L humerus in [**2100**], with recent hospitalization [**Date range (1) 25253**] for LUE cellulitis d/c'd on course of vacn/unasyn, possibly c/b drug rash, presented to [**Hospital1 18**] on [**1-12**] with dyspnea at rest x 3 days. At admission, pt denied associated CP/n/v/diaphoresis. In ED vitals: 100.8, BP 229/109, hr 106. CTA showed moderate b/l pleural effusions, multiple pulm nodules, no PE. EKG with no ischemic changes. Pt given benadryl 50 mg, lasix 20 mg, lopressor 5 mg, NTP, tylenol, unasyn 3 gmn, toprol 200 mg, lisinopril 40 mg, and 1 unit prbcs. . On the floor, pt. became progressively more dyspneic c RR 40s requiring 6 L NC to maintain normal O2 sats. Received lasix 20 IV x 1 and atrovent nebulizer treatment with good response. He was subsequently transferred to [**Hospital Unit Name 153**] for further management. . In the ICU, patient received 4 units PRBCs, with last 2 units on [**2103-1-9**]. Hct increased appropriately and was stable for past 18 hours. ICU course c/b acute renal failure, elevated troponin,congestive heart failure and increased temp to 100.9 while receiving 4th unit of PRBCs. . Upon transfer to the floor, patient denies feeling short of breath. Denies cp, n/v/lightheadness. Responding to questions appropriately. Past Medical History: Past Medical History: ONC HX: 65-year-old with renal cell carcinoma diagnosed in [**2085**], status post right nephrectomy. He did well until [**2100**] when he noticed some tingling in his left elbow. In [**2100-2-6**], he sustained a left humerus pathologic fracture. Biopsy at the time of broad-plate fixation showed metastatic clear cell carcinoma. CT at the time showed two discrete cortical masses in the left kidney upper pole mass being 3 cm in diameter, lower pole mass being 3.5 cm x 5 cm, and a sixth rib lesion. After radiation therapy to the left humerus, he received high dose IL-2 x 1 in [**2100-5-6**]. He also has received a CyberKnife treatment to his left arm mass. There had been some suggestion in [**2100-10-6**] of an increase in size of the left upper pole tumor. In [**2101-9-7**], he had minimal asymptomatic progression of the mass above the left renal vein and the expansive lesions within the sixth rib associated with a new soft tissue mass were noted. He began treatment with Avastin off protocol, starting [**2101-12-5**]. Most recently, he has had difficulty with metastatic tumor nodules in his left arm. His Avastin was stopped secondary to concerns of poor wound healing. It was also decided to hold off on radiation treatments for this reason. Since that time, he has been started on Sutent. . PMH: # metastatic renal cell cancer # hypertension secondary to Avastin and Sutent # cerebral aneurysm, resulting in lack of smell and taste # recent admit for cellulitis possibly c/b osteomyelitis Social History: 50-pack-year smoking history. Quit in [**2100**]. Drinks a few beers per night, but not as much while on Sutent. Family History: No family history of cancer. Parents died of heart disease. Physical Exam: VS: 99.9 161/74 90 96%RA 24 hr: +620 LOS:-770 Gen: fatigues appearing, in mild resp distress HEENT: PERRL, sclera-anicteric; OP-clear Neck: JVD to angle of jaw at 45 degrees; +hepatojuglar reflex CVS: s2 s2 RRR o m/r/h Chest: crackes to [**Date range (1) 5082**] on right and [**1-9**] on left with decresed BS; with prolonged expiratory phase ABd: soft, NT ND ext: no c/c/edmea neuro: alert and oriented to person and place; able to repsond appropriately to questions Pertinent Results: Labs at admission: . [**2104-1-7**] 04:32PM HGB-6.2* calcHCT-19 [**2104-1-7**] 12:50PM GLUCOSE-101 UREA N-20 CREAT-1.0 SODIUM-143 POTASSIUM-3.2* CHLORIDE-104 TOTAL CO2-28 ANION GAP-14 [**2104-1-7**] 12:50PM LD(LDH)-633* CK(CPK)-35* TOT BILI-0.7 DIR BILI-0.3 INDIR BIL-0.4 [**2104-1-7**] 12:50PM CK-MB-NotDone cTropnT-0.04* [**2104-1-7**] 12:50PM CALCIUM-8.6 PHOSPHATE-3.0 MAGNESIUM-2.0 [**2104-1-7**] 12:50PM HAPTOGLOB-<20* [**2104-1-7**] 11:40AM LACTATE-1.5 [**2104-1-7**] 11:30AM WBC-2.8*# RBC-1.64*# HGB-6.2*# HCT-17.9*# MCV-109*# MCH-37.9* MCHC-34.7 RDW-20.9* [**2104-1-7**] 11:30AM PT-15.8* PTT-39.2* INR(PT)-1.4* [**2104-1-7**] 11:30AM PLT COUNT-211 [**2104-1-7**] 11:30AM FIBRINOGE-478* [**2104-1-7**] 11:30AM RET AUT-4.8* . [**2104-1-7**] CXR Increased interstitial markings and pulmonary vascular prominence are suggestive of a new mild interstitial pulmonary edema. Persistent lytic sclerotic lesion in the right sixth rib posteriorly. . [**2104-1-7**] CTA . 1. Extremely limited study from poor contrast opacification. No evidence of central pulmonary embolism. . 2. Innumerable pulmonary nodules concerning for metastases. Destructive bony lesions as described above. Left upper pole renal cell carcinoma. Left adrenal nodule could be a metastasis. Some small liver lesions are not definitely cysts and could be metastases. . 3. Bilateral moderately large pleural effusions, right slightly greater than left. Small pericardial effusion. . 4. Emphysema. . EKG: ST@ 100 bpm, nl axis, nl intervals, no T wave inversions, ST changes . [**2104-2-5**] WBC-5.8 RBC-2.33* Hgb-7.6* Hct-22.7* Plt Ct-67*# [**2104-2-5**] Neuts-82* Bands-0 Lymphs-12* Monos-4 Eos-1 Baso-0 Atyps-1* Metas-0 Myelos-0 [**2104-2-4**] Gran Ct-5610 [**2104-2-5**] Glucose-140* UreaN-21* Creat-1.0 Na-141 K-4.4 Cl-115* HCO3-20* [**2104-2-4**] ALT-9 AST-4 LD(LDH)-100 AlkPhos-98 TotBili-0.8 [**2104-2-5**] Calcium-6.7* Phos-2.7 Mg-1.9 [**2104-1-8**] Triglyc-95 HDL-30 CHOL/HD-2.5 LDLcalc-27 [**2104-1-23**] Cortsol-20.0 [**2104-1-16**] IgM HAV-NEGATIVE [**2104-1-15**] HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-POSITIVE [**2104-1-15**] HCV Ab-NEGATIVE Brief Hospital Course: Mr. [**Known lastname 916**] is a 65 y/o male with metastatic renal carcinoma initially admitted on [**2104-1-7**] with dyspnea, hypertension, and anemia (hct of 18, found to be hemolytic). The pt had a brief admission to the [**Hospital Unit Name 153**], with elevated LFT's and ARF followed by rash, fevers, and worsening acute renal failure. The pt's course was then c/b thrombocytopenia and cholestasis and low fibrinogen, fevers, neutropenia, thrombocytopenia, increasing coags, worsening renal failure, and increasing bilirubin. He was later found to have a Pseudomonas UTI on [**1-29**] along with a new rash and sore throat. His complicated hospital course, by problem is as follows. . 1. Sore throat Pt had evidence of well-demarcated lesions in posterior oropharynx, seen first on [**2-2**]. Differential was broad. Concerns included bacterial (e.g. Group A strep), viral (CMV, HSV), and [**Female First Name (un) 564**] esophagitis. He was maintained and subsequently discharged home on Nystatin S&S. His throat lesions improved everyday and were much better by the time of discharge. . 2. Rash A new rash developed on [**12-12**], morbilliform, blanching, similar in appearance to previous rashes (he has had several during the admission). Most likely drug-related (aztreonam/meropenem/ethacrinic acid) vs. transfusion related (was transfused on [**2-1**]). He was afebrile. Per ID recommendations, aztreonam was changed to ciprofloxacin (Pseudomonas is pan-sensitive). Urine eosinophils rare positive, but normal eosinophil count in differential. He was sent home to complete a 2 wk course of ciprofloxacin. . 3. Anemia Thought to be hemolytic anemia vs. bone-marrow suppression. No evidence of bleeding (stools, other than the ones on admission, have been guaiac negative). Presented with hemolytic anemia (likely hapten-mediated given beta-lactam exposure), but no evidence of hemolysis (normal haptoglobin, normalizing LDH and bilirubins) in recent days. Has tolerated transfusions well on [**2-20**], and [**2-1**] (did not receive pre-transfusion fluids during last transfusion). High dose Epogen was also started during this admission. Subsequently, his HCT remained stable. . 4. UTI Urine culture positive on [**1-29**] for Pseudomonas (pan-sensitive). Initially on meropenem and cipro (with vanco and Flagyl, given febrile and neutropenic). Pseudomonas was pan-sensitive. Antibiotics narrowed to meropenem, then changed to aztreonam on [**2-1**] given more distant from beta-lactams), then changed on [**2-2**] to ciprofloxacin (given development of rash). Surveillance urine cultures have been negative. The pt was discharged home to complete a 2 wk course of ciprofloxacin. . 5. Fevers Pt's last fever was on [**1-29**]. Cultures on admission were negative. Fevers initially thought to be secondary to drug effect (Unasyn); antibiotics (Unasyn/Vanco) were discontinued on [**1-20**]. Febrile on [**1-29**], urine culture positive (Pseudomonas, pan-sensitive). Started meropenem, cipro (both for Pseudomonas), vancomycin and metronidazole (additional coverage given neutropenic). ID re-consulted. Vancomycin d/c'd [**1-29**]. Cipro d/c'd, meropenem changed to aztreonam on [**2-1**] (more distant from beta-lactams), aztreonam switched back to cipro on [**2-2**] given new rash. . 6. Acute renal failure On admission, creatinine was 1.0, but he developed acute renal failure after CTA (~1.5). Went into further ARF on [**1-18**] (peaked at 2.9), improved after antibiotics discontinued. Renal consulted [**1-20**], concerned for AIN from Unasyn vs. ATN from vanco vs. pigment induced renal failure. Creatinine increased again [**Date range (1) 23500**], unclear etiology (possibly related to Pseudomonas urosepsis). By the time of discharge, pt's creatinine returned to normal. . 5. Thrombocytopenia Pt's PLTs started trending downward on [**1-18**]. Bone marrow suppression (from Sutent vs. urosepsis) was most likely cause; initially may have been secondary to an autoimmune process, as platelets improved on steroids (but steroids need to be weaned given infection and recent neutropenia). Microangiopathic process less likely (no schistocytes on smear, normal fibrinogen and FDP's). HIT negative. Started steroids [**1-23**], tapered to 20 mg daily on [**1-28**]. . 6. Neutropenia ANC is now >1000. Likely secondary to Sutent vs. urosepsis (causing suppression of bone marrow). Given Neupogen daily. . 7. Lower extremity edema Lower extremities are wrapped in ACE bandages. He has been given ethacrynic acid 50 mg IV DAILY for diuresis given likely Lasix allergy. He was discharged home with TEDS stockings. . 8. Abdominal distention On physical exam, he had abdominal distention without tympany, and multiple abdominal x-rays had shown no evidence of obstruction or perforation. He had minimal bowel sounds, but continued to have bowel movements. More concerning given that he is on steroids. Abdominal X-Ray on [**1-29**] showed no evidence of free air or obstruction. Improved upon discharge. . 9. Dyspnea/pulmonary edema Pt was dyspneic with minimal activity. Most likely related to pulmonary hypertension (etiology: lymphangitic carcinomatisis vs. COPD vs. both, pulmonary consulted [**2104-1-12**]). Sats stable at 95%-100% on room air. Also has known pleural effusion; consulted interventional pulmonary on [**1-22**] re: possible thoracentesis, but not enough fluid to safely tap. Breathing was much improved upon discharge. . 10. Renal Cell Carcinoma Considering Avastin as outpatient. Further management per primary oncologist. . 11. Hypertension Hypertensive on admission; once Sutent was discontinued, he became normotensive. Renal ultrasound showed no evidence of renal artery stenosis. Went back on Sutent with BP's as high as 210 systolic; developed hypotension (90's systolic) on [**1-29**], when urine culture grew Pseudomonas. His antihypertensives were gradually restarted. . 12. Pulmonary hypertension Diagnosed on echo. Pulmonary consulted on [**1-13**]. V/Q scan on [**1-14**] was low suspicion for PE. CXR shows intermittent pulmonary edema, stable pulmonary effusions. PFT's show obstructive pattern with DSB 30% predicted. Outpatient follow up. . 13. Shoulder pain. Calcified tendonitis, seen by ortho given concern for fracture (but they determined it was tendonitis). Oxycodone for pain management, outpatient follow up. . 14. Elevated cardiac enzymes. Enzymes elevated on admission, cards consulted, decided that it was in the setting of demand ischemia (given increased BP) and no heparin required. No further issues. . 15. LUE cellulitis Cause of recent hospitalization, sent out on 6wk course of Unasyn/vanco. Improved s/p 3 week antibiotic course (before abx were d/c'd). . 16. Hypothyroidism Continued levothyroxine. Medications on Admission: Medications at home: sutent 50 mg po daily days [**2-3**] followed by a holiday on days 29-42 each cycle--not currently taking Toprol 200 QD Zometa 4mg IV QMonth Lisinopril 40 mg QD Levothyroxine 50 mcg QD Vancomycin 1g QD Unasyn 3 g Q8 Discharge Medications: 1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* 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. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Megestrol 40 mg/mL Suspension Sig: Four Hundred (400) mg PO BID (2 times a day). Disp:*qs mg* Refills:*2* 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed for throat pain. Disp:*200 mL* Refills:*0* 9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 6 days. Disp:*12 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Pseudomonas urosepsis Pancytopenia Beta lactam allergy Furosemide allergy Hypertension secondary to Sutent Oropharyngeal Candidiasis Acute renal failure, now resolved . Secondary: Metastatic Renal Cell Carcinoma Discharge Condition: The patient was discharged hemodynamically stable and afebrile with appropriate follow up. Discharge Instructions: Please take all of your medications as prescribed. Please make all of your follow up appointments. . If you experience worsening confusion, shortness of breath, fever, or other concerning symptoms, please call your doctor or go to the ER. . You will follow up on Monday, [**2-11**] with Dr. [**Last Name (STitle) **]. His office will contact you regarding the time. . Please continue PICC line care as directed. . Please continue wound care as directed. Followup Instructions: Please follow up on Monday with your oncologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The office will call you with an appointment time. ([**2104**]. Please discuss Aranesp (long-acting Procrit) administration at that appointment. Completed by:[**2104-2-12**]

[ "288.03", "041.7", "511.9", "707.8", "599.0", "584.5", "198.5", "599.7", "486", "576.8", "428.0", "726.11", "283.9", "682.3", "414.8", "416.8", "999.8", "197.0", "693.0", "401.9", "707.03", "285.22", "462", "244.9", "E947.9", "197.7", "287.5", "V10.52" ]

icd9cm

[ [ [] ] ]

[ "99.04", "99.06" ]

icd9pcs

[ [ [] ] ]

14495, 14501

6238, 13018

308, 330

14766, 14859

4046, 6215

15362, 15659

3480, 3541

13305, 14472

14522, 14745

13044, 13044

14883, 15339

13065, 13282

3556, 4027

261, 270

358, 1780

1824, 3333

3349, 3464

27,243

163,153

48938

Discharge summary

report

Admission Date: [**2114-10-14**] Discharge Date: [**2114-10-21**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 398**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: This is an 84 year-old with atrial fibrillation, COPD, metastatic colon cancer to liver and pleura, recurrent right pleural effusions, who presents with altered mental status. Patient recently discharged to home from ICU with placement of pleurex catheter for recurrent right pleural effusion leading to acute respiratory distress. His family declined hospice services and VNA services were set up on last discharge. Past Medical History: . Acute respiratory failure. 2. Status post insertion of right thoracic PleurX catheter. 3. Right pleural effusion. 4. Stage IV colon cancer (metastases to liver, pleura) - [**2-28**]: diagnosed after labs revealing low HCT and Iron 19, ferritin 30, TIBC within normal limits. - [**2114-3-19**] (Colonscopy): A single sessile polyp of benign appearance found. - [**2114-3-20**] (CT abd): No colon mass visualized. Liver lesions demonstrated; pleural effusions, right greater than left. - [**2114-3-21**] (Ultrasound-guided liver biopsy): Metastatic adenocarcinoma consistent with colonic origin. Immunostain for CK-20 positive, CK-7 negative, consistent with colonic origin. - s/p 5FU/LV chemotherapy (last chemo C2D8 on [**8-15**]), no further chemo per most recent progress note 5. Chronic obstructive pulmonary disease (home oxygen dependent, steroid dependent). 6. Congestive heart failure. 7. Pulmonary hypertension. 8. Macular degeneration. 9. Hypertension. 10. Status post torn right rotator cuff. 11. Atrial fibrillation. Social History: Lives at home w/wife of 50+ [**Name2 (NI) 1686**], has 2 children who are involved in his care. Former smoker (40 pk [**Name2 (NI) 1686**]) quit approx 20 [**Name2 (NI) 1686**] pta. No ETOH, no IVDU. Retired Family History: The patient's parents lived to be elderly. His sister has a history of colon cancer, diagnosed in her 70s. Physical Exam: Admission: eneral Appearance: pleasant, comfortable, NAD, non toxic Eyes: : PERLLA, EOMI, no conjuctival injection, anicteric ENT: no sinus tenderness, MMM, op without exudate or lesions, no supraclavicular or cervical lymphadenopathy, JVP to cm, no carotid bruits, no thyromegaly or thyroid nodules Respiratory: CTA b/l with good air movement throughout Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops appreciated Gastrointestinal: nd, +b/s, soft, nt, no masses or hepatosplenomegaly Musculoskeletal/extremities: no cyanosis, clubbing or edema Skin/nails: warm, no rashes/no jaundice/no splinters Neurological: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. No pass-pointing on finger to nose. 2+DTR's-patellar and biceps.No pronator drift, fluent speech. Positive myoclonus and asterixis. Psychiatric:pleasant, appropriate affect Heme/Lymph: no cervical or supraclavicular lymphadenopathy GU: no catheter in place Rectal: guiaic negative Pertinent Results: CBC's [**2114-10-14**] 04:00PM BLOOD WBC-32.6* RBC-3.49* Hgb-10.9* Hct-34.7* MCV-99* MCH-31.2 MCHC-31.4 RDW-22.4* Plt Ct-409 [**2114-10-20**] 04:35AM BLOOD WBC-11.9* RBC-2.19* Hgb-6.7* Hct-21.7* MCV-99* MCH-30.8 MCHC-31.0 RDW-20.6* Plt Ct-276 [**2114-10-21**] 04:06AM BLOOD WBC-18.8*# RBC-1.69* Hgb-5.3* Hct-17.1* MCV-101* MCH-31.5 MCHC-31.2 RDW-21.6* Plt Ct-264 [**2114-10-21**] 11:44AM BLOOD Hct-16.1* . Coagulation panel [**2114-10-15**] 01:35AM BLOOD PT-36.5* PTT-33.4 INR(PT)-4.0* [**2114-10-17**] 02:19AM BLOOD PT-14.6* PTT-25.9 INR(PT)-1.3* [**2114-10-19**] 04:51AM BLOOD PT-30.4* PTT-32.2 INR(PT)-3.2* [**2114-10-20**] 06:25AM BLOOD PT-47.7* PTT-30.9 INR(PT)-5.6* [**2114-10-21**] 04:06AM BLOOD PT-104.5* PTT-31.9 INR(PT)-14.6* [**2114-10-21**] 11:44AM BLOOD PT-45.8* PTT-32.4 INR(PT)-5.3* . Chem 7's [**2114-10-14**] 04:00PM BLOOD Glucose-177* UreaN-32* Creat-1.3* Na-127* K-7.0* Cl-77* HCO3-46* AnGap-11 [**2114-10-21**] 04:06AM BLOOD Glucose-107* UreaN-58* Creat-1.1 Na-139 K-4.8 Cl-86* HCO3-GREATER THan 50 [**2114-10-14**] 04:00PM BLOOD Calcium-9.0 Phos-5.7* Mg-2.2. . Cardiac Enzymes [**2114-10-19**] 12:01AM BLOOD CK-MB-7 cTropnT-0.07* [**2114-10-19**] 04:51AM BLOOD CK-MB-6 cTropnT-0.08* [**2114-10-19**] 01:00PM BLOOD CK-MB-5 cTropnT-0.08* . CT head [**2114-10-14**] IMPRESSION: No intracranial hemorrhage or mass effect. Chronic microvascular ischemic change and several remote lacunar infarcts in the right basal ganglia. . CXR 's [**10-14**]: The marked interval changes are predominantly focused within the left lower lung with patchy opacity and air bronchograms and associated pleural effusion. Given history of altered mental status, an infectious process such as pneumonia cannot be entirely excluded. There, therefore, may be an associated parapneumonic effusion. There is known underlying emphysema, and as such, pulmonary edema may have unusual distributions. Correlate with other clinical signs of infection. If not present, this may be an atypical manifestation of edema and repeat radiography following diuresis is recommended to assess for underlying infection. [**10-15**]:Bilateral increasing pleural effusions, left worse than right.Bibasilar atelectasis. Underlying pneumonia in left lower lobe cannot be excluded. Tortuous right chest tube. [**10-17**]: Grossly unchanged appearance of the chest with left lower lobe consolidation which might be a combination of atelectasis and infection. Clinical correlation is recommended. [**10-21**]:Accounting for technical and positional differences, there is no significant interval change. Persistent bilateral effusions and retrocardiac density again noted. Pleural fluid layers in the minor fissure. No PTX. . EKG's [**10-14**]: Atrial fibrillation with controlled ventricular response. Probable left anterior fascicular block. Probable prior anterior myocardial infarction. Compared to prior tracing of [**2114-10-5**] no diagnostic interim change. [**10-18**]:Atrial fibrillation with a rapid ventricular response, average about 120 beats per minute. Borderline left axis deviation. Slow R wave progression. Cannot exclude underlying anterior myocardial infarction. Probable left ventricular hypertrophy. Non-specific ST-T wave changes. Compared with previous tracing of [**2114-10-18**] ventricular response is somewhat faster. Clinical correlation is suggested. [**10-19**]: Atrial fibrillation with a relatively rapid ventricular response of about 105 beats per minute. Compared with previous tracing of [**2114-10-18**] QRS axis is more leftward. Ventricular response is not quite as fast. Multiple other abnormalities are as reported. . Echocardiography [**10-19**] The left atrium is moderately dilated. The right atrium is markedly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular EF is preserved (LVEF>55%). Inferior hypokinesis is suggested, but due to varying R-R interval and resting tachycardia, this is not confirmed. There is no ventricular septal defect. The right ventricular cavity is moderately dilated. Right ventricular systolic function is normal. The aortic valve leaflets are moderately 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. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2114-8-3**] the degree of mitral regurgitation and pulmonary hypertension detected have increased. The patient is more tachycardic. Inferior hypokinesis is suggested but not confirmed. If clinically indicated, a repat study after better rate/rhtyhm control may better define regional LV systolic function. . Cultures: Blood Cultures: negative UCx: >100,000 enterococcus sensitive to Vancomycin Legionella Urinary Antigen: negative UA: no WBC, no nitrites, no RBC's Brief Hospital Course: Mr. [**Known lastname 30984**] is an 84 year-old with atrial fibrillation, COPD, metastatic colon cancer to liver and recurrent right pleural effusions who initially presented on [**10-14**] with altered mental status and was admitted to the hospital wards. He was first transfered to the [**Hospital Unit Name 153**] with respiratory distress on the day of admission. He was subsequently transfered back to the floor once his mental and respiratory status improved. He was then re-admitted to the [**Hospital Unit Name 153**] with afib w/ RVR. In the [**Hospital Unit Name 153**], the patient developed GI bleeding. After discussion with the family, it was decided not to escalate care (no pressors, FFP, IVF or transusions) and the patient died on [**2114-10-21**]. The patient's code status during his entire hospital course was DNR/DNI per the patient's and family's wishes. . # Mental status change: Initially admitted on [**10-14**] with concerns of changing mental status, difficulty ambulating and increasing shortness of breath. At home was 88% on 2L. At the time of admission, he was noted to be hyperkalemic (K = 7) with a ABG showing 7.38/53/84 on 5 liter with bicarb >50 on Chem 7. He was noted to have mycoclonus on exam consistent with hypercarbia and elevated bicarbonate. He was also found to have a pneumonia and UTI which along with hypercarbia likely contributed to his altered mental status. His pneumonia and UTI were treated with antibiotics - Zosyn and Vancomycin. He was also briefly started on Theophylline to increase his respiratory drive and to decrease his serum Co2 and bicarbonate levels. However, he then developed atrial fibrillation w/RVR, and theophylline was discontinued. His mental status waxed and waned during his hospital stay with occaisonal agitation treated with Haldol and then Zydis. . # Respiratory Distress: The patient was admitted to the hospital wards but developed respiratory distress with tachypnea and SaO2 72%. His respiratory distress was thought to be multifactorial with end-stage COPD, peumonia, pulmonary edema and pleural effusions. He was maintained on Advair 250/50, Tiotoprium and Prednisone 40mg daily for COPD. ABG's showed chronic respiratory acidosis with significant hypercarbia compensated by high bicarbonate levels. He was briefly started on Theophylline to increase his respiratory drive and decrease his hypercarbia. He received IV lasix dialy and PRN with some improvement of pulmonary edema. An echo was obtained to evaluate heart function and found an EF >55% but severe MR which may have contributed to pulmonary edema. His pneumonia was treated with Zosyn and Vancomycin. An attempt was made to drain his pleural effusions via his right pleurex catheter but no fluid was obtained; per family, his VNA had also been unable to obtain fluid on the last visit prior to hospitalization. On [**10-18**], IP saw the patient and were unsuccessful in removing any blockage in his pleurex catheter or enabling any further drainage. They also felt that his desaturations were not secondary to pleural effusions but rather from pulmonary edema and lymphangitic spread and pneumonia. In addition, it was noted that his CXR showed relatively little pleural effusion on the right side of his chest and a significant amount of pleural effusion on his left side. Due to an elevated INR, thoracentesis was not immediately performed. And, on further disccusion with the family, it was decided not to perform left chest thoracentisis because of bleeding risk, limited benefit and likely rapid reaccumulation. Given his respiratory distress and severe hypercarbia, non-invasive positive pressure ventilation was offered although the patient's underlying lung disease or respiratory distress were unlikely to resolve. However, NIPPV was not initiated as the family felt that this would distress the patient further and as the patient refused it. His respiratory distress stabilized enough at the end of his first [**Hospital Unit Name 153**] stay for him to be briefly transfered to the floor on NC 4L. He required high-flow oxygen on face mask during the rest of his stay with SaO2 ranging 88-92%. . #Anemia: The patient was admitted with chronic iron deficiency anemia secondary to colon cancer. Inititally, his HCT remained stable from 27-30. His coumadin was intially held and vit K given given the consideration of performing a thoracentisis. When it was decided not to perform a thoracentesis, his coumadin was briefly restarted while on the hospital wards but then discontinued with supratherapeutic INR's. On readmission to the [**Hospital Unit Name 153**], his INR climbed from 3.2->5.6->14.6->5.6. On [**10-20**], he was noted to have a decreased HCT 21->17. He was found to be guiac positive with dark stool suggestive of a GI bleed given the setting of a high INR and colon CA. He was initially typed and screened for transfusion, given vitamin K and given IVF as his blood pressure began decreasing and his mental status worsened. His respiratory status did not permit EGD or colonoscopy without intubation. And, given his DNI status, he did not receive endoscopy. His family was contact[**Name (NI) **] and indicated that they did not want any further interventions including blood transfusion, FFP, IVF or pressors. All anti-hypertensives and atrial fibrillation rate controlling medications were held due to low blood pressures. . #. Afib with RVR: While on the hospital wards, he was noted to be in afib with RVR with HR 130's and SBP 100's. An EKG showed afib with depressions in V4-V6 as complared to old. Was given 10mg IV diltiazem and 30mg PO. At the time, the patient also complained of chest pain. He was given SL nitro x1 and placed on morphine PRN. In addition, he received ASA 325mg x1. Cardiac enzymes were then found to be negative. He was transfered to the [**Hospital Unit Name 153**], given a diltiazem bolus and placed on a diltiazem drip overnight with improvement of HR to 90-100's. He was subsequently changed to Diltiazem 60mg QID and digoxin. In addition, his theophylline was discontinued. . # Leukocytosis: On admission, his WBC was found to be great than 30 but then trended down to 18.5 today with treatment of PNA and UTI. . # Enterococcal UTI: UA was bland but Urine Culture grew enteroccocus. Given the patient's change in mental status, he was placed on Vancomycin . # Aspiration: The patient was noted to aspirate with wet cough when drinking fluid. A speech/swallow evaluation showed no "overt" aspiration but could not rule out silent aspiration. Radiologic speach and swallow evaluation could not be obtained given the pt's respiratory status. Based on clinical exam while drinking, he most likely had silent aspiration and was at risk for aspiration pneumonitis/ PNA. He was placed on aspiration precautions and a diet order was placed for nectar thickened liquids, crushed medications in puree with Ensure pudding between meals. . # Colon CA: No treatment was given for his metastatic colon CA but morphine PRN was administerd for abdominal pain. Medications on Admission: 1. Diltiazem HCl 240 mg daily 2. Lisinopril 40 mg daily 3. Furosemide 80 mg [**Hospital1 **] 4. Prednisone 20 mg Daily - started [**10-13**] then taper 5. Coumadin 3 mg daily 6. Fluticasone-Salmeterol 500-50 mcg/(1) [**Hospital1 **] 7. Albuterol Sulfate 0.083 % Q4hrs PRN 8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device daily 9. Serax 15 mg QHS 10. Senna 8.6 mg QHS 11. Potassium Chloride 20 mEq SR QD Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: N/A Followup Instructions: N/A

[ "799.02", "397.0", "V46.2", "416.8", "197.7", "427.31", "041.04", "196.1", "458.9", "197.2", "276.1", "491.21", "599.0", "428.30", "286.9", "276.2", "428.0", "285.9", "293.0", "427.5", "486", "362.50", "276.8", "153.9", "V66.7", "578.1" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

15914, 15923

8359, 15422

285, 291

15974, 15983

3183, 8336

16035, 16041

2033, 2141

15886, 15891

15944, 15953

15448, 15863

16007, 16012

2156, 3164

224, 247

319, 738

760, 1792

1808, 2017

18,848

150,678

47514

Discharge summary

report

Admission Date: [**2125-1-19**] Discharge Date: [**2125-1-24**] Service: MEDICINE Allergies: Ampicillin / Codeine / Tetracyclines Attending:[**First Name3 (LF) 689**] Chief Complaint: HA and chest pain Major Surgical or Invasive Procedure: None History of Present Illness: 82 y/o female with s/p AAA repair, HTN, CVA in [**2119**] presented to the ED with complaints of HA, sore throat, chest pain with inspiration, chronic cough, and tightness in head x 1 day. CXR revealed left pleural effusion but no CHF or PNA. Due to pulsatile HA there was concern for ICH so a head CT was performed which revealed no ICH. She was treated with lopressor, aspirin, levofloxacin and SLNTG. Due to CP and pulsatile HA with hx of AAA there was concern for aortic and carotid dissection so there was decision for MRA of the chest and head. She was unable lay flat secondary to pain and orthopnea so she was electively intubated for MRI. MRA/ MRI revealed no acute infarct or dissection of intracranial or thoracic vessels. Due to somnolence off of propofol and continued need for intubation she was admitted to the ICU. While in the ICU she was treated with levofloxacin for suspected PNA and ruled out for MI with CE x3. TTE was performed due to concern that effusion was due to CHF which revealed only minimal AS with preserved EF. She was successfully extubated this afternoon. Past Medical History: 1. HTN 2. AAA s/p intravascular repair [**2-25**] 3. CVA [**1-26**], lacunar infarct with no residual deficits 4. Hypercholesterolemia 5. Hypothyroid 6. Chronic back pain 7. OA 8. GERD 9. Bilateral parotid gland masses 10. Diverticulitis 11. Chronic bronchitis 12. Anemia with baseline 31 to 34 13. CRI with baseline 2.2 Social History: Widowed since [**2111**], currently lives alone, has 3 sons. Smokes 1ppd, no alcohol, no recreational drugs. Family History: Noncontributory Physical Exam: VS: Tmax 99.9 curr 99.2 HR: 78 BP: 145/75 RR:30 O2:91% on 50% shovel mask GEN: sitting up in bed in mild resp distress HEENT: PERRL, anicteric sclerae, arcus senilis bilat, MMM, JVP to 8cm CV: 2/6 SEM at LLSB. RRR, nl s1, s2 LUNGS:poor air movement at bases bilat, no crackles, rt sided rhonchi ABD: + BS, high-pitched bruit at site of AAA repair, NT, ND. EXT: No edema, cyanosis, or clubbing. SKIN: stage II sacral decub NEURO: CNII-XII intact, [**3-31**] UE and LE strength, 2+ dtr at knees bilat, oriented to person and place Pertinent Results: IMAGING: CHEST (PORTABLE AP) [**2125-1-18**] 7:11 PM FINDINGS: Single frontal view of the chest demonstrates appropriate position of the endotracheal tube with tip approximately 3 cm above the carina. A nasogastric tube courses through the stomach with tip below the inferior margin of the radiograph. Otherwise, there has been no short interval change in appearance of the chest. Given differences inpatient positioning, a small left pleural effusion is unchanged. Calcified nodules are again noted at the base of the right lower lobe. Mild cardiomegaly persists. IMPRESSION: ET tube in appropriate . MRA BRAIN W/O CONTRAST [**2125-1-18**] 8:59 PM IMPRESSION: 1. No acute infarct. 2. Atherosclerotic disease involving the cavernous ICA bilaterally. The study is somewhat limited due to motion artifacts. 3. Bilateral parotid masses, incompletely evaluated on the present study. . MRA CHEST W/O CONTRAST [**2125-1-18**] 8:59 PM IMPRESSION: 1. No evidence of aortic dissection. Mild atherosclerotic disease of the thoracic aorta with an unfolded aorta. 2. Right lower lobe dependent atelectasis versus consolidation. . CT HEAD W/O CONTRAST [**2125-1-18**] 1:39 PM IMPRESSION: Findings consistent with small vessel ischemic disease. No evidence of acute intracranial hemorrhage or territorial infarct. . CHEST (PA & LAT) [**2125-1-18**] 12:51 PM IMPRESSION: 1. Small left pleural effusion with no evidence of acute parenchymal consolidation, pulmonary edema, or pneumothorax. 2. Small hiatal hernia. This may be better evaluated with dedicated esophagram if clinically indicated. . ECHO Study Date of [**2125-1-19**] Conclusions: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. 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 moderately thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is severe mitral annular calcification. No mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . RENAL U.S. [**2125-1-20**] 9:09 AM IMPRESSION: Multiple simple cysts in both kidneys. No evidence of hydronephrosis. . CHEST (PA & LAT) [**2125-1-20**] 9:31 AM IMPRESSION: Worsening left-sided pleural effusion. Small right-sided pleural effusion. Bibasilar atelectasis. . MICRO: [**2125-1-18**] Blood Cultures: No growth Urine Culture: No growth . [**2125-1-19**] MRSA Screen: no MRSA . LABS: [**2125-1-18**] 11:55AM BLOOD WBC-12.4*# RBC-4.62 Hgb-11.5* Hct-35.0* MCV-76* MCH-24.8* MCHC-32.8 RDW-17.1* Plt Ct-392 [**2125-1-24**] 06:25AM BLOOD WBC-5.6 RBC-3.63* Hgb-9.2* Hct-27.5* MCV-76* MCH-25.3* MCHC-33.4 RDW-17.3* Plt Ct-358 [**2125-1-18**] 11:55AM BLOOD Neuts-84.9* Bands-0 Lymphs-8.0* Monos-4.7 Eos-0.5 Baso-2.0 [**2125-1-18**] 11:55AM BLOOD Glucose-103 UreaN-25* Creat-2.6* Na-135 K-5.2* Cl-103 HCO3-21* AnGap-16 [**2125-1-21**] 07:00AM BLOOD Glucose-96 UreaN-35* Creat-3.2* Na-139 K-3.6 Cl-105 HCO3-19* AnGap-19 [**2125-1-24**] 06:25AM BLOOD Glucose-91 UreaN-31* Creat-3.0* Na-139 K-3.7 Cl-107 HCO3-22 AnGap-14 . Cardiac enzymes [**2125-1-18**] 11:55AM BLOOD CK(CPK)-64 [**2125-1-19**] 03:59AM BLOOD CK(CPK)-38 [**2125-1-19**] 05:29AM BLOOD CK(CPK)-40 [**2125-1-22**] 06:10AM BLOOD CK(CPK)-69 [**2125-1-18**] 11:55AM BLOOD cTropnT-<0.01 [**2125-1-19**] 03:59AM BLOOD CK-MB-NotDone cTropnT-0.14* [**2125-1-19**] 05:29AM BLOOD CK-MB-NotDone cTropnT-0.16* Brief Hospital Course: 82 y/o female with HTN, AAA s/p repair, CVA, smoking, chest pain and H/A now with resolving hypoxia and acute on chronic RF. . # Respiratory Distress: differential includes pneumonia, COPD exacerbation, acute on chronic bronchitis, heart failure exacerbated by renal failure, or some combination of these factors. Given markedly increased BNP it is likely that the patient has some element of failure. Patient's ECHO is without wall motion abnormalities. The patient was treated with Levofloxacin for empiric pneumonia for a total of 7 days. The patient was also given nebulizers as needed for symptomatic relief. During her hospital course her breathing gradually improved. . # Acute on Chronic RF: Initial FeNA > 1, although patient on Lasix. Further urine studies suggested that the patient was not pre-renal and her disease is likely a result of progressive atherosclerotic disease. She had a Renal US which was negative for obstruction. The patient's PTH was increased although likely secondary to CRI. Her creatinine peaked at 3.2 and then decreased to 3.0 and she was discharged home with plans for close follow up. . # s/p CVA, AAA repair: Patient was continued on aspirin, Lipitor, diltiazem-XR, but Metoprolol was held initially as per renal in order to avoid renal hypoperfusion. . # Anemia: baseline HCT 31-34. Anemia appears to be iron deficiency anemia. Patient was started on iron supplementation, plus some component of anemia of chronic disease, possibly from renal failure. She was started on Epogen. An attempt was made to have her insurance cover the cost of Epogen as an outpatient. The family and patient asked to have this dealt with as an outpatient. . # Hypothyroid: Patient continued on levothyroxine . After discussion with the patient and the medical staff, all were in agreement that [**Known firstname 100462**] [**Known lastname 100463**] was a suitable candidate for discharge. Medications on Admission: Diltiazem Lipitor Synthroid Discharge Medications: 1. Outpatient Lab Work Chem 10, HCT, please send results to Dr. [**Last Name (STitle) **],[**First Name3 (LF) 569**] M. [**Telephone/Fax (1) 133**] Date Friday [**2125-1-26**] 2. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO DAILY (Daily). 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 4. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO once a day. 5. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 1 days: Stop [**2125-1-26**]. Disp:*1 Tablet(s)* Refills:*0* 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO once a day for 1 months. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnosis: CRI causing hypervolemia and respiratory distress Empiric pneumonia . Secondary Diagnoses: 1. Hypertension 2. AAA s/p intravascular repair [**2-25**] 3. CVA [**1-26**], lacunar infarct with no residual deficits 4. Hypercholesterolemia 5. Hypothyroid 6. Chronic back pain 7. OA 8. GERD 9. Bilateral parotid gland masses 10. Diverticulitis 11. Chronic bronchitis 12. Anemia with baseline 31 to 34 13. CRI with baseline 2.2 Discharge Condition: Afebrile, stable vital signs, tolerating POs, ambulating with assistance. Discharge Instructions: You were admitted with difficulty breathing thought to be due to fluid overload on account of chronic renal insufficiency. You were admitted briefly to the ICU for evaluation. You did not have a heart attack. . 1. Please take all medication as prescribed. 2. Please attempt to make all medical appointments. 3. Please return to the Emergency Room if you have any concerning symptoms. Followup Instructions: You have an appointment with your PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 569**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 133**] on [**1-30**] at 2:45pm. . Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2125-3-5**] 2:30 . You will need to have your blood work drawn on Friday [**1-26**]. You will be given a prescription for the blood work. . We believe that you would benefit from a medication called epogen given your renal failure. This medication requires prior approval and you have requested to be discharged before approval has been granted. Discuss restarting this medication with your doctor [**First Name (Titles) **] [**Last Name (Titles) 80550**] anemia and renal failure. In the hospital your dose was Epoetin Alfa 4000 subcutaneous every Monday, Wednesday, and Friday.

[ "285.9", "272.0", "562.11", "244.9", "584.9", "486", "707.03", "585.6", "403.91" ]

icd9cm

[ [ [] ] ]

[ "96.04", "93.90" ]

icd9pcs

[ [ [] ] ]

8983, 9041

6186, 8109

261, 268

9525, 9601

2458, 6163

10035, 10922

1876, 1893

8188, 8960

9062, 9062

8135, 8165

9625, 10012

1908, 2439

9172, 9504

204, 223

296, 1389

9081, 9151

1411, 1734

1750, 1860

27,894

107,975

30904+57784

Discharge summary

report+addendum

Admission Date: [**2107-7-20**] Discharge Date: [**2107-8-11**] Date of Birth: [**2036-4-3**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 689**] Chief Complaint: Transferred for evaluation of left piriform sinus mass Major Surgical or Invasive Procedure: Chest Tubes Surgical Biopsy Gastric Tube Tracheostomy Thoracentesis History of Present Illness: 71M with multiple medical problems including a 59 pack year smoking history, 45 year alcoholic hx and CABG, recently discharged from [**Hospital3 **] for pneumothorax s/p chest tube placement, now transferred from the same hospital for work-up for a left piriform sinus mass, after presenting with difficulty swallowing. Patient reports gradual dysphagia for 5 months, first to solids, later to liquids. Immediately prior to presentation to [**Hospital3 **], he was regurgitating baby food (all he could tolerate) through his nasal passages. Subsequent to this dysphagia, the patient experienced a 45 pound weight loss over the past 5 months. He denied hematemesis, chest pain, sob, palpitations, abd pain, hematuria or dysuria. CT of the neck at [**Hospital3 **] showed a 3.6 cm mass in the L piriform sinus. An EGD was unable to be completed due to severe esophageal stricture. A modified barium study showed achalasia and severe esophageal narrowing. The patient's course there was additionally complicated by hypertension requiring IV meds, given his intolerance for PO. The patient was transferred to [**Hospital1 18**] for further work-up of this mass. Past Medical History: Diabetes Hypertension Coronary Artery Disease, s/p CABG x 5 Permanent Pacemaker for ?sick sinus/tachy brady Peripheral Vascular Disease (AAA s/p repair) COPD Spontaneous Pneumothorax s/p chest tube Colon Cancer s/p resection in approximately [**2102**] Social History: Patient is not married. He does not have any children. He reports he has been an alcoholic for the past 45 years. He now drinks 2 glasses of wine per day. He has a 59 pack year smoking history. Family History: NC Physical Exam: VS T98.3 BP 180/84 HR 76 R18 O2sat 92%RA GEN Cachetic male in NAD, able to speak in full sentences HEENT extremely poor dentition, few teeth in mouth, blackened tongue; hardened immobile mass measuring about 2 inches can be appreciated along the R lateral neck ( may be displacement of anatomy) HEART nl rate, S1S2, no gmr; due to emaciated status heart can appreciate every heart LUNGS CTA b/l no RRW ABD sunken, concave, surgical scar, otherwise benign EXT no cce Pertinent Results: [**2107-7-21**] 06:15AM BLOOD Digoxin-0.7* [**2107-7-21**] 06:15AM BLOOD Triglyc-72 [**2107-7-22**] 06:15AM BLOOD %HbA1c-5.7 [**2107-7-25**] 05:09AM BLOOD calTIBC-189* Hapto-155 Ferritn-300 TRF-145* [**2107-7-29**] 06:33AM BLOOD Hapto-163 [**2107-7-21**] 06:15AM BLOOD Albumin-3.7 Calcium-9.4 Phos-2.8 Mg-1.4* [**2107-7-22**] 12:40AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.2 [**2107-7-22**] 06:15AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.2 [**2107-7-23**] 09:07AM BLOOD Calcium-9.4 Phos-2.5* Mg-2.5 [**2107-7-24**] 05:28AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.0 [**2107-7-25**] 05:09AM BLOOD Calcium-8.4 Phos-3.4 Mg-1.9 Iron-23* [**2107-7-26**] 05:34AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.3 [**2107-7-27**] 04:31AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.2 [**2107-7-28**] 05:59AM BLOOD Calcium-8.4 Phos-4.0 Mg-2.0 [**2107-7-29**] 06:33AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.9 [**2107-7-29**] 03:13PM BLOOD Calcium-PND Phos-PND Mg-PND [**2107-7-21**] 06:15AM BLOOD CK-MB-NotDone cTropnT-0.02* [**2107-7-21**] 03:40PM BLOOD CK-MB-NotDone cTropnT-0.02* [**2107-7-22**] 12:40AM BLOOD CK-MB-NotDone cTropnT-0.02* [**2107-7-21**] 06:15AM BLOOD CK(CPK)-58 [**2107-7-21**] 03:40PM BLOOD CK(CPK)-55 [**2107-7-22**] 12:40AM BLOOD CK(CPK)-86 [**2107-7-25**] 05:09AM BLOOD TotBili-0.4 [**2107-7-29**] 06:33AM BLOOD TotBili-0.5 [**2107-7-21**] 06:15AM BLOOD estGFR-Using this [**2107-7-29**] 06:33AM BLOOD estGFR-Using this [**2107-7-21**] 06:15AM BLOOD Glucose-129* UreaN-6 Creat-1.0 Na-139 K-2.9* Cl-101 HCO3-26 AnGap-15 [**2107-7-22**] 12:40AM BLOOD Glucose-158* UreaN-16 Creat-1.0 Na-141 K-3.9 Cl-104 HCO3-24 AnGap-17 [**2107-7-22**] 06:15AM BLOOD Glucose-146* UreaN-17 Creat-1.0 Na-141 K-3.8 Cl-105 HCO3-26 AnGap-14 [**2107-7-23**] 09:07AM BLOOD Glucose-153* UreaN-27* Creat-1.0 Na-144 K-3.6 Cl-109* HCO3-29 AnGap-10 [**2107-7-24**] 05:28AM BLOOD Glucose-195* UreaN-21* Creat-0.9 Na-141 K-3.6 Cl-106 HCO3-29 AnGap-10 [**2107-7-25**] 05:09AM BLOOD Glucose-224* UreaN-16 Creat-0.7 Na-142 K-3.5 Cl-107 HCO3-28 AnGap-11 [**2107-7-26**] 05:34AM BLOOD Glucose-193* UreaN-16 Creat-0.8 Na-141 K-4.0 Cl-109* HCO3-28 AnGap-8 [**2107-7-27**] 04:31AM BLOOD Glucose-121* UreaN-16 Creat-0.8 Na-142 K-4.0 Cl-109* HCO3-30 AnGap-7* [**2107-7-28**] 05:59AM BLOOD Glucose-161* UreaN-15 Creat-0.8 Na-139 K-4.0 Cl-106 HCO3-30 AnGap-7* [**2107-7-29**] 06:33AM BLOOD Glucose-160* UreaN-13 Creat-0.8 Na-137 K-4.3 Cl-104 HCO3-30 AnGap-7* [**2107-7-29**] 03:13PM BLOOD Glucose-PND UreaN-PND Creat-PND Na-PND K-PND Cl-PND HCO3-PND [**2107-7-25**] 05:09AM BLOOD Ret Aut-0.8* [**2107-7-29**] 06:33AM BLOOD Ret Aut-1.2 [**2107-7-21**] 06:15AM BLOOD Plt Ct-209 [**2107-7-22**] 06:15AM BLOOD Plt Ct-233 [**2107-7-23**] 09:07AM BLOOD Plt Ct-175 [**2107-7-23**] 09:35PM BLOOD PT-11.5 PTT-47.5* INR(PT)-1.0 [**2107-7-24**] 05:28AM BLOOD Plt Ct-151 [**2107-7-25**] 05:09AM BLOOD PT-11.8 PTT-29.8 INR(PT)-1.0 [**2107-7-25**] 05:09AM BLOOD Plt Ct-136* [**2107-7-26**] 05:34AM BLOOD Plt Ct-136* [**2107-7-27**] 04:31AM BLOOD Plt Ct-158 [**2107-7-28**] 05:59AM BLOOD PT-11.6 PTT-27.8 INR(PT)-1.0 [**2107-7-28**] 05:59AM BLOOD Plt Ct-153 [**2107-7-29**] 06:33AM BLOOD Plt Ct-135* [**2107-7-29**] 03:13PM BLOOD Plt Ct-PND [**2107-7-21**] 06:15AM BLOOD WBC-7.2 RBC-3.90* Hgb-11.7* Hct-34.0* MCV-87 MCH-29.9 MCHC-34.4 RDW-15.8* Plt Ct-209 [**2107-7-22**] 06:15AM BLOOD WBC-12.8*# RBC-3.62* Hgb-10.7* Hct-31.2* MCV-86 MCH-29.6 MCHC-34.4 RDW-15.9* Plt Ct-233 [**2107-7-23**] 09:07AM BLOOD WBC-9.3 RBC-3.06* Hgb-9.2* Hct-26.7* MCV-87 MCH-30.1 MCHC-34.5 RDW-16.1* Plt Ct-175 [**2107-7-23**] 12:00PM BLOOD Hct-30.6* [**2107-7-23**] 09:35PM BLOOD Hct-28.0* [**2107-7-24**] 05:28AM BLOOD WBC-7.6 RBC-3.12* Hgb-9.3* Hct-27.6* MCV-89 MCH-29.7 MCHC-33.6 RDW-15.8* Plt Ct-151 [**2107-7-24**] 11:39AM BLOOD Hct-28.8* [**2107-7-24**] 11:03PM BLOOD Hct-28.0* [**2107-7-25**] 05:09AM BLOOD WBC-6.2 RBC-3.02* Hgb-9.0* Hct-26.8* MCV-89 MCH-29.7 MCHC-33.4 RDW-15.7* Plt Ct-136* [**2107-7-25**] 04:47PM BLOOD Hct-28.5* [**2107-7-26**] 05:34AM BLOOD WBC-6.0 RBC-2.64* Hgb-7.7* Hct-23.3* MCV-88 MCH-29.2 MCHC-33.1 RDW-15.8* Plt Ct-136* [**2107-7-26**] 09:37AM BLOOD Hct-22.0* [**2107-7-27**] 12:13AM BLOOD Hct-25.7* [**2107-7-27**] 04:31AM BLOOD WBC-7.5 RBC-2.82* Hgb-8.4* Hct-25.7* MCV-91 MCH-29.9 MCHC-32.9 RDW-16.1* Plt Ct-158 [**2107-7-28**] 05:59AM BLOOD WBC-7.6 RBC-2.89* Hgb-9.1* Hct-25.6* MCV-89 MCH-31.4 MCHC-35.4* RDW-15.8* Plt Ct-153 [**2107-7-28**] 12:54PM BLOOD Hct-27.4* [**2107-7-29**] 06:33AM BLOOD WBC-5.7 RBC-2.68* Hgb-8.2* Hct-23.7* MCV-88 MCH-30.5 MCHC-34.6 RDW-16.0* Plt Ct-135* [**2107-7-29**] 03:13PM BLOOD WBC-PND RBC-PND Hgb-PND Hct-PND MCV-PND MCH-PND MCHC-PND Plt Ct-PND . CXR ([**7-21**]): Single chest AP performed to evaluate pneumothorax, the heart and mediastinum are midline. A pacer pack is noted in the left infraclavicular area. The left lung is expanded. There is the large pneumothorax on the right with total collapse of the right lower lobe, partial collapse of the left middle lobe and the right upper lobe. There has not been a significant shift in the mediastinum however. There are no previous films for comparison. . CXR ([**7-23**]): Two views. Comparison with the previous study done [**2107-7-22**]. A second chest tube has been inserted on the right. The second chest tube terminates medially near the right lung apex. A right pneumothorax is no longer apparent. There is interval increase in subcutaneous emphysema on that side. The lungs appear clear. There is interval decrease in a small right effusion. The heart and mediastinal structures are unchanged. A bipolar transvenous pacemaker remains in place. A PICC line has been pulled back and now terminates at the level of the superior vena cava. IMPRESSION: Right pneumothorax no longer apparent post placement of a second right chest tube. PICC line has been pulled back. . CXR ([**7-29**]): CHEST, PA AND LATERAL: Comparison is made to the prior day. Patient is status post CABG. A right-sided PICC line and dual lead pacemaker are unchanged. Cardiac and mediastinal contours are also unchanged. There is no pneumothorax. Density along the right lateral chest wall, at the site of the recent catheter tract, has a similar appearance. More inferiorly, there is greater right lower lobe opacity which may represent loculated effusion, atelectasis, or consolidation. In addition, free-flowing bilateral pleural effusions are increased. IMPRESSION: No evidence of pneumothorax. Increased effusions and right lower lobe opacity. . Rest MIBI ([**2107-7-22**]): Following injection of MIBI while patient was at rest and experiencing chest pain, static and gated SPECT images were obtained and analyzed. Gated images and the rest of the test including stress images were not performed due to patients pulmonary and blood pressure problems. Imaging Protocol: This study was interpreted using the 17-segment myocardial perfusion model. The image quality is good. The left ventricular cavity size is normal. There are no perfusion defects seen in the rest images. IMPRESSION: Normal rest myocardial perfusion. Ejection fraction and stress images not obtained. . CT Neck ([**2107-7-27**]): FINDINGS: There is an ill-defined, heterogeneous, enhancing mass filling the left piriform sinus with the bulk centered at the C5 level on the lateral scout film. This mass extends into the left tonsillar space and has several central areas of hypodensity consistent with necrosis. There is associated narrowing and compression of the airway at the level of the hyoid bone and more inferiorly at the valleculae. At its largest size at the C5 level, this mass measures 4.8 x 3.0 cm in the axial plane. The inferior portion of the mass abuts the superior aspect of the thyroid gland. There is no associated neck pathologic lymphadenopathy. There is diffuse atherosclerotic calcification at the aortic arch and of the carotid arteries bilaterally. The cavernous portions of the carotid arteries are especially calcified. Limited views of the inferior portion of the brain are unremarkable. Incidental note is made of extensive degenerative, multilevel disease with mild narrowing of the spinal canal at the C5 level secondary to posterior osteophytosis. Limited views of the lung apices demonstrate striking centrilobular emphysematous changes with several peripheral bullae noted. Furthermore, there is a partially imaged tubular structure extending along the anterior aspect of the right lobe. IMPRESSION: Large, heterogeneously enhancing suspicious mass centered within the left piriform sinus at the C5 level suspicious for underlying malignancy such as squamous cell carcinoma. Encroachment of the airway at the inferior border of the hyoid bone. No pathologic associated lymphadenopathy within the neck. . CTA Abdomen & Pelvis ([**2107-7-27**]): IMPRESSION: 1. No evidence for retroperitoneal hematoma. 2. Status post abdominal aneurysm repair. This likely explains the unusual appearance of the aorta at the level of the renal arteries where a waist is seen as well as a left lateral wide-mouthed focal outpouching. Comparison with prior outside studies would be helpful to ensure stability of this finding. High grade stenosis of the left renal artery and celiac trunc as described above. 3. Small-to-moderate bilateral pleural effusions. 4. Small left kidney with perfusion abnormality likely due to compromise of the left renal artery by the aneurysm. 5. Calcified granulomas in the spleen and liver. 6. Left hydrocele and presacral fluid of uncertain clinical significance. 7. 3D reformations were not available at the time of this dictation. An addendum will be added once they have become available. . Echo ([**2107-7-26**]): Conclusions: The left atrium is mildly dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. The estimated right atrial pressure is 5-10 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**2-8**]+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved biventricular systolic function. Mild-moderate mitral regurgitation. Moderate pulmonary hypertension. Mildly dilated ascending aorta. PLEURAL FLUID: exudative, negative for malignant cells. Brief Hospital Course: 71 y.o. male w/ MMP including extensive alcohol and smoking hx, transferred from an outside hospital with a 3.5 cm piriform sinus mass and right tension PTX. The following issues were investigated during this hospitalization: . # PTX: Patient had had a spontaneous PTX at the OSH, which per CXR report on transfer, had resolved s/p chest tube placement. Thus, the PTX observed on arrival was felt to be recurrent rather than persistent. Thoracic surgery was consulted and the patient eventually received two chest tubes with resolution of the pneumothorax after removal of the chest tubes. Patient was maintained on supplemental oxygen with appropriate saturation for the remainder of his hospitalization. . # Pirifrom Mass: Per pathology, squamous cell carcinoma, patient has history of heavy smoking and alcohol. ENT was consulted and though determined to be a high risk surgical candidate given cardiac history, but otherwise medically cleared, the patient underwent biopsy. Tracheostomy was perfomed as well. Given the patient's inability to swallow, he was made NPO and started on TPN before eventual G tube placement. The tracheostomy was uncomplicated; but it was decided to transfer the patient to the MICU for close oxygen monitoring given his multiple comorbidities. Upon transfer back to the floor, he underwent several speech and swallow evaluations. Although initially he was deemed safe for comfort POs (coffee, water sips), subsequent evaluations demonstrated that he has a high risk of aspiration. Thus, he is NPO with only mouth swabs and ice chips. The patient must see radiation oncology (Dr [**Last Name (STitle) 35885**] [**Telephone/Fax (1) 73095**]), Dr [**First Name (STitle) **] (ENT) and Dr [**Last Name (STitle) **] (Oncology) at discharge. . Respiratory failure: The patient did well after his tracheostomy and quickly transitioned to trach mask. There was concern for developing pneumonia on the R lobe of the lung and for this reason unasyn and vancomycin were started. He completed a 10 course of vancomycin and zosyn, although all cultures remained negative: urine, blood, sputum, and pleural fluid. He underwent thoracentesis which yielded exudative fluid with [**Numeric Identifier 73096**] RBCs and no malignant cells. . # Anemia: Hematocrit gradually trended down from admission with no clear source. Patient had brown, heme negative stool. He did not have hematemesis or hemoptysis. Hemolysis labs were negative. Given abdominal bruit on exam with history of AAA s/p repair, an endoleak was considered, but there was no evidence of RP bleed on CTA. Iron studies pointed to anemia of chronic disease. The patient received several blood transfusions for continuously dropping hematocrit. For the past 14 days prior to discharge, his hematocrit stabilized and had no further changes. . # HTN: Poorly-controlled and chronically elevated. Furthermore, patient was unable to tolerate PO medications [**3-11**] mass. Patient was not symptomatic with this hypertension and was continued on IV/TD antihypertensives with SBP goal of 160- 170: permissive hypertension given chronic elevation as an outpatient. . # Arrythmia: Patient has pacemaker and was on Digoxin. The indication was not documented in his transfer paperwork, but according to the history given by the patient, the indication appeared to be tachy-brady/sick sinus. Patient was on Digoxin as an outpatient and serum levels were appropriate. The patient remained rate-controlled and in sinus on successive EKGs. On telemetry, he had occasional PVCs. He had one run of 7 beats VT which resolved spontaneously and during which the patient remained asymptomatic. . # Diabetes: Well-controlled with HbA1C of 5.7 during this hospitalization. Patient was continued on an Insulin sliding scale as well as received Insulin in his TPN. After TPN was discontinued, once his tube feeds were at goal, his sugars became elevated >200. He was then transitioned to glargine as well as RISS, with better sugar control. . # Fevers: In the week prior to d/c, he spiked fevers to 101 twice. He was pancultured but all cultures were negative. He was asymptomatic. It was thought that these were most likely tumor fevers. He has remained afebrile for >48 hours and is ready for discharge. Medications on Admission: (Unsure of doses) Amlodipine Isosorbide Digoxin Toprol - XL Lipitor Actos Metformin KCl Metformin Percocet Discharge Medications: 1. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q8H (every 8 hours) as needed for fever,pain. 2. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours). 3. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q2H (every 2 hours) as needed. 4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 14 days. 5. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTHUR (every Thursday). 6. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. HydrALAzine 20 mg IV Q6H:PRN SBP > 160 8. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units Subcutaneous at bedtime. 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Nitroglycerin 2 % Ointment Sig: One (1) Transdermal Q6H (every 6 hours) as needed for BP>150. 13. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 15. Budesonide 0.25 mg/2 mL Solution for Nebulization Sig: One (1) ML Inhalation [**Hospital1 **] (). 16. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO DAILY (Daily) for 14 days. 17. Insulin sliding scale 18. Tracheostomy care per protocol 19. Lortab Elixir 2.5-167 mg/5 mL Solution Sig: [**2-8**] PO every 4-6 hours as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 38**] Discharge Diagnosis: Left Piriform Sinus Mass: Squamous Cell Carcinoma Right Pneumothorax Diabetes Hypertension Discharge Condition: Stable Discharge Instructions: You were seen and evaluated for a tumor in your throat as well as a collapsed lung. A biopsy was performed of this tumor and it is a cancer that has not spread (squamous cell carcinoma). You had two chest tubes placed in order to treat your collapsed lung and this was successful. A tracheostomy was placed in your throat so you can breathe easily. You cannot take anything per mouth except ice chips, as you run the risk of a fatal pneumonia if you do that. You are now being discharged. Take all of your medications as directed. You need to see radiation oncology as directed, as well as the other doctors that saw [**Name5 (PTitle) **] in the hospital. See the appointments below. Keep all of your follow-up appointments. Call your doctor or go to the ER for any of the following: fevers/chills, nausea/vomiting, chest pain, shortness of breath or any other concerning symptoms. Followup Instructions: Call your primary care physician and schedule an appointment in [**8-16**] days. You need also to see: DR [**Last Name (STitle) **] (radiation Oncology) [**Telephone/Fax (1) 73097**] DR [**First Name (STitle) **] : [**8-25**], at 1 pm. (ENT) An appointment has been made for you. . Provider: [**Name10 (NameIs) **] [**Name8 (MD) 490**], MD, PHD[**MD Number(3) 708**]:[**0-0-**] Date/Time:[**2107-8-18**] 10:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7706**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2107-8-18**] 10:30 Name: [**Known lastname 12362**],[**Known firstname **] J Unit No: [**Numeric Identifier 12363**] Admission Date: [**2107-7-20**] Discharge Date: [**2107-8-11**] Date of Birth: [**2036-4-3**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 161**] Addendum: Re- Patient's fevers of unknown source: these occurred while the patient was still on his regimen of vancomycin and zosyn for ten days as documented above under respiratory. AS stated above, they were intermittent, and resolved spontaneously. The patient was afebrile and asymptomatic for > 48 hours prior to discharge. Discharge Disposition: Extended Care Facility: [**Hospital3 2215**] Northeast - [**Location (un) **] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 165**] MD [**MD Number(1) 166**] Completed by:[**2107-8-12**]

[ "707.03", "V45.3", "512.8", "230.0", "V12.59", "799.4", "285.29", "V10.00", "V53.31", "305.1", "V45.81", "560.1", "250.00", "496", "511.9", "303.90", "401.9" ]

icd9cm

[ [ [] ] ]

[ "96.6", "29.12", "34.91", "34.09", "99.21", "99.15", "99.04", "34.92", "43.19", "38.93", "31.1" ]

icd9pcs

[ [ [] ] ]

21868, 22103

13377, 17644

368, 438

19633, 19642

2637, 13354

20575, 21845

2131, 2135

17802, 19394

19519, 19612

17670, 17779

19666, 20552

2150, 2618

274, 330

466, 1627

1649, 1904

1920, 2115

31,724

198,547

476

Discharge summary

report

Admission Date: [**2131-10-20**] Discharge Date: [**2131-11-4**] Date of Birth: [**2050-1-1**] Sex: F Service: MEDICINE Allergies: Levofloxacin / Allopurinol Attending:[**First Name3 (LF) 759**] Chief Complaint: Bilateral hip pain Major Surgical or Invasive Procedure: Left hip hemiarthroplasty Right hip ORIF Intubation PICC placement History of Present Illness: 81 yo woman with PMH signficant for SLE, gout, CHF and MVR, severe osteoporosis who was admitted on [**2131-10-11**] to [**Location (un) **] [**Location (un) 1459**] from NH, c/o bilateral hip pain. She denied trauma but had an overlying hematoma on the right side, however she does not "recall anything" at this point. Plain x-rays showed bilateral hip fractures, intratrochanteric on one side and femoral neck on other. The patient was initially hypotensive to the 80s but then responded to fluids. She was admitted to Medicine due to medical comorbidity. Surgery was initally planned for [**2131-10-16**] but on that day, she developed hypoxemia and cyanosis and CXR showed pulmonary edema, so she was diuresed with Lasix and Bumex and she did well though her O2 sats remained in the high 90??????s on 2-3LNC. Cardiology and Pulmonary were consulted. Pulmonary felt, that she likely has interstitial underlying lung disease as well that is contributing to her hypoxemia. Duonebs were given. She was continued on betablockers for rate control but Coumadin was held. She was not on any other form of DVT prophylaxis or anticoagulation. She was also found to have a UTI from ESBL-E.coli and was treated with Zosyn. The patient was also noted to be thrombocytopenic, chronically around 65K which was attributed to SLE. Her anemia was ranging around a Hgb 8.3-8.5. She was transfused 1 Unit PRBC??????s, Hct 27.9 prior to transfer. The patient also has ARF with an unclear baseline (last 1.0 in [**2124**]) now Creatinine 1.2 per last report. . She was admitted to [**Hospital1 18**] on [**2131-10-21**]. She was evaluated by orthopaedics for operative repair of her hips. She was assessed to be fluid overloaded as part of her hypoxia. Diuresis was started. There was concern about a PE, so a CTA was done on [**10-22**] which showed no PE, but did show bilateral pleural effusions with patchy ground glass opacities, apical interlobular septal thickening and peripheral reticulation. There was mediastinal and hilar adenopathy. . The decision was made to diurese further, and her oxygen requirement was decreased from 3L to 1L nc. She had a repeat UA which showed E.coli that was sensitive to bactrim, so the zosyn was changed to bactrim. . On [**10-24**] she was felt stable to go to the OR the following day for possible surgical repair of both hips. On [**10-25**] she was taken to the OR and the left hip repair was started. She was noted to have a large amount of bleeding, and an intraopeartive hct was 21% (from 30% the previous day). She was given 3u PRBC intraoperatively. She was noted to have an arrhythmia vs ST depressions on telemetry during this time. The decision was made to not proceed with the right hip at this time. . There was a postoperative attempt at extubation, which per report she failed due to rising CO2. . At this time she is intubated, on a propofol gtt. . [**First Name8 (NamePattern2) **] [**Location (un) 582**] NH, no evidence of trauma. Past Medical History: 1) Rheumatic heart disease - h/o rheumatic fever at age 11; s/p porcine MVR [**7-/2124**]. S/p pacemaker insertion, also [**7-/2124**]. h/o LV dysfunction. 2) PAF 3) SLE - reportedly associated with pneumonitis and pancytopenia. 4) s/p R total knee replacement - [**2122**], c/b septic arthritis in [**2124**] MSSA 5) Hypothyroidism 6) Old R hip surgery 7) Gout 8) Osteoporosis Social History: She is a widow. She has family in the area. Daughter and husband live nearby. Previous tobacco use, she quit 30 years ago. She uses alcohol very infrequently. Functional status is poor, she ambulates very little at baseline in a wheelchair. She lives in a NH. . Family History: Brother status post CABG at age 69. Physical Exam: On Admission to MICU: Physical exam: VS T 99.0 BP 110/50 HR 70 RR 12 O2Sat 100% on AC 500x12 RR 12 40% Ge: Intubated, sedated HEENT: NC/AT, PERRLA, anicteric NECK: no LAD, JVD at 8cm, no carotid bruit, left EJ in place COR: S1S2, regular rhythm, no r/g, split 2, III/VI holosystolic murmur over apex. No RV heave. PULM: crackles about 1/3 up both lung fields anteriorlly. No wheeze. ABD: + bowel sounds, soft, nd, nt Skin: warm extremities, large hematoma over R knee, back not examined. EXT: 1+ DP, 2+ edema, swelling of b/l hip. Left hip bandaged with soft tissue swelling of thigh. RLE shortened and externally rotated. GU: Perineal bruising / hematoma with swelling of left labia > right labia. Pertinent Results: ECHO at OSH: Preserved LV function, R pulm HTN, RV enlargement, TV 51mmHg . ECHO here: The left atrium is moderately dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is dilated. Right ventricular systolic function is borderline normal. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The aortic valve leaflets are mildly thickened. Mild (1+) aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. The transmitral gradient is normal for this prosthesis. No mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2125-2-13**], left ventricular systolic function appears preserved. Tricuspid regurgitation is now more prominent and pulmonary artery systolic pressure is now higher. . CTA: 1. No evidence of pulmonary embolism. 2. Bilateral pleural effusions with patchy ground-glass opacity, apical interlobular septal thickening, and peripheral reticulation. Findings likely, at least in part, reflect a degree of hydrostatic pulmonary edema. It is unclear what component of these changes are chronic in nature. If indicated, followup CT after the patient's acute clinical findings have been treated may be performed. 3. Numerous thoracic compression fractures, age indeterminate. 4. Coronary artery and other vascular calcifications consistent with atherosclerosis. 5. Mediastinal and hilar lymphadenopathy. . HIP Xray: 1. Displaced right femur intratrochanteric fracture with pins in situ. 2. Left femur fracture. . CT HEAD: No acute intracranial pathology including no sign of intracranial hemorrhage. . R Elbow: 2views: Radial head fracture . BNP: [**10-17**] 9000 at OSH . Admission EKG: Afib, V-paced, HR 70, ST scooping in I; throughout three sequential EKG on [**12-15**]/[**10-17**] patient is developing a TWI in isolated V2 Brief Hospital Course: # B/l hip fractures [**1-12**] osteoporosis s/p repair: The patient was originally admitted with bilateral hip fractures, the left newer than the right, of unclear origin as there was no known trauma or fall. However, there was no suspicion of abuse and social work confirmed this. After some respiratory optimization, described below, and reversal of her INR with vitamin K and FFP, the patient underwent a left hemiarthroplasty on [**10-25**]. Intraoperatively, some abnormal appearing changes, possible ST depressions, appeared on her telemetry and the operation limited to only the left side at that time. She was a difficult ween from the ventilator and was transferred to the MICU for rule out ACS and vent ween. She was ruled out by a normal EKG and 3 sets of negative cardiac biomarkers. She also required several units of PRBCs for postoperative anemia. She was extubated shortly thereafter. She returned to the OR for a right ORIF and removal of the preexisting hardware on [**10-29**]. Again, post operatively she developed respiratory distress and had to be reintubated and transferred to the MICU. During her time in the MICU, there was noted to be soft tissue swelling of her R knee and thigh but an ultrasound showed no DVT and no gross hematoma. After stabilization the patient returned to the floor and began working with physical therapy. She was WBAT with anterolateral hip precautions. Her pain was controlled initially with IV morphine and PO oxycodone but she was eventually transitioned to Percocet with good effect. She was also begun on calcium and vitamin D supplementation to augment her Actonel usage. She was maintained on enoxaparin prophylaxis until her coumadin level returned to a therapuetic range. She will continue physical therapy at her rehabilitation center with a follow up with Dr. [**Last Name (STitle) 1005**] in orthopedics. # Respiratory distress: Upon transfer from the OSH, the patient had a new oxygen requirement of unknown etiology. After an initial concern of PE a CTA was done that showed no PE but chronic interstitial lung disease with possible acute pulmonary edema overlying it. A repeat echocardiogram showed a preserved LVEF but moderate to severe pulmonary hypertension. She carries a diagnosis of CHF but discussions with the PCP could not further clarify its cause or current status. Based on clinical status, it is likely diastolic dysfunction. Prior to her first operation, the patient was diuresed with IV Lasix with improvement in her oxygen requirement. After the operation, she was not able to intially extubated but was extubated within 24 hours and did well subsequently. She returned to the OR on [**10-29**] and developed postoperative respiratory distress and hypercarbia (ABG 7.0/99/84), likely from fluid overload and sedation. She was reintubated, diuresed with IV lasix and extubated sucessfully the next day. The patient was weened from her O2 to room air and placed back on her outpatient regimen of 40mg Lasix PO BID and Spironolactone 25mg PO daily to maintain her current fluid balance. She remained stable on room air with minimal subjective shortness of breath. # Anemia: Over the course of her admission, the patient has required a total of 9 units of PRBCs to be transfused for intra and postoperative blood loss, including a small amount of bleeding into her bilateral thighs. The last transfusion was on [**10-31**] and her hematocrit has remained stable since with no further signs of bleeding. . # Afib: Initially her INR was reversed with vitamin K and FFP. She was maintained on good rate control using her metoprolol. After completion of her surgeries, her coumadin was restarted. Her INR will need to be checked 2-3x/week until it is therapeutic with a goal INR of [**1-13**]. Her digoxin was also restarted after the completion of her surgeries. . # Hyperkalemia: Pt noted to be hyperkalemic post-op, with no peaked T waves on EKG (in setting of baseline intraventricular conduction delay). Hyperkalemia resolved after administration of calcium, insulin, and D50; this issue has remained stable. . # Prosthetic (porcine) valve/MVR: No need for continued anticoagulation for this reason. Valve function appears to be good based on echocardiogram. . # ARF: Cr was noted to be 1.2 on admission and 1.7 at the OSH, with no recent recorded baseline (last Cr [**2124**]). Currently, this issue is resolved after blood transfusion with recent Cr of 0.9 - 1.0. The etiology was likely prerenal with poor forward flow from CHF. . # UTI: E.Coli UTI here, noted on admission. Reported as ESBL at OSH and initially got Zosyn, however then found to be bactrim sensitive, which was treated with 7 day course of Bactrim which finished [**2131-10-28**]. No further signs of infection. . # Depression: Patient continued on home regimen of citalopram 20mg PO daily. . # Hypothyroidism: Patient continued on home regimen of levothyroxine 88mcg daily. . # FEN: Regular as tolerated. Patient not hungry, so have added Ensure TID to supplement . # Prophylaxis: Enoxaparin 40mg SC daily, pneumoboots, PPI PO (home regimen), bowel regimen. . # Access: PICC . # Code: DNR, not DNI (form in chart), confirmed with daughter. . # Comm: Daughter [**Name (NI) 4014**] [**Telephone/Fax (1) 4015**], also HCP Medications on Admission: Medications at home: Actonel 35mg po Daily MVI Daily Protonix 40mg po Daily MOM 30cc po prn BIsacodyl supp one rectal prn Mylanta 20cc po Daily prn Peptobismol 2 TSP po Duonebs Q6h prn Citalopram 20mg po Daily Spironolactone 25mg Daily Digoxin 0.125mg Daily Vitamin C Daily 500mg Colchicine 0.3mg Daily Furosemide 40mg [**Hospital1 **] Metoprolol 50mg [**Hospital1 **] Tylenol Loperamide 2mg po Daily prn Levoxyl 88mcg Daily Coumadin 5mg Daily Discharge Medications: 1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 2. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous DAILY (Daily): Continue until INR >2. 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 4. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day) as needed. 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO twice a day: Hold for SBP<100 or HR<60. 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO BID (2 times a day). 13. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Warfarin 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 19. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a day. 20. DuoNeb 0.5-2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. 21. Colchicine 0.6 mg Tablet Sig: 0.5 Tablet PO once a day. 22. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 23. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Location (un) 582**] - [**Location (un) **] Discharge Diagnosis: Bilateral Hip Fractures s/p L hemiarthroplasty ([**10-25**]) and R ORIF ([**10-29**]) Diastolic Congestive Heart Failure Lupus with interstitial lung disease. Discharge Condition: All vitals signs stable, off oxygen. Hematocrit stable. Pain well controlled. Discharge Instructions: You were admitted with fractures of both hips. You also had some trouble breathing, requiring oxygen. This was likely from fluid build up in your lungs, backing up from your heart. This is called congestive heart failure. This fluid was removed using IV Lasix and then will be kept off using the oral form of Lasix you were previously on. Your hip fractures were repaired surgically, however after each surgery, you had increased trouble breathing, requiring intubation and stays in the medical ICU. However, you quickly recovered after more fluid was taken off with Lasix. You also had a drop in your blood count after the operations, from blood loss during the operation and some bleeding into the legs after the operation. You received a number of blood transfusions to correct this. However, your blood count is now stable and you have no further signs of bleeding. You also had a small and temporary decrease in your kidney function upon admission, likely due to some dehydration. This improved and was normal by the time of discharge. You also had a urinary tract infection treated with a course of antibiotics, finished in the hospital. During your first operation, there was a concern about your heart based on the EKG taken during the operation. However, subsequent labs tests showed no damage to the heart and no heart attack. You were also given some pain medications to control your pain. These will continue at the rehab facility. You will also continue Followup Instructions: Please call Dr.[**Name (NI) 4016**] office at ([**Telephone/Fax (1) 2007**] to schedule a follow up appointment in the next 1-2 weeks. Please call Dr. [**Last Name (STitle) 4017**] office at [**Telephone/Fax (1) 4018**] to schedule a follow up appointment in the next few weeks. Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2131-12-24**] 11:30

[ "996.49", "517.8", "428.30", "733.13", "E849.5", "458.9", "285.9", "427.31", "584.9", "287.5", "428.0", "274.9", "733.19", "E878.8", "518.81", "244.9", "V42.2", "733.14", "799.02", "733.09", "V45.01", "041.4", "599.0", "416.8", "710.0", "398.90" ]

icd9cm

[ [ [] ] ]

[ "99.04", "81.52", "38.93", "79.35", "78.65" ]

icd9pcs

[ [ [] ] ]

15128, 15201

7235, 12517

305, 374

15404, 15484

4861, 6894

17004, 17399

4086, 4123

13011, 15105

15222, 15383

12543, 12543

15508, 16981

12564, 12988

4176, 4842

247, 267

402, 3389

6903, 7212

3411, 3790

3806, 4070

57,599

173,496

38115

Discharge summary

report

Admission Date: [**2109-1-23**] Discharge Date: [**2109-2-11**] Date of Birth: [**2059-8-24**] Sex: F Service: CARDIOTHORACIC Allergies: Topamax / Percocet / Tizanidine / Lyrica / Tramadol / Methocarbamol / Naproxen / Gabapentin / Sulfa (Sulfonamide Antibiotics) / Cefazolin / Albuterol Attending:[**First Name3 (LF) 5790**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: [**2109-1-24**]: Flexible bronchoscopy: moderate supraglottic edema, severe cervical TM. Small amount of GT at distal trachea [**2109-1-26**]: Rigid bronchoscopy, flexible bronchoscopy revision of tracheostomy stoma, and placement of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] tracheostomy tube size 12. [**2109-1-28**]: Flexible & Rigid bronchoscopy Removal of T tube. Placement of a #8 [**First Name9 (NamePattern2) 67572**] [**Last Name (un) 295**] TTS tube at 88 mm in length. Therapeutic aspiration of secretions. [**2109-1-28**]: Flexible bronchoscopy under moderate sedation. [**2109-1-31**]: Flexible bronchoscopy at bedside [**2109-2-1**]: Tracheostomy changed to #6 cuffed [**Year/Month/Day 67572**] over a suction catheter. Flexible bronchoscopy to ensure adequate position of trach. History of Present Illness: Ms. [**Known lastname **] [**Known lastname **] is a 49 year old female with TBM s/p right thoractomy and tracheoplasty on [**2108-11-28**] by Dr. [**Last Name (STitle) **]. She discharged home with VNA on [**2108-12-17**]. She was last seen [**2109-1-1**] by Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] at which time she had bronchoscopy and minitrach downsize. She went home, but called with increasing shortness of breath mostly feeling air is not able to fully pass through windpipe. She is not coughing secretions and has suctioned her minitrach which is capped and patent. She denies fevers. Her blood sugars have been labile, along with headache yesterday, and GERD, otherwise ROS is unchanged. Past Medical History: -Severe TBL at both mainstem bronchi and bronchus intermedius, s/p both metal and silicone stents (unsuccessful [**1-2**] inflammation requiring intubation during stent removal [**6-9**]), s/p Trach/PEG [**6-9**]. - Recent MSSA VAP and PNA x3 in recent years -Osteopenia/osteoarthritis -Chronic pain -Type II DM -Diabetic neuropathy -Depression -Fibromyalgia -Herpes -Hiatal hernia -Hypertension -Hypothyroidism -IBS -GI bleed -nephrolithiasis -Irregular heart rhythm -NASH (w/up Hepatitis serologies, Fe studies, alpha-1-antitrypsin neg). -PTSD -Agoraphobia -GERD -Latent TB - INH course stopped (with ID input) [**1-2**] - transaminitis -Carpal tunnel -S/P appendectomy -S/P C-section -S/P cholecystectomy -S/P hysterectomy -S/P R oophorectomy -S/P L ovarian cystectomy -S/P shoulder surgery x4 -S/P L breast ductal excision -S/P liver biopsy x2 Social History: - Lives in VT w/ husband and mom. - Tobacco history: none, has used medical marijuana in the past. - ETOH: allergic (hives) - Illicit drugs: none Family History: noncontributory Physical Exam: Vital signs on discharge T 99.2, BP 112/68, HR 72-96 SR, RR 18, O2 sats 94-100% RA, ambulating on room air 92-99%. Occassionally drops to 88% for seconds then rebounds with deep breathing. Blood sugars: 86-250. Discharge Physical Exam: Gen: pleasant, slightly anxious, in NAD HEENT: #6 [**Month/Day (2) **] trach intact. Lungs: rhonchi t/o CV: RRR S1, S2, no MRG or JVD Abd: soft, NT, ND Ext: warm without edema Pertinent Results: [**2109-2-10**] 04:22AM BLOOD WBC-6.4 RBC-3.46* Hgb-9.0* Hct-28.2* MCV-82 MCH-26.2* MCHC-32.0 RDW-14.6 Plt Ct-241 [**2109-1-23**] 05:05PM BLOOD WBC-7.9 RBC-4.10* Hgb-11.0* Hct-33.4* MCV-82 MCH-26.8* MCHC-32.8 RDW-13.1 Plt Ct-258 [**2109-1-28**] 08:00PM BLOOD WBC-13.6*# RBC-4.00* Hgb-10.3* Hct-32.9* MCV-82 MCH-25.7* MCHC-31.3 RDW-13.0 Plt Ct-262 [**2109-1-29**] 05:23AM BLOOD WBC-13.6* RBC-3.57* Hgb-9.3* Hct-29.5* MCV-83 MCH-25.9* MCHC-31.4 RDW-13.2 Plt Ct-261 [**2109-2-10**] 04:22AM BLOOD Glucose-105* UreaN-7 Creat-0.5 Na-141 K-3.9 Cl-105 HCO3-30 AnGap-10 [**2109-2-4**] 01:57AM BLOOD ALT-21 AST-25 AlkPhos-138* TotBili-0.2 [**2109-2-10**] 04:22AM BLOOD Calcium-9.3 Phos-5.0* Mg-2.2 AFB on [**2109-2-1**], [**2109-2-2**], [**2109-2-3**]: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR [**2109-1-28**] 8:23 pm URINE Source: CVS. **FINAL REPORT [**2109-1-29**]** URINE CULTURE (Final [**2109-1-29**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Blood cultures x 2 [**2109-1-28**] negative. [**2109-1-28**] 7:42 pm BRONCHOALVEOLAR LAVAGE **FINAL REPORT [**2109-1-31**]** GRAM STAIN (Final [**2109-1-28**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN SHORT CHAINS. RESPIRATORY CULTURE (Final [**2109-1-31**]): Commensal Respiratory Flora Absent. STREPTOCOCCUS PNEUMONIAE. >100,000 ORGANISMS/ML.. PRESUMPTIVELY PENICILLIN SENSITIVE BY OXACILLIN SCREEN. STAPH AUREUS COAG +. >100,000 ORGANISMS/ML.. OF TWO COLONIAL MORPHOLOGIES. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STREPTOCOCCUS PNEUMONIAE | STAPH AUREUS COAG + | | CLINDAMYCIN----------- <=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S PENICILLIN G---------- S TRIMETHOPRIM/SULFA---- <=0.5 S CHEST RADIOGRAPH [**2109-2-8**]: INDICATION: Status post tracheostomy, evaluation for pneumonia, evaluation for interval change. COMPARISON: [**2109-2-5**]. FINDINGS: As compared to the previous radiograph, the tracheostomy tube is in unchanged position. Also unchanged is the left PICC line. Normal lung volumes. Decrease in extent of the pre-existing signs suggesting pulmonary edema. Improved ventilation of the lung bases with resolution of the pre-existing retrocardiac atelectasis. Small left basal atelectasis. No pleural effusions. Known right apical rib defect. Brief Hospital Course: Ms. [**Known lastname **] [**Known lastname **] was admitted to [**Hospital1 1170**] on [**2109-1-23**] for shortness of breath. A flexible bronchoscopy was performed by interventional pulmonology on HD#2 for evaluation of her tracheobronchomalacia. Flexible bronchoscopy showed moderate supraglottic edema, severe cervical, and small amount of granulation tissue at the stoma site. Severe TM was seen at the mid-trachea. Mod to severe TM at distal trachea. Moderate TM was seen at the Right mainstem bronchus. Thick non-purulent secretions were seen. On [**2109-1-26**] she was taken to the operating room for Rigid bronchoscopy, flexible bronchoscopy revision of tracheostomy stoma, and placement of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] tracheostomy tube size 12. Below is a systems review of her hospital course after the [**Location (un) **] T-tube: Respiratory: 24-48 hours following T-tube placement she developed respiratory distress and hoarseness. She was emergently taken back to the operating room for Flexible bronchoscopy, Rigid bronchoscopy and Removal of T tube. She had placement of a #8 [**First Name9 (NamePattern2) 67572**] [**Last Name (un) 295**] TTS tube at 88 mm in length and aspiration of secretions. She was transfer to the PACU and while there developed respiratory distress. Bedside Flexible bronchoscopy was performed under moderate sedation with aspiration of thick secretions was performed. Her respiratory status improved but she required 1:1 monitoring with frequent deep tracheal suction, and FIO2 70% to maintain oxygen adequate oxygen saturation. On [**2109-1-30**] following transfer to the floor she continued to have intermittent desaturation requiring suction and high 02 requirements. She was transferred to the TSICU and interventional pulmonary performed a bedside flexible bronchoscopy which showed minimal secretions and trachael edema with overgrowth of tissue at distal portion of trach. On [**2109-2-1**] her trach was changed to #6 cuffed [**Date Range 67572**], and she was maintained on the ventilator to allow for imrovement in granulation tissue and inflammation. Bronchoscopy on [**2109-2-4**] showed improvement of granulation tissue and inflammation. She was removed from the vent [**2109-2-5**] and tolerated Trach mask at 50%. She was rested on the ventilator [**2109-2-6**] overnight. She was monitored closely and her respiratory status improved. She was transferred to the floor on [**2109-2-7**] on TC 35% Fi02 with oxygen saturations of 98%. Aggressive pulmonary toilet continued with xopenex and mucomyst inhalers Mucinex 1200mg po bid was also continued. She failed passey muir valve trial on [**2109-2-11**], but was able to phonate around the trach with cuff deflated. She ambulated with oxygen saturation above 92% on room air. Cardiac: She remained hemodynamically stable in sinus rhythm 70's. Her home blood pressure medication was continued. GI: She continued high dose PPI and H2 blockers for her GERD. She tolerated a regular diet without signs of aspiration followed her trach change. She had a regular bowel movement prior to discharge. She had no nausea or vomiting. Renal: Renal function remained normal with good urine output. Her electrolytes were repleted as needed. Endocrine: Her blood sugars were labile into the high 200's and at times just below 100. [**Last Name (un) **] was consulted [**2109-2-8**] to assist in management. Her glargine was changed to 30units in the am, and 32 units in the pm. She was sent home on this new regimine with a regular insulin sliding scale. ID: An infectious disease consult was made [**2109-1-31**], after her [**1-28**] BAL cultures grew MSSA and S.pneumoniae, both of which patient appears to have been colonized with on prior sampling. However, given her worsening secretions, fever, leukocytosis post-procedure along with CXR showing b/l patchy infiltrates, she was treated with nafcillin + levofloxacin through [**2109-2-14**].(Initially she received broad spectrum antibiotics until cultures speciated). ID felt she was fine to stop nafcillin on date of discharge and continue PO levofloxacin 750mg po daily through [**2-14**]. The patient carries dx of LTBI for which prior isoniazid course was interrupted by transaminitis. AFB x 3 was done and negative. Vascular access: TLC was placed on [**2020-2-1**] for IV antibiotics and fluids, until left-sided PICC line with tip in the mid to low SVC was placed [**2109-2-4**]. The PICC wasd discontinued [**2109-2-11**] prior to discharge by the IV nurse. Pain/Anxiety: Her home dilaudid and ativan po regimine was continued while in house. She required IV dilaudid and ativan midstay, but transitioned back to oral dosing. Pastoral care saw her and assisted with relieving anxiety through meditation exercises, which was reported effective. Disposition: Physical therapy consultation was obtained. The patient was cleared for home with a cane and home physical therapy. She continued to make steady progress and was discharged to home with her husband in [**Name (NI) 3914**] on [**2109-2-11**], and will follow-up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] with bronchcoscopy in two weeks. She has had VNA services in the past and has trach humidfied O2 and suction supplies with nebilizers. Medications on Admission: insulin- lantus 50 units qhs, and regular insulin SS, acyclovir 400', alprazolam 1''', amitriptyline 75', fluoxetine 80', hydromorphone 6''', ipratropium'''', kapidex 60', calcium/vitD, colace 100'', guafenesin 1200'', MVI, senna Discharge Medications: 1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*6* 5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. hydromorphone 2 mg Tablet Sig: Three (3) Tablet PO Q8H (every 8 hours). 9. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO ONCE (Once). 11. insulin glargine 100 unit/mL Solution Sig: 30 units in am, 32 units 12 hours later in pm units Subcutaneous as directed. 12. Regular insulin sliding scale Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Humalog Humalog Humalog Humalog 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 71-100 mg/dL 0 Units 0 Units 0 Units 0 Units 101-150 mg/dL 6 Units 6 Units 8 Units 0 Units 151-200 mg/dL 8 Units 8 Units 10 Units 0 Units 201-250 mg/dL 10 Units 10 Units 12 Units 4 Units 251-300 mg/dL 12 Units 12 Units 14 Units 5 Units 301-350 mg/dL 14 Units 14 Units 16 Units 6 Units 351-400 mg/dL 16 Units 16 Units 18 Units 7 Units 13. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day: last dose 3/17. Disp:*3 Tablet(s)* Refills:*0* 14. amitriptyline 75 mg Tablet Sig: One (1) Tablet PO at bedtime. 15. fluoxetine 20 mg Tablet Sig: Four (4) Tablet PO once a day. 16. Mucinex 1,200 mg Tablet, ER Multiphase 12 hr Sig: One (1) Tablet, ER Multiphase 12 hr PO every twelve (12) hours. Disp:*60 Tablet, ER Multiphase 12 hr(s)* Refills:*2* 17. acetylcysteine 20 % (200 mg/mL) Solution Sig: Three (3) ml Miscellaneous every twelve (12) hours: take with xopenex. 18. home oxygen 2L NC for Oxygen sats <92% 19. humidified oxygen 35% cool mist trach collar while resting at night. suction trach prn secretions. Discharge Disposition: Home With Service Facility: Central [**Hospital 3914**] Home Health & Hospice Discharge Diagnosis: - Tracheobronchomalacia with moderate supraglottic edema, severe cervical TM, small amount of granulation tissue at distal trachea - MSSA and Streptococcus pneumoniae pneumonia - Latent TB - HTN - DM type 2 - NASH - Hyperlipidemia - Hypothyroidism - Osteopenia - Osteoarthritis - Hiatal Hernia - Carpal Tunnel - IBS - GI bleed - Hemorrhoids - Kidney stones (4 in last 10 years) - PNA (x 3, all in last 7 years) - Chronic Pain - Herpes - Depression - Fibromyalgia 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: Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you have: -Fevers greater than 101.5 or chills -Increased cough, shortness of breath -#6 cuffed [**Telephone/Fax (1) 67572**] trach care as previous: wear humidified trach collar 35% while resting at night. Suction as needed. -Keep trach cuff deflated. Do not place passey muir valve over trach at this time. -Continue with mucomyst and xopenex and mucinex 1200 mg twice daily indefinitely. Diabetes: Your long acting glargine insulin was changed to twice a day: Take 30 units in the morning and 32 units in the evening. Take your sliding scale as noted. Follow up with your primary care doctor regarding your diabetes and changing your insulin. Check your blood sugars before meals and at bedtime. You will go home on levofloxacin 750 mg once a day through [**2109-2-14**] for your pneumonia. Please complete this antibiotic course. Walk a few times a day. While on narcotics: take stool softeners and do not drive. Followup Instructions: Please call Dr.[**Name (NI) 14679**] office [**Telephone/Fax (1) 3020**] for your appointment times. We are working on your followup appointment. Followup with your primary care doctor in a week regarding diabetes and medical management, pain, and anxiety. Completed by:[**2109-2-11**]

[ "V02.59", "519.19", "466.0", "401.9", "795.5", "482.41", "244.9", "V58.67", "357.2", "571.8", "E878.1", "530.81", "E879.8", "478.6", "250.62", "482.49", "518.5", "996.59", "519.09" ]

icd9cm

[ [ [] ] ]

[ "31.74", "33.21", "96.04", "97.23", "33.24" ]

icd9pcs

[ [ [] ] ]

14740, 14820

6733, 12073

436, 1253

15329, 15329

3523, 6710

16526, 16815

3058, 3075

12354, 14717

14841, 15308

12099, 12331

15512, 16503

3090, 3301

377, 398

1281, 2005

15344, 15488

2027, 2877

2893, 3042

3326, 3504

3,784

114,778

26113

Discharge summary

report

Admission Date: [**2150-2-18**] Discharge Date: [**2150-3-10**] Date of Birth: [**2124-5-17**] Sex: M Service: CARDIOTHORACIC Allergies: Hurricaine Attending:[**First Name3 (LF) 5790**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Thoracentesis [**2150-2-19**] Bronchoscopy, Right VATS with lung decortication and chest tube placement [**2150-2-20**] Bronchoscopy, Right VATS, evacuation of hematoma [**2150-2-25**] Transesophageal Echocardiogram [**2150-3-6**] History of Present Illness: This is a 25 year old gentleman with a history of IV drug abuse who presented to [**Hospital1 **] [**Location (un) 620**] on [**2150-2-17**] with 2 weeks of pleuritic chest pain and was found to have a large right-sided pleural effusion and a left lower lobe infiltrate. The patient reports pain with deep inspiration and coughin. He describes chills. He has no prior history of pneumonia or pulmonary problems. At [**Name2 (NI) **] he was febrile to a temp of 102 and cultures were drawn; he was started empirically on ceftriaxone and zithromax. He became progressively hypoxic to 88 on room air (up to 95% on 4 liters). A thoracentesis was performed but failed and his effusion worsened. Past Medical History: Depression Polysubstance Abuse Suicidal Ideation Motor Vehicle Accident Social History: The patient has a history of IV heroin and cocaine use. He smokes 4 packs of tobacco/week. He completed some community college. He lives with his mother in [**Name (NI) 932**], MA. He is working in construction. Family History: Noncontributory Physical Exam: ON admission: v/s 101.8, 148/66, pulse 120 sinus, 27, 93% on 4 L Gen: answering questions appropriately, falling asleep (sedatives on-board) HEENT: PERRL, EOMI, MMM Neck: no LAD CV: sinus tachycardia, no murmur Chest: poor inspiratory effort, bronchial breath sounds at right base, crackles at left base Abd: soft, + BS, nontender Extr: warm, 2+ DP, no edema Neur: CN 2-12 grossly intact, strength 5/5 throughout Pertinent Results: SEROLOGIES [**2150-2-18**] 09:41PM BLOOD WBC-24.4* RBC-4.19* Hgb-12.3* Hct-34.5* MCV-82 MCH-29.5 MCHC-35.8* RDW-13.0 Plt Ct-354 [**2150-2-19**] 06:45PM BLOOD WBC-18.3* RBC-3.21* Hgb-9.8* Hct-27.0* MCV-84 MCH-30.4 MCHC-36.1* RDW-13.2 Plt Ct-276 [**2150-2-19**] 11:53PM BLOOD WBC-20.5* RBC-3.74* Hgb-11.0* Hct-31.3* MCV-84 MCH-29.4 MCHC-35.1* RDW-13.1 Plt Ct-349 [**2150-2-23**] 10:40AM BLOOD WBC-12.9* RBC-2.97* Hgb-9.2* Hct-24.9* MCV-84 MCH-30.9 MCHC-36.9* RDW-13.1 Plt Ct-500* [**2150-2-26**] 03:29PM BLOOD WBC-16.6* RBC-2.90* Hgb-8.7* Hct-24.4* MCV-84 MCH-30.1 MCHC-35.9* RDW-13.5 Plt Ct-571* [**2150-3-6**] 06:00AM BLOOD WBC-12.7* RBC-3.50* Hgb-9.9* Hct-29.0* MCV-83 MCH-28.3 MCHC-34.1 RDW-13.4 Plt Ct-592* [**2150-3-7**] 10:00AM BLOOD WBC-10.5 RBC-3.36* Hgb-9.6* Hct-27.8* MCV-83 MCH-28.6 MCHC-34.5 RDW-13.4 Plt Ct-541* [**2150-3-8**] 04:35AM BLOOD WBC-9.6 RBC-3.56* Hgb-10.5* Hct-29.3* MCV-82 MCH-29.4 MCHC-35.8* RDW-13.3 Plt Ct-474* [**2150-2-18**] 09:41PM BLOOD PT-14.3* PTT-35.3* INR(PT)-1.4 [**2150-2-20**] 01:58AM BLOOD PT-13.6* PTT-33.2 INR(PT)-1.2 [**2150-3-5**] 11:46AM BLOOD Fibrino-738* [**2150-3-6**] 06:00AM BLOOD Fibrino-767* [**2150-3-6**] 09:00AM BLOOD Eos Ct-490* [**2150-2-21**] 01:16PM BLOOD Ret Aut-1.0* [**2150-2-18**] 09:41PM BLOOD Glucose-123* UreaN-8 Creat-0.7 Na-132* K-4.0 Cl-96 HCO3-26 AnGap-14 [**2150-2-19**] 06:45PM BLOOD Glucose-97 UreaN-7 Creat-0.6 Na-134 K-4.0 Cl-97 HCO3-28 AnGap-13 [**2150-2-20**] 01:58AM BLOOD Glucose-119* UreaN-9 Creat-0.6 Na-135 K-3.8 Cl-97 HCO3-29 AnGap-13 [**2150-3-6**] 06:00AM BLOOD Glucose-89 UreaN-21* Creat-1.8* Na-142 K-4.8 Cl-103 HCO3-26 AnGap-18 [**2150-3-7**] 10:00AM BLOOD Glucose-91 UreaN-23* Creat-1.8* Na-140 K-4.5 Cl-104 HCO3-26 AnGap-15 [**2150-3-8**] 04:35AM BLOOD Glucose-104 UreaN-24* Creat-1.7* Na-141 K-4.2 Cl-104 HCO3-26 AnGap-15 [**2150-2-18**] 09:41PM BLOOD ALT-13 AST-17 LD(LDH)-197 AlkPhos-75 TotBili-0.6 [**2150-2-18**] 09:41PM BLOOD Albumin-3.5 Calcium-9.1 Phos-3.9 Mg-1.7 [**2150-2-19**] 06:45PM BLOOD Albumin-3.3* Calcium-8.9 Phos-4.3 Mg-1.8 [**2150-2-21**] 01:16PM BLOOD Calcium-8.1* Phos-3.8 Mg-1.9 Iron-10* [**2150-2-20**] 01:58AM BLOOD VitB12-714 Folate-7.2 [**2150-2-21**] 01:16PM BLOOD calTIBC-183* Ferritn-465* TRF-141* [**2150-2-20**] 01:58AM BLOOD TSH-2.7 [**2150-3-6**] 09:00AM BLOOD C3-210* C4-50* [**2150-2-26**] 05:13PM BLOOD HIV Ab-NEGATIVE [**2150-2-22**] 06:00AM BLOOD Vanco-7.2* [**2150-2-22**] 09:02PM BLOOD Vanco-4.4* [**2150-2-28**] 08:34PM BLOOD Vanco-18.5* [**2150-3-2**] 04:34PM BLOOD Vanco-24.2* [**2150-3-4**] 09:45AM BLOOD Vanco-17.4* RADIOLOGY: [**2150-2-18**] CXR: There is a large right pleural effusion. Cannot exclude loculation and decubitus chest radiograph could be performed if indicated. The large pleural effusion obscures the detail of the lung parenchyma. The left lung demonstrates only mild atelectasis of the left base. No focal consolidations of the left lung is seen. The pleural effusion is causing mass effect and mild shift of the mediastinal structures to left side. There is no evidence of pneumothorax. [**2150-2-19**] CT Chest: 1) Massive right-sided pleural effusion, with associated atelectasis of the entire right lung. No hematocrit level. No particular loculations are seen, and the density attenuation values are at the upper limits of normal for simple fluid. Empyema should be considered in patient with history of IVDA. Differential diagnosis includes TB, malignancy, and trauma (no evidence of active or recent bleeding). 2) Left-sided peripheral ground glass opacities are likely infectious. Septic emboli should be considered given history of IVDA. [**2150-2-23**] CT Chest: 1. Interval placement of two right-sided chest tubes, as detailed above, with decrease in size of massive right-sided effusion. 2. Residual loculated fluid collections within the right hemithorax as detailed above with higher attenuation collections near the right lung apex, which could represent areas of hemothorax. 3. Small focal area of consolidation in the left lung base medially, which could represent an area of rounded atelectasis or small developing infiltrate. [**2150-2-27**] Renal US: . No evidence of hydronephrosis. 2. Large kidneys bilaterally with relatively echogenic cortices. [**2150-3-4**] Ultrasound: No evidence of DVT in either lower extremity. [**2150-3-6**] TEE: A catheter is seen in the right atrium that extends to the tricuspid annulus. There is no associated thrombus/vegetation. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. A TEE procedure related complication occurred (see comments for details). IMPRESSION: Low normal LV systolic function with mild mitral regurgitation. Mild mitral regurgitation with normal valve morphology. No definite evidence of endocarditis. PATHOLOGY: Pleural rind": - Scant fibroadipose tissue and granulation tissue with abundant fibrinopurulent exudates. - No malignancy identified. MICROBIOLOGY: [**2150-2-19**] Pleural fluid culture: negative [**2149-2-20**] Bronchial Fluid culture: negative Brief Hospital Course: This is a 25 year old gentleman with polysubstance abuse who presented from [**Hospital1 18**] [**Location (un) 620**] with fevers and a large right pleural effusion that was not drainable via thoracentesis. He was admitted to the medical intensive care unit. He was started on broad-spectrum antibiotics. Ultrasound-guided thoracentesis was performed on admission but was unsuccessful in draining adequate fluid. Thoracic surgery was consulted and the pateint underwent a VATS with mechanical pleurodesis and placement of a chest tube and [**Doctor Last Name 406**] drain on [**2150-2-19**] (please see the operative note of Dr. [**Last Name (STitle) **] for full details). Infectious disease consultation was obtained and the patient was started on Zosyn and Vancomycin; AFB and sputum cultures were sent but were negative. Given the patient's aggitation on admission and substance abuse history, psychiatric consultation services were obtained and recommended refraining from benzodiazepenes and Haldol/Seroquel prn. On post-operative day 4 a CT scan revealed worsening effusion and the patient again was taken for VATS with evacuation of hemothorax. He did well post-operatively with no pain-related or respiratory complications. A Trans-esophageal echocardiogram was performed on [**2150-3-3**] but discontinued secondary to hypoxia from meth-hemoglobinemia; a repeat TEE performed on [**2150-3-7**] revealed no evidence of endocarditis. The patient developed a rise in his creatinine around this time and Renal consultation was obtained; it was thought that he developed acute interstitial nephritis from his antibiotics and the Vancomycin was discontinued. He remained afebrile with the Zosyn and his leukocytosis resolved. His [**Doctor Last Name 406**] drain was changed to a Heimlich valve on [**2150-3-5**]. His chest-tube was removed on [**2150-3-6**] and his [**Doctor Last Name 406**] drain on [**2150-3-8**]. A PICC was placed for outpatient continuation of his 4 weeks of antibiotics. Because of the patient's substance abuse history, he was not deemed a candidate for home antibiotic therapy and a rehabilitation hospital was found for him. He was discharged with continuation of his inpatient medications and planned follow-up with thoracic surgery, infectious diseases, and psychiatry. All questions were answered to his satisfaction upon discharge. Medications on Admission: Motrin Discharge Medications: 1. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*30 Tablet(s)* Refills:*0* 2. Senna Oral 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 4. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q2-3 PRN () as needed for pain. 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection [**Hospital1 **] (2 times a day). 8. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for prn agitation. 9. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift 10. Haloperidol 5 mg IV Q4H:PRN agitation 11. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: 4.5 g Recon Solns Intravenous Q8H (every 8 hours): Continue for total of 4 weeks, through [**2150-3-24**]. 12. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 13. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN Peripheral IV - Inspect site every shift Discharge Disposition: Extended Care Facility: [**Hospital6 2222**] - [**Location (un) 538**] Discharge Diagnosis: Primary: Right-sided hemothorax Secondary: polysubstance abuse, depression, acute renal failure from interstitial nephritis Discharge Condition: Tolerating POs. Good pain control. Afebrile. Discharge Instructions: Take all medications as prescribed. You should call the office with any worsening shortness of breath or chest pain, or fevers to 102. Only take narcotics as necessary for pain control, and note that they can cause confusion and nausea. You may shower and resume your regular diet and physical activity, but refrain from strenuous activity for 3 weeks. Please call with any questions. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4340**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2150-3-24**] 11:30 [Infectious [**Hospital 2228**] Clinic] You should follow-up in the office with Dr. [**First Name (STitle) **] [**Name (STitle) **] (thoracic surgery) within 2 weeks-- call for an appointment at a time of your convenience at [**Telephone/Fax (1) 170**] Follow-up with your outpatient psychiatrist (Dr. [**Last Name (STitle) 64786**] [**Telephone/Fax (1) 64787**]) within 2 weeks. Completed by:[**2150-3-9**]

[ "486", "310.0", "305.90", "300.4", "V09.0", "998.11", "510.9", "041.11", "462", "511.8", "584.5", "289.7", "518.82", "780.6", "528.9", "285.9", "907.0" ]

icd9cm

[ [ [] ] ]

[ "33.24", "38.93", "34.91", "99.04", "34.09", "33.23", "34.6", "34.51", "94.62", "34.04", "88.72" ]

icd9pcs

[ [ [] ] ]

11412, 11485

7796, 10166

288, 520

11653, 11700

2047, 7773

12133, 12697

1581, 1598

10223, 11389

11506, 11632

10192, 10200

11724, 12110

1613, 1613

238, 250

548, 1239

1628, 2028

1261, 1335

1351, 1565

154

162,891

7846+55880

Discharge summary

report+addendum

Admission Date: [**2118-4-5**] Discharge Date: [**2118-4-11**] Date of Birth: [**2073-7-26**] Sex: M Service: CARDIOTHOR CHIEF COMPLAINT: Coronary artery disease. HISTORY OF PRESENT ILLNESS: The patient is a 44 year old male with known coronary artery disease status post inferior myocardial infarction and status post stenting of the right coronary artery in [**2117-12-4**]. The catheterization at that time also demonstrated multiple lesions of the left anterior descending and left circumflex. Subsequently he was stable and underwent a second catheterization in [**2118-12-4**] because of more recurrent chest pain, which showed good result in the right coronary artery, no change in the left coronary artery lesion. Since then he continued on a stable course until the past week when he developed progressive episodes of chest pain. The pain began to occur at rest and it was not relieved with Nitroglycerin sublingual. He was promptly brought to [**Hospital1 69**]. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Decreased HDL. 4. Coronary artery disease; myocardial infarction in 12/[**2117**]. PAST SURGICAL HISTORY: 1. Status post right coronary artery stenting in [**2117-12-4**]. 2. Status post left ankle surgery. ALLERGIES: Include Vicodin and question of an intravenous antibiotics, unknown name. MEDICATIONS ON ADMISSION: 1. Aspirin 325 mg p.o. q. day. 2. Toprol XL 100 mg p.o. q. day. 3. Lisinopril 5 mg p.o. q. day. 4. Lipitor 10 mg p.o. q. day. 5. Multivitamin one p.o. q. day. 6. Calcium supplement q. day. SOCIAL HISTORY: The patient is married with three children, exercises on a regular basis. He is a past smoker who quit in [**2100**]. Denies any ETOH. PHYSICAL EXAMINATION: On admission, the patient has vital signs which are stable. HEENT is within normal limits. Neck shows no lymphadenopathy, no bruits. Chest is clear to auscultation. Heart is regular rate and rhythm with no murmur. Abdomen is soft, nontender. Extremities with normal pulses; no edema. LABORATORY: On admission, white blood cell count of 6.0, hematocrit of 39, platelets of 216. Sodium of 143, potassium of 4.5, BUN of 14, creatinine of 1.2, glucose of 69, INR 1.0. EKG was significant for normal sinus rhythm with normal axis. No evidence of ischemia. HOSPITAL COURSE: On the day of admission, the patient underwent cardiac catheterization. This revealed 90% stenosis of the right coronary artery, 70% stenosis of the proximal left anterior descending, mid-LAD, and 70% stenosis of the diagonal 1, 70% stenosis of the proximal circumflex and 90% stenosis of the obtuse marginal 1. On hospital day two, the patient went to the Operating Room where he underwent coronary artery bypass graft times five. He had left internal mammary artery to the left anterior descending, saphenous vein graft to diagonal, saphenous vein graft ramus; saphenous vein graft to right coronary artery and left radial artery to the obtuse marginal. He tolerated this procedure well; was transferred to the Intensive Care Unit, intubated and on a Nitroglycerin drip. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Last Name (NamePattern1) 3835**] MEDQUIST36 D: [**2118-4-10**] 14:39 T: [**2118-4-11**] 14:01 JOB#: [**Job Number 12115**] Name: [**Known lastname 4946**], [**Known firstname **] Unit No: [**Numeric Identifier 4947**] Admission Date: [**2118-4-5**] Discharge Date: [**2118-4-11**] Date of Birth: [**2073-7-26**] Sex: M Service: CARDIOTHOR ADDENDUM: This is a continuation from the Discharge Summary. The patient was in stable condition in the Intensive Care Unit. He was weaned and extubated. On postoperative day number one, hematocrit was found to be 18 and repeat was found to be 19. After discussion with the patient, the patient did not wish to have a transfusion unless absolutely necessary. It was decided that the patient would not will not receive a transfusion unless he became unstable and then upon which he will be reapproached with the idea. The patient remained stable postoperatively and remained in the Unit for close monitoring. On postoperative day number two, his hematocrit remained stable at 19. His respiratory and cardiovascular status remained stable. He was transferred to the Floor. After transfer to the Floor, the patient's chest tube was then discontinued. The patient was seen by Physical Therapy. He was ambulating; his diet was advanced on postoperative day number three. His wires were discontinued and his Foley catheter was removed. His hematocrit remained stable at 19.5. On postoperative day number four, he continued to advance his level of activity which is up to currently a Level 5. He remained stable. His most recent hematocrit is 21.8. The patient is tolerating a regular diet and is stable for discharge to home. DISCHARGE DIAGNOSES: 1. Coronary artery disease status post coronary artery bypass graft times five. 2. Hypertension. 3. Hypercholesterolemia. DISCHARGE MEDICATIONS: 1. Colace 100 mg p.o. twice a day. 2. Enteric coated aspirin 325 mg p.o. q. day. 3. Isosorbide mononitrate 30 mg p.o. q. day. 4. Lasix 20 mg p.o. q. day times seven days. 5. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 3112**] 20 mEq p.o. q. day times seven days. 6. Lipitor 10 mg p.o. q. day. 7. Multivitamin, one p.o. q. day. 8. Lopressor 12.5 mg p.o. twice a day. 9. Niferex 150 mg p.o. q. day. 10. Lisinopril 5 mg p.o. q. day. 11. Percocet 5/325, one to two p.o. q. four hours p.r.n. CONDITION AT DISCHARGE: Good. DISPOSITION: The patient was discharged home. DISCHARGE INSTRUCTIONS: 1. He is to follow-up with Dr. [**Last Name (STitle) 71**] in six weeks. 2. To follow-up with Dr. [**Last Name (STitle) 4948**] who is the primary care physician, [**Name10 (NameIs) **] two weeks. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 2728**] Dictated By:[**Last Name (NamePattern1) 4949**] MEDQUIST36 D: [**2118-4-10**] 14:45 T: [**2118-4-11**] 14:16 JOB#: [**Job Number 4950**]

[ "414.01", "272.0", "V15.82", "411.1", "V45.82", "996.72", "401.9", "412" ]

icd9cm

[ [ [] ] ]

[ "36.15", "88.72", "36.14", "88.53", "39.61", "88.56" ]

icd9pcs

[ [ [] ] ]

5048, 5174

5197, 5722

1395, 1591

2349, 5027

5818, 6321

1177, 1369

1769, 2331

5738, 5794

156, 182

211, 999

1021, 1154

1608, 1746

57,157

175,583

54462

Discharge summary

report

Admission Date: [**2137-6-16**] Discharge Date: [**2137-6-21**] Date of Birth: [**2053-6-7**] Sex: F Service: MEDICINE Allergies: Cymbalta / Penicillins / Keflex / Coumadin Attending:[**First Name3 (LF) 1845**] Chief Complaint: Asymtomatic Hypotension and Tachycardia Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a 84 y/o F with CAD s/p BMS, sCHF w/EF 30%, PAFib, DM2, PAD, HTN, HL, h/o DVT/PE with recent admission for CHF exacerbation coming with asymptomatic hypotension and tachycardia. She was in her prior state of health until ~3 days ago where she was diagnosed with a UTI and prescribed ciprofloxacin. She decided to take only 1 dose. Then, during the last day she has noticed increase fatigue. She denies any nausea, vomitting, chills, fever, diarrhea, changes in her medications. Her son took her BP and found her 70/50 and HR 100-150's, so held her metoprolol. He called Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] who recommended for the patient to be evaluated in the ER. Family called EMS who found her sats in the mid 80s on room air and hypotensive up to 80/40 with an ECG showeing AFib with RVR at 140s. Pt received diltiazem by EMS (unknown dose). In the [**Hospital1 1388**] ER her initial VS were T 99.2 F, HR 119 BPM, BP 96/63 mmHg, RR 19 X', SpO2 ? and no pain. She was good apearing, no crackles, wheezes or ronchi, but with a pressure ulcer in her heel. Her initial ECG showed AFib with RVR at 140s and her labs showed WBC 11.2, HCT 31.7 at her baseline, PLTs of 258, normal coags, Trop-T: 0.12, CK: 42 MB: Notdone, Na:129, K:4.7, Cl:101, TCO2:17, Glu:63, Lactate:1.8, BUN 46, creatinine 1.2 and a negative UA. There was concern for MI, because the ER physicians did not think that the renal function was elevated enough to explain the elevation in the Trop T so she was started on a heparin gtt. She was noted to have ECG ischemic changes. CXR was concerning for LLL PNA, so pt received Vanc 1g/Levofloxacin 750(radiology read it as normal). PE-CT did not show infection or clots. Blood pressure was fluctuating in the mid 80s and responded to fluid, patient receiving aproximately 3 L NS. Pt received her metoprolol 12.5 dose (home dose) and her AFib was rate controlled. Pt received tylenol as well. Past Medical History: -CAD s/p BMS x 3 to RCA [**2136-6-22**] -Chronic systolic heart failure with EF 30% 02/10 -Chronic diastolic CHF -Atrial fibrillation with hx of RVR -[**Month/Day/Year 2320**] -PAD s/p R ant tib artery stent [**2136-7-5**] -Normocytic anemia, Hct ~33% at baseline -Post-partum DVT/PE [**2093**] -HTN -Hyperlipidemia -Peripheral neuropathy -OA -s/p appendectomy -s/p bilateral total hip replacement -6/27/9 - 7/2/9 for right 1st toe ulcer w/maggot infection, with amputation 6/28/9 Social History: Married, 6 living children. Lives in [**Location 745**], lived with husband until recent admission to rehab. - Tobacco history: Never - ETOH: None - Illicit drugs: None Has one son who lives out of state but is involved in her care. Family History: Father - Deceased, MI at 50 Mother - Deceased, MI at 65 3 brothers died of [**Name (NI) 5290**] in 60s and 70s. Pt also reports significant FH of HTN Physical Exam: Admission Physical Exam: VITAL SIGNS - Temp F, BP 117/64 mmHg, HR 83 BPM, RR X', O2-sat 98% RA GENERAL - well-appearing woman in NAD, comfortable, appropriate, not jaundiced (skin, mouth, conjuntiva) HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, 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 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding. EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**6-5**] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait Discharge Physical Exam: Gen - Alert, NAD HEENT - NC/AT CV - RRR; No m/r/g Resp - CTA B Abd - S/NT/ND; BS present Pertinent Results: --------------- Admission Labs: --------------- [**2137-6-15**] 10:30PM BLOOD WBC-11.2* RBC-3.62* Hgb-10.4* Hct-31.7* MCV-88 MCH-28.6 MCHC-32.6 RDW-20.2* Plt Ct-258 [**2137-6-15**] 10:30PM BLOOD PT-13.1 PTT-31.8 INR(PT)-1.1 [**2137-6-15**] 10:30PM BLOOD Fibrino-642* [**2137-6-16**] 06:52AM BLOOD Glucose-159* UreaN-37* Creat-1.0 Na-129* K-4.5 Cl-102 HCO3-17* AnGap-15 [**2137-6-15**] 10:30PM BLOOD Calcium-8.6 Phos-3.0 Mg-1.6 [**2137-6-16**] 06:52AM BLOOD calTIBC-168* VitB12-474 Folate-16.8 Ferritn-100 TRF-129* [**2137-6-16**] 06:52AM BLOOD Iron-16* [**2137-6-16**] 01:30PM BLOOD TSH-4.2 [**2137-6-16**] 01:30PM BLOOD T4-5.7 [**2137-6-15**] 10:38PM BLOOD Glucose-63* Lactate-1.8 Na-129* K-4.7 Cl-101 calHCO3-17* --------------- Cardiac Enzymes: --------------- [**2137-6-15**] 10:30PM BLOOD cTropnT-0.12* [**2137-6-15**] 10:30PM BLOOD CK-MB-NotDone [**2137-6-16**] 06:52AM BLOOD CK-MB-NotDone cTropnT-0.10* [**2137-6-16**] 01:30PM BLOOD CK-MB-NotDone cTropnT-0.09* [**2137-6-15**] 10:30PM BLOOD CK(CPK)-42 [**2137-6-16**] 06:52AM BLOOD CK(CPK)-47 [**2137-6-16**] 01:30PM BLOOD CK(CPK)-42 --------------- Urine Studies: --------------- [**2137-6-19**] 12:03AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.021 [**2137-6-19**] 12:03AM URINE Blood-LG Nitrite-NEG Protein-75 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [**2137-6-19**] 12:03AM URINE RBC-[**4-5**]* WBC->50 Bacteri-MOD Yeast-MANY Epi-0-2 [**2137-6-18**] 03:29AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.020 [**2137-6-18**] 03:29AM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG [**2137-6-18**] 03:29AM URINE RBC-13* WBC-525* Bacteri-NONE Yeast-FEW Epi-0 [**2137-6-15**] 11:50PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013 [**2137-6-15**] 11:50PM URINE Blood-NEG Nitrite-NEG Protein-25 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2137-6-15**] 11:50PM URINE RBC-0 WBC-[**4-5**] Bacteri-FEW Yeast-NONE Epi-1 --------------- Other Labs: --------------- [**2137-6-15**] 10:30PM BLOOD Lipase-25 [**2137-6-16**] 06:52AM BLOOD calTIBC-168* VitB12-474 Folate-16.8 Ferritn-100 TRF-129* [**2137-6-16**] 01:30PM BLOOD TSH-4.2 [**2137-6-16**] 01:30PM BLOOD T4-5.7 [**2137-6-17**] 03:13AM BLOOD Cortsol-23.7* [**2137-6-18**] 03:28AM BLOOD Vanco-25.2* --------------- Discharge Labs: --------------- [**2137-6-21**] 06:55AM BLOOD WBC-5.5 RBC-3.83* Hgb-10.5* Hct-34.1* MCV-89 MCH-27.3 MCHC-30.7* RDW-19.9* Plt Ct-211 [**2137-6-21**] 06:55AM BLOOD Glucose-93 UreaN-52* Creat-2.3* Na-132* K-3.9 Cl-104 HCO3-18* AnGap-14 [**2137-6-21**] 06:55AM BLOOD Calcium-7.6* Phos-3.8 Mg-2.2 --------------- Micro Data: --------------- C.Diff + VRE Screen + Blood Cx PENDING at time of d/c with no growth to date --------------- Imaging: --------------- CTA chest ([**6-16**]): No pulmonary embolism or dissection. no focal areas of consolidation. Small hiatal hernia. CXR ([**6-15**]): The lungs are clear without consolidation or edema. There is mild aortic tortuosity with calcified plaque seen at the arch. The cardiac silhouette is borderline enlarged but stable. No effusion or pneumothorax is seen. The visualized osseous structures are diffusely osteopenic with no displaced fractures evident. IMPRESSION: No acute pulmonary process. CXR ([**6-19**]): New small bilateral right greater than left pleural effusion. Brief Hospital Course: Pt is 84-year-old woman with CAD s/p BMS, sCHF w/ EF 30%, PAFib, DM2, PAD, HTN, HL, h/o DVT/PE with recent admission for CHF exacerbation coming with asymptomatic hypotension and tachycardia. # Paroxysmal atrial fibrillation, question of sick sinus syndrome - Patient with diarrhea at home and poor oral intake after being discharged at rehab. She was feeling very tired and with poor appetite. She probably became orthostatic and hypotensive that caused someone to hold her metoprolol. Afterwards patient went into PAF that responded to her home medications. Her CHADS2 score is 4 and she is not anticoagulated because in the past she has developed nausea and discomfort with coumadin. She was briefly started on a heparin gtt out of concern for ACS, but this was stopped as the suspicion for ACS was low. During the admission, her metoprolol was held initially for concern of hypotension. On the first hospital night, she was noted to develop several [**6-6**] second sinus pauses on telemetry; her heart rate was observed to fall to the 30s transiently throughout the night. During these times, she was asymptomatic with stable blood pressure. Her sinus pauses and bradycardia were felt to be secondary to sick sinus syndrome. It is possible that the combination of acute illness, excessive AV nodal blockade (from metoprolol and diltiazem she had received in the ED and en route to the hospital), and underlying conduction disease, caused her heart rate to drop. Given the patient's desires for less invasive interventions, we did not consult cardiology. Her beta-blocker was held though the acute illness and restarted after she was felt to be more stable clinically. However, later in her hospital course, she was noted to have some additional episodes of bradycardia to the 20's with associated lightheadedness. Her metoprolol was therefore held. # Leukocytosis/UTI - Patient with WBC of 11.2 at admission. Patient with recent antibiotic use and subsequent diarrhea, poor PO intake. She was treated with broad-spectrum antibiotics, which included vancomycin (empiric cellulitis/foot ulcer coverage), Flagyl (empiric C dif coverage), and meropenem (empiric UTI coverage given history of resistant Klebsiella UTIs). C.diff came back positive, and the patient was continued on flagyl. Vancomycin was discontinued because it was felt that her foot ulcers did not appear infected. She was presumed to have a UTI her UA findings; however, her urine cultures only grew out yeast. Given her history of resistant Klebsiella in her urine in the past, she was treated with meropenem throughout her hospitalization. This was changed to cefpodoxime prior to discharge. She will continue a total course of 10 days of antibiotics for her UTI. # Diarrhea: Found to be positive for c.diff during her admission. She was placed on flagyl, which she will continue for 14 days (10 days after she completes the cefpdoxime for her UTI). # Melena: Pt developed guaiac positive dark stools during her hospital course. Hematocrit remained relatively stable. GI was consulted and saw the patient. She declined any invasive procedures for further evaluation, given her goals of care. Her ASA and plavix were stopped. She did not have any further episodes of melena. ASA and plavix can be restarted 7 days after discahrge. # Acute Renal Failure - Was initially thought to be related to dehydration. However, creatinine was continuing to rise when the patient was called out to the medical floor. FeNa was 1.17%. It was felt that the patient's ARF was likely multifactorial, related to dehydration, ATN in the setting of her initial hypotension, as well as kidney injury from her CTA contrast. Pt was given IV fluids and her creatinine improved. Creatinine peaked at 3.2 and was improving at the time of discharge. # Hyponatremia - Was thought to possibly be related to free water administration, as pt had been getting D5W. Could also be related to hypovelmia. Improved with NS boluses. # CAD - We initially continued her home ASA, Plavix, and Lipitor. Imdur was held given her hypotension at presentation. ASA and Plavix were later held given her melena and can be restarted 7 days after discharge. # Pump - Patient with EF 30%, no signs of failure, clean lungs. In the setting of her hypotension, Lasix, spironolactone and metoprolol were held. these were not restarted at discharge; further adjustments of these medications can be done by the patient's outpatient providers. # Diabetes mellitus - She was treated with humalog insulin sliding scale. Glargine and glipizide were held due to hypoglycemia. These can be restarted by the patient's outpatient providers. # PVD - We continued her home statin. ASA and plavix were held after the patient developed melena. These can be restarted 7 days after discharge. # Code - DNR/DNI (this was confirmed with patient and with her son and health-care proxy). Medications on Admission: Atorvastatin 80 mg PO Daily Plavix 75 mg PO Dialy Lasix 20 mg PO Daily Glipizide 5 mg PO BID Lantus 20 U QHS Imdur 30 mg PO Daily Metoprolol 12.5 mg PO BID Nitroglycerin 0.4 mg SL PRN Silver sulfadiazine 1% in ankle Spironolactone 25 mg PO Daily Aspirin 325 mg PO Daily Bacitracin-polymixin B Discharge Medications: 1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 2. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual PRN as needed for chest pain: [**Month (only) 116**] repeat after 5 minutes if chest pain has not resolved. If pt continues to have chest pain after 3 doses or 15 minutes, please contact covering MD. 3. Insulin Lispro 100 unit/mL Solution Sig: As Directed Units Subcutaneous As Directed: Please follow provided sliding scale. 4. Imdur 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 14 days: To complete 10 days of treatment AFTER cefpodoxime is finished. Last day of flagyl should be [**2137-7-5**]. 6. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 7. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days: To complete a total of 10 days of treatment, ending on [**2137-6-25**]. 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 9. Anticoagulation Patient's aspirin and plavix were held due to GI bleeding. These medications should be restarted 7 days after discharge, on [**2137-6-28**]. The patient's dosages were as follows: Aspirin 325 mg daily Plavix (Clopidogrel) 75 mg daily 10. Outpatient Lab Work Patient should have a CBC and a Chem 10 (Na, K, Cl, HCO3, BUN, Cr, Glucose, Ca, Mg, Phos) drawn on Monday [**2137-6-24**] and faxed to her PCP. [**Name10 (NameIs) **] fax number is [**Telephone/Fax (1) 3382**] (Attn: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]). Discharge Disposition: Extended Care Facility: [**Hospital1 599**] Senior Healthcare of [**Location (un) 55**] Discharge Diagnosis: Primary Diagnosis: - Urosepsis - Clostridium Difficile Colitis - Atrial Fibrillation with Sick Sinus Syndrome Secondary Diagnosis: - Coronary Artery Disease - Systolic Heart Failure - Diabetes Mellitus - Peripheral Artery Disease - Hypertension 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 for low blood pressure and a fast heart rate. You were felt to likely have a urinary tract infection, and you were treated with antibiotics for this. You were also found to have a bacterial infection in your colon, for which you were placed on antibiotics. Your hospital course was also complicated by fast and slow heart rates and some kidney dysfunction. At the time of discharge, your kidney function was improving and your heart rate was stable. CHANGES TO YOUR MEDICATIONS: - Hold plavix and aspirin. These medications should be restarted 7 days after discharge ([**2137-6-28**]). - START Iron suppplementation - START Pantoprazole, given your recent GI bleeding - START Cefpodoxime 200 mg daily for 4 more days, to complete a total course of 10 days of therapy (ending on [**2137-6-25**]). - START Flagyl 500 mg every 8 hours for 14 more days, to complete a total course of 10 days of Flagyl AFTER you complete your other antibiotics. You last day of Flagyl will be [**2137-7-5**]. - Your lasix and spironolactone were stopped given your low blood pressure and renal dysfunction. You should discuss with your PCP when you will restart these medications. - You lantus and glipizide were stopped because your blood sugars were low. You should discuss with your PCP when to restart these medications. You are being continued on sliding scale insulin. - You metoprolol was stopped given your slow heart rate. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. It was a pleasure taking part in your medical care. Followup Instructions: You have the following follow-up appointments scheduled: Department: PODIATRY When: FRIDAY [**2137-6-28**] at 3:50 PM With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM [**Telephone/Fax (1) 543**] Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: [**Hospital3 249**] When: FRIDAY [**2137-7-12**] at 9:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6310**], NP [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: TUESDAY [**2137-7-16**] at 4:20 PM With: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1849**], 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

[ "995.92", "414.01", "427.81", "707.22", "578.1", "428.22", "428.0", "V49.71", "599.0", "250.80", "401.9", "443.9", "008.45", "707.07", "276.2", "V12.51", "038.9", "707.13", "427.31", "272.4", "584.5", "276.1", "V45.82" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

14653, 14743

7698, 12593

342, 348

15032, 15032

4257, 4273

16820, 17882

3106, 3257

12937, 14630

14764, 14764

12619, 12914

15207, 15692

6645, 7675

3297, 4123

15721, 16797

5007, 6295

263, 304

376, 2335

14896, 15011

4289, 4990

14783, 14875

15047, 15183

2357, 2840

2856, 3090

6307, 6629

4148, 4238

20,573

122,611

9493

Discharge summary

report

Admission Date: [**2129-6-16**] Discharge Date: [**2129-6-17**] Service: CME The patient was transferred to the CCU with a retroperitoneal hematoma status post carotid catheterization. HISTORY OF PRESENT ILLNESS: The patient is an 82-year-old female with a history of CVA with no residual defects, severe aortic stenosis, mild to moderate mitral stenosis who was referred to [**Hospital1 18**] for cerebral angiography. The patient was to undergo an AVR/MVR and a preop workup demonstrated conflicting information regarding her carotid disease. An ultrasound in [**3-9**] showed an 86% RCA stenosis while a subsequent ultrasound in [**5-8**] showed a 60-79% left ICA stenosis. Therefore, the patient was to go on carotid catheterization today to determine the extent of her disease. The catheterization was complicated by hypertension and bradycardia status post removal of her arterial sheath for which she was given atropine, IV fluids, and dopamine. Her postprocedure hematocrit was 29.3, which was decreased from 37.2 on admission. She was given 1 unit of packed red blood cells. She was transferred to the CCU for further monitoring. PAST MEDICAL HISTORY: 1. CVA in [**2126**] with no residual defects. 2. Severe AS. 3. Mild to moderate mitral stenosis. 4. Hypothyroidism. 5. Hypertension. 6. Dyslipidemia. 7. History of colonic polyps. 8. Peptic ulcer disease. 9. Peripheral vascular disease. 10. History of GI bleed on Plavix. ALLERGIES: She is allergic to Plavix which causes a GI bleed; Pravachol, which is, diarrhea; and Demerol with an unknown allergy. MEDICATIONS ON ADMISSION: 1. Synthroid 100 mcg p.o. q.d. 2. Norvasc 5 mg p.o. q.d. 3. Toprol XL 50 mg p.o. q.d. 4. Effexor 75 mg p.o. q.d. 5. Zetia 10 mg p.o. q.d. 6. Folgard. 7. Aggrenox. 8. [**Doctor First Name **]. 9. Avalide 300/12.5 mg q.d. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: She is widowed and lives alone. Currently, the patient denies any chest pain, shortness of breath, nausea or vomiting. She has mild abdominal pain in her left lower quadrant but otherwise no complaints. PHYSICAL EXAMINATION: Patient was afebrile. Pulse 76, blood pressure 114/45, respiratory rate 19. She was saturating 97 percent on 2 liters. Pertinent exam findings are, her neck was supple. Her JVD was approximately 7 cm. Her lungs were clear. Her heart was regular rate and rhythm. She had a grade 4/6 systolic ejection murmur heard throughout the precordium, best at the right upper sternal border. On abdominal exam, her belly was soft, normoactive bowel sounds. She had mild left lower quadrant tenderness without rebound. She had mild voluntary guarding. On extremity exam, she had no edema. She had 2 plus dorsalis pedis pulses bilaterally and [**Name (NI) **] PT pulses bilaterally. LABORATORY DATA: Her preop hematocrit was 37.2 and as mentioned, the patient had a drop in her hematocrit to 29.3. Her chem-7 was unremarkable. CT of the abdomen showed a large hematoma in the left groin which extended into the left pararenal space and up to the left renal hilum. With regard to her cerebral angiography, her left common carotid artery was normal. There was a mild osteal stenosis in the left external carotid artery. The ICA was normal to the brain. The right common carotid artery was normal. There was a severe osteal external carotid artery stenosis with a calcified bulb, but the ICA was normal to the brain. HOSPITAL COURSE: She was admitted to the CCU for further monitoring. Her blood pressure medications were held until the next day. She was transfused an additional unit of packed red blood cells with an appropriate response to her hematocrit. Her hematocrit on the day of discharge was 35.2 and had remained stable. Furthermore, her blood pressure remained stable during her hospital course. In addition, her abdominal exam on the day of discharge was stable, and she had no evidence of rebound or guarding. After discussion with the attending, it was felt that she was safe to be discharged, given her stable vital signs and hematocrit. DISCHARGE INSTRUCTIONS: She is instructed to call her primary care provider should she develop any lightheadedness or dizziness, chest pain, shortness of breath, abdominal pain, nausea or vomiting. She was also instructed to take only her Toprol XL and Norvasc for now, and she was told not to take her hydrochlorothiazide or her Avapro until she followed up with her primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 3816**] [**6-21**]. DISCHARGE DIAGNOSES: 1. Retroperitoneal hematoma. 2. Hypertension. 3. Depression. 4. Dyslipidemia. 5. Severe aortic stenosis. 6. Mild to moderate mitral stenosis. 7. Carotid angiography: Severe osteal disease of the right external carotid artery with only mild atherosclerotic disease of both internal carotid arteries. She was instructed to follow up with Dr. [**Last Name (STitle) 32300**] on [**Last Name (STitle) 3816**] [**6-21**] at 11:30 a.m. Her valve replacement surgery was canceled because of her recent bleeding. MAJOR SURGICAL/INVASIVE PROCEDURES: Carotid catheterization/angiography. DISCHARGE MEDICATIONS: 1. T4 100 mcg p.o. q.d. 2. Toprol XL 50 mg p.o. q.d. 3. She was told to hold her hydrochlorothiazide. 4. Effexor 75 mg p.o. q.d. 5. Norvasc 5 mg p.o. q.d. She was told not to take this medicine until she followed up with her PCP. 6. Irbesartan 300 mg. She was told not to take this until she followed up with her primary care doctor. 7. [**Doctor First Name **] 60 mg p.o. q.d. 8. Multivitamin 1 tablet p.o. q.d. 9. Aggrenox 200/25 mg. She was instructed not to take this until she followed up with her PCP, [**Name10 (NameIs) 3**] it could cause bleeding. 10. She was also discharged on aspirin 81 mg p.o. q.d. However again, she was told not to take this until she followed up with her primary care doctor. [**First Name11 (Name Pattern1) 487**] [**Last Name (NamePattern4) **], [**MD Number(1) 32301**] Dictated By:[**Doctor Last Name 10457**] MEDQUIST36 D: [**2129-7-6**] 12:29:34 T: [**2129-7-7**] 03:17:13 Job#: [**Job Number 32302**]

[ "433.30", "E879.8", "401.9", "396.2", "998.11", "244.9", "438.9", "272.0", "458.29" ]

icd9cm

[ [ [] ] ]

[ "88.41", "99.04" ]

icd9pcs

[ [ [] ] ]

1859, 1877

4567, 5156

5179, 6178

1620, 1842

3459, 4086

4111, 4546

2123, 3441

227, 1160

1182, 1594

1894, 2100

16,943

128,643

28359

Discharge summary

report

Admission Date: [**2146-3-8**] Discharge Date: [**2146-3-14**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 26489**] Chief Complaint: hypotension, bacteremia Major Surgical or Invasive Procedure: RIJ central line placement History of Present Illness: [**Age over 90 **] year old male with chief complaint of fevers 103, foot redness and pain, Podiatrist Dr. [**Last Name (STitle) **],MDS, anemia of chronic renal insufficiency, and cryptogenic cirrhosis. BUE Psuedogout, also has cough with productive sputum. Daughter-[**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) **]. Patient reports redness swelling at foot. Daughter was concerned and brought patient to hospital given fever at home to 103 and redness swelling. . In the ED, initial vs were: T98.4 P90 BP 90/40 R16 O2 sat 100% RA. Patient was given vanco/zosyn for toe infection. Patient reported fevers, and cough at home with worsening redness at foot. Initial exam notable for decreased breath sounds at bases, guaiac positive brown stool, +erythema and warmth at R-great toe. Was transiently hypotensive in ED with SBP as low as 78/30. Was mentating well with that BP, however. Received 1.5L NS (gentle given low EF), and R-IJ placed. Podiatry consulted who felt patient would likely need amputation of great toe and this was potential source for sepsis. Also received hydrocortisone for stress dose steroids given h/o prednisone use in past. Cards curbsided on patient for troponin of 0.35 (new from baseline). Was c/p free in ED. ECG with new TWI in V2/V3 but otherwise unchanged with baseline RBBB. Recommended against heparin. . Was seen by podiatry on [**2146-3-1**] and 2nd hallux was noted to be w/o e/o infection. . On arrival to floor, was mentating well w/o pain or other complaints. Past Medical History: 1. Myelodysplasia w/ anemia, thrombocytopenia and leukopenia 2. Chronic GI bleed, transfusion dependent, on iron therapy. 3. h/o endocarditits [**2140**] 4. Vasculitis 5. Chronic kidney disease, baseline Cr 2.0-2.1 6. Cryptogenic cirrhosis. 7. Coronary artery disease. 8. Thrombocytopenia. 9. BPH. 10. Gait disturbance. 11. Gastric antral vascular ectasia. Social History: Lives in 2 family home in daughter's house, does well at home with baseline. Retired foreign service officer, previous [**Last Name (un) 68836**] Scholar, and spent career in [**Country 2559**] working at Consulate. Family History: Father, mother, brother all died of "heart disease" Physical Exam: Vitals: T: BP: P: R: 18 O2: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: [**2146-3-8**] 10:30AM BLOOD WBC-13.03*# RBC-2.22* Hgb-6.5* Hct-20.5* MCV-93 MCH-29.5 MCHC-31.9 RDW-17.8* Plt Ct-41* [**2146-3-9**] 05:58AM BLOOD WBC-8.4 RBC-2.91*# Hgb-8.6*# Hct-26.0* MCV-89 MCH-29.7 MCHC-33.2 RDW-17.7* Plt Ct-37* [**2146-3-10**] 02:01AM BLOOD WBC-8.2 RBC-3.04* Hgb-9.4* Hct-27.2* MCV-89 MCH-30.9 MCHC-34.6 RDW-17.6* Plt Ct-34* [**2146-3-8**] 10:30AM BLOOD PT-15.5* PTT-30.0 INR(PT)-1.4* [**2146-3-10**] 02:01AM BLOOD PT-15.2* PTT-26.9 INR(PT)-1.3* [**2146-3-8**] 10:30AM BLOOD Glucose-253* UreaN-61* Creat-2.6* Na-130* K-4.6 Cl-96 HCO3-24 AnGap-15 [**2146-3-9**] 05:58AM BLOOD Glucose-158* UreaN-61* Creat-2.2* Na-137 K-4.4 Cl-103 HCO3-23 AnGap-15 [**2146-3-10**] 02:01AM BLOOD Glucose-125* UreaN-57* Creat-2.0* Na-135 K-3.9 Cl-103 HCO3-24 AnGap-12 [**2146-3-8**] 10:30AM BLOOD CK(CPK)-226* [**2146-3-8**] 06:36PM BLOOD CK(CPK)-226* [**2146-3-9**] 05:58AM BLOOD LD(LDH)-292* CK(CPK)-166 [**2146-3-8**] 10:30AM BLOOD cTropnT-0.35* [**2146-3-8**] 06:36PM BLOOD CK-MB-6 cTropnT-0.33* [**2146-3-9**] 05:58AM BLOOD CK-MB-6 cTropnT-0.20* [**2146-3-10**] 02:01AM BLOOD Calcium-7.9* Phos-3.1 Mg-2.3 [**2146-3-8**] 06:35PM BLOOD Type-[**Last Name (un) **] Temp-35.8 Rates-/19 pO2-43* pCO2-36 pH-7.44 calTCO2-25 Base XS-0 Intubat-NOT INTUBA [**2146-3-9**] 12:34AM BLOOD Type-ART Temp-35.6 pO2-136* pCO2-31* pH-7.46* calTCO2-23 Base XS-0 Intubat-NOT INTUBA [**2146-3-8**] 10:28AM BLOOD Lactate-5.3* [**2146-3-8**] 12:56PM BLOOD Lactate-1.7 [**2146-3-8**] 06:35PM BLOOD Lactate-1.5 [**2146-3-9**] 06:21AM BLOOD Lactate-1.6 TTE: Suboptimal echo views.The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is probably mild to moderate regional left ventricular systolic dysfunction with distal LV/apical akinesis. There is no ventricular septal defect. 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) 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. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. No valvular vegetations seen. UE Doppler: No DVT CXR: FINDINGS: A single AP upright view of the chest was obtained. The cardiomediastinal silhouette is stable in appearance. There is atherosclerotic disease of the aorta. Again noted is a right-sided pacemaker with two leads terminating in the right atrium and two leads terminating in the right ventricle. The lungs are clear bilaterally without focal opacity identified. The right costophrenic angle is not included on this study. No left pleural effusion or pneumothorax is identified. The osseous structures are intact. IMPRESSION: No acute intrathoracic process. Brief Hospital Course: This is a [**Age over 90 **] y/o M w/ h/o ischemic cardiomyopathy, endocarditis, cryptogenic cirrhosis, and MDS p/w cellulitis, severe sepsis and demand ischemia. . #Severe Sepsis: Likely [**2-21**] to toe infection. Other infectious workup was negative including CXR, C diff toxin, UA, TTE, influenza antigen. On [**3-8**] grew 2/2 blood cxs and superficial wound culture grew Staph aureus. Surveillance cultures were subsequently negative. He was treated with vancomycin for possible MRSA. He was given stress-dose steroids. Podiatry followed him and considered debridement but opted for conservative management with outpatient follow-up for further. Vascular surgery followed him. ABIs showed mild bilateral tibial disease. TTE and TEE were negative for signs of endocarditis. When cultures grew methicillin-resistant staph aureas, the ID team made the decision to treat with an extended course of vancomycin until [**4-8**]. PICC was placed for this purpose. He will also complete a quick taper of steroids back to his outpatient dose. . # Cirrhosis: Stable, no h/o ascites. No suspicion for SBP . # Anemia/Myelodysplastic syndrome: Baseline Hct is 22-25, transfusion dependent. Transfused 3 units PRBC [**3-8**] and 2 units [**3-9**]. Hct was subsequently stable. PPI was continued. He will need to resume Aranesp (q2weekly) as an outpatient. . #Thrombocytopenia: Platelets were at baseline 40-60. . # CAD: Has h/o ischemic cardiomyopathy, and pacer. Initial trop bump likely [**2-21**] demand ischemia from anemia and sepsis physiology. Received 3 units PRBCs [**3-8**]. He ruled out for ACS by enzymes. . # Acute on Chronic Renal Failure: Likely poor forward perfusion and sepsis physiology. Cr trended down towards baseline with resuscitation. . # GAVE/Watermelon stomach: PPI was continued; pRBC were given as above. . # Diabetes: Not on diabetes medications as outpatient. Fingersticks were elvated to the upper 100s in the setting of stress dose steroids. He was given insulin sliding scale. . # Right upper extremity swelling: Apparently chronic. Upper extremity doppler studies showed no clot. . Medications on Admission: Ammonium Lactate 12% cream to heels once daily Aranesp 200ucg for Hgb < 12.0 q2 weeks Astelin two sprays each nostril [**Hospital1 **] Benzonatate 100mg [**Hospital1 **] Colesevelam 1875mg qlunch Folic Acid, Vit B6, B12 Furosemide 40mg daily Lidoderm patch Losartan 25mg daily Mom[**Name (NI) 6474**] 50ucg [**Name2 (NI) **] daily Nitro SL 0.4mg x1 Omeprazole 40mg daily Prednisone 5mg daily Propranolol 20mg [**Hospital1 **] Sulfadiazine 1% cream Flomax 0,4mg daily Cyanocobalamin 500ucg daily docusate sodium ferrous sulfate 325 mg TID Mucinex Lactobacillus bulgaricus Loperamide Psyllium Pyrixodine Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: primary: bacteremia, toe infection secondary: myelodysplasia, chronic renal insufficiency, cryptogenic cirrhosis, coronary artery disease Discharge Condition: stable Discharge Instructions: You came to the hospital with fever. This was likely caused by an infection in your toe which was also in your blood. You were treated with antibiotics. The following medications were changed: furosemide was increased prednisone was temporarily increased and will be tapered vancomycin was started, to continue until [**4-8**] Please return to the hospital or contact your doctor if you experience high fevers and shaking chills, chest pain, shortness of breath, or other symptoms that are concerning to you. Followup Instructions: Please follow up as below: Podiatry: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2146-3-15**] 3:50 Hematology: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6952**], MD Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2146-3-16**] 10:40 Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], RN Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2146-3-16**] 11:15 Infectious Disease: [**2146-4-8**] 09:00a, LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), BASEMENT ID WEST Renal: [**2146-3-31**] 01:00p, [**Hospital6 29**], [**Location (un) **] RENAL DIV-CC7 Cardiology: [**2146-3-31**] 11:00a [**Last Name (LF) **],[**First Name3 (LF) **] S, [**Hospital 273**], [**Location (un) **] CC7 CARDIOLOGY (SB) Device Clinic: [**2146-3-31**] 10:30a DEVICE CLINIC (SB), SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] DEVICE CLINIC (SB) Completed by:[**2146-3-15**]

[ "414.8", "707.21", "428.0", "707.03", "585.9", "285.9", "537.83", "276.2", "038.11", "428.22", "250.00", "584.9", "707.15", "788.20", "287.5", "995.92", "682.7", "458.9" ]

icd9cm

[ [ [] ] ]

[ "38.93", "88.72" ]

icd9pcs

[ [ [] ] ]

8901, 8986

6115, 8248

286, 314

9170, 9179

3065, 6092

9741, 10795

2496, 2549

9007, 9149

8274, 8878

9203, 9718

2564, 3046

223, 248

342, 1865

1887, 2246

2262, 2480

61,667

150,705

27131

Discharge summary

report

Admission Date: [**2160-5-19**] Discharge Date: [**2160-5-21**] Service: MEDICINE Allergies: Amoxicillin Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Anemia Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] yo M with transfusion-dependent anemia attributed to autoimmune hemolysis & chronic GI bleeding on coumadin for a mechanical aortic valve admitted with Hct drop and shortness of breath. . Mr. [**Known lastname 66590**] has been hospitalized frequently at [**Hospital1 18**], most recently in late [**2160-4-1**] with recurrent anemia attributed to GIB without hemolysis (negative Coombs test and normal LDH.) Of note those previous hospitalizations have identified component of autimmune hemolysis. Typically, he is transfused at [**Hospital 100**] Rehab q2weeks. On a routine check today, his Hct was 16.4 down from 27.4 on [**5-14**]. He complained of shortness of breath at rest and mild chest pressure. . Initial evaluation in the ED was notable for VS: 97.4, 80, 98/50, 18, 100%ra. Hct 17.9, LDH 199, BUN/Cr 48/1.5, bili 0.2, INR 3.3, hapto pending. His BP was transiently 84/47 for which he was given 1L NS with increase in his SBPs to the 90s and improvement in his sxs. He was not given blood b/c his extensive cross-matching requirements have not yet been completed. EKG notable for an old RBBB. No imaging obtained. Guiaic positive brown stool. . Of note, the patient has had extensive workup in the past for GI bleed(EGD x4, [**Last Name (un) **] x2, capsule x3, CT abd/pelvis, bleeding scan) without clear source or site, and felt to be most likely bleeding from an UGI source that is not possible to reach endoscopically. On prior admissions, further invasive testing was discussed, and the patient and HCP opted for more conservative measures including transfusions and iron supplementation. . On the floor, the patient denies any recent BRBPR, melena or hematemesis. He denies any dizziness or confusion either at the moment or over the last few days. He denies any chest pain but does have some shortness of breath over his baseline. Past Medical History: # Anemia, multifactorial as below, baseline HCT 28 # Autoimmune hemolytic anemia (Coomb's +, warm autoantibody), on prednisone 10mg Po daily # Listeria Endocarditis s/p AVR, suppressive amoxicillin stopped due to hemolytic anemia # Aortic mechanical valve, recently Coumadin resistant so intermittently on Lovenox bridge, followed by Dr. [**Last Name (STitle) **] # hx recent GI bleeds: colonoscopy [**1-10**]: noted normal colon with melanotic stool in terminal ileum # GERD: EGD [**12/2159**] Polyp in the area of the papilla; found on the wall opposite the ampulla. Small hiatal hernia. Otherwise normal EGD to third part of the duodenum. # H/o presyncope # CKD Cr 1.6-2.0 Stage III # CAD s/p NSTEMI [**7-10**] # Chronic CHF, likely diastolic, ([**9-9**] EF=50%) # Hyperlipidemia # Hypertension # Depression vs adjustment disorder after death of brother # Prostate cancer- s/p radiation # Bladder/bowel incontinence # Right lateral malleolus stage 1 pressure ulcer # Dementia Social History: Never smoked, no EtOH or other drugs. Currently living at [**Hospital 100**] Rehab. Uses wheelchair typically. Requires a significant degree of assistance in all his ADLs and IADLs. Has 2 sons and 4 grandchildren. Family History: No bleeding diatheses. Father had stomach cancer. No other cancers including colon. Physical Exam: ADMISSION EXAM: Vitals: 96.2 71 122/73 19 99% 2L General: pale, tired-appearing elderly male, lying in bed in NAD, alert and oriented, conversational HEENT: NCAT, dry MM Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally (anterior/lateral only) CV: Regular rate and rhythm, S1 + S2, mechanical ao valve sounds Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema DISCHARGE EXAM: unchanged VS:97 66 107/36 66 12 98% RA Pertinent Results: ADMISSION LABS: [**2160-5-19**] 08:50PM GLUCOSE-158* UREA N-48* CREAT-1.5* SODIUM-139 POTASSIUM-4.9 CHLORIDE-107 TOTAL CO2-24 ANION GAP-13 [**2160-5-19**] 08:50PM LD(LDH)-199 TOT BILI-0.2 DIR BILI-0.1 INDIR BIL-0.1 [**2160-5-19**] 08:50PM HAPTOGLOB-15* [**2160-5-19**] 08:50PM WBC-4.2 RBC-1.76*# HGB-6.2*# HCT-17.9*# MCV-102*# MCH-35.3* MCHC-34.7 RDW-22.4* [**2160-5-19**] 08:50PM NEUTS-84* BANDS-0 LYMPHS-13* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [**2160-5-19**] 08:50PM PT-33.1* PTT-31.5 INR(PT)-3.3* [**2160-5-19**] 08:50PM RET MAN-6.9* DISCHARGE LABS: [**2160-5-21**] 10:15AM BLOOD Hct-28.1* [**2160-5-21**] 03:42AM BLOOD WBC-4.3 RBC-2.81*# Hgb-9.4*# Hct-27.4* MCV-98 MCH-33.4* MCHC-34.2 RDW-20.7* Plt Ct-134* [**2160-5-21**] 03:42AM BLOOD Glucose-77 UreaN-28* Creat-1.2 Na-142 K-4.4 Cl-111* HCO3-24 AnGap-11 [**2160-5-21**] 03:42AM BLOOD Calcium-7.6* Phos-2.8 Mg-2.2 . Imaging: [**5-20**] CXR 1. No evidence of edema. Small left-sided pleural effusion remains unchanged. 2. Right-sided PICC appears slightly retracted when compared to the prior study and ends in the upper SVC/central right brachiocephalic vein. Brief Hospital Course: [**Age over 90 **]M with autoimmune hemolytic anemia, mechanical aortic valve on coumadin and recurrent GIB and admissions for anemia presenting from rehab with anemia. . #. Anemia: Most likely related to recurrent ongoing GIB given recent hx of the same; of note, he had not had any large bowel movements to explain this bleed on admission to the ICU. Etiology of current bleed likely coagulopathy with INR 3.3, above goal range 2 to 2.5. He has had work up in past including colonoscopy and capsule endoscopy without finding source of bleed. Patient asymptomatic and HD stable throughout his [**Hospital Unit Name 153**] stay. Other possible etiologies of his HCT drop are recurrent autoimmune or mechanical hemolysis, but this seems unlikely with LDH and bilirubin nl range. Of note, the patient is appropriately compensating for anemia, with Retic 6.9. This is likely the etiology of his elevated MCV and RDW. . Coumadin was held, a small dose of Vitamin K was given, and the patient was transfused with 3 units of RBCs. His hct was trended over 24 hours and remained stable 27-28. . He was discharged on 2mg of coumadin. # Dyspnea: Patient presented with dyspnea that was likely secondary to anemia. There was no concern for ACS given nl EKG and No concern for PNA clinically or on CXR. . # Coagulopathy: INR 3.3 with goal 2-2.5. This is likely due to coumadin dosing. Per discussion above, was given Vitamin K 0.5 mg PO x1 on admission. . # Mechanical Aortic valve: The patient has a goal INR of [**3-5**].5. Coumadin was held on admission due to supratherapeutic INR; he was discharged with INR 2.1 and 2mg coumdin daily. Please check INR daily for the next week to ensure he remains therapeutic. . # Acute on CKD: Cr currently at baseline (1.2-1.5) . # GERD: Patient was on PPI drip here but discharged on home omeprazole dose of 40mg [**Hospital1 **]. . #. CAD/Hyperlipidemia/HTN: Continued statin. Held carvedilol in setting of GIB and stable blood pressures during admission but resumed home dose of medications prior to discharge. Medications on Admission: -oxycodone 2.5 mg TID prn -warfarin 3 mg daily -tylenol 650 mg q6h prn -Vitamin B12 [**2149**] mcg daily -folic acid 4 mg po daily -omeprazole 40 mg [**Hospital1 **] -simvastatin 40 mg daily -carvedilol 3.125 [**Hospital1 **] -Bactrim SS daily (400-80) -clindamycin 600 mg prn po -levothyroxine 75 mcg daily -senna daily -prednisone 10 mg daily -acetaminophen 1000 mg [**Hospital1 **] Discharge Medications: 1. oxycodone 5 mg Capsule Sig: 0.5 Capsule PO three times a day as needed for pain. 2. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 3. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 4. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 5. folic acid 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - LTC Discharge Diagnosis: Anemia, secondary to chronic GI bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Mr. [**Known lastname 66590**], It was a pleasure taking care of you in the hospital. You were admitted with a hematocrit drop at rehab. Here we gave your blood and your hematocrit improved. . The only change that we made to your medication is: We DECREASED Coumadin from 3 mg to 2 mg daily . We did not make any other changes to your medications. . Please continue your medical care as prior to admission. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Department: HEMATOLOGY/BMT When: THURSDAY [**2160-5-29**] at 12:00 PM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3919**], RNC [**Telephone/Fax (1) 3241**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/BMT When: THURSDAY [**2160-5-29**] at 12:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD [**Telephone/Fax (1) 3241**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2160-5-21**]

[ "585.3", "272.4", "428.0", "E934.2", "V10.46", "790.92", "530.81", "428.32", "280.0", "578.9", "V43.3", "V58.65", "V58.61", "414.01", "403.90" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8691, 8756

5240, 7288

233, 239

8838, 8838

4072, 4072

9545, 10356

3394, 3482

7723, 8668

8777, 8817

7314, 7700

9023, 9522

4653, 5217

3497, 3997

4013, 4053

187, 195

267, 2139

4088, 4637

8853, 8999

2161, 3143

3159, 3378

10,983

101,261

54612

Discharge summary

report

Admission Date: [**2132-3-28**] Discharge Date: [**2132-4-10**] Date of Birth: [**2069-7-1**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5790**] Chief Complaint: Incidental finding of right upper lobe nodule Major Surgical or Invasive Procedure: Right upper lobectomy [**3-27**] for Right upper lobe nodule History of Present Illness: 62 year oldg entleman who has had a right upper lobe nodule incidentally noted on a chest CT dated [**2130-2-2**]. Serial follow up of this scan has noted an increase from 9 mm in size to 13 mm. Past Medical History: recurrent falls executive dysfunction and dementia- s/p extensive neurologic work-up Seasonal allergies Thyroid carcinoma s/p thyroidectomy. Depression/ dementia Hypercholesterolemia Mediastinoscopy for lymph node dissection [**2132-3-14**] Recent largngoscopy showing findings consistent with recurrent right laryngeal nerve palsy Social History: No history of ethanol, tobacco, drugs. He formerly worked as a customer service representative for a telephone company, but is currently unemployed. He is divorced and has two kids who are very involved in his care. They both live in [**Hospital1 614**], but one is planning to move to [**Location (un) 86**] shortly. He currently lives with his mother. Family History: Father died of myocardial infarction at the age of 68. Mother is alive and is OK. He has no siblings. Physical Exam: General- older appearing middle/elderly male, NAD. poor historian HEENT- dry mucous membranes, EOMI, PERRLA; Lungs-clear to ausculatation bilat Cor-RRR Abd-soft, NT, ND Ext- no edema, 2+ DP, PT [**Name (NI) 111708**], oriented x2, fleeting attention, resting tremor in left thumb and index finger, rhythmic movements in both lower extremities; Strength 5/5 throughout; balance-poor, need 2 full assist; gait- limited LE movement. Pertinent Results: [**2132-3-28**] 06:48PM PLT COUNT-285# [**2132-3-28**] 06:48PM WBC-13.7*# RBC-4.10* HGB-13.0* HCT-37.5* MCV-91 MCH-31.7 MCHC-34.7 RDW-13.6 [**2132-3-28**] 06:48PM CALCIUM-8.4 PHOSPHATE-3.9 MAGNESIUM-1.8 [**2132-3-28**] 06:48PM GLUCOSE-152* UREA N-30* CREAT-1.4* SODIUM-140 POTASSIUM-4.6 CHLORIDE-107 TOTAL CO2-22 ANION GAP-16 [**2132-3-28**] 09:17PM TYPE-ART PO2-171* PCO2-43 PH-7.35 TOTAL CO2-25 BASE XS--1 Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2132-4-2**] 06:25AM 11.7* 3.66* 11.8* 33.6* 92 32.1* 35.1* 13.1 239 BASIC COAGULATION (PT, PTT, PLT, INR) Plt Ct [**2132-4-2**] 06:25AM 239 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2132-4-2**] 10:58AM 100 25* 1.1 140 4.31 106 20* 18 SLIGHT HEMOLYSIS 1 HEMOLYSIS FALSELY INCREASES THIS RESULT ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2132-3-31**] 03:31PM 65* 64* 263* 64 0.5 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2132-4-2**] 10:58AM 8.8 3.2 1.9 SLIGHT HEMOLYSIS PITUITARY TSH [**2132-3-31**] 03:31PM <0.02* [**2132-3-31**] 05:40AM <0.02* ADDED TSH [**2132-3-31**] 9:35AM THYROID T4 Free T4 [**2132-4-1**] 09:45AM 7.9 1.5 RADIOLOGY Final Report CT HEAD W/O CONTRAST [**2132-4-1**] 9:01 AM FINDINGS: There is no significant interval change in the appearance of the present noncontrast head CT scan compared to the prior [**Hospital3 **] study of [**2131-11-11**], as well as the outside study from [**Hospital3 417**] Hospital. There is no sign for the presence of a visible intracranial mass lesion. Both studies show slightly asymmetric atrophy of the cerebellum, more evident in the region of the right cerebellar hemisphere. Images of the cerebellum, at this time, are moderately degraded by patient motion. In any case, visualization of the MR- described cavernous hemangioma would be extremely difficult, given its reported small size and typically limited visibility on a noncontrast head CT scan. The surrounding osseous and soft tissue structures show no additional abnormalities. CONCLUSION: No interval change from prior study of [**2131-11-11**]. In view of the questions you have raised in the history, kindly forward the original report of the [**Hospital3 417**] Hospital CT scan for our independent review. CTA CHEST W&W/O C &RECONS [**2132-4-3**] 8:11 AM CT ANGIOGRAM FINDINGS: The main right and left, lobar and proximal segmental pulmonary arteries are widely patent and appear normal, no evidence of acute pulmonary embolus. At the peripheral segmental level the contrast opacification is slightly suboptimal. Normal heart size and central pulmonary arterial vasculature. Normal caliber thoracic aorta. Patient is status post right upper lobectomy. Small right posterior basal pleural effusion. Partial atelectasis of the medial segment of the right middle lobe. Patchy consolidation in the posterior aspect of the right lower lobe also patchy airspace consolidation in the posterior portion of left lower lobe. There is associated increased ground-glass attenuation in these areas more marked on the left lung. Differential possibilities include aspirational pneumonia. Although the appearances were asymmetric, worse on the left side, asymmetric pulmonary oedema is also a consideration. However, the nondependent interlobular septae in the right lung do not appear thickened at present. Minor area of residual localized pneumothorax in the central medial thorax. No bone lesions demonstrated. In the arterial phase scan, there is an ill-defined area of hypodensity in the posteromedial aspect of segment VII (series 4, image 100) which remains unchanged in size compared to prior CT of [**2131-11-12**]. CONCLUSION: 1. No acute pulmonary embolus demonstrated. 2. Extensive patchy consolidation in the left lung and posterior aspect of the remaining right lower lobe with associated ground-glass attenuation in those areas. Differential considerations include aspiration pneumonia possibly with some associated and asymmetric pulmonary edema. Small localized right posterior basal pleural effusion. CHEST (PA & LAT) [**2132-4-8**] 11:02 AM The patient is status post partial resection of the right lung with volume loss and a persistent small right apical pneumothorax. The heart is normal in size. There are bibasilar areas of consolidation, left greater than right, which appear worsened in the interval. Small right pleural effusion is without change. IMPRESSION: 1. Evolving bibasilar pneumonia. 2. Small right apical pneumothorax. Bronchial lavage [**2132-4-4**]: ATYPICAL. Rare isolated atypical cells, can not exclude malignancy. Neutrophils, histiocytes and red blood cells. Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 111709**],[**Known firstname **] [**2069-7-1**] 62 Male [**Numeric Identifier 111710**] [**Numeric Identifier 111711**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 1533**] Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/mtd SPECIMEN SUBMITTED: PARIETAL PLEURA (FS), RIGHT. UPPER LOBE WEDGE (FS), BRONCHIAL MARGIN, LEVEL 10 HILAR, AND LEVEL 11 INTER LOBAR. Procedure date Tissue received Report Date Diagnosed by [**2132-3-28**] [**2132-3-28**] [**2132-4-4**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/vf Previous biopsies: [**Numeric Identifier 111712**] 4 R/L LOWER PARATRACHEAL,2 R UPPER PARATRACHEAL,7 DIAGNOSIS: I. Parietal pleura (A): Fragments of lung and pleura with focal fibrosis. Note: By immunohistochemistry, the aggregates of cells present are negative for cytokeratin cocktail (AE1/AE3, CAM5.2), S-100, HMB-45, and MART-1. Calretinin is weakly positive in the mesothelial cells present. II. Right upper lobe, wedge resection (B-J): Malignant melanoma (1.0 cm), see note. Note: Sections show a monotypic population of atypical spindled and epithelioid cells with prominent nucleoli, arranged in nodules and small nests. By immunohistochemistry, these cells are positive for S-100 and MART-1; they are negative for cytokeratin cocktail, 34BE12, synaptophysin, chromogranin and TTF1. This immunophenotype supports the diagnosis of malignant melanoma. III. Lung, right upper lobectomy (K-R): 1. Bronchial and vascular margins with no malignancy. 2. Lung parenchyma with emphysematous changes and vascular congestion; no malignancy identified. 3. Pleural fibrosis. IV. Lymph node, level 9, pulmonary ligament (S): Two lymph nodes with no malignancy identified (0/2). V. Lymph node, level 10, hilar (T): One lymph node with no malignancy identified (0/1). VI. Lymph node, level 11, interlobar (U): One lymph node with no malignancy identified (0/1). VII. Lymph node, level 12, lobar (V): One lymph node with no malignancy identified (0/1). Clinical: Right upper lobe nodule. Gross: The specimen is received in seven parts each labeled with the patient's name, "[**Known lastname **], [**Known firstname 3075**]" and the medical record number. Part 1 is received fresh in the OR and consists of two fibrofatty fragments measuring 0.7 x 0.4 x 0.3 cm in aggregate. The specimen is inked and submitted entirely for frozen section and carries a frozen section diagnosis by Dr. [**Last Name (STitle) 10165**] of: "Parietal pleura, focal cellular spindle/epithelial proliferation, FDPPS". The specimen is submitted entirely in A Part 2 is received fresh in the OR and consists of an unoriented lung wedge of spongy grey tissue measuring 5.3 x 2.5 x 1.2 cm. The margin is inked in [**Location (un) 2452**] and the rest in black and the specimen is noted to be previously incised by the surgeon for microbiology. The specimen is serially sectioned to show a [**Doctor Last Name 352**] well-circumscribed nodule measuring 1.0 x 0.9 x 0.9 cm approximately 1.3 cm from the staple line, but does not involve the overlying visceral pleura. A portion of the specimen is frozen and carries a frozen section diagnosis by [**Doctor Last Name 10165**] of: "Right upper lobe wedge, spindle/epithelioid tumor, FDPPS". The frozen section remnant is submitted entirely in B. The staple line is cut away from the remainder of the specimen. The specimen is serially sectioned and submitted entirely in cassettes C-J with the nodule in E-H. Part 3 is additionally labeled "bronchial margin" and is received fresh in the OR and consists of a lung lobectomy specimen measuring 16.0 x 8.0 x 2.5 cm. The bronchial margin is identified and submitted en face for frozen section and carries a frozen section diagnosis by Dr. [**Last Name (STitle) 7108**] of: "Bronchial margin, negative for malignancy". The bronchial margin frozen section is submitted entirely in K. On the pleural and inferior surface of the specimen approximately 5.5 cm away from the bronchial resection margin is a pleural nodule that is tan-[**Doctor Last Name 352**] in color that measures 3.5 x 2.0 cm and is inked entirely in black. The specimen is serially sectioned and represented as follows: L = multiple sections of pleural nodule, M = representation of unremarkable lung adjacent to pleural nodule, N-P = additional sections of bronchus and vascular resection margins, Q = multiple areas suggestive of lymph nodes, R = unattached small free floating piece of dark [**Doctor Last Name 352**] tissue contained with lung specimen. Part 4 is additionally labeled "level 9 pulmonary ligament". The specimen consists of two small soft specimens of red and dark [**Doctor Last Name 352**] tissue measuring 0.6 x 0.4 x 0.4 cm in aggregate. The specimen is submitted entirely in cassette S. Part 5 is additionally labeled "level 10 hilar". The specimen consists of multiple pieces of soft pink, red and [**Doctor Last Name 352**] tissue measuring 1.0 x 0.6 x 0.4 cm in aggregate. The specimen is submitted entirely in T. Part 6 is additionally labeled "level 11 interlobar". The specimen consists of multiple fragments of soft dark red and [**Doctor Last Name 352**] tissue measuring 1.3 x 0.6 x 0.4 cm in aggregate. The specimen is submitted entirely in cassette U. Part 7 is additionally labeled "level 12 lobar". The specimen consists of a single piece of dark red and [**Doctor Last Name 352**] tissue measuring 0.7 x 0.5 x 0.3 cm. The specimen is submitted entirely in V. Brief Hospital Course: 62 M s/p RUL lobectomy [**3-27**] for RUL nodule. Patient tolerated procedure fairly well, slow to wake post procedure, pain control w/ dilaudid/bup epidural. On arrival to PACU extubated, pt unarrousable to verbal stimuli; CT x2right to suction. PACU course sig for continued lethergy, epidural decreased with improvement in mental status- awake to verbal and tactile stimuli, speech slurred, VSS. Transferred to floor after 5 hour PACU course in stable condition per PACU protocol. POD#1--[**3-29**] HLIV/Reg diet/CT to waterseal, blakes to bulb- not holding suction overnight.Neuro- drowsy, arrousable, slurred speech, LE tremors( baseline), A&Ox2-3, sitter 1:1> hx falls at home; no falls in house. POD#2--[**3-30**]: [**Doctor Last Name 406**] chest tubes x2 bulbs placed to pleuravac to suction b/c of + leak, bulbs not holding suction. BS congested, dim BS bilat, course bilat at bases; 98%=2L POD#3--[**3-31**] brief Afib, TSH < 0.02, CT to water seal: Neuro status- confusion, worse memory and language per family report; Neuro consult obtained.> 62 yo man with a rapidly dementing illness over the past year, previously was working as a PhD in chemistry, all thought to be secondary to paraneoplastic process. Some tremor episodes somewhat suspicious for seizure. PE:easily distracted, paucity of speech with poor naming, difficult to engage in activities and amotivational. + ataxia on right (may be related to right CBL hemangioma), + cogwheeling on the left. Very unsteady gait. +asterixis. Dx: beclouded dementia; Plan: toxic and metabolic w/u; pna (by CXRY)tx w/ levofloxacin x10d; monitor O2 sats- O2, nebs, CPT; T4= baseline-see below; d/c all sedating meds (trazodone) done; EEG done- pending;CT- head (given hx falls- r/o SDH)- negative-NO SDH, has right CBL atrophy .Staffed with Dr. [**First Name (STitle) 6817**]. POD#4--[**4-1**] one Chest Tube was dc, CT head was neg, CXR: expanded L consolidationeffusion; Swallow-thins/pureed w/ supervision only. Epid cap&flag -to be d/c, foley out, T4 7.9 Free T4 1.5 (in normal range). POD#5--[**4-2**]- 2nd Chest Tube was dc, CXR-sm R apical ptx. Physical Exam more alert. D/C sedative rx per Neuro (trazadone/benedryl);Rapid afib- dilt drip started. POD#6--[**4-3**] desaturation episode in a.m, transfer to ICU: re-intubated. Bronch: diffuse alveolar bleeding, Methylprednisolone x 1, WBC 20 POD#7--[**4-4**] WBC 15, extubated, bradycardic episode- cardiology consulted-amio gtt started; no anticoag, no pacer. POD#8--[**4-5**] stable, transferred out of unit. levaquin dc'd POD#9--[**4-6**] Card rec to keep Amio 400 [**Hospital1 **], no need for IV Hep. ANCA Neg. POD#10--[**4-7**] cxr improved, wbc 9.9 POD#11--[**4-8**] No sitter, CxR better POD#12--Dispo planing. Medications on Admission: asa 325', gemfibrozil 600", lisinopril 30', amlodipine 5', trazodone 25 qhs, synthroid 175, CACO3 500"', Vit D, buspirone 30', trifluoperazine 4 qhs, fluoxetine 160', colace, tylenol Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 5. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY (Daily). 8. Trifluoperazine 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 9. Buspirone 10 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 11. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 14. Aspirin EC 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: syncope, dementia, thyroid CAncer s/p thyroidectomy, depression, hyperchol, s/p mediastinoscopy [**3-14**], laryngeal nerve palsy, Right upper lobe nodule Discharge Condition: good Discharge Instructions: Call Dr.[**Name (NI) 2347**]/ Thoracic Surgery office ([**Telephone/Fax (1) 170**]) for: fever, shortness of breath, chest pain. Followup Instructions: Call Dr.[**Name (NI) 2347**]/ Thoracic Surgery office ([**Telephone/Fax (1) 170**]) for an appointment in [**11-15**] days. The Cutaneous or [**Hospital 29684**] clinic at [**Hospital1 18**] will contact patient's daughter [**Name (NI) **] for a follow up appointment for w/u of melanoma Completed by:[**2132-4-10**]

[ "780.2", "427.31", "427.89", "294.8", "403.91", "V15.88", "162.3", "272.4", "478.30", "486", "V10.87", "518.5", "311", "786.3", "293.9", "427.1" ]

icd9cm

[ [ [] ] ]

[ "32.29", "40.29", "96.04", "34.04", "34.24", "34.21", "33.24", "32.4", "33.23", "96.71" ]

icd9pcs

[ [ [] ] ]

16571, 16643

12397, 15138

366, 430

16843, 16850

1967, 12374

17027, 17346

1399, 1502

15371, 16548

16664, 16822

15164, 15348

16874, 17004

1517, 1948

281, 328

458, 655

677, 1011

1027, 1383

21,185

140,466

46598

Discharge summary

report

Admission Date: [**2141-8-17**] Discharge Date: [**2141-8-28**] Date of Birth: [**2096-10-7**] Sex: F Service: MEDICINE Allergies: Aspirin Attending:[**First Name3 (LF) 3913**] Chief Complaint: Substernal/epigastric pain Major Surgical or Invasive Procedure: Pericardiocentesis with drain placement [**2141-8-17**], lumbar puncture, bone marrow biopsy, intrathecal chemotherapy History of Present Illness: 44 yo F with PMH of obesity, PCOS, HTN, h/o DVT s/p IVC filter, seizure and encephalitis/meningitis [**3-20**] to severe sinus infection ([**2137**]) on dilantin, who presented to ED as transfer from [**Hospital1 18**] [**Location (un) 620**] ED with 3 days of substernal/epigastric pain. Discomfort started on [**8-13**] after eating dinner, a/w fullness/bloating, no nausea/vomiting. Her meal did not contain fatty foods. She lay down and went to sleep. On [**8-14**], she was anorexic and had early satiety, no frank pain. On [**8-15**], patient noticed more pain, worse with movement, radiation to RUQ, no change with position or exertion. She did feel short of breath after climbing stairs in her home, which is not her baseline. She again tried to eat dinner, but was full after a few bites. On [**8-16**], patient presented to her PCP, [**Name10 (NameIs) 1023**] referred her to [**Hospital1 18**] [**Location (un) 620**]. That morning, she also reports having a loose, mustard-colored BM. Of note, patient now recalls a prior mild episode of similar pain one month ago, after gardening but while at rest. She reports a sick contact w/ brother-in-law w/ GI bug. There, she had ultrasound consistent with acute cholecystitis with stone impacted in neck, pericholecystic fluid. CT showed massive pericardial effusion, pericholecystic fluid, nonspecific RLQ stranding, normal appendix and right pleural effusion. Hemodynamically stable, labs significant for alk phos 195, AST 79, ALT 51, Tbili 0.6, WBC 12.8, lipase 127. ECG showing sinus tachycardia, relatively low voltage not meeting criteria, QT prolongation with QTc of 508. Seen by surgery at [**Location (un) 620**] who suggested conservative management for gallbladder, received cipro/flagyl. Transferred to [**Hospital1 18**] [**Location (un) 86**] for further management of pericardial effusion. . On arrival here to [**Hospital1 18**] ED, vitals were T98.2 HR103 BP146/92 97% on RA. Found to have pulsus of 30, bedside ECHO showed large pericardial effusion with some RA/RV compromise and evidence of tamponade. Seen by surgery in ED for cholecystitis, who recommended conservative management with IV Unasyn and to keep patient NPO. Received 1 liter of NS, had BCx sent, 1 PIV placed in hand. Admitted to CCU for further monitoring. On transfer, vitals were HR104, BP116/80, RR16 96% on RA. . On arrival to CCU, patient was hemodynamically stable. She was scheduled for pericardiocentesis in the cath lab. . On review of systems, she has a prior hx of stroke and DVT in the context of her viral meningitis in [**2137**]. She has been coughing while in the ED. She reports an intentional 20 lb weight loss w/ Weight Watchers. She denies any prior history of pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, 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 paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. She has mild ankle edema at baseline. . . Past Medical History: 1. Rare migraines 2. HTN 3. Obesity 4. PCOS/infertility 5. Viral encephalitis/meningitis-->ICH-->seizure/stroke ([**2137**]) - from severe sinus infxn, caused mild non-focal residual deficits 6. CSF leak w/ meningitis s/p lumbar drain placement 7. R LE DVT s/p IVC filter placement 8. Knee surgery Social History: Married, lives with husband in [**Name (NI) **]. No past/present tob or EtOH. Works as nail technician in beauty salon. -Tobacco history: smoked socially x 5 yrs in high school/college -ETOH: minimal -Illicit drugs: none Family History: Father had MI in 50's and DM2. Uncle w/ leukemia, no other cancer hx. Physical Exam: PHYSICAL EXAMINATION: VS: T=97.1 BP= 124/89 (pulsus ~10) HR=99 RR=24 O2 sat= 97%/2L NC GENERAL: obese female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. MMM. No xanthalesma. NECK: Supple with no JVD or HJR. No Kussmaul's. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No pericardial rub. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, tender to palpation in RUQ and mild diffuse TTP. No guarding/rebound. No HSM. EXTREMITIES: 1+ edema R>L to shin SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: 2+ DP 2+ PT 2+ Left: 2+ DP 2+ PT 2+ Pertinent Results: LABORATORY DATA: 136 | 99 | 10 / 112 AGap=17 3.4 | 23 | 0.6\ . Ca: 9.1 Mg: 2.0 P: 3.2 ALT: 76 AP: 172 Tbili: 0.7 Alb: 4.0 Globulin: 2.6 AST: 56 LDH: Dbili: TProt: 6.6 [**Doctor First Name **]: Lip: 27 TSH: Pnd Phenytoin: 6.4 Lactate: 1.6 . 12.3 89 >---< 307 35.4 N:79.0 L:16.2 M:4.0 E:0.6 Bas:0.2 . PT: 13.7 PTT: 24.3 INR: 1.2 . Paracentesis fluid WBC-[**Numeric Identifier **]* HCT-7* POLYS-6* LYMPHS-1* MONOS-1* OTHER-92* Paracentesis fluid TOT PROT-5.6 GLUCOSE-6 LD(LDH)-[**Numeric Identifier **] AMYLASE-16 ALBUMIN-3.3 . Immunohistochemistry Report: Pericardial fluid involvement by kappa light chain restricted CD10-positive monotypic B-cell lymphoproliferative process. Examination of cytospin reveals pleomorphic cells with vacuolated basophilic cytoplasm. The providing physician (Dr. [**Last Name (STitle) **] was informed of this diagnosis. Correlation with cytogenetics and imaging studies recommended. If a lymphadenopathy is seen, a biopsy will be helpful. . MICRO: blood cx P . EKG ([**8-16**] 4:00): rate 100, NSR, NA/NI, low voltages, Q waves in III, no ST/T wave abn. Borderline QTc prolongation. . IMAGING: [**Hospital1 18**] [**Location (un) **] RUQ U/S: stone impacted in neck, perichole fluid CT abd: massive pericardial effusion, perichol fluid, nonspecific RLQ stranding. Normal appendix. Right pleural effusion . 2D-ECHOCARDIOGRAM: TTE ([**8-16**]): Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Left ventricular systolic function is hyperdynamic (EF>75%). There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. There is a large circumferential pericardial effusion, ranging 1.5-2.5 cm adjacent the RV to 3.3 cm adjacent to the LV in diastole. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. . Compared with the prior study (images reviewed, see below) of [**2140-7-12**], there is now a large circumferential pericardial effusion with RV diastolic collapse. The LV appears more hyperdynamic. . [**2141-8-19**] TTE: Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There is abnormal septal motion/position. The mitral valve leaflets are structurally normal. There is a small to moderate sized pericardial effusion which is mainly located posteriorly. There is a small echodense effusion (1.1 cm) anterior to the right ventricle. No right atrial diastolic collapse is seen. No right ventricular diastolic collapse is seen. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling . Cardiac MRI [**8-21**]: 1. Right atrial mass with heterogeneous late gadolinium hyperenhancement suggesting cardiac lymphoma, although primary cardiac tumor or metastatic disease cannot be fully excluded. 2. Normal left ventricular cavity size with normal regional left ventricular systolic function. The LVEF was normal at 59%. No CMR evidence of prior myocardial scarring/infarction. 3. Normal right ventricular cavity size and systolic function. The RVEF was normal at 55%. 4. No significant valvular regurgitation. 5. The indexed diameters of the ascending and descending thoracic aorta were normal. The main pulmonary artery diameter index was normal. 6. Mild [**Hospital1 **]-atrial enlargement. 7. A note is made of a gallbladder calculus. Brief Hospital Course: This is a 44 year old female with PMH of PCOS, GBS meningitis with intracranial hemorrhage and residual seizure activity, and h/o right DVT with IVC filter who presented with symptoms of cholecystitis and was found incidentally to have a large pericardial effusion. A pericardiocentesis was performed and the fluid analysis was consistent with Burkitt's lymphoma. . # Pericardial effusion: A large pericardial effusion was found incidentally on an abdominal CT and there was evidence of tamponade physiology on echocardiogram and pulsus paradoxus. Pericardiocentesis with drain placement was performed on [**2141-8-17**] which drained a total of 1200cc. Fluid analysis was suggestive of Burkitt's Lymphoma. . # Burkitt's Lymphoma: Pericardial fluid was kappa light chain restricted CD10 positive monotypic B cells expressing FMC-7, CD19, CD20, and myc rearrangement consistent with Burkitt's Lymphoma. A subsequent lumbar puncture and bone marrow biopsy were negative for any involvement which made this a primary cardiac lymphoma. A cardiac MRI showed a mass that was 3cm x 1cm on the lateral wall of the right atrium adjacent to the AV junction. Chemotherapy using the [**Doctor Last Name 98945**] regimen for Burkitt's lymphoma was started and the patient tolerated it well. Tumor lysis/DIC labs were drawn every 8 hours and the patient was started on D5W with bicarb and allopurinol for prohylaxis. She will continue Acyclovir prophylaxis and will report to the [**Hospital Ward Name 23**] 7 Clinical center for an appointment with Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **] on Wednesday [**8-30**] at 9:00am. She will receive chemotherapy later that morning, to be administered by the [**Hospital Ward Name 23**] 7 nursing staff. After her chemotherapy, she will be discharged home and will be scheduled to return on [**9-1**]. At this time she will proceed to 7 [**Hospital Ward Name 1826**] for hospital admission for high-dose methotrexate. . # Acute cholecystitis: Right upper quadrant U/S was consistent with acute cholecystitis on admission. She was started on a Cipro/Flagyl regimen and her transaminitis quickly improved. She was tolerating fatty foods with no residual pain and her antibiotics were discontinued after 9 days. Geberal surgery originally suggested follow-up with Dr. [**First Name (STitle) **] for cholecystectomy 2-4 weeks after discharge. Her epigastric pain resolved after her pericardiocentesis. . # Hx seizure: Once chemotherapy was started, neuro was consulted and the patient was switched to Keppra from Dilantin because of the possibility of drug-drug reactions with Dilantin. She tolerated the switch well and will continue this regimen as an outpatient. . # h/o DVT: She received an IVC filter in the past because anticoagulation was contraindicated in the setting of an intracranial hemorrhage and neurosurgical procedure. Neuro was confident that she was no longer at an increased risk for intracranial bleeding and anticoagulation was discontinued when chemotherapy was started. Prior to discharge on [**8-27**], she was found to have a clot in the right basilic vein associated with her indwelling PICC line. As a result, her PICC line was removed prior to discharge with the understanding that a new PICC line would need to be placed when she returns for her next hospital admission on [**9-1**]. Medications on Admission: HCTZ 12.5 PO daily Dilantin ER 300mg PO BID Nasonex folate calcium 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 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 3. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 4. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 5. Keppra 750 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 6. Zofran 8 mg Tablet Sig: One (1) Tablet PO three times a day as needed for nausea. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary cardiac Burkitt's Lymphoma Secondary diagnoses: -PCOS -seizure disorder -migraines -history of Group B strep meningitis causing intracranial hemorrhage -history of DVT with IVC filter Discharge Condition: stable, afebrile, ambulatory Discharge Instructions: You were admitted to [**Hospital1 **] Hospital for evaluation of a pericardial effusion incidently found on an abdominal CT scan. You underwent a pericardiocentesis to drain this fluid and the analysis showed that it contained tumor cells that were consistent with Burkitt's Lymphoma. There was no evidence of tumor in your bone marrow or in your spinal fluid. On [**8-27**], you were found to have a clot in the basilic vein of your arm, associated with your indwelling PICC line. As a result, your PICC line was removed before your discharged. You will need to have a new PICC line placed when you return for your next hospital admission on Friday [**9-1**]. The following changes have been made to your home medication regimen: You will continue taking acyclovir, levetiracetam, and ondansetron as needed for nausea. You will also be getting chemotherapy as an outpatient. You should stop Dilantin and HCTZ. Please keep all of your follow-up appointments listed below. Please seek medical care if you experience any concerning symptoms such as fevers, chills, abdominal pain, shortness of breath, or palpitations. Followup Instructions: Please keep your follow-up appointments listed below: * Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (General Surgery) regarding your gallbladder [**Telephone/Fax (1) 2998**], 2-4 weeks from discharge. * Please report to the [**Hospital Ward Name 23**] 7 Clinical center for an appointment with Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **] on Wednesday [**8-30**] at 9:00am. You will receive chemotherapy later that morning, to be administered by the [**Hospital Ward Name 23**] 7 nursing staff. After your chemotherapy, you will be discharged to home. You will be scheduled to return next Friday, [**9-1**], when you will be seen in the clinic and will then proceed to 7 [**Hospital Ward Name 1826**] for hospital admission for high-dose methotrexate. As above, you will need a new PICC line inserted on that day. * You will also be [**Hospital Ward Name 653**] regarding an appointment for a repeat echocardiogram this week.

[ "V12.51", "996.74", "200.20", "790.7", "423.3", "574.00", "345.90", "041.89", "453.8", "346.90" ]

icd9cm

[ [ [] ] ]

[ "03.92", "38.93", "03.31", "41.31", "37.0", "99.25" ]

icd9pcs

[ [ [] ] ]

12732, 12738

8617, 11989

295, 416

12975, 13006

5051, 8594

14178, 15171

4177, 4249

12107, 12709

12759, 12795

12015, 12084

13030, 14155

4264, 4264

12816, 12954

4286, 5032

229, 257

444, 3599

3621, 3920

3936, 4161

55,944

170,191

41588

Discharge summary

report

Admission Date: [**2192-3-21**] Discharge Date: [**2192-4-17**] Date of Birth: [**2117-8-8**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3326**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: intubation bilateral thoracentesis with pigtail catheter placement talc pleurodesis History of Present Illness: 74 y/o F with hx of pneumonia and atypical cells on thoracentesis, treated several approximately 1.5 weeks ago at [**Hospital 1281**] hospital, with levoflox for 10 days, presents with acute respiratory failure. Last few days has been increasingly shortness of breath at home. Has had dry, non-productive cough. Was thought she was still just recovering from recent pneumonia. Today, it was particularly bad so her son brought her to the [**Name (NI) **]. She was not having fevers or chills. . In the ED, inital vitals were T97.4, P 125, R 28, 90% on NRB. She had triggered in triage for hypoxia to 50s. She appeared to be in respiratory distress, so was intubated. She had a CXR showing effusion and potentially recurrent pneumonia. Initial lactate was 4. She received levo, ceftriaxone. Initial BPs in 130s, but then had hyoptension after intubation and did not rebound back to normal. BP lows were 70s systolic, so was started on levophed. Also received 3 L of NS. They had difficulty sedating her and she required large amounts of versed and fentanyl in order for her to be come in-sync with the ventilator. She was autopeeping and overbreathing the vent prior to arrival to the floor. . On the floor, she is intubated and sedated. Her family is at the bedside. She is calm. Past Medical History: Recent pneumonia HTN Hyperlipidemia Social History: lives with her son; widowed. Was functioning with all her ADLs. No hx of tobacco, no etoh or illicits. Family History: brother with pancreatic cancer; husband died of prostate cancer. Physical Exam: VS: 99.6 (101.1) 134/74 96 18 100% RA 920/227+inc GA: AOx3 (person, place, read date from calender on wall, president), tachypneic but in no respiratory distress HEENT: PERRLA. MMM. no LAD. JVD to ear. neck supple. Cards: RRR S1/S2 heard. no murmurs/gallops/rubs. Pulm: diffuse crackles with decreased air movement throughout, LUL was the only area with normal breath sounds Abd: soft, obese, distended, NT, +BS. no g/rt. neg HSM. Extremities: warm, well perfused, trace pitting edema. DPs 2+. Skin: W/D/I Neuro: somewhat poor historian, said things that werent clearly sensical from time to time Pertinent Results: ADMISSION LABS CBC: WBC-14.2* RBC-5.02 Hgb-15.0 Hct-46.2 MCV-92 MCH-29.9 MCHC-32.5 RDW-12.8 Plt Ct-553* Diff: Neuts-84.3* Lymphs-9.2* Monos-5.5 Eos-0.5 Baso-0.3 Coags: PT-14.2* PTT-20.8* INR(PT)-1.2* Chemistries: Glucose-197* UreaN-45* Creat-1.7* Na-137 K-8.5* Cl-96 HCO3-28 AnGap-22* ALT-19 AST-46* LD(LDH)-495* CK(CPK)-407* AlkPhos-96 TotBili-0.3 Calcium-10.1 Phos-7.2* Mg-2.9* Cardiac Enzymes: cTropnT-0.39* proBNP-6293* Lactate-4.0* MICRO DATA [**2192-4-1**] 12:51AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.014 [**2192-4-1**] 12:51AM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2192-4-1**] 12:51AM URINE RBC-8* WBC-18* Bacteri-NONE Yeast-FEW Epi-<1 [**2192-4-1**] 12:51AM URINE CastGr-11* CastHy-6* [**2192-3-22**] 01:41PM PLEURAL WBC-1500* RBC-[**Numeric Identifier 16351**]* Polys-4* Lymphs-28* Monos-6* Meso-47* Other-15* [**2192-3-22**] 01:41PM PLEURAL TotProt-4.2 Glucose-102 LD(LDH)-599 [**2192-3-21**] BLOOD CULTURE x 2 Negative [**2192-3-22**] PLEURAL FLUID GRAM STAIN (Final [**2192-3-22**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2192-3-25**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2192-3-28**]): NO GROWTH. [**2192-3-22**] 4:56 pm SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. GRAM STAIN (Final [**2192-3-22**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. RESPIRATORY CULTURE (Final [**2192-3-24**]): NO GROWTH. [**2192-3-31**] Blood cultures x 2 - PENDING [**2192-3-31**] 11:06 am STOOL CONSISTENCY: WATERY Source: Stool. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2192-4-1**]): Feces negative for C.difficile toxin A & B by EIA. [**2192-4-1**] 12:51 am URINE Source: Catheter. URINE CULTURE (Pending): CXR [**2192-3-21**] Large bilateral pleural effusions, left greater than right with underlying atelectasis and central vascular congestion. PATHOLOGY [**2192-3-22**] Pleural fluid, cell block: Tumor cells are positive for B72.3, [**Last Name (un) **]-31, WT-1, and PAX-2, but negative for calretinin, TTF-1, mammoglobin, and GCDFP. The findings support an ovarian serous carcinoma. CTA [**2192-3-23**] 1. No pulmonary embolism. 2. Small peribronchial nodular opacities in the lingula likely representing an acute infectious process. 3. Large right pleural effusion with associated right lower lobe collapse and leftward mediastinal shift. 4. Small-to-moderate left pleural effusion with left pleural drain in place. CXR [**2192-3-31**] The left-sided pigtail catheter has been removed. Right-sided pig tail catheter remains in place. A small loculated left-sided pleural effusion appears unchanged. There is increased opacity obscuring the right hemidiaphragm likely representing a combination of increasing effusion and atelectasis. The retrocardiac opacity with air bronchograms persists. No pneumothorax is appreciated. The stomach air filled and distended. CXR [**2192-4-1**] The right basilar pigtail catheter has been removed. There is a persistent right-sided pleural effusion which appears relatively stable since the previous study. There are low lung volumes. Increased density at the right base and perihilar areas are again seen. No pneumothoraces are present. The heart size is upper limits of normal but stable. CT CHEST [**2192-4-1**] (pending) Brief Hospital Course: Ms. [**Known lastname 90426**] is a 74y/o lady who presented with acute respiratory failure due to malignant effusion and was found to have serous ovarian adenocarcinoma. Her respiratory status was stabilized via thoracentesis, pigtail catheter placement, and pleurodesis. Ms. [**Known lastname 90426**] had multiple medical issues stemming from newly diagnosed metastatic ovarian cancer. Those issues included malignant pleural effusions which led to respiratory distress and respiratory failure leading to intubation. Similarly, she had a distended abdomen from carcinomatosis. Finally she developed renal failure after one dose of chemotherapy, from which her kidney's did not rebound. After careful consideration and thoughtful discussion, it was decided along with her children, that it was in the best intrest of Ms. [**Known lastname 90426**] to make her comfort measures only. She was extubated on [**2192-4-17**] in the morning, and passed away at [**2111**] peacefully with her children at her bedside. Her hospital course up until her readmission to the Medical Intensive Care Unit is outlined below. ACTIVE ISSUES IN THE ICU: . # Respiratory failure on presentation: due to malignant effusion. Patient was intubated in the ED and arrived to the ICU on mechanical ventilation. Echocardiogram showed a hypokinetic right ventricle suggestive of PE, so a CT angiogram of her chest was performed which showed no evidence of PE. Initial CXR demonstrated large bilateral pleural effusions with evidence of pneumonia, and she was started on vancomycin and cefepime for healthcare associated pneumonia. Outside records obtained from [**Hospital 1281**] hospital indicate that a pleural fluid analysis revealed malignant cells, most likely papillary serous adenocarcinoma, most consistent with origin from Muellerian duct. Her pleural effusions were tapped and pleural fluid analysis were consistent with exudate and cytology was preliminarily positive for malignancy. After thoracentesis, her respiratory rapidly improved. She bit through the ET tube cuff pilot line on hospital day 6, and was extubated without complication. . # Septic Shock: Patient was started on vancomycin and cefepime for presumed hospital acquired pneumonia. She was aggressively fluid resusciated with IVF with a goal CVP of [**9-14**] mmHg and initially supported with norepinephrine infusion to maintain a MAP of > 65. Echocardiogram demonstrated normal ejection fraction with no focal wall motion abnormalities. Norepinephrine was weaned on hospital day 6. Lactate trended down from 4.0 on admission to 1.8. . # Elevated troponin: Likely demand ischemia in the setting of sepsis. No changes suggestive on infarct on EKG, no all motion abnormalities on echo. . ACTIVE ISSUES ON THE MEDICINE AND ONCOLOGY FLOORS: . # Intermittent Hypoxia: combination of recurrent effusions, CHF, and HCAP. Upon transfer to the Oncology floor, her O2 sat dropped from 100%RA to the 60's. With supplemental O2 and diuresis, she was stabilized on 6L NC......Please see the sections below. # Recurrent effusions: malignant. Once she was on the floor, she was found to have reaccumulated the effusions. These were tapped by I.P. with pigtail catheter placement and pleurodesis was performed on [**3-28**] and [**3-30**]; the catheters were removed [**3-30**] and [**3-31**] with sats in the low 90s on 1L. She had evidence of reaccumulation. If her pulmonary disease is due to her peritoneal disease, paracentesis may need to be considered........... . # CHF: right- and left- sided. Echocardiogram had shown a hypokinetic/dilated right ventricle and she has JVD/LE edema and in addition to these signs of RHF she also likely has pulmonary edema. her BNP is 2467. . # HCAP: with leukocytosis. While she was in the ICU, she was started on HCAP coverage and she was given 8 days of vancomycin/cefepime ([**Date range (1) **]). She spiked a fever of [**3-30**]. Upon arrival to the Oncology floor, given her recent fever, hypoxia, and unresolved leukocytosis she was restarted on Vanc/Cefepime ([**4-1**]) and Flagyl was added to cover for anaerobes in the case of aspiration. # Leukocytosis/Fever: likely HCAP but evaluated for other causes as well. When she was on the floor, WBC continued to trend up, which was to be expected in the context of inflammation s/p pleurodesis. IP requested avoiding anti-inflammatory meds as the inflammation is necessary for success of pleurodesis. She had a negative workup for C. diff and blood cultures remained negative. She was treated for HCAP as above. # Acute Kidney Injury: Pre-renal. Baseline Cr 0.8 and her Cr was 1.7 on admission. Her azotemia, creatinine and urine output gradually improved with aggressive fluid resuscitation. She was pre-hydrated for her CTA and further CT contrast was avoided. # Hypertension: BP reasonably controlled. As patient was initially hypotensive, her home diovan was held. On transfer from the ICU to the floor, she was mildy hypertensive and diovan 80mg PO daily was started. # Ovarian cancer: metastatic serous adenocarcinoma. CT abdomen/pelvis without contrast at [**Hospital 1281**] Hospital on [**2192-3-8**] showed ascites but no definite disease; however, this was a very limited study secondary to lack of contrast. Palliative chemo with carbotaxol is a possibility; while her respiratory status was tenuous this was not pursued. Medications on Admission: Diovan, dose unknown Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired Completed by:[**2192-4-18**]

[ "486", "789.59", "995.92", "584.9", "285.22", "518.81", "511.81", "275.41", "038.9", "V16.0", "183.0", "V66.7", "401.1", "276.7", "348.31", "785.52", "276.2", "275.3", "272.4" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "96.72", "96.6", "38.93", "34.09", "99.25", "38.91", "34.92" ]

icd9pcs

[ [ [] ] ]

11630, 11639

6131, 11531

311, 396

11690, 11699

2599, 2979

11755, 11793

1900, 1966

11602, 11607

11660, 11669

11557, 11579

11723, 11732

1981, 2580

2996, 6108

264, 273

424, 1705

1727, 1764

1780, 1884

13,108

176,789

53274+53275

Discharge summary

report+report

Admission Date: [**2117-10-1**] Discharge Date: [**2117-10-18**] Date of Birth: [**2051-1-22**] Sex: F Service: CSU HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 109638**] is a 66-year-old woman with a history of renal cell CA treated 13 years ago with a right nephrectomy. No chemo or distant mets at that time. Presented to her primary care provider with an anxiety attack, crying, mental anxiety, no physical symptoms who at that time was noted to have a new heart murmur. Also had a history of 2 weeks of dyspnea on exertion with climbing stairs and no shortness of breath at rest. No chest pain, no lower extremity edema, no fatigue, no night sweats, no weight loss, no hematuria or abdominal pain. An echo done on [**9-30**] showed a dilated right ventricle with hypertrophy and depressed function, consistent with RV pressure overload, severe pulmonary stenosis. A CAT scan also done at that time showed a 2-3 cm mass in the main pulmonary artery with calcifications. PAST MEDICAL HISTORY: Significant for renal cell CA, diagnosed in [**2106**]. Last renal ultrasound was in [**2112-10-21**], normal left kidney, status post CCY, status post appendectomy, status post hysterectomy. MEDICATIONS: Aspirin. ALLERGIES: Penicillin, sulfa and Dimetapp. FAMILY HISTORY: Daughter with cervical CA and mother with [**Name2 (NI) 499**] CA. Cousin with renal cell CA. SOCIAL HISTORY: No tobacco, former saleswoman. PHYSICAL EXAM: General: No acute distress. Neck: No JVD. No bruits. Lungs: Clear to auscultation bilaterally. Cardiovascular: Regular rate rhythm with a 3/6 systolic murmur at the right upper sternal border. Abdomen is soft, nontender, nondistended with positive bowel sounds and no masses. Extremities with no edema. LABORATORY DATA: White count 12.4, hematocrit 41.2, platelets 263, sodium 140, potassium 4.9, chloride 106, CO2 of 22, BUN 21, creatinine 1.2, glucose 92. Chest x-ray shows no acute cardiopulmonary process. CTA shows a 2-3 cm mass in the main pulmonary artery with calcifications. HOSPITAL COURSE: The patient was admitted to the medical service. Thoracic surgery as well as a Heme consult were called at that time. Following an extensive workup which includes ultrasound, TEE, MRA and cardiac catheterization which showed normal coronaries and a large calcific plaque distal to the pulmonary vein, the patient was ultimately scheduled for pulmonary vein homograft repair with excision of the pulmonary artery mass and on [**10-8**], the patient was brought to the operating room. Please see the OR report for full details. In summary, the patient had a pulmonary artery resection with excision of a mass and replacement with a 27 mm homograft. Additionally the patient had a PDA ligation. The patient's bypass time was 204 minutes with no cross-clamp time. She tolerated the operation well and was transferred from the operating room to the Cardiothoracic Intensive Care Unit. At the time transfer, the patient had milrinone at 0.25 mcg/kg/min, Neo at 1.5 mcg/kg/min and propofol at 30 mcg/kg/min. The patient did well in the immediate postoperative period. However, following reversal of anesthesia, the patient trended down hemodynamically. She was therefore re-sedated and the decision was made to keep her intubated and to attempt to wean on postoperative day two. On postoperative day two, the sedation was again weaned. The patient tolerated the wean initially. However following the initial wean, she had oxygenation problems and was again sedated and fully ventilated. At that time, a decision was made to change sedatives with an additional attempt to wean to extubate on postoperative day three. The patient remained hemodynamically stable throughout these episodes. Ultimately on postoperative day three, the patient successfully weaned from the ventilator and extubated. Following extubation, the patient's milrinone infusion was also weaned as were her Neo-Synephrine infusion. On postoperative day four, the patient continued to be hemodynamically stable. Her milrinone was discontinued. Her Swan-Ganz catheter was removed. The chest tubes, Foley catheter and temporary pacing wires were also removed and the patient was begun on beta blockade as well as standing diuretics. The patient remained in the ICU for hemodynamic monitoring as well as respiratory monitoring. On postoperative day five, the patient continued to look well and was transferred to the floor for continuing postoperative care and rehabilitation. Once on the floor, the patient had an uneventful postoperative course. Her activity level was increased with the assistance of the nursing staff and Physical Therapy staff and ultimately on postoperative day 14, the decision was made that the patient was stable and ready to be discharged to home. At the time of this dictation, patient's physical exam is as follows. Vital signs: Temperature 98.4, heart rate 86, sinus rhythm, blood pressure 95/63, respiratory rate 18, O2 sat 93 percent on room air. LABORATORY DATA: White count 12.3, hematocrit 34.6, platelets 393, sodium 136, potassium 4.5, chloride 105, CO2 of 19, BUN 17, creatinine 1.0, glucose 102. PHYSICAL EXAMINATION: Neuro: Alert and oriented times three. Moves all extremities. Follows commands. Respiratory: Somewhat diminished at the bases. Otherwise,clear to auscultation. Cardiovascular: Regular rate and rhythm, S1-S2. Distant heart sounds. Sternum is stable. Incision with Steri-Strips open. Abdomen: Soft, nontender, nondistended with normoactive bowel sounds. Extremities: Warm and well-perfused with no edema. Initial read of PA mass biopsy is renal cell versus sarcoma, more likely sarcoma than renal cell. Pathology to be further identified. CONDITION ON DISCHARGE: Patient's condition at discharge is good. She is to be discharged home with VNA. DISCHARGE DIAGNOSES: Status post excision of pulmonary artery mass and homograft repair with PDA ligation, status post nephrectomy, status post CCY, status post TAH and anxiety. FO[**Last Name (STitle) 996**]P: The patient is to have follow-up in the [**Hospital 409**] Clinic in 2 weeks. She is to have follow-up with Dr. [**Last Name (STitle) **] on [**10-25**] at 1:00 p.m. Follow-up with Dr. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 17399**] in [**2-23**] weeks and follow-up with Dr. [**Last Name (Prefixes) **] in 4 weeks. DISCHARGE MEDICATIONS: 1. Colace 100 mg b.i.d. 2. Aspirin 325 mg once daily. 3. Potassium chloride 20 mEq once daily times 2 weeks. 4. Lasix 20 mg once daily times 2 weeks. 5. Lopressor 50 mg b.i.d. 6. Tylenol with codeine 300/30, one-half to one tablet p.o. q.4-6h. 7. Klonopin 0.25 mg p.o. q.8h. p.r.n. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern4) 1718**] MEDQUIST36 D: [**2117-10-18**] 20:15:11 T: [**2117-10-19**] 15:30:24 Job#: [**Job Number 109639**] Admission Date: [**2117-10-1**] Discharge Date: [**2117-10-18**] Date of Birth: [**2051-1-22**] Sex: F Service: MEDICINE Allergies: Sulfonamides / Penicillins / Dimetapp Attending:[**First Name3 (LF) 898**] Chief Complaint: Abnormal Echocardiagram; dyspnea on exertion for 2 weeks Major Surgical or Invasive Procedure: none History of Present Illness: 66F w/ a hx of anxiety, Renal cell carcinoma 13 yrs ago, s/p nephrectomy, who was sent to the ED from her PCP??????s office after presenting with a panic attack and was found on exam to have a new systolic murmur. A TTE on [**2117-9-30**] showed severe supravalvular pulmonic stenosis with RV hypertrophy and dilation, EF 55%. She reports DOE x 2 weeks and no other symptoms, including no CP, orthopnea, PND, edema, fainting, lightheadedness. She does have a chronic morning cough from post-nasal drip. Past Medical History: Renal Cell Carcinoma -- dx in [**2106**], s/p nephrectomy of right kidney, no chemo, no distant mets. s/p appy s/p Cholecystectomy s/p hyperectomy for endometriosis Social History: No tobacco, EtOH or drugs. Lives in [**Location 2251**] w/ husband. [**Name (NI) **] 4 children. Not working. Former salesperson. Family History: Daughter with cervical cancer, mother with [**Name2 (NI) 499**] cancer, father with DM Physical Exam: Vitals: T 97.9 HR 80s reg BP 110-144/80s-90s RR 18 94-96% on RA ?????? after 1.5 flights of stairs, O2 sat 92-97% with no CP, some SOB, HR to 110s. Gen: Well-groomed elderly female who looks healthy, wearing make-up, lying in bed wide awake. Skin: Warm, dry. Large (~1cm) pigmented lesion on Right upper back with central lack of pigmentation, which pt says has been biopsied by a dermatologist as ??????normal.?????? HEENT: Normal Nodes: None palpable; no thyroid masses Heart: JVP 6 cm. III/VI systolic murmur loudest at RUSB and LUSB. No rubs, no S3 or S4 Lungs: CTA Abd: Soft, non-tender, no masses, no organomegaly. Extrem: No edema. No calf tenderness. Legs equal in size. Warm bilat. Neuro/Psy: Anxious, but not actively panicking. Pertinent Results: -Chem-7 WNL -CBC WNL -CXR [**2117-9-30**]: unremarkable -Echocardiogram [**2117-9-30**]: possible extrinsic compression of the main pulmonary artery; severe supravalvular pulmonic stenosis; MR imaging or CT scanning recommended to delineate the cause of pulmonic stenosis -CTA [**2117-10-1**]: Low-density lesion in main pulmonary artery, measuring 2 x 3 cm in diameter, with extensive coarse calcification. The etiology is uncertain, however, this can represent myxoma with calcification, and osteogenic sarcoma. Diffdx includes neoplasm including metastasis from renal cell carcinoma, or angiosarcoma or other mesenchymal tumor. Alternatively, this can represent thrombus with calcification or migrated iatrogenic material if the patient has appropriate history. -TEE [**2117-10-4**]: normal LV systolic fxn (LVEF>55%). RV cavity dilated. RV fxn could not be accurately assessed. Pulmonary valve not well seen. Scattered calcifications in the main pulmonary artery at the level of the pulmonic valve. Turbulent flow in the main pulmonary artery consistent with obstruction. Other valves WNL. -Repeat creat after CTA Chest and hydration with bicarb: 1.2->1.3 -Panorex films [**2117-10-5**]: WNL Brief Hospital Course: 66F with h/o anxiety, renal cell CA [**26**] yrs ago sent to ED fr PCP's office after outpt echo showed severe pulm art HTN. New DOE (e.g., going up stairs) x 2 wks. ROS o/w noncontributory. Admitted to medicine for evaluation of her pulmonary HTN and workup of the pulmonic stenosis. # Pulmonary Valve Stenosis and Pulm Artery Mass: A TTE prior to admission showed severe supravalvular pulmonic stenosis suggestive of a compressed pulmonary artery. Pt refused all closed MRI studies, even with premedication, due to fears of claustrophobia but pt agreed to a CT chest with contrast. CT showed a 3.2 cm calcified mass in her main pulmonary artery. The Diffdx included a calcified thrombus, metastatic renal cell carcinoma (likely from a new primary in her remaining kidney), myxoma, or sarcoma (though very rare). Hematology-Oncology was consulted and suggested a renal U/S or CT to evaluate for a new RCC primary. Renal U/S showed no definite evidence of disease recurrence within the right nephrectomy bed, although this study was limited by pt's body habitus. Interventional cardiology was consulted and performed cardiac cath on [**2117-10-4**] to further evaluate new pulm stenosis. Cath revealed elevated right sided pressures (RV 113/13 mmHg) and normal pulmonary pressures (PA 26/19 mmHg) with a calculated pulmonary valve area of 0.29 cm and a gradient of 35.68 mmHg between the RV and the PA. Intravascular ultrasound showed a significant and large calcific plaque distal the pulmonary valve. The pulmonary valve was not well visualized, but did not appear mobile. Based on this information, Thoracic Surgery was consulted and the patient was brought to the OR for surgery on [**10-8**] for both pulmonic valve replacement and pulm artery mass evaluation/excision. Plan outpt f/u with Heme/Onc based on path results. # Renal: s/p nephrectomy; creat 1.1 w/1 working kidney; rec'd 75cc optiray for CT PE protocol on [**10-1**] + hydration. Creat stable throughout remainder of hospital course on Medicine service. Renal U/S ([**10-3**]): No evidence of mass in left kidney or R nephrectomy bed. # FEN: pt tolerated house diet well. # Prophyl: maintained on H2B & SC heparin prophylaxis. # Dispo: transferred to Thoracics service on [**10-8**] when pt went to OR (see above). Medications on Admission: None Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: pulmonary artery hypertension; mass in pulmonary artery Discharge Condition: stable Completed by:[**2118-1-7**]

[ "424.3", "V10.52", "198.89", "171.4", "300.01", "747.0", "416.0" ]

icd9cm

[ [ [] ] ]

[ "88.43", "35.25", "38.65", "37.21", "39.61", "88.72", "88.56", "38.85" ]

icd9pcs

[ [ [] ] ]

12721, 12779

10380, 12666

7355, 7362

12879, 12915

9160, 10357

8246, 8334

5894, 6430

6453, 7242

12800, 12858

12692, 12698

2080, 5191

8349, 9141

5214, 5764

7259, 7317

7390, 7895

7917, 8083

8099, 8230

5789, 5872

31,190

159,351

33273

Discharge summary

report

Admission Date: [**2124-2-24**] Discharge Date: [**2124-3-21**] Date of Birth: [**2047-7-25**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 78**] Chief Complaint: Subarachnoid hemorrhage, cerebral aneurysm Major Surgical or Invasive Procedure: 1. External ventricular drain placement 2. Cerebral aneurysm coiling History of Present Illness: 76yo RHF fell/found down in her kitchen, no apparent traumatic injuries, taken to [**Hospital3 **] ED where NCHCT revealed Grade V SAH. Pt reportedly developed pupillary assymetry with dimished reactivity and decerebrate posturing thus was intubated, administered 25g IV mannitol and PHT load, and transferred to [**Hospital1 18**] for further care. On arrival to ED, patient still with intermittent decerebrate posturing and pupillary assymetry. Past Medical History: Diverticulitis Bilateral THR Cholecystectomy Social History: non-contribuitory Family History: non-contribuitory Physical Exam: On arrival: VS: 37.1c 101 147/88 General: intubated, mildly sedated HEENT: Anicteric, MMM without lesions, ETT in place Neck: Supple, no LAD, no carotid bruits, no thyromegaly CV: RRR s1s2 no m/r/g Resp: CTAB no r/w/r Abd: soft/NT/ND no HSM/masses Ext: No c/c/e, distal pulses intact MS: intubted, no response to verbal cues or commands, minimal withdrawl to tactile stim with posturing to ungual pressure L>R CN: R pupil 4.mm minimally responsive to light, L 2.5mm sluggish reaction to light; no spontaneous saccades; corneal reflex intact bilat; no apparent facial weakness/asymmetry; OCR intact bilaterally Motor: nl bulk and tone, minimal purposeful spontaneous movements, intermittent decerebrate posturing DTRs: [**Name2 (NI) 19912**] throughout with bilat extensor plantar responses [**Last Name (un) **]: some w/d to deep pressure but induces decerebrate posturing L>R ON DISCHARGE: Vital signs stable, AOx2, able to move all four extremities spontaneously, following commands. Pertinent Results: Head CT ([**2124-2-24**]): 1. Diffuse subarachnoid hemorrhage and intraventricular hemorrhage as described. No focus of intraparenchymal hemorrhage identified. 2. Diffuse brain swelling as evidenced by obliteration of the sulci. Cerebral Angio([**2124-2-24**]):Left vertebral artery arteriogram demonstrates normal filling of the left vertebral artery along with the left vertebral artery and its branches. The basilar artery and its branches including both posterior cerebral arteries and SCA and AICA are seen with no evidence of any aneurysms. There was no reflux into the right vertebral artery, however, we had information from the CT angiogram that we decided not to study, the right vertebral artery. Left common carotid artery arteriogram shows normal bifurcation. The left external carotid artery and its branches fill well. The left internal carotid artery fills well along its cervical, petrous, cavernous and supraclinoid portion. The anterior cerebral artery and the middle cerebral artery are seen normally with no evidence of aneurysms or arteriovenous malformation. Right internal carotid artery arteriogram shows right posterior communicating artery aneurysm measuring approximately 7 x 5 mm with what appears to be a daughter sac which seems to be at the fundus of the aneurysm. The right internal carotid artery fills well along its cervical, petrous, cavernous and supraclinoid portion. No stenosis seen. The middle cerebral artery and the anterior cerebral artery are seen normally. The anterior communicating segment is also seen with no evidence of aneurysms at this location. Post-coiling right internal carotid artery arteriogram shows near complete obliteration of the aneurysm with a small residual filling of the aneurysm at the neck of the aneurysm. Right aortic bifurcation arteriogram shows normal filling of both common iliac and its distal branches. The below examinations are the most recent examinations prior to d/c Head CT ([**2124-3-10**]): IMPRESSION: Unchanged appearance of the brain with diffuse subarachnoid hemorrhage, aneurysm clip, and intraventricular blood. Angio([**2124-3-3**]): IMPRESSION: Successful cerebral angiogram performed on Ms. [**Known firstname 2127**] [**Known lastname 77254**]. No significant vasospasm is identified on this study, which signifies interval resolution of the vasospasm. Chest XR([**2124-3-14**]) Compared with [**2124-3-14**], the ET tube, NG tube, and right subclavian line have been removed. A tracheostomy tube is now present. Otherwise, I doubt significant interval change. There is hazy opacity at the right base suggestive of a small layering effusion and associated atelectasis. There is minimal atelectasis at the left base. Rounded opacity at the left base is noted, most likely represents a nipple shadow. Heart size is mildly enlarged. No CHF is identified. No new infiltrate is detected. Brief Hospital Course: 76yo with large SAH (Grade V) transferred emergently from referring hospital intubated with pupillary assymetry and intermittent decerebrate posturing. Given extent of SAH and declining neurological status, EVD placed in ED without complication. Pt found to have right p-comm aneurysm thus taken to angiography suit for aneurysm coiling. Pt tolerated procedure well with no complications (please see dictated op note for full details). Post procedure pt admitted to Neuro ICU with Nimodipine, daily ASA, Dilantin 100mg IV q8h, let BP autoregulate for now with SBP goal <160, EVD@10cm, open. . On POD#1, pt extubated, was alert, oriented to person and "hospital" and could move all four extremities purposefully and to command. On POD#2 pt developed hyponatremia to Na=129, this was likely from cerebral salt wasting and pt was treated with normal saline IVF. [**2124-2-28**]: CTA was stable with a corrected dilantin level of 8.3. On [**2-29**], she became less responsive and was allowed to have the BP rise. Corrected dilantin level was 7.4 and was bolused 300mg. She also had another angiogram done today that showed some vasospasm. [**3-1**] the angiogram was repeated and demonstrated less vasospasm, she also received papaverine, and the nimodipine was decreased. [**3-3**], angiogram was again repeated showing no new spasm. On [**3-4**], a RLE ultrasound showed a pseudoaneurysm off the right CFA, which was treated on [**3-7**] with an ultrasound guided thrombin injection. EVD clampedx2, and she passed the clamping trial, her EVD was removed. [**3-14**] she underwent trach and peg. [**3-16**] she was able to be taken off the ventilator to breath on her own. [**3-17**], her central line was removed and transferred to stepdown. [**3-18**] she was transferred to floor status after tolerating 24hours of step down. Nimodipine was discontinued on day 21. She also had an increase in her WBC and a urinalysis was performed and she was determined to have a UTI. She was then started on cipro for treatment of this. She completed a course of Diflucan for vaginal candidiasis. On today, this day of discharge, her mental status is greatly improved. I suspect whe will tolerate and pass a speech and swallow eval as well as may be able to have her trach decanulated. . Medications on Admission: In transport: Mannitol 25g IV x1 Dilantin 1g IV x1 propofol gtt At home: Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 2. Sodium Chloride 1 gram Tablet Sig: Four (4) Tablet PO TID (3 times a day). 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 10. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 11. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. 12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 13. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection Sliding Scale. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Grade IV Subarachnoid Hemorrhage, Right Posterior Communicating Aneurysm, respiratory Failure, dysphagia Discharge Condition: Stable Discharge Instructions: Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? You have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.[**First Name (STitle) **] TO BE SEEN IN 4 WEEKS. YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST Completed by:[**2124-3-21**]

[ "331.4", "285.1", "998.12", "435.8", "599.0", "482.83", "999.9", "430", "276.1", "442.3", "787.20", "112.1", "997.2" ]

icd9cm

[ [ [] ] ]

[ "02.2", "96.72", "88.48", "43.11", "99.10", "88.41", "39.72", "99.29", "31.1", "96.04", "38.93", "99.04", "96.71" ]

icd9pcs

[ [ [] ] ]

8534, 8604

5001, 7290

360, 430

8753, 8762

2088, 4978

9828, 10037

1029, 1048

7414, 8511

8625, 8732

7316, 7391

8787, 9805

1063, 1959

1973, 2069

278, 322

458, 910

932, 978

994, 1013

75,064

116,225

38651

Discharge summary

report

Admission Date: [**2157-12-23**] Discharge Date: [**2158-1-9**] Service: CARDIOTHORACIC Allergies: Iodine Containing Multivitamin / Shellfish Derived Attending:[**First Name3 (LF) 922**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2157-12-23**] - 1. Emergent coronary artery bypass grafting x3 on intra-aortic balloon pump with left internal mammary artery to left anterior descending coronary; reverse saphenous vein single graft from aorta to the first obtuse marginal coronary artery; as well as reverse saphenous vein single graft from the aorta to the posterior descending coronary artery. History of Present Illness: Chronic angina that has been increasing over last several weeks. Had positive stress test and was referred for cardiac cath that showed severe left main disease. Now referred for emergent CABG Past Medical History: HTN, DM2, hyperlipidemia, Arthritis, Chronic renal insufficiency, Osteoarthitis, Hard of hearing Social History: Race:Caucaisian Last Dental Exam: Lives with: wife [**Name (NI) 29633**] [**Name (NI) 6934**] with Cane Occupation: retired pharmacist and stock broker Tobacco: none ETOH: social Family History: non contributory Physical Exam: Pulse: 92 Resp: 21 O2 sat: 99% 2LNP B/P Right: 121/78 Left: Height: 5' 10" Weight: 97Kg General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally []scattered rhonchi Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [] Varicosities: Edema: 1+ bilat pedal edema None [] Neuro: Grossly intact[x] non-focal, MAE follows commands Pulses: Femoral Right: cath site Left: 2+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: Left: Radial Right: 2+ Left: 2+ Carotid Bruit Right: no Left: no Pertinent Results: [**2158-1-9**] INR 1.6- 3mg coumadin BUN 61/creat 1.7, HCT 28 [**2157-12-23**] - Cardiac Catheterization Successful placement of an intra-aortic balloon pump. [**2157-12-23**] - ECHO Pre Bypass: The left atrium is moderately dilated. The left atrium is elongated. A patent foramen ovale is present. There is mild symmetric left ventricular hypertrophy. There is moderate to severe regional left ventricular systolic dysfunction with severe hypokinesis of the entire anterior and anteroseptal walls. There is akinesis of the inferior wall with a possible basal aneurysm. Remaining segments are all hypokinetic. LVEF 20-25%. . The right ventricular cavity is mildly dilated with normal free wall contractility. There are complex (>4mm) atheroma in the aortic arch. The descending thoracic aorta is mildly dilated. There are complex (>4mm) atheroma in the descending thoracic aorta. There are three aortic valve leaflets. There is a moderate calcifed aortic valve with an aortic valve area which averages 1.8-2.2 cm2 representing borderline mild aortic stenosis.. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**11-26**]+) mitral regurgitation is seen and is central and dynamic, vena contracta 4.5 mm. There is no pericardial effusion. IABP seen in descending aorta 8 cm below the Left subclavian- surgeons notified of position. Post Bypass: Patient is AV paced on epinepherine 0.07 mcg/kg/min and phenylepherine 2mcg/kg/min. The anterior and Anteroseptal wall motion is improved. The septal wall motion is consistent with AV pacing. The inferior wall remains akinetic. Overall LVEF 35%. Mitral regurgitation remains [**11-26**]+. There is mild TR. Aortic contours intact. IABP is readjusted to a position 1-1.5 cm below the left subclavian takeoff. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. [**2157-12-28**] Upper Extremity Ultrasound Cephalic vein thrombus and no evidence of deep vein thrombosis. Brief Hospital Course: Mr. [**Known lastname 85873**] was admitted to the [**Hospital1 18**] on [**2157-12-23**] via transfer from [**Hospital3 **] for surgical management of his coronary artery disease. Ipon arrival he had 10/10 chest pain. A Nitro drip was started and an emergent intra-aortic balloon pump was placed in the cardiac catheterization laboratory. He was then taken to the operating room where he underwent urgent coronary artery bypass grafting to three vessels. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring on serveral vasoactive infusions: esmolol, vasopressin, milrinone, epinephrine and an insulin drip. IABP and vasoactive medications were slowly weaned off once hemodynamic stability was achieved. He remained intubated for acute CHF and PNA. He was aggressively diuresed with a lasix drip and treated with a 10 day course of vanco/zosyn which was completed on [**2158-1-9**]. He was extubated on POD#5 but remained in the ICU for aggressive pulmonary tiolet and NT suctioning. Mr.G was confused post-op requiring short term haldol prn. He is presently clear and cooperative. His chest tubes and wires were removed per protocol. On POD#5 he was noted to have LUE swelling and an ultrasound revealed cephalic vein thrombus for which a heparin drip was started. Enteral feedings via a dobhoff tube were intitiated for nutritional support which have since been d/c'd and Mr. G has a healthy appetite. He was noted to have a sternal click on POD# 11 which has remained stable and does not [**Doctor Last Name **]. He NEEDS STRICT STERNAL PRECAUTIONS. He was transferred to the stepdown unit on POD#14. Mr. [**Known lastname 85873**] developed rapid afib which was treated with betablockers and amiodarone and has converted to sinus with brief periods of atrial fibrillation which is rate controlled. He was on a heparin drip bridge to coumadin. He has been receiving low dose coumadin while on amiodarone- Most recent INR 1.6 on [**2158-1-9**]- and recieved 3mg coumadin. He has failed repeated voiding trials -most recently [**2158-1-8**]- foley remains in place. Of note, he has a stage 1 area on his coccyx. His post operative course was complicated by Afib, coag +Staph PNA, respiratory failure and sternal click. Medications on Admission: Diovan 80', Lipitor 10', Amlopidine 5', Glyburide 5", Tramadol 50 TID, Isorbide 60', Atenolol 50', Celebrex 200' Discharge Medications: 1. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO DAILY (Daily) as needed for constipation. 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing/sob. 5. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 6. Valsartan 80 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 10. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Insulin Lispro 100 unit/mL Solution Sig: as directed Subcutaneous ASDIR (AS DIRECTED). 12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day: Dose couamdin based on INR goal 2-2.5 for Afib. 15. Outpatient Lab Work Draw INR daily until on stable coumadin dose Draw Sma7 twice weekly. Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Coronary artery disease s/p CABGx3 on IABP Currently has sternal click Discharge Condition: Alert and oriented x3 nonfocal Pivot stand - CANNOT use walker for full weight bearing due to HIGH RISK for sternal dehissence Sternal pain managed with percocet prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Please call to schedule appointments Surgeon Dr. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**] Primary Care Dr. [**Last Name (STitle) **] in [**11-26**] weeks Cardiologist Dr. [**Last Name (STitle) 85874**] in [**11-26**] weeks Completed by:[**2158-1-9**]

[ "410.21", "389.9", "E849.7", "585.9", "414.01", "518.81", "396.2", "599.70", "998.0", "403.90", "427.31", "285.9", "511.9", "482.41", "250.00", "745.5", "E878.8" ]

icd9cm

[ [ [] ] ]

[ "33.24", "36.12", "37.61", "96.04", "36.15", "96.6", "39.61", "97.44", "96.72", "38.93" ]

icd9pcs

[ [ [] ] ]

7742, 7789

3975, 6256

274, 642

7904, 8072

1946, 3952

8613, 8893

1198, 1216

6420, 7719

7810, 7883

6282, 6397

8096, 8590

1231, 1927

224, 236

670, 865

887, 985

1001, 1182

5,953

160,390

10547

Discharge summary

report

Admission Date: [**2166-6-3**] Discharge Date: [**2166-6-9**] Date of Birth: [**2097-10-27**] Sex: M Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: The patient is a 68 year old male who presented to the [**Hospital6 2018**] for same day arrival coronary artery bypass graft with Dr. [**Last Name (STitle) **], Cardiothoracic Surgery. Briefly he is a 68 years old, status post stenting of his right coronary artery and left coronary artery in [**2164**]. He had substernal chest pain over the last four to five weeks at rest and prior to this he had exertional angina for six to eight months. His cardiac catheterization data showed a mid left anterior descending, 60% stenosis, left circumflex 40%, right coronary artery was 100% proximally occluded with an ejection fraction of 77%. He had a marginal branch of the left circumflex. PAST MEDICAL HISTORY: Significant for as above, diabetes Type 1, atrial fibrillation in the past with removal of a curtain rod on which he had impaled himself in his youth and he denied hypertension. He denied asthma. MEDICATIONS AT HOME: Isosorbide Dinitrate now 30 mg once a day, Mavik 1 mg every morning, Lipitor 10 mg once a day, Aspirin 325 mg once a day, Sotalol 40 mg p.o. b.i.d., Novolin 45 units in the morning and 40 units in the evening. ALLERGIES: No known drug allergies. FAMILY HISTORY: His father died of cancer. He states there was no family history of bleeding disorders and there was no family history of stroke. SOCIAL HISTORY: He denied ethanol abuse. His personal history was also not significant for stroke and not significant for bleeding disorder. He works as an engineer. He lived with his wife. [**Name (NI) **] is an ex-smoker and he only takes occasional social drinks. PHYSICAL EXAMINATION: His physical examination showed a heartrate of 55 with a blood pressure of 113/60 and 120/58, right and left respectively, weight of 189 lbs and a height of 6 feet. His physical examination was only remarkable for some light copper wiring of his retina. There was no lymphadenopathy. His lungs were clear to auscultation. He had a regular rate and rhythm to his heart without systolic ejection murmur. His abdomen had no scars and was soft and benign. He had palpable dorsalis pedis and posterior tibial distally, slight loss of hair over the toes indicative of possible early peripheral vascular disease but no obvious chronic signs of ischemia. He had no varicosities. Neurologically he was alert and oriented without any focal deficits on presentation. He had palpable radial artery pulses as well. He had no carotid artery bruits bilaterally. HOSPITAL COURSE: The patient underwent a relatively uneventful coronary artery bypass graft on same day arrival on [**2166-6-9**] times two with left internal mammary artery to left anterior descending, saphenous vein graft, obtuse marginal, saphenous vein graft to posterior descending artery. Anesthesia was general. His indication was unstable angina. The surgeon was Dr. [**Last Name (STitle) **]. Postoperatively he had a right radial arterial line, a right internal jugular triple lumen, he had two ventricular and two atrial wires, he had two mediastinal tubes and one left pleural tube. Cardiopulmonary bypass time was 46 minutes and crossclamp time of the aorta was 37 minutes. He was transferred back to the Cardiothoracic Intensive Care Unit immediately post surgery on Propofol at 20 mcg/kg/min and Neo-Synephrine at 0.5 mcg/kg/min. Over night he was doing well and on the evening of his surgery he was extubated successfully. He required some intermittent pacing at this time. His chest tubes were not putting out much. In fact, his chest tubes were discontinued as were as lines. The original plan was to transfer him to the floor, however, later on that afternoon prior to his transfer he went into atrial fibrillation with a heartrate into the 140s to at times 150 without evidence of hemodynamic compromise. He was then brought back to sinus rhythm using a combination of beta blockers and Digoxin and Sotalol on top of Lopressor. The decision was made not to coumadinize him. He was in uncontrolled atrial fibrillation for less than 48 hours. However, he did require Neo-Synephrine to be restarted for his atrial fibrillation transiently. The chest tube which had prior been scheduled to be pulled out was not pulled out because of an air leak and was discontinued on [**6-6**]. A chest x-ray following that showed that he had a small pneumothorax. He was transferred to the floor successfully without incident and on [**6-7**], follow up film showed that he did not have any substantial pneumothorax, therefore he was stable. The patient's wires, Foley catheter, and central lines were all discontinued during the course of his admission without any problem. [**Name (NI) **] was discharged home on [**2166-6-9**]. He, upon discharge, had physical examination which showed that he was afebrile with stable vital signs, pulse 79, blood pressure 134/66, saturations 94% on room air. He had a regular rate and rhythm. He had no sternal drainage. He had no erythema. He had no discharge whatsoever and his wound was clean, dry and intact. His abdomen was soft, nontender and his extremities did not have any significant edema. DISCHARGE MEDICATIONS: 1. Amiodarone 400 mg p.o. t.i.d. times three days, 400 mg b.i.d. times seven days and then 200 mg q.d. for his episode of atrial fibrillation which has at this time been in sinus rhythm for more than 48 hours. 2. Lipitor 10 mg p.o. q.d. 3. Aspirin 325 mg p.o. q.d. 4. Colace 100 mg p.o. b.i.d. 5. Potassium chloride 20 mEq p.o. q.d. for four days 6. Lasix 20 mg p.o. q.d. times four days 7. Lopressor 25 mg p.o. b.i.d. 8. Tylenol 500 mg 1 gm q. [**3-1**] h. prn pain 9. Motrin 600 mg q. 6 h. prn pain 10. Resume all home medications 11. Prescription given for narcotic pain killers DISPOSITION: Home. FOLLOW UP: He is to follow up with Dr. [**Last Name (STitle) **] in four weeks and his primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 34715**] in three to four weeks. DISCHARGE INSTRUCTIONS: He was discharged home without any difficulty and to resume his home medication on discharge with regards to his diabetes control and cardiac medications as stated above. The staples will come out 15 days postoperatively. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Name8 (MD) 16758**] MEDQUIST36 D: [**2166-6-12**] 08:14 T: [**2166-6-12**] 08:54 JOB#: [**Job Number 34716**]

[ "411.1", "V45.82", "414.01", "401.9", "427.31", "250.01", "996.72" ]

icd9cm

[ [ [] ] ]

[ "36.12", "36.15", "39.61", "42.23", "88.72" ]

icd9pcs

[ [ [] ] ]

1382, 1514

5358, 5971

2684, 5335

6196, 6684

1116, 1365

5983, 6171

1809, 2666

183, 873

896, 1094

1531, 1786

19,246

165,764

2749

Discharge summary

report

Admission Date: [**2127-4-15**] Discharge Date: [**2127-4-17**] Date of Birth: [**2067-10-24**] Sex: F Service: [**Hospital Unit Name 196**] HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old female with an extensive cardiac history including coronary artery disease (three vessel) status post coronary artery bypass graft x 3 in [**2120**], re-do in [**2123**], atrial fibrillation status post DDD pacemaker in [**2123**], end stage congestive heart failure with an ejection fraction of less than 20%, hypertension, noninsulin dependent diabetes mellitus, peripheral vascular disease, not a candidate for heart transplant, on home dopamine drip and Hospice status, reversed to full code during this admission, initially presenting with chest pain and ruled out for myocardial infarction and now called out of the Coronary Care Unit and transferred to the [**Hospital Unit Name 196**] team for EP evaluation of apparent tachy arrhythmia. The patient reportedly had tachycardia up to the 170s by EMS in the field, and resolved with 20 mg of intravenous Diltiazem x 1. During this hospital stay, the patient has had no nonsustained ventricular tachycardia on telemetry. The patient has only occasional sinus tachycardia and premature ventricular contractions, as well as atrial tachycardia with 2:1 block. The patient was comfortable and asymptomatic while on the floor. PAST MEDICAL HISTORY: 1. Coronary artery disease 2. Atrial fibrillation 3. Congestive heart failure with an ejection fraction of less than 20% 4. Hypertension 5. Noninsulin dependent diabetes mellitus 6. Hypercholesterolemia 7. Peripheral vascular disease 8. Depression 9. Obesity 10. Anal fissure 11. Anemia of chronic disease ALLERGIES: Ceclor (hives). MEDICATIONS AT HOME: 1. Dopamine 8 mcg/mg/minute drip 2. Pantoprazole 3. Aspirin 4. Atorvastatin 5. Spironolactone 6. Trazodone 7. Enalapril 8. Mesalamine 9. Furosemide 10. Ferrous sulfate 11. Sertraline 12. Oxycontin 13. Carvedilol 14. Epogen 15. Coumadin PHYSICAL EXAMINATION (on transfer to [**Hospital Unit Name 196**] service): Vital signs: Temperature 97.8, blood pressure 108/44, heart rate 112, respiratory rate 15 to 20, oxygen saturation 98% on room air. General: No acute distress, alert and awake. Head, eyes, ears, nose and throat: Jugular venous pressure to approximately 10 cm. Cardiovascular: Tachycardic, regular rhythm, loud S1, normal S3, III/VI systolic ejection murmur at the left lower sternal border. Lungs: Clear to auscultation bilaterally, without rales, rhonchi or wheezes. Abdomen: Soft, nontender, nondistended, with normal active bowel sounds. Extremities: Trace edema bilaterally in the lower extremities. LABORATORY DATA: White blood cells 9.1, hematocrit 30.2. Sodium 139, potassium 3.7, chloride 102, bicarbonate 327, BUN 24, creatinine 0.5, glucose 167. Calcium 8.8, phosphate 3.5, magnesium 1.9, Digoxin 1.7. Telemetry: Atrial tachycardia with 2:1 block, occasional premature ventricular contractions. HOSPITAL COURSE: The patient is a 59-year-old female with an extensive cardiac history, including end stage congestive heart failure with an ejection fraction of less than 20% on home dopamine, found to have an apparent tachy arrhythmia in the field. The patient was initially accepted to the Coronary Care Unit given the patient was on home dopamine drip, and then transferred to the [**Hospital Unit Name 196**] service for EP evaluation for possible AICD vs. amiodarone for rate control. The [**Hospital 228**] medical regimen at home was continued while in-hospital.Pacer interrogation showed underlying rhythm was atrial tachycardia The EP service performed atrial pacing, atrialardia patient was paced out of her atrial tachycardia. The patient was then DDDR paced at 70 beats per minute with isolated premature ventricular contractions. The patient was started on an amiodarone loading schedule at 800 mg once daily for one week, 600 mg once daily for three weeks, and 200 mg once daily thereafter. The patient's Digoxin was discontinued. The patient was restarted on her Coumadin. The patient will follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] as well as the Device Clinic in three weeks. The patient was discharged home in stable condition. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSIS: 1. Coronary artery disease 2. Atrial fibrillation, paroxysmal 3. End stage congestive heart failure with ejection fraction of less than 20% on home dopamine drip 4. Hypertension 5. Noninsulin dependent diabetes mellitus 6. Hypercholesterolemia 7. Peripheral vascular disease 8. DDD pacemaker 9. Anemia of chronic disease 10. Regular atrial tachyarrhythmia with variable block, pace terminated. DISCHARGE MEDICATIONS: 1. Dopamine drip 8 mcg/kg/minute 2. Protonix 40 mg by mouth 3. Aspirin 325 mg by mouth once daily 4. Atorvastatin 10 mg by mouth once daily 5. Spironolactone 25 mg by mouth once daily 6. Trazodone 50 mg by mouth daily at bedtime 7. Enalapril 5 mg by mouth twice a day 8. Mesalamine 500 mg rectally once daily 9. Amiodarone 800 mg by mouth once daily for one week, 600 mg by mouth once daily for three weeks, 200 mg by mouth once daily ongoing 10. Lasix 80 mg every morning, 40 mg every evening 11. Iron 325 mg by mouth three times a day 12. Sertraline 150 mg once daily 13. Oxycontin 10 mg by mouth once daily 14. Carvedilol 6.25 mg by mouth twice a day 15. Epogen 10,000 units subcutaneously every [**Last Name (NamePattern1) 2974**] 16. Coumadin 5 mg by mouth once daily [**First Name11 (Name Pattern1) 420**] [**Last Name (NamePattern4) 421**], M.D. [**MD Number(1) 422**] Dictated By:[**Last Name (NamePattern1) 1183**] MEDQUIST36 D: [**2127-4-18**] 18:37 T: [**2127-4-19**] 02:55 JOB#: [**Job Number 13575**] 1 1 1 DR

[ "285.9", "401.9", "427.0", "V45.81", "250.00", "443.9", "427.31", "414.8", "428.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

4362, 4400

4848, 5921

4421, 4825

3058, 4340

1792, 3040

192, 1403

1425, 1771

45,431

144,259

36395

Discharge summary

report

Admission Date: [**2149-6-25**] Discharge Date: [**2149-6-28**] Date of Birth: [**2103-4-12**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1854**] Chief Complaint: metastatic melanoma to brain Major Surgical or Invasive Procedure: Left occipital craniotomy for tumor resection History of Present Illness: [**Known firstname **] [**Known lastname 82452**] is a 46-year-old right-handed man with history of cutaneous melanoma who has enhancing lesions in the brain suggesting brain metastases. He is seen in consultation as requested by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1729**] for evaluation of probable brain metastases. His oncological problem began in [**2147**] when he noted an abnormal lesion in the right forearm. He underwent initial resection on [**2147-1-12**], followed by wide excision yielding clean margin. He went back to his physicians for regular check up once every 6 months. He had 2 more resection of cutaneous lesions, one on [**2146-12-19**] showing seborrheic keratosis and two others on [**2147-2-10**] and [**2147-9-21**] showing dysplastic moles. His neurological problem began in [**2148-10-14**] when he noted right groin pain during a flight from [**Location 652**] to [**Location (un) 86**]. He was fine thereafter. But after falling on ice, his right groin pain was reactivated. He underwent chiropractor for low back maneuver but worsened his right groin pain. CT of the pelvis on [**2149-6-10**] showed destruction of the right pubic ramus. It was biopsied on [**2149-6-12**] that showed metastatic melanoma. Further staging evaluations with CT of the torso on [**2149-6-20**] showed metastases in the lungs and right axilla. A staging head CT on [**2149-6-20**] showed 2 enhancing lesions, one in the left occipital brain that is more than 3 cm in diameter while the other is in the right frontal brain that is 1 cm in diameter. A lumbar spine X-ray showed pathological fracture of the L3 vertebral body. Past Medical History: He has a history of cutaneous melanoma and hypercholesterolemia. He does not have diabetes, hypertension, or COPD. Social History: He is a graphic designer. He smoked 1 pack of cigarettes per day for 20 years; he stopped smoking 4 to 5 years ago. He does not drink alcohol or use illicit drugs. Family History: His mother is alive with metastatic breast cancer. His maternal grandfather died of lymphoma. His father is healthy. His brother is healthy. His 3-year-old son is healthy. Physical Exam: Physical Examination: His skin has full turgor. HEENT is unremarkable. Neck is supple and there is no bruit. He does not have cervical, supraclavicular, or axillary lymphadenopathy. Cardiac examination reveals regular rate and rhythms. His lungs are clear. His abdomen is soft with good bowel sounds. His extremities do not show clubbing, cyanosis, or edema. Neurological Examination: His Karnofsky Performance Score is 100. He is awake, alert, and oriented times 3. There is no right/left confusion or finger agnosia. His calculation is intact. His language is fluent with good comprehension, naming, and repetition. His recall is intact. Cranial Nerve Examination: His pupils are equal and reactive to light, 4 mm to 2 mm bilaterally. Extraocular movements are full. Visual fields are full to confrontation. Funduscopic examination reveals sharp disks margins bilaterally. His face is symmetric. Facial sensation is intact bilaterally. His hearing is intact bilaterally. His tongue is midline. Palate goes up in the midline. Sternocleidomastoids and upper trapezius are strong. Motor Examination: He does not have a drift. His muscle strengths are [**6-17**] at all muscle groups. His muscle tone is normal. His reflexes are 2- bilaterally. His ankle jerks are 2-. His toes are down going. Sensory examination is intact to touch and proprioception. Coordination examination does not reveal dysmetria. His gait is normal. He can do tandem. He does not have a Romberg. Pertinent Results: [**Known lastname **],[**Known firstname **] [**Medical Record Number 82453**] M 46 [**2103-4-12**] Radiology Report MR HEAD W & W/O CONTRAST Study Date of [**2149-6-24**] 5:25 PM [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**2149-6-24**] 5:25 PM MR HEAD W & W/O CONTRAST; MR 3D RENDERING W/O POST PROCE Clip # [**Clip Number (Radiology) 82454**] Reason: please eval left occipital tumor Contrast: MAGNEVIST Amt: 20 [**Hospital 93**] MEDICAL CONDITION: 46 year old male patient with left occipital tumor REASON FOR THIS EXAMINATION: please eval left occipital tumor CONTRAINDICATIONS FOR IV CONTRAST: None. Final Report INDICATION: 46-year-old male patient with left occipital tumor with brain lesions, history of cutaneous melanoma, to evaluate further. COMPARISON: CT of the head done at OSH scanned on to [**Hospital1 18**] PACS [**2149-6-20**]. TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the head was performed without and with IV contrast per brain tumor protocol. FINDINGS: There are two enhancing lesions in the brain, one in the right frontal lobe at the vertex and another one in the left occipital lobe, parasagittal in location. The right frontal lesion measures 1.5 x 1.7 x 2.0 cm with mild surrounding edema. The left occipital lesion measures 3.5 x 3.1 x 2.6 cm. There is moderate amount of surrounding edema. Both the lesions have areas of negative susceptibility representing blood products/melanin as well as heterogeneous enhancement with nonenhancing necrotic areas. There is effacement of the left occipital [**Doctor Last Name 534**] and part of the atrium of the left lateral ventricle from the mass effect and surrounding edema around the left occipital lesion. There are also a few cystic areas noted in the left occipital lesion. The major vascular intracranial arterial flow voids are noted. The visualized portions of the paranasal sinuses are clear. Evaluation for bony lesions is limited MR study. There is a prominent extra-axial CSF space, noted in the superior part of the posterior fossa, causing indentation on the superior aspect of the cerebellar hemisphere, best seen on the sagittal reformations and measures 1.7 x 3.2 cm in the AP CC dimensions. The visualized portions of the paranasal sinuses are clear. IMPRESSION: 1. Two enhancing lesions in the brain, one in the right frontal and another one in the left occipital lobe as mentioned above, representing metastatic lesions. 2. Moderate surrounding vasogenic edema with effacement of the left occipital [**Doctor Last Name 534**] and part of the atrium of the left lateral ventricle. 3. Prominent extra-axial CSF space in the superior aspect of the posterior fossa causing indentation on the superior part of the cerebellum as described above, which can represent prominent CSf space with a differential diagnosis of arachnoid cyst in this location. DR. [**First Name (STitle) 10627**] PERI Approved: WED [**2149-6-25**] 1:11 PM [**Known lastname **],[**Known firstname **] [**Medical Record Number 82453**] M 46 [**2103-4-12**] Radiology Report CT HEAD W/O CONTRAST Study Date of [**2149-6-25**] 2:39 PM [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 12630**] CC1A [**2149-6-25**] 2:39 PM CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 82455**] Reason: Pre surgery wand protocol for marking place for intraoperati [**Hospital 93**] MEDICAL CONDITION: 46 year old male patient with left occipital tumor REASON FOR THIS EXAMINATION: Pre surgery wand protocol for marking place for intraoperative navigation CONTRAINDICATIONS FOR IV CONTRAST: None. Final Report INDICATION: Left occipital tumor. COMPARISON: [**2149-6-20**]. NON-CONTRAST HEAD CT There has been an interval left parietooccipital craniotomy and resection of a left occipital mass. There is pneumocephalus overlying the left temporal lobe and along the left parietal lobe. Increased opacification consistent with blood products are seen at the resection site as well as air within the tissues. (Series 1, image 23). Otherwise, there is no new hemorrhage, loss of [**Doctor Last Name 352**]- white matter junction differentiation, there is no significant mass effect. A tracheostomy tube is seen. Mastoid air cells and visualized paranasal sinuses are clear. IMPRESSION: Expected postoperative changes status post resection of left occipital mass with no significant midline shift. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) 5206**] [**Name (STitle) **] DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**] Approved: [**Doctor First Name **] [**2149-6-26**] 10:15 AM Imaging Lab [**Known lastname **],[**Known firstname **] [**Medical Record Number 82453**] M 46 [**2103-4-12**] Radiology Report MR HEAD W & W/O CONTRAST Study Date of [**2149-6-26**] 9:04 AM [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 12630**] CC1A [**2149-6-26**] 9:04 AM MR HEAD W & W/O CONTRAST Clip # [**Clip Number (Radiology) 82456**] Reason: eval for postop changes Contrast: MAGNEVIST Amt: 18 [**Hospital 93**] MEDICAL CONDITION: 46 year old man with s/p resection of occipital mass -- metastatic melanoma REASON FOR THIS EXAMINATION: eval for postop changes CONTRAINDICATIONS FOR IV CONTRAST: None. Provisional Findings Impression: [**First Name9 (NamePattern2) 82457**] [**Doctor First Name **] [**2149-6-26**] 4:16 PM PFI: 1. Expected postoperative changes status post resection of occipital mass. 2. New hemorrhage and right frontal lesion. Final Report INDICATION: Status post resection of occipital mass, metastatic melanoma, evaluate for postoperative changes. COMPARISON: [**2149-6-24**]. TECHNIQUE: Sagittal short TR, short TE spin echo images were obtained through the brain. Axial imaging was performed with long TR, long TE, fast spin echo, FLAIR, gradient echo and diffusion technique. Axial, coronal short TR, short TE spin echo imaging was repeated after intravenous administration of gadolinium contrast. FINDINGS: Left occipital lobe postoperative changes are seen with high T1 signal material with negative susceptibility suggestive of blood. There has been a craniotomy. Moderate edema surrounds this postoperative site and the occipital [**Doctor Last Name 534**] of the left lateral ventricle is again effaced. The right frontal lesion (series 6, image 23) demonstrates a new negative susceptibility suggestive most suggestive of a hemorrhage. Edema about this lesion seems grossly similar to prior with no obvious mass effect proximally. The visualized orbits appear normal. The visualized paranasal sinuses are unremarkable. Again seen is a prominent extra-axial CSF space in the superior part of the posterior fossa, indenting the superior cerebellar hemisphere likely an arachnoid cyst. IMPRESSION: 1. Expected postoperative changes in the left occipital lobe. 2. Apparent new hemorrhage of the right frontal metastasis without edema or significant mass effect. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) 5206**] [**Name (STitle) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**] Approved: [**Doctor First Name **] [**2149-6-26**] 10:04 PM Imaging Lab Brief Hospital Course: The patient underwent the procedure on [**6-26**] and tolerated it well. He was extubated without event and was brought to the ICU in stable condition on a nitroglycerin drip for blood pressure control. He had normal mental status and normal gross visual fields on exam in his postoperative check. He was transferred from the ICU on POD 1 to the floor. He tolerated PO intake and is voiding freely. He is ambulatory in the [**Doctor Last Name **] without assistance. He is to be discharged to home today and agrees with the plan. Medications on Admission: DEXAMETHASONE - (Prescribed by Other Provider) - 4 mg Tablet - 1 (One) Tablet(s) by mouth three times a day started on [**2149-6-22**] OXYCODONE - (Prescribed by Other Provider) - 5 mg Capsule - 1 (One) Capsule(s) by mouth every four (4) hours Discharge Medications: 1. Dexamethasone 2 mg Tablet Sig: Two (2) Tablet PO three times a day. Disp:*180 Tablet(s)* Refills:*2* 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: DO NOT DRIVE WHILE TAKING THIS MEDICATION . Disp:*40 Tablet(s)* Refills:*0* 3. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q 8 HOURS as needed for nausea. Disp:*90 Tablet, Rapid Dissolve(s)* Refills:*0* 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): DO NOT STOP TAKING THIS MEDICATION WHILE ON DEXATHEMASONE. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: left occipital craniotomy for tumor resection Discharge Condition: neurologically intact Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. Do not drive until you are cleared by the neurosurgery service / you can call the office to speak to your surgeon if necessary. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in 10 days for removal of your staples or sutures. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast. ??????You will not need an MRI of the brain. YOU WILL NEED TO BE SEEN IN THE BRAIN [**Hospital **] CLINIC. PLEASE CALL THIS MONDAY TO HAVE AN APPOINTMENT SCHEDULED TO BE SEEN IN THE NEXT 2 WEEKS. YOU WILL NOT NEED AN MRI FOR THAT APPOINTMENT AS YOU HAD ONE POSTOPERATIVELY IN THE HOSPITAL, PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE THIS APPOINTMENT. Completed by:[**2149-6-28**]

[ "V10.82", "198.3", "197.0", "198.5", "272.0" ]

icd9cm

[ [ [] ] ]

[ "01.59", "38.91" ]

icd9pcs

[ [ [] ] ]

13226, 13232

11764, 12298

348, 395

13322, 13346

4161, 4664

14750, 15455

2442, 2620

12594, 13203

9545, 9621

13253, 13301

12324, 12571

13370, 14727

2635, 2635

2658, 4142

280, 310

9653, 11741

423, 2104

2126, 2243

2259, 2426

8,636

182,550

15252

Discharge summary

report

Admission Date: [**2173-9-24**] Discharge Date: [**2173-10-7**] Date of Birth: [**2148-12-18**] Sex: M Service: Thoracic Surgery CHIEF COMPLAINT: Status post motor vehicle accident HISTORY OF PRESENT ILLNESS: The patient is a 24-year-old gentleman who, on [**2173-8-12**], was in a motor vehicle accident of which he suffered multiple injuries. The patient had been recently at [**Hospital1 700**] and was diagnosed with tracheal stenosis. He presents to [**Hospital6 649**] for further evaluation and likely surgical intervention. He had in addition suffered a right pneumothorax, liver hematoma, mediastinal hematoma, bilateral posterior rib fractures, right transverse fractures at T8 and T10. During his immediate post accident recovery, he had been intubated secondary to respiratory failure due to ARDS. He had a tracheostomy tube placed on [**2173-9-1**]. He was weaned off ventilatory support at that time. During his stay, a gastrostomy tube was also placed and he was nutritionally maintained on tube feedings. He has subsequently been at rehabilitation and has been progressing well and now is ready for treatment of his tracheal stenosis. PAST MEDICAL HISTORY: As above. ADMISSION MEDICATIONS: 1. Multivitamin 5 cc per G-tube qd 2. Valium 5 mg per G-tube [**Hospital1 **] 3. Tylenol 975 mg per G-tube q6h 4. Oxycodone 5 mg per G-tube q3h prn 5. Haldol 5 mg per G-tube q8h prn agitation 6. Combivent 10 puffs q4h 7. Nystatin 5 cc swish and swallow prn 8. Zantac 150 mg per G-tube [**Hospital1 **] ALLERGIES: No known drug allergies. PHYSICAL EXAM: GENERAL: The patient is in no acute distress. VITAL SIGNS: Stable. HEAD, EARS, EYES, NOSE AND THROAT: The patient had a trach collar in place. Pupils are equal, round and reactive to light. HEART: He is regular with tachycardia with no murmurs, rubs or gallops. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft, tender. G-tube is intact with no peripheral edema. ADMISSION LABORATORIES: White count of 8.7, hematocrit of 32.5, platelets 313. Sodium 136, potassium 3.9, chloride 107, bicarbonate 28, BUN 13, creatinine 0.7, glucose 76. HOSPITAL COURSE: The patient was admitted to the interventional pulmonology service. The patient remained stable and on hospital day #4 the patient went to the Operating Room where he underwent a rigid and flexible bronchoscopy. This was significant for near complete obstruction of the trachea with a pinpoint lumen located 1.5 cm below the vocal cords. During the procedure, the stenosis was attempted to be dilated which was unsuccessful. The patient underwent CT of the trachea which was significant for 3.4 cm in length stenosis starting slightly above the trachea without tracheostomy tube and extending below. The patient was evaluated by thoracic surgery and was planned for tracheal resection. On hospital day #6, the patient went to the Operating Room on [**2173-9-29**] and underwent a complete resection of the trachea with a primary end to end anastomosis. The patient tolerated this procedure well. Tracheostomy tube was removed and the patient was extubated without any incident. The patient was transferred to the Cardiothoracic Intensive Care Unit for closer monitor. Immediate postoperative course, the patient remained stable with good O2 saturations at 100% and blood gases which showed no ............ base and balance and good ventilation and oxygenation. The patient received racemic epinephrine every four hours as a standing order and otolaryngology evaluation demonstrated edema of the false vocal cords and edema of the posterior arytenoids and posterior cricoid region. The patient received Decadron 10 mg intravenous x3 doses. Subsequent evaluation showed improvement of the edema. The patient continued to remain stable. Gastrostomy tube feeds were advanced as tolerated. The patient ambulated and over the next several days the patient's voice improved. The patient had no stridor and the patient was stable for transfer to the floor. The racemic epinephrine was stopped on postoperative day #5. The patient received a course of perioperative antibiotics for five days. The patient had a bronchoscopy on postoperative day #7 which was significant for minimal edema and airway obstruction. Patient stable and now ready for discharge to home on bolus tube feeds which he is tolerating and following up with Dr. [**Last Name (STitle) 952**] in one week. The patient will then undergo a speech swallow evaluation and if cleared will have the gastrostomy tube removed and resume po feeds. DISCHARGE DIAGNOSIS: Tracheal stenosis, status post tracheal resection with primary anastomosis DISCHARGE MEDICATIONS: 1. Oxycodone 5 to 10 mg per G-tube q 3 to 4 hours prn 2. Diazepam 5 mg per G-tube [**Hospital1 **] 3. Multivitamin 5 ml per G-tube qd 4. Combivent 2 puffs q4h during the day and 2 puffs q4h prn at night 5. Nystatin swish and spit 5 ml po qid prn 6. ProMod with fiber bolus tube feeds DISCHARGE CONDITION: Stable FOLLOW UP: The patient will follow up with Dr. [**Last Name (STitle) 952**] in one week and Dr. [**Last Name (STitle) **] in one week, will call for appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**] Dictated By:[**Last Name (NamePattern1) 3835**] MEDQUIST36 D: [**2173-10-7**] 09:56 T: [**2173-10-7**] 10:18 JOB#: [**Job Number 44360**]

[ "519.02", "519.1", "E878.3" ]

icd9cm

[ [ [] ] ]

[ "31.79", "31.5", "33.22", "33.21", "96.6", "33.23" ]

icd9pcs

[ [ [] ] ]

5029, 5037

4716, 5007

4617, 4693

2177, 4595

1241, 1590

1605, 2159

5049, 5480

168, 204

233, 1184

1207, 1218

51,833

171,659

41968

Discharge summary

report

Admission Date: [**2198-8-29**] Discharge Date: [**2198-8-31**] Date of Birth: [**2155-10-20**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 10293**] Chief Complaint: liver failure due to acetaminophen overdose Major Surgical or Invasive Procedure: None History of Present Illness: 42 yo M with history of Chiari malformation s/p surgery, depression, past suicide attempt, transferred from [**State 40074**]Hospital for liver transplant evaluation in the setting of acetaminophen overdose. . On [**2198-8-26**], in the a.m., the patient took 75 tablets of Vicodin. He presented to [**State 44256**], where Tylenol level was 124. He was admitted to psychiatry, without receiving N-acetyl cysteine. . On the morning of [**2198-8-28**], medicine was consulted for transaminases of ~1000. Transaminases were rechecked later in the day, and were ~3000. N-acetyl cysteine was started at that time, although it was already 36 hours after the overdose. . The patient is transferred to [**Hospital1 18**] due to concern for fulminant hepatic failure in the setting of Tylenol overdose, and initiation of liver transplant evaluation. At the time of transfer, the patient was hemodynamically stable, not encephalopathic, complaining of pain in left lower rib cage. INR 1.7. ABG with respiratory alkylosis. He has poor access. . On review of systems, patient complains of 2 days of nausea and vomiting. Vomiting precipitated by PO intake. Otherwise, patient denies fevers, chills, shortness of breath, chest pain, wheezing, cough, abdominal pain, swelling, or rash. Past Medical History: HTN Hypothyroidism GERD Vertigo Depression one prior suicide attempt [**Doctor Last Name **] chiari malformation s/p decompression in [**2196**] craniotomy in [**2189**] Social History: Works as a submarine engineer. Lives with wife and son. Cigarettes 10PY. 2-3 [**Name2 (NI) 17963**] per week. Denies h/o abuse, binging, withdrawal, seizures. Remote THC. No other drugs of abuse. Family History: Has had 2 sons with [**Name2 (NI) **] bifida (one died). Physical Exam: Admission: VS: 36.6 65 128/80 14 96% RA Gen: alert, oriented x 3, in no acute distress HEENT: sclera anicteric; MMM, no JVD or lymphadenopathy Card: Normal S1, S2, no murmurs, rubs, or gallops Resp: Lungs CTA bilaterally Abd: Softly distended; markedly TTP in LLQ at tip of 12th rib; otherwise non-tender; no rebound or guarding; no organomegaly; [**Doctor Last Name **] sign negative Ext: Non-edematous, no rashes . . . DISCHARGE: Vitals:99.3max, 98 Tcurr, 103-130/66-78, 60, 20, 98% 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, no carotid bruits LUNGS - CTAB HEART - RRR, no MRG, nl S1-S2 ABDOMEN - NABS, not distended, some pain along rib edge, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**5-24**] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait Pertinent Results: [**2198-8-29**] 05:03AM GLUCOSE-125* UREA N-21* CREAT-0.8 SODIUM-139 POTASSIUM-3.5 CHLORIDE-105 TOTAL CO2-24 ANION GAP-14 [**2198-8-29**] 05:03AM ALT(SGPT)-4225* AST(SGOT)-2829* LD(LDH)-2930* ALK PHOS-60 AMYLASE-36 TOT BILI-1.4 [**2198-8-29**] 05:03AM LIPASE-24 [**2198-8-29**] 05:03AM ALBUMIN-4.1 CALCIUM-8.7 PHOSPHATE-2.1* MAGNESIUM-2.0 IRON-171* CHOLEST-158 [**2198-8-29**] 05:03AM TRIGLYCER-133 HDL CHOL-30 CHOL/HDL-5.3 LDL(CALC)-101 [**2198-8-29**] 05:03AM calTIBC-259 FERRITIN-4319* TRF-199* [**2198-8-29**] 05:03AM AMA-NEGATIVE [**2198-8-29**] 05:03AM [**Doctor First Name **]-NEGATIVE [**2198-8-29**] 05:03AM CEA-1.9 AFP-5.4 [**2198-8-29**] 05:03AM IgG-783 IgA-164 IgM-43 [**2198-8-29**] 05:03AM WBC-9.5 RBC-5.01 HGB-15.1 HCT-41.5 MCV-83 MCH-30.2 MCHC-36.5* RDW-12.8 [**2198-8-29**] 05:03AM NEUTS-84.1* LYMPHS-11.9* MONOS-3.4 EOS-0.2 BASOS-0.5 [**2198-8-29**] 05:03AM PLT COUNT-149* [**2198-8-29**] 05:03AM PT-18.2* PTT-27.0 INR(PT)-1.6* [**2198-8-29**] 05:29AM LACTATE-1.1 . CXR: FINDINGS: Upright AP and lateral views of the chest are normal. The cardiomediastinal, pleural, and pulmonary structures are unremarkable. Surgical clips overlying the area of the gallbladder. IMPRESSION: Normal chest examination. . . RUQ ultrasound: 1. Normal echogenicity of the liver without focal lesion. 2. Normal hepatic Doppler with patency and normal directional flow of all the above-mentioned vessels. . [**2198-8-31**] 05:00AM BLOOD WBC-4.9 RBC-4.65 Hgb-14.1 Hct-39.5* MCV-85 MCH-30.2 MCHC-35.6* RDW-13.4 Plt Ct-129* [**2198-8-31**] 05:00AM BLOOD Glucose-104* UreaN-17 Creat-0.9 Na-141 K-3.6 Cl-107 HCO3-25 AnGap-13 [**2198-8-31**] 05:00AM BLOOD ALT-2331* AST-408* LD(LDH)-329* AlkPhos-59 TotBili-0.9 [**2198-8-30**] 03:27AM BLOOD ALT-3423* AST-1089* LD(LDH)-777* AlkPhos-55 TotBili-1.4 [**2198-8-29**] 09:17PM BLOOD ALT-4066* AST-1624* LD(LDH)-1379* AlkPhos-60 TotBili-1.4 [**2198-8-29**] 01:39PM BLOOD ALT-4174* AST-2103* LD(LDH)-[**2147**]* AlkPhos-59 TotBili-1.3 [**2198-8-29**] 05:03AM BLOOD ALT-4225* AST-2829* LD(LDH)-2930* AlkPhos-60 Amylase-36 TotBili-1.4 [**2198-8-29**] 05:03AM BLOOD Lipase-24 [**2198-8-31**] 05:00AM BLOOD Albumin-4.0 Calcium-9.0 Phos-3.7 Mg-2.1 [**2198-8-29**] 05:03AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE [**2198-8-29**] 05:03AM BLOOD AMA-NEGATIVE [**2198-8-29**] 05:03AM BLOOD [**Doctor First Name **]-NEGATIVE [**2198-8-29**] 05:03AM BLOOD CEA-1.9 AFP-5.4 [**2198-8-29**] 05:03AM BLOOD IgG-783 IgA-164 IgM-43 [**2198-8-29**] 01:39PM BLOOD HIV Ab-NEGATIVE [**2198-8-29**] 05:03AM BLOOD HCV Ab-NEGATIVE [**2198-8-29**] 05:29AM BLOOD Lactate-1.1 Brief Hospital Course: 42 yo M with history of Chiari malformation s/p surgery, depression, past suicide attempt, transferred from [**Hospital 40074**]Hospital for acute liver failure in the setting of acetaminophen overdose, now resolving. # Acetaminophen overdose - Overdosed on 75 tabs vicodin on [**8-26**]. Acetaminophen level at the time 124. He did not receive NAC initially but was started on a drip before transfer. It was not entirely clear how much time elapsed between the time of the ingestion and the time of the level. AST and ALT rose to the 4000s. In MICU, course of NAC was completed, pt's INR, LFTs improved and mental status was at baseline. He was transferred out of the MICU to [**Doctor Last Name 3271**] [**Doctor Last Name 679**]. Pt was stable on floor and transaminitis continued to improve. After one day, pt was determined to be medically stable for discharge. #Hepatic failure - Hepatic failure due to acetaminophen overdose. On transfer from OSH, AST/ALT in 3000s, INR 1.7, T bili 2.1. AST/ALT rose in to 4000s, INR was 1.6 on admission, and T bili had fallen to 1.4 by admission. He had no evidence of encephalopathy. A liver transplant work up was begun, involving hepatology, transplant surgery, social work, and psychiatry. Pt was determined not to be candidate given numerous suicide attempts in the past. At time of discharge, pt's transaminitis was trending down and stable to be discharged. He does not require a liver transplant. #Depression/suicide attempt - Patient with history of depression and one prior suicide attempt. Psychiatry evaluated the patient and found him to be impulsive, but ambivalent about suicide. They recommended inpatient psychiatric hospitalization once he was medically stable. #HTN - His home amlodipine was held in the acute setting. On discharge, he was normotensive and amlodipine still on hold. #Hypothyroidism - He was continued on his home levothyroxine. #GERD - He was continued on his home pantoprazole. #Transitional care: Pt will be transferred to inpatient psychiatry on [**Hospital1 **] 4 He will need to follow up with PCP and hepatology service Medications on Admission: Medications on transfer to [**Hospital1 18**]: N-acetylcysteine Amloidipine 10 mg daily escitalopram 10 mg daily levothyroxine 125 mcg daily pantoprazole 40 mg [**Hospital1 **] bismuth subsallcylate liq 30 ml q2h prn clonidine 0.1 mg q1h prn dicyclomine 20 mg q8h prn mag-[**Doctor Last Name **] liq (no simethicone) 30 ml q8h prn milk of magnesia 30 ml qhs prn ondansetron 4mg q6h prn Discharge Medications: 1. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Extended Care Discharge Diagnosis: Acetominophen Overdose induced hepatitis Depression with suicide attempt Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr [**Known lastname **], It was a pleasure taking care of you. You were admitted to the hospital for an overdose of tylenol, which caused serious damage to your liver. We treated you with a medication called N-acetylcysteine. Your liver function improved, and you are medically cleared to leave the hospital. However, your liver function is still not back to baseline and there is a possibility that you have permanent liver damage. You will need to avoid tylenol and alcohol in the future. You will also need to follow up with a hepatologist (liver doctor). We have made the following changes to your medications: STOP: Amlodipine. Your blood pressure was normal at time of discharge and you can discuss restarting a blood pressure medication with your primary care doctor. STOP: Lexapro. We have stopped your lexapro dose because of your liver impairment. Lexapro is metabolized by the liver and blood concentrations of this medication can become elevated with liver impairment. We recommend that if you are going to restart this medication you will need to take it at a lower dose. START: omeprazole 20mg tablet, take one tablet by mouth daily . Please continue all the rest of your home medications. Followup Instructions: You will need follow up with your primary care doctor. Also, we would like you to establish care at the liver service at [**Hospital1 1535**]. We are in the process of arranging an appointment for you with one of our hepatologists within the next several weeks. `

[ "570", "922.2", "V62.84", "965.4", "E950.0", "E976", "530.81", "276.3", "790.92", "311", "401.9", "244.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8757, 8772

5988, 8115

350, 356

8904, 8904

3327, 5965

10301, 10571

2089, 2147

8552, 8734

8793, 8883

8141, 8529

9055, 9655

2162, 3308

9684, 10278

267, 312

384, 1660

8919, 9031

1682, 1854

1870, 2073

25,049

128,381

10611

Discharge summary

report

Admission Date: [**2141-11-10**] Discharge Date: [**2141-11-15**] Date of Birth: [**2078-1-6**] Sex: M Service: MEDICINE Allergies: Vicodin Attending:[**First Name3 (LF) 5368**] Chief Complaint: penile pain, lower extremity weakness Major Surgical or Invasive Procedure: Placement of central line in RIJ vein History of Present Illness: This is a 63 y.o. male with PMH significant for ischemic CM (EF 45%), OSA on CPAP, DM who presents with chief complaint of bilateral leg weakness, cough, DOE, and low urine output after surgery. He is currently POD#3 s/p penile pump implant ([**Date range (1) 34882**]/05 ) during which time the glans was persistently dusky in color. On POD #2 his foley cath was removed, but he failed to have significant urine output. Post void residual was 250 cc of urine, and he was discharged with a foley in place. His wife notes that he had less that 200 cc of urine during the day he was at home. Today he noticed that his legs were weak and he had pain in his penis, so he decided to go the ED instead of his scheduled follow up visit. . In the ED he was found to be hypotensive to 81/41 with temperature of 99.3. He received 500 mg of levoquin IV and a code sepsis was called. A central line was inserted and he received 3 liters of normal saline without apprecible urine output. Levophedrine was started for persistently low pressures. He was transferred to the MICU for further evaluation. Past Medical History: 1) Cardiomyopathy, mixed LV systolic and diastolic dysfunction. EF 45%. Most recent ECHO [**6-5**]. 2) CAD. Selective coronary arteriography in [**2139-6-2**] revealed RA 5, RV 31/8, PA 33/14 with a mean of 23, pulmonary capillary wedge pressure 6, LVEDP 9, cardiac output 5.8, CVR 235. Also revealed angiographically normal vessels with mild coronary artery disease of the left circumflex artery. Left ventriculography revealed an LVEF of 63%, mitral valve was normal. Non-ST-segment elevation myocardial infarction in [**Month (only) 547**] of [**2139**]. 3) Diabetes mellitus x 12 years, with neuropahty, nephropathy. 4) Hypertension 5) Anemia of chronic disease. 6) BPH. 7) Glaucoma; on carbonic and hydrase inhibitor 8) Chronic restrictive ventilatory disease related to a bile duct leak with development of pulmonary fibrosis requiring decortication 9) Depression 10) CRI with baseline creatinine of 1.7 Sleep apnea on BiPAP, currently [**10-10**] 11) Anemia of chronic disease. 12) BPH. 13) Erectile dyscunction s/p Penile implant 12/05 per HPI .. Past surgical history is significant for: 1) History of roux-en-y reconstruction after laparoscopic cholecystectomy in [**2139-4-2**]. 2) [**2139**] status post decordication for fibrothorax complicated respiratory failure requiring tracheostomy. 3) History of appendectomy. 4) History of left knee and hip replacement complicated by chronic pain. Social History: married, retired, worked at Polaroid. He has 3 children. He denies any history of tobacco, alcohol or drug use. Family History: CVA - brother Breast [**Name (NI) 3730**] - mother Physical Exam: Tm 99.2 Tc 99.2 BP (cuff) 84/51 P57 R20 99% 5LNC CVP 18 SVO2 65-73% Gen: NAD, sitting comfortably in bed, alert and oritented x 3 HEENT: R pupil teardrop shaped, both reactive to light. OP clear. MM dry. JVP 14 cm Resp: right side with coarse breath sounds, left side bronchial but clear CV: RRR nl s1s2 physiologically split S2 no murmurs Abd: obese, soft, nontender, ND +BS Ext: trace edema, cool to touch, no cyanosis Penis: shaft pink, tender to touch, with no purulent discharge. Testicles ecchymotic with CDI bandaged from surgery. Foley in place. Neuro: CN 2-12 intact. Strength 4/5 hip flexors bilaterally. Sensation intact bilaterally. Skin: no rash. Pertinent Results: [**2141-11-10**] 10:55AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-MOD [**2141-11-10**] 10:55AM URINE RBC-21-50* WBC-[**5-12**]* BACTERIA-MANY YEAST-NONE EPI-[**2-4**] [**2141-11-10**] 10:55AM WBC-12.7*# RBC-3.71* HGB-11.4* HCT-33.0* MCV-89 MCH-30.7 MCHC-34.4 RDW-14.2 [**2141-11-10**] 10:55AM proBNP-[**Numeric Identifier **]* [**2141-11-10**] 10:55AM GLUCOSE-166* UREA N-72* CREAT-4.5*# SODIUM-134 POTASSIUM-6.6* CHLORIDE-103 TOTAL CO2-21* ANION GAP-17 [**2141-11-10**] 10:59AM LACTATE-2.3* [**2141-11-10**] 02:00PM CRP-110.8* . Renal US [**2141-11-11**]: No hydronephrosis. Somewhat suboptimal examination. . CXR [**2141-11-10**]: Stable left pleural thickening. Mild upper tracheal narrowing stable compared to the prior exam. . LLE US [**2141-11-11**]: No DVT in the left lower extremity, no change compared to the prior study. Brief Hospital Course: In the ED the pt was given 3000ml of fluids. He was continued on Levoquine 500mg iv initially. Levophed was started to maintain adequate blood pressure. He was transferred to the ICU where he received a total of 2750cc of fluid in form of boluses. He was found to be in acute on chronic renal failure with a creatinine of 4.6. A central line and arterial line was placed. Levophed was continued. Levaquine was stopped and the pt was started on Vancomycin and Ceftriaxone. Urology was consulted. The acute event was not thought to be in relation to the operative procedure three days prior. The swelling and pain the pt experienced in his penis and scrotum was consistent with normal postoperative changes. The pt was found to have elevated troponins (0.29). He never complained of chest pain. EKGs showed T wave changes but no ST segment changes. Echo showed no evidence of RV dysfunction c/w PE, no change in mild TR; overall function similar to old EF showing EF 45%. Recent stress test without evidence of ischemia. The etiology was thought to be demand ischemia in the setting of hypotension. The BNP was elevated to [**Numeric Identifier 6085**] although there were no signs of Lsided heartfailure on CXR and overt signs of R sided failure on exam. The LE edema was at baseline for the pt. Bilateral LE US was negative for DVT. Losartan was hold during the hsopital course adn was substituted by hydralazine and imdur to achieve afterload reduction. Losartan should be restarted once acute renal failure is resolved. toprol was switched to metoprolol for better ability to titrate. The pt was given metoprolol 12.5mg [**Hospital1 **]. The pt was found to be adrenally deficient and was started on Hyrdocortisone and Fludrocortisone. The pt responded well to IVF and Levophed was discontinued. The pt remained normotensive and was restarted on metoprolol for blood pressure and heart rate control. He was transferred to the floor for further management. Vancomycin was stopped after three days per ID recommendations. Ceftriaxone was continued until the day prior to discharge when it was changed to oral Cefpodixime which should be continued for seven days suspecting a complicated urinary tract infection as the urine analysis was suggesting. Urine and Blood cultures remained negative. Fludrocortisone and Hydrocortisone were discontinued. The pt remained normotensive and afebrile. The central line was removed. Outpatient furosemide dose was restarted at 60mg QD on day 4 of admission. A set of urine lytes was checked and was most consistent with prerenal azotemia. The pt creatinine continued to trend down to 2.1 on the day of discharge. A voiding trial was done on the day of discharge. The pt was not able to void most likely due to obstruction. The pt was send home with a catheter in place to follow up with urology. The pt's diabetes mellitus was controlled with Lantus and SSC as [**First Name8 (NamePattern2) **] [**Last Name (un) **] Diabetes center sliding scale. The pt's hematocrit was reduced from baseline which was attributed to dilution. The pt has a chronic anemia chronic disease. BIPAP at night was continued on outpatient settings ([**10-10**]). Lexapro was continued for depression. Medications on Admission: Ecotrin 325 PO QD Vit D [**Numeric Identifier 1871**] Q monday Levofloxacin 500 mg POQD Docusate Sodium 100 mg PO BID Tamsulosin 0.8 mg PO QHS Furosemide 60 mg PO QD Ranitidine HCl 150 mg POBID Escitalopram 5 QAM, 10 mg QHS Losartan 50 mg POQD Beclomethasone 1 spray PO BID Toprol XL 100 POQD Percocet 7.5-325 mg PRN humalog SS: range 3-12 units in the morning for sugar 51-401, 3-12 units at lunch for 51-401, 6-14 units in the evening for blood sugars from 51-351, 1-4 units in the evening for blood sugars from 251-401. lantus 8 QHS Discharge Medications: 1. Escitalopram 10 mg Tablet Sig: 0.5 Tablet PO QAM (once a day (in the morning)). Disp:*20 Tablet(s)* Refills:*2* 2. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Disp:*20 Tablet(s)* Refills:*2* 3. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 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 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO Q MONDAY (). Disp:*30 Capsule(s)* Refills:*2* 8. 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* 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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**3-8**] hours: please do not take together with oxcycodone/acetaminophen. Please do not exceed 4g/d. Disp:*30 Tablet(s)* Refills:*0* 12. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed): for sore throat. Disp:*20 Lozenge(s)* Refills:*0* 13. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 14. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*28 Tablet(s)* Refills:*0* 15. Insulin Glargine 100 unit/mL Solution Sig: One (1) 8U Subcutaneous at bedtime. Disp:*qs 8U* Refills:*2* 16. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) Subcutaneous four times a day: per sliding scale. Disp:*qs * Refills:*2* 17. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 18. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Hypotension Possible sepsis, culture negative Possible cardiogenic shock Discharge Condition: Good, hypotension resolved, ambulatory Discharge Instructions: Please come back to the hospital or see your primary care physician if you develop any shortness of breath, chest pain, lightheadedness, weakness, fevers, chills or any other concerns. . Please take the antibiotics for seven more days twice daily. Please continue to take your other medications as prior to admissions except for the Losartan (Cozaar) and the Toprol. Please do not take the Losartan (Cozaar) until Dr. [**Last Name (STitle) **] instructs you to do so. Please take hydralazine 25mg three times daily and Imdur 60mg once daily until you are restarted on Losartan. Please take metoprolol 12.5mg twice daily instead of the toprol. Please take Pantoprazole instead of ranitidine. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in the next week. Please call for an appointment: [**Telephone/Fax (1) 1247**]. . Please follow up with Dr. [**Last Name (STitle) **] Date/Time:[**2141-11-16**] 2:15 ([**Telephone/Fax (1) 3331**]). . Please follow up with Dr. [**Last Name (STitle) 34883**],[**First Name3 (LF) **] A. MEN'S HEALTH Date/Time:[**2141-11-20**] 1:30 as instructed by Dr. [**Last Name (STitle) **].

[ "583.81", "V58.67", "584.9", "V45.89", "311", "414.01", "250.50", "410.71", "V43.65", "995.92", "412", "458.9", "428.0", "285.21", "403.91", "607.84", "585.9", "362.01", "276.7", "038.9", "276.2", "250.40", "365.9", "425.4", "785.51", "780.57" ]

icd9cm

[ [ [] ] ]

[ "93.90", "38.93", "38.91" ]

icd9pcs

[ [ [] ] ]

10935, 10993

4714, 7932

307, 346

11110, 11151

3786, 4691

11993, 12425

3038, 3090

8519, 10912

11014, 11089

7958, 8496

11175, 11970

3105, 3767

230, 269

374, 1463

1485, 2892

2908, 3022

29,376

198,773

51016

Discharge summary

report

Admission Date: [**2109-9-2**] Discharge Date: [**2109-9-8**] Date of Birth: [**2046-2-6**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2109-9-3**] - Off-pump coronary artery bypass graft x3, saphenous vein grafts to ramus, obtuse marginal and posterior descending arteries. History of Present Illness: This 63 year old woman has a history of hyperlipidemia, COPD, diabetes and Crohn??????s disease. Since the spring she has been bothered by episodes of chest discomfort that have been felt across the chest, occurring at rest several times a week. She underwent stress testing in [**2109-5-7**] which did not reveal any perfusion abnormalities. LVEF was 68%. In [**Month (only) **] she was evaluated at [**Hospital3 2737**] for similar complaints. She reportedly ruled out for an MI. She has continued to have chest discomfort several times a week and was seen by cardiology today. She has since been prescribed Aspirin, plavix and SL nitroglycerin and is now referred for cardiac catheterization to further evaluation. Past Medical History: Diabetes Crohn??????s disease diagnosed in the [**2081**]??????s COPD Hyperlipidemia Tonsillectomy [**2082**] removal of a breast cyst Partial thyroidectomy Cosmetic surgery Diabetes HTN Social History: SOCIAL HISTORY: Patient is married with three children. Lives with: Husband Occupation: none ETOH: None Active smoker Family History: Father died from an MI at age 61. Mother also with MI??????s in her 60??????s. Physical Exam: 64 sr 14 150/78 60" 118 GEN: NAD SKIN: Unremarkable NECK: Supple, FROM LUNGS: Clear HEART: RRR, Nl S1-S2 ABD: S/NT/ND/NABS EXT: Warm, well perfused. Pulses 2+ NEURO: Grossly intact Pertinent Results: [**2109-9-2**] 09:30AM PT-16.8* PTT-28.6 INR(PT)-1.5* [**2109-9-2**] 09:30AM WBC-11.5* RBC-4.16* HGB-12.8# HCT-35.8*# MCV-86# MCH-30.7 MCHC-35.7* RDW-14.2 [**2109-9-2**] 09:30AM ALT(SGPT)-17 AST(SGOT)-13 CK(CPK)-73 ALK PHOS-80 AMYLASE-57 TOT BILI-0.5 DIR BILI-0.1 INDIR BIL-0.4 [**2109-9-2**] 10:40AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2109-9-2**] 09:30AM GLUCOSE-122* UREA N-12 CREAT-0.6 SODIUM-139 POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-22 ANION GAP-14 [**2109-9-2**] Cardiac Cath 1. Selective coronary angiography of this right dominant system with significant intermedius branch revealed 3 vessel coronary artery disease. The LMCA and LAD did not had any angiographically apparent coronary artery disease. The LCx had a proximal 80% OM1 lesion. The RI had an ostial 60% lesion. The RCA had severe disease throughout the entire vessel with up to 90% stenosis in the distal vessel. 2. Limited resting hemodynamics revealed mildly elevated left sided filling pressures (LV 168/18 mmHg). The systemic arterial pressure was moderately elevated at 168/68 mmHg. There was no gradient during pullback of the pigtail catheter from the left ventricle to the aorta. 3. Left ventriculography showed normal systolic left ventricular function. Ejection fraction was calculated at 77%. There were no regional wall motion abnormalities. There was no mitral regurgitation. [**2109-9-3**] ECHO The left atrium is normal in size. 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. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild to moderate ([**2-6**]+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results on Mrs. [**Known lastname **] at 8:30AM. During the OPCAB, there was inferior wall motion abnormality which recovered. [**2109-9-5**] CXR No evidence for pneumothorax following removal of chest tubes. Retrocardiac atelectasis possibly with small effusion. Overall, standard appearance for post-bypass graft chest film.. Brief Hospital Course: Mrs. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2109-9-2**] for a cardiac catheterization. This revealed two vessel disease. Given the severity of her disease, the cardiac surgical service was consulted for surgical evaluation. She was worked-up in the usual preoperative manner and was ready for surgery. On [**2109-9-3**], Mrs. [**Known lastname **] was taken to th eoperating room where she underwent off pump coronary artery bypass grafting to three vessels. Please see operative note for details. Postoperatively she was taken to the intensive care unit for monitoring. Within 24 hours, Mrs. [**Known lastname **] awoke neurologically intact and was extubated. Beta blockade, aspirin and plavix were resumed. She stayed in the intensive care unit for hypotension responsive to neosynephrine. On postoperative day two, she was transferred to the step down unit for further recovery. She was gently diuresed towards her preoperative weight. The physical therapy was consulted for assistance with her postoperative strength and mobility. She has remained hemodynamically stable, passed her physical therapy evaluation, and is ready to be discharged to home. Medications on Admission: Questran 1 packet/day, Glyburide 5', Effexor XR 37.5 QOD, Chantix 1', Plavix 75', ASA 81', Simvastatin 40', SLNG PRN, Advaid 500/50", Spiriva" Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). [**Known lastname **]:*30 Tablet(s)* Refills:*2* 2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 6 days. [**Known lastname **]:*12 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [**Known lastname **]:*60 Tablet(s)* Refills:*2* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**Known lastname **]:*60 Capsule(s)* Refills:*2* 5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). [**Known lastname **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. [**Known lastname **]:*50 Tablet(s)* Refills:*0* 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Known lastname **]:*30 Tablet(s)* Refills:*2* 8. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [**Known lastname **]:*60 Tablet(s)* Refills:*2* 9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). [**Hospital1 **]:*60 Disk with Device(s)* Refills:*2* 10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). [**Hospital1 **]:*30 Cap(s)* Refills:*2* 11. Chantix 0.5 mg Tablet Sig: One (1) Tablet PO daily (): continue as directed by PCP. [**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*2* 12. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) Packet PO BID (2 times a day). [**Name Initial (NameIs) **]:*60 Packet(s)* Refills:*2* 13. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*2* 14. Venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO DAILY (Daily). [**Name Initial (NameIs) **]:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2* 15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. [**Name Initial (NameIs) **]:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: CAD s/p off pump CABG Diabetes Crohn??????s disease diagnosed in the [**2081**]??????s COPD Hyperlipidemia Tonsillectomy [**2082**] removal of a breast cyst Partial thyroidectomy Cosmetic surgery 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) 4044**]. 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) Call with any questions or concerns. Followup Instructions: Follow-up with Dr. [**First Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**] Please follow-up with Dr. [**Last Name (STitle) 7047**] in 2 weeks. Please follow-up with Dr. [**Last Name (STitle) 66033**] [**Name (STitle) **] in [**3-10**] weeks. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2109-9-8**]

[ "305.1", "413.9", "272.4", "V45.89", "414.01", "496", "250.00", "458.29" ]

icd9cm

[ [ [] ] ]

[ "88.56", "36.13", "37.22", "88.53", "39.64" ]

icd9pcs

[ [ [] ] ]

8097, 8152

4461, 5646

308, 452

8392, 8401

1866, 4438

9138, 9514

1561, 1642

5839, 8074

8173, 8371

5672, 5816

8425, 9115

1657, 1847

258, 270

480, 1199

1221, 1409

1441, 1545

60,624

196,710

16765

Discharge summary

report

Admission Date: [**2138-9-19**] Discharge Date: [**2138-9-27**] Date of Birth: [**2059-11-22**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2138-9-23**] Coronary artery bypass grafting x 4 with left internal mammary artery to left anterior descending coronary; reverse saphenous vein single graft from aorta to ramus intermedius coronary artery; reverse saphenous vein single graft from aorta to first obtuse marginal coronary artery; as well as reverse saphenous vein single graft History of Present Illness: Patient is a 78 yo male with history of Coronary Artery Disease (MI in past) who states that for the past 2-3 weeks he has noted exertional angina requiring increased NTG SL use. For the past few weeks he has been using SL NTG daily when he would exert himself (wash the floor, run errands). On the day PTA he had chest pain associated with diaphoresis and he took 24 SL NTG to relief waxing and [**Doctor Last Name 688**] chest discomfort - prompting his to present to [**Hospital 8125**] Hospital where he was started on IV NTG and transferred to NEBH ICU. His CK peaked at 445, CK MB 7.7 and Troponin went from 0.47 to 0.32. He was then transferred to [**Hospital1 18**] for cardiac cath. Past Medical History: Coronary Artery Disease s/p Myocardial Infarction with known subtotal occlusion of RCA Hypertension Hyperlipidemia Diabetes Mellitus Peripheral vascular disease s/p left SFA stenting, right carotid endartarectomy, s/p Right common femoral endarectomy [**2132**] Benign Prostatic Hypertrophy Social History: Occupation: Retired special [**Doctor Last Name 360**] armed services Edentulous Lives with wife [**Name (NI) **]: Caucasian Tobacco: Remote use ETOH: 1 drink/night Family History: n/c Physical Exam: Pulse: 49 Resp: 19 O2 sat: 100% RA B/P Right: 117/42 Height: 5'[**40**]" Weight: 161 lbs General: Skin: Dry [X] intact [X] HEENT: PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] Chest: Lungs clear bilaterally [X] Heart: RRR [X] Irregular [] Murmur Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Edema Varicosities: None [] Neuro: Grossly intact Pulses: Femoral Right: 2+ Left:2+ DP Right: 2+ Left:2+ PT [**Name (NI) 167**]: 2+ Left:2+ Radial Right: 2+ Left:2+ Carotid Bruit Right: - Left:- Pertinent Results: [**2138-9-19**] Cardiac Cath: 1. Coronary angiogrpahy in this right dominant system demostrated three vessel disease. The LMCA was heavily calcified with non-critical disease. The LAD was calcified with moderate disease. The LCx had an ostial 99% stenosis. The RCA was totally occluded proximally and filled via left to right collaterals. 2. Resting hemodynamics revealed normal right and left sided filling pressures with RVEDP of 9mmHg and LVEDP of 17mmHg. There was mild pulmonary arterial systolic hypertension with PASP of 30mmHg. The cardiac index was preserved at 2.45 L/min/m2. The calculated Fick cardiac output was 4.81 L/min. There was normal central arterial pressure with a systolic of 119mmHg, diastolic of 39mmHg, and mean of 69mmHg. 3. There was no significant gradient accross the aortic valve suggesting no appreciable aortic stenosis. 4. Left ventriculography revealed no mitral regurgitation. The LVEF was grossly normal with no regional wall motion abnormalities. 5. Aortic fluoroscopy revealed a moderately calcified aortic arch. [**2138-9-19**] Carotid U/S: Right ICA with no stenosis. Left ICA stenosis <40%. [**2138-9-19**] Vein mapping: Duplex evaluation performed of both lower extremity venous systems. Right greater saphenous vein shows patency with diameters of 0.24 to 0.46 and the left greater saphenous vein, 0.21 to 0.61 [**2138-9-19**] Chest CT: 1. Pulmonary nodule (5-mm right) for which chest CT followup is recommended at six months [**First Name8 (NamePattern2) **] [**Last Name (un) 8773**] guidelines. 2. Dense atherosclerosis of the thoracic aorta and coronary arteries. [**2138-9-23**] Echo: PRE-BYPASS: The left atrium is mildly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. There is moderate regional left ventricular systolic dysfunction with moderate anterior and antero-septal hypokinesis. The right ventricular cavity is mildly dilated with normal free wall contractility. There are simple atheroma in the ascending aorta. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. The mitral valve leaflets are myxomatous. There is mild mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. POST CPB: 1. Mildly improve global and focal LV systolci function. 2. Mitral regurgitationis now mild. No other change [**2138-9-27**] 05:17AM BLOOD WBC-8.9 RBC-2.66* Hgb-7.6* Hct-23.5* MCV-88 MCH-28.6 MCHC-32.5 RDW-14.1 Plt Ct-212 [**2138-9-27**] 05:17AM BLOOD Glucose-188* UreaN-20 Creat-0.8 Na-138 K-4.0 Cl-106 HCO3-24 AnGap-12 Brief Hospital Course: As mentioned in the HPI, Mr. [**Known lastname **] was transferred to [**Hospital1 18**] for cardiac cath. Cath revealed severe three vessel coronary artery disease. He was appropriately work-up for bypass surgery which also included carotid u/s, chest ct, echo and vein mapping. On [**9-23**] he was brought to the operating room where he underwent a coronary artery bypass graft x 4. Please see operative note for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring. He was extubated. He experienced atrial fibrillation with a rapid ventricular response, for which he was placed on amiodarone and converted back to sinus rhythm. His pressors were weaned and his chest tubes were removed. He was disoriented for the first couple of days post-operatively and then cleared. On post-operative day three his epicardial wires were removed and he was transferred to the surgical step down floor. By post-operative day four he had progressed well and was cleared for discharge to home by Dr. [**Last Name (STitle) 914**]. Medications on Admission: Medication at home: Amlodipine 5 mg daily, Clonazepam 0.5 mg Tablet at bedtime, Clopidogrel 75mg daily, Nexium 40 mg daily, [**Doctor First Name **] 60 mg [**Hospital1 **], Furosemide 40 mg Tablet mon / wends / fri, Imdur 30 mg daily, Metformin 500 mg daily, Toprol XL 12.5 mg daily, Nasonex 50 mcg 2 sprays each nostril daily in the am, NitroQuick 0.4 mg Sublingual, Pravastatin 80 mg daily, Aspirin 325 mg daily Medications on transfer: Aspirin 325 mg daily, Pravastatin 80 mg daily, Norvasc 5 mg daily, Metoprolol ER 12.5 mg daily, Plavix 75 mg daily, Imdur 30 mg daily, Lovenox 80 mg [**Hospital1 **], Zantac 150 mg [**Hospital1 **], Sliding scale Insulin Discharge Medications: 1. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day: take 2 pills (40mg) daily for one week, then decrease to 2 pills (40mg) Mon/Wed/Fri ongoing. Disp:*30 Tablet(s)* Refills:*2* 2. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: take 2 pills (400mg) daily for one week, then decrease to 1 pill (200mg) daily. Disp:*60 Tablet(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Disp:*120 Tablet(s)* Refills:*2* 7. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 8. Ultram 50 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1376**] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 Past medical history: Myocardial Infarction in past with known subtotal occlusion of RCA Hypertension Hyperlipidemia Diabetes Mellitus Peripheral vascular disease s/p left SFA stenting, right carotid endartarectomy, s/p Right common femoral endarectomy [**2132**] Benign Prostatic Hypertrophy Discharge Condition: Good Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming Monitor wounds for infection and report any redness, warmth, swelling, tenderness or drainage Please take temperature each evening and Report any fever 100.5 or greater 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 until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**Last Name (STitle) 914**] (cardiac surgery) in 4 weeks ([**Telephone/Fax (1) 11763**] Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 47367**] (PCP) in in [**1-17**] weeks ([**Telephone/Fax (1) 47368**] Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11679**] (cardiology) in [**2-18**] weeks Completed by:[**2138-9-27**]

[ "E878.2", "285.9", "427.31", "440.20", "414.01", "E935.8", "401.9", "303.90", "V64.2", "997.1", "493.90", "291.81", "307.9", "272.4", "410.71", "250.00", "600.00" ]

icd9cm

[ [ [] ] ]

[ "36.15", "38.93", "37.23", "88.56", "94.62", "39.61", "36.13", "88.53" ]

icd9pcs

[ [ [] ] ]

8422, 8473

5523, 6584

332, 678

8870, 8876

2563, 5167

9505, 9872

1912, 1917

7296, 8399

8494, 8555

6610, 7026

8900, 9482

1932, 2544

282, 294

706, 1399

7051, 7273

8577, 8849

1729, 1896

5177, 5500

23,678

145,560

46201

Discharge summary

report

Admission Date: [**2128-7-30**] Discharge Date: [**2128-8-4**] Date of Birth: [**2055-7-21**] Sex: F Service: MEDICINE Allergies: Allopurinol Attending:[**First Name3 (LF) 3151**] Chief Complaint: Back pain and Tachycardia Major Surgical or Invasive Procedure: none History of Present Illness: HPI: Patient is a 73 y/o F with history of HTN, DM II, stage IV CRI, L Papillary renal cell carcinoma s/p partial L nephrectomy, and s/p splenectomy, who presented to the ED complaining of low back pain x 2 days. The patient felt that it was her "kidneys" and localized the pain to her right lower back. The pain started after the patient awoke from sleep one morning. Pain was exacerbated by movement of any kind, although she was able to walk slowly. T#3's at home did not improve the pain. She denied any abdominal pain, chest pain, palpitations, shortness of breath, headache, nausea/vomiting, diarrhea, dysuria or hematuria. She also denied any fevers and was actively monitoring her temperature while at home. The patient denied recently falling, over exerting herself, and or experiencing any trauma recently that could contribute to her symptoms. She has never had a history of arthritis in the past, and has never had back pain like this before. The patient was schedule to see her outpatient PCP earlier next week, but due to her on-going symptoms, decided to be evaluated in the emergency department. While in the ED, the patient complained of back pain, but was found to be tachycardic with HR's to the 130's - 150's. The rest of her vital signs were stable and she was also hypertensive with BP's in the 180's/60's. EKG was consistent with sinus tachycardia, and also showed ST segment depression in leads I, II, AVF, V5, and V6. In the setting of DM, dyslipidemia and HTN, this was somewhat concerning for cardiac ischemia, however the patient was not complaining of any chest discomfort or pressure. The patient was given IVF with some improvement in her tachycardia which on repeat was in the 120's. However, given her persistent tachycardia, leukocytosis, gap acidosis and renal insuffiency, the patient was admitted to the MICU for further evaluation. Past Medical History: PMH: HTN DM II, recently started on insulin, w h/o DKA Stage IV CKD secondary to diabetic nephropathy Gout Dyslipidemia Secondary hyperparathyroidism Anemia L Papillary renal cell carcinoma Social History: nc Family History: nc Physical Exam: Physical Exam: Vitals in ED: T: 98.1 BP: 188/62 P: 122 RR: 16 O2Sat: 100% RA Gen: Appears comfortable, resting in bed in NAD HEENT: PERRL, EOMI, sclerae anicteric, MMM NECK: supple, no palpable LAD CV: Regular, nl s1/s2, no extra heart sounds, no audible murmurs, no JVD LUNGS: CTAB ABD: softly distended, large midline abdominal scar w/keloid formations. L lateral horizontal surgical scar well healed. + NS, no hepatomegaly. No rebound, no guarding. EXT/SKIN: RUE forearm slightly erythematous with small amts of scattered petechiae. LUE without rashes, lesions or petechiae. No lower extremity edema noted. Extremities warm and well perfused Neuro: AAOX3, CN II-XII intact, tongue midline, no facial droop. Negative bilateral straight leg raise. Sensation equal and neuro exam grossly non-focal. Back: Mild tenderness to palpation over R sacro-iliac joint without palpable mass,or local erythema or edema. No midline tenderness to palpation over spine. No CVAT. Pertinent Results: [**2128-7-30**] 10:25AM BLOOD WBC-21.5* RBC-3.87* Hgb-11.2* Hct-33.0* MCV-85 MCH-28.8 MCHC-33.8 RDW-13.9 Plt Ct-379 [**2128-7-30**] 10:25AM BLOOD Neuts-72.3* Lymphs-22.3 Monos-4.4 Eos-0.9 Baso-0.2 [**2128-8-4**] 04:35AM BLOOD WBC-15.9* RBC-3.06* Hgb-8.8* Hct-26.6* MCV-87 MCH-28.8 MCHC-33.2 RDW-13.6 Plt Ct-400 [**2128-7-30**] 10:25AM BLOOD Calcium-10.6* Phos-5.0* Mg-2.0 [**2128-8-4**] 04:35AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.2 [**2128-7-30**] 10:25AM BLOOD Glucose-198* UreaN-108* Creat-2.4* Na-137 K-5.0 Cl-100 HCO3-19* AnGap-23* [**2128-8-4**] 04:35AM BLOOD Glucose-214* UreaN-77* Creat-1.6* Na-136 K-4.9 Cl-104 HCO3-23 AnGap-14 . [**2128-7-30**] 10:25AM BLOOD PT-12.9 PTT-27.5 INR(PT)-1.1 [**2128-8-1**] 05:30AM BLOOD PT-14.8* PTT-33.2 INR(PT)-1.3* [**2128-7-30**] 10:25AM BLOOD ALT-24 AST-30 CK(CPK)-66 TotBili-0.207/25/08 [**2128-7-30**] 12:26PM BLOOD Lactate-1.3 . 06:24PM BLOOD D-Dimer-3776* [**2128-7-30**] 06:24PM BLOOD Acetone-NEGATIVE Osmolal-321* [**2128-7-30**] 10:20AM BLOOD PTH-60 [**2128-7-31**] 05:30AM BLOOD ESR-125* [**2128-8-1**] 05:30AM BLOOD ESR-128 . [**2128-7-31**] 05:30AM BLOOD CK(CPK)-91 [**2128-7-31**] 03:00PM BLOOD CK(CPK)-110 [**2128-8-1**] 05:30AM BLOOD CK(CPK)-60 [**2128-8-2**] 04:30AM BLOOD CK(CPK)-47 [**2128-7-30**] 10:25AM BLOOD cTropnT-0.02* [**2128-7-31**] 05:30AM BLOOD CK-MB-NotDone cTropnT-0.18* [**2128-7-31**] 03:00PM BLOOD CK-MB-7 cTropnT-0.19* [**2128-8-1**] 05:30AM BLOOD CK-MB-NotDone cTropnT-0.19* [**2128-8-2**] 04:30AM BLOOD CK-MB-NotDone cTropnT-0.14* CT TORSO PERFORMED ON [**2128-7-30**] without contrast: IMPRESSION: 1. No findings to explain patient's pain. 2. Post-surgical changes in the left kidney with hypodensity in the surgical bed, which is incompletely assessed, though appears similar in size to prior study. Consider MRI for further evaluation to assess for recurrence Lung scan [**2128-8-2**]: IMPRESSION: 1. Normal lung scan. 2. Cardiomegaly. LENIS [**2128-7-30**]: IMPRESSION: No evidence of DVT in either lower extremity. EKG [**2128-7-31**]: #1 Sinus tachycardia with atrial premature beats. Probable old inferior myocardial infarction. Non-specific ST-T wave changes. Compared to tracing the ventricular rate is faster. #2 Sinus tachycardia with atrial premature beats. Borderline left ventricular hypertrophy. Non-specific ST-T wave changes. Possible inferior myocardial infarction, age indeterminate. Compared to tracing #1 the R wave is absent in lead aVF. Sinus tachycardia and atrial premature beats are new. Brief Hospital Course: Assessment and Plan: Pt is a 73 y/o F with history of HTN, DM II, stage IV CRI, L Papillary renal cell carcinoma s/p partial L nephrectomy, and s/p splenectomy, who presented to the ED complaining of low back pain x 2 days with tachycardia and leukocytosis but afebrile. The lower back pain was due to either bursitis or gout. R hip and low back: The patient was admitted for R low back/R hip pain that was thought to be due to either a bursitis or gout (see details on gout below). A CT of the abdomen and pelvis was done to look for hydronephrosis, a stone, or a AAA and showed no etiology for her back pain. . Gout: The patient developed gout of her mid foot which presented with acute pain and swelling over the mid foot but no erythema. There was no fluid to aspirate. The patient cannot take NSAID or colchicine due to her CKD. She also does not take allopurinol due to an allergy to the medication. She was started on a 5 day course of Prednisone 40mg PO daily and her gout started to improve after one dose. She was set up with an outpatient allergy appointment for allopurinol desensitization. She was also set up to see Rheumatology as an outpatient. The patient had a high ESR on admission and it is possible that her low back/hip pain was gout as well. . DM: The patient had blood sugars in the 200s during her admission after starting the prednisone. She is being discharged with VNA services to check her blood sugar and she will also check her blood sugar on her own QID. She is being discharged on her normal PO diabetes medication, lantus 10qHS, and a humalog sliding scale. . BP: The patient had several episodes of HTN with SBP in the low 200s. Her HTN medications were increased during the admission. At one point she developed hypotension with a SBP in the 80s and her medications were titrated down slightly. Her new BP regimen is: Clonidine 0.2mg PO TID, Metoprolol 25mg PO TID, and Lisinopril 40mg PO daily. Her lasix was stopped due to an acute worsening in kidney function with an increased creatinine. She has a follow up appointment to see Dr. [**Last Name (STitle) 665**] next week to follow up on her HTN and blood sugars. . D-dimer: She was found to have an elevated D-dimer of 3776. Lower extremity LENIs and a V/Q scan were done and both were normal. . Anemia: The patient has a history of anemia related to CKD. She was previously on Aranesp injections. Hgb was 33 on admission but later dropped to 26.3. She was guiac negative. The next day her HCT was up to 29.5 despite receiving IV fluids. . Tachycardia: The patient's tachycardia was likely secondary to her pain as her tachycardia and BP responded well to fentanyl. Cardiac enzymes were checked she had negative CK and CK-MB with a positive troponin. She was monitored on telemetry. She was also given fluid in case the tachycardia was secondary to dehydration which is unlikely given the specific gravity of her urine. . Leukocytosis: The patient had leukocytosis on admission with no bands and a slight left shift. She had a history of leukocytosis in the past with no clear shift. She was afebrile, had a negative UA, negative CXR, and negative blood cx. It is possible that the leukocytosis was due to the gout she developed after being hospitalized. The leukocytosis developed prior to her receiving steroids for her gout. . Medications on Admission: Home Meds: Lantus 20 units Qday Glipizide 10mg po BID Precose 25mg po TID Furosemide 40 mg po bid clonidine 0.2 mg po bid calcitriol 0.25 mcg po daily lisinopril 40 mg po daily Lipitor 40 mg po daily ferrous sulfate 325 mg po daily nifedipine XL 60 mg po daily metoprolol 25 mg po BID T#3 [**1-7**] tabls po Q8 prn Cinacalcet 30 mg po daily Discharge Medications: 1. Atorvastatin 40 mg PO DAILY 2. Cinacalcet 30 mg PO DAILY 3. Calcitriol 0.25 mcg PO DAILY 4. Nifedipine 60 mg PO DAILY 5. Prednisone 20 mg PO DAILY for 2 days one dose on [**8-5**] and one on [**2128-8-6**]. 6. Lisinopril 20 mg Two (2) Tablet PO once a day. 7. Clonidine 0.2 mg PO TID 8. Metoprolol Tartrate 25 mg PO TID 9. Iron 325 mg PO once a day. 10. Insulin regimen 11. Precose 25 mg PO three times a day. 12. Glipizide 10 mg PO twice a day. 13. Lorazepam 1 mg PO three times a day. Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary Diagnoses: 1. Labile Hypertension 2. Right gluteal bursitis or gout 3. Right midfoot gout 4. Stage III chronic kidney disease 5. Diabetes Mellitus Secondary Diagnoses: 1. Dyslipidemia 2. Secondary hyperparathyroidism 4. Anemia Discharge Condition: Stable. Discharge Instructions: You have been admitted to the hospital with right lower back/buttock pain that we believe was caused by bursitis or gout. You also developed gout in your R foot which we are treating with prednisone which has caused a transient rise in your blood sugar. Please check your blood sugar 4x a day at home and call your PCP if your blood sugar is > 400. You also experienced high blood pressure and a high heart rate while here and your blood pressure medications were adjusted. You developed an increased creatinine due to acute worsening of your kidney functioning and thus we are temporarily stopping your lasix and decreasing your lisinopril dose. You should talk to your PCP about when to restart these medications at their previous doses. The following changes have been made to your medications: The following new medications were started: Prednisone 20mg PO Daily x2 days (last day [**2128-8-6**]) The following medication was discontinued: Lasix 40mg PO BID, please discuss with your PCP when to restart this The following medications had a dose or frequency change: Clonidine 0.2mg PO TID Metoprolol 25mg PO TID No changes were made to the following medications, please continue to take them at their previous dose. -Lantus, glipizide, precose, calcitriol, lipitor, nifedipine, cinacalcet, tylenol #3, ferrous sulfate Please return to the ED for chest pain, dyspnea or any other medical concern. Followup Instructions: Please call and make an appointment with any physician or RN as an episodic visit for [**2128-8-6**]. Please call [**Telephone/Fax (1) 250**]. This visit is to check your blood pressure, review your blood sugars and examine your foot for gout. . Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) **], MD. Phone [**Telephone/Fax (1) 250**] Date/Time: [**2128-8-11**] at 12:00 for blood pressure and blood sugar control . Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2128-8-12**] 11:00 . Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at Rheumatology, Phone: [**Telephone/Fax (1) 2226**] Date/Time: [**2128-8-18**] at 8:00am on [**Hospital Ward Name 517**] of [**Hospital1 18**] in lobby [**Hospital Unit Name **] . [**First Name8 (NamePattern2) 2602**] [**Name8 (MD) 2603**], M.D., Allergy appointment, Phone [**Telephone/Fax (1) 9316**] Date/Time: [**2128-8-31**] at 9:45 am at [**Hospital1 18**] [**Location (un) 8170**] [**Apartment Address(1) 9702**] . Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1114**], M.D. Phone [**Telephone/Fax (1) 250**] Date/Time:[**2128-10-5**] 11:20 Completed by:[**2128-9-1**]

[ "588.81", "285.21", "V10.52", "726.5", "584.9", "585.3", "250.40", "276.2", "272.4", "403.90", "274.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10230, 10279

5978, 9323

297, 303

10559, 10569

3459, 5955

12026, 13281

2454, 2458

9715, 10207

10300, 10456

9349, 9692

10593, 12003

2488, 3440

10477, 10538

232, 259

331, 2204

2226, 2418

2434, 2438

11,928

121,322

22171

Discharge summary

report

Admission Date: [**2119-9-13**] Discharge Date: [**2119-9-20**] Date of Birth: [**2051-7-9**] Sex: F Service: GYN ADMISSION DIAGNOSES: Malignant ascites. Carcinomatosis. DISCHARGE DIAGNOSES: Metastatic primar peritoneal carcinoma. Bilateral pleural effusions. HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old gravida 4, para 4 0-1-4, who presented on [**2119-9-13**] as a transfer of care from [**Hospital3 7571**]Hospital. The patient had been diagnosed with possible ovarian cancer one month prior to presentation when she presented to her primary care physician with increasing shortness of breath and abdominal distention. A paracentesis was performed at that time secondary to increasing shortness of breath and ascites with positive malignant cells on cytology. The patient's CA-125 was 24,890. A CEA was obtained, which is 1.2. The patient was transferred on [**2119-9-13**] to [**Hospital1 188**] for preoperative care with plan for tumor debulking. The patient underwent a preoperative chest x-ray, which revealed bilateral pleural effusions, which were consistent with the pleural effusions seen on her chest CT with the right greater than left pleural effusions. PAST MEDICAL HISTORY: Status post multiple fractures after a car accident, status post surgical repair. PAST OB HISTORY: NSVD x4. Delivery one set of twins. SAB x1 status post D and E. PAST GYN HISTORY: Patient has been menopausal since age 45. She has had no postmenopausal bleeding, normal Pap smears. Her last mammogram was greater than five years. The patient was unsure of her last Pap smear. FAMILY HISTORY: The patient denied breast, ovarian, and colon cancer. SOCIAL HISTORY: She denied tobacco, alcohol, or drug use. MEDICATIONS: She presented on [**2119-9-13**] on: 1. Lasix 40 mg p.o. q.d. 2. Levaquin 500 mg p.o. q.d. 3. Lexapro 10 mg p.o. q.d. 4. MS Contin 15 mg b.i.d. for pain. ALLERGIES: She is allergic to sulfa. PHYSICAL EXAMINATION: Vital signs on presentation: Temperature 97.6, blood pressure 100/60, heart rate of 96, respiratory rate 16, and saturating 94-95 percent on 2 liters. Physical examination on presentation: She generally is in no apparent distress. Cardiovascular examination is regular, rate, and rhythm. Pulmonary examination was clear to auscultation bilaterally. Abdomen was soft, nontender, and distended secondary to ascites. Sterile vaginal examination was limited secondary to body habitus. There is palpable cervix and vagina, which were within normal limits. Her rectal was guaiac negative with no masses. Extremities: There is trace edema bilaterally. No erythema. LABORATORY EVALUATION ON PRESENTATION: Her white blood cell count was 7.2, hematocrit was 33.5 percent, platelets were 476. Her coagulation profile was within normal limits. Her Chem-10 was within normal limits. Her ALT, AST, amylase, T bilirubin, alkaline phosphatase, and albumin were all within normal limits. A preoperative chest x-ray was obtained at [**Hospital3 **] on [**2119-9-13**], which showed bilateral pleural effusions consistent with prior imaging. BRIEF HOSPITAL COURSE: Primary peritoneal carcinoma: The patient was taken to the operating room on [**2119-9-14**] and underwent cytoreductive surgery including total omentectomy and bilateral salpingo-oophorectomy and drainage of ascites. Surgery was uncomplicated with a blood loss of 300 cc and approximately 4 liters of ascites drained. The patient was admitted to the ICU postoperatively secondary to difficulty with oxygenation and pain control issues. Patient's pathology and cytology from the surgery are consistent with metastatic primary peritoneal carcinoma Stage IV papillary serous pathology. Postoperative course: On postoperative day number one, the patient was transferred to the ICU secondary to oxygenation issues. She required 4 liters nasal cannula with 100 percent face mask to keep her O2 saturations approximately 94-96 percent. On postoperative day number two, after being called out from the ICU, the patient was found to have an acute desaturation in her oxygen status. Her O2 saturations declined to 88 percent on room air, improved to 94 percent on 4 liters. Her urine output was also found to be borderline less than 30 cc/hour. Initially, her pH was 7.47, bicarb is 34, PO2 is 65, base access was 7. After diuresis, the repeated pH was 7.46, PO2 was 77, PCO2 is 46, calculated bicarb was 34. Patient underwent a chest x-ray, which showed worsening bilateral pulmonary effusions. She was continued on IV Lasix. On postoperative day number three, she had a decline in her oxygenation again. She underwent a CTA to rule out a pulmonary embolus, for which she was ruled out. She also had some mild chest pain for which she underwent serial cardiac enzymes, which came back negative. EKG was obtained, which was also unchanged from baseline. On postoperative day number four, the patient was evaluated by the Medicine consult team and a repeat chest x-ray showed worsening of her right pleural effusion. She underwent a therapeutic thoracentesis with removal of approximately 2 liters of fluid. This was sent for cultures and cytology. On postoperative day number five, she underwent a chest x-ray post thoracentesis, which showed a very small pleural effusion. However, she appeared clinically stable at approximately 94 percent on 4 liters nasal cannula. This was then followed up by a repeat chest x-ray on postoperative day four, which showed no change in the pneumothorax. On postoperative day number six, her chest x-ray was repeated, which showed no change in her pneumothorax, and still remains small and the patient remains clinically stable. Per the Medicine consult team, the patient remained on oxygen supplementation 100 percent by face mask and the plan was for followup on postoperative day number seven on [**2119-9-21**] with repeat chest x-ray. Plan per the Medicine consult team is if chest x-ray is improved, patient should be weaned off her oxygen as tolerated. However, if the pneumothorax starts to increase or worsen, plan for pleurodesis. GI: The patient initially had nausea and vomiting postoperatively, which resolved and she was able to tolerate regular diet prior to discharge. Disposition: The patient is being discharged to [**Hospital6 57874**] for medical management postoperatively while concurrently being evaluated for chemotherapy. DISCHARGE CONDITION: Stable. DISCHARGE DIAGNOSES: Primary peritoneal carcinoma metastatic disease. Bilateral pleural effusions. Pneumothorax. DISCHARGE MEDICATIONS: 1. Dilaudid p.o. as needed for pain. 2. Motrin p.o. as needed for prn pain. FOLLOW UP: The patient is to followup with Dr. [**Last Name (STitle) 2406**] for a postoperative visit as scheduled and to receive chemotherapy at [**Hospital6 17032**]. [**First Name11 (Name Pattern1) 333**] [**Last Name (NamePattern4) **], [**MD Number(1) 57875**] Dictated By:[**Doctor Last Name 57876**] MEDQUIST36 D: [**2119-9-20**] 12:02:47 T: [**2119-9-20**] 12:52:33 Job#: [**Job Number 57877**]

[ "197.0", "158.8", "518.0", "198.6", "197.5", "198.89", "512.1", "496", "998.32" ]

icd9cm

[ [ [] ] ]

[ "54.4", "34.91", "65.61" ]

icd9pcs

[ [ [] ] ]

3151, 6455

6477, 6486

1641, 1696

6508, 6603

6626, 6705

6717, 7142

157, 194

1988, 3127

316, 1217

1240, 1624

1713, 1965

24,454

135,363

25348+57447

Discharge summary

report+addendum

Admission Date: [**2189-7-28**] Discharge Date: [**2189-8-14**] Date of Birth: [**2111-8-14**] Sex: M Service: VSU CHIEF COMPLAINT: Asymptomatic bilateral carotid artery stenosis. HISTORY OF PRESENT ILLNESS: This 77-year-old gentleman states that his bilateral carotid artery stenosis was an incidental finding, and he was referred to Dr. [**Last Name (STitle) 1391**] for surgery. The patient is an unreliable historian and says that he has had either a MRI or a CTA ultrasound of carotids. He does have a history of stroke in [**2167**]. Denies any amaurosis fugax, slurred speech, weakness in the extremities. REVIEW OF SYSTEMS: General review of systems is positive for dyspnea on exertion. No chest pain, no chest pressure, left arm pain. No constitutional symptoms. PAST MEDICAL HISTORY: Hypertension, history of coronary artery disease, history of type 2 diabetes (on oral agents), history of glaucoma left eye, history of hypercholesterolemia, history of Parkinson disease (on carbidopa/levodopa), history of stroke in [**2167**], history of peripheral vascular disease. PAST SURGICAL HISTORY: Includes right fem/[**Doctor Last Name **] bypass, coronary artery bypasses x 3 in [**2186**], pericardial aortic valve replacement. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: Include Lasix 40 mg daily, aspirin 81 mg daily, lisinopril 20 mg daily, glyburide 5 mg b.i.d., Colace 100 mg b.i.d., atenolol 25 mg daily, carbidopa/levodopa 25/100 one and a half tablets q.a.m. and one and half tablets q.p.m., Coumadin 4 mg at bedtime, Lipitor 40 mg daily, metformin 500 mg b.i.d., brimonidine eye drops left eye 1 b.i.d. SOCIAL HISTORY: Negative for tobacco use. Rare alcohol. The patient is married. Lives with his spouse. [**Name (NI) **] is independent with his ADLs. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: This is an elderly male, looks stated age and with essential tremors noted. He is alert and oriented x 3. In no acute distress. There is some pronator drift on the left upper extremity. The neck is supple with full range of motion. No lymphadenopathy. No carotid bruits. The lungs are clear to auscultation bilaterally. Heart is a regular rate and rhythm with a 2/6 systolic ejection murmur at the base. The abdomen is soft, nontender, and nondistended with bowel sounds present. Extremities with 1+ edema (right greater than left). The patient has biphasic PT bilaterally and monophasic DP bilaterally. CARDIAC WORKUP: Included an equilibrium radionuclide angiography at rest. The right ventricle was normal in size with no hypertrophy. Ejection fraction was 49%. There were regional wall abnormalities with motion of dyskinesis, inferoposterior/apical were dyskinetic. Resting end-diastolic volume was normal. Resting end-systolic volume was 36. Left atrium was normal in size. Right atrium was enlarged. Right ventricle was moderately enlarged. Pulmonary artery not enlarged. Echocardiogram on [**2189-5-5**] with no previous changes from echo of [**2188-3-18**]. P-MIBI was nondiagnostic. Stress with no evidence of nuclear images to suggest any significant ischemia. Carotid ultrasound showed critical left internal carotid artery stenosis and a right internal carotid artery stenosis of 70%. HOSPITAL COURSE: The patient was admitted to the vascular service. His Coumadin was held, and his INR was monitored; and when it was less than 2.0 IV heparinization was begun. Repeat carotid studies were done in our vascular lab which showed a right internal carotid artery stenosis of 40% to 59%, a left internal carotid artery stenosis of 80% to 99%. On [**7-30**] the patient underwent a left carotid endarterectomy. He tolerated the procedure well and was transferred to the PACU in stable condition where he developed airway stridor. Returned to the OR with a right neck exploration and evacuation of a hematoma. He remained intubated. On [**7-31**] he returned to the OR for airway stridor and underwent evacuation of a right neck hematoma. ENT was consulted. Their recommendations were steroids and to continue intubation for 48 to 72 hours. The patient should be extubated under controlled situations; i.e., in ICU or surgery with a pediatric bronchoscope. The patient was transferred to the SICU on [**7-31**]. On [**8-1**] the neck JP was discontinued. On [**8-3**] tube feeds were begun. On [**8-4**] the patient developed new atrial fibrillation. His tube feeds were held. He required beta blockade for rate control. Cardiology saw the patient; that if the patient did not covert - or rate was not controlled - over the next 24 hours would consider a electrical cardioversion. IV amiodarone was begun. On [**8-4**] the patient was extubated under direct visualization. He tolerated the extubation. On [**8-5**] steroid tapering was begun. He had a laryngoscopy by ENT. There was no vocal cord paralysis but some mild right laryngeal edema. The patient converted to a normal sinus rhythm. Anticoagulation was started. On [**8-6**] the patient was transferred to the VICU for continued monitoring and care. His tube feeds were restarted. Speech and swallow was requested to see the patient to evaluate for signs and symptoms of aspiration. This was not able to be done, and recommendations to re-consult when the patient was not confused, could sit up, and was talking. Neurology was consulted because there was noted left-sided movement changes. Recommendations were EEG (which was negative for seizures), MRI (which was negative for acute process). An infections process of blood cultures, urine cultures, and CBCs were obtained which were negative. Cardiac enzymes were done to rule out for myocardial infarction which were negative. The patient was begun on levofloxacin and Flagyl. On [**8-9**] he had a right PICC line placed, and the femoral triple lumen catheter was removed. An insulin drip was started because of his hyperglycemia. Physical therapy was requested to see the patient who recommended rehab placement. On [**8-10**] the patient was to be continued on his antibiotics of levofloxacin and Flagyl for 5 more days. Speech and swallow saw the patient and felt that there were no signs or symptoms of aspiration. The patient was begun on p.o.'[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] was consulted because of the patient's hyperglycemia. He was placed on an insulin drip, and this was tapered once his glycemic control was improved. The patient was begun on p.o. diet, and cycling of his tube feeds were begun on [**8-11**]. His telemetry was discontinued. He was transferred to the regular nursing floor for continued care, and ambulation to chair was begun. DISCHARGE MEDICATIONS: Brimonidine tartrate ophthalmic 0.5% 1 drop left eye b.i.d.; miconazole nitrate powder to affected areas t.i.d.; nystatin swish-and-swallow q.i.d.; Colace 100 mg b.i.d.; Lasix 40 mg daily; atenolol 75 mg daily; lisinopril 30 mg daily; hydralazine 20 mg q.4.h. (hold for systolic blood pressure of less than 100); aspirin 81 mg daily; lisinopril 40 mg daily; carbidopa/levadopa 25/100 tablets 1.5 tablets t.i.d.; warfarin 4 mg daily; atorvastatin 40 mg daily; acetaminophen 325-mg tablets 1 to 2 q.4-6h. p.r.n. (for pain). DISCHARGE INSTRUCTIONS: Include monitoring of his INR for a goal between 2.0 and 2.5. Continued evaluation of his nutritional status with p.o. intake and eventually discontinuing his tube feeds. DISCHARGE FOLLOWUP: The patient should follow up with his cardiologist on return home for monitoring of his INR and Coumadin dosing. He is to follow up with his primary care physician for high blood pressure control. He should follow up with Dr. [**Last Name (STitle) 1391**] in 2 to 3 weeks; he should call for an appointment at ([**Telephone/Fax (1) 63405**]. FINAL DIAGNOSES: 1. Bilateral carotid stenosis, asymptomatic; right internal carotid artery 40% to 59%, left internal carotid 80% to 99%. 2. Left carotid endarterectomy on [**7-30**]. 3. Right neck exploration for airway stridor with evacuation of hematoma on [**7-30**] and [**7-31**]. 4. Extubation with pediatric bronchoscopy direct visualization on [**8-4**]. 5. Right peripherally inserted central catheter line placement with removal of femoral line on [**8-9**]. 6. Postoperative airway compromise; reintubated. 7. Postoperative neck hematoma; evacuated. 8. New onset of atrial fibrillation; chemically converted. 9. Postoperative blood loss anemia; transfused. 10. Postoperative metabolic encephalopathy; resolved. 11. Failure to thrive; requiring tube feeds. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**] Dictated By:[**Last Name (NamePattern1) 2382**] MEDQUIST36 D: [**2189-8-11**] 15:21:23 T: [**2189-8-11**] 16:46:46 Job#: [**Job Number 63406**] Name: [**Known lastname 11317**],[**Known firstname **] Unit No: [**Numeric Identifier 11318**] Admission Date: [**2189-7-28**] Discharge Date: [**2189-8-13**] Date of Birth: [**2111-8-14**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 231**] Addendum: [**2189-8-12**] Patient tube feed were discontinued and boots were added to his diet. His home glycemic agents were restarted and Insulin drip discontinued.[**Hospital 11319**] Rehab. Pt to rehab [**2189-8-13**] Discharge Disposition: Extended Care Facility: [**Hospital3 1933**] [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**] Completed by:[**2189-8-13**]

[ "250.00", "433.30", "272.0", "414.00", "427.31", "997.1", "280.0", "348.31", "V45.81", "478.6", "998.12", "401.9" ]

icd9cm

[ [ [] ] ]

[ "38.12", "86.09", "96.71", "31.42", "96.04", "99.04", "38.93" ]

icd9pcs

[ [ [] ] ]

9502, 9706

1841, 1859

6728, 7251

1331, 1672

3303, 6704

7276, 7448

1132, 1304

7829, 9479

1882, 3285

658, 799

154, 203

7469, 7812

232, 638

822, 1108

1689, 1824

20,957

179,236

10127

Discharge summary

report

Admission Date: [**2101-9-15**] Discharge Date: [**2101-10-26**] Date of Birth: [**2052-4-4**] Sex: F Service: GOLD SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old woman with a history of Crohn's disease for about 12 years. She is status post Billroth type II gastrotomy with subsequently multiple abdominal surgeries, including a Roux-en-Y for biliary drainage. These surgical interventions were all the consequence for initial peptic ulcer disease treatment. She was recently discharged on [**2101-9-13**], from [**Hospital6 1760**] for nausea, vomiting, abdominal pain, fevers, and bacteremia for which she is currently still under treatment. She presented again to the Emergency Room with worsening nausea and vomiting with diarrhea and biliary emesis. She was originally scheduled for a revision of her Roux-en-Y by Dr. [**Last Name (STitle) **] on [**2101-9-23**]. After Emergency Room evaluation, she was admitted initially to the Medicine Service for management. PAST MEDICAL HISTORY: 1. Peptic ulcer disease status post Billroth II, Roux-en-Y to common bile duct, times two revisions of gastrojejunostomy secondary to anastomotic stenosis, status post microperforation leading to abdominal abscess, status post EGD and small bowel follow through which showed short Roux limb with reflux into the stomach and stenosis in the efferent limb. 2. Anemia of chronic disease. 3. VRE. 4. Chronic TPN. 5. History of fungemia. 6. History of vertebral fracture with steroid use. 7. Osteoporosis. 8. Femoral fracture. 9. Appendectomy. 10. Cholecystectomy. 11. Chronic diarrhea. ALLERGIES: THE PATIENT IS ALLERGIC TO SULFA. MEDICATIONS ON ADMISSION: Lasix 10 mg q.d., Dilaudid 8 mg q.3-4 hours p.r.n., Ativan, Protonix 40 mg q.d., ............... 1 g q.i.d., Compazine 10 mg q.d., Vitamin D 50,000 U every Friday, Fentanyl patch 225 mcg q.72 hours, continued Zosyn 4.5 g q.4 hours for bacteremia. PHYSICAL EXAMINATION: General: On admission exam showed a middle-aged woman in no acute distress. Vital signs: She was afebrile with a temperature of 98.4??????, heart rate 77, blood pressure 105/52, respirations 12, oxygen saturation 98% on room air. Head: Nontraumatic. Pupils equal, round and reactive to light. Extraocular movements intact. Heart: Normal rate and rhythm with normal heart sounds. There was no murmur. Lungs: Clear to auscultation bilaterally. Abdomen: The patient had extensive surgical scars, diffusely tender without any rebound. Extremities: No peripheral edema. LABORATORY DATA: On admission white blood cell count was 5.5, hematocrit 31, platelet count 309,000; sodium 139, potassium 3.9, chloride 105, bicarb 23, BUN 15, creatinine 0.3, blood sugar 96. HOSPITAL COURSE: The patient was admitted to the Medical Service with management of her symptoms of nausea and vomiting. During the course, a series of blood cultures and urinalyses were performed, and the result of these cultures remained negative. The patient's condition improved over approximately a week of the hospital stay. Therefore, she was brought to the Operating Room on [**9-23**] for a scheduled revision of her Roux-en-Y procedure. Given the patient's history of her problems with biliary vomiting, inability to tolerate food intake since her gastric operations, and her multiple surgical procedures, and the most recent endoscopy showed that there was a finding of segment in the Roux of only 8 or 9 cm long which probably led to significant reflux problems, she was then scheduled to have takedown of Roux-en-Y gastrojejunostomy of recreation of another Roux-en-Y gastrojejunostomy with feeding tube placed in the jejunum. The patient tolerated the procedure well. The operation had an estimated blood loss of 200 cc, and the patient was subsequently transferred to the Postsurgical Intensive Care Unit intubated and sedated. She remained in the SICU from on postoperative day #1 to on postoperative day #10 where she was successfully extubated on postoperative day #4. Blood culture monitoring and sputum culture obtained in the unit showed that she had bacteremia with coag negative staph. In her sputum there was growth of pseudomonas. She was covered with intravenous antibiotics of Vancomycin, Ceftazidime and Ciprofloxacin. Her stay in the SICU was essentially noneventful where she remained on tube feeds and TPN. Her drainage tubes provided adequate wound drainage. On postoperative day #10, she was found to have enough drainage where a cutaneous fistula was suspected. Therefore, Dr. [**Last Name (STitle) **] of the Surgical Service was consulted, and based on their consultation, she was continued with close monitoring of her nutrition status, and her TPN and tube feeds were also adjusted according to her nutrition needs. Over the course of the hospital stay, her surgical wound continued to improve with decreased level of drainage, and therefore, there was no surgical repair performed. She is somewhat difficult to manage for her pain control issues. She was placed on a prolonged time of patient-controlled anesthesia with Dilaudid, and on the day prior to discharge, she was placed on her preadmission regimen of Dilaudid by mouth with 8 mm every 3-4 hours as needed which appears to provide enough coverage for her pain issue. She is planned to be discharged to a rehabilitation facility where her nutritional status can be closely monitored and her wound care can be adequately provided. The plan is to continue her tube feeds and possibly continue TPN on an outpatient basis. DISCHARGE MEDICATIONS: Clonidine TTS-3 patch every Tuesday, Protonix 40 q.d., .................. 100 mcg t.i.d., ..................1 g q.i.d., Cholestyramine 0.5 pack t.i.d., Albuterol inhaler 4-6 puffs every 4 hours p.r.n., Fentanyl patch 225 mcg/hr every 72 hours, Zofran 2 mg p.r.n., Promethazine 25 mg q.6 hours p.r.n., Colace 100 mg b.i.d., Zinc Sulfate 200 mg q.d., Insulin sliding scale, Albuterol nebulizer every 4-6 hours as needed, Dilaudid 8 mg q.4-6 hours p.r.n., tube feeds, TPN. CONDITION ON DISCHARGE: Fair. DISCHARGE STATUS: To rehabilitation facility with service. DISCHARGE DIAGNOSIS: Status post revision of Roux-en-Y gastrojejunostomy. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**] Dictated By:[**Dictator Info 33844**] MEDQUIST36 D: [**2101-10-25**] 13:35 T: [**2101-10-25**] 15:16 JOB#: [**Job Number 33845**]

[ "790.7", "997.4", "E878.2", "555.9", "482.1", "285.29", "998.6" ]

icd9cm

[ [ [] ] ]

[ "99.15", "46.39", "44.5", "48.23" ]

icd9pcs

[ [ [] ] ]

5622, 6093

6208, 6532

1716, 1964

2780, 5598

1987, 2762

174, 1016

1039, 1689

6118, 6186

10,939

192,357

20264+57135+57136

Discharge summary

report+addendum+addendum

Admission Date: [**2181-1-9**] Discharge Date: [**2181-1-21**] Date of Birth: [**2129-8-11**] Sex: M Service: MICU ORANG THIS IS A DICTATION UP UNTIL [**2181-1-21**]. HISTORY OF PRESENT ILLNESS: The patient is a 51 year old male with a history of alcohol abuse, transferred from [**Hospital3 3834**] after presenting with weakness, falls and a large left leg hematoma. The patient was apparently also stuporous and was not able to provide any history. According to the transfer summary, the patient's wife, who has limited contact with the patient, reported some weight loss, heavy drinking and multiple falls with some recent vomiting, although she was unsure if there was any blood present. He has also had a chronic cough that is unchanged. At [**Location (un) **], the patient was found to have a hematocrit of 11% which rose to 19% after eight units of packed red blood cells. Platelets were 47 to 26 and PT was 17.3, PTT 33.5. His blood pressure was 97/54, heart rate in the 90s with saturations 95% on two liters nasal cannula. He had a head CT scan that was negative and a CT scan of the abdomen where there was some question of retroperitoneal varices and soft tissue swelling of the left leg. The patient has a large left leg ecchymosis. Apparently, there has been no evidence of an obvious source of blood loss, no evidence of hematemesis, bright red blood per rectum or melena at the outside hospital. PHYSICAL EXAMINATION: On examination, temperature 99.5 F.; blood pressure 135/79; heart rate 94; respiratory rate 16; oxygen saturation 96% on two liters nasal cannula. Generally, he is stuporous and jaundiced, opens his eyes to repeated commands, but otherwise unresponsive. He is disheveled and tremulous appearing. HEENT: Normocephalic, atraumatic; icteric. Pupils are equal, round and reactive to light. Oropharynx with poor dentition and dried blood, but mucous membranes moist. Neck is supple with no lymphadenopathy and no jugular venous distention but prominent venous waves. Cardiovascular: Distant heart sounds but regular rate and rhythm; no murmurs, rubs or gallops. Lungs clear to auscultation bilaterally. Abdomen soft, mildly distended; some mildly tender hepatomegaly and a reducible umbilical hernia; no fluid wave. Extremities with large ecchymosis of the left hip to lower leg with mild pain on passive flexion of the left hip but no point tenderness. Two plus pitting edema of the left lower extremity, no clubbing. Skin shows jaundice and spider angiomata. Neurological: Tremulous bilateral upper extremities, symmetric bilateral upper extremities and lower extremities with hyperactive deep tendon reflexes. LABORATORY: White count 6.8, hematocrit 19.4, platelets 61, fibrinogen 98, D-dimer positive. INR 2.2. PTT 33.5, 73% polys, 17% lymphocytes, 6% bands, 4% monocytes. Chem-7 with sodium of 135, potassium 3.5, chloride 100, bicarbonate 24, BUN 17, creatinine 0.9, glucose 78, calcium 7.1, magnesium 2.0, phosphate 2.5, albumin 2.4, total protein 6.2, total bilirubin 7.9, direct bilirubin 3.2. ALT 34, AST 99, alkaline phosphatase 102. GGT 100, LDH 334. CK 372, troponin I less than 0.04. Head CT scan was negative for bleed, reviewed by Radiology here at [**Hospital1 69**]. Chest x-ray shows chronic obstructive pulmonary disease and no acute process. Abdominal CT scan shows cirrhosis with no clear evidence of retroperitoneal varices or retroperitoneal hematoma but shows a left gluteal hematoma. No ascites or splenomegaly. HOSPITAL COURSE: 1. FALLING HEMATOCRIT: The patient presented initially with a hematocrit of 11% and an INR of 4 with a left lower extremity hematoma. His CT scans were reviewed here and were consistent with a left gluteal hematoma, but no retroperitoneal bleeding and no gross evidence of gastrointestinal bleed. The Gastrointestinal Service performed an esophagogastroduodenoscopy to rule out varices and he was found to have no varices. He is to have a full esophagogastroduodenoscopy prior to his discharge. His hematocrit was stabilized here and improving. For left lower extremity hematoma: He was given fresh frozen plasma intermittently for an elevated INR. 2. METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS BACTEREMIA: the patient initially p9resented with high grade bacteremia on [**1-16**] with four out of four positive bottles. On [**1-17**], he also had four out of four positive bottles after Vancomycin had been started. On [**1-18**], he had one out of two positive bottles with an unclear source of his Methicillin resistant Staphylococcus aureus bacteremia. He had no joint symptoms. Transesophageal echocardiogram was negative for any evidence of endocarditis. He has had no central venous lines this admission and only had peripheral intravenous lines and an arterial line. There was some question that his left lower extremity hematoma had been super-infected. He is to have a tagged white blood cell scan on Monday, [**1-22**]. The Infectious Disease team has been following. Gentamicin was added for synergy and Gentamicin was increased to 1500 twice a day to achieve an adequate peak level. He had no tenderness to palpation of his spine and no meningeal signs. No ascites by CT scan. 3. DECREASING MENTAL STATUS: This initially was thought to be alcohol withdrawal and he was initially Ativan responsive, presenting with an increased heart rate and blood pressure. Now, his mental status is likely secondary to hepatic encephalopathy as he is beyond the window for alcohol withdrawal. He has had no evidence of seizure activity this admission and no meningeal signs. He was continued on lactulose and initially intubated for airway protection but extubated two days later. 4. COAGULOPATHY SECONDARY TO HEPATIC DYSFUNCTION. Fresh frozen plasma was given to decrease his INR less than 1.6 for bleeding from his A-line site. The hematocrit has remained relatively stable. No gross evidence of gastrointestinal bleeding. Gastrointestinal to perform scope later this admission. 5. CIRRHOSIS SECONDARY TO ALCOHOL ABUSE: Evidence on ultrasound and stigmata present on examination. No esophageal varices by esophagogastroduodenoscopy, complicated by coagulopathy. Continued on lactulose this admission. 6. ALCOHOL ABUSE: Continue proton pump inhibitor, thiamine, folate, lactulose. He is now beyond the window for significant alcohol withdrawal. He has had no seizures this admission. 7. ASPIRATION PNEUMONIA: Questionable left lower lobe infiltrate on his admission with an elevated temperature. He has finished a ten day course of Levaquin and Flagyl. He was intubated briefly for two days for airway protection secondary to decreased mental status. 8. CODE STATUS: He is full code. This Discharge Summary is from [**1-9**] until [**2181-1-21**]. The rest of his hospital admission will be dictated as a Discharge Summary addendum. [**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**] Dictated By:[**Last Name (NamePattern1) 5819**] MEDQUIST36 D: [**2181-1-21**] 16:19 T: [**2181-1-21**] 17:57 JOB#: [**Job Number 54404**] Name: [**Known lastname **], [**Known firstname 63**] Unit No: [**Numeric Identifier 10125**] Admission Date: [**2181-1-9**] Discharge Date: [**2181-2-23**] Date of Birth: Sex: M Service: [**Location (un) 571**] This is a continuation of the dictation from [**2181-1-21**]. The initial two weeks of the hospital course are dictated in a previous dictation. HOSPITAL COURSE: 1. Bacteremia. As stated in the previous discharge summary, the patient had MRSA bacteremia. This was treated with multiple antibiotics. However, after transfer out of the MICU on [**1-22**], the patient remained persistently febrile despite negative surveillance blood cultures. Infectious disease service was consulted. The patient was treated with vancomycin, cefepime and Flagyl. Vancomycin was changed on [**2-6**] to Linezolid. This change was made after the patient was readmitted to the MICU after worsening shortness of breath and tachypnea on the floor. The patient was initially managed on a nonrebreather mask and then required intubation. After vancomycin was switched to Linezolid in the MICU for coverage of possible vancomycin resistant Enterococcus pneumonia, cefepime and Flagyl were discontinued. The patient was extubated after two days during his second stay in the MICU. The patient continued to have low grade fevers which were thought to be possibly due to aspiration pneumonia. He was continued on Linezolid and after approximately two to three days on Linezolid defervesced. For the remainder of the hospital course the patient remained afebrile and had no further signs or symptoms of ongoing infection. Linezolid was continued for a full 10 day course and then was discontinued. After discontinuation of Linezolid the patient remained afebrile with a normal white blood cell count and had no further signs or symptoms of infection. 2. Mental status. The patient's decreased mental status was initially thought to be due to alcohol withdrawal as stated in the previous discharge summary, however, subsequently thought to be most likely due to hepatic encephalopathy. After discharge from his second MICU admission, the patient was aggressively treated with lactulose to aid in clearance of possible hepatic encephalopathy. The patient did show slow improvement in his mental status. However, he remained not completely oriented to place and time. He was alert and responsive. It was thought that there may be an underlying alcoholic encephalopathy and that the patient may not return to his previous baseline. 3. Anemia. The patient's hematocrit, which was very low on admission, subsequently stabilized during his second admission to the ICU. After being transferred from the ICU to the floor, the patient did have several days where he had gradual decrease in his hematocrit. This was thought to be possibly due to Linezolid which can cause myelosuppression. A reticulocyte count was checked at that time which showed that there was inadequate reticulocytosis for the anemia, which again correlates with possible myelosuppression from Linezolid. After discontinuation of Linezolid, the patient's hematocrit stabilized somewhat. There was no evidence of active bleeding. The patient did have one day of mild bleeding after some minor Foley trauma. However, after transfusion of platelets and fresh frozen plasma, this stopped and there was no further bleeding from the site. With regard to the radial artery, which had been bleeding previously, vascular surgery continued to follow the patient. The artery was ligated and a pressure dressing was applied. The patient subsequently had mild oozing and then eventually had complete cessation of bleeding from the site. 4. Hepatic failure. The patient continued to have coagulopathy secondary to hepatic failure. The liver service continued to follow the patient. The patient had an intermittent increase in his total bilirubin to 7.6 with subsequent decline. He was continued on lactulose. He was also given repeated doses of vitamin K for help in correcting the coagulopathy. However, his coagulation studies remained elevated. 5. Rash. After being transferred out of the ICU and onto the floor, the patient developed a total body, erythematous rash. The most likely cause of this rash was IM injections of vitamin K that the patient had received. Once this was discontinued and the patient was put on p.o. vitamin K, the rash resolved on its own. 6. Fluids, electrolytes and nutrition. The patient was started on tube feeds via nasogastric tube for nutrition as his mental status did not allow him to take p.o. intake without the possibility of aspiration. On [**2-12**] after some improvement in his mental status, p.o. was initiated and the patient tolerated this well without evidence of aspiration. Several days later the tube feeds were discontinued and the patient continued to take a p.o. diet. The patient also had persistent hypomagnesemia despite p.o. and IV repletion. This was thought possibly to be due to diarrhea that the patient was having subsequent to large doses of lactulose. He was maintained on p.o. magnesium oxide and IV magnesium sulfate as needed. His other electrolytes were stable for the most part. 7. Prophylaxis. The patient was maintained on a proton pump inhibitor for GI prophylaxis. He was also maintained on thiamine, folate and multivitamin for nutritional supplementation, given his history of alcohol abuse. 8. Code status. The patient was full code on admission and at discharge. 9. Social. Discussion was conducted with the patient and his family regarding cessation of alcohol use in hopes that the patient could receive a liver transplant for his hepatic cirrhosis. Although the patient's mental status was not completely intact, the patient's wife agreed and was encouraged to continue the patient's abstinence of alcohol. The rest of this dictation will be completed in a discharge summary addendum. [**Name6 (MD) 1034**] [**Name8 (MD) 1035**], M.D. [**MD Number(1) 1036**] Dictated By:[**Name8 (MD) 3520**] MEDQUIST36 D: [**2181-2-19**] 16:41 T: [**2181-2-19**] 17:59 JOB#: [**Job Number 10126**] Name: [**Known lastname **], [**Known firstname 63**] F Unit No: [**Numeric Identifier 10125**] Admission Date: [**2181-1-9**] Discharge Date: [**2181-2-23**] Date of Birth: [**2129-8-11**] Sex: M Service: [**Location (un) 571**] PLEASE SEE THE PREVIOUS DICTATION SUMMARY FOR THE HOSPITAL COURSE: DISCHARGE STATUS: The patient is to be discharged to an extended care facility at [**Hospital **] Healthcare. DISCHARGE CONDITION: Patient is in good condition, afebrile, hemodynamically stable, tolerating po and ambulating with assistance. DISCHARGE DIAGNOSES: 1. Hepatic cirrhosis. 2. Hepatic encephalopathy. 3. Aspiration pneumonia. DISCHARGE MEDICATIONS: 1. Ursodiol 300 mg b.i.d. 2. Lopressor 25 mg b.i.d. 3. Lactulose 30 mL po t.i.d. to q.i.d. 4. Protonix 40 mg q.d. 5. Magnesium oxide 400 mg t.i.d. 6. Thiamine 100 mg q.d. 7. Folic acid 1 mg q.d. 8. Multivitamins 5 mL po q.d. 9. Zinc oxide. 10. Cod liver oil 40% ointment to be applied topically prn. DISCHARGE INSTRUCTIONS AND FOLLOW-UP PLANS: The patient is to be discharged to [**Hospital **] Healthcare Facility for extended care. He will subsequently follow-up with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4999**]. The patient and his wife were also instructed to follow-up with the Liver Service at [**Hospital6 5442**] after discharge. [**Name6 (MD) 1034**] [**Name8 (MD) 1035**], M.D. [**MD Number(1) 1036**] Dictated By:[**Doctor Last Name 10127**] MEDQUIST36 D: [**2181-3-22**] 02:32 T: [**2181-3-22**] 14:39 JOB#: [**Job Number 10128**]

[ "518.81", "571.2", "997.2", "998.11", "572.2", "280.0", "924.10", "038.11", "507.0" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.04", "96.04", "45.13", "96.71", "38.83", "00.14", "96.6", "88.72" ]

icd9pcs

[ [ [] ] ]

13918, 14029

14050, 14128

14151, 14488

7623, 13896

1471, 3530

14506, 15095

219, 1447

5291, 7606

975

165,225

43494

Discharge summary

report

Admission Date: [**2139-1-12**] Discharge Date: [**2139-1-24**] Date of Birth: [**2074-5-16**] Sex: M Service: MEDICINE Allergies: Roxicet Attending:[**First Name3 (LF) 348**] Chief Complaint: black stools and Hematocrit drop Major Surgical or Invasive Procedure: gastroscopy History of Present Illness: 64 yo male w/ hx of Afib, CAD s/p CABG ([**2132**]), [**Year (4 digits) 1291**] on warfarin, HTN, diverticulosis, and gastritis, s/p recent admission in [**10/2138**] for Hct drop w/ gastritis and recent nl EGD in [**12-1**] who presented to the ED on [**2139-1-12**] with black/tarry stools x 2 and lightheadedness with standing. His Hct was found to be decreased by 9 points from the beginning of [**Month (only) 1096**]. He was also found to be bradycardic to the high 30s with BPs in the 70s systolic. He received a 1 time dose of Atropine that brought his HR up to the 70s. He received 40 mg IV Protonix and 2L IVFs with improvement in SBPs to 90s. He was admitted to the ICU. He received a total of 4 U PRBC with stabilization of his HCT. He remained HD stable but continued to be relatively bradycardic (asymptomatic) with HRs in 40s. He had a small bowel enteroscopy which showed mild gastritis. He was undergoing a capsule endoscopy on transfer to the floor. Past Medical History: 1. Bicuspid AV-s/p [**First Name8 (NamePattern2) **] [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 1291**] in 92, MSSA endocarditis and abscess- s/p redo in 5/00 2. Afib on amiodarone 3. Bronchomalecia and Bronchiectesis 4. Gastritis 5. CABG times 3- [**2132**] ([**2136**], LVEF>55%) 6. hypercholesterolemia 7. HTN 8. Diverticulosis and Lymphoid aggregates on Colonoscopy in [**2135**] 9. impotence 10. hernisted disc 11. STROKE ([**2137**]) ax 12. thoracic aneurysm Social History: Divorced, 2 sons, [**Name (NI) **] ETOH (per pt) but + h/o drinking 1 gallon of wine daily in [**2133**] that pt always denied, no current tobacco, 4ppd times 30 years and quit in 92, no IVDU, divorced, can do all ADLS. At baseline he walks a quarter of a mile every day. He will get short of breath on walking quickly [**2-28**] blocks. Family History: NC per patient Physical Exam: General: NAD. HEENT: PERRL, EOMI, sclera anicteric. MMM, OP without lesions Neck: supple, no JVD. Pulm: decreased breath sounds bibasilar, crackles in the left base, no wheezes, or rhonchi. Cardiac: nl s1/s2 w/ mechanical click, + 2/6 SEM loudest at LUSB. Abdomen: soft, NT, ND, + BS, + small ventral hernia, reducible. no masses. (+) HM ~3 cm below costal margin. no rebound/guarding Ext: no edema b/l, 2+ DP pulses b/l. Skin: no rashes or lesions noted. Ecchymosis over epigastrium. Neuro: Alert & Oriented x 3. Cranial nerves: II-XII intact. Normal strength, and tone throughout. Pertinent Results: [**2139-1-12**] 09:04PM HGB-8.7* calcHCT-26 [**2139-1-12**] 08:45PM GLUCOSE-113* UREA N-43* CREAT-1.7* SODIUM-140 POTASSIUM-3.2* CHLORIDE-99 TOTAL CO2-28 ANION GAP-16 [**2139-1-12**] 08:45PM estGFR-Using this [**2139-1-12**] 08:45PM ALT(SGPT)-23 AST(SGOT)-20 CK(CPK)-74 ALK PHOS-63 AMYLASE-190* TOT BILI-0.3 [**2139-1-12**] 08:45PM LIPASE-53 [**2139-1-12**] 08:45PM CK-MB-NotDone cTropnT-<0.01 [**2139-1-12**] 08:45PM ALBUMIN-4.5 [**2139-1-12**] 08:45PM WBC-9.6 RBC-2.62*# HGB-8.3*# HCT-23.2*# MCV-89 MCH-31.6 MCHC-35.6* RDW-16.6* [**2139-1-12**] 08:45PM NEUTS-71.4* LYMPHS-22.6 MONOS-3.3 EOS-2.4 BASOS-0.2 [**2139-1-12**] 08:45PM ANISOCYT-1+ [**2139-1-12**] 08:45PM PLT COUNT-331 [**2139-1-12**] 08:45PM PT-30.0* PTT-28.3 INR(PT)-3.2* [**2139-1-15**]: Capsule Endoscopy: 1. Multiple non bleeding angioectasias in the small bowel 2. puntacte erythematous patches throughout the proximal small bowel 3. Lymphangiectasias 4. Fresh bleeding in the mid and distal small bowel without an identifiable site. Brief Hospital Course: In brief, the patient is a 64 year old male with history of CAD s/p CABG, mechAVR on coumadin, GIB in past, admitted to ICU w/black, tarry stools x 2 days and a hct drop of 9 points, s/p 4 U PRBC now HD stable with stable HCT. . 1.) GIB: The patient presented with 2 days of melanotic stools and a significant hematocrit drop. He remained hemodynamically stable. Small Bowel Enteroscopy relatively unrevealing. Pill enteroscopy revealed possible AVMs vs Mass. His Hct stabilized. He will follow-up with general surgery for intra-enteroscopy as outpatient. . 2.) Mechanical [**Month/Day/Year 1291**]: Pts HCT stablizied as above. He was bridged to coumadin with heparin. . 3.) CAD: known CAD with CABG in [**2132**]. There were no active issues. He continued on his beta-blocker and statin. He can resume his aspirin after following up with general surgery to plan the next steps in his GI bleed evaluation. 4.) Prophylaxis: iv heparin, po ppi . 5.) Code: Full Medications on Admission: Lopressor 12.5 mg twice a day Protonix 40 mg twice a day Aspirin 1 tablet a day Dicloxacillin 250 mg three times a day Lipitor 80 once a day Hydrochlorothiazide 25 mg daily Amiodarone 200 mg once a day Coumadin 7.5 mg once a week and 5 mg on the other days Multivitamin daily Zetia 10 mg once a day Lisinopril 5 mg once a day Iron daily Discharge Medications: 1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Dicloxacillin 250 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 8. Warfarin 2.5 mg Tablet Sig: asdir Tablet PO at bedtime: take 7.5 mg on [**2139-1-24**] then take 5 mg therafter until f/u with clinic. 9. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary: GI bleed, Bradycardia . Secondary: Aortic Valve replacement CAD Discharge Condition: good. stable hematocrit and vital signs. tolerating oral medication and nutrition. Discharge Instructions: You have been evaluated and treated for a gastro-intestinal bleed. The likely source of the bleed was a small area in the intestine. The bleeding stopped and your blood counts stabilized. You will need to follow-up with the GI Surgeon to plan the next steps of your treatment for the bleeding. Please continue all of the medications as prescribed. You should discuss with Dr. [**Last Name (STitle) 519**] when you should restart taking the aspirin which normally take for your heart. Please attend the recommended follow-up appointments. If you develop any new or concerning symptom particularly bright red stools, chest pain, shortness of breath; please seek medical attention immediately. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. Phone:[**Telephone/Fax (1) 6554**] Date/Time:[**2139-2-2**] 11:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2139-2-26**] 1:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD Phone:[**Telephone/Fax (1) 34552**] Date/Time:[**2139-4-6**] 10:00 Please call the [**Hospital 2786**] clinic at [**Hospital **] to get your blood checked in [**2-28**] days.

[ "285.1", "V43.3", "V58.61", "401.9", "V45.81", "578.9", "272.0", "427.31", "493.20", "584.9" ]

icd9cm

[ [ [] ] ]

[ "45.13", "99.04" ]

icd9pcs

[ [ [] ] ]

6024, 6030

3878, 4845

300, 313

6147, 6232

2826, 3855

6978, 7533

2192, 2208

5233, 6001

6051, 6126

4871, 5210

6256, 6955

2223, 2737

228, 262

341, 1310

2753, 2807

1332, 1820

1836, 2176

49,534

141,368

25171

Discharge summary

report

Admission Date: [**2147-10-30**] Discharge Date: [**2147-11-21**] Date of Birth: [**2096-7-6**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5569**] Chief Complaint: liver laceration s/p fall shock liver r/t hypotension pituitary macroadenoma rxn/XRT ([**4-/2147**]), Major Surgical or Invasive Procedure: None History of Present Illness: 51M s/p pituitary macroadenoma resection [**4-/2147**] c/b intracranial hemorrhage (details unknown) s/p post-op radiation therapy (completed 2 weeks ago) presented to [**Hospital 8**] Hospital from [**Hospital3 **] [**Hospital1 8**] (where he has been since operation) after [**2147**] (CT head negative for acute injury) but on [**2147-10-29**], he was found to be unresponsive, hypotensive(SBP 60s) and hypoxic (O2 sats 70s) w/ Hct 22 in ED. CT abd w/ PO contrast only (had acute renal failure) demonstrated liver laceration/hematoma and 3 right-sided rib fractures. He was resuscitated w/ crystalloid (3L) and 4 pRBCs and no pressors were required - has been hemodynamically stable since. At baseline,he ambulates, speaks normally but is oriented to only person and has memory issues. However, his mental status had significantly declined and was only responding to noxious stimuli. Repeat head CT [**10-29**] did not demonstrate any new evidence of acute changes. His transminases were increasing and were >2800 on transfer,TBili 1.2. He was transferred to [**Hospital1 18**] for further management. Past Medical History: pituitary macroadenoma s/p resection via craniotomy and radiation completed 2 weeks prior to admission c/b ICH w/ residual cortical encephalomacia; hypothyroidism; adrenal insufficiency; diabetes insipidus; psychosis; s/p falls x2 Social History: previously worked in construction, lives in [**Location 5110**],MA; married w/ two children; +smoking hx >35 pack years; no EtOH;occasional marijuana use in past Family History: unable ot obtain Physical Exam: O: T: 97.3 HR: 89 BP: 151/95 R: 21 O2Sats: 96% 4L NC Gen: WD/WN, comfortable, NAD. HEENT: R eye edema and ecchymosis Neck: Supple; RIJ CVL C/D/I Lungs: diminished bilaterally. Cardiac: RRR Abd: decreased BS, Soft, +TTP RUQ (patient grimaces), +mild distension, no fluid wave, no rebound Extrem: 1+ edema bilaterally Neuro: Mental status: lethargic, wakes to noxious stimuli and voices intermittently, oriented to person only. Language: says name, mumbles. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2mm bilaterally. III, IV, VI: Extraocular movements appear intact but minimal movements bilaterally V, VII: did not follow command VIII: Hearing intact to voice. IX, X: did not follow command [**Doctor First Name 81**]: did not follow command XII: did not follow command Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Weak movement to toes and hand grip bilaterally. CT/MRI: Labs: 134 103 28 AGap=9 -------------<115 4.1 26 1.1 Ca: 8.9 Mg: 2.3 P: 2.6 ALT: 3195 AP: 377 Tbili: 1.0 Alb: AST: 2812 LDH: 2820 Dbili: TProt: [**Doctor First Name **]: 46 Lip: 47 9.9 \ 11.0 / 106 / 30.7 \ PT: 16.0 PTT: 25.8 INR: 1.4 Pertinent Results: [**2147-11-1**]:MRA BRAIN W/O CONTRAST 1. No evidence of acute ischemia, or acute hemorrhage. 2.Bilateral ACA infarct of uncertain chronicity, likely chronic with signal abnormality suggesting cortical laminar necrosis and developing encephalomalacia. 3. Post-surgical changes at the sella turcica, with evidence of packing material (uncertain on procedure performed), and sella turcica floor remodeling, presumably related to resected mass. Significant residual tumor encasing the right cavernous sinus. [**2147-11-5**]: CT CHEST/[**Last Name (un) **]/PELVIS 1. Evolving large subcapsular hematomas with the more anterior hematoma displaying internal liquification and a thick surrounding rim. The additional irregular surrounding low-density lesions within the right lobe are most suggestive of underlying evolving lacerations and intraparenchymal hematomas although some may be bilomas. If there remains a high clinical concern for superinfection, these would be amenable to diagnostic needle aspiration under ultrasound or CT. 2. Irregular thickening and enlargement of the left adrenal gland is nonspecific with differential including focal adrenal lesion such as adenoma or adrenal hematoma. Can consider evaluation with MRI on non emergent basis. 3. Nondisplaced rib fractures involving the right fifth through ninth ribs. Interval increase in size to simple right pleural effusion. 4. Extensive atherosclerotic disease involving the aorta with occlusion of the left common iliac and proximal portions of the left internal and external iliac vessels. Infrarenal aortic ectasia measuring just under 3 cm. [**2147-10-30**] 02:48PM BLOOD Glucose-115* UreaN-28* Creat-1.1 Na-134 K-4.1 Cl-103 HCO3-26 AnGap-9 [**2147-10-31**] 10:03AM BLOOD Glucose-99 UreaN-20 Creat-1.0 Na-153* K-4.0 Cl-118* HCO3-28 AnGap-11 [**2147-11-2**] 03:07AM BLOOD Glucose-91 UreaN-15 Creat-0.7 Na-142 K-3.1* Cl-107 HCO3-31 AnGap-7* [**2147-11-3**] 03:00AM BLOOD Glucose-86 UreaN-11 Creat-0.6 Na-143 K-4.3 Cl-108 HCO3-32 AnGap-7* [**2147-11-4**] 08:05AM BLOOD Glucose-112* UreaN-11 Creat-0.7 Na-140 K-3.9 Cl-102 HCO3-32 AnGap-10 [**2147-11-5**] 12:25PM BLOOD Glucose-127* UreaN-19 Creat-1.1 Na-151* K-4.2 Cl-111* HCO3-28 AnGap-16 [**2147-11-6**] 01:31PM BLOOD Glucose-137* UreaN-15 Creat-0.8 Na-142 K-4.1 Cl-106 HCO3-27 AnGap-13 [**2147-11-7**] 08:58AM BLOOD Na-146* K-4.3 Cl-111* [**2147-11-10**] 06:15AM BLOOD Glucose-81 UreaN-15 Creat-0.5 Na-143 K-4.0 Cl-108 HCO3-28 AnGap-11 [**2147-11-13**] 07:40AM BLOOD Glucose-72 UreaN-11 Creat-0.6 Na-131* K-4.3 Cl-96 HCO3-26 AnGap-13 [**2147-11-15**] 07:40AM BLOOD Glucose-109 UreaN-11 Creat-1 Na-148* K-5.9 Cl-111 HCO3-24 AnGap-19 [**2147-11-21**] 05:00AM BLOOD Glucose-90 UreaN-15 Creat-0.6 Na-139 K-3.9 Cl-102 HCO3-27 AnGap-14 [**2147-10-30**] 02:48PM BLOOD WBC-9.9 RBC-3.87* Hgb-11.0* Hct-30.7* MCV-79* MCH-28.3 MCHC-35.7* RDW-18.4* Plt Ct-106* [**2147-10-31**] 02:47AM BLOOD WBC-8.0 RBC-3.73* Hgb-10.4* Hct-29.5* MCV-79* MCH-27.9 MCHC-35.3* RDW-18.4* Plt Ct-104* [**2147-11-1**] 03:01AM BLOOD WBC-6.4 RBC-3.40* Hgb-9.7* Hct-27.7* MCV-82 MCH-28.5 MCHC-35.0 RDW-18.8* Plt Ct-88* [**2147-11-2**] 03:07AM BLOOD WBC-6.1 RBC-3.18* Hgb-8.9* Hct-26.0* MCV-82 MCH-28.0 MCHC-34.3 RDW-18.9* Plt Ct-81* [**2147-11-5**] 06:55AM BLOOD WBC-9.5 RBC-3.58* Hgb-9.7* Hct-29.2* MCV-82 MCH-27.2 MCHC-33.4 RDW-18.7* Plt Ct-225 [**2147-11-10**] 03:01PM BLOOD WBC-11.1* RBC-3.33* Hgb-9.3* Hct-28.3* MCV-85 MCH-28.1 MCHC-32.9 RDW-19.3* Plt Ct-668* [**2147-11-13**] 07:40AM BLOOD WBC-5.0 RBC-3.57* Hgb-9.8* Hct-29.7* MCV-83 MCH-27.3 MCHC-32.8 RDW-18.5* Plt Ct-676* [**2147-11-21**] 07:40AM BLOOD WBC-6.3 RBC-3.46* Hgb-9.6* Hct-28.9* MCV-84 MCH-27.9 MCHC-33.3 RDW-18.4* Plt Ct-467* Brief Hospital Course: He was admitted to the West 1 service under Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for management of liver lac, altered mental status. A CVL was inserted for IV hydration. Serial hematocrits were done and stabilized. IV hydrocortisone, DDAVP and levoxyl were resumed. A post pyloric feeding tube was inserted and feedings were started. He became confused and non-responsive. He was found to be hypernatremic and alteration of thyroid function. This was treated with D5W infusion. Hepatology was consulted. Elevated LFTs were attributed to shock liver. Hepatitis serologies were sent and were negative. Dilantin was held. Dilantin level was 24.6. Neurology was consulted for acute mental status changes noting up going left today. MRI was done to r/o ischemia noting no evidence of acute ischemia, or acute hemorrhage. Bilateral ACA infarct of uncertain chronicity, likely chronic with signal abnormality suggesting cortical laminar necrosis and developing encephalomalacia. There was significant residual tumor encasing the right cavernous sinus. Altered mental status was felt to be partially due to elevated dilantin level as well as metabolic derangement due to pan pituitary failure in addition to hypoxic insult due to hypotension experienced on [**10-29**]. Dilantin dose was adjusted. On [**11-1**]: Endocrinology was consulted. TSH was low 0.029 with low T3 & T4. Levoxyl was given IV then switched to po once diet was resumed. Hydrocortisone dose was increased. Hyernatremia was felt to be from not enough free water and not diabetes insipidus. Free water was given via the tube feeding with improvement of sodium. Cabergoline was resumed when diet was resumed. Hydrocortisone doses were decreased. On [**11-2**]: a CXR was done noting a large right pleural effusion with adjacent large atelectasis of the right middle and right lobes with increased left lower lobe opacities consistent with increasing atelectasis and small pleural effusion. On [**11-3**]: PO 0.1 mg PO BID DDAVP,and SQH were started.IV free water replacement was stopped and, free water replacement via dobhoff was increased to 315 Q6H. On [**11-4**], patient was discharged to the floor however late that night the patient devloped fevers and had NA upto 153,so he was transferred back to the ICU. [**11-5**]: He was restarted on D5W gtt. CT A/P showed bile lakes secondary to hepatic arterial infarct/ischemia, but no e/o abscess. Large right pleural effusion w/ associated collapse of the RLL.A right side IJ line for access. [**11-6**]: IV D5W was increased to 150cc/hr. Desmopressin dose was changed from 0.1mg PO BID to 1 mcg SC BID. PICC line was placed but it was coiled, so it was pulled back to midline. The patient was again febrile to 101.6, repeat cultures. [**11-7**]: The PICC line got rewired in IR. The patient had an episode of AFib w/ response of ~130BPM. The rythm converted to sinus when his CVL was removed, and was given 5mg lopressor. He passed S&S, started on pureed diet/thin liquids. His IV D5W was D/ced as his Na levels improved. [**11-8**]: He got 2U RBCs for Hct of 21.His post transfusion Hct was 27.8. His G-tube flushes were decreased to Q6hr given improving Na 134. [**11-9**]: He was transferred to the floor.His foley was d/ced. [**11-10**]:His free water flush through the tube feeds was increased to 500cc/q6h from 300 q6h because of increasing sodium levels. Also because if his low blood dilaintin levels he was given increased doses of dilantin. [**11-11**]:His dilantin level continued to stay low despite an increased dose, so he was given 1200 mg of IV dilantin over an hour.Free water flush through the tube feeds was decreased to 400cc/q6h. [**11-12**]:He was started on Phenytoin Infatab and po demporessin.Free water flush through the tube feeds was decreased to 350 cc/q6h. He pulled off his dobhoff tube. [**11-13**]: His blood sodium levels continued to be stable.An IR guided postpyloric dobhoff was replaced. [**11-14**]:His diet was advanced to thin liquids.Blood sodium checks continued. [**11-15**]:Patients serum sodium was high (148-151).Free water flushes were increased to 500cc q4h. [**11-16**]: As the phenytoin levels continued to be low despite trying various formulations,a/p neuro recs the patient was started on Levetiracetam with the plan to bridge and later d/c phenytoin on an outpatient basis. [**11-17**]:Patients serum sodium continued to stay high. Free water flushes were increased to 500cc q3h. [**11-18**]:Desmopressin Acetate was increased to 0.2 mg PO BID due to high serum sodium levels. [**11-20**]:Serum sodium was decreasing to around 140.The free water flushes were decreased to 500 q 6hrs. [**11-21**]: The serum sodium level continued to stay normal at 141 on this regimen. On the day of discharge the patient was tolerating tubefeeds, tolerating a thin regular diet,having stable sodium levels on the current tubefeeds regimen,and having improving mentation. He would need regular daily sodium checks and would be following up in neurology clinic in 2 weeks for appropriate management of the antiseizure medication. Medications on Admission: Levothyroxine 125 po qd, Cabergoline 0.5po qd, Hydrocortisone 20 po qd, Desmopressin 0.1 po qd, pantoprazole 40 po qd, Loratadine 10 po qd, Ferrous sulfate 325 po qd, Lisinopril 5po qd, Magnesium oxide 400 po bid, Methylphenidate (dosage uncertain), Phenytoin 150 q8h, Potassium Chloride 40mg po qd Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: One (1) inj Injection TID (3 times a day). 2. hydrocortisone 5 mg Tablet [**Month/Day (2) **]: Three (3) Tablet PO DAILY (Daily): AM dose. Disp:*30 Tablet(s)* Refills:*2* 3. hydrocortisone 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO QPM (once a day (in the evening)). Disp:*20 Tablet(s)* Refills:*2* 4. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Disp:*20 Tablet,Rapid Dissolve, DR(s)* Refills:*2* 5. levothyroxine 125 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 6. acetaminophen 650 mg/20.3 mL Solution [**Last Name (STitle) **]: One (1) PO Q6H (every 6 hours) as needed for fevers. 7. cabergoline 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO 3X/WEEK (3 times a week). 8. miconazole nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for rash. 9. insulin regular human 100 unit/mL Solution [**Hospital1 **]: as per sliding scale Injection ASDIR (AS DIRECTED). 10. levetiracetam 500 mg Tablet [**Hospital1 **]: 1.5 Tablets PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 11. desmopressin 0.1 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 12. phenytoin 50 mg Tablet, Chewable [**Hospital1 **]: Six (6) Tablet, Chewable PO three times a day: 300 mg TID. Please follow weekly level, dose adjustment in hospital. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 8**] Discharge Diagnosis: liver laceration s/p fall shock liver r/t hypotension pituitary macroadenoma rxn/XRT ([**4-/2147**]), Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Fall Risk Discharge Instructions: You will be transferred to [**Hospital3 **] in [**Hospital1 8**] Please call [**Hospital1 2177**] Endocrine -Dr. [**Last Name (STitle) 63100**] (on vacation, back in 2 weeks but will have coverage for emergencies) [**Last Name (NamePattern1) 63101**]. [**Location (un) 20473**] Family Building- [**Location (un) 551**] [**Location (un) 86**], [**Numeric Identifier 13108**] Fax [**Telephone/Fax (1) 63102**] PCP [**Name9 (PRE) **] Center- [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 951**] [**Location (un) 63103**], [**Numeric Identifier 25248**] [**Telephone/Fax (1) 6951**] fax [**Telephone/Fax (1) 63104**] *** Patient needs daily sodium level drawn. Please follow closely and discuss with endocrinologist as indicated Followup Instructions: [**Hospital1 2177**] Endocrine -Dr. [**Last Name (STitle) 63100**] [**Last Name (NamePattern1) 63101**]. [**Location (un) 20473**] Family Building- [**Location (un) 551**] [**Location (un) 86**], [**Numeric Identifier 13108**] Fax [**Telephone/Fax (1) 63102**] PCP [**Name9 (PRE) **] Center- [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 951**] [**Location (un) 63103**], [**Numeric Identifier 25248**] [**Telephone/Fax (1) 6951**] fax [**Telephone/Fax (1) 63104**] Completed by:[**2147-11-21**]

[ "348.89", "807.05", "E888.9", "V12.54", "253.7", "V12.41", "V15.3", "518.0", "E879.8", "285.1", "V15.88", "864.01", "511.9", "E878.8", "276.0", "298.9", "864.05", "244.9", "253.5", "996.59", "255.41", "458.8", "570" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

14048, 14119

6983, 12123

418, 424

14265, 14265

3273, 6960

15217, 15732

2015, 2033

12473, 14025

14140, 14244

12149, 12450

14450, 15194

2048, 2378

276, 380

452, 1564

2528, 3254

14280, 14426

1586, 1819

1835, 1999

51,459

186,203

33004

Discharge summary

report

Admission Date: [**2107-11-28**] Discharge Date: [**2107-12-15**] Service: MEDICINE Allergies: Penicillamine / Doxycycline Attending:[**First Name3 (LF) 1711**] Chief Complaint: elective valvuloplasty Major Surgical or Invasive Procedure: Cardiac Catheterization - Aortic valvuloplasty with [**Location (un) 109**] of 0.7 to 1.1 cm 2. History of Present Illness: This 86 year old woman has been followed by Dr. [**Last Name (STitle) 59323**] for severe aortic stenosis. On [**2106-3-17**], she underwent successful aortic valvuloplasty at [**Hospital1 18**] under the care of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. A post procedure echo showed symmetric left ventricular hypertrophy. The left ventricular cavity size normal. Left ventricular systolic function is hyperdynamic (EF>75%). The aortic valve leaflets are severely thickened/deformed. Mild (1+) aortic regurgitation is seen. Since then, the patient had been doing well until the last few months when she started to experience pleuritic pain with deep inspiration and shortness of breath. She describes dyspnea with activity such as walking a few steps or climbing stairs. She also has fatigue. She denies lightheadedness or syncope. Denies claudication, orthopnea or PND. She has chronic lower extremity edema. The patient was recently seen by Dr. [**Last Name (STitle) 59323**] who did a repeat echocardiogramon [**2107-10-25**]. This revealed mild pulmonary hypertension, severe aortic stenosis with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.7cm2, mild aortic insufficiency, mitral annular calcification mild mitral insufficiency, normal LV function. EF 65%. Patient was admitted for elective balloon valvuloplasty which she underwent sucessfully on [**11-28**]. Post procedure, she was noted to have right groin pain, the site of the cath, and an ultrasound showed a right common femoral arterial pseudoaneurysm. HCT initially decreased from 28 to 22 but back up to 27 on recheck without intervention. She then received 1 unit of PRBCs with subsequent stable HCTs. A CT abd/pelvis showed no evidence of RP bleed. She was planned to discharge today. . However, this AM she was noted to have right groin pain with an expanding hematoma. AM HCT was noted to be down to 24.8. Pt. noted nausea as well and was given IV morphine and Zofran. SBPs then were noted to have dropped to the 60s. IVFs were hung and bolused and 1mg atropine was administered. Pressure was held but the decision was made to take her to surgery. The patient went emergency to vascular surgery for emergent femoral artery repair. However, she was not able to be intubated because of a difficult airway and underwent the procedure using an LMA. She had a significant witnessed aspiration event with significant laryngeal edema and continued intubation attempts failed after >30 minutes. She then underwent a tracheostomy procedure. She was given 4 units of PRBCs during the surgery. Post procedure she remained intubated but hemodynamically stable. She was parylyzed with cisatracuronium and rocuronium during the procedure. Pre-op ABG HCT was 23. Post transfustion ABG HCT was 35. . Further review of systems unable to be obtained as the patient is intubated. Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: Severe aortic stenosis s/p aortic valvuloplasty [**3-13**] Hyperlipidemia Hypertension Rheumatoid arthritis Osteoporosis Anemia s/p bilateral knee replacements with subsequent revision of the left knee cervical spinal surgery (C1) hand surgery glaucoma pressure ulcer on buttucks, ? stage I to II UTI in [**2107-10-4**] ? memory problems per daughter Social History: Lives with her husband and has 5 children. Occupation: Retired ETOH: No Contact person upon discharge: Son, [**Name (NI) 3979**] [**Known lastname 76750**]: [**Telephone/Fax (1) 76751**]-cell Home Services: NO Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ----- ON ADMISSION ----- VS: 97.8, 105, 166/83, 100% AC TV 450, RR 16, FIO2 100%, PEEP 5 GENERAL: Intubated and sedated. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, missing anterior tooth with diffuse OP blood NECK: Supple with JVP not elevated CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. 2/6 SEM. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: Large right groin hematoma with bruit. 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: [**2107-12-13**] 05:07AM BLOOD WBC-11.7* RBC-3.45* Hgb-9.4* Hct-28.5* MCV-83 MCH-27.1 MCHC-32.9 RDW-16.3* Plt Ct-494* [**2107-12-13**] 05:07AM BLOOD PT-11.9 PTT-49.2* INR(PT)-1.0 [**2107-12-13**] 05:07AM BLOOD Glucose-103 UreaN-13 Creat-0.4 Na-139 K-4.2 Cl-101 HCO3-34* AnGap-8 [**2107-12-3**] 06:39PM BLOOD ALT-8 AST-25 AlkPhos-41 TotBili-1.5 [**2107-11-28**] 09:38PM BLOOD CK(CPK)-50 [**2107-11-28**] 09:38PM BLOOD CK-MB-NotDone [**2107-11-29**] 05:50AM BLOOD CK(CPK)-67 [**2107-11-29**] 05:50AM BLOOD CK-MB-NotDone [**2107-11-30**] 10:29AM BLOOD ALT-7 AST-18 LD(LDH)-291* CK(CPK)-110 AlkPhos-40 TotBili-1.0 [**2107-11-30**] 10:29AM BLOOD CK-MB-5 cTropnT-0.02* [**2107-12-13**] 05:07AM BLOOD Calcium-6.9* Phos-4.1# Mg-2.1 [**2107-12-5**] 03:33PM BLOOD Lactate-0.9 ----- [**2107-12-12**] 12:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2107-12-12**] 12:20PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009 ----- URINE CULTURE (Final [**2107-12-1**]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ----- [**2107-12-11**] 11:19 am URINE Source: Catheter. **FINAL REPORT [**2107-12-12**]** URINE CULTURE (Final [**2107-12-12**]): NO GROWTH. ----- All blood cultures negative thus far. ----- 2D-ECHOCARDIOGRAM [**2107-11-29**] (post intervention): The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is small. Left ventricular systolic function is hyperdynamic (EF 80%). Right ventricular chamber size and free wall motion are normal. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. . Compared with the findings of the prior study (images reviewed) of [**2106-3-17**], the aortic valve effective orifice area appears increased. . CARDIAC CATH [**2107-11-28**]: 1- Retrograde arterial access via the R groin with a 6 French arterial sheath and antegrade venous access via a 5 French venous sheath. 2- RHC performed with a 4 French MPA-1 catheter passed rto the PA over the J wire. 3- The patient was anticoagulated prophylactically and therapeutic ACT was confirmed. 4- After several attempts, the AV was crossed with the straight wire and 4 French JR4 catheter. We exchaned for a 4 French Pegtal catheter over the wire and perform hemodynamic assessment. 5- Limited resting hemodynamic assessment showed mildly elevated left and right sided filling pressures with LVEDP of 19 mmHg and RVEDP of 9 mmHg. The cardiac output and cardiac index were preserved at 5.26 l/min and 3.79 l/min/m2. The baseline mean aortic valve gradient was 30 mmHg with a calculated [**Location (un) 109**] of 0.7 cm2. 6- After hemodynamic assessment, the 6 French arterial sheath was exchanged for an 8 French sheath and the straight wire was exchanged for an Amplatz Stiff wire. We then positioned a 22 mm Tyshak balloon was across the AV. 7- Under rapid RV pacing (at 190 beats/min), we performed 4 inflations (22 mm Tyshak) with excellent result: mean aortic valve gradient dcreased to 15 mmHg and calculated [**Location (un) 109**] increased to 1.1 cm2. 8- Heparin was reversed with 10 mg Protamine and the sheaths removed in the holding area with adequate hemostasis. [**11-28**] Femoral U/S IMPRESSION: Right common femoral arterial pseudoaneurysm with the aneurysm sac measuring 22 x 10 x 16 mm communicating via a 2.4-mm neck. . [**11-29**] CT Abd/Pel 1. No retroperitoneal hematoma. Right inguinal hemorrhagic stranding and small hematomas, as described. 2. Sigmoid diverticulosis without acute diverticulitis. 3. Severe lumbar spondylosis with multilevel vertebral compression deformities, associated with a sclerotic vertebral body at T11, a nonspecific finding. No history of malignancy is known. If outside priors are available, these could be compared or MRI could be pursued for further evaluation, as indicated. . [**12-3**] CTA Abd 1. Large hematoma with fluid-fluid levels within the medial compartment of the thigh anterior to the common and superficial femoral arteries. Small hematoma in the right pectineus muscle. Linear foci of high attenuation best seen on the venous phase could represent hemorrhage from a tiny artery or vein of uncertain origin. . 2. No active extravasation from the common or superficial femoral artery or evidence of communicating pseudoaneurysm. . [**12-8**] CT Neck 1. Diffuse pharyngeal edema with narrowing of the airway particularly at the level of the epiglottis. 2. Aberrant foci of gas posterior to the oropharynx. No discrete collection identified to suggest an abscess. 3. Bilateral apical pleural effusions. Left apical atelectasis and ground glass opacities. 4. Multinodular goiter. 5. Hardware of the upper cervical spine with an abnormal C1/C2 widening and grade 1 anterolisthesis of C2 on C3. . [**12-12**] CT lower extremity Marked interval decrease in large hematoma surrounding right CFA/SFA. Otherwise, unchanged. Brief Hospital Course: # tracheostomy - Reported laryngeal edema after multiple intubation attempts. Patient was weaned from ventilator to trach collar with good oxygen saturation without difficulty over the course of hospitalization. Last downsized to #6 by thoracics on [**12-8**]. Patient failed Passy-Muir trial earlier during hospitalization; she was able to make a good effort but not able to voice, likely [**3-7**] continued laryngeal edema. CT neck confirmed these findings and showed no evidence of abscess, fluid collection. - Continue speech/swallow therapy as tolerated. - Cannot place Passy-Muir valve at this time as patient cannot breathe past it at this time [**3-7**] laryngeal edema. - Downsize and/or d/c trach when indicated. . # nutrition - Patient had significant gastric residuals on tube feeds, likely [**3-7**] nausea and/or opiate-induced gastroparesis. Dobhoff was placed post-pyloric under fluoro guidance to avoid this problem and it was unable to be secured with nasal bridle in order to avoid displacement; patient occasionally sundowns at night and has pulled out tubes in past. Some hypophosphatemia was noted initially with tube feeds, but was repleted and is now normal. - Continue tube feeds. - Speech/swallow therapy as tolerated. - Continue Zofran for nausea, can try weaning off and see if patient tolerates. . # pseudoaneurysm - status post repair by vascular surgery. Complicated by hematoma development during hospitalization requiring drainage. Currently on wound VAC dressing. Will continue to be followed by vascular surgery as outpatient. Last CT lower extremity showed improved hematoma and no signs of infection (abscess). . # leukocytosis - Patient had Klebsiella UTI on admission and was appropriately treated with 7 days of ciprofloxacin. Shortly after discontinuation of abx therapy patient spiked fever again and had white count; unclear what source is as all cultures remained negative, UA negative, CXR shows no interval change. Started on vancomycin + cefepime empirically for 7 day course to treat potential PNA. The patient's CXR are poor at baseline [**3-7**] limited inspiratory effort, likely from deconditioning, so there is concern that PNA may not be fully appreciated. Patient improved on empiric abx therapy and is no longer febrile. - vancomycin + cefepime for 6 day course, started [**12-11**], to end [**12-20**] - Flagyll 500mg TID x 6days, last dose 11/17 . # LUE DVT - Patient was noted to have L upper arm swelling on admission and was found to have clot in brachial/cephalic veins on U/S. Questionable if this is truly a deep vein. This was provoked, likely [**3-7**] attempted Cordis placement during intubation. Patient initially was placed on heparin gtt but developed R leg hematoma. It was thus discontinued and felt that anticoagulation for this is not indicated, especially in the setting of patient's risk of rebleeding. Serial L arm exams have shown improvement in swelling. . # urine output - Patient had several episodes of low urine output during hospitalization, easily correctable with IV fluids. As patient has good cardiac function, low threshold to replete with IVF if clinically thought necessary. . # atrial tachycardia - Patient was noted to have atrial tachycardia during hospitalization. Pain may be playing a role in this response. Spoke with EP, who recommended beta-blocker therapy alone. - continue metoprolol - pain control . # delirium / agitation - Initially confused during hospitalization. Patient had received stress dose steroids, which made this the likely etiology. Improved over course of hospitalization although patient occasioanal sundowns a little at night. - consider very low dose zyprexa / haldol to control agitation as needed - per rheum c/s - cont. chronic steroid dose, watch for steroid induced delirium . # aortic stenosis - s/p balloon valvuloplasty with good effect. No signs of volume overload currently. - continue ASA 325mg . # rheumatoid arthritis - Continue daily prednisone, weekly methotrexate + leucovorin rescue. - pain control with fentanyl patch and oxycodone . # hyperlipidemia - d/ced statin Medications on Admission: MEDICATIONS at home: LEUCOVORIN CALCIUM 5mg on Saturday's, 10 hours after Methotrexate METHOTREXATE SODIUM 12.5mg PO q Saturday OXYCODONE-ACETAMINOPHEN 10mg-325 mg Tablet -q4PRN PRAVASTATIN 40 mg daily PREDNISONE 4mg PO daily TRAVOPROST 0.004 % Drops - 1 drop to each eye every evening ASPIRIN 81 mg Tablet PO daily CALCIUM CARBONATE-VIT D3-MIN [CALTRATE 600+D PLUS MINERALS] - (Prescribed by Other Provider) - 600 mg-400 unit Tablet - 2 Tablet(s) by mouth once a day DOCUSATE SODIUM . Meds on Transfer: Aspirin 325 mg PO DAILY Oxycodone-Acetaminophen 2 TAB PO Q4H:PRN pain Calcium Carbonate 1000 mg PO DAILY Pravastatin 40 mg PO HS Docusate Sodium 100 mg PO BID PredniSONE 4 mg PO DAILY Travatan *NF* 0.004 % OU q hs Vitamin D 800 UNIT PO DAILY Order date: [**11-28**] @ 1621 Discharge Medications: 1. Leucovorin Calcium 5 mg Tablet Sig: One (1) Tablet PO once a week: Saturdays. 2. Methotrexate Sodium 2.5 mg Tablets, Dose Pack Sig: Five (5) Tablets, Dose Pack PO once a week: On Saturdays. 3. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Calcium Carbonate-Vit D3-Min 600-400 mg-unit Tablet Sig: Two (2) Tablet PO once a day. 7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 8. Travoprost 0.004 % Drops Sig: One (1) Ophthalmic q hs (). Disp:*3 bottles* Refills:*2* 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever: maximum total acetaminophen per day is 4g. Disp:*120 Tablet(s)* Refills:*3* 10. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day): hold for diarrhea. Disp:*60 tabs* Refills:*2* 11. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). Disp:*60 Tablet, Chewable(s)* Refills:*2* 12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO Q24H PRN () as needed for delirium. Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*3* 14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day): d/c once patient is up and moving around. Disp:*90 injection* Refills:*2* 15. Oxycodone 5 mg/5 mL Solution Sig: Five (5) ML PO Q4H (every 4 hours) as needed for pain. Disp:*500 ML* Refills:*2* 16. 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* 17. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours): hold for HR<60, SBP<100. Disp:*120 Tablet(s)* Refills:*2* 18. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 6 days. Disp:*17 Tablet(s)* Refills:*0* 19. Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:*120 Tablet(s)* Refills:*2* 20. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) injection Injection Q8H (every 8 hours). Disp:*90 injections* Refills:*2* 21. Pantoprazole 40 mg Recon Soln Sig: One (1) injection Intravenous Q24H (every 24 hours). Disp:*30 injection* Refills:*2* 22. Cefepime 2 gram Recon Soln Sig: One (1) injections Injection Q12H (every 12 hours) for 6 days. Disp:*60 injections* Refills:*2* 23. Vancomycin 1,000 mg Recon Soln Sig: One (1) dose Intravenous once a day for 6 days. Disp:*6000 mg* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) **] Discharge Diagnosis: Severe Aortic Stenosis Right femoral pseudoaneurysm Anemia Hypertension Hyperlipidemia Severe Rheumatoid Arthritis Discharge Condition: v/s:98.4 69 91/46 93% Lungs:CTA b/l CV:s1s2 early peaking systolic murmur of AS Ext:warm, well perfused, no leakage from RLE, LUE Discharge Instructions: You had an aortic valvuloplasty for symptomatic severe aortic stenosis ([**Location (un) 109**] 0.7 cm2). You were found to have a pseudoaneurysm of your right femoral artery. Abdominal CT did not show a retroperitoneal bleeding. You received 1 unit of red blood cells for a hematocrit of 27 post cardiac catheterization. If have chest pain, SOB, feel like you want to pass out- please call Dr. [**Last Name (STitle) 11250**]. If you have right groin pain/swelling/bleeding - please call Dr. [**Last Name (STitle) 11250**] The following changes were made to your medications: For your pneumonia you were started on Vancomycin and Cefepime, you should continue these medications until [**12-19**] You were started on flagyll for aspiration pneumonia, which you should take until [**12-21**] You were started on Ondansetron and Reglan for your vomitting, these should be stopped when your feeding tube is removed. You can restart your methotrexate when your doctors feel that your peripheral edema has resolved Your pain meds were changed to Fentanyl patch and oxycodone liquid, you should take these as instructed by your Nursing Facility. Your Percocet has been STOPPED. You were started on pantoprazole which you should stop when your tracheal tube is removed. You were started on metoprolol 25mg 4x per day, this should be consolidated to a one time long acting dose when you leave rehab. Followup Instructions: Cardiology: Dr. [**Last Name (STitle) 11250**] - office will call you with an appointment for early next week Thoracic Surgery: . Completed by:[**2107-12-15**]

[ "424.1", "307.9", "427.89", "293.0", "272.4", "998.12", "442.3", "478.6", "507.0", "453.83", "V15.1", "997.39", "401.9", "E879.8", "788.5", "599.0", "790.01", "E878.8", "997.2", "998.89", "427.0", "714.0", "V55.0", "536.3", "E879.0", "041.3", "733.00" ]

icd9cm

[ [ [] ] ]

[ "31.1", "37.23", "38.93", "96.6", "35.96", "33.21", "97.23", "88.56", "38.91", "96.07", "38.68" ]

icd9pcs

[ [ [] ] ]

18911, 18981

11261, 15392

260, 358

19140, 19272

5080, 11238

20718, 20880

4067, 4182

16225, 18888

19002, 19119

15418, 15418

19296, 20695

15439, 15907

4197, 5061

3383, 3441

198, 222

3943, 4051

386, 3273

3472, 3824

3295, 3363

3840, 3927

15925, 16200

32,414

189,094

2927

Discharge summary

report

Admission Date: [**2106-4-23**] Discharge Date: [**2106-5-24**] Date of Birth: [**2056-1-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2817**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: RIJ triple-lumen placement Intubation Arterial line placement History of Present Illness: 50 yo male with history of HIV ([**2-26**] - CD4 908, VL < 50 copies) and previous episode of PCP was admitted with 2-3 days of fevers, myalgias, and malaise. . Patient reports that 2-3 days ago, he developed sudden onset of increased fatigue, malaise, and muscle aches in his legs bilaterally. Additional ROS was notable for the following: - vomiting after trying to drink water - decreased PO intake - sick contacts including multiple co-workers sick with fatigue, fevers, and cough - loose stools - 2 loose, watery stools per day - fevers and chills to 104 at home - bitemporal headache pain which is now slightly improved - reported abdominal pain in the ED but denies upon arrival to the floor . He otherwise denies productive cough, facial pain, postnasal drip, nasal congestion, sore throat, abdominal pain, dysuria, hematuria, melena, or shortness of breath at home. Denies any recent travel or antibiotic use. Did not receive the flu shot. Patient has only tried tylenol at home for relief. . Upon arrival to the ED, temp 100.6, HR 118 (98-130), BP 144/78 (119-144/59-79), RR 36, and O2 sat 93% on 4L. While in the ED, his temperature peaked to 101.3, O2 requirement increased to 97% on 100% NRB. CXR was notable for a right lower lobe infiltrate. RUQ US and Head CT were unremarkable. He received motrin 800mg x 1, zosyn 4.5g x 1, levofloxacin 750mg x 1, combivent, and tylenol 1g x 1. He received 3-4L NS in the ED. Past Medical History: 1. HIV/AIDS 2. h/o PCP [**Name Initial (PRE) 1064**] Social History: Home: lives with mother in [**Location 1268**] Occupation: Machinist EtOH: Denies Drugs: Denies Tobacco: 25 PPY history Family History: N/C Physical Exam: T 98.9 / HR 132 / BP 182/95 / RR 42 / 91% on NRB Gen: resting in bed, uncomfortable appearing but no acute distress HEENT: Clear OP, dry mucous membranes NECK: Supple, No LAD, No JVD CV: tachycardic but No murmurs, rubs or gallops LUNGS: scattered wheezes throughout with crackles at LLB ABD: obese, decreased BS, soft, NT, ND, no rebound EXT: No edema. 2+ DP pulses BL. Onychomycoses on all toenails SKIN: No lesions NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: Admission labs: Na 129 / K 3.5 / Cl 93 / CO2 20 / BUN 18 / Cr 1 / BG 128 Ca 9 / Mg 1.6 / Phos 1.4 ALT 34 / AST 62 / Alk Phos 55 / TB .5 / Amylase 15 / Lipase 19 LDH 320 WBC 17.5 / Hct 42.9 / Plt 212 N 91 / Bands 4 / L 5 / M 0 / E 0 / B0 INR 1.2 Lactate 1.7 UA large blood, neg nit, neg prot, neg glu, neg ket, 0 RBCs, [**3-24**] WBCs, occasional bacteria, no yeast, 0-2 epis . [**2106-4-24**] pH 7.39 / PCO2 32 / PO2 61 . Baseline Hct 42-45 . MICROBIOLOGY: Urine legionella antigen presumptively positive Blood cultures from [**5-15**] grew coagulase negative staphylococcus Otherwise, several blood, urine, BAL, CSF and sputum cultures were negative CSF showed 2+ PMNs . ADMISSION STUDIES: - ECG [**2106-4-23**] - Sinus tachycardia - Portable CXR - [**2106-4-23**] - New right hilar opacity and vague opacity in the left lung which likely represent pneumonia. Dedicated PA and lateral films may be helpful Suggest followup to resolution. - RUQ US - [**2106-4-23**] - No evidence of cholelithiasis, gallbladder wall thickening, or edema. - CT Head w/o contrast - [**2106-4-23**] - No acute hemorrhage or mass effect. . CSF: Cytology: negative Protein 46/ Glucose 74/ 100 WBC's/ 213,500 RBC's/ with 92% polys . MRI [**5-17**] FINDINGS: There is marked FLAIR hyperintensity within the bilateral posterior parietal and occipital subcortical white matter and milder FLAIR abnormality within the bilateral cerebellar hemispheres, suggestive of posterior reversible encephalopathy syndrome (PRES). No diffusion abnormality is seen in these areas, also consistent with PRES. Tiny scattered punctate areas of restricted diffusion are seen within the left frontal and right parietal lobes, suggesting tiny embolic infarcts. There is no evidence of hemorrhage or mass effect. The ventricles are normal in size and configuration. Fluid is seen in the mastoid air cells and nasopharynx, likely related to prolonged intubation. On post-contrast images, there is a small amount of enhancement within the right occipital cortex, also likely related to PRES and breakdown of the blood -brain barrier. MRA OF THE HEAD AND NECK: The MRA is normal, with normal caliber of the carotid and vertebral arteries and their intracranial branches. No evidence of stenosis or aneurysm. IMPRESSION: 1. Marked edema within the posterior parietal, occipital, and cerebellar hemispheres without diffusion abnormality, suggestive of PRES (posterior reversible encephalopathy syndrome). 3. Small punctate foci of restricted diffusion within the left frontal and right parietal lobes, likely small embolic infarcts. . CT HEAD [**2106-5-20**] Dramatically progressed subcortical hypodensities in bilateral cerebral hemispheres with early left uncal herniation. The differential in the context of HIV is broad and includes vascular etiologies (posterior reversible encephalopathy syndrome), infectious etiologies, PML, metabolic encephalopathy, and less likely HIV encephalopathy. Brief Hospital Course: Hospital course by problem: . Respiratory failure: Legionella positive (matching clinical sx of (1) diarrhea, (2) hyponatremia, (3) office coworkers ill en masse). Underlying contribution from COPD; question of PCP given no outpatient ppx. The patient was intubated shortly after admission for hypoxia/respiratory failure. He was ventilated per ARDSnet protocol, though very difficult to oxygenate. He initially required proning to improve oxygenation. He continued to have difficulty with ventilation eventually requiring paralysis with cisatracurium, and a pentobarbital induced coma. He was eventually taken off the proning bed, and eventually was weaned off paralysis and was maintained on pressure control. He was switched to assist control, and eventually as his oxygenation improved, he was switched to pressure support. He had a tracheostomy placed on [**2106-5-14**] as well as a PEG tube. He continued to improve from a respiratory standpoint. During his course, he was noted to have a pleural effusion, which was difficult to perform a thoracentesis because of his positioning and difficulty with dysynchronus breathing. He developed a pneumothorax which required chest tube placement by thoracic surgery. He was eventually weaned off of respiratory support fully and his chest tube was removed. . Sepsis: Source likely legionella. He was initially started on vancomycin, levofloxacin, cefepime, and oseltamivir which was stopped once when the influenza test was negative. He was maintained on the levofloxacin, cefepime, and vancomycin and because of his poor respiratory status, azithromycin was added for double coverage of legionella. He continued to spike very high temperatures (>103) despite antibiotics and despite negative cultures. Eventually, it was thought that he was having a drug fever, so all of his antibiotics were stopped, but he did complete a 14 day course of levofloxacin. Despite being off antibiotics, he continued to spike fevers. His cultures (sputum, blood, stool, urine) all remained negative. He had viral studies sent which were also negative. He was never hypotensive requiring pressors, though at one point during his hospitalization, he was transiently hypotensive with MAPs in the 50s-60s which responded to IVFs. He developed acute kidney injury secondary to his sepsis, and he also developed DIC. He was given a 96 hr course of activated protein C when he developed these multiple organ failures. During the workup of his ongoing temperatures, he was found to have a DVT in his right leg, for which he had an IVC filter placed given his very tenuous respiratory status and the inability to anticoagulate while on activated protein C and in DIC. He was also noted to have pancreatitis based on lab tests, but on CT abdomen, there was no evidence of pancreatitis or hemorrhage. . Acute Kidney Injury: The patient developed acute kidney injury likely in the setting of sepsis and hypovolemia. He was given IVFs with improvement in his renal function. He then had to undergo CT Torso with contrast to evaluate for source of fever, which once again increased his creatinine. Then, it slowly began to trend towards baseline. He did not require hemodialysis. Increasing Cr: Likely [**2-20**] dehydration. . DIC: During the early part of his hospitalization, the patient developed discoloration of his fingers and toes. During the workup, he was found to have DIC with elevated FDP, decreased fibrinogen, and decreased platelets. He never required blood products for these derangements. His digital cyanosis continued, and vascular surgery was consulted who felt that he would eventually need amputation of his digits, but that it did not need to be done acutely. He was treated with 96 hour of APC, and his DIC labs improved. . Anemia: The patient's HCT was stable during most of his hospitalization, but did begin to decline and at one point, was <21 requriring 1 unit of pRBCs. His HCT then continued to trend upwards. It was thought that this was likely secondary to his acute illness, and phlebotomizing. His B12/Folate were WNL. His ferritin was elevated, but iron and TIBC were low, likely from his acute illness. He was started on PO iron supplementation via his PEG tube. . HIV: Patient has a history of HIV and h/o PCP [**Name Initial (PRE) 1064**]. He was adequately controlled on [**Name Initial (PRE) 2775**] therapy. It was held during the acute period, but after speaking with his HIV physician, [**Name10 (NameIs) **] [**Name11 (NameIs) 2775**] therapy was restarted once he had a PEG tube placed. . Mental status: Since [**5-16**] mental status not back at baseline, [**5-19**] patient nodding appropriately and would wiggle toes to command. MRI brain showing ring enhancing lesions right occipital [**Last Name (un) 14097**], suggestive PRES. LP performed [**5-19**] and sent for flow cytometry, HIV VL, and various viral cultures/PCR. LP was largely unrevealing, except for a leftward shift. He was started on empiric antibiotics for this. CT showed early uncal herniation. The decision was made by the family to make the patient CMO Medications on Admission: 1. Ritonavir 100mg PO daily 2. Atazanavir 300mg PO daily 3. Combir 150-300mg Tab [**Hospital1 **] Discharge Medications: 1. Morphine Concentrate 10 mg/0.5 mL Solution Sig: 1.5-3.0 ml PO Q2H as needed for pain: =30-60mg for breakthrough pain. . Disp:*60 mL* Refills:*0* 2. Acetaminophen 160 mg/5 mL Solution Sig: Twenty (20) mL PO Q6H (every 6 hours) as needed for pain. 3. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day) as needed for constipation. 4. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours): for pain. Disp:*10 Patch 72 hr(s)* Refills:*2* 5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. Disp:*12 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Old [**Hospital **] Hospice Discharge Diagnosis: Legionella pneumonia Acute respiratory failure Septic shock Diseminated intravascular coagulopathy PRES resulting in uncal herniation Discharge Condition: Comfortable on a fentanyl patch Discharge Instructions: Patient was admitted to the ICU for acute respiratory distress. On admission he was intubated for airway support. It was found that he had a legionella pneumonia which was treated with approrpiate antibiotics. Patient's course was complicated by sepsis, DIC, severe digital ischemia leading to necrosis of fingers and toes, and PRES syndrome, unfortunately resulting in uncal herniation. He was made CMO and discharged home with hospice. Followup Instructions: NA

[ "276.2", "276.0", "512.8", "577.0", "518.81", "038.8", "348.39", "584.5", "276.51", "787.91", "496", "453.40", "286.6", "276.1", "276.52", "285.8", "042", "482.84", "V66.7", "995.92", "785.52" ]

icd9cm

[ [ [] ] ]

[ "99.15", "99.04", "43.11", "96.72", "03.31", "38.7", "38.91", "34.04", "31.1", "38.93", "00.11", "96.04" ]

icd9pcs

[ [ [] ] ]

11647, 11705

5719, 5719

323, 386

11883, 11917

2749, 2749

12406, 12412

2072, 2077

11003, 11624

11726, 11862

10881, 10980

11941, 12383

2092, 2730

276, 285

5747, 10313

414, 1843

2765, 5696

10328, 10855

1865, 1919

1935, 2056

57,445

100,085

1002

Discharge summary

report

Admission Date: [**2126-8-30**] Discharge Date: [**2126-9-8**] Date of Birth: [**2054-2-16**] Sex: F Service: CARDIOTHORACIC Allergies: Relafen Attending:[**First Name3 (LF) 4679**] Chief Complaint: Recurrence of lung cancer Major Surgical or Invasive Procedure: [**2126-8-30**]: Redo right thoracotomy, Lysis of adhesions and decortication of lung, Wedge resection of right lower lobe lung cancer. History of Present Illness: Ms. [**Known lastname 6610**] is a 72 year-old woman on whom we performed a right thoracotomy, right lower lobe superior segmentectomy on [**2125-7-27**]. The pathology revealed a 2.5cm, moderately differentiated, adenocarcinoma with negative margins. The lymph nodes were negative. pT1bN0Mx, stage IA. She was seen in clinic [**2126-7-16**] and local recurrence was noted on CT. On [**2126-7-19**] her PET showed an FDG-avid subpleural nodule in the right lower lobe, compatible with recurrence as well as in the chest wall in the region of the right 5th and 6th ribs is new from [**2125-7-3**] and also concerning for recurrence. She underwent a core biopsy [**2126-8-2**] and path revealed recurrent adenocarcinoma. She denies any symptoms at this time. Past Medical History: Hypertension Hyperlipidemia breast CA s/p lumpectomy in [**2118**] nodal negative and adjuvant chemorads Renal angiomyolipoma Emphysema PSH: RLL superior segmentectomy [**2125-7-27**], Recurrent PTX requiring partial resection via thoracotomy Social History: She quit smoking in [**2109**] and smoked 40 years 2 packs a day. Denies alcohol use. Unfortunately, husband has terminal gastric cancer, is hospitalized at the VA which greatly upsets patient. Family History: She has two daughters who are healthy. There is a history of allergies and emphysema in her family. Physical Exam: Gen: NAD, anxious Neck: no [**Doctor First Name **] Chest: clear ausc, incisions c,d,i Cor: RRR no murmur Ext: no CCE Pertinent Results: ADMISSION LABS [**2126-8-30**] 11:30AM BLOOD WBC-10.5 RBC-3.27* Hgb-10.1* Hct-29.9* MCV-91 MCH-30.9 MCHC-33.8 RDW-14.0 Plt Ct-333 [**2126-8-30**] 03:30PM BLOOD Glucose-167* UreaN-20 Creat-0.9 Na-140 K-4.1 Cl-106 HCO3-22 AnGap-16 [**2126-8-30**] 03:30PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.5* DISCHARGE LABS [**2126-9-7**] 07:05AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.0* Hct-24.2* MCV-92 MCH-30.0 MCHC-32.8 RDW-14.9 Plt Ct-455* [**2126-9-7**] 07:05AM BLOOD Glucose-127* UreaN-12 Creat-0.7 Na-136 K-3.9 Cl-96 HCO3-30 AnGap-14 [**2126-9-7**] 07:05AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.8 [**8-30**] CXR post op Right pneumothorax post surgery with three chest tubes in place [**9-7**] CXR Interval removal of the right basilar chest tube. There continues to be some subcutaneous emphysema within the right lateral chest wall soft tissues. Post-surgical changes of the right hemithorax and lung are stable. Stable right lateral pleural thickening and right basilar pleural thickening could be post-operative or represent some pleural fluid. However, the appearance is stable. No pneumothorax is seen. The left lung remains well inflated and clear. Cardiac and mediastinal contours are stable. Clips in the right upper quadrant are consistent with cholecystectomy. No pulmonary edema. Brief Hospital Course: Patient was admitted on [**2126-8-30**] to the thoracic surgery service for a planned right thoracotomy, right lower lobe wedge resection with decortication. She tolerated the procedure well, was extubated and recovered in the PACU prior to being transferred to the ICU in stable condition. For full details please see the operative report. Three chest tubes were placed during the procedure and a postoperative chest x-ray showed expected right pneumothorax post surgery with three chest tubes in place. Pathology revealed a 1.8 cm poorly differentiated adenocarcinoma with negative margins and no positive nodes. She was started on a clear liquid diet, her pain was controlled with an epidural and she was started on her home medications. On POD 1 her diet was advanced to regular and she was transferred to the surgical floor from the ICU. On POD 2 she was noted to have increased somnolence which was thought to be related to her pain medications so her epidural was turned down and narcotics for breakthrough pain were discontinued. She was given a unit of PRBC for a Hct of 20.3 with an appropriate increase to 24.4 and improved somnolence. On POD 3 metoprolol was started because of elevated systolic blood pressures. She continued to have an air leak from all three chest tubes. Her epidural was discontinued and her foley catheter was removed. She was started on oxycodone and tramadol for pain. By POD 4 the air leak had stopped in the anterior chest tube so it was removed. The posterior chest tube was removed on POD 6. On POD 7 she noted that she felt dizzy when she was getting out of bed and was found to be in atrial fibrillation with RVR. She was given metoprolol once without effect and was then given IV diltiazem once with return to sinus rhythm. Cardiac enzymes were negative and she was monitored with telemetry without recurrence. On POD 8 the air leak had resolved in the basilar chest tube so it was removed. A post pull chest xray showed no PTX. Because her pain was well controlled, she was tolerating her diet and was ambulating without assistance, she was discharged to home on POD 9 with instructions to follow up in Dr.[**Name (NI) 5067**] clinic with a chest x-ray. Medications on Admission: 1. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] twice a day Rinse mouth after use 2. Nortriptyline 30 mg PO HS 3. Pravastatin 40 mg PO DAILY 4. Tiotropium Bromide 1 CAP IH DAILY 5. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp #*60 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*30 Capsule Refills:*0 3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] twice a day Rinse mouth after use 4. Nortriptyline 30 mg PO HS 5. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain RX *oxycodone 5 mg [**12-10**] tablet(s) by mouth every 4 hours Disp #*50 Tablet Refills:*0 6. Pravastatin 40 mg PO DAILY 7. Senna 1 TAB PO BID RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp #*30 Tablet Refills:*0 8. Tiotropium Bromide 1 CAP IH DAILY 9. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY 10. Metoprolol Tartrate 12.5 mg PO BID HTN Hold for SBP < 100 or HR < 60 RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a day Disp #*15 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Recurrent lung cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for surgery on your lung. You have done well after the procedure and may return home to continue your recovery. There is a dressing over the site of your chest tube- this may be removed in 24 hours. You can leave the incision open to air after that. You may shower with the dressing in place. Please take the prescribed pain medication as needed. Constipation can be a problem with narcotic use, therefore drink plenty of fluid to stay well hydrated and use a stool softener while taking narcotics. Do NOT drive while taking narcotic pain medications. While in the hospital, you were noticed to have a heart rhythm called atrial fibrillation. We were able to convert the rhythm back to normal using medication; please ask your primary care doctor if you need further tests or treatment. We also started you on a new medication called Metoprolol for your high blood pressure and new dysrhythmia, please ask your primary care doctor if you need to continue it. If you develop any chest pain, shortness of breath or any other symptoms that concern you, please call your surgeon or go to the nearest Emergency Room. Thank you for allowing us to participate in your care. Followup Instructions: Please follow up with Dr. [**First Name (STitle) **] in 2 weeks. Please call [**Telephone/Fax (1) 2348**] to schedule a follow up appointment in 2 weeks with a chest x ray. Please report to the [**Location (un) **] of the [**Hospital Ward Name 23**] center 30 min prior to your appointment for a chest x-ray. Please follow up with your primary care doctor within a week from discharge.

[ "198.89", "162.5", "401.9", "V10.3", "E878.6", "V15.82", "427.31", "511.0", "492.8", "272.4", "512.2" ]

icd9cm

[ [ [] ] ]

[ "34.51", "32.29", "33.43", "40.11" ]

icd9pcs

[ [ [] ] ]

6717, 6775

3282, 5482

299, 438

6841, 6841

1978, 3259

8219, 8610

1722, 1825

5773, 6694

6796, 6820

5508, 5750

6992, 8196

1840, 1959

234, 261

466, 1226

6856, 6968

1248, 1494

1510, 1706

21,706

164,207

29350

Discharge summary

report

Admission Date: [**2113-11-28**] Discharge Date: [**2113-12-15**] Date of Birth: [**2047-11-30**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5880**] Chief Complaint: s/p Pedestrian struck by auto Major Surgical or Invasive Procedure: [**2113-12-13**] ORIF right shoulder [**2113-12-6**] ORIF facial fractures [**2113-12-1**] Open tracheostomy & percutaneous PEG placement History of Present Illness: 66 yo male pedestrian who was struck by auto; + LOC. He was taken to an area hospital where he was combative and required intubation. He was then transferrd to [**Hospital1 18**] for continued care. Past Medical History: Diabetes s/p cholecystectomy Family History: Noncontributory Pertinent Results: [**2113-11-28**] 08:08PM TYPE-ART PO2-156* PCO2-41 PH-7.37 TOTAL CO2-25 BASE XS--1 [**2113-11-28**] 08:08PM LACTATE-2.0 [**2113-11-28**] 08:01PM GLUCOSE-128* UREA N-18 CREAT-0.8 SODIUM-143 POTASSIUM-3.7 CHLORIDE-112* TOTAL CO2-23 ANION GAP-12 [**2113-11-28**] 08:01PM CALCIUM-7.6* PHOSPHATE-2.2* MAGNESIUM-2.0 [**2113-11-28**] 08:01PM WBC-15.1* RBC-3.45* HGB-11.2* HCT-30.5* MCV-89 MCH-32.6* MCHC-36.7* RDW-13.6 [**2113-11-28**] 08:01PM PLT COUNT-166 [**2113-11-28**] 08:01PM PT-15.1* PTT-27.6 INR(PT)-1.4* CHEST (PORTABLE AP) Reason: fever, increased sputum production [**Hospital 93**] MEDICAL CONDITION: 65 year old man ped struck s/p trach possible aspiration tonight REASON FOR THIS EXAMINATION: fever, increased sputum production PORTABLE CHEST, 8:14 A.M., [**12-6**] INDICATION: MVA. Possible aspiration. FINDINGS: Compared with [**2113-12-3**], the tracheostomy remains in unremarkable position. The tip of the left subclavian central line is unchanged, but may be tenting the wall of the upper SVC laterally. Dr. [**First Name (STitle) 4135**] was paged with these findings. Otherwise, allowing for some mild bibasilar atelectasis, the lungs remain grossly clear. CT UP EXT W/O C Reason: eval prox humerus fracture. does not need arthrogram, just [**Hospital 93**] MEDICAL CONDITION: 66 year old man with right proximal humerus fracture. preop eval REASON FOR THIS EXAMINATION: eval prox humerus fracture. does not need arthrogram, just CT of prox humers and glenohum joint CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: Right proximal humeral fracture. TECHNIQUE: Contiguous thin section axial images were obtained from the volumetric (64 detector GE) CT scanner and reconstructed in both bone and standard algorithms. Coronal and sagittal reformatted images were also generated. CT UPPER EXTREMITY WITHOUT CONTRAST: The preliminary wet read report by the resident issued in the PACS requisition is as follow: "Impacted comminuted fracture of the neck of the right humerus with bone fragments as seen on prior plain film and CT study, with large surrounding hematoma." There is a comminuted fracture of the proximal humerus, with components involving the surgical neck and both greater and lesser tuberosities. The fracture is impacted, with varus and anterior apex angulation. There is nearly half shaft width anterior displacement of the humeral shaft with respect to the humeral head (series 103B, image 27). The glenohumeral joint is grossly congruent, but slightly diastatic. Of note, fracture lines are seen extending into the articular surface of the humeral head, both at its superior margin (series 104B, image 45 and series 3, image 31) and in the mid portion of the articular surface (series 104B, image 38). There is fluid and edema and probable hemorrhage about the shoulder joint and fluid within the joint space. Deformity of several upper right thoracic ribs suggests fractures, likely old. Limited assessment of the lung shows atelectasis. IMPRESSION: Comminuted fracture of the proximal right humerus, with intra-articular extension. CT HEAD W/O CONTRAST Reason: MVA; NOW WITH DIMINISHING NEURO EXAM; EVAL FOR BLEEDING [**Hospital 93**] MEDICAL CONDITION: 66 year old man s/p mva now w/ diminishing neuro exam REASON FOR THIS EXAMINATION: eval interval bleeding/ [**Doctor First Name **] CONTRAINDICATIONS for IV CONTRAST: None. CLINICAL HISTORY: 66-year-old male status post motor vehicle accident now with diminishing neuro exam. Evaluate interval bleeding. FINDINGS: The previously identified rounded high density within the right frontal lobe, representing hemorrhage versus hemorrhagic contusion appears stable. The small amount of blood within bilateral posterior parietal sulci appears slightly more conspicuous compared to prior CT head obtained on [**2113-11-28**]. Small amount of blood is seen layering in the dependent region of the occipital horns of the lateral ventricle slightly increased compared to prior study. However, this could be attributed to differences in slice selection and technique. No shift of normally midline structures or hydrocephalus is identified. Again seen are high-density air-fluid levels within bilateral maxillary sinus and sphenoid sinus, likely representing evolving blood products. There is opacification of the right frontal sinus as well as air-fluid level within the left frontal sinus and mucosal thickening in the ethmoid sinuses, largely unchanged from prior study. The right mastoid air cells remain normally aerated while the left is partially fluid filled. Multiple fractures are again noted within the facial bones. There is soft tissue swelling overlying the region lateral to the right orbit, likely representing slowly resolving hematoma. IMPRESSION: 1. Direct comparison with prior study obtained on [**2113-11-28**] is difficult given patient's different positioning, however, t right frontal lobe hemorrhage/contusion, and small bilateral parietal subarachnoid blood is unchanged in distribution and likely unchanged in size. 2. Small amount of intraventricular blood layering in the dependent region of the occipital horns of the lateral ventricles slightly increased compared to prior study, however, direct comparison is difficult secondary to different patient positioning. 3. Multiple facial bone fractures, and high-density air-fluid level within multiple sinuses largely unchanged from prior exam. Cardiology Report ECG Study Date of [**2113-11-28**] 3:34:12 PM Sinus tachycardia, rate 106. There may be a previous anteroseptal wall myocardial infarction. Diffuse ST-T wave abnormalities are noted. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 106 120 88 346/408 48 37 39 Brief Hospital Course: He was admitted to the Trauma service. Neurosurgery, Orthopedic and Plastic Surgery were all [**Date Range 4221**] because of his multiple injuries. His intraparenchymal hemorrhage was non operative; serial head CT scans were followed and were stable. He will need to follow up with Dr. [**Last Name (STitle) **] in 4 weeks for repeat head imaging. His right zygomatic facial fracture was repaired in the operating room on [**12-6**]. Ophthalmology was [**Month/Year (2) 4221**] as well to rule out globe injury; none was identified. He will need to follow up with Dr. [**First Name (STitle) 3228**] in 4 weeks. On [**11-28**] he was taken to the operating room by Orthopedics for ORIF of his right tib/fib fracture and again on [**12-13**] for ORIF of his right shoulder fracture. His staples will need to be removed in 2 weeks and he will require follow up with Dr. [**Last Name (STitle) 1005**] in 4 weeks. An open tracheostomy and percutaneous PEG was placed on [**12-1**] and he was started on tube feedings which he is tolerating at this time. [**Last Name (un) **] Diabetes Center was also [**Last Name (un) 4221**], he reportedly has a history of diabetes and it was unclear if this was under control prior to his trauma. He was placed on sliding scale insulin. His systolic blood pressure was intermittently high during his hospital stay; he required IV Hydralazine prn; he was started on beta blockade and an ACEI; both of these medications were increased periodically; he will likely require further adjustment of these medications for better blood pressure control. Wound Ostomy nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**] for skin care issues; several recommendations were made (see treatment portion of Page 1). He was placed on a First Step mattress for pressure relief. Nutritional services were also closely involved in his care. Physical and Occupational therapy were [**Last Name (Titles) 4221**] and have recommended rehab stay because of his multiple injuries. Medications on Admission: None known Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 2. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for dry eyes. 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) dose Injection TID (3 times a day). 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed for pain. 6. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane TID (3 times a day): please swab mouth with this preparation. 7. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic [**Hospital1 **] (2 times a day). 8. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 9. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constiaption. 10. Enalapril Maleate 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): hold for SBP <110. 11. Lopressor 50 mg Tablet Sig: Three (3) Tablet PO three times a day: hold for HR <60, SBP <110. 12. Regular insulin sliding scale Sig: One (1) dose four times a day as needed for per sliding scale. 13. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN 10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 14. Dulcolax 10 mg Suppository Sig: One (1) supp Rectal twice a day as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: s/p Pedestrian Struck by Auto Right frontal intraparenchymal hemorrhage Bilateral orbital fractures Right humeral head fracture Right tibia/fibula fracture Right rib fracture Discharge Condition: Stable Discharge Instructions: DO not bear any weight on your right upper extremity. Followup Instructions: Follow up in 4 weeks with Dr. [**Last Name (STitle) 1005**], Orthopedics, call [**Telephone/Fax (1) 1228**] for an appointment. If the rehab facility is unable to remove your staples in 2 weeks you will need to be seen sooner than 4 weeks. Follow up with Dr. [**First Name (STitle) 3228**], Plastics in 4 weeks, call [**Telephone/Fax (1) 5343**] for an appointment. Follow up in 4 weeks with Dr. [**Last Name (STitle) **], Neurosurgery, call [**Telephone/Fax (1) 1669**] for an appointment. Inform the office that you will need a repeat head CT scan for this appointment. Completed by:[**2113-12-15**]

[ "870.0", "707.8", "250.00", "812.09", "E814.7", "518.5", "823.02", "599.7", "401.9", "802.8", "802.4", "851.02", "787.91", "873.20" ]

icd9cm

[ [ [] ] ]

[ "76.79", "96.72", "79.31", "96.6", "43.11", "38.93", "79.36", "76.72", "31.1" ]

icd9pcs

[ [ [] ] ]

10253, 10300

6618, 8627

347, 487

10519, 10528

819, 1406

10630, 11238

783, 800

8688, 10230

4043, 4097

10321, 10498

8653, 8665

10552, 10607

278, 309

4126, 6595

515, 715

737, 767

69,483

167,994

52000

Discharge summary

report

Admission Date: [**2168-5-9**] Discharge Date: [**2168-5-15**] Service: MEDICINE Allergies: Codeine / Vasotec / Cortisporin / Ciloxan / Atenolol / Lisinopril / Diovan Attending:[**First Name3 (LF) 1515**] Chief Complaint: Malaise and weakness. Major Surgical or Invasive Procedure: None. History of Present Illness: Mrs. [**Known firstname 2894**] [**Known lastname **] is an 86 year-old woman with history of CAD, systolic CHF (EF 40%), peripheral [**Known lastname 1106**] disease, insulin-dependent diabetes, hypertension, and hyperlipidemia who presents from home with malaise and increasing shortness of breath. She felt short of breath and weak at home this afternoon at about 3 p.m. She felt that her legs were weak. She could not endorse any change in urine output. She has felt short of breath at this time and had some chest pressure at the upper part of her sternum. This chest pressure occurred when she was sitting at the dining table - she lay over the bed. It did not resolve so her husband called EMS. Her pain had begun to resolve by her arrival. In the ED, she was found to be bradycardic with HR in the 40s and a systolic blood pressure that dropped from 130 to 80s. Her initial potassium was 7.8, non-hemolyzed, with a creatinine of 3.7 up from baseline 1.8 to 2.0. EKG revealed junctional rhythm with slightly peaked t-waves. She was given atropine 0.5 mg x1 with increase in heart rate to 70s and systolic blood pressure to 110s. Her hyperkalemia was treated with 2g calcium gluconate, 10 units insulin and one amp D50. Additionally she was given 30 grams of kayexalate. Of note, the patient was admitted on [**2168-1-22**] for hyperkalemia. While inpatient, she was found to have an NSTEMI. Cath showed non-intervenable two vessel disease, which was managed medically with beta blocker, aspirin, plavix, statin and blood pressure control. She was also treated for CHF exacerbation. The patient was admitted again on [**2168-2-10**] for fatigue and generalized weakness, thought to be due to a combination of poor glycemic control, orthostasis, and deconditioning. She was more recently admitted from [**3-1**] to [**3-12**] for shortness of breath. Pneumonia was diagnosed radiographically and she was started on IV Vancomycin and Cefepime, expanded to include Levoquin subsequently. Tracheobronchomalacia was noted on CT. Nebulizer treatements and diuresis (Lasix 40 mg IV Q6H, then DC on 60 mg PO QD) also helped improve her respiratory status and O2 was weaned to 2L of NC and she was discharged to rehab. That admission was also complicated by acute on chronic renal failure (2.3 from baseline 1.6), which seems to have be attributed to poor forward flow, pre-renal azotemia. NSTEMI occurred on the second day of admission, attributed to strain, without intevention but requiring a stay in the CCU. It was medically managed with ASA, Carvedilol, Plavix, Simvastatin, Integrillin, and a Heparin gtt as her coronaries were not amenable to intervention. Her enzymes subsequently trended down and she remained chest pain free for the remainder of her hospital stay. On [**2168-5-4**], the patient could not be roused by her husband. [**Name (NI) **] called EMS and she was found to be hypoglycemic. She presented to [**Hospital1 18**] ED and was given dextrose. UTI was treated with Bactrim, which she took. Past Medical History: 1. CAD, status post cardiac catheterization in [**2167-3-15**] with bare metal stenting and PTCA of an ostial 90% RCA lesion, complicated by dissection and pseudoaneurysm 2. Peripheral [**Year (4 digits) 1106**] disease with lower extremity c/b neuropathy 3. Insulin-dependent diabetes mellitus 4. Hypertension 5. Hyperlipidemia 6. Asthma 7. Gastroesophageal reflux disease 8. Osteoarthritis 9. Recent contrast-induced nephropathy after cardiac catheterization with a peak creatinine of 4.4 requiring transient renal replacement therapy 10. CRI baseline 1.1 - 1.2 11. Hyperparathyroidism 12. B12 deficiency anemia 13. Appendectomy 14. Bladder suspension 15. Right meniscectomy in [**2161-1-11**] 16. Excision of benign breast mass times two Social History: The patient currently lives in [**Location 745**] with her [**Age over 90 **] year old husband. She has 1 son who lives in [**Name (NI) 701**]. At baseline she walks with a cane, she is otherwise independent in all ADLs. Tobacco: None ETOH: None Illicits: None Family History: -Father: heart problems, DM -Mother: heart problems -4 brothers: CAD, one with stroke Physical Exam: VS: T= Afebrile BP= 120/34 HR= 45 RR= 18 O2 sat= 97% Orthostatics - 120s systolic lying and standing with little change in HR. GENERAL: Overweight woman appears stated age. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Xanthalesma present. NECK: Supple with JVD. CARDIAC: PMI enlarged. Regular, II/VI systolic murmur, blowing, normal S2. No r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Large echymoses around flanks. Resp were unlabored, no accessory muscle use. Some crackles at very bases. No wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: Edema from upper shin, knees and thighs 3+. No c/c. Venous and arterial insufficiency from mid-calf down. SKIN: Stasis dermatitis. No ulcers, scars. Pertinent Results: Labs at Admission: [**2168-5-9**] 08:35PM BLOOD WBC-6.8 RBC-3.10* Hgb-9.7* Hct-30.6* MCV-99* MCH-31.3 MCHC-31.7 RDW-15.7* Plt Ct-189 [**2168-5-9**] 08:35PM BLOOD Neuts-75.7* Lymphs-16.1* Monos-6.9 Eos-1.2 Baso-0.2 [**2168-5-9**] 08:35PM BLOOD PT-11.8 PTT-25.3 INR(PT)-1.0 [**2168-5-9**] 08:35PM BLOOD Glucose-267* UreaN-93* Creat-3.7*# Na-138 K-8.0* Cl-106 HCO3-19* AnGap-21* [**2168-5-9**] 08:35PM BLOOD Calcium-8.8 Phos-5.9*# Mg-2.9* Labs at Discharge: [**2168-5-15**] 06:15AM BLOOD WBC-4.5 RBC-2.76* Hgb-9.1* Hct-26.8* MCV-97 MCH-32.9* MCHC-33.9 RDW-15.6* Plt Ct-189 [**2168-5-13**] 03:36AM BLOOD PT-10.6 PTT-24.6 INR(PT)-0.9 [**2168-5-15**] 06:15AM BLOOD Glucose-189* UreaN-63* Creat-2.1* Na-137 K-5.3* Cl-106 HCO3-23 AnGap-13 [**2168-5-15**] 06:15AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.8* Cardiac Enzymes: [**2168-5-9**] 08:35PM BLOOD CK-MB-13* MB Indx-10.6* [**2168-5-9**] 08:35PM BLOOD cTropnT-0.12* [**2168-5-9**] 09:15PM BLOOD proBNP-4461* [**2168-5-10**] 01:15AM BLOOD CK-MB-12* MB Indx-11.4* cTropnT-0.14* [**2168-5-10**] 09:01AM BLOOD CK-MB-NotDone cTropnT-0.13* [**2168-5-10**] 12:57PM BLOOD CK-MB-NotDone cTropnT-0.13* [**2168-5-10**] 05:29PM BLOOD CK-MB-NotDone cTropnT-0.12* [**2168-5-10**] 10:15PM BLOOD CK-MB-NotDone cTropnT-0.15* [**2168-5-11**] 05:33AM BLOOD CK-MB-15* MB Indx-12.8* cTropnT-0.37* [**2168-5-12**] 04:30AM BLOOD CK-MB-NotDone cTropnT-0.95* [**2168-5-13**] 03:36AM BLOOD CK-MB-5 cTropnT-0.65* EKG ([**2168-5-9**]): Baseline artifact. Junctional or other supraventricular bradycardia. Possible inferior myocardial infarction of indeterminate age. Since the previous tracing of [**2168-3-3**] the rate is slower, P waves are less apparent and ST-T wave abnormalities are now less prominent. EKG ([**2168-5-11**]): Sinus rhythm with slight A-V conduction delay. Left atrial abnormality. Consider prior inferior myocardial infarction although is non-diagnostic. Modest non-specific ST-T wave changes. Since the previous tracing of [**2168-5-10**] the rate is slower, inferior lead Q waves appear more prominent but there may be no significant change and precordial lead T waves are less prominent. CXR ([**2168-5-9**]): FINDINGS: AP upright portable chest radiograph is obtained. An overlying EKG lead and an external pacer wire project over the patient. Low lung volumes limits evaluation. Cardiomegaly is noted with pulmonary [**Month/Day/Year 1106**] prominence likely indicating mild failure. Small pleural effusions cannot be entirely excluded. The retrocardiac region is difficult to assess though the remaining areas of both lungs demonstrate no evidence of pneumonia. Atherosclerotic calcification along the aortic knob is noted. Tiny clips are noted to the right of the trachea. Bony structures appear grossly intact. IMPRESSION: Mild congestive heart failure. Limited exam. Brief Hospital Course: In summary this is an 86 year-old woman with history of CAD, systolic CHF (EF 40%), peripheral [**Month/Day/Year 1106**] disease, insulin-dependent diabetes, hypertension, and hyperlipidemia who presents from home with malaise and increasing shortness of breath. She was found to have acute on chronic renal failure, hyperkalemia, hypermagnasemia, hyperphosphatemia and EKG changes indicative of junctional escape rhythm. # Bradycardia. The EKG findings were classic for hyperkalemia with a probably junctional escape. P-waves were difficult to appreciate. Her hyperkalemia and acute kidney injury were treated, and she returned to sinus rhythm. Carvedilol, which was initially held, was restarted at low-dose prior to discharge. # Renal Failure. Her creatinine at admission was 4.0, up from recent baseline 2.0. Renal service was involved and it was felt that the acute kidney injury was secondary to lisinopril. Bactrim toxicity was also considered. Both medications were held and her renal function returned to baseline. Per the renal consult service, she should never be treated with ACEIs or ARBs again given the risk of precipitating acute kidney injury and hyperkalemia. # Hyperkalemia. As above, lisinopril and Bactrim were held. Hyperkalemia was treated in the ED with calcium gluconate, insulin, and D50. By the time she reached the CCU her potassium was downtrending. She was given additional insulin and D50 followed by kayexalate. Additionally, Lasix was restarted when her kidney function improved. With these interventions, her hyperkalemia resolved and she returned to [**Location 213**] sinus rhythm. Her potassium at time of discharge is 5.3. She has been instructed in a low potassium diet. She will follow-up in renal clinic where they may consider addition of low-dose fludrocortisone if the mild increase in potassium persists. # Diabetes. The [**Last Name (un) **] consult service was involved in management of her diabetes. They recommended to stop Lantus and begin NPH, given her degree of renal impairment. Additionally, they made changes to her Humalog sliding scale. We have recommend that she follow-up with her [**Last Name (un) **] provider within one week of discharge. # Coronary Artery Disease. There was a slight troponin leak which was felt to be secondary to either demand in the setting of bradycardia versus NSTEMI. She was treated for 48 hours with heparin drip. Her aspirin and Plavix were continued, and simvastatin was increased to full dose. Carvedilol was added back prior to discharge. Cardiac enzymes were down-trending at time of discharge. # Chronic Congestive Systolic Heart Failure. LVEF of 40% on transthoracic echo in [**Month (only) 404**] of this year. We held her lisinopril, as above, added back her carvedilol at low-dose, and added back her lasix at 40 mg once daily. # Hypertension. We continued her clonidine throughout admission. Hydralazine, carvedilol, amlodipine, and Lasix were added back as her clinical status improved. # FEN: cardiac, heart-healthy diet, diabetic diet. # Access: peripheral IVs. # Prophylaxis: DVT prophylaxis with subcutaneous heparin. Bowel regimen prn. # Code: full code. # Communication: with patient and son [**Name (NI) 3065**] (c) [**Telephone/Fax (1) 107646**] # Disposition: she was discharged back to [**Hospital3 **] with plan for home physical therapy and visiting nursing for assistance with medications. Medications on Admission: Prescription Amlodipine 10 Coreg 12.5 [**Hospital1 **] Clonidine 0.2 [**Hospital1 **] Plavix 75 Advair 250/50 1P [**Hospital1 **] Lasix 40 QD (in [**Hospital3 **] list is [**Hospital1 **]) Hydralazine 75 TID Novolog ISS Glargine 46 U QD Combivent 1-2P Q6H PRN SOB/wheeze Isosorbide mononitrate 30 mg TID Lidoderm QD Lisinopril 10 QD (in [**Hospital3 **] 40 QD) Lorazepam 0.5 [**Hospital1 **] PRN anxiety Nitroglycerine spray 0.4 mg Q5Min PRN chest pain Simvastatin 20 QD Telehealth monitoring OTCs Vit C 500 QD ASA 325 QD Ca-carbonate 1000 Q6H Vit D3 1000 U QD B12 1000 mcg QD Tears Naturale Multivitamin Omega-3 1000 mg QD ([**Hospital1 **] at [**Hospital3 **]) (Colace 100 [**Hospital1 **] at [**Hospital3 **]) (Senna 8.6 [**Hospital1 **] at [**Hospital3 **]) Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for Chest pain . 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q8H (every 8 hours). 7. Clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 10. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Inhalation 11. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO three times a day. 13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 14. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. 15. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO every six (6) hours as needed for Reflux. 16. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day. 17. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 18. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. 19. Tears Naturale Ophthalmic 20. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. Omega-3 Fatty Acids 1,000 mg Capsule Sig: One (1) Capsule PO once a day. 22. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 23. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 24. Humalog 100 unit/mL Cartridge Sig: ASDIR Subcutaneous four times a day. Disp:*30 qs* Refills:*2* 25. NPH Insulin Human Recomb 100 unit/mL Cartridge Sig: Sixteen (16) units Subcutaneous qam. Disp:*30 qs* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary Diagnosis Complete heart block secondary to hyperkalemia and acute kidney injury Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: You were admitted to the hospital for evaluation of an irregular heart rhythm. We believe the rhythm was due to high potassium levels and kidney injury from a medicine you had been taking called lisinopril. We stopped this medicine and your symptoms improved. It is very important that you NOT take lisinopril or any medicines similar to this in the future. The medicines that you should ABSOLUTELY AVOID in the future are called ACE-inhibitors and angiotensin-receptor blockers (ARBs). These medicines can cause the potassium levels to be elevated. We made the following changes to your medicines: - we STOPPED lisinopril. Please do not take this medicine again - we STOPPED insulin Glargine - we DECREASED the dose of Lasix to 40 mg once daily from twice daily - we DECREASED the dose of carvedilol to 3.125 mg twice daily from 12.5 mg twice daily - we CHANGED the Humalog insulin sliding scale (please see attached) - we INCREASED the dose of simvastatin to 80 mg daily from 10 mg daily - we ADDED insulin NPH 16 units each day at breakfast - there were no other changes to your medicines Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: -***Please schedule an appointment with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 216**] or his nurse practitioner for next week at Healthcare Asssociates. You should schedule the appointment for early to mid next week at [**Hospital3 **]. They will need to check blood levels to look at kidney function and electrolytes. The number to call is [**Telephone/Fax (1) 250**].*** -***Please schedule an appointment with Dr. [**First Name (STitle) **] at [**Hospital **] [**Hospital 982**] clinic next week. This is important to schedule since we have made changes to your insulin regimen during this hospital admission.*** - [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2168-5-27**] 12:00 - [**Month/Day/Year **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB) Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2168-7-18**] 11:15 - [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2168-7-18**] 11:50 Completed by:[**2168-5-15**]

[ "416.8", "585.9", "410.71", "250.80", "275.3", "E942.9", "426.0", "493.90", "272.4", "V58.67", "355.8", "443.9", "414.01", "428.23", "428.0", "403.90", "427.89", "530.81", "584.5", "275.2", "276.7" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

14775, 14824

8316, 11729

303, 311

14957, 14957

5474, 5912

16344, 17494

4421, 4508

12542, 14752

14845, 14936

11755, 12519

15137, 16321

4523, 5455

6286, 8293

242, 265

5932, 6268

339, 3363

14972, 15113

3385, 4127

4143, 4405

54,385

161,191

41869

Discharge summary

report

Admission Date: [**2192-1-31**] Discharge Date: [**2192-2-10**] Date of Birth: [**2142-12-9**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 668**] Chief Complaint: abdominal pain, distension, decreased ostomy output Major Surgical or Invasive Procedure: [**2192-2-2**]: diagnostic/therapeutic paracentesis [**2192-2-3**]: diagnostic/therapeutic paracentesis History of Present Illness: 49F with EtOH cirrhosis recently admitted to [**Hospital1 18**] for multiple abdominal abscesses and peritonitis, ultimately found to have perforated sigmoid colon, s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3379**] procedure on [**2191-12-25**]. Discharged to rehab 7 days ago on tube feeds and broad spectrum IV antibiotics. For the past 4 days she has had increasing abdominal distension and pain, and has apparently gained 25 lbs. Per report her ostomy output has significantly decreased. She reports several episodes of emesis 2 days ago but has not vomited since. She is currently not nauseous. She does report low grade fevers. Past Medical History: Appendectomy at age 19, [**2191-12-14**] Exploratory laparotomy, drainage of subdiaphragmatic bilateral abscess, drainage of pelvic abscess, drainage of pericolic gutter abscess both on the right and left side. Drainage interloop abscess. [**2191-12-16**] 1. Exploratory laparotomy. 2. Washout, drainage interloop abscess and component separation. 3. Ventral hernia repair with mesh. (open abdomen) [**2191-12-22**] Exploratory laparotomy, abdominal washout. [**2191-12-25**] Exploratory laparotomy, Hartmann's procedure, and rigid sigmoidoscopy for distal sigmoid perforation Social History: Widowed (husband committed suicide 1 year after daughter died from brain tumor at age 6) - Previous to prior admit- Tobacco: [**1-16**] pack per day, extensive history - none since previous to prior admit-Alcohol: 6 drinks per day, last drink 1 week ago - Illicits: Denies Family History: Non-contributory Physical Exam: Admission Physical: Gen: NAD. A&Ox3. HEENT: Anicteric. Tacky mucosal membranes. Neck: No JVD. No LAD. No TM. CV: RRR. Pulm: CTAB. Abd: distended and tense with + fluid wave. large ventral wound granulating nicely, no active drainage. diffusely mildly tender to palpation. nonperitoneal. no hernias/masses. LLQ ostomy with scant air and small amount of fluid. Ext: Warm and well perfused. B/L LE edema to knee. Neuro: Motor and sensation grossly intact. Pertinent Results: [**2192-1-31**] CT a/p: IMPRESSION: 1. Overall increased fluid overload and third spacing with anasarca. 2. Increased bilateral pleural effusions with associated compressive atelectasis. 3. Increased free ascites in lesser sac as well as continued chronic ascites noted throughout the remaining abdomen. 4. Decreased size of known bilateral rim-enhancing paracolic fluid collections, cannot exclude a superimposed infectious process. 5. New mild right hydronephrosis with mild dilatation and enhancement of the proximal right ureter. No current cause of obstruction identified though unable to trace distal ureter. Given enhancement pattern of the proximal ureter, please correlate with lab work for possible infection. [**2192-2-1**] ielography: Large bowel proximal to colostomy is normal in course and caliber. No evidence of obstruction or stricture. [**2192-2-2**] 1:29 pm PERITONEAL FLUID **FINAL REPORT [**2192-2-8**]** GRAM STAIN (Final [**2192-2-2**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2192-2-5**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2192-2-8**]): NO GROWTH. [**2192-2-3**] 4:00 pm PERITONEAL FLUID **FINAL REPORT [**2192-2-9**]** GRAM STAIN (Final [**2192-2-3**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 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 [**2192-2-6**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2192-2-9**]): NO GROWTH. [**2192-1-31**] 10:05 pm BLOOD CULTURE #2. **FINAL REPORT [**2192-2-6**]** Blood Culture, Routine (Final [**2192-2-6**]): NO GROWTH. [**2192-1-31**] 11:25AM BLOOD WBC-13.5* RBC-2.84* Hgb-8.7* Hct-27.7* MCV-98 MCH-30.7 MCHC-31.4 RDW-18.4* Plt Ct-436# [**2192-2-10**] 05:09AM BLOOD WBC-14.2* RBC-3.59* Hgb-11.3* Hct-35.2* MCV-98 MCH-31.5 MCHC-32.1 RDW-18.2* Plt Ct-181 [**2192-1-31**] 11:25AM BLOOD Glucose-101* UreaN-14 Creat-0.4 Na-138 K-3.9 Cl-101 HCO3-31 AnGap-10 [**2192-2-10**] 05:09AM BLOOD Glucose-151* UreaN-13 Creat-0.4 Na-134 K-3.5 Cl-95* HCO3-34* AnGap-9 [**2192-1-31**] 11:25AM BLOOD Albumin-1.8* Calcium-7.9* Phos-2.8 Mg-1.5* [**2192-2-10**] 05:09AM BLOOD Calcium-8.3* Phos-2.5* Mg-1.9 Brief Hospital Course: 49F with EtOHcirr (MELD 21) hx bowel perforation s/p exlap s/p closure & repeat exlap hartmann's for free contrast on CT admitted in the setting of decreased ostomy output. Upon admission pt was managed with NGT, npo/IVF. Ileography was perfomred which revealed patent colon with no stricture or obstruction. On [**2192-2-2**] underwent paracentesis, only able to aspirate 3 mL. cultures and gram stain were negative. On ultrasound during paracentesis noted fluid collection around pancreas that was drained on [**2192-2-3**], removing 950 mLs. Again gram stain and cultures were negative. Given pt's long duration of abx therapy since previous admission, afebrile during addmision, with negative peritoneal fluid cultures, all abx were stopped on [**2192-2-8**]. On [**2192-2-3**], pt was noted to have increased work of breathing and decreased oxygen saturdation to 90% on room air. CXR revealed mild to moderate pulm edema. Pt was transferred to ICU for observation and diuresis. Transferred to back to floor on [**2192-2-5**]. Ostomy output increased HD3. Was started on lactulose. Advanced to clears on [**2192-2-5**] and to regular diet on [**2192-2-9**]. Tolerated diet fairly well except for two eposides emesis on clear diet. Noted increased abdominal distention on [**2192-2-8**], KUB at that time showed no ileus, SBO, or dilated loops of bowel. Air was seen throughout colon. Urology consult during admission for incidental R hydronephrosis on admission CT. Recommended outpt follow up. Discharged back to rehab on Cipro for SBP ppx. Will continue lactulose. Medications on Admission: Albuterol, Ergocalciferol, folate, oxycodone, rifaximin 550'', spironolactone 100', lasix 40', azithromycin 500', flagyl 500''', micafungin 100', zosyn 4.5''', famotidine 20'', glargine 6 QHS, RISS, Discharge Medications: 1. Cipro 250 mg Tablet Sig: One (1) Tablet PO once a day. 2. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 4. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 7. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 8. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. glargine Sig: Six (6) units at bedtime. 10. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 11. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation every six (6) hours as needed for wheezes. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: 1. ascites 2. fluid overload/edema 3. decreased ostomy output 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 will be transferring back to [**Hospital **] Rehab in [**Hospital1 **] to continue your rehab. Tube feeds will be continued. Your abdominal wound will be dressed with moist to dry [**Last Name (un) 26535**] dressings twice a day. All cultures during this hospitlization were negative, and your antibiotics were stopped. You will remain on SBP ppx. Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2192-2-15**] 11:00 Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2192-2-17**] 3:40 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2192-3-1**] 1:00 Follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3748**], urologist, in 3 to 6 weeks. Call his office for an appointment (([**Telephone/Fax (1) 8791**]). Completed by:[**2192-2-10**]

[ "263.9", "518.4", "305.1", "591", "789.59", "V44.3", "571.2", "560.1", "593.4", "518.81", "303.90" ]

icd9cm

[ [ [] ] ]

[ "96.6", "54.91" ]

icd9pcs

[ [ [] ] ]

7722, 7793

4997, 6573

355, 461

7899, 7899

2577, 4974

8451, 9106

2063, 2082

6822, 7699

7814, 7878

6599, 6799

8075, 8428

2097, 2558

263, 317

489, 1150

7914, 8051

1172, 1756

1772, 2047